For some time now the concept of mental illness and its corollary, an alliance between medicine and psychiatry, have come under attack from various sources. Dr. Thomas Szasz has been one of the first and one of the most outspoken of the critics. It will be the purpose of this paper to critically examine his book THE MYTH OF MENTAL ILLNESS, which Szasz considers fundamental to much of his later work. I will try to show that the arguments he presents against the mental illness concept are, in the last analysis, inadequate and that there are important shortcomings in his alternative theory of behavior. I shall also consider some of the implications of his position for several traditional problems in the field of psychiatry.
I want to make it clear that what I am not taking issue with is Szasz's point, made in THE MYTH OF MENTAL lLLNESS and brought out emphatically in subsequent publications, that involuntary commitment of mental patients is an abuse of the human right to liberty. Dr. Szasz instigated and contributed a great deal to the recent changes in some of the laws violating that right. Although he would probably disagree, I think that is a separate issue and ought to be argued on a different basis from the contention that "mental illness" is a myth—it therefore does not stand or fall with the arguments for the latter.
THE FORM OF SZASZ'S ARGUMENT
Before approaching the reasons Szasz offers for rejecting "mental illness" as a myth, it is important to understand the objectives he has in mind and his view of science. Szasz is arguing from within two current movements in the field of psychiatry, one of which is to emphasize the moral and ethical nature of human behavior. His position is (along with others who argue in this direction) that the psychiatrist should make his values explicit in the therapeutic situation. He further contends that the notion'of mental illness is used as an obscuring label for what are really conflicts of everyday living, i.e., ethical conflicts.
The second movement with which he aligns himself is the current attempt to bolster the scientific foundations of psychiatry and psychology. There is considerable confusion these days within both as to what it means to be scientific in a study of human beings. Szasz clearly argues against reductionism. He not so clearly argues for a "liberal empiricism" (p. 92) by which a diversity of methods and languages is considered appropriate for science because of the diversity of subject matter from one discipline to the next. I contend it is "not so clearly" because this is the extent of his explicit discussion of the matter. Implicitly empiricism means, for him, adherence in science to observables which are publicly verifiable. It is my point here merely to state his position because it has a bearing on his treatment of the subject, e.g., what we can say about causes of human behavior, what constitutes the subject matter of psychiatry (and psychology), and the relevance of "subjective" as opposed to "objective" symptoms.
How does Szasz's conviction that "mental illness" is a myth tie in with his ethical and scientific orientation for psychiatry? According to him the particular scientific framework of traditional medicine, with which psychiatry is identified through usage of the concept,"mental illness," necessarily determines the scientific basis and precludes the ethical aspects of psychiatry. So if we agree that psychiatry should be (in some way) both scientific (in its own right) and ethical (value-oriented), then we have only to further agree that both are conditional upon divorcing psychiatry from medicine.
The premises and conclusion of this argument are tied in with Szasz's major point that there is no such thing as "mental illness": it is a myth,and therefore has no place in science; it is a mask for ethical problems, and should therefore be abandoned; if indeed there is no such thing as mental illness then, again, psychiatry has no place within medicine. So there are two broad issues to be considered here, first, whether the purportedly necessary relationship between medicine and psychiatry obtains and, second, whether Szasz's contention that "mental illness" is a myth is well-founded.
MEDICINE AND PSYCHIATRY
Szasz's objection to considering some of man's behavior within the "confines" of medicine arises because he insists that to speak of psychiatry as a branch of medicine is to identify the two in every significant respect. Then, since medicine is grounded on the principles of physics and chemistry, psychiatry must be also. The latter is thus necessarily tied to a conceptual framework inappropriate for a scientific study of man.
This view depends on erroneously uniting two aspects of the concept of medicine. We can think of medicine as entailing both "treatment" and "(treatment) of what"; there is no necessary relationship between treatment as such and some specific object being treated. To say that medicine (physical) is treatment and corresponds to a body of scientific knowledge and to further assert that psychiatry is treatment is not to say that it is dependent on the same knowledge or facts. In other words the relationship between medicine and psychiatry need not be (and is not) one of identity in specific content or method.
Of course we cannot ignore the fact that a number of psychiatrists have preferred to limit themselves to the physicochemical framework of medicine with their belief in the eventual discovery of organic bases for all mental illness. But this is neither a necessary nor universal outcome of the assertion that psychiatry can be considered a branch of medicine which offers treatment for certain dysfunctions.
A second argument given is that the physicochemical framework of medicine commits psychiatry to a deterministic model of causality, thereby ruling out significant aspects of human behavior, namely, choice, responsibility, and valuation. This point is again dependent on Szasz's insistence on the identification of psychiatry and medicine. On this basis if one is to look for the cause of a behavioral disorder which is presented in a medical (i.e. psychiatric) situation, one is committed to looking for an organic, or at least a physical-mechanical (hence deterministic), explanation.
But if we recognize that psychiatry is not necessarily based on physics and chemistry because of its medical association, then we do not have to choose Szasz's solution, which is (in order to avoid determinism) to dismiss causality from psychiatry altogether. According to him if we re-define the problem in terms of different languages (instead of "mental illness"), then there is no need to search for causes. To understand another language we view it from the standpoint of learning and meaning, not causes and treatments. But there are problems with this dismissal, for we may not seek causes if, for example, a man grew up in France and speaks French, but if he grew up in Italy and we observe him speaking French we are inclined to look for causes.
Admittedly the idea of accountability and responsibility for one's actions and how this relates or cannot relate to the notion of mental illness is a fundamental issue for psychiatry. The problem for Szasz is that he implicitly accepts the Humean model as the only model of causality. In this he is like the behaviorists. Of course he differs from them in that he finds this model inappropriate to an explanation of human action. He therefore rejects it for psychiatry, but because he accepts only this one model of causality, this rejection leads him to deny the possibility (or appropriateness) of considering causes in a discussion of human action.
However, if causal explanations are ruled out by redefining the problem, it becomes difficult to talk, as Szasz wants to, about choice and responsibility. The latter concepts are dependent on the notion of personal causal efficacy in regard to one's own actions. And this is one kind of causality. So the alternative to determinism which Szasz offers is of dubious value for bringing ethical considerations into psychiatry.
Related to the above is Szasz's point that "psychiatrists cannot expect to solve ethical problems by medical methods" (p. 8). Underlying this is his contention that a so-called mental illnesses are really problems in living, i.e., ethical problems. Even if we accept this, what constitutes "medical methods" remains unclear. If he means to argue against the organicists who hope to eventually solve all mental illnesses by medical means or against such things as the present increase in prescribing mood-changing drugs, then he has a point. But his implication is that all psychiatrists who practice as doctors or in a medical situation are, and should not be, using "medical methods" (all of traditional methods? some of them?).
Szasz presents Freud as a prime example of the above:
"Problems in living . . . were thus treated as though they
were manifestations of physical illnesses" (p. 75). But
just the opposite is the case.
Freud, in the problem of hysteria with which his work began, took the apparent manifestations of physical illness and treated them as though they arose from conflicts in life situations. He used the "talking cure" which is not a traditional medical method. And for the most part psychiatrists, although they regard what they treat as illness, primarily employ other methods than those characteristic of physical medicine. So it seems that Szasz is demolishing a straw man.
On the basis of the arguments presented it is not necessary to disengage psychiatry from medicine, particularly as regards the scientific foundations and the specific methods of the two fields. The issue of whether our use of "mental illness" and "responsibility'' are mutually exclusive is less conclusive. However, it is not impossible to think, even in some illnesses of the body, of the person being directly or indirectly responsible or culpable for bringing on or encouraging his own illness. So a tentative proposition might be suggested, that although the tendency has been to greatly overuse "mental illness" as an excusing concept, it is possible to re-think without discarding the notion of mental illness.
IS MENTAL ILLNESS A MYTH?
The greater part of Szasz's effort to debunk "mental illness" is spent in an attempt to show that it has no valid scientific foundations; it cannot be rationally justified; it is a myth. The arguments for this conclusion can be summarized in these four points: 1) Since what psychiatrists really deal with is "problems in living" they should stop talking about "mental illness" and re-define their field; 2) Psychiatry began with the studies of hysteria by Charcot and Freud, who classified it as a disease for social and historical, i.e., nonscientific, reasons; 3) In the classic fiction of hysteria as mental illness logical distinctions were obscured and epistemological errors made, and the same type of errors are perpetuated in subsequent classification; 4) "Mental illness" does not denote a disease entity; use of the concept is therefore an attempt to explain "problems in living" in terms of a myth.
I will not deal with the second argument since it relies on psycho-historical explanation. That is a kind of deterministic model itself and defeats one of the purposes given by Szasz for arguing against "mental illness." In addition, its importance is unclear since the "scientific" status of a theory, model, or type of explanation does not rest on the historical factors involved in its origin.
A note is in order here regarding Szasz's use of conversion hysteria as the paradigm of mental illness. He contends that whatever can be said about hysteria "pertains equally, in principle, to all other so-called mental illnesses and to personal conduct generally" (p. 9) since the diversity of mental illnesses is analogous to the diversity of languages. There are several difficulties with Szasz's choice of paradigm. (a) Hysteria is not a "typical" mental illness in that it (uniquely) involves functional disorder of the body. It is somewhere between uncomplicated physical illness and uncomplicated mental illness. As such, what is concluded about its correct or incorrect classification as mental illness may not be particularly relevant in a consideration of the general validity of "mental illness" as a category. (b) Szasz hopes to bridge this gap by comparing the diverse mental illnesses to languages. Although he develops in great detail and with some success the idea that hysteria is (is like? we're not quite sure) a language, it is never clear how we are to take the step from this to all mental illnesses are (are like?) languages.
At many points Szasz tries to underline his thesis by showing that the issues can be (and therefore should be) re-stated in terms of his own theory that behavior is communicational and rule-following and game-playing. Since Szasz offers his own model not only as an alternative to take the place of the one he is attempting to invalidate, but also as supporting reason for abandoning it, much of his argument depends on its explanatory value. This will be taken up later, but some of its shortcomings will become apparent already in looking at his arguments against "mental illness."
First, we are to see that "mental illness" is a myth by examining what it is that psychiatrists do. The traditional definition of psychiatry is: the branch of medicine dealing with disorders of the mind, including neuroses and psychoses. But what psychiatrists really do is "communicate with patients by means of language, nonverbal signs, and rules" (p. 3). Thus his characterization of psychiatry: the discipline whose method is communication—in its broadest sense (p. 3). More formally, psychiatry "consists of the study of personal conduct—of clarifying and 'explaining' the kinds of games people play with each other" (p. 7), and is differentiated from psychotherapy, which consists of the alteration of human behavior.
There are several problems here. First, Szasz takes the value of the first definition to be its reference to methodology rather than subject matter; it is an operational definition and therefore scientific (p. 2). But physics and biology, e.g., are defined in terms of subject matter, not the physicists' or biologists' methods or tools of study and intervention. Operational definitions are used within a science but defining the discipline itself is an extra-scientific problem. What Szasz hoped to accomplish with this move was to do away with the subject matter of the traditional definition.
His second definition, rather than excluding the subject matter, re-defines it as personal conduct (games). The problem with this is that is obscures an important distinction between psychiatry and psychology by including in the former all of behavior rather than the abnormal. Thus the traditional definition of psychology (the science dealing with the mind and mental processes, feelings, etc.) is ignored and implicitly done away with also. A strategic move for Szasz because in this way, with no opening left to talk of mind, mental processes, etc., there is no opening to talk of something going wrong there, i.e., of mental illness.
According to Szasz "personal conduct may be studied fruitfully by considering man's 'mind' mainly as a product of his social environment" (p. 13, emphasis added). This turns out to be a position much like that of the behaviorists who contend that, at least for the purpose of scientific study, the mind of man, if it exists, is a by-product (for the reductionists, a by-product of physical processes). So we can't talk about the influence of mind on body or body on mind or mental illness. There are only different languages, different games. The latter are descriptions of directly observable behavior and it is in keeping with Szasz's notion of science that this is the proper subject matter of psychiatry-psychology.
Granted that there are problems with the one sidedness of the subject matter designated by the traditional definition , excluding the defining characteristic of human beings rather than expanding the definition to include more aspects is not the best solution. In any case this re-definition with no mention of mind or mental processes does not show that "mental illness" is a myth. It merely defines it out of existence, at the expense of some important distinctions.
THE LOGlC OF "MENTAL ILLNESS"
There are several examples by means of which Szasz tries to show that "mental illness" is a myth because its logical foundations are in error. The first of these is based on the logic of classification: if illness is a class of phenomena, say A, then there must be a class of non-A (some of these may look like A but turn out not to be) and a class of counterfeit-A, "similarity in appearance being deliberately created by a human operator for some purpose" (p. 39). The use of hysteria as a paradigm is crucial to Szasz's point here, because although it may look like physical illness ( A ) it has no organic basis and must logically be distinguished from A. So it is a logical error to place hysteria, as imitation of illness, in the class of illness itself.
For this to be so we must accept two assumptions made by Szasz: (1) that there are only two options in classifying someone who exhibits symptoms of physical disorder: "a person who complains of bodily symptoms may be a 'sick patient' or a 'healthy malingerer' " (p.39), and (2) that Charcot and Freud, in classifying the hysteric as ill were in fact placing him in the same logical class as those with physicochemical disorders of the body. But Charcot and Freud recognized that hysteria only appeared to be physical illness; they did not illogically place it in class A (physical illness), but in a special class of non-A (non-physical illness) called "mental illness." Before their time hysteria was more or less considered one with malingering (counterfeit-A). However their distinction between the two rested on the logical fact that not all non-A, and not even all imitations of A, are counterfeit-A.
A second example based on the logic of classification is the later development in psychiatry of classifying malingering itself as mental illness, a move which Szasz contends denies the possibility of imitation, i.e., counterfeit-A is accepted as A. Again this reflects his refusal to accept mental illness as a distinctive category in the class "illness." If we call physical illness A and mental illness B, and further distinguish within both various kinds of illness (A1, A2, B1, B2, etc.), then, e.g., B5 is malingering, i.e., deliberate imitation of another kind of illness. This does not deny the possibility of imitating, but proposes that in certain situations, (we would distinguish between the faked illness of children playing hospital and that of a man who hates his job) conscious imitation of illness is not, by a given standard, the appropriate way to deal with a problem.
Szasz also wants to show an epistemological error at the base of Freud's theory. To explain conversion hysteria Freud relied on a physical model of energy discharge. Says Szasz, "no such complicated explanation is required" (p. 82); the problem is "epistemological rather than psychiatric. In other words there is no problem of conversion unless we insist on so framing our questions that we inquire about physical disorders where, in fact, none exist" (p. 83).
It is Szasz's conviction that the traditional mind-body problem can and should be avoided in psychiatry: "We shall not regard the relationship between the psychological and physical as the relationship between two different types of events or occurrences, but shall rather consider it to be akin to two different modes of representation or language" (p. 83). Accordingly, Freud's physical model of energy discharge should be replaced by thinking of what happens in terms of translation from one language to another.
There are two objections to this: (1) The error to be seen in Freud's thinking is pointed up by reference to Szasz's own theory ("it should be re-phrased this way because it can be"); and (2) We are still left with the problem of explaining by what means a nonphysical problem is changed into physical bodily "language" which can be distinguished from "real" body "language" (real physical illness). Because he objects to Freud's mechanical explanation, Szasz maintains that it is an epistemological error to seek explanation for an "apparent" mind-body problem. His thinking here can be traced to his contention that there is no place for (causal) explanations in psychiatry.
"MENTAL ILLNESS" AS DISEASE ENTITY
There are two aspects to Szasz's argument that "mental illness" does not denote a disease entity, one medical-logical and the other social. First of all, Szasz chooses to define "disease entity" as bodily disorder (pp. 101-02), thereby ruling out any other than physical disorder as well as any other than physical entities counting as disease. In any case, his position that physical illness, e.g., the common cold, denotes "an entity found in nature" whereas hysteria (and mental illness in general) is "an abstraction or theoretical construct made by man" (p. 88) is erroneous. The common cold is not "an entity found in nature"; it is not, as Szasz implies, an observable phenomenon, although its symptom-complex is. "Common cold" is a term, such as "hysteria," under which its specific symptoms can be subsumed. The crucial difference, of course, is in the nature of the symptoms, a point which Szasz does not discuss. (After all, if there is no such thing as mental illness then there are no symptoms of mental illness.) Instead he bases his argument on a discussion of physical symptoms (again his choice of paradigm is crucial), but of physical illness.
Szasz carefully points out that in physical medicine there are three types of symptoms: bodily complaints, bodily signs, and empirical evidence of functional or structural alteration of the body. "Illness," logically, is an inference from some combination of these, generally including the last. But he makes a crucial jump here. The logic of medical diagnosis requires the last type of symptom as a justification for inferring that the patient's complaint in fact indicates organic disorder, not, as he argues, as a verification of the first type of symptom. In analyzing hysteria Szasz assumes that since there is no organic basis for the patient's complaint, the referent of the complaint, e.g., pain, is not real; the patient is lying. (Note his bias: only publicly observable evidence counts.)
This is why he says that Freud made an epistemological error in inquiring about a nonexistent physical disorder, and that hysteria is only imitation. Freud, and psychiatrists in general, do not commit the logical error of inferring organic disorder only on the basis of the "subjective" evidence of bodily complaint; they do not infer organic disorder. They do however accept the patient's report of pain, and finding no organic basis for it infer that it requires psychological explanation.
From a social analysis, too, Szasz believes we can conclude that the terms "hysteria" and "mental illness" do not denote a disease entity. "Actually they arise from and reflect characteristic features of the social matrix of the therapeutic situation" (p. 296). To support this he compares medical systems in the U.S. and the Soviet Union, showing that in the first instance the psychotherapist is the patient's agent whereas in Russia the physician is the agent of the state. He then cites statistics of increasing diagnosis of mental illness in the United States in contrast to a high incidence of malingering in the Soviet Union. From this he concludes that "mental illness" reflects a social condition, but not a disease entity.
In the first place there is an assumption that the same "somethings" are being presented in the two countries and are only being diagnosed differently. Second, he is interpreting a high statistical correlation of two phenomena as evidence for a causal relationship, in this case, that agent-pattern determines diagnosis-pattern. Third, is the assumption that social conditions can tell us something about the nature of the subject, i.e., whether there is a disease entity that can be called "mental illness." But this is like drawing conclusions about the intelligence of children by looking at the various types of education provided them because of varying social contexts. Neither on the basis of this social argument nor of the logic of diagnosis can we conclude that "mental illness" does not refer to a disease entity.
This concludes the discussion of Szasz's attempt to show that "mental illness" is a myth. Without ignoring that Szasz has touched upon some of the crucial problems which complicate our use of the concept, e.g., personal responsibility and the deterministic model of causality, his arguments do not support the conclusion that "mental illness" is a myth, i.e., nonexistent or illogical.
HOW VIABLE IS THE ALTERNATIVE?
Szasz proposes three explanatory models to replace the current mental illness concept (and to explain all of human behavior). They are the sign-using, rule-following, and game-playing models. He offers a detailed analysis particularly of the first, showing the types and functions of language (signs) and relating hysteria (as paradigm) to these and to specific social rules. He then shows how hysteria can be considered a game. Since he sees it as the most comprehensive model, I will point out some general objections to game-playing as a theory of behavior, then discuss the implications of his explanation in two areas: intention and personal responsibility.
First, any model borrowed from an existing field of distinct activity cannot adequately serve to explain those activities which fall outside the original. That is the problem with virtually all game theory models, so it is not exclusive to Szasz's discussion. Then, games simply differ from behavior in general by virtue of the freedom we enjoy in making up the rules of a game, while we lack such freedom in devising a successful way of talking and dealing with, say, the circulatory system or the stratosphere. (So, as has been suggested, behavior might better be compared to fire-fighting than to games, the former being an activity that is varied and yet rule-bound.) Finally, this entire emphasis on the concept "game" is open to question because it relies on a philosophical heritage (Wittgenstein's discussion of "language" and "game") which is a problem area in its own right—so surely not to be taken for granted.
Szasz defines the game situation conventionally, as "characterized by a system of set roles and rules considered more or less binding for all of the players" (p. 7). But many human activities involve only one person. (Some, like Wittgenstein, have argued for single-party games. What they seem to be saying is that we can play the above, but not that by playing we automatically engage in a party game.) It is questionable even whether most interactions occur in the context of mutually understood, let alone binding, rules.
If game-playing is to explain all behavior, it is not enough either that we can see the behavior as directed toward a goal or as following some rules. Otherwise how can we distinguish between accidentally going through the motions of a particular game, and actually playing the game? Ordinarily we would have to ask the players; i.e., to be playing a game according to "rules considered binding" the players must know the rules and be aware that they are game-playing.
Then, even within an ordinary game there are actions which cannot be understood by reference to the rules alone. A chess player's moves but not his skill may be understood by rules; or the rules of tennis prescribe what actions are to be taken, but not what grip is best. There are also activities during a game which may be incidental or irrelevant, e.g., dropping a pawn or wiping one's forehead. If these are to be construed in the light of still other games (the rules of how best to hold one's racket or the rules for wiping) then this leads to an infinite regression. The same problem is encountered with one's reasons for playing the game and such things as the history of the game.
It is revealing to see some behavior as game-like and we commonly do this, e.g., "playing cat and mouse with each other." But this is a metaphor, meaningful only if there is some non-game-playing behavior to which we are comparing it. A metaphorical account loses significance when applied as a general theory.
This is just a broad outline of some objections to Szasz's theory. The assumption has been that an explanatory theory which seeks to relate phenomena to something already known must depend on the general understanding of at least the essentials of that thing. But the game-playing model ignores or distorts characteristic aspects of what is generally understood when we talk not only of games, but also of behavior. Perhaps one of the most crucial of these is the concept of intention.
Szasz, contrary to the traditional psychiatric view, maintains that hysteria is willful imitation of illness. This is dependent on his seeing the hysteric's symptoms as strategy, i.e., moves in a game. That there are results of the symptoms is undeniable (e.g., he may receive sympathy); that these are the intended aims and goals, that they are part of a game, where the players are aware of the rules and goals, is another matter. But note Szasz's prejudice toward this interpretation of all behavior: "If it appears that human beings are not so engaged [in purposeful, goal-directed activity], it is useful nevertheless to assume that they are and that we have been unable to comprehend the goals and rules of their games" (p. 14). Now there are difficulties with this, but most human behavior can be seen to achieve some goal, and, since Freud, it is plausible that many of these are not explicitly known to their holders.
The problem for Szasz lies in his failure to make the distinction between goal-directed and/or rule- following, and game-playing, i.e., strategic, behavior. He wants to extend the notion of the goal directed- ness of most behavior and say that to reach any end is to have made moves in a game-strategy. We are uneasy with this interpretation when we find the player(s), as in hysteria, unable to avow either the point of the "game" or the rules which are supposedly being followed.
Szasz attempts to get around this difficulty by imputing unconscious intention to the strategies of the mentally ill. But "feigning," "impersonating," "cheating," "lying," and even "strategy" depend for their meaning on the concept of conscious action. It becomes even more complicated when Szasz refuses to discuss the difference between "conscious" and "unconscious," insisting instead that it is more meaningful to talk about goal-directed and rule-following activity as opposed to making mistakes. This doesn't help because "goal-directed, rule-following" and "mistaken" are not descriptive of the same dichotomy as conscious-unconscious: since hysteria has been interpreted as game-playing "it is more accurate to regard hysteria as a lie than as a mistake" (pp. 142-43).
Szasz's ascription of "unconscious" to the intention of the mentally ill is thus of no practical significance other than to make his use of "strategy" more palatable. Whether or not the person is aware is then insignificant in determining whether strategy is involved. But recall that ordinarily, in difficult cases, we must ask the players if a game is in fact being played. In Szasz's treatment of "mental illness" the criteria becomes whether or not the behavior can be interpreted by the observer as achieving some goal, and if so, then it is to be assumed that rules are being followed, a game is being played, i.e., there is strategy intended, whether consciously or unconsciously.
This poses a difficulty because some actions have results which may appear to have been goals and involved strategy without this being the case. For example, good health can result from cycling without ever having been a consciously or unconsciously intended goal (I cycle because it is the cheapest transportation). And, crucial to Szasz's use of "unconscious intention," there are neither conscious nor unconscious strategies for improving health here. Another counterexample is the case where one accidentally performs a sequence of motions which could be interpreted as moves in a game by an observer; e.g., in the process of throwing out (discarding) a dart one may (accidentally) hit a perhaps unseen dart board. These exceptions make it questionable whether the idea that all behavior, even if goal-directed, is strategic (rule-following) and game-like has universal application, and Szasz's treatment of the concept of intention fails to help in making that point.
Szasz gets into this confusing position of calling the behavior of the mentally ill unconsciously willed in order to get away from the mental illness concept with its tendency to remove blame and responsibility for one's actions. However there is a paradox in his view of personal responsibility which is worth noting. On the one hand he criticizes Freud and the entire mental illness model for a deterministic view of human nature which "undermines the principle of personal responsibility . . , by assigning to an external source (i.e., the 'illness') the blame for anti-social behavior" (p. 297). On the other hand Szasz implicitly adopts a deterministic position himself. It is his belief that a game-playing theory can correct the defect of determinism in psychiatry: how this is to be accomplished is not made clear, except as noted at the outset—that determinism is avoided if causal explanations are avoided.
In some ways Szasz falls into an environmentalist position which implicitly entails a variety of determinism. Recall his description of man's "mind" as a product of his social environment. Then there is his view that whatever "language" one speaks, whatever game one plays, "each has its own 'raison d'etre' . . ., because of the particular circumstances of the communicants, each is as valid as any other" (p. 12, emphasis added). This turns out to be very similar to Skinner's view that no one can be praised or blamed for any action because that "action" is determined by environmental contingencies.
So there is this deterministic tendency and at the same time an indeterminism in Szasz's thinking, e.g., in that every game is equally valid. The latter tendency is based on the contention that ethics, i.e., the rules of behavior games, are arbitrarily devised (just as the rules of oridinary, e.g., chess, games), for they vary from one culture and era to the next, It has been argued often, but there are serious problems with the position that there is nothing more to ethics than arbitrarily agreed upon rules. If that were the case then there would be no way to identify, e.g., criminal "games" such as murder by objectively established criteria, and act accordingly, as even Szasz would advocate. (There are other explanations besides arbitrariness which account for variations between culture's ethics. Furthermore, the variations are more apparent than real.)
Szasz's attempt to explain even the hysteric's behavior with the game model, and then his assertion that every game is valid, begs a serious question, namely, whether there are objective criteria for evaluating any behavior. Then it becomes just as difficult to know what "personal responsibility" refers to in such an indeterminate scheme, as in a deterministic explanation of human behavior. The closest he comes to an objective standard of evaluation is to speak of maturity, i.e., "flexible integration of rules as behavior regulating agencies" (p.180). However an "operational meaning" can be given to maturity only on the basis of "certain preferential values of a given society" (p. 288).Again the indeterminism. And one wonders where the rules come from. Part of the problem is that he speaks in passing of following one's own rules (p. 175) but doesn't integratethis into his general theory.
So in Szasz there is not a resolution of the problem with "responsibility" encountered in speaking of mental illness and health. And in general his alternative explanation falls short of adequacy. The conclusion that we reach is that "mental illness" ought not be discarded either because it is a myth, because on the basis of Szasz's arguments it isn't, or because the alternative offered provides a better explanation.