Thomas Szasz & the diagnosis of abnormality as a moral or social judgement in the guise of scientific statement.
In many cases psychiatry can be seen as providing treatment for disorders previously undertaken by rural ‘wise-folk’1 the majority of whom were little more than eccentric older women (the archetypal ‘witch’) or nubile young maidens.2 Women represent four per cent of the prison population but form one fifth of patients in special hospitals and are one and a half times more likely than men to be diagnosed as suffering from psychopathic disorder. “This diagnosis can be seen to be alarmingly flexible when applied to women and allows subjective values to play a central role”.3
The comparison is not so far fetched as it might appear. Arguably the position of those who are mentally ill is no less invidious than the unfortunate victims of mediaeval witch-hunts. Jules Michelet suggests many alleged ‘witches’ were midwives and lay physicians whose knowledge of painkillers, abortion and herbal or ‘faith healing’ threatened the Church’s anti-scientific, anti-sexual doctrines.4 Thomas Szasz writes; “the witch, like the involuntary mental patient, is cast into a degraded and deviant role against her will; is subjected to certain diagnostic procedures to establish whether or not she is a witch; finally is deprived of liberty and often of life, ostensibly for her own benefit.”5
Ancient and mediaeval methods of treating psychic disorder are not so far removed from modern psychiatric treatments. Trepanning was believed to release demons thought to cause headaches and proved to be a highly effective treatment albeit for a usually self-limiting condition. Isolation, hydrotherapy, physical abuse and shock therapy first practised by witch-hunters remain in the armoury of psychiatric techniques. Chemical tranquillisers, anti-depressants, Electro-Convulsive Therapy (ECT) and modern psycho-surgical intervention effectively supplement the physical restraints of nineteenth century asylums. The difference between trepanning and pre-frontal lobotomy is one of degree not of kind.
Since the decline of witchcraft and demonology an alternative mode of representing deviant behaviour has been a disease model of mental illness based upon an empirical paradigm. This model has been subject to widespread criticism notably by Thomas Szasz (1960, 1976, 1987, 1991, 1993), Erving Goffman (1961), Thomas Scheff (1966), R. D. Laing (1967) and Torrey (1974). Scheff states dogmatically that eliminating the category of mental illness reduces or ends the suffering of those labelled. This is surely questionable! Siegler and Osmond (1976) note there is no instance of an illness disappearing by abolishing the category. Experience of the medical model indicates that better understanding and early identification results in gradual lifting of the stigma attached to illness. To define a disease as a ‘problem in living’ (Szasz) does not make the disease easier to bear though re-labelling may make it more acceptable.
Siegler and Osmond criticise Scheff’s (1966) belief that by ignoring the symptoms of mental illness it will go away, by stating that for most sufferers the illness is neither benign nor self-limiting even though ‘some schizophrenics have transitory perceptual anomalies.’6 They suggest by identifying the mentally ill as victims of a social rather than medical problem makes it easy to criticise social and political institutions, the family in particular, for producing abnormality. Siegler and Osmond argue that proponents of a non-medical model of madness should shoulder responsibility for consequences if mistaken. They rightly suggest responsibility should be proportionate to the “extent of the changes imposed by any model”.7 The suggestion that more damage would be caused by describing mental illness in terms of a situational or semantic context compares with wrongful diagnosis or being (mis-) labelled (and stigmatised) as mentally ill. The consequences are more far-reaching for psychiatry than for a ‘reconstruction’ of outmoded concepts of mental illness8. Psychiatry also needs to admit of the same obligation should it be mistaken.
Anthony Clare (1976) highlights the danger of indiscriminate labelling. Applying value-laden terms to common, minor, problems of limited duration misleads and mitigates against any trend towards a more tolerant and less superstitious attitude. Chronic mental illness accounts for a relatively small proportion, perhaps three to five per cent, of the total psychiatric illness in the community. The implication of this has perhaps been explored most fully by Laing though his contention that those who are ‘mad’ differ from the rest of us only in degree is not without precedent. John Connoly, a nineteenth century psychiatrist, criticised those who attempted to find a definable boundary between sanity and insanity. There may be no definable mutual exclusiveness between the two but a continuum of being more or less sane, stable or unstable, most of us tottering in between the two. The contention of critics like Szasz, Laing, Goffman, Scheff, Torrey, Bentall and others that the mentally ill differ from the rest of us in no real degree, that we are all vulnerable depending upon circumstances is not the issue. The real issue and the central problem is a semantic one. Labelling of and attitude to the mentally ill is based upon stereotyped (usually nineteenth century) images of madness which props up a discontinuous attitude of ‘us’ and ‘them’.
The cause(s) of mental illness are not fully understood, there is confusion about relevant criteria for classification.9 A ‘grey-area’ of dissent and lack of consensus exists among clinicians as to precise diagnosis. Disease is a product of cause(s) not a ’cause in itself’. It is a fallacy to reify disease as cause (Szasz 1961, 1976, 1991, Scadding 1990, 1992). Scadding (1990) states “Uncritical reification of diseases as causes is implicit in colloquial usage, and constant vigilance is required to exclude it from medical discourse.”10 Furthermore, for individuals “whose condition cannot be related to specifiable physical disorders or causal agents, it is especially important to avoid the danger of reifying abstract concepts, whether they be called diseases, disorders, syndromes or anything else, as causes.”11 Such concepts may be a hindrance to clear communication.
Comparing schizophrenia research with the quest for the elusive mythical unicorn, after Salzinger (1973), Sarbin and Mancuso (1980) approach the dichotomy of medical diagnosis or moral verdict through analysis of root metaphor. They provide a formidable argument for the need to be aware of the context and consequences of the creation of descriptive and explanatory metaphor used by mental health professionals. The origin of the metaphor is located historically within the context of social milieu. Going beyond simple historical analysis they provide a systematic analysis of contemporary research. The ineluctable conclusion is that schizophrenia, like the mystical unicorn, is a myth. Previously Szasz has described schizophrenia as a symbol sacred to psychiatry (Szasz, 1976). Such myths generate “actions designed to strengthen the beliefs and actions that give it force”.12 Science attempts to locate a presumed empirical basis of the myth – the search for a convincing causal factor has been inconclusive and mainly unsuccessful. Critics quote the massive amount of research as evidence of the inability to firmly pin down any empirical basis. The disease metaphor, they argue, is not only wrong but deceptive, it implies the existence of an ideal ‘dis-ease’ free state which even the most orthodox professional would be reluctant to claim. Clare (1976), a proponent of the medical model, demonstrates the fallacy of such a claim. If schizophrenia were proven to be a myth the implications and consequences would be less far-reaching than those implicit in the concept of an ideal of mental health against which those who are deemed to be ill are judged.
The intensity of reply by those who question the scientific validity of criticisms levelled against the medical model is evidence of its intractability while the sceptical approach of clinicians not prepared to assert or deny the possibility of biological factors in abnormal conditions of mood and behaviour, which reluctance, to my mind, is a measure of the weakness of empirical evidence for the model), contrasts sharply with Szasz’s dogmatic iconoclasm in denying any biological explanation for mental illness. Despite his dogmatism, Szasz (and other critics) succeed in bringing to attention the undesirable consequences of reifying mental illness as cause in itself and the lack of consensus about definition and boundaries of medical responsibility. The contextual approach advocated by Sarbin and Mancuso as an alternative paradigm to the disease metaphor favoured by theorists of the medical model requires a consideration of the consequences of such a paradigm shift. The legitimacy of the mental health profession as an officially sanctioned social institution for dealing with ‘problems in living’ would be brought into question. By demonstrating a metaphoric foundation and the illegitimacy of reification critics attempt to expose the myth of mental illness. There is a danger that exploding the myth of the reification of ’cause as disease’ metaphor becomes itself part of the process of creating a new myth. In addition, the central social and political question as to who, in a democratic pluralistic society, should be sanctioned to make moral judgements viz a viz medical diagnoses, to whom they are to be applied and by which criteria – if they are to be made at all – remains unanswered.
Notes
1I think an even stronger case could be made for the argument that psychotherapy has to a great extent replaced confession and both psychiatrist and priests are in comparable professions of ministering to psychic needs.
2Overt sexuality posed a threat to an anti-libidinous, anti-pagan church Establishment.
3The Guardian, 25th June 1991. In the same article Dr. Gillien Mezey (formerly a senior registrar at Broadmoor) on the question of misogyny, denies any conspiracy against women and sees the psychiatric system as simply reflecting society’s attitudes. Perhaps this is an indictment not just of a predominantly male dominated psychiatry with authoritarian attitudes in the guise of benevolence but also of society in general and its superstitious attitudes to women and madness based upon a confused mix of mediaeval and nineteenth century stereotyped images.
4Jules Michelet, Satanism and Witchcraft: A Study in Medieval Superstition, (Toronto: Citadel Press, 1939).
5Thomas Szasz, The Myth of Mental Illness; A Foundation of a Theory of Personal Conduct, (New York:Hoeber-Harper, 1961) quoted in Phyllis Chesler, Women and Madness, (New York: Avon Books, 1972) p102
6Siegler & Osmond (1976). Taking the Myth out of Madness, Psychology Today, 2 (2), p19
7Siegler & Osmond (1976) op. cit., p 62
8Richard Bentall, Reconstructing Schizophrenia, (London: Routledge, 1990, 1992)
9Which seems in part to follow cultural trends and norms e.g.- homosexuality and DSM-III
10Scadding (1990). The Semantic Problems of Psychiatry, Psychological Medicine, 20, 246
11Scadding (1990). op. cit., p246
12Sarbin & Mancuso (1980) Schizophrenia; Medical Diagnosis or Moral Verdict, (New York: Pergamon Press, 1980) p221