MENTAL ILLNESS AS A NAME FOR PROBLEMS IN LIVING
The term “mental illness” is widely used to describe something which is very different than a disease of the brain. Many people today take it· for granted that living is an arduous process. Its hardship for modern man, moreover, derives not so much from a struggle for biological survival as from the stresses and strains inherent in the social intercourse of complex human personalities. In this context, the notion of mental illness is used to identify or describe some feature of an individual’s so-called personality. Mental illness — as a deformity of the personality, so to speak — is then regarded as the cause of the human disharmony. It is implicit in this view that social intercourse between people is regarded as something inherently harmonious, its disturbance being due solely to the presence of “mental illness” in many people. This is obviously fallacious reasoning, for it makes the abstraction “mental illness” into a cause, even though this abstraction was created in the first place to serve only as a shorthand expression for certain types of human behavior. It now becomes necessary to ask: “What hinds of behavior are regarded as indicative of mental illness, and by whom?”
The concept of illness, whether bodily or mental, implies deviation from some clearly defined norm. In the case of physical illness, the norm is the structural and functional integrity of the human body. Thus, although the desirability of physical health, as such, is an ethical value, what health is can be stated in anatomical and physiological terms. What is the norm deviation from which is regarded as mental illness? This question cannot be easily answered. But whatever this norm might be, we can be certain of only one thing: namely, that it is a norm that must be stated in terms of psycho-social, ethical, and legal concepts. For example, notions such as “excessive repression” or “acting out an unconscious impulse” illustrate the use of psychological concepts for judging (so-called) mental health and illness. The idea that chronic hostility, vengefulness, or divorce are indicative of mental illness would be illustrations of the use of ethical norms (that is, the desirability of love, kindness, and a stable marriage relationship). Finally, the widespread psychiatric opinion that only a mentally ill person would commit homicide illustrates the use of a legal concept as a norm of mental health. The norm from which deviation is measured whenever one speaks of a mental illness is a psycho-social and ethical one. Yet, the remedy is sought in terms of medical measures which — it is hoped and assumed — are free from wide differences of ethical value. The definition of the disorder and the terms in which its remedy are sought are therefore at serious odds with one another. The practical significance of this covert conflict between the alleged nature of the defect and the remedy can hardly be exaggerated.
Having identified the norms used to measure [p. 115] deviations in cases of mental illness, we will now turn to the question: “Who defines the norms and hence the deviation?” Two basic answers may be offered: (a) It may be the person himself (that is, the patient) who decides that he deviates from a norm. For example, an artist may believe that he suffers from a work inhibition; and he may implement this conclusion by seeking help for himself from a psychotherapist. (b) It may be someone other than the patient who decides that the latter is deviant (for example, relatives, physicians, legal authorities, society generally, etc.). In such a case a psychiatrist may be hired by others to do something to the patient in order to correct the deviation.
These considerations underscore the importance of asking the question “Whose agent is the psychiatrist?” and of giving a candid answer to it (Szasz, 1956, 1958). The psychiatrist (psychologist or nonmedical psychotherapist), it now develops, may be the agent of the patient, of the relatives, of the school, of the military services, of a business organization, of a court of law, and so forth. In speaking of the psychiatrist as the agent of these persons or organizations, it is not implied that his values concerning norms, or his ideas and aims concerning the proper nature of remedial action, need to coincide exactly with those of his employer. For example, a patient in individual psychotherapy may believe that his salvation lies in a new marriage; his psychotherapist need not share this hypothesis. As the patient’s agent, however, he must abstain from bringing social or legal force to bear on the patient which would prevent him from putting his beliefs into action. If his contract is with the patient, the psychiatrist (psychotherapist) may disagree with him or stop his treatment; but he cannot engage others to obstruct the patient’s aspirations. Similarly, if a psychiatrist is engaged by a court to determine the sanity of a criminal, he need not fully share the legal authorities’ values and intentions in regard to the criminal and the means available for dealing with him. But the psychiatrist is expressly barred from stating, for example, that it is not the criminal who is “insane” but the men who wrote the law on the basis of which the very actions that are being judged are regarded as “criminal.” Such an opinion could be voiced, of course, but not in a courtroom, and not by a psychiatrist who makes it his practice to assist the court in performing its daily work.
To recapitulate: In actual contemporary social usage, the finding of a mental illness is made by establishing a deviance in behavior from certain psychosocial, ethical, or legal norms. The judgment may be made, as in medicine, by the patient, the physician (psychiatrist), or others. Remedial action, finally, tends to be sought in a therapeutic — or covertly medical — framework, thus creating a situation in which psychosocial, ethical, and/or legal deviations are claimed to be correctible by (so-called) medical action. Since medical action is designed to correct only medical deviations, it seems logically absurd to expect that it will help solve problems whose very existence had been defined and established on nonmedical grounds. I think that these considerations may be fruitfully applied to the present use of tranquilizers and, more generally, to what might be expected of drugs of whatever type in regard to the amelioration or solution of problems in human living.