The Myth of Mental Illness:
Foundations of a Theory of Personal Conduct

Thomas S. Szasz

his classic work is the product of the 1960s, a period of ferment in psychiatry and a period of self-criticism in society. In this book, Szasz put forth his controversial belief that mental illness is only a metaphor, and that psychiatric disorders are not diseases, but are attempts by the patient at communicating distress.

Szasz focuses mainly on conversion hysteria, a disorder that preoccupied Freud and his contemporaries. In conversion hysteria, the patient develops physical symptoms because of a neurosis. Freud and others believed this revealed a connection between physical and mental disease. Neurosis was thus conceptualized as a sort of toxic substance that sought release and found its expression in the body.

Conversion hysteria is rarely diagnosed today, and it may seem strange to us that Freud focused on it. But in those days, Cartesian dualism was an important factor in people's thinking. The Freudians saw conversion hysteria as a clue as to how the mind and body are connected. Even today, the connections between the mind and brain remain poorly understood. Unfortunately, the early obsession with hysteria may have led doctors down the wrong path--a path many are still following a century later.

Most biologists today would agree that "mental illness" is a metaphor, and most would probably agree that the psychodynamic concepts on which psychiatry is founded have little or no scientific basis. Szasz considers mental illness to be political--a failure by the patient to abide by the social rules of behavior. The patient cannot be "cured", because he or she is not really sick, but can only learn to adapt to the social rules using gamesmanship. There is much to be said for this view. However, Szasz leaves himself open to criticism when he considers all psychiatric disorders to be social constructions. Many disorders once regarded as psychiatric, such as schizophrenia and depression, are now thought to be predominantly, if not exclusively, physical disorders of the brain. Szasz's characterization of these disorders as mythological has hindered acceptance of his other ideas.

Szasz performed a valuable service in pointing out that nonphysical disorders which cannot be measured, even in principle, cannot properly be classified as diseases; the general failure of psychiatry to make progress toward a cure of such disorders has convinced even those who disagree with Szasz that psychiatry has a faulty theoretical basis. The question of whether socially disruptive behavior in physiologically normal individuals should be medicalized (as is done routinely today, even in children) is one that society has still, fifty years later, not fully grappled with.