Now only an expert can deal with the problem because half the problem is seeing the problem.
- Laurie Anderson
In the animal kingdom, the rule is, eat or be eaten; in the human kingdom, define or be defined.
- Thomas Szasz
In Christopher Moore’s novel, The Lust Lizard of Melancholy Cove, we watch the cartoonish results of a town going off their antidepressants. When a local housewife commits suicide, the town psychiatrist becomes upset, believing that her tranquilizing medications might be insufficient in preventing such tragedies. She blackmails the local pharmacist into dispensing placebos instead of Prozac. Cold weather approaches and the town gets the blues. They start singing the blues. They also get their sex drive back, which coincides with the arrival of an aphrodisiacal sea monster. It’s all quite absurd and strange. Though his intent is more comedic than moral, it does push us to wonder about our reliance on professionals to manage our personal troubles and the influence of psychiatric experts in our lives.
If there ever was a critic of our enchantment with psychiatry, it was Thomas Szasz, MD, who died this past week at the age of 92. His 1961 book, The Myth of Mental Illness, provided the philosophical basis for the antipsychiatry and patient advocate movements that began in the 1960s and have flourished ever since. Szasz (pronounced “zoz”) argued that a disease model was a category error when it comes to accounting for “problems in living.” The New York psychiatrist, who was born in Budapest and immigrated to the United States in 1938, was originally trained as a psychoanalyst and was on the faculty of SUNY Upstate until retirement. He shunned the medical model of psychiatry, which he saw as inherently coercive. He was an early critic of psychiatry’s former disease model of homosexuality. He argued vigorously against the use of involuntary hospitalizations, the insanity defense, and the psychiatric control of psychotropic medications. His influence has permeated both clinical psychiatry and psychology, leaving the profession with a stronger emphasis on social justice and a legacy of psychiatric skepticism.
One of Szasz’s basic arguments is that mental illness is a myth. He was highly critical of the so-called medical model for understanding human struggles and difficulties. He saw the uses of diagnostic systems (such as the DSM) as wrongly implying the presence of actual disease. Furthermore, he saw such efforts as medicalizing morality and the typical dilemmas and struggles of human life.
To be sure, Szasz was not without his critics. His central view that mental illness is a myth has been dismissed, if not outright rejected, by the American Medical Association, America Psychiatric Association, and National Institute of Mental Health. Even Dr. Allen Frances, himself a critic of the modern diagnostic approach in psychiatry, has said that Szasz “goes too far.”
Still, the critique offered by Szasz deserves careful reflection, even if some of his views seem radical. We will soon witness a new, fifth revision to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). It is widely assumed that the DSM-5 represents an advancement in knowledge that will further our understanding in treating psychopathology. The experts have said we should not be concerned. In fact, we should applaud because we have come so far. There is less stigma associated with having a mental illness. Treatment works and suffering is reduced. And so on.
And what could possibly be controversial? At the most basic level, the American Psychiatric Association maintains a kind of monopoly on what constitutes a mental illness. As pointed out recently by Allen Francis, M.D., chair of the previous DSM-IV, the new manual has become a victim of its own success. It has become the chief arbiter of who is ill and who is not, and such decisions affect everything from access to school services to disability payments and insurance eligibility. The benevolent view would be that there will be more access to treatment for everyone. A more cynical view suggests an increase in pathologizing normal experience (e.g., converting shyness into social anxiety disorder) . With the addition of many new diagnoses and a broadening of diagnostic criteria for existing diagnoses, the DSM-5 could shape notions of normality and illness in ways that cannot possibly be anticipated. What is clear is that Its continued dominance as psychiatry’s sacra scriptura ensures a continued deference to experts when we are troubled.
If Szasz would have us question our fidelity to experts, psychoanalysis gives us a language for talking about why we might be drawn to experts in the first place. Freud reminds us that there is something intrinsically unmanageable about being human. We struggle to bear what seems unbearable. Our turning to experts is a self-cure for what we cannot tolerate or explain. But is it easier to bear if it can be explained and potentially alleviated by experts? If one is experiencing a persistent and stubborn shyness, is it usefully viewed as social anxiety disorder–a treatable mental illness (complete with psychotherapies and medications)? Thus, we thrust our fears about what we can’t seem to bear into the arms of experts.
If Freud would have us be critical of what we assume to be true in our nature, William James would push us to decide on the usefulness of what we’ve come up with. Would it be more or less helpful to think of one’s introverted nature and social fearfulness as a mental health condition? If we think of severe shyness as a treatable illness, am I more likely to seek some solutions rather than others? What are the side effects of a medical metaphor?
It would be hard to argue against the idea that we are better off with the kind of compassionate, non-discriminatory, science-based approaches we enjoy for conditions like autism, cognitive impairments, and severe depression. We no longer live in a demon-haunted world. We would also have a hard time imagining the kind of world that J.G. Ballard described in his futuristic short story, “The Insane Ones,” where psychiatrists and psychologists have been outlawed in a kind of libertarian utopia (under the fictitious Mental Freedom legislation) that Szasz might relish. “Discharging their self-hate and anxiety onto a convenient scapegoat, the new rulers, and the great majority electing them, outlawed all forms of psychic control, from the innocent market survey to lobotomy...the mentally ill were on their own, spared pity and consideration, made to pay to the hilt for their failings.”
There is surely a middle path–somewhere between Moore’s parody and Ballard's libertarianism. Our conceptions about what is normal or sane involve a much bigger project than the DSM, and perhaps we will see the DSM take its place alongside other relics we no longer need (lobotomies come to mind). Similarly, our ideas about self-improvement surely go beyond the language and treatment methods of psychiatry. While appreciating evidence-based practices in psychotherapy and medical advances in psychopharmacology, we need to be alert to a full range of avenues for self-help. Szasz would also remind us not to “mistake medicine for magic.”
* An earlier version of this article did not include the photo credit. My apologies to Jeffrey Schaler for not including this in the earrlier draft.
© 2012 Bruce C. Poulsen, All Rights Reserved