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Is Mental Illness a Disease? by Thomas S. Szasz

The following essay is reproduced here by permission of Sheldon Richman, Editor, Ideas on Liberty, [formerly The Freeman].
Ideas on Liberty is published by The Foundation for Economic Education, Irvington-on-Hudson, NY 10533.
Szasz, T. Is mental illness a disease?. The Freeman, 49: 38-39 (November), 1999.

IS MENTAL ILLNESS A DISEASE?

Thomas S. Szasz, M.D.

"You can know the name of a bird in all the languages of the world, but when you're finished, you'll know absolutely nothing whatever about the bird. ... So let's look at the bird and see what it's doing -- that's what counts. I learned very early the difference between knowing the name of something and knowing something."
-- Richard Feynman

Tipper Gore says that "One of the most widely believed and most damaging myths is that mental illness is not a physical disease. Nothing could be further from the truth.'' Similarly, the National Alliance for the Mentally Ill (NAMI), the most influential mental health lobby in the nation, states: "Mental diseases are brain disorders." Are these assertions true?

Illness and Mental Illness

I say that "mental illnesses" are not diseases. Why? Because -- although medical and legal authorities call them "diseases" and treat them as if they were diseases -- mental illnesses simply do not meet the established scientific criterion for disease, namely, a derangement in the structure or function of cells, tissues and organs. Mental illnesses can be neither detected nor diagnosed by examining cells, tissues or organs. Instead, they are identified by certain behaviors, and what concerns Mrs. Gore, NAMI, and others is not the theoretical question of what counts as a disease, but the practical problems posed by these behaviors. In fact, whether a person who has a disease feels well or ill, accepts or denies that he is ill, consults a doctor or not, benefits from or is harmed by drugs are all issues important to the practice of medicine but not to the definition of disease. Likewise, whether a person obeys or breaks the law is irrelevant to the definition of disease. Disease is a physical concept and verifiable phenomenon, the name scientists give to an organism's biological condition accounting for abnormalities in cell, tissue, and organ structure and function. Accordingly, gastroenterologists study the abnormal states of the digestive system -- not gluttony. Urologists study the abnormal states of the genito-urinary system -- not prostitution. Neurologists study the abnormal states of the brain and nervous system -- not murder or suicide.

What do psychiatrists study? Do they, as Nancy Andreasen, professor of psychiatry at the University of Iowa, puts it , study "the brain rather than the mind, ... molecules and chemical transmitters rather than drives and fantasies..."? Or do they, as Shakespeare put it, study the persons who suffer "the slings and arrows of outrageous fortune"? This is the crucial distinction masked by equating brain with mind. If "mental illness" means brain disease, then it is not a disease of the mind and psychiatry would be absorbed into neurology and disappear. But this is patently not the case. Psychiatrists regularly occupy themselves with personal conduct of social interest, such as homosexuality, aggression, racism, suicide, and murder.

Expanding the Concept of Disease

It is an elementary principle of logic that one cannot prove a negative. One cannot prove the nonexistence of mental illnesses, just as one cannot prove the nonexistence of ghosts. One can only point out that a belief in mental illness as a disease of the brain is a negation of the distinction between persons as social beings and bodies as physical objects, in the same way that a belief in ghosts is the negation of the distinction between life as activity and death as the cessation of it. When we negate the distinction between social beings and physical objects the concept of disease ceases to be limited to the dysfunction of cells, tissues, and organs and is expanded to include "dysfunctional" conduct, especially behavior people in authority find troublesome. Interestingly, the pioneers of psychiatry understood this distinction and acknowledged that the term "mental illness" was a figure of speech. In 1845, the Viennese psychiatrist Ernst von Feuchtersleben wrote: "The maladies of the spirit (Geist) ... can be called diseases of the mind only per analogiam. They come not within the jurisdiction of the physician, but that of the teacher or clergyman, who again are called physicians of the mind only per analogiam." And in his classic, Lectures on Clinical Psychiatry (1901), Emil Kraepelin (1856-1927) -- who created the first modern classification of mental diseases -- acknowledged: "It is true that, in the strictest terms, we cannot speak of the mind as becoming diseased." In short, a sick mind, like a sick economy, is a metaphor.

Mind is not Brain

Treating the metaphor as the thing itself -? the metaphorization of disease, in our case -- has led to the confusion of production with product, person with body, and mind with brain. Note that unlike the term "brain," the term "mind" implies agency, intentionality, and motivation. Accordingly, behavior per se that may result in disease is often categorized as a mental disease, but is never categorized as a medical disease. For example, excessive drinking is considered a mental disease, not a gastrointenstinal disease -- though cirrhosis of the liver is. A competent speaker of English may thus assert that schizophrenia has caused a person to kill an innocent bystander and excuses him of his deed, but he would never say that diabetes has either caused such lawless behavior or excuses it. Herein lies one of the most important philosophical?political consequences of the concept of mental illness: it removes, with one fell swoop, motivation from action, encompasses it within illness and thus destroys the very possibility of separating disease from non?disease, since it offers the possibility that any intentionality or motivation is a potential "disease."

In 1924, the great Eugen Bleuler, the inventor of schizophrenia, declared: "Those who simulate insanity with some cleverness are nearly all psychopaths and some are actually insane." The idea that pretending to be ill is, itself, an illness became socially acceptable during World War II and has since become psychiatric dogma. In 1951, Kurt Eissler, founder and long-time director of the Freud Archives, framed the doctrine thus: "It can be rightly claimed that malingering is always the sign of a disease..." The current edition of the American Psychiatric Association's authoritative Diagnostic and Statistical Manual of Mental Disorders defines "Factitious Disorders" as "characterized by physical or psychological symptoms that are intentionally produced or feigned in order to assume the sick role." Earlier editions of this same Manual listed homosexuality as a disease, then delisted it. The current edition added new diseases, such as nicotine dependence. In short, medical diseases are discovered and then given a name, whereas mental diseases are invented and then given a name.

Behavior is not -- and cannot be -- a disease, except in psychiatry. Controlling behavior, with or without a person's consent is not -- and cannot be -- a treatment, except in psychiatry. And faking illness is not -? and cannot be -? an illness, except in psychiatry.

Paradoxically, the intellectual bankruptcy of the idea of mental illness is the pillar on which modern psychiatry rests is. Credo quia absurdum est.

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Thomas Szasz is the author of The Myth of Mental Illness. He wishes to thank Alice Michtom, M.D. for help in the preparation of this column.