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Is Mental Illness a Myth? -- Introduction

Szasz’s entire oeuvre can be considered to revolve around two premises. The first is that mental illness does not exist; the second that mental illness is a socially damaging concept that leads to stigmatization, dehumanization, and the application of all sorts of coercions. In this chapter I will comment on the first premise from a theoretical and conceptual point of view. In chapter VI some of the consequences of that conceptualization will be considered from a practical point of view. The second premise insofar as involuntary intervention and coercive measures are concerned, will be discussed in Chapter VII.

Szasz’s opinion that there is no such thing as mental illness was discussed in Chapter I, 4.2. He reaches this conclusion by defining illness as a process that affects the body in a way that makes the physical aberrations that ensue demonstrable by physicochemical methods. I will call this the biomedical concept of illness, in which I distinguish between two variations:
  1. The materialistic biomedical concept of illness. In this concept man is a physicochemical machine. The methods of investigation are physical and chemical. Disease is present only when bodily aberration can be demonstrated by these methods.
  2. The biomedical concept of illness in a broader sense. Man is not seen only as a physicochemical machine, but also as a biological entity, involving biology in addition to physics and chemistry.
It is not entirely clear which of these two variations is chosen by Szasz as his premise. Usually he mentions only physics and chemistry as prime sciences which implies that he chooses a materialistic biomedical concept of illness. Occasionally, however, his descriptions include biological references. Therefore I will consider the concept of illness used by Szasz as biomedical unless there is a special reason to add the word materialistic.

It is not surprising that using this premise Szasz arrives at the proposition that the majority of psychiatric disorders cannot involve disease. To date no organic aberrations have been demonstrated for many psychiatric disorders. The question is, what are the arguments Szasz uses for the biomedical concept of illness? This position is not obvious. The literature on this subject contains several different concepts. Not only is there no consensus but ideas on this subject vary greatly. That was already the case before Szasz’s publications kindled animated discussion about this subject.

Szasz’s most important arguments for his choice can be summarized as follows:
  1. Health can be defined in anatomical and physiological terms, illness in physicochemical terms. Thus the definition of disease is objective, value-free, ontologically anchored, valid in all places and at all times.
  2. The development and differentiation in the sciences, and the organization and structure of our knowledge and insight, are thus that only the biomedical concept of illness meets the requirements of scientific and methodological purity.
  3. Man’s ideas about disease have always throughout history been linked to the presentation of organic aberrations.
So Szasz’s first reason is the value-free nature of the biomedical concept of illness. The tenability of this position is debatable. Even though physicochemical aberrations are objective findings which can be described as facts or processes, not these aberrations in themselves are of primary importance but their significance in the context of a human being experiencing suffering and disability, and feeling menaced. In other words, from all possible formal aberrations, only those that are significant in connection with illness are selected. Abnormalities that are not connected to illness are not considered. The word disorder, as indeed the word aberration, in itself implies a value judgment of that which can be objectively determined. In this sense illness – and health – is not only an explicatory concept but also one that imparts significance. Probably this implicit value judgment does not attract attention because of the fairly general consensus regarding these values. It goes without saying. Pain, suffering, and the specter of death are so universally experienced as negative that these values assume the nature of universal values. The values involved in psychiatric disorders are more controversial and thus more obvious.

Szasz’ second argument will be discussed further in 2.4. The third was discussed in Chapter II, 3.1.

Significantly, in his chosen definition as well as in his argumentation, Szasz, as a matter of principle, approaches and defines the concept of illness from the viewpoint of the professional, the man of science, the physician. He does not explain this choice even though it is for him a rather peculiar choice to make for two reasons. The first is that in his book Pain and Pleasure he sides against the professional’s viewpoint in favor of that of the patient (p. 23). Secondly, for Szasz, human liberty and dignity are top priority even when a person is ill. Choosing the professional’s viewpoint is risky considering the ethical and moral context in which medicine develops and justifies its existence. Professionals are mainly interested in the factual aspects of disease, taking the ethical context for granted.

The person who is ill, suffering, and seeking assistance is the center of every form of medicine, whether it is defined as a science, helping profession, or social institution. Therefore being ill is the most obvious starting point for developing ideas about illness. It is up to medical science to design concepts that produce workable strategies by conceptualizing the problems of ill people in a certain way, the more pragmatic the better. However, this conceptualization, this redefinition, risks emphasizing certain elements more and others less, or even omitting them altogether. By using the professional concept as his point of departure Szasz hazards not or insufficiently recognizing these shifts of emphasis. Below I will argue that indeed he did not escape this hazard.

As in my opinion Szasz has chosen an unfortunate point of departure for his ideas on illness and mental illness, this and the following chapters will not be a direct commentary on his views. First I will detail my own ideas on this subject. Then I will compare my considerations and conclusions to Szasz’s. I will describe the phenomenon of “being ill” more closely as a descriptive, and in combination with the concept of health, classifying concept (2.1). Then illness will be described as a conceptualization, a theory about being ill, and thus an explicatory concept (2.2). After that the relationship between disease and organic aberration will be discussed (2.3). Next I will discuss the concept of mental illness (2.4) and finally, the connection between mental illness and organic aberration (2.5). My intention is to provide a general view of the meaning of the concept of illness, particularly in psychiatry.

Precisely by starting with being ill and with the ill person rather than the professional, the concept of being ill is revealed to have two poles: it is a value concept and an ontological concept. It is a value concept because a negative value judgment is always involved in illness. Being ill is ominous, frightening, disabling, etc. It is an ontological concept because it involves changes in reality, be that in material reality or be it in the reality of events, behaviors, and experiences.

Due to the enormous expansion of somatic medicine illness as an ontological concept has increasingly attracted attention. It is generally viewed as an objectively given fact or event. But this representation is incorrect. Demonstrated bodily aberrations are objective facts and processes. Illness is an abstraction of that, a concept which imparts meaning, a theory about the facts. The facts have been selected for their significance in connection with being ill. Viewed from a purely utilitarian angle it could for instance be argued that an infection proceeds most “advantageously” when the “participants” – the host who is ill and the bacteria causing the illness – fair well. At the same time this view is nonsensical because in medicine the point is that the host recovers and the pathogenic bacteria are killed. The value judgment remains implicit and goes without saying.

My argumentation will lead to choosing a different concept of illness than the Szaszian one, namely the biopsychosocial concept of illness. This integrated concept of illness accommodates both the value element and psychical and social factors relevant to illness in addition to physical ones. Szasz’s point of departure is the professional; mine is the ill person. From these two different vantage points different concepts of illness are derived.

Although medical science is based on the concept of illness as a theory about being ill, the value of every concept of illness is determined by its utility. That means that when evaluating concepts for medicine, and for psychiatry in particular, a kind of ledger of gains and losses should be compiled. In addition to considerations of the conceptualization itself, considerations about its implications should be included. The second part of this chapter will be about these. I will discuss the connection between the concept of illness and views about the human condition (“la condition humaine”) (3.1), the competition among different possible explanations for being ill (3.2), validation in medicine and in psychiatry in particular (3.3), and finally the significance of symptoms and disorders in psychiatry as well as in general medicine (3.4). It will become obvious that in a biomedical concept of illness the principle of causality applies to organic aberrations. In a biopsychosocial concept of illness for which no organic aberration can be demonstrated, loss of freedom and autonomy determine being ill. In the next chapter the balance of loss and gain will be expanded by discussing the roles of the physician, the patient, and their relationship, as well as the social institutions of medicine and psychiatry.

Finally, two comments: The first is that in viewing the problem of being ill and illness from the ill person’s perspective, the environment’s view cannot be ignored, and thus should be included in the argumentation. The second is that the expression “medical model” – so often used in debates about the utility and applicability of the concept of illness in psychiatry – has countless unexplained meanings, as Begelman, Bremer, Leenen, Fischer, and others posited, and will therefore be avoided as much as possible.
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