Almost 50 years have passed since I first proposed that the concept of mental illness and the profession of psychiatry rest on fictitious foundations. "Mental illnesses" (henceforth without scare quotes) are behaviors, not diseases. Psychiatry is religion, rhetoric, and repression, not medicine. The basis for understanding mental illness lies in semeiotics (the study of signs and symbols). The basis for understanding psychiatric practices lies in ethics, philosophy, law, and criminology.

Not surprisingly, psychiatrists and the public have not been eager to relinquish a system of ideas and interventions, sanctioned by tradition as necessary and proper, and by "medical science" as true. I was prepared for this. In The Subjection of Women (1869), John Stuart Mill wisely observed:

"So long as an opinion is strongly rooted in the feelings ... the worse it fares in argumentative contest, the more persuaded its adherents are that their feeling must have some deeper ground, which the arguments do not reach; and while the feeling remains, it is always throwing up fresh intrenchments of argument to repair any breach in the old. ... the understanding of the majority of mankind would need to be much better cultivated than has ever yet been the case, before they can be asked to place such reliance in their own power of estimating arguments as to give up practical principles in which they have been born and bred and which are the basis of much existing order of the world, at the first argumentative attack which they are not capable of logically resisting."

Exactly such has been the case with my effort to expose the myth of mental illness and abolish psychiatric coercions and excuses. Instead of yielding to the arguments supporting this view, psychiatrists and their adherents -- relatives of the mentally ill, politicians, pundits, and the public -- have replaced what had been a shaky house of random cards (the unstable mixture of the state hospital and psychoanalysis) with a solid house of pure aces (the stable mixture of biological psychiatry and neuropharmacology).

Until well past the end of World War II, the model mental illness was hysteria, that is, a person complaining of pain or paralysis without an "organic basis" for his, more often her, "disability." I showed that hysteria was not a disease, but a type of nonverbal communication. Psychiatrists adopted this view as if it had always been their opinion, deleted hysteria from their official list of mental diseases, and replaced it with schizophrenia as the "sacred symbol" of the new "biological psychiatry." They then declared that certain drugs were effective "treatments" for this disease and "discharged" most of the patients from state mental hospitals. Now, deinstitutionalization and psychiatric miracle drugs make up the building blocks of the new psychiatric house of aces.

The masses of mental patients are, and have always been, poor and imprisoned, that is confined against their will. Psychiatrists deny, and have always denied this. They maintain (as they must, to justify their practices) that "mental illness is like any other illness" and that mental hospitals are like medical hospitals, to which patients are "admitted" and from which, after successful treatment, they are "discharged."

So, after 300 years of "psychiatric reforms" -- and 100 years of "scientific advances," crowned with a Nobel Prize for the inventor of lobotomy -- where are we?

The Mental Hospital as Prison

The Economist (2004) reports: "When many of the country's mental-health hospitals were shut down in the 1960s, the idea was that patients would be looked after by local health systems. Instead ... many have ended up in jail. ... The number of mentally ill in Santa Clara County's jails jumped by 300 percent in the four years after a nearby California state hospital closed." Many medical hospitals have also shut down but medical patients have not ended up in prisons. A widely reported study by Human Rights Watch concludes that "jails and prisons have become the nation's default mental health system," that one in five of the 2.1 million Americans in jail and prison are seriously mentally ill, "far outnumbering the number of mentally ill who are in mental hospitals." In 1999, the Justice Department estimated that 16 percent of state and federal prisoners and inmates in jails were suffering from mental illness. "These illnesses included schizophrenia, manic depression (or bipolar disorder) and major depression." There are no objective, biological tests for these illnesses. Hence, how many prisoners, if any, "have" these diseases is pure guess.

Persons who know that mental illnesses exist and are real, and that the mentally ill are or may be dangerous to themselves and others, are not interested in asking questions about psychiatric principles and practices. They simply want better "services" for the mentally ill. For persons willing to entertain doubts about the foundations of psychiatry, I offer the following brief comments.

1. The authorities who lament the presence of many mentally ill persons in prisons do not claim that the prisoners are innocent of lawbreaking. If the incarcerated individuals are, in fact, guilty of the crimes with which they have been charged, it seems reasonable that they are in prisons rather than hospitals'; if they are mentally ill, they ought to be treated for their illness in the prison. Prisoners who have medical illnesses -- diabetes, hypertension, epilepsy -- receive treatment for them in prison. The lamenters, after all, insist that "mental illnesses are like other illnesses."

2. Most of the hundreds of thousands of mental patients who, prior to deinstitutionalization, lived in mental hospitals, were housed there because they were, in effect, homeless: poor, rejected by their relatives, they were "committed" as "dangerous to themselves and others." In plain English, they were imprisoned, but their prisons were called a "hospitals," and they were called "patients" instead of "inmates."

3. Psychiatrists do not acknowledge that it is deinstitutionalization, their latest "reform," that led to the rehousing of mental patients from asylums to jails. Instead, they advocate the large-scale drugging of mental patients as a method of crime-prevention -- as if crime were caused by mental illness and if all mental patients were properly "medicated," crime would disappear from the face of the earth.

4. Because mental illness is a fiction there can be no treatment for it. In the golden era of hospital psychiatry, prior to World War II, mental illness was considered a real but untreatable disease: most mental patients were left unmolested by doctors. Looking back, we call the hospitals "snake pits" and the patient management "neglect." Today, in the golden era of biological psychiatry, mental illness is considered a real and treatable disease: mental patients are forcibly drugged, in prisons, prison-like facilities, and while on psychiatric parole ("outpatient commitment"). Future observers will decide what names to attach to the now-fashionable psychiatric delusion and brutality.

Thomas Szasz (tszasz@aol.com) is professor of psychiatry emeritus at SUNY Upstate Medical University in Syracuse. His latest works are Words to the Wise: A Medical-Philosophical Dictionary (January 2004) and Faith in Freedom: Libertarian Principles and Psychiatric Practices (May 2004), both published by Transaction.

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