Virtual Journal Club--Week of August 29, 2016

Reaching into the archives for a classic critique of our profession--one you may have heard about, but not actually read for yourself, The Myth of Mental Illness, by Thomas Szasz. (American Psychologist, 15: 113-118, 1960.) Szasz delivers a scathing critique of the psychiatry of his day, noting the tendency (which to be honest, still exists today) for us to wish to medicalize deviations from social norms as "illness", when in his view, almost all such problems stem from "... the everyday fact that life for most people is a continuous struggle, not for biological survival, but for a 'place in the sun,' 'peace of mind,' or some other human value." He seems bothered by the lack of pathophysiological lesions, such as found in syphilis, and notes that what is considered as a sign or symptom of psychiatric disorder is to a great extent based in the values and beliefs of the observer. It should be noted that Dr. Szasz is driven very much by an ethical concern regarding involuntary treatment and commitment, and the slippery slope societies find themselves on when they label some beliefs as pathological, and how that might be (and has been) abused by political systems. This comes out strongly, even fifty years later, as Szasz gets the uncommon opportunity to revisit his views in a retrospective second article, The myth of mental illness: 50 years later (The Psychiatrist, 35, 179-182, 2011). "The thesis I had put forward in The Myth of Mental Illness was not a fresh insight, much less a new discovery. It only seemed that way, and seems that way even more so today, because we have replaced the old religious-humanistic perspective on the tragic nature of life with a modern, dehumanised, pseudomedical one." "Formerly, when church and state were allied, people accepted theological justifications for state-sanctioned coercion. Today, when medicine and the state are allied, people accept therapeutic justifications for state-sanctioned coercion. This is how, some 200 years ago, psychiatry became an arm of the coercive apparatus of the state. And this is why today all of medicine threatens to become transformed from personal care into political control."

I also attach a brief response by Dr. Edward Shorter, Still tilting at windmills: Commentary on "The myth of mental illness" (The Psychiatrist, 35, 183-184, 2011), in which he appears to charge Szasz with the perpetuation of stigma against psychiatric illness, and a stubborn refusal to accept physiological facts supporting psychiatric symptoms as brain-based abnormalities.  Nevertheless, one gets the impression that Shorter and Szasz are arguing about two different entities when they term something as illness. After fifty-six years, I suspect that the dialogue will continue for another fifty or so--our DSM is still quite remarkably lacking in pathophysiological correlations, and if anything, the tendency to medicalize psychosocial problems has intensified.  However, I think that we are finally beginning to appreciate that these are not self-contradictory explanations--the arrow of causation clearly points in both directions. For example, Newsweek recently published a synopsis highlighting what many of us see everyday in our patients, and what was in part the topic of last week's papers: the toxic effects of a stressful social environment on brain development.  I think if Szasz had had more evidence for this at hand, he might have been less dualistic in his "mind" vs "brain" ideation.

Google Drive links:  Szasz; Szasz Retrospective; Commentary-Shorter