Deviance readings: Week 11
The Myth of Mental Illness, Thomas S. Szasz
Today mental illness is widely regarded as the cause of innumerable diverse happenings (similar to
such explanatory concepts as deities and witches, etc)
Goal: describe the main uses to which the concept of mental illness has been put, argue that it has
outlived it‟s usefulness and that it now functions merely as a convenient truth.
Mental Illness as a Sign of Brain Disease
If mental illness is a sign of brain disease this implies that people cannot have troubles from anything
All problems in living are attributed to physiochemical processes
Mental illnesses are thus regarded as basically no different than all other diseases
2 fundamental errors with this:
1. A person‟s beliefs cannot be explained by a defect or disease of the nervous system
2. Epistemological: an error pertaining not to any mistakes in observation or reasoning, as such,
but rather to the way in which we organize and express our knowledge.
a. The statement “x is a mental symptom” involves rendering a judgment
b. The notion of a mental symptom is tied to the social context in which it is made
Mental symptoms definition: a patient‟s communications about himself, others, and the world about
SUM: What they mean is that people labeled as mentally ill suffer from diseases of the brain and it
would be clearer if they said that instead.
Mental Illness as a Name for Problems in Living
Implicit in this view (of mental illness as the cause of human disharmony) 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.
Concept of illness implies deviation from some clearly defined norm
The norm from which deviation is measured whenever one speaks of a metnal illness is a psycho-social
and ethical one YET the remedy is sought in terms of medical measures. What defines the norms and hence the deviation? 2 basic answers
1. May be the person himself who decides he is deviant
2. May be someone other than the patient who decides the patient is deviant
Whose agent is the psychiatrist? This changes the ethical concerns
The Role of Ethics in Psychiatry
Anything that people do takes place in a context of value
By making the practice of medicine neutral in regard to some specific issues of value need not,
and cannot, mean that it can be kept free from all such values.
o It does make a difference what the psychiatrist‟s socioethical orientations happen to be;
for these will influence his diagnosis/treatment of the patient.
o Also, people seek psychiatric help in accordance with their social status and ethical
What is intended by the idea that mental illness is some sort of disease entity is that it can
somehow be transmitted to others
o No support for this idea
o Author believes that what we call mental illness are for the most part communications
expressing unacceptable ideas.
This disease model doesn‟t accept that
o Human relations are inherently fraught with difficulties and to make them even
relatively harmonious requires much patience and hard work.
Choice, Responsibility, and Psychiatry
Mental illnesses do not exist BUT the social and psychological occurrences to which this label is
currently attached do exist.
Authors Aim: phenomena now called mental illnesses should be looked at afresh and removed from the
category of illness and regarded as expressions of a man’s struggle with the problem of how he
Man suffers a burden of understanding and this burden is to be expected. Our only rational means for
lightening it is more understanding.
The notion of mental illness now functions as a convenient myth.
The role of all these belief-systems was to act as a social tranquilizer.
Life for most people is a continuous struggle.
It is the making of good choices in life that others regard, retrospectively, as good mental health
o NOT that mental health automatically insures the making of right and safe choices in
one‟s conduct of life
What we have are problems of living. On Being Sane in Insane Places, D.L. Rosenhan
Normality and abnormality are not universal
What is normal in one culture may be abnormal in another
Patients present symptoms, those symptoms can be categorized, and, implicitly, that the sane
are distinguishable from the insane.
Psychiatric diagnoses, in this view, are in the minds of the observers and are not valid
summaries of characteristics displayed by the observed.
o Diagnoses betray little about the patient but much about the environment in which an
observer finds him
8 sane people gained secret admission to 12 different hospitals.
Pseudopatients and Their Settings
Varied group, some studying psych or in health profession, some not.
All employed pseudonyms, kept everything else the same
Hospitals were located in 5 different states on east and west coast
At admission the patients said they heard voices, often unclear but sometimes saying “empty”,
Voices were unfamiliar but of same sex as patient
Beyond alleging the symptoms and falsifying name, vocation, and employment, no further
altercation of person, history, or circumstances were made.
Immediately after admission to the psychiatric ward the pseudopatient ceased simulating any
symptoms of abnormality.
The Normal are Not Detectably Sane
The pseudopatients were never detected
Each was discharged with a diagnosis of schizophrenia “in remission”
Once labeled schizophrenic the pseudopatient was stuck with that label
Uniform failure to recognize sanity
o Cannot be attributed to
Quality of the hospital because they varied in quality and some were considered
Length of stay, which varied from 7-52 days. Avg 19 days
Fact that they weren‟t behaving sanely
Quite common for other patients to “Detect” the pseudopatients sanity
o Possible causes
Physicians operate with strong bias toward type 2 error
More inclined to call healthy person sick a sick person health Another experiment
Staff at hospital informed that in next 3 months a pseudopatient would be arriving.
Staff rated each patient with a 10 point-scale reflecting confidence that a patient was a fake
o 41/193 patients were alleged, with high confidence, to be pseudopatients by at least one
member of the staff
o 23 were considered suspect by at least one psychiatrist
o 19 were suspected by one psychiatrist AND one other staff member
o No pseudopatient was actually presented during this period
This is instructive:
o Tendency to designate sane people as insane can be reversed when the stakes are high
o But what of the 19 suspected to be sane by 1 psychiatrist and 1 other staff member?
Were they truly sane or were the staff making more errors of the first sort –
calling the crazy “sane”?
Any diagnostic process that can have such massive errors cannot be very reliable!!!
The Stickiness of Psychodiagnostic Labels
Elements are given meaning by the context in which they occur
Once a person is designated abnormal all of his other behaviors and characteristics are colored by
The perception of a pseudopatients‟ circumstances was shaped entirely by the diagnosis
Even the patients‟ note taking was characterized as suspicious “writing behaviour”
Notes taken by pseudopatients are full of (non-pseudo) patient behaviours that were misinterpreted
by well-intentioned staff
The label endures well beyond discharged, with the unconfirmed expectation that he will behave as
a schizophrenic again.
This label also affects relatives and friends, as well as the patient himself, as a self-fulfilling
It seems much more useful to limit our discussions to behaviors, the stimuli that provoke them, and
The Experience of Psychiatric Hospitalization
The mentally ill are society‟s lepers
This attitude affects the general population as well as health professionals
Staff and patients are very segregated – as if the disorder is catching
Staff spend most of their time in “the cage”
Percent of time spent outside cage: Attendants: 11.3
# of times left cage:
o Daytime nurses: 11.5
o Nighttime nurses: 9.4
o Physicians (emerged onto ward): 6.7
Most power = least time with patients Powerlessness and Depersonalization
Patients are deprived of many legal rights by dint of psychiatric commitment
o Ex: freedom of movement, loss of credibility, privacy, etc
Pseudopatients had the sense they were invisible or at least unworthy of account
Initial examinations sometimes in semipu