While I have argued that mental illnesses do not exist, I obviously did not imply that the social and psychological occurrences to which this label is currently being attached also do not exist.  Like the personal and social troubles which people had in the Middle Ages, they are real enough.  It is the labels we give them that concerns us and, having labelled them, what we do about them.  While I cannot go into the ramified implications of this problem here, it is worth noting that a demonologic conception of problems in living gave rise to therapy along theological lines. Today, a belief in mental illness implies -- nay, requires--therapy along medical or psychotherapeutic lines. What is implied in the line of thought set forth here is something quite different.  I do not intend to offer a new conception of "psychiatric illness" nor a new form of "therapy."  My aim is more modest and yet also more ambitious. It is to suggest that the phenomena now called mental illnesses be looked at afresh and more simple, that they be removed from the category of illness, and that they be regarded as the expressions of man's struggle with the problem of how he should live. The last mentioned problem is obviously a vast one, its enormity reflecting not only man's inability to cope with his environment, but even more his increasing self-reflectiveness.

The diversity of human values and the methods by means of which they may be realized is so vast, and many of them remain so unacknowledged, that they cannot fail but lead to conflicts in human relations.  Indeed, to say that human relations at all levels -- from mother to child, through husband and wife, to nation and nation -- are fraught with stress, strain, and disharmony is, once again, making the obvious explicit.  Yet, what may be obvious may be also poorly understood. This I think is the case here.  For it seems to me that -- at least in our scientific theories of behavior -- we have failed to accept the simple fact that human relations are inherently fraught with difficulties and that to make them even relatively harmonious requires much patience and hard work. I submit that the idea of mental illness is now being put to work to obscure certain difficulties which at present may be inherent -- not that they need be unmodifiable -- in the social intercourse of persons.  If this is true, the concept functions as a disguise; for instead of calling attention to conflicting human needs, aspirations, and values, the notion of mental illness provides an amoral and impersonal "thing" (an "illness") as an explanation for problems in living (Szasz, 1959).  We may recall in this connection that not so long ago it was devils and witches who were held responsible for men's problems in social living.  The belief in mental illness, as something other than man's trouble in getting along with his fellow man, is the proper heir to the belief in demonology and witchcraft. Mental illness exists or is "real" in exactly the same sense in which witches existed or were "real."  

Psychiatry, I submit, is very much more intimately tied to problems of ethics than is medicine. I use the word "psychiatry" here to refer to that contemporary discipline which is concerned with problems in living (and not with diseases of the brain, which are problems for neurology).  Problems in human relations can be analyzed, interpreted, and given meaning only within given social and ethical contexts. Accordingly, it does make a difference -- arguments to the contrary notwithstanding -- what the psychiatrist's socioethical orientations happen to be; for these will influence his ideas on what is wrong with the patient, what deserves comment or interpretation, in what possible directions change might be desirable, and so forth.  Even in medicine proper, these factors play a role, as for instance, in the divergent orientations which physicians, depending on their religious affiliations, have toward such things as birth control and therapeutic abortion.  Can anyone really believe that a psychotherapist's ideas concerning religious belief, slavery, or other similar issues play no role in his practical work? If they do make a difference, what are we to infer from it?  Does it not seem reasonable that we ought to have different psychiatric therapies -- each, expressly recognized for the ethical positions which they embody -- for, say, Catholics and Jews, religious persons and agnostics, democrats and communists, white supremacists and Negroes, and so on?  Indeed, if we look at how psychiatry is actually practiced today (especially in the United States), we find that people do seek psychiatric help in accordance with their social status and ethical beliefs (Hollingshead & Redlich, 1958).  This should really not surprise us more than being told that practicing Catholics rarely frequent birth control clinics.

To recapitulate: In actual contemporary social usage, the finding of a mental illness is made by establishing a deviance in behavior from certain psychosocial, ethical, or legal norms.  The judgment may be made, as in medicine, by the patient, the physician (psychiatrist), or others.  Remedial action, finally, tends to be sought in a therapeutic -- or covertly medical -- framework, thus creating a situation in which psychosocial, ethical, and/or legal deviations are claimed to be correctible by (so-called) medical action.   Since medical action is designed to correct only medical deviations, it seems logically absurd to expect that it will help solve problems whose very existence had been defined and established on nonmedical grounds.  I think that these considerations may be fruitfully applied to the present use of tranquilizers and, more generally, to what might be expected of drugs of whatever type in regard to the amelioration or solution of problems in human living.  

"Mental illnesses" are thus regarded as basically no different than all other diseases (that is, of the body).  The only difference, in this view, between mental and bodily diseases is that the former, affecting the brain, manifest themselves by means of mental symptoms; whereas the latter, affecting other organ systems (for example, the skin, liver, etc.), manifest themselves by means of symptoms referable to those parts of the body.  This view rests on and expresses what are, in my opinion, two fundamental errors. In the first place, what central nervous system symptoms would correspond to a skin eruption or a fracture?  It would not be some emotion or complex bit of behavior. Rather, it would be blindness or a paralysis of some part of the body. The crux of the matter is that a disease of the brain, analogous to a disease of the skin or bone, is a neurological defect, and not a problem in living. For example, a defect in a person's visual field may be satisfactorily explained by correlating it with certain definite lesions in the nervous system.  On the other hand, a person's belief -- whether this be a belief in Christianity, in Communism, or in the idea that his internal organs are "rotting" and that his body is, in fact, already "dead" -- cannot be explained by a defect or disease of the nervous system.  Explanations of this sort of occurrence -- assuming that one is interested in the belief itself and does not regard it simply as a "symptom" or expression of something else that is more interesting -- must be sought along different lines. The second error in regarding complex psycho-social behavior, consisting of communications about ourselves and the world about us, as mere symptoms [p. 114] of neurological functioning is epistemological.  In other words, it is 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. In the present case, the error lies in making a symmetrical dualism between mental and physical (or bodily) symptoms, a dualism which is merely a habit of speech and to which no known observations can be found to correspond. Let us see if this is so. In medical practice, when we speak of physical disturbances, we mean either signs (for example, a fever) or symptoms (for example, pain). We speak of mental symptoms, on the other hand, when we refer to a patient's communications about himself, others, and the world about him.  He might state that he is Napoleon or that he is being persecuted by the Communists. These would be considered mental symptoms only if the observer believed that the patient was not Napoleon or that he was not being persecuted[sic] by the Communists. This makes it apparent that the statement that "X is a mental symptom" involves rendering a judgment. The judgment entails, moreover, a covert comparison or matching of the patient's ideas, concepts, or beliefs with those of the observer and the society in which they live.  The notion of mental symptom is therefore inextricably tied to the social (including ethical) context in which it is made in much the same way as the notion of bodily symptom is tied to an anatomical and genetic context (Szasz, 1957a, 1957b). To sum up what has been said thus far: I have tried to show that for those who regard mental symptoms as signs of brain disease, the concept of mental illness is unnecessary and misleading.  For what they mean is that people so labeled suffer from diseases of the brain; and, if that is what they mean, it would seem better for the sake of clarity to say that and not something else.

My aim in this essay is to raise the question "Is there such a thing as mental illness?" and to argue that there is not. Since the notion of mental illness is extremely widely used nowadays, inquiry into the ways in which this term is employed would seem to be especially indicated.  Mental illness, of course, is not literally a "thing" -- or physical object -- and hence it can "exist" only in the same sort of way in which other theoretical concepts exist. Yet, familiar theories are in the habit of posing, sooner or later -- at least to those who come to believe in them -- as "objective truths" (or "facts").  During certain historical periods, explanatory conceptions such as deities, witches, and microorganisms appeared not only as theories but as self-evident causes of a vast number of events.  I submit that today mental illness is widely regarded in a somewhat similar fashion, that is, as the cause of innumerable diverse happenings.  As an antidote to the complacent use of the notion of mental illness -- whether as a self-evident phenomenon, theory, or cause--let us ask this question: What is meant when it is asserted that someone is mentally ill? In what follows I shall describe briefly the main uses to which the concept of mental illness has been put.  I shall argue that this notion has outlived whatever usefulness it might have had and that it now functions merely as a convenient myth.

As the sleep-waker pronounced these latter words, in a feeble tone, I observed on his countenance a singular expression, which somewhat alarmed me, and induced me to awake him at once. No sooner had I done this, than, with a bright smile irradiating all his features, he fell back upon his pillow and expired. I noticed that in less than a minute afterward his corpse had all the stern rigidity of stone. His brow was of the coldness of ice. Thus, ordinarily, should it have appeared, only after long pressure from Azrael's hand. Had the sleep-waker, indeed, during the latter portion of his discourse, been addressing me from out the region of the shadows?

This, probably, is because you have no sufficiently generic conception of the term "substance" itself. We must not regard it as a quality, but as a sentiment: -- it is the perception, in thinking beings, of the adaptation of matter to their organization. There are many things on the Earth, which would be nihility to the inhabitants of Venus -- many things visible and tangible in Venus, which we could not be brought to appreciate as existing at all. But to the inorganic beings -- to the angels -- the whole of the unparticled matter is substance, that is to say, the whole of what we term "space" is to them the truest substantiality; -- the stars, meantime, through what we consider their materiality, escaping the angelic sense, just in proportion as the unparticled matter, through what we consider its immateriality, eludes the organic.

V. When I say that it resembles death, I mean that it resembles the ultimate life; for when I am entranced the senses of my rudimental life are in abeyance, and I perceive external things directly, without organs, through a medium which I shall employ in the ultimate, unorganized life.

V. [After much hesitation.] I could not have said this ; it is an absurdity.

Your objection is answered with an ease which is nearly in the ratio of its apparent unanswerability. -- As regards the progress of the star, it can make no difference whether the star passes through the ether or the ether through it. There is no astronomical error more unaccountable than that which reconciles the known retardation of the comets with the idea of their passage through an ether: for, however rare this ether be supposed, it would put a stop to all sidereal revolution in a very far briefer period than has been admitted by those astronomers who have endeavored to slur over a point which they found it impossible to comprehend. The retardation actually experienced is, on the other hand, about that which might be expected from the friction of the ether in the instantaneous passage through the orb. In the one case, the retarding force is momentary and complete within itself -- in the other it is endlessly accumulative.

Yes; and I now see the confusion of idea. Motion is the action of mind -- not of thinking. The unparticled matter, or God, in quiescence, is (as nearly as we can conceive it) what men call mind. And the power of self-movement (equivalent in effect to human volition) is, in the unparticled matter, the result of its unity and omniprevalence; how I know not, and now clearly see that I shall never know. But the unparticled matter, set in motion by a law, or quality, existing within itself, is thinking.

V. If I were awake I should like to die, but now it is no matter. The mesmeric condition is so near death as to content me.

I consented of course to make this experiment. A few passes threw Mr. Vankirk into the mesmeric sleep. His breathing became immediately more easy, and he seemed to suffer no physical uneasiness. The following conversation then ensued: -- V. in the dialogue representing the patient, and P. myself.

"These considerations have led me to think that some good results might ensue from a series of well-directed questions propounded to me while mesmerized. You have often observed the profound self-cognizance evinced by the sleep-waker -- the extensive knowledge he displays upon all points relating to the mesmeric condition itself; and from this self-cognizance may be deduced hints for the proper conduct of a catechism."

As I entered his room he greeted me with a cheerful smile, and although evidently in much bodily pain, appeared to be, mentally, quite at ease.

I had been long in the habit of mesmerizing the person in question, (Mr. Vankirk,) and the usual acute susceptibility and exaltation of the mesmeric perception had supervened. For many months he had been laboring under confirmed phthisis, the more distressing effects of which had been relieved by my manipulations; and on the night of Wednesday, the fifteenth instant, I was summoned to his bedside.

There can be no more absolute waste of time than the attempt to prove, at the present day, that man, by mere exercise of will, can so impress his fellow, as to cast him into an abnormal condition, of which the phenomena resemble very closely those of death, or at least resemble them more nearly than they do the phenomena of any other normal condition within our cognizance; that, while in this state, the person so impressed employs only with effort, and then feebly, the external organs of sense, yet perceives, with keenly refined perception, and through channels supposed unknown, matters beyond the scope of the physical organs; that, moreover, his intellectual faculties are wonderfully exalted and invigorated; that his sympathies with the person so impressing him are profound; and, finally, that his susceptibility to the impression increases with its frequency, while, in the same proportion, the peculiar phenomena elicited are more extended and more pronounced.