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The Myth of Mental Illness Book Summary – Thomas S. Szasz

What you will learn from reading The Myth of Mental Illnes:

– Why mental illnesses cannot be classified in the same category as actual ‘illness’

– Why physciatry should concern itself with goals, values and personal conduct rather then biology.

– How the process of diagnosis has moved physchiatry from behavioural problems to medical problems and what this means.

The Myth of Mental Illness Book Summary:

This is a fascinting book which has given me an alternative view of how mental illnesses could be viewed as. I don’t neccesarily agree with everything Thomas Szasz says but I do think some of the points are increidbly astute and very interesting to consider. All uses of the terms ‘I’ and ‘my’ are from the Author Thomas Szasz and not me, they are direct quotes taken from the book itself. After reading this book you will begin to question and potentially understand deeper the incredibly difficult task of categorising misbehaviour.


Are mental Illnesses really illnesses?

The claim that “mental illnesses are diagnosable disorders of the brain” is not based on scientific research; it is a lie, an error, or a naive revival of the somatic premise of the long-discredited humoral theory of disease. 

My claim that mental illnesses are fictitious illnesses is also not based on scientific research; it rests on the materialist-scientific definition of illness as a pathological alteration of cells, tissues, and organs. If we accept this scientific definition of disease, then it follows that mental illness is a metaphor, and that asserting that view is asserting an analytic truth, not subject to empirical falsification.

Fifty years ago, the question “What is mental illness?” was of interest to the general public as well as to philosophers, sociologists, and medical professionals. This is no longer the case. The question has been answered-“dismissed” would be more accurate-by the holders of political power: representing the State, they decree that “mental illness is a disease like any other.” Political power and professional self-interest unite in turning a false belief into a “lying fact.”

Once I grasped the scientific concept of disease, it seemed to me self-evident that many persons categorised as mentally ill are not sick, and depriving them of liberty and responsibility on the grounds of a nonexistent disease is a grave violation of basic human rights.

This brings us back to our core problem-namely, whether the mimicry of neurological illness, such as the hysteric exhibits, is to be regarded as a “physicochemical alteration” or as a “psychosocial communication,” a happening or an action, an occurrence or a strategy.


The Ethical injunction of Psychiatry:

The practice of Western medicine is informed by the ethical injunction-Primum non nocere!-and rests on the premise that the patient is free to seek, accept, or reject medical diagnosis and treatment. 

Psychiatric practice, in contrast, is informed by the premise that  the mental patient may be “dangerous to himself or others'” and that it is the moral and professional duty of the psychiatrist to protect the patient from himself and society from the patient.


Human problems and brain diseases:

Each organ has a “natural function,” and when one of these fails, we have a disease. If we define human problems as the symptoms of brain diseases, and if we have the power to impose our definition on an entire society, then they are brain diseases, even in the absence of any medically ascertainable evidence of brain disease. We can then treat mental diseases as if they were brain diseases.

For Szasz, who has continued to uphold these opinions for the last forty 660 years, mental illness is not a disease, whose nature is being elucidated by science; it is rather a myth, fabricated by psychiatrists for reasons of professional advancement and endorsed by society because it sanctions easy solutions for problem people. Over the centuries, he alleges, medical men and their supporters have been involved in a self-serving “manufacture of madness,” by affixing psychiatric labels to people who are social pests, odd, or challenging.


Goals, values and human behaviour:

In sum, then, in as much as psychiatric theories seek to explain, and systems of psychotherapy seek to change, human behaviour, statements concerning goals and values must remain indispensable for all theories of personal conduct and psychotherapy.


Behaviour as Symptoms:

It is important to understand clearly that modern psychiatry-and the identification of new psychiatric diseases-began not by identifying such diseases by means of the established methods of pathology, but by creating a new criterion of what constitutes disease: to the established criterion of detectable alteration of bodily structure was now added the fresh criterion of alteration of bodily function; and, as the former was detected by observing the patient’s body, so the latter was detected by observing his behavior. 

This is how and why conversion hysteria became the prototype of this new class of diseases-appropriately named “mental” to distinguish them from those that are “organic,” and appropriately called also “functional” in contrast to those that are “structural.” Thus, whereas in modern medicine new diseases were discovered, in modern psychiatry they were invented. Paresis was proved to be a disease; hysteria was declared to be one.


Classification and rules:

But the names, and hence the values, we give to paintings-and to disabilities–depend on the rules of the system of classification that we use. Such rules, however, are not God-given, nor do they occur “naturally.” 

Since all systems of classification are made by people, it is necessary to be aware of who has made the rules and for what purpose. If we fail to take this precaution, we run the risk of remaining unaware of the precise rules we follow, or worse, of mistaking the product of a strategic classification for a “naturally occurring” event.


The problem of generalisation:

The relationship between observations and inferences is the same in medicine as it is in any empirical science. As singular events, diagnostic inferences may be verified or falsified–for example, when a surgeon operates for a peptic ulcer: he either finds the ulcer or he does not. As generalizations, however, assertions of the type “All persons who complain of X symptoms or who display Y signs  have Z diseases, can neither be verified nor falsified. Actually, some such patients will have Z diseases and others will not.


Complaints are translated into illness:

In short, the patient speaks (listens) in the language of complaints; and the physician listens (and speaks) in the language of illness. The task that faces them is therefore similar to the task I sketched above; in this case, it is to translate from the language of complaints to the language of illness and vice versa.


Interpretation of  Anxiety in young kids:

A child’s experience of anxiety on being left alone is open to two antithetical interpretations. 

First, it may be considered pathological-that is, “bad”- if it is assumed that the reaction signifies excessive susceptibility to feeling unloved.

Second, it may be considered normal-that is, “good”-if it is assumed that the reaction signifies the chilď’s ability to make connections between more or less dissimilar situations.

So you can see here that it can be viewed as both good or bad depending on how you frame the situation and it’s function.


Conduct and pyschological motives?

The problem of whether the “meaning” of pain could also be its “cause,” and if so in what way, is far more complicated than the psychoanalytic theory of hysteria would have it. According to the latter, some pains are “organic,” others “hysterical.” Thus a longing, a wish, a need-broadly speaking, psychological “meanings” of all sorts-are regarded as “causal agents” similar, in all significant respects, to tumors, fractures, and other bodily lesions.

Clearly, nothing could be  more misleading, since fractures and tumors belong in one logical class, while desires, aspirations, and conflicts belong in another.“ I am not saying that psychological motives can never be regarded as the “causes” of human conduct, for evidently this is often a useful way of describing social behavior. But it’s not the only cause of conduct.


Language and proto-language:

The point is that when some persons in some situations cannot make themselves heard by means of ordinary language-for example, speech or writing-they may try to make themselves heard by means of protolanguage, for example, weeping or “symptoms.” 

Think of language as the more rational and methodical communication method we all use and protolanguage as more of a behaviroual and tonal way of communicating something.

Others in other situations may try to overcome this obstacle in exactly the opposite way, that is, by shifting from ordinary language spoken in a normal tone of voice to ordinary language spoken in a shout or in a threatening tone. Obviously, the weak tend to use the former strategy, and the strong the latter. When a child cannot get his mother to listen, or a wife her husband, each might try tears; but when a mother cannot get her child to listen, or a husband his wife, each is likely to shout.


Rule following behaviour and goal direction:

I think it is more useful to distinguish between goal-directed and rule-following behavior on the one hand, and indifferent mistakes on the other. In psychoanalytic theory there is no room for indifferent mistakes-because it is tacitly assumed that all action is goal-directed. It then follows that a person’s failure to perform adequately cannot be due to his ignorance of the rules of the game or to his lack of skills in playing it. Instead, the failure itself is regarded as a goal, albeit an unconscious one. 

This perspective is useful for the therapeutic attitude it inspires. But it is obvious that not all human error is of this purposive kind. To insist on this view is to deny the very possibility of genuine error.


The use of indirect messages:

When the relationship between two people is emotionally significant but uncertain-or when either one feels dependent on or threatened by the other-then the stage is set for the exchange of indirect messages between them. There is good reason for this-namely, that indirect messages serve two important functions-to transmit information and to explore and modify the relationship between the communicants. The exploratory function may include the aim of attempting, however subtly, to change the other person’s attitude to make him more receptive to the speaker’s needs and desires.

The protective function of indirect communications is especially important when they convey embarrassing or prohibited ideas or wishes, such as sexual and dependency needs and problems about money. Faced with such “delicate” matters, indirect communications permit the expression of a need and its simultaneous denial or disavowal. 

A classic example from medical practice is the physician’s avoidance of discussing fees with patients and his assigning this task to a secretary or nurse. The physician communicating through his employee is simultaneously asking for money and not asking for it. The first message is contained explicitly in the secretary’s request; the second is contained implicitly in the doctor’s avoidance of the subject.

The main advantage of hinting over more direct forms of communication is the protection it affords the speaker by enabling him to communicate without committing himself to what he says. Should the message be ill received, hinting leaves an escape route open. Indirect communications ensure the speaker that he will be held responsible only for the explicit meaning of his message. The overt message is thus a sort of vehicle for the covert message whose effect is feared.

Such communicational interactions, common between husbands and wives and between parents and children, are fostered by situations which make people closely interdependent, requiring that each person curb some of his desires in order to satisfy any of them. Moreover, having curbed some of his needs, the person then demands that his partner(s) do likewise. Thus, the open, undistorted expression of needs is discouraged, and various types of indirect communications and need-satisfactions are encouraged.


The difference between giving reasons and motives:

Further, Peters notes that when a person is asked to state the motives for his actions, it is often implied that he might be up to no good; and when it is said that his motives are unconscious, it is implied that he is not only up to no good but does not even know it. 

In other words, there is an important difference between giving a reason for one’s action and giving a justification for it. We hear of causes and reasons in contexts which are ostensibly morally neutral; whereas we hear of motives and justifications in contexts in which moral considerations are essential ingredients.


Inaction leads to piece of mind:

In other words, when choices are made either by specific action, or more often by inaction -and when these lead to unhappy consequences, people often feel that “it was not their fault” that things turned out as they did. In a purely conventional moral sense they might be correct. But this is simply because common sense assigns guilt or blame only to the specific commission of acts-much less often to omissions-and even among these usually only to acts whose deleterious effects are immediate or short-range.


Personal development and rule following:

The crucial notion in this connection is the relative rigidity or flexibility of the superego. The childish, immature, or neurotic superego is rigid; it is characterized by slavish adherence to rules which, moreover, may not be clearly understood. The mature or normal superego, on the other hand, is flexible: it can evaluate the situation at hand and modify the rules accordingly.

Furthermore, rule awareness leads to a fresh condition-namely, to the deliberate creation of occurrences designed for the purpose of bringing the operation of certain rules into play. Thus, as soon as men became intelligent, sign-using animals and hence aware of the kinds of relationships that invariably obtain between children and parents, the stage was set to imitate childishness to gain certain ends.


Social Contraversies become the medical game:

I shall try to show that, today, the notion of mental illness is used chiefly to obscure and explain away problems in personal and social relationships; and that the notion of witchcraft had been used in the same way during the declining Middle Ages. We now deny moral, personal, political, and social controversies by pretending that they are psychiatric problems: in short, by playing the medical game. During the witch hunts, people denied these controversies by pretending that they were theological problems: in short, by playing the religious game.

Now we are using medical diagnoses to remove people of responibility of misbehaviour.


Scapegoating and the law:

The law expressed high ethical ideals to which most people had no intention to adhere. Their goal became, instead, to evade the laws, to appear as if they were law-abiding, and to make sure that there were suitable scapegoats available to be caught and punished. In situations of this sort, it is the scapegoat’s social function to play the role of the person who violates, or is said to violate, the rules, is caught, and is duly punished.


Rules and Games:

Beginning at the level of the basic rules-assuming, that is, the presence of players, equipment, and so forth-it is evident that there is much more to an actual, true-to-life tennis game than could be subsumed under the basic rules. This is because there is more than one way to play tennis, while still adhering to these rules. For example, one player might aspire at winning at any cost; another at playing fairly. Each of these goals implies rules specifying, first, that in order to play tennis one must follow rules A, B, and C, and second, how one should conduct oneself while following these rules. 

The latter prescriptions constitute the rules of “metatennis.” In everyday language, the term “tennis” is used, of course, to denote all of the rules of this game. The fact that ordinary games may be played in more than one way-that is, that they contain games at different logical levels-leads to conflict whenever different types of players meet.

Looking at problems in living from this point of view, it seems apparent that much of what goes by the names of “growing up,” “becoming sophisticated,” “getting treated by psychoanalysis” (and by other methods as well) are all processes having one significant characteristic in common: the person learns that the rules of the game-and the very game itself-by which he has been playing are not necessarily the same as those used by others around him. For example, he learns that others are not interested in playing the game which he has been so avidly pursuing; or, if they are, that they prefer some modifications of the game rules.

Piaget, as we have seen, describes the evolution of children’s games and, through it, of the human moral sense, as a developmental sequence that starts with heteronomy and proceeds toward autonomy. If we rephrase this in terms of interpersonal rules or strategies, we could say that as children develop, they move from regulation, by external controls toward regulation by self-control, from coercion toward cooperation.


Why do we make Diagnoses?

For more than a century, psychiatrists have thus constructed diagnoses and pretended that they are diseases-and no one in authority challenged their deceptions. As a result, few people now realise that not only are medical diagnoses not the same as medical diseases, but that (most) psychiatric diagnoses are merely disease-sounding names for psychiatrically stigmatized patterns of behavior.

These considerations raise the question, Why do we make diagnoses? There are several reasons: 

1. scientific – to identify the organs or tissues affected and perhaps the cause of the illness; 

2. professional – to enlarge the scope, and thus the power and prestige, of a state-protected medical monopoly and the income of its practitioners; 

3. legal – to justify state-sanctioned coercive interventions outside of the criminal justice system; 

4. political-economic -to justify enacting and enforcing measures aimed at promoting public health and providing funds for research and treatment on projects classified as medical; and 

5. personal – to enlist the support of public opinion, the media, and the legal system for bestowing special privileges, and imposing special hardships, on persons diagnosed as (mentally) ill.

Lawmakers do not discover prohibited rules of conduct, called “crimes”; they create them, by forbidding conduct deemed undesirable. Killing is not a crime; only unlawful killing is, for example, murder. 

Similarly, psychiatrists do not discover (mis)behaviors called “mental diseases”; they create them. Killing is not a mental disease; only killing defined as due to mental illness is; schizophrenia thus “causes” heterohomicide (not called “murder”) and bipolar illness “causes” auto-homicide (called “suicide”). Psychiatrists who create diagnoses of mental diseases by giving disease-names to (mis)conduct function as legislators, not as scientists.


Lying as a mutual game:

Lying, as in the marriage game described earlier, serves this function of relationship management well, especially if it is mutual. This value of lying derives not so much from its direct, communicative meanings as it does from its indirect, metacommunicative ones. By telling a lie, the liar in effect informs his partner that he fears and depends on him and wishes to please him: this reassures the recipient of the lie that he has some control over the liar and therefore need not fear losing him.

At the same time, by accepting the lie without challenging it, the person lied to informs the liar that he, too, needs the relationship and wants to preserve it. In this way, each participant exchanges truth for control, dignity for security. Marriages and other “intimate” human relationships often endure on this basis.


Ganser Syndrome and Feigning madness:

If the Ganser “patient” impersonates what he thinks is the behavior of the mentally sick person-to plead irresponsibility and avoid punishment-how does his behavior differ from that of a person who cheats on his income tax return? One feigns insanity, the other poverty. Nevertheless, psychiatrists continue to view this sort of behavior as a manifestation of illness and to speculate about its nature, causes, and cures.

A type of impersonation of special interest and importance to psychiatrists is the so-called Ganser syndrome, which, simply put, is the strategic impersonation of madness by a prisoner.

When an actor has been typecast, he has succeeded in making his assumed role so believable and accepted that people will think he no longer “acts” but “plays himself.” Similarly, if a person diagnosed as suffering from malingering, hysteria, or the Ganser syndrome has been accepted as truly ill, as a sick patient (even if the sickness is mental sickness), then he too has succeeded in making his assumed role so believable that people will think he no longer “acts” but “is sick.”


The material and the Experiential:

Science is synonymous with materialism, with the study of facts, with how things are. 

It is axiomatic that there can be no scientific investigation or scientific theory of nonmaterial “entities” and moral concepts, such as angel and devil, spirit and mind, virtue and vice. To say that is not the same as saying that those things “do not exist.” They “exist,” but they are not a part of the material world. 

Their study entails inquiry into and reasoning about not facts but beliefs (explanations), experiences (how things feel), values (good and bad), and social policies (what actions in what circumstances ought to be considered licit and illicit).


The Gold standard of illness:

The gold standard, perhaps even more than a parliamentary system or federalism and a system of checks and balances-symbolized that the powers of the government were not only strictly limited, but that the state respected that limitation.

The difference between the lesion standard of disease and the fiat standard of (mental) illness is similar to the difference between the gold monetary standard and the fiat paper-money standard. 

The Virchowian standard is fixed by biological-physical criteria, limiting the medical system from arbitrarily expanding its scope and hence its power. Neither doctors, patients, politicians, nor any other interested parties can create diseases by manipulating the language. New diseases cannot be invented; they have to be discovered. In contrast, the psychopathological standard of disease is flexible, letting medical and political authorities and popular opinion define, ad hoc, what should or should not count as a disease; they do so by attaching diagnostic labels to unwanted behaviors.


The Rise of Pharmacracy:

The old quacks peddled fake cures to treat real diseases.

The new quacks peddle fake diseases to justify chemical pacification and medical coercion. The old quacks were politically harmless: they could harm individuals only with those individuals’ consent. The new quacks are a serious threat to individual liberty and personal responsibility: they are agents of the therapeutic state who can and do harm individuals both with and without those individuals’ consent.

Theocracy is the alliance of religion with the state. Pharmacracy is the alliance of medicine with the state.