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Is mental illness a myth?

Psychiatrists, physicians, and lawyers are among those arguing over whether deviant, dangerous, or self-destructive behavior has a biological basis.

There has been a running debate over the validity of "mental illness" and its status in the marketplace of ideas. This is to some extent the culmination of many years of criticism of the view that mental illnesses are real illnesses - termed the "medical model" - and more than a decade of efforts in biological psychiatry aimed at demonstrating that they do indeed have a biological basis. The best evidence is that most of the behaviors called mental illnesses are not illnesses and that the skepticism regarding psychiatric claims is increasing, not decreasing.

Psychiatrist Thomas Szasz, whom columnist and former psychiatrist Charles Krauthammer calls "the premier critic of his own profession," has contended for more than 30 years that mental illness is a myth, a point requiring careful explanation. Szasz does not deny that the behaviors labeled mental illness exist. Yet, this remains the most frequent misunderstanding - or purposeful distortion - of his views. As one typical example, Harvard University law professor Alan Dershowitz said of Szasz's position in an interview, "If you've seen somebody who is ... [severely] troubled, you can't believe Tom Szaszs argument that theres no such thing as mental illness."

What Szasz maintains, however, is that calling deviant, dangerous, and/or self-destructive behavior mental illness distracts from an understanding of such acts. Moreover, this type of invidious labeling leads to depriving of the freedoms of some innocent people, such as in involuntary psychiatric interventions. In other situations, it allows the unjustified relieving of individuals of responsibility for their actions, even to the point of exculpation of heinous crimes, such as in the case of would-be presidential assassin John Hinckley.

Szasz believes that the great preponderance of what is called mental illness constitutes problems in living and/or deviant behavior. Illness, he argues, is exclusively "a condition of the body... I define illness as the pathologist defines it - as a structural or functional abnormality of cells, tissues, organs, or bodies."

Psychiatrists employ a number of rhetorical devices to promote mental illness as illness, despite there being no such medical evidence for any but a few of the so-called mental disorders. One is to hitch the general term to a few specific mental illnesses neuropsychiatrists believe have been established as likely authentic brain diseases.

In recent years, biological psychiatrists have concluded that schizophrenia is a disease since structural and chemical abnormalities have been discovered in the brains of some schizophrenics. The notion that certain individuals labeled schizophrenic may have a brain disease is accepted unquestioningly by the public and is conceded by Szasz in his book, Insanity.

Having provided some interesting evidence and having won acceptance for the view that one type of mental illness may be a bonafide disease, mental health interests try to transfer the credibility of schizophrenia research to imply that all mental illness constitutes proven brain disease. The hope apparently is that, if it is accepted that there is an identifiable brain disease at the root of some behaviors labeled schizophrenic, the assumption will be that there also is one at the root of the tremendous range of behaviors that have at times been labeled as mentally ill.

How many people are seen by psychiatry as mentally ill, and how is it determined? As Yale University psychiatry professor Jay Katz conceded several years ago, "If you look at [the diagnostic manual], you can classify all of us under one rubric or another of mental disorder." The National Institute of Mental Health (NIMH) determined a few years ago through questioning by lay interviewers that 17-23% of adults in America have at least one "psychiatric disorder," and that there is a 29-38% lifetime prevalence. Responding to this "discovery," the Archives of General Psychiatry stated that the results indicated that "we need no longer blindly grope about the prevalence of |psychiatric illness': its prevalence is about that of hypertension."

Does the public think such determinations are legitimate? It probably does, and these views once got little skepticism from the media, few of which ever dispute such "scientific" findings. Speaking with psychiatrists and NIMH representatives on "Nightline" following publication of the survey, Ted Koppel asked only what can be done about this epidemic of mental illness, with no questions about the validity of the survey.

Although they mouth shibboleths like "mental illness is like any other illness" when speaking publicly, many leading psychiatrists and mental health specialists clearly are quite skeptical of their own claims. This can be seen most clearly in psychiatry's Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) and journal articles discussing the upcoming revision, DSM-IV.

The diagnostic manual does not refer to mental illness, only to mental disorders. It almost entirely is a description of behaviors and experiences, a style the American Psychiatric Association (APA) calls "etiologically neutral," meaning it does not deal with the causes. Actually, as a result of this neutrality, there is absolutely no medical validation, much less criteria, for the vast majority of mental disorders. An article discussing "conundrums" facing the Task Force on DSM-IV (authored by several members) in the Journal of Abnormal Psychology admits that, "unfortunately, in most instances," biological tests can not be used even as "diagnostic indicators" since they are not specific to particular "mental disorders."

In addition, the article reports that there is heavy lobbying of the Task Force to influence its revisions of DSM-IV ("The zeal ... is extraordinary"), based on ideological and financial motives. Members of the Task Force wrote in 1990 in the APA's American Journal of Psychiatry, "There has been concern that several proposed diagnoses ... would have adverse effects on women." In the 1991 "conundrums" piece, they stated that "there are those who want some or all mental disorders designated as diseases in order to protect reimbursement and research funding...."

Regarding the concern for diagnostic categories adversely affecting women, they wrote that "it is unclear to what extent the DSM-IV Task Force should be influenced" by such considerations. Regarding reimbursement issues, a frequent topic in diagnostic manual revision articles, they maintain that it "cannot be overly influenced" by them.

One neurologist, who dismisses psychiatry's medical pretensions for all but schizophrenia and certain bipolar disorders (e.g., manic-depression), says of these debates over DSM-IV revisions: "In discussing the biological basis and classification of authentic disease, one would never raise the question of political and economic ramifications. Those issues might have to be addressed in some other forum, but science is science. When you discuss other considerations, you are simply not doing science."

Szasz argues that the mind is not an organ, so there can be no such thing as mental illness. Moreover, not only are the vast majority of mental illnesses not illnesses, if psychiatry were successful in convincing the medical world that they were, it paradoxically would "destroy psychiatry's ruison d'etre as a medical specialty distinct and separate from neurology." Regardless, how successful is the effort to persuade people to believe that mental illness is like any other illness?

Increased skepticism

There appear to be efforts among many mental health interests to maintain that the battle for the medical model for mental illness is won. Such a claim was made by a psychologist in an article in Contmentary, as well as in a 1990 book on the homeless, Madness in the Streets. The latter blamed "anti-psychiatry" for the homelessness caused by de-institutionalizing those involuntarily committed in psychiatric hospitals. (Szasz opposed both the forced incarcerations and the forced exits.)

In 1987, when Szasz wrote Insanity, perhaps his best treatise on what he claims is the myth of mental illness, there was little response, despite a favorable review in the Journal of the American Medical Association which conceded that "[Szasz] does an excellent job of answering all of the arguments against his position...."

In 1990 in Commentary, Carol Iannone, the embattled nominee to the Advisory Council of the National Endowment for the Humanities, reviewed William Styron's book, Darkness Visible, describing his suffering from the "disease" of depression. The review was skeptical of the notion of "depression-as-disease." She wrote that Styron's description of his emergence from depression makes one doubt that it is a disease without choice or a moral dimension. Styron, Iannone notes, states that, while in the throes of being enraptured by Brahms' "Alto Rhapsody," he steeled himself against an act (suicide) which would devastate his loved ones and constitute a "desecration on myself." "What," Iannone asked, "were all his neurotransmitters and chemicals and hormones up to?" How, she implied, could a disease be so amenable to the power of thought?

The reaction to Iannone's heresy was swift and vehement. In an article in the Washington Post, she says she was asked about her views on mental illness by senators opposed to her nomination to the National Endowment for the Humanities. One psychiatrist at Columbia University asked angrily in a letter to Commentary, "How is it possible that, in the year 1990, one can still come across a person of considerable education (and literary erudition) who somehow has not learned that depression (and, most especially, suicidal depression) is a psychiatric illness, not primarily a moral dilemma or a mortal sin?"

There is, in fact, evidence that a slowly increasing skepticism is emerging regarding what psychologist Stanton Peele calls "the diseasing of America." Doubts about behavioral addictions abound in the popular press. A column in U.S. News and World Report deplored "the it's-not-my-fault syndrome"; Pulitzer Prize-winning feature writer Alice Steinbach derided "The Addiction Addiction" in The Baltimore Sun; and a New York magazine cover story titled "Don't Blame Me" skeptically examined the exculpatory language of behavioral addiction. Herbert Fingarettes Heavy Drinking: The Myth of Alcoholism as a Disease gained substantial attention. Moreover, since the Hinckley verdict, criticisms of the insanity plea have caused the American Psychiatric Association to retreat from its claims to be able to certify whether people can control their commission of criminal actions.

Even within the field of psychiatry, there is doubt about the medical nature of mental illness. Just before his death, Karl Menninger, the dean of American psychiatry, wrote, "[Szasz's] new book, Insanity, makes some points that I agree with and have been trying to get across for years." In a published letter to Szasz, Menninger spoke with derisive skepticism about psychiatric diagnosis, prognosis, and treatment, and at one point used the term psychiatric "sickness" in quotation marks. He ended his letter with an implicit admission that much psychiatric treatment might not be the cause of patients' feeling better: "Long ago I noticed that some of our very sick patients surprised us by getting well even without much of our "treatment.'"

If Menninger came to doubt even partially the major premise of psychiatry - that mental illnesses are authentic illnesses - after a lifetime of accepting and promoting it, the debate over the medical identity of such conditions may be just beginning. That should trigger discussions about a multitude of crucial related matters, ranging from the insanity plea to third - party reimbursements for mental illnesses.
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Author:Vatz, Richard E.; Weinberg, Lee S.
Publication:USA Today (Magazine)
Date:Jul 1, 1993
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