The Legacy of Thomas Szasz: A Meditation on Mental Illness and Metaphor

Yesterday I got an email from a company who has released a trailer of a documentary about the last interview given by Thomas Szasz. The trailer can be viewed here.

To catch many of you up, Thomas Szasz was the radical and iconoclastic psychiatrist who spent most of his life attacking the profession of psychiatry by arguing that "mental illness" did not exist. Rather, Szasz argued, "mental illness" was a social construct created so that society could use it as a form of social control via the medical and legal professions. According to Szasz, mental illness was a myth as he wrote in his famous book The Myth of Mental Illness, published in 1961.

I read Szasz when I was getting my Masters degree in Clinical Psychology. Szasz blew my mind. The Myth of Mental Illness is a wonderfully subversive book, one of those classic radical reads from the 1960s. Szasz argues that mental illness is a social fiction that is used to mask moral conflicts within society. Crudely, behaviors we don't like we label "ill." Behaviors we like we label "healthy." We then use the medical profession, backed up by the state, to regulate social behavior.

To be sure, this is a radical vision that I think Szasz pushed too far. Still, Szasz opens your eyes to just how socially malleable, and exploitable, is this notion of "mental illness."

Consider, for example, how mental illnesses come and go. Take hysteria as one historical example. Sigmund Freud cut his teeth on treating hysteria. Freud's first significant work, penned with Josef Breuer, was Studies in Hysteria. This is the book with the famous case of Anna O., the patient who birthed the "talking cure" and launched the modern psychotherapy movement as we know it. Anna O. (Bertha Pappenheim) suffered from hysteria, a odd assortment of neurological and psychosomatic symptoms, that was common at that time. Breuer and Freud would hypnotize hysterics talking them back to the origin of the symptoms and, once that had been done, the symptoms would often relieve themselves. Freud eventually ditched the hypnosis and began to use "analysis" to talk back to the root of the ailment.

But here's my point. Where have all the hysterics gone? To be sure we still have psychosomatic disorders, but the particular constellation and prevalence of what Freud diagnosed as "hysteria" has gone away. Hysteria was a mental illness that had its day and then vanished.

Half-jokingly, I tell my college students that dehydration is the hysteria of the modern era. Everybody, it seems, is dehydrated in a way that seems very psychosomatic. The slightest physical symptoms are quickly traced back to not drinking enough water. I see students on my campus carrying around large jugs of water like magic talismans in their constant efforts to ward off the specter of dehydration.

I point out to my students that when I was growing up no one was dehydrated. We never heard it talked about or worried about it. No one, growing up, complained about dehydration. So what happened? Bottled water happened. Dehydration only became a chronic worry after bottled water appeared.

I remember the first years of bottled water. Many of us were incredulous. Really, we thought, you're going to sell water? To whom? And you are going to make water the same price as, say, a Coke? That'll never fly, we reasoned. You can get water for free from the tap. Shoot, we used to drink out of garden hoses when were playing outside. Why would anyone pay for water? And shouldn't water be, at most, half the cost of a Coke?

Well, I totally missed the boat on that. Bottled water is now ubiquitous. And it costs the same as a Coke. And with the ascendance of bottled water came the never-before-heard-of worries and complaints about being dehydrated.

The lesson? This: Our physical and mental symptoms reflect our times. Jesus had demon-possession. Freud had hysteria. We have dehydration.

Consider also examples of more interest to Szasz, places where "illness" is used to mask debates about morality. For example, while many people believe that alcoholism is a "disease" there is actually, you may be surprised to know, some sharp debate about this in mental health circles. I think most of my faculty reject the disease model for alcoholism. And currently there is a lot of debate about if "sexual addiction" really is an addiction. (And to be clear, rejecting the disease model of alcoholism isn't a denial of the problem and pain, it's simply a shift in treatment conceptualization.)

This is why the publication of the DSM is so contested and controversial. If you don't know, the Diagnostic and Statistical Manual of Mental Disorders is the bible of mental illness diagnoses in the United States. It is published by the American Psychiatric Association. The 5th edition of the DSM has just been published, which is a pretty big deal in my field. When the new DSM arrived at our offices we all gathered around to check it out. Nothing more fun than flipping through the DSM with a bunch of psychologists.

The reason the DSM is so contested and controversial is that here is a book that defines the boundaries between "sick" and "well," psychologically speaking. And unsurprisingly, lots of people have opinions about that boundary. This boundary is often hotly contested between religious groups and the mental health community, one reason many churches don't trust psychologists or psychology. For example, on our own campus our psychology majors will occasionally receive worried comments from bible professors or from people at their church. Why this anxiety? Because a particular religious group who defines a behavior as "sinful," "unnatural" and even "harmful" can get "overruled" by the mental health community (through things like the DSM) who steps in to declare the behavior in question as "normal" and "healthy." So a turf battle ensues about the boundaries of mental illness and moral approbation.

This boundary wouldn't be so contested if, in fact, the boundary didn't shift very much. But it has. Behaviors that the DSM used to classify as a "disorder" are now no longer so classified. And new disorders are created for things that once were considered normal. A kid used to be fidgety. Now she has ADHD.

As Szasz noted, what is or is not an illness shifts with society and we should pay attention to how society is using the category "mental illness."

Take another example, depression. Depression used to be called melancholia, and the ancients actually found melancholia to possess some personal and social benefits. Realism, for instance. For example, some have argued that one of the reasons behind Abraham Lincoln's greatness and kindness was that he suffered from chronic depression (and even suicidality as a young man). That struggle with depression, it is argued, gave Lincoln the psychological resources to deal with the early setbacks of the Civil War along with the empathic capacity to bind up the wounds of the nation in the face of suffering and tragedy. Depression has some benefits.

Does that mean that depression isn't a black hole of despair and pain? No. But calling depression an "illness" may obscure the ways that depressed people have advantages, capacities, insights and skills relative to the non-depressed. Maybe depression wouldn't sting so bad in our modern era if we turned toward the melancholics, like the ancients did, for insight, wisdom, perspective, and guidance. Depressives also tend to make better art.

Let's also go back and reconsider that ADHD diagnosis above. Think of attentional capacities as existing, like many natural phenomena, on a bell curve. Some of you have amazing attentional abilities. You can read a book in the middle of a maelstrom. But for every one of you there is, because this is a bell curve, a person who is distracted by the smallest stimuli. For these people, attention is a struggle and a chore.

Think, then, about those children in a classroom who are, of statistical necessity, at the bottom 10% of attentional abilities. Are these kids the ADHD kids? Are they sick or ill? Do they have a disorder? Or are they just natural variants along the attentional ability continuum?

There are tall kids and there are short kids. There are kids who can attend and those who cannot. Why, then, call the bottom of the curve disordered? Why do they need a diagnosis?

This isn't to say that those kids at the bottom aren't struggling with attention. This isn't to say that those kids don't need to learn to cope with with their situation or that psychopharmacology can't be of help. Shoot, I drink coffee--a stimulant--to pay better attention.

So we are not denying that there are kids who struggle with attention and that they might need some help. What we are questioning is if it's a good idea to give these kids a "diagnosis." Is it healthy to have the word "disorder" as a part of your self-description at a young age?

Which brings me back to Szasz. There is no doubt that we suffer psychologically in various ways. I don't think psychological suffering is a myth. But I do think the notion of "mental illness" is, very often, a metaphor. And like all metaphors it can be used well or poorly. The metaphor of "mental illness" used well can promote sympathy, care and nursing. Because we generally rally around sick people.

And yet, this same metaphor can be misused, becoming a location of shame, helplessness, stigmatization and exploitation.

And this, I would argue, is the value of reading someone like the radical Thomas Szasz. Pay attention to the metaphor of mental illness, the language of diseases, addictions, disorders, diagnoses, treatments, therapies and so on. It's not wrong to call something "mentally ill" but great care and caution is needed.