A psychiatrist who didn’t believe in mental illness (2013)
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I don't have the book available at the moment, but in the introduction he says something to the effect of "I don't regret writing this book, but I regret calling it what I did, because people judge it without reading it."
The gut-reaction to such a title is to think the writer is saying "depression doesn't exist" or "schizophrenia doesn't exist" or "manic depressives are lying."
This isn't what he says in the book at all. Rather, his argument is more along the lines of:
1. The word "illness" should be used to represent a cause-- and resolving the cause should cure the illness. Cancer, the flu, hyperparathyroidism--all map to causes.
2. The conditions which we call mental illness don't have a knowable cause. They are symptoms which we pattern match against.
3. Corollary: Illnesses should be hypothetically curable. There may be a cure for cancer. But there cannot be a "cure" for most "mental illnesses" because there is no shared, physical cause that underlies say, all cases of "bipolar disorder".
3. So we shouldn't call them "illnesses". We should call them something else.
Unfortunately that's about as much as I remember of his argument, but it's very different than the common accusation... And it also strikes me as accurate.
The problem with naming things is that it makes them real. I think often the hacker news crowd forgets how ill-informed most of the world is, and the degree to which people crave certainty.
When a person is told by a psychiatrists "Your 8 year has depression so we'll put her on X pill" or "You have bipolar type 2, so I recommend Y medicine", it has a certain finality.
Most people don't think "The doctor is telling me that my behavior matches some patterns. That is it. She does not know why, and we may never know why, there may not even be a reason why. So we should think about what we can do to mitigate this."
No. The we think "I've been diagnosed with a disease. (Sorry I'm being an a-hole|I won't go to your party|didn't get out of bed), I suffer from bipolar and there's no cure".
Even at the more generous level of “mental illness is different from physical illness” it is wrong, and dangerously so.
> The word "illness" should be used to represent a cause-- and resolving the cause should cure the illness.
This has never been what “illness” means; illness (both in general and in specific named instances) is often recognized and identified long before causes.
> The conditions which we call mental illness don't have a knowable cause.
They don't usually have a known cause. That they don't have knowable cause is an unwarranted conclusion. Plenty of physical illness don't have known mechanisms, and most of those that do were noticed and given names as illnesses before (sometimes centuries before) the mechanism was identified. This doesn't mean they don't generally have knowable causes, as is evident from the ones whose causes were later learned.
> Illnesses should be hypothetically curable.
That doesn't even remotely follow. Having a know cause doesn't imply curability because causes are not necessarily reversible.
> I think often the hacker news crowd forgets how ill-informed most of the world is
True. It's easy to forget that many people do not even realize that pattern matching on symptoms is how much diagnosis of physical illness is done, and that even where causes are known it's often not worthwhile (and sometimes not practical) to actually test for them directly.
The dangerous thing is to presume that's not true. Or even worse: to lie about it. The phrase "chemical imbalance" comes to mind. Complete and utter fabrication of a physical cause.
It may be that a physical cause is discovered for some conditions which today are considered "mental illnesses"... say, schizophrenia. Well, when that happens it will stop being known as a mental illness and just a physical illness.
No, it's not, it's a subset of physical illness. It's not even possible for it to be otherwise without magic.
Perhaps consider: what things would someone who calls some things “mental illnesses” and not call them “physical illnesses”, contrasted with the things they would call “physical illnesses” and would not call “mental illnesses”. What name would you give to these two categories?
I am reminded of a conversation I had with my dad, perhaps 5 years ago, where he referred to something as a plant, and I was confused because he meant that in a way that excluded trees, while I hadn’t interpreted it that way. Now, of course, in the technical sense, trees are plants, being members of the kingdom Plantae. But at the same time, if one is in an area with 5 trees, and a plant which is not a tree, and someone tells you “look at the plant”, the pragmatic way to interpret what they mean, is that they want you to look at the plant (i.e. the plant which is not a tree).
Scott Alexander said (as a paraphrase/snowclone of Christ’s “The Sabbath was made for man, not man for the Sabbath.”) “The categories were made for man, not man for the categories.”.
Edit: small formatting fix
I think GP's point is that you can't determine a mental illness with physical characteristics/measurements. Can you diagnose schizophrenia with a blood test? X-Rays? Nope. Perhaps an MRI? Maybe, though AFAIK this still isn't really possible.
With physical illnesses it's easy. Broken bone. Cancer. Viral infection. All of these can be diagnosed without communicating to the patient at all, simply by making physical observations using chemistry and physics.
Not so with mental illness. With mental illness you basically have to just talk to the patient, take their word at face value, and then deduce based on symptom pattern matching. A determined fraudster could fake a mental illness, and it would be impossible for doctors to be able to tell AFAIK (correct me if I'm wrong), the same which cannot be said for tumors.
Then it was removed. What happened? Did it stop existing? No. Were homosexual individuals "cured"? No.
Quite simply, the psychiatric community decided that individuals with same-sex desires were not, _and never had been_ mentally ill. The illness was no more.
The same is not true of physical illness.
Different argument:
The diagnostic criteria for "mental illness" overlap. So it's possible to be diagnosed with say, ADD and "Bipolar type 2" and "generalized anxiety disorder".
Which is it? Which illness does the patient have? How does one decide? Which _physical_ mechanism is responsible for one vs the other two?
Physical illness has no such ambiguity.
Nobody knows. Because the map does not map to reality. It's like asking if a hot dog is a kind of sandwich. Maybe. Who cares. It's the wrong question.
Last example:
People suffering from grief/bereavement match many, if not all, the diagnostic criteria for "Depression". Are they depressed? Or are they merely grieving? The answer (if you're a psychiatrist) depends on which volume of the DSM you use (the latest one does not exclude bereavement from the diagnostic criteria).
Is there similar subjectivity with physical illness? No. So they are clearly categorically different kinds of diagnoses, and Thomas Szasz's argument is that for that reason we should not use the word "illness" to talk about these kinds of very real problems.
Autopsies of mentally ill individuals (no history of drug use) and chronic drug users that developed mental illnesses have found many of the same structural defects in the brain.
There's many non-mental diseases that we don't yet understand fully enough to know how to cure completely. There are many diseases where there are varied causes of the disease, where we are still learning these causes, and still learning what could be a cure. Should all these not be called an illness too?
The disease like this that I'm most familiar with is Cystic Fibrosis. 35 years ago, doctors had no idea what caused it. Now we know it is genetic. However, the disease is caused by many different possible combinations of gene mutations and we're still discovering more that can cause it. There's currently over a thousand gene mutations that cause Cystic Fibrosis. While a lot of progress in slowing disease progression has been made, there is no cure. We're not even certain about what would be needed for a full cure as science is still learning about the full extent of the disease. Cystic Fibrosis does not meet your criteria for an illness either. Should we not call it as such? I think that would be absurd. It is clearly an illness.
Just because we don't fully understand a disease yet doesn't mean it can't be called an illness. If you want to come up with a new word that can clarify the fact that we don't fully understand it yet, I guess that's fine, but I don't like confusing people by trying to deny the common understanding of a word.
I think that's actually the crux of the argument. The phrase "mental illness" IS the perversion of a common understanding of a word. When people hear "illness" they think "thing that is broken". Is a runny nose an illness? No, the flu is an illness.
I don't think it's about whether we fully understand the cause or not; I think it's about whether or not we think there probably is a single, physical cause.
So we absolutely should call Cystic Fibrosis an illness even if we don't know the cause, because we think there probably IS one. And heck, there may be two causes! And then... well, then it would be TWO illnesses with similar symptoms, not one.
At this point I'm straying from the book because I don't remember it too well, so this is editorializing: I don't think that holds for many mental illnesses.
"Depression"--do we think there's one, or few, underlying physical causes of it? Highly doubtful. And we know it's highly doubtful because the treatments that make the symptoms go away are so varied in their mechanisms of action and effectiveness. Exercise. Sunlight. Changing jobs. Medication. Time. Talk therapy. All these things "work", to some degree or another, but the odds that they are targeting the same underlying, malfunctioning, physical mechanism are very slim. So one would say "depression is not an illness, the same way a runny nose is not an illness. It's a pattern."
Would that be a correct interpretation of your thoughts?
Yes. You are absolutely correct! It is pedantic.
It's also pedantry in pursuit of a point. By characterizing a group of symptoms as a disease, we coerce it into the mental model of a germ-caused disease. Which is to say there's one unifying and underlying cause, which can be ideally be addressed in a unified way that reflects the singular cause.
Szasz would not agree that Cystic Fibrosis is an illness. He would argue that it's thousands of illnesses with the same set of symptoms. His point would be that calling Cystic Fibrosis "an illness" is misleading and confuses people by denying the common understanding of a word.
The underlying point from Szasz being that illnesses need to be conceptualized in a meaningfully narrow way so that causes can be identified and a way to address them found. Otherwise medicine might wind up deeply invested in a quest to cure coughing and ignoring what coughing might be a symptom of.
Again, you're absolutely correct. The point at hand is incredibly pedantic. Might it also, perhaps, be a useful one as well?
After the Enlightenment, Church was separated from State, but the need for the subjugation of thought criminals remained. In fact, the first psychiatrists asserted that the witches of the Inquisition were in fact just insane people.
The Soul was rebranded as the Mind, and heretics were rebranded as insane while the truth about the mind remained a mystery.
However. There's a dangerous perspective held by a conservatively-minded minority of more people who say mental illness "isn't real" and you just need to "suck it up" and "have stronger character", and it amounts to victim-blaming. Arguing to eliminate the insanity plea sounds very much along those lines, regardless of what the book said. Whether the doctor in question falls into that camp or not, it's a dangerous line to walk.
Personally I think of mental illness as analogous to obesity: it is simply a current state of being, and a spectrum at that. But it's important not to let it slide outside the realm of medicine and of having factors outside of the victim's control. People have fought long and hard for that ground and it's understandable they would feel threatened when someone (even just seemingly) tries to undercut it.
I don't think most cases of depression are an illness for the same reason that I don't think that hunger is an illness. It's the body and mind's natural response to a life which it wasn't evolved to cope with. Which isn't at all the same thing as telling people to suck it up. If everyone is forced to take drugs in order to thrive in what civilization has become, it's not the depressed person who is sick.
Like if a building is on fire, you don't just do first aid on people that get burned. You evacuate the building and put the fire out.
https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2...
The situations with those two patients is revealing - the same genetic condition underlying two different diagnoses. The same treatment. The fact that not everyone with those conditions has the same defect or can benefit from that treatment. The field really is in its infancy. But sometimes there really is a physical cause and treatment.
That being said, while "bipolar disorder" is clearly a disease, or like cancer, a set of diseases, it is true that the mental health profession has an unfortunate long history of making non-majority personality traits "mental illnesses" -- homosexuality was considered a mental illness until the mid 1970s, for example.
If we understood bleeding as poorly as we understood cancer, then everything from R&D for better bandages to public campaigns to reduce gun violence would be lumped together as "treatment for bleeding."
Just because we don't know now, doesn't mean we will never know. That's how science works.
People have 'mental illness' because of mental problems, not physical problems.
Also: everything has some genetic component, this is trivially true. Genetics are what separates humans from dogs and plants. It doesn't necessarily help us to explain the phenomenon adequately.
Also also: another way science works is its inability to prove negatives. Therefore, saying, "someday we might discover this" can be said for pretty much anything that remains unproven.
If your identical twin has schizophrenia, there is a 48% chance that you will have it too. This is compared to the chance of the general population, which is something like 1%. This feels like something is physically wrong in those who are schizophrenic. I don't know how else you would get that kind of result.
There are many types of cancer just like there are many types of bacterial infection. But they are both well identified. We can see the cancer cells and bacteria, and when they are gone, the patient is cured.
Mental illnesses are more like the "flu-like syndrome". The causes can range from leukemia to heroin withdrawal to a wide variety of viral infections like AIDS, the common cold, and of course, the flu. You can treat the symptoms with Tylenol but we can't really call that a disease, more like the symptoms of a yet undiscovered disease.
Also, once it's there, we know it's there, and we know exactly how to cure it: destroy all the cancer cells. The hard part is doing it without killing you in the process, and making sure that not a single cell is left in the end.
Straw man argument and incredibly insensitive. The proposed causation between diagnosis and excuse making behavior is ridiculous. People will make excuses regardless of their knowledge of a diagnosis. It's about what they _want_ to do and their level of comfort with confrontation.
Medicine will continue categorization because it assists with treatment. IMO, it's stigma like your pov that needs to be re-educated.
"that there's a certain fatalism that one experiences once they've been "diagnosed" with mental illness."
I argue that the right education about mental health applied to the mass population would greatly mitigate the occurrences of many if not all of the arguments here.
Much of the current problems of Psychiatry stem from the split of neurology and psychiatry [0]. Over the last 60+ years investigators have found many physiological considerations for the so-called "mental" disorders. The core of the resistance against psychiatry (slandered as "antipsychiatry") are the experiences of patients whose conditions deteriorate from medications that do not address the cause of their conditions.
Stress is one of the most important factors in every psychiatric diagnosis. Malnutrition is a type of stress; emotional stress and genetic mutations [1] creates a need for more of certain nutrients.
[0] https://en.wikipedia.org/wiki/Neuropsychiatry
[1] https://www.gxsciences.com/methylation-testing-s/2.htm
[2] https://en.wikipedia.org/wiki/Moral_treatment#England
I appreciate Szasz's comment about the crucifixion of Ignaz Semmelweis, the Hungarian obstetrician who had the audacity to suggest that his fellow doctors should wash their hands between autopsies and childbirths:
"It taught me, at an early age, the lesson that it can be dangerous to be wrong, but, to be right, when society regards the majority’s falsehood as truth, could be fatal. This principle is especially true with respect to false truths that form an important part of an entire society’s belief system. In the past, such basic false truths were religious in nature. In the modern world, they are medical and political in nature." (emphasis added)
The enduring mistreatment of those labeled as "mentally ill" is one of the great tragedies of our time.
edit: added reference [2] edit2: extraneous words removed
- Change increases stress
- To-Do list items are also known as "stressors"
- Implementing someone else's suggested "happiness plan" in your life could easily kill you, simply because it's new to _you_ and requires dramatic change
To be "right" as per Szasz means to fit into and apply a preferred template in order to bring about that template's preferred outcome more than it means to be true. It is the difference in template that causes the fatal dynamic, not any difference in truth. More true does an individual feel, the more their acted-out template matches their own psychology, and the more they see the template benefiting others who are amenable to its way of framing things. More do they demonstrate alarming symptoms, the more their preferred, best, most trusted template is overridden both objectively and within their subjective experience.
To make all of HN go "mentally ill" simply confine its membership to Facebook fashion groups or the neighborhood butcher shop or the religious cult. The method of or reason for confinement or the place of confinement will always differ, but the result will be the same--absolutely devastating symptoms and strange diseases, etc. Just change, and unknowingly set at an unsustainable pace right from the start.
The illness model has its leverage points in e.g. its natural provision for quick social exits, but other models also contribute much to our self care and other-care.
This fascinating statement makes me wonder about the rise of mental illness in children. I've tended to fall on the side of prior under-diagnosis, but I wonder if some is actually a result of the children being 'trapped' by modern helicopter parenting and educational systems by removing the time they would need to remain sane by engaging in free, unstructured, self-directed play?
So the problem here is that our ability to observe physiological differences, particularly given the development of EEG/MRI/CT/etc, has radically outpaced our ability to have any clue what they mean. The point being that just because a "condition" has a physiological manifestation in no way whatsoever then directly implies that the condition is therefore physical or can even be realistically 'treated'. For instance, we're not going to develop a drug to make you a strong chess player anytime in the foreseeable future. And while perhaps you could create a drug to make a master a weak player again, it would almost certainly be little more than a glorified lobotomy.
(sorry, tangent)
And one very important third link. [3]
[1] - https://www.nature.com/articles/35088119
[2] - https://www.sciencedirect.com/science/article/pii/S002839321...
https://en.wikipedia.org/wiki/Thomas_Szasz#Szasz's_main_argu...
Of course the problem is related to wider social issues about permissive violence. If one person murders another because of their delusions, it's a crime and a medical failure. If an entire country declares war on another for similar reasons we assume we're in the realm of politics and history, not mass mental illness.
We're far too harsh on individuals and far too lenient on mass systems of thought and belief that have horrific outcomes.
Sure, but then again most non-psychotic people are as well. It's not like the majority of murders is done by psychotic people.
That's because mental illness diagnosis is subjective and authoritarian.
For example, runaway slaves in the US were diagnosed with drapetomania, and anti-war acitivists who smoked marijuana were diagnosed with schizophrenia.
I had no idea there was a documentary film about him. Thanks very much for sharing that.
Maybe Dr. Moskowtizs. His technique is the subject of chapter 1 in Norman Doidge’s “The Brain’s Way of Healing”
Fields are designed to protect the degreed professional. The words are crafted as weapons forged in the defense of each thesis.
Everything you confront is the product of some long-dead intellectual chess match conducted in an ivory tower, and from that moment forward concepts are, by turns, weaponized.
This principle extends to all fields, economics, sociology, psychology, biology, chemistry, physics, math. Don't believe me? Try on the "divide by zero" argument for size.
It's just notation, to communicate expressions, that relay ideas.
If you were to have nothing, and hypothetically cut nothing into a number of parts, you'd still have nothing. If you have something, and divide it into zero parts, then that too, is nothing.
But people have a professional stake in fighting such compromises. Having won an argument in the past means their reputation rests on defending that stance until they finally die and get out of the way.
It's pretty easy to let an expression that communicates division with zero exist. But because we have an academic norm standing in the way, the conversation of whether or not we should serves better to reveal the brainwashed drones, parroting their instructors until death.
What a load of crap.
This article does a poor job of laying out Szasz's actual beliefs. Szasz sounds like a right-wing wonk and little else.
He has since been proven completely wrong in the 50 years since publication: There is a biological component to mental illness.
It focuses on his persecution complex as a right-wing libertarian in a laregly liberal field.
They bring up the completly irrelevant Semmelweis to attach an air of legitimately to his crackpot beliefs. They do it again with Arendt.
HN is for intellectual curiosity—see https://news.ycombinator.com/newsguidelines.html.
I have a lot going on in my life right now, and some of that stress is leaking out into my social media. I've deleted my twitter recently for similar reasons. If I could scramble my HN username and delete the account, I would do that until I'm in a better place.
I will try to do better in the future.
You make some interesting points, but I will say that you can absolutely become, and remain, unhappy even while living a stress-free life. So while stress is absolutely an important factor, it is not "the deciding factor"