Some
Myths About "Mental
Illness"
Michael S. Moore, JD
\s=b\ Radical psychiatrists and others assert that mental illness is myth. The opening and closing portions of the article deal with the impact such an argument has had in law and psychiatry. The body of the article discusses the five following versions of the myth argument prevalent in radical psychiatry: (1) that there is no such thing as mental illness; (2) that those called "mentally ill" are really as rational as everyone else, only with different aims, that the only reasons anyone ever thought differently was (3) because of unsophisticated category mistakes or (4) because of an adherence to the epistemology of a sick society;and (5) that the phrase "mental illness" is used to mask value judgments about others' behavior in pseudoscientific respectability. Reasons are given for rejecting each of these versions of the ar¬ gument that mental illness is a myth. (Arch Gen Psychiatry 32:1483-1497, 1975) a
of mental illness has had a long and in man's thoughts about himself, his nature, and his responsibility. It stands at one junction of law, morals, and medicine, with the result that lawyers, psychiatrists, and philosophers have long shared a concern for the nature of the concept. This shared concern has not given rise to any consensus, however, and the debates, particularly between lawyers and psychiatrists, have often been acrimonious and unfruitful. Since the advent of "radical psychiatry," the theoretical justification of which is to be found notably in the works of Thomas Szasz, the battle lines have been redrawn somewhat along other than professional lines, but the result has not been added clarity about the nature of the concept of mental disease or its moral and legal relevance. Indeed, quite the reverse has occurred, so that essen¬ tially ethical and political questions about psychiatric practices or legal doctrines with regard to the mentally ill are increasingly answered by the trundling out of the con¬ temporary shibboleth that mental illness is a myth rather than in terms of the ethical and political arguments neces¬ sary to answer such questions. There is a disturbing tend-
concept Theinteresting history
Accepted for publication July 30, From the
1975.
University of Kansas School of Law, Lawrence. Reprint requests to University of Kansas School of Law, Lawrence,
66045
(Prof Moore).
KS
issues, notably the proper place of mental illness in various legal tests (of insanity in criminal trials, of incompetency to perform various legal acts or to stand trial, the tests for civil commitment), as solved by the new truth that mental illness is but a myth anyway. Equally disturbing is the apparent belief that problems of social policy and social justice, such as what in fact society should do with dangerous persons who have not committed any criminal acts, are satisfactorily re¬ solved if legislatures would but recognize mental illness ency to regard complicated legal
for the sham that it is. If mental illness were a myth, acceptance of such a truth would provide straightforward answers to such le¬ gal, ethical, and political questions. One would not have to muddle along in the grubby details of comparing awful prisons with almost as awful hospitals for the criminally insane. One would not have to grapple with difficult policy issues, such as the rationale for punishment generally and its relation to those found to be not guilty by reason of in¬ sanity, for it would be instantly clear that those we call mentally ill should be punished just like anyone else if they commit a criminal act; that they should have all the rights of an accused criminal if society should seek to de¬ prive them of their liberty no matter how the proceeding or the place of confinement might be named; that legal tests should abolish the phrase; and, easiest of all, that psychiatrists should mind their own business and leave the law to the lawyers. The problem is that mental illness is not a myth. It is not some palpable falsehood propagated among the popu¬ lace by power-mad psychiatrists, but a cruel and bitter reality that has been with the human race since antiquity. This is such an obvious truism that to have stated it 20 years ago would have been an embarrassment. Since the advent of radical psychiatry and its legal entourage, how¬ ever, such truths need restatement. Even more, they need restatement in a form specifically addressed to the various senses in which mental illness has been thought to be a myth. Since on my reading of the radical psychiatrists there seem to be five distinguishable points they have in mind in thinking of mental illness as a myth, the discus¬ sion will proceed by considering them seriatim.
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THE MYTHOLOGY OF RADICAL PSYCHIATRY The Myth as a Question of Ontological Status: There Is No Such Thing as Mental Illness Because There Is No Referent of the Phrase
Mental illness is
myth because, as quoted by the pres¬ Supreme Court, "there is neither such a thing as 'insanity' nor such a thing as 'mental disease.' These terms do not identify entities having separate existence. ."11',"MI As was more formal¬ ly stated: a
ent Chief Justice of the United States
.
.
term without ostensive referrent [sic], and lacking any, it cannot even be said to have outlived its usefulness, because there is no reason to think that it ever had any.2"'16'"
It is
a
Szasz and his psychiatric and legal followers are suspicious of mental illness as an entity or thing; when looking into their ontology, they see no such thing. The following three points require discussion here: 1. If the argument is that entity-thinking as such is to be regarded with suspicion, as Szasz at times suggests, then the critique is radical indeed. As Quine has noted, "we talk so inveterately of objects that to say we do so seems almost to say nothing at all; for how else is there to talk?"3""' Thing-theory is implicit throughout our ordi¬ nary and scientific speech, and it is simply wrong to re¬ gard it as some primitive form of speech that is replaced with a more sophisticated mode of talk with the maturity of a science. Thus, Szasz's statement that "Entity-think¬ ing has always preceded process-thinking"4(pl> is not an accurate characterization of the development of modern science. In fact, higher order theoretical statements char¬ acteristic of advancing science increase the number of en¬ tities we admit into our ontology, not decrease it. Forces, fields, and electrons are obvious examples. 2. If the argument is that entity-thinking is scien¬ tifically legitimate, but only about those entities referred to by terms capable of ostensive reference, such as "Nixon," or "St Elizabeth's Hospital," the radical psychia¬ trists have a radically impoverished ontology—a nomi¬ nalist ontology that would not admit the "thinghood" of abstract entities such as the number two, squareness, shape, zoological species, or, more to the point perhaps, psychological states. Such a restricted ontology is charac¬ teristic neither of science nor of common understanding. Indeed, in such a restrictive ontological system physical illnesses would not exist either. The names of physical ill¬ nesses do not refer to concrete entities, for "Diseases are not things in the same sense as rocks, or trees, or rivers. Diseases are not material."5 Although diseases might be caused by the presence in the body of some such entity (as a cold may be caused by a virus), and although they might be associated with symptoms that are concrete en¬ tities (eg, the fluid present in the sinuses), a physical ill¬ ness is not (identical with) either its causes or its symp¬ toms. The only thing one can fix as the reference of the names of various physical illnesses are states the ill are in, abstract entities incapable of being pointed at in some os¬ tensive definition. 3. In any case, most of the things people have wanted to say about mental illness can be said without making onto¬ logical commitments to any entity, concrete or abstract, .
.
.
referred to by the phrase, and thus any criticism of its use based on its lack of a referent, ostensive or otherwise, is misconceived. In his essay on Sense and Reference Frege made famous the distinction between the sense of a term, and its reference.6 The important corollary for our purpose is that words may be used significantly (make good sense) and yet not refer. As Quine has elaborated, "Being a name of something is a much more special feature than being meaningful." Even "[a] singular term need not name to be
significant.""pp911)
This is particularly evident in our use of predicates. We say "some dogs are white" or "some houses are red," without making ontological commitments to (without pre¬ supposing there are such things as) whiteness or redness. Similarly, we can say that "some persons are mentally ill" without making ontological commitments to any thing re¬ ferred to by "illness." More colloquially, the denial of the existence of any thing called mental illness hardly entails a denial of the existence of persons who are mentally ill. In addition to describing people as being mentally ill, we also often wish to explain their behavior as being due to their mental illness. While such statements as "He did it because of his mental illness" appear to require an en¬ tity referred to by the phrase "mental illness," in fact such explanations mean nothing more than is conveyed by "He did it because he is mentally ill"—another use of the predicate, "is mentally ill" that does not require a refer¬ ence to be significant. To the extent that common and psychiatric discourse about mental illness can be paraphrased so as to avoid the hypostasis of an entity named by the phrase, then any criticism that complains that there is no such thing as mental illness is beside the point; for orthodox psychiatry and common understanding can happily agree, but still use the phrase to make significant (albeit nonreferring) statements. We often make use of the names of states, at¬ tributes, properties, and traits as if they named some things in our ontology, for economy of speech is often gained by so doing. To be sure, if someone (such as Szasz) makes an issue of the ontological commitments involved in our uses of "redness," or "illness," "the burden is of course on us to paraphrase or retract."3""001 However, if we can paraphrase the usage into the noncommitting use of "ill," then the phraseology is a harmless but convenient mode of speaking, against which the "ontological dis¬ covery" of radical psychiatry is irrelevant. For my own part, I think this detour into ontology is a red herring. The lack of any thing one can point to as the referent of the phrase "mental illness" does not do ortho¬ dox psychiatry the damage Szasz and his followers sup¬ pose; if mental illness is a myth in this sense, it is in the good company of many other words and phrases useful in science and everyday life that have either no reference or a reference only to abstract entities. That this herring is constantly being dragged across our path is doubtless due to the immense popular appeal the denial-of-existence idiom has when used in the hands of a skillful polemist. It makes the study of mental illness sound about as useful as the study of unicorns. Once one perceives that ontological status is not really an issue here, then other types of arguments must be marcan
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shalled in favor of
vocabulary. The
Myth
eliminating as an
"mental illness" from
our
Empirical Discovery: Mentally III
No One Is in Fact
.
The residents who remain in 'mental hospitals' are behaving in a perfectly rational manner to achieve a personally satisfying way in of life—of ten the most satisfying of which they are capable a certain sense an individual chooses his career as a mental pa¬ tient; it is not thrust upon him as a consequence of his somehow becoming 'mentally ill.' But in just what sense does the individual 'choose' his career? In our view, having and maintaining the status of a mental patient is the outcome of purposive behavior. Furthermore, given the life circumstances of most of the persons who become and remain residents of mental hospitals, their doing so evinces a realistic appraisal of their available alternatives; it is, in short, a rational choice.2""'" ...
The central thrust of this form of the argument is not to claim that "mental illness" or "mentally ill" are mean¬ ingless—their meaning is assumed to be closely connected with that of "irrational"—but to dispute as a factual mat¬ ter that there are persons who fit the agreed-upon defini¬ tion of mental illness (irrationality). In fact, however, what has been done here is not to present a discovery of new facts, overlooked by orthodox psychiatrists because of their own self-interest or whatever, but rather to stretch our concepts of "rationality" and "purposive behavior" to accommodate within their criteria facts well-known to or¬ thodox, as well as to radical, psychiatrists. The facts—the behavior of patients—are often undisputed. What is dis¬ puted is the precise nature of the criterion to be applied in judging the behavior as rational or not. As the above quotations from Szasz and Braginsky et al make clear, the notion of rationality relevant here is linked to the actor having reasons (purposes, motives) for his actions. A more precise account of the relationship be¬ tween an agent being thought to be rational and his act¬ ing for reasons may perhaps best be brought out by the following schema of reason-giving explanations. When we explain an action by giving the actor's motive, the follow¬ ing premises are involved: 1. Agent X wants result R to obtain. 2. X believes that in situation S, action A will 3. X believes that he is in situation S.
cause
premises, it follows that X will do A. ordinary English, in order to make out a motivation¬ explanation we need to know what the agent wanted
With these
Often mental illness is said to be a myth, not just in the sense that it does not exist, but also in the sense that no one is in fact mentally ill. The claim, in other words, denies not just that "mental illness" is a name of some thing, but that "mentally ill" is ever truly predicable of a person. The claim is that no one is really mentally ill. This claim that mental illness is a myth is put forward as an empirical discovery—all of those people that have been thought to be mentally ill (ie, irrational) are in fact just as rational as you and I. Szasz makes this claim when he argues that "insane behavior, no less than sane, is goaldirected and motivated ." and concludes from this that we should regard "the behavior of the madman as per¬ rational from the point of view of the actor. fectly »8
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Secondly, Szasz in other points in his works makes the rather curious argument that psychiatrists cannot classify human behavior because human beings react to the classificatory labels placed upon them, whereas stones, plants, stars, etc, do not. This error is "not due to any lack of hu¬ mane feeling in psychiatrists, but rather to the fallacy of thinking in terms of natural science." This approach ig¬ nores "the differences between persons and things and the effects of language on each." In the orthodox account of mental disease, Szasz asks, 'What is the status of human action ..?' The answer is: 'None.' There is no such thing as action to attain a goal—only behavior de¬ termined by causes. Herein lies the fundamental error of the med¬ ical and mechanomorphic approach to human behavior and to psy¬ chiatric classification.24"""91-1961 .
The first of these two additional attacks
on
the classi-
ficatory scheme is mistaken for the reasons discussed in the following subsection—there is no logical error in sup¬ posing that mental incapacities can be correlated with brain events to form composite aggregations of symptoms
even if minds are not identical with brains. Discussion of this will be deferred briefly. The second of Szasz's argu¬ ments here obviously has nothing to do with "the logic of classification," as Szasz sometimes terms his Rylean weap¬ onry. The blunt fact of the matter is that in everyday life and in social science we do classify human behavior all the time, and the fact that those labelled "patriotic," "am¬ bitious," "greedy," or "schizophrenic" may not care for the label has nothing whatsoever to do with their propriety for descriptive or explanatory purposes. One might have ethical qualms about telling the subjects they are being so classified, particularly if one has the authority of a psychi¬ atrist in a mental hospital to make the label stick; such ethical qualms, or their associated therapeutic concerns, are totally beside the point if one is judging psychiatric classifications of behavior by their logical or scientific methodology. The error, if any there be, is more akin to that of a nuclear physicist working on the atomic bomb—a mistaken sense of personal value, perhaps, but hardly a mistake in the scientific methodology of nuclear physics. There are questions that might be raised about the diagnostic categories of psychiatry, but they are not ques¬ tions of category difference. The aggregation of symp¬ toms associated with hysteria, schizophrenia, etc, form in¬ ductive claims whose nature is clear—as clear as the nature of the claim that people who tend to look in the mirror often also tend to feel pleased when flattered, avoid conversations in which others are praised, etc (Ryle's partial unpacking of the character trait of vanity). There is nothing logically suspect about the inductive pro¬ cess by which we classify familiar, as well as bizarre be¬ havior, into character traits and mental diseases. 4. The heaviest burden placed by Szasz on the category mistake version of the myth argument comes in another of his uses of it-his attempt to construct a logical chasm out of Ryle's categorical differences. For Szasz not only as¬ serts that "schizophrenia" and other terms are not pres¬ ently to be explained by reference to mechanical causes, but appears to insist that such explanations cannot be given, no matter what medical discoveries might be made; unlike physical illnesses, those syndromes we call mental
illnesses cannot be caused by some set of physiological events. In this logical claim he is surely in error. What Szasz has in mind here are the distinctions R. S. Peters (building on Ryle and Wittgenstein) drew between actions and movements and between reasons and causes.25 Physical bodies, including the physical bodies of human beings, move through space in a manner describable by physical descriptions in terms of velocities, accelerations,
spatial coordinates, directions,
etc.
According
to
Peters,
such movements of the human body constitute actions, however, only if they are seen in the light of human con¬ ventions—the physical movements of the arm and fingers in moving wooden figures on a checkered board only con¬ stitute the action of "castling his king" in light of an in¬ telligent agent following the rules of chess. Further, on the Peters view, it is only physical movements that can be explained by the mechanical causes provided by the laws of physics, whereas for actions, only reasons (purposive rule-following) are appropriate. One neither explains the orbiting of the planets by reference to their motives nor does one explain why another human being castled his king by reference to his synaptic firing patterns. While I do not believe that Peters' (or Szasz's) rule-fol¬ lowing analysis is adequate as a general account of human action, but rather represents an analysis of one species of complex actions, it does not matter for present purposes. For Szasz and Peters do have hold of part of a very impor¬ tant and far-reaching result of the analytic philosophy of the last 25 years—embedded in our language are two fun¬ damentally dissimilar ways of describing and explaining things in the world, variously polarized as the language of actions vs that of movements, of reasons vs that of causes, of teleology vs that of mechanism, Intentional idioms vs the nonlntentional, intensional talk vs extensional, the language used to describe meaningful behavior vs that used to describe the inanimate, those claims known with certainty vs those claims supported only by fallible, induc¬ tive inferences, as in science. In numerous ways philoso¬ phers have sought to capture the striking fact that the words we apply to describe and explain the doings of per¬ sons differ significantly from the words we use to describe and explain natural phenomena. The even more striking result of this work has been to revive (with some dissent) Brentano's irreducibility thesis, which holds that one can¬ not reduce our "person-talk" to the language of physical science. We not only have two dissimilar modes of speak¬ ing, but we are stuck with them for we have no way to paraphrase the idiom of one to that of the other. If one accepts none of this, then of course it is no mis¬ take to believe that mental illness may be physically caused. Even if one grants the existence of this funda¬ mental cleavage in one's speech, and its irreducibility, however, that does not mean (contra Peters and Szasz) that the various mental illnesses may not be explained by reference to physiological events or any other mechanical causes; this, for two reasons-(l) what the irreducibility thesis entails is that one cannot identify mental entities such as beliefs, desires, pains, etc, with physical events, ei¬ ther behavioristic or physiological. One of the reasons for this is the idea that Szasz quotes4"1171· from Peters: move¬ ments "cannot be characterized as intelligent or unintelli-
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gent, correct or incorrect, efficient or inefficient." One may
only describe actions with such adjectives.25""" Since one of the principal requirements of using the identity sign is that the expressions referring to the same thing be substitutable for one another without change of truth value, one cannot identify action with movements, but this argu¬ ment goes only against identifying mental entities with physical ones; it says nothing about correlating the two and calling one the cause of the other, for there is no substitutivity requirement for the names of effects and their causes. More generally, the irreducibility thesis does not entail that one may not correlate, eg, the mental experi¬ ence of pain, with certain physiological events (the stimu¬ lation of C fibers in the brain). Nor does it entail that, eg, schizophrenia may not be correlated with some sorts of events in the brain. As importantly, "mental illness" does not seem to share just those features of mental concepts that differentiate them from the concepts used in physical science. Specifi¬ cally, (a) "mental illness" and its subspecies are not the names of mental experiences, as are "pain," "wish," etc; the names of the various forms of mental illness are more like the names of character traits, such as "stupidity" or "greed," that is, inductively built up from overt behavior alone. (6) The names of the various forms of mental illness do not imply intelligent, purposive behavior, as do some character traits. Like "stupidity" and "violent character," but unlike "greed," "schizophrenia," and like terms do not presuppose goal-directed behavior. Rather, the names of the various mental illnesses negate the assumption of ra¬ tionality, which is in some cases to negate the goal-di¬ rected nature of the behavior, (c) Like character traits, but unlike mental experiences and intentional actions, mental illness is known to the subject only by the usual infer¬ ential processes of scientific thinking. One knows what ac¬ tion he is performing, or that he is in pain, without evi¬ dence or observation; he knows that he is mentally ill only on the basis of evidence (that is often brought to his at¬ tention by others). Hence, even if such correlations were logically impos¬ sible for most other mental-conduct terms, it would be possible to correlate schizophrenia and like terms with events in physiology without significant change in mean¬ ing of the terms. One could only support this assertion with a detailed review of the various arguments given against such a thesis in general, and by demonstrating how each such argument fails to apply to the nonintelli¬ gent, nonexperiential, fallibly known syndromes we call mental illnesses. Since in any event, there is no logical reason for denying causal correlations in the first place, one need not pursue this line of argument here. None of this is to say that such correlations between the syndromes we label as mental illnesses of various kinds and physiology do exist—for one cannot tell in advance what slices of behavior can be correlated with what slices of physiology (this is true no matter how strictly one sub¬ scribes to determinism). It is a question for empirical discovery, and logical arguments either way are not de¬ terminative. The correlations between the disposition to bleed profusely and certain chemical states of the blood (hemophilia); violent character and XYY genetic makeup;
and certain addictions (dispositions to act in certain ways) and the events in physiology that cause them are all sug¬ gestive examples. Whether similar correlations can be found between schizophrenia and certain happenings in physiology is a matter calling for painstaking research, not for the armchair guess-work more frequently found in philosophy than in medicine. It might be argued that it is illegitimate of psychia¬ trists to anticipate such discoveries before they are made by use of implicitly causal disease words such as "schizo¬ phrenia" or "kleptomania." Szasz argues, for example, that it is "faulty reasoning for it makes the abstraction 'mental illness' into a cause of, even though this abstrac¬ tion was originally created to serve only as a shorthand expression for, certain types of human behavior."24
Myths About "Mental
Illness"
Michael S. Moore, JD
\s=b\ Radical psychiatrists and others assert that mental illness is myth. The opening and closing portions of the article deal with the impact such an argument has had in law and psychiatry. The body of the article discusses the five following versions of the myth argument prevalent in radical psychiatry: (1) that there is no such thing as mental illness; (2) that those called "mentally ill" are really as rational as everyone else, only with different aims, that the only reasons anyone ever thought differently was (3) because of unsophisticated category mistakes or (4) because of an adherence to the epistemology of a sick society;and (5) that the phrase "mental illness" is used to mask value judgments about others' behavior in pseudoscientific respectability. Reasons are given for rejecting each of these versions of the ar¬ gument that mental illness is a myth. (Arch Gen Psychiatry 32:1483-1497, 1975) a
of mental illness has had a long and in man's thoughts about himself, his nature, and his responsibility. It stands at one junction of law, morals, and medicine, with the result that lawyers, psychiatrists, and philosophers have long shared a concern for the nature of the concept. This shared concern has not given rise to any consensus, however, and the debates, particularly between lawyers and psychiatrists, have often been acrimonious and unfruitful. Since the advent of "radical psychiatry," the theoretical justification of which is to be found notably in the works of Thomas Szasz, the battle lines have been redrawn somewhat along other than professional lines, but the result has not been added clarity about the nature of the concept of mental disease or its moral and legal relevance. Indeed, quite the reverse has occurred, so that essen¬ tially ethical and political questions about psychiatric practices or legal doctrines with regard to the mentally ill are increasingly answered by the trundling out of the con¬ temporary shibboleth that mental illness is a myth rather than in terms of the ethical and political arguments neces¬ sary to answer such questions. There is a disturbing tend-
concept Theinteresting history
Accepted for publication July 30, From the
1975.
University of Kansas School of Law, Lawrence. Reprint requests to University of Kansas School of Law, Lawrence,
66045
(Prof Moore).
KS
issues, notably the proper place of mental illness in various legal tests (of insanity in criminal trials, of incompetency to perform various legal acts or to stand trial, the tests for civil commitment), as solved by the new truth that mental illness is but a myth anyway. Equally disturbing is the apparent belief that problems of social policy and social justice, such as what in fact society should do with dangerous persons who have not committed any criminal acts, are satisfactorily re¬ solved if legislatures would but recognize mental illness ency to regard complicated legal
for the sham that it is. If mental illness were a myth, acceptance of such a truth would provide straightforward answers to such le¬ gal, ethical, and political questions. One would not have to muddle along in the grubby details of comparing awful prisons with almost as awful hospitals for the criminally insane. One would not have to grapple with difficult policy issues, such as the rationale for punishment generally and its relation to those found to be not guilty by reason of in¬ sanity, for it would be instantly clear that those we call mentally ill should be punished just like anyone else if they commit a criminal act; that they should have all the rights of an accused criminal if society should seek to de¬ prive them of their liberty no matter how the proceeding or the place of confinement might be named; that legal tests should abolish the phrase; and, easiest of all, that psychiatrists should mind their own business and leave the law to the lawyers. The problem is that mental illness is not a myth. It is not some palpable falsehood propagated among the popu¬ lace by power-mad psychiatrists, but a cruel and bitter reality that has been with the human race since antiquity. This is such an obvious truism that to have stated it 20 years ago would have been an embarrassment. Since the advent of radical psychiatry and its legal entourage, how¬ ever, such truths need restatement. Even more, they need restatement in a form specifically addressed to the various senses in which mental illness has been thought to be a myth. Since on my reading of the radical psychiatrists there seem to be five distinguishable points they have in mind in thinking of mental illness as a myth, the discus¬ sion will proceed by considering them seriatim.
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THE MYTHOLOGY OF RADICAL PSYCHIATRY The Myth as a Question of Ontological Status: There Is No Such Thing as Mental Illness Because There Is No Referent of the Phrase
Mental illness is
myth because, as quoted by the pres¬ Supreme Court, "there is neither such a thing as 'insanity' nor such a thing as 'mental disease.' These terms do not identify entities having separate existence. ."11',"MI As was more formal¬ ly stated: a
ent Chief Justice of the United States
.
.
term without ostensive referrent [sic], and lacking any, it cannot even be said to have outlived its usefulness, because there is no reason to think that it ever had any.2"'16'"
It is
a
Szasz and his psychiatric and legal followers are suspicious of mental illness as an entity or thing; when looking into their ontology, they see no such thing. The following three points require discussion here: 1. If the argument is that entity-thinking as such is to be regarded with suspicion, as Szasz at times suggests, then the critique is radical indeed. As Quine has noted, "we talk so inveterately of objects that to say we do so seems almost to say nothing at all; for how else is there to talk?"3""' Thing-theory is implicit throughout our ordi¬ nary and scientific speech, and it is simply wrong to re¬ gard it as some primitive form of speech that is replaced with a more sophisticated mode of talk with the maturity of a science. Thus, Szasz's statement that "Entity-think¬ ing has always preceded process-thinking"4(pl> is not an accurate characterization of the development of modern science. In fact, higher order theoretical statements char¬ acteristic of advancing science increase the number of en¬ tities we admit into our ontology, not decrease it. Forces, fields, and electrons are obvious examples. 2. If the argument is that entity-thinking is scien¬ tifically legitimate, but only about those entities referred to by terms capable of ostensive reference, such as "Nixon," or "St Elizabeth's Hospital," the radical psychia¬ trists have a radically impoverished ontology—a nomi¬ nalist ontology that would not admit the "thinghood" of abstract entities such as the number two, squareness, shape, zoological species, or, more to the point perhaps, psychological states. Such a restricted ontology is charac¬ teristic neither of science nor of common understanding. Indeed, in such a restrictive ontological system physical illnesses would not exist either. The names of physical ill¬ nesses do not refer to concrete entities, for "Diseases are not things in the same sense as rocks, or trees, or rivers. Diseases are not material."5 Although diseases might be caused by the presence in the body of some such entity (as a cold may be caused by a virus), and although they might be associated with symptoms that are concrete en¬ tities (eg, the fluid present in the sinuses), a physical ill¬ ness is not (identical with) either its causes or its symp¬ toms. The only thing one can fix as the reference of the names of various physical illnesses are states the ill are in, abstract entities incapable of being pointed at in some os¬ tensive definition. 3. In any case, most of the things people have wanted to say about mental illness can be said without making onto¬ logical commitments to any entity, concrete or abstract, .
.
.
referred to by the phrase, and thus any criticism of its use based on its lack of a referent, ostensive or otherwise, is misconceived. In his essay on Sense and Reference Frege made famous the distinction between the sense of a term, and its reference.6 The important corollary for our purpose is that words may be used significantly (make good sense) and yet not refer. As Quine has elaborated, "Being a name of something is a much more special feature than being meaningful." Even "[a] singular term need not name to be
significant.""pp911)
This is particularly evident in our use of predicates. We say "some dogs are white" or "some houses are red," without making ontological commitments to (without pre¬ supposing there are such things as) whiteness or redness. Similarly, we can say that "some persons are mentally ill" without making ontological commitments to any thing re¬ ferred to by "illness." More colloquially, the denial of the existence of any thing called mental illness hardly entails a denial of the existence of persons who are mentally ill. In addition to describing people as being mentally ill, we also often wish to explain their behavior as being due to their mental illness. While such statements as "He did it because of his mental illness" appear to require an en¬ tity referred to by the phrase "mental illness," in fact such explanations mean nothing more than is conveyed by "He did it because he is mentally ill"—another use of the predicate, "is mentally ill" that does not require a refer¬ ence to be significant. To the extent that common and psychiatric discourse about mental illness can be paraphrased so as to avoid the hypostasis of an entity named by the phrase, then any criticism that complains that there is no such thing as mental illness is beside the point; for orthodox psychiatry and common understanding can happily agree, but still use the phrase to make significant (albeit nonreferring) statements. We often make use of the names of states, at¬ tributes, properties, and traits as if they named some things in our ontology, for economy of speech is often gained by so doing. To be sure, if someone (such as Szasz) makes an issue of the ontological commitments involved in our uses of "redness," or "illness," "the burden is of course on us to paraphrase or retract."3""001 However, if we can paraphrase the usage into the noncommitting use of "ill," then the phraseology is a harmless but convenient mode of speaking, against which the "ontological dis¬ covery" of radical psychiatry is irrelevant. For my own part, I think this detour into ontology is a red herring. The lack of any thing one can point to as the referent of the phrase "mental illness" does not do ortho¬ dox psychiatry the damage Szasz and his followers sup¬ pose; if mental illness is a myth in this sense, it is in the good company of many other words and phrases useful in science and everyday life that have either no reference or a reference only to abstract entities. That this herring is constantly being dragged across our path is doubtless due to the immense popular appeal the denial-of-existence idiom has when used in the hands of a skillful polemist. It makes the study of mental illness sound about as useful as the study of unicorns. Once one perceives that ontological status is not really an issue here, then other types of arguments must be marcan
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shalled in favor of
vocabulary. The
Myth
eliminating as an
"mental illness" from
our
Empirical Discovery: Mentally III
No One Is in Fact
.
The residents who remain in 'mental hospitals' are behaving in a perfectly rational manner to achieve a personally satisfying way in of life—of ten the most satisfying of which they are capable a certain sense an individual chooses his career as a mental pa¬ tient; it is not thrust upon him as a consequence of his somehow becoming 'mentally ill.' But in just what sense does the individual 'choose' his career? In our view, having and maintaining the status of a mental patient is the outcome of purposive behavior. Furthermore, given the life circumstances of most of the persons who become and remain residents of mental hospitals, their doing so evinces a realistic appraisal of their available alternatives; it is, in short, a rational choice.2""'" ...
The central thrust of this form of the argument is not to claim that "mental illness" or "mentally ill" are mean¬ ingless—their meaning is assumed to be closely connected with that of "irrational"—but to dispute as a factual mat¬ ter that there are persons who fit the agreed-upon defini¬ tion of mental illness (irrationality). In fact, however, what has been done here is not to present a discovery of new facts, overlooked by orthodox psychiatrists because of their own self-interest or whatever, but rather to stretch our concepts of "rationality" and "purposive behavior" to accommodate within their criteria facts well-known to or¬ thodox, as well as to radical, psychiatrists. The facts—the behavior of patients—are often undisputed. What is dis¬ puted is the precise nature of the criterion to be applied in judging the behavior as rational or not. As the above quotations from Szasz and Braginsky et al make clear, the notion of rationality relevant here is linked to the actor having reasons (purposes, motives) for his actions. A more precise account of the relationship be¬ tween an agent being thought to be rational and his act¬ ing for reasons may perhaps best be brought out by the following schema of reason-giving explanations. When we explain an action by giving the actor's motive, the follow¬ ing premises are involved: 1. Agent X wants result R to obtain. 2. X believes that in situation S, action A will 3. X believes that he is in situation S.
cause
premises, it follows that X will do A. ordinary English, in order to make out a motivation¬ explanation we need to know what the agent wanted
With these
Often mental illness is said to be a myth, not just in the sense that it does not exist, but also in the sense that no one is in fact mentally ill. The claim, in other words, denies not just that "mental illness" is a name of some thing, but that "mentally ill" is ever truly predicable of a person. The claim is that no one is really mentally ill. This claim that mental illness is a myth is put forward as an empirical discovery—all of those people that have been thought to be mentally ill (ie, irrational) are in fact just as rational as you and I. Szasz makes this claim when he argues that "insane behavior, no less than sane, is goaldirected and motivated ." and concludes from this that we should regard "the behavior of the madman as per¬ rational from the point of view of the actor. fectly »8
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Secondly, Szasz in other points in his works makes the rather curious argument that psychiatrists cannot classify human behavior because human beings react to the classificatory labels placed upon them, whereas stones, plants, stars, etc, do not. This error is "not due to any lack of hu¬ mane feeling in psychiatrists, but rather to the fallacy of thinking in terms of natural science." This approach ig¬ nores "the differences between persons and things and the effects of language on each." In the orthodox account of mental disease, Szasz asks, 'What is the status of human action ..?' The answer is: 'None.' There is no such thing as action to attain a goal—only behavior de¬ termined by causes. Herein lies the fundamental error of the med¬ ical and mechanomorphic approach to human behavior and to psy¬ chiatric classification.24"""91-1961 .
The first of these two additional attacks
on
the classi-
ficatory scheme is mistaken for the reasons discussed in the following subsection—there is no logical error in sup¬ posing that mental incapacities can be correlated with brain events to form composite aggregations of symptoms
even if minds are not identical with brains. Discussion of this will be deferred briefly. The second of Szasz's argu¬ ments here obviously has nothing to do with "the logic of classification," as Szasz sometimes terms his Rylean weap¬ onry. The blunt fact of the matter is that in everyday life and in social science we do classify human behavior all the time, and the fact that those labelled "patriotic," "am¬ bitious," "greedy," or "schizophrenic" may not care for the label has nothing whatsoever to do with their propriety for descriptive or explanatory purposes. One might have ethical qualms about telling the subjects they are being so classified, particularly if one has the authority of a psychi¬ atrist in a mental hospital to make the label stick; such ethical qualms, or their associated therapeutic concerns, are totally beside the point if one is judging psychiatric classifications of behavior by their logical or scientific methodology. The error, if any there be, is more akin to that of a nuclear physicist working on the atomic bomb—a mistaken sense of personal value, perhaps, but hardly a mistake in the scientific methodology of nuclear physics. There are questions that might be raised about the diagnostic categories of psychiatry, but they are not ques¬ tions of category difference. The aggregation of symp¬ toms associated with hysteria, schizophrenia, etc, form in¬ ductive claims whose nature is clear—as clear as the nature of the claim that people who tend to look in the mirror often also tend to feel pleased when flattered, avoid conversations in which others are praised, etc (Ryle's partial unpacking of the character trait of vanity). There is nothing logically suspect about the inductive pro¬ cess by which we classify familiar, as well as bizarre be¬ havior, into character traits and mental diseases. 4. The heaviest burden placed by Szasz on the category mistake version of the myth argument comes in another of his uses of it-his attempt to construct a logical chasm out of Ryle's categorical differences. For Szasz not only as¬ serts that "schizophrenia" and other terms are not pres¬ ently to be explained by reference to mechanical causes, but appears to insist that such explanations cannot be given, no matter what medical discoveries might be made; unlike physical illnesses, those syndromes we call mental
illnesses cannot be caused by some set of physiological events. In this logical claim he is surely in error. What Szasz has in mind here are the distinctions R. S. Peters (building on Ryle and Wittgenstein) drew between actions and movements and between reasons and causes.25 Physical bodies, including the physical bodies of human beings, move through space in a manner describable by physical descriptions in terms of velocities, accelerations,
spatial coordinates, directions,
etc.
According
to
Peters,
such movements of the human body constitute actions, however, only if they are seen in the light of human con¬ ventions—the physical movements of the arm and fingers in moving wooden figures on a checkered board only con¬ stitute the action of "castling his king" in light of an in¬ telligent agent following the rules of chess. Further, on the Peters view, it is only physical movements that can be explained by the mechanical causes provided by the laws of physics, whereas for actions, only reasons (purposive rule-following) are appropriate. One neither explains the orbiting of the planets by reference to their motives nor does one explain why another human being castled his king by reference to his synaptic firing patterns. While I do not believe that Peters' (or Szasz's) rule-fol¬ lowing analysis is adequate as a general account of human action, but rather represents an analysis of one species of complex actions, it does not matter for present purposes. For Szasz and Peters do have hold of part of a very impor¬ tant and far-reaching result of the analytic philosophy of the last 25 years—embedded in our language are two fun¬ damentally dissimilar ways of describing and explaining things in the world, variously polarized as the language of actions vs that of movements, of reasons vs that of causes, of teleology vs that of mechanism, Intentional idioms vs the nonlntentional, intensional talk vs extensional, the language used to describe meaningful behavior vs that used to describe the inanimate, those claims known with certainty vs those claims supported only by fallible, induc¬ tive inferences, as in science. In numerous ways philoso¬ phers have sought to capture the striking fact that the words we apply to describe and explain the doings of per¬ sons differ significantly from the words we use to describe and explain natural phenomena. The even more striking result of this work has been to revive (with some dissent) Brentano's irreducibility thesis, which holds that one can¬ not reduce our "person-talk" to the language of physical science. We not only have two dissimilar modes of speak¬ ing, but we are stuck with them for we have no way to paraphrase the idiom of one to that of the other. If one accepts none of this, then of course it is no mis¬ take to believe that mental illness may be physically caused. Even if one grants the existence of this funda¬ mental cleavage in one's speech, and its irreducibility, however, that does not mean (contra Peters and Szasz) that the various mental illnesses may not be explained by reference to physiological events or any other mechanical causes; this, for two reasons-(l) what the irreducibility thesis entails is that one cannot identify mental entities such as beliefs, desires, pains, etc, with physical events, ei¬ ther behavioristic or physiological. One of the reasons for this is the idea that Szasz quotes4"1171· from Peters: move¬ ments "cannot be characterized as intelligent or unintelli-
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gent, correct or incorrect, efficient or inefficient." One may
only describe actions with such adjectives.25""" Since one of the principal requirements of using the identity sign is that the expressions referring to the same thing be substitutable for one another without change of truth value, one cannot identify action with movements, but this argu¬ ment goes only against identifying mental entities with physical ones; it says nothing about correlating the two and calling one the cause of the other, for there is no substitutivity requirement for the names of effects and their causes. More generally, the irreducibility thesis does not entail that one may not correlate, eg, the mental experi¬ ence of pain, with certain physiological events (the stimu¬ lation of C fibers in the brain). Nor does it entail that, eg, schizophrenia may not be correlated with some sorts of events in the brain. As importantly, "mental illness" does not seem to share just those features of mental concepts that differentiate them from the concepts used in physical science. Specifi¬ cally, (a) "mental illness" and its subspecies are not the names of mental experiences, as are "pain," "wish," etc; the names of the various forms of mental illness are more like the names of character traits, such as "stupidity" or "greed," that is, inductively built up from overt behavior alone. (6) The names of the various forms of mental illness do not imply intelligent, purposive behavior, as do some character traits. Like "stupidity" and "violent character," but unlike "greed," "schizophrenia," and like terms do not presuppose goal-directed behavior. Rather, the names of the various mental illnesses negate the assumption of ra¬ tionality, which is in some cases to negate the goal-di¬ rected nature of the behavior, (c) Like character traits, but unlike mental experiences and intentional actions, mental illness is known to the subject only by the usual infer¬ ential processes of scientific thinking. One knows what ac¬ tion he is performing, or that he is in pain, without evi¬ dence or observation; he knows that he is mentally ill only on the basis of evidence (that is often brought to his at¬ tention by others). Hence, even if such correlations were logically impos¬ sible for most other mental-conduct terms, it would be possible to correlate schizophrenia and like terms with events in physiology without significant change in mean¬ ing of the terms. One could only support this assertion with a detailed review of the various arguments given against such a thesis in general, and by demonstrating how each such argument fails to apply to the nonintelli¬ gent, nonexperiential, fallibly known syndromes we call mental illnesses. Since in any event, there is no logical reason for denying causal correlations in the first place, one need not pursue this line of argument here. None of this is to say that such correlations between the syndromes we label as mental illnesses of various kinds and physiology do exist—for one cannot tell in advance what slices of behavior can be correlated with what slices of physiology (this is true no matter how strictly one sub¬ scribes to determinism). It is a question for empirical discovery, and logical arguments either way are not de¬ terminative. The correlations between the disposition to bleed profusely and certain chemical states of the blood (hemophilia); violent character and XYY genetic makeup;
and certain addictions (dispositions to act in certain ways) and the events in physiology that cause them are all sug¬ gestive examples. Whether similar correlations can be found between schizophrenia and certain happenings in physiology is a matter calling for painstaking research, not for the armchair guess-work more frequently found in philosophy than in medicine. It might be argued that it is illegitimate of psychia¬ trists to anticipate such discoveries before they are made by use of implicitly causal disease words such as "schizo¬ phrenia" or "kleptomania." Szasz argues, for example, that it is "faulty reasoning for it makes the abstraction 'mental illness' into a cause of, even though this abstrac¬ tion was originally created to serve only as a shorthand expression for, certain types of human behavior."24
