Wednesday, 28 March 2018

Critique of Szasz The Myth of Mental Illness

This mini-essay will discuss the section “MENTAL ILLNESS AS A SIGN OF BRAIN DISEASE” only.
The paper can be found at
(also at bottom of page)

I will argue that Szasz’s argument ignores that other models exist that do not assume mental illness is necessarily brain disease, that his arguments about differences between physical illness and mental illness are not accurate and he does not make the case that mental symptoms are epistemological errors.

Szasz begins the section by acknowledging that brain diseases can cause “disorders of thinking and behaviour” and correctly states that some believe that mental illnesses are all due to brain diseases. (This somatic school of thought was epitomised by Griesinger for whom all mental illnesses are brain diseases.) He then states “many” doctors (psychiatrists and physicians – perhaps meaning general and family medicine doctors) and scientists agree with this assertion. This is imprecise – does he mean almost all doctors and scientists or a bare majority or substantial minority? And which geographical grouping of doctors/ scientists – his colleagues, the US, the World? If Szasz is trying to prove mental illness is a myth he needs to establish this is the case for all conceptions of mental illness and if this somatic school is not a belief held by a majority of doctors/ scientists he cannot even argue he has proven mental illness is a myth spread by most doctors and scientists. Szasz also omits to mention the influential Jaspers whose “General Psychopathology” textbook was opposed to viewing all mental illness as brain disease. Depending on how influential Jaspers and those with similar viewpoints were depending on location and time, some doctors/ scientists may not hold the view that all mental illness is caused by brain disease. Since this model is ignored by Szasz he can only at best assert that he has demonstrated that mental illness is always brain disease is a myth as he has ignored other models.

Szasz states that the somatic school “implies” that “all problems in living” as an alternative to term for mental illness must be caused by changes in physical processes (amenable to scientific discovery) and not due to intrapsychic or social conflicts. He does not make the case that a broad conception of “problems in living” is believed by the somatic school is due to brain illness. What is encompassed by this broad term? Is it restricted to mental illness and what examples of mental illness is it restricted to? If it applies to mental illness – however so defined – then Szasz could make this argument for the somatic school - whilst ignoring mental illness models such as those of Jaspers and the biopsychosocial model. Biomedical models do accept the causative role of social factors via biological intermediaries. Szasz also does not state how and why the somatic school separates problems caused by intrapsychic/ social factors from mental illness.  Finally, “problems in living” seems a deeply inadequate descriptor for severe forms of mental illness for example someone starving themselves close to death for fear of fatness.

Szasz states that mental illness is viewed as identical to bodily disease but we know illness (of any type) does not correspond exactly to disease. Many medical illnesses – such as functional medical conditions -  do not have proven disease processes and some clear biological abnormalities are not regarded as illnesses such as benign glycosuria. Szasz then uses the term “mental and bodily diseases” so it is unclear if he is referring to all mental illness or just mental illness with or without proven brain disease.

Szasz next compares CNS symptoms to a rash or fracture but this is a category error- a rash would be more clearly categorised as a sign observed on examination and a fracture categorised as an investigation finding or diagnosis. Szasz claims CNS symptoms could not be “emotion or complex…behaviour” yet counter-examples exist – epilepsy or Alzheimer’s can cause these symptoms. Szasz claims beliefs cannot be a product of disease despite counter-examples including some he mentioned earlier associated with unusual beliefs such as GPI syphilis and delirium – even if we do not understand the mechanism of how these unusual beliefs are formed they seem likely as a product of these diseases. Even if we exclude examples or proven brain disease as not mental illness the precedent has been set and given our imperfect knowledge especially of mind/brain and the possibility of discovery in the future of disease processes the most that can be said is in “for mental illness in the absence of proven brain disease there are no established disease processes causing beliefs”.

Szasz asserts mental symptoms are an epistemological error by claiming mental symptoms are different from physical symptoms specifically pain but this is a category error – pain is at least in part a psychological experience involving the mind so is at least partly also a mental symptom and arguably since all symptoms are communications by patients, minds/brains are always involved. That we lack the ability to measure adequately physical counterparts of mental activity now does not mean we will not be able to in future – in the past we could not measure many bodily activities that are possible now.

Szasz asserts mental health symptoms are classified using psychosocial comparisons/ judgements but physical symptoms and signs are also compared to the doctor’s judgements e.g. of what heart sounds should sound like. Psychosocial factors including culture also affect what are thought of physical symptom expression e.g. pain. Given the importance of psychosocial factors affecting expression of mental outputs of speech and behaviour it is a strength, not a weakness,  that these are taken account of e.g. before a belief is classified as delusional it must be outside the patient’s cultural norms.
Szasz only addresses one model of mental illness – the somatic school – and by failing to address other models cannot prove mental illness is a myth. His arguments against the somatic school are weakened by counter-examples and category errors and false distinctions between physical and mental illness.

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