When I was a young man, working through a medical course in the 1960s, there were 10,000 psychiatric beds in the State of Victoria. That is, in a population of about 3 million. Now our population has doubled and the number of psychiatric beds has fallen by about 80%. We spent weeks and weeks’ as students’ in the confines of psychiatric hospitals talking to the ‘disturbed’ and ‘mentally ill’. Merely a generation earlier these institutions were called lunatic asylums. The deinstitutionalization of psychiatric care was one of the greatest advances in medical care of the modern era, and it was no accident.
There were many triggers for this movement. David Rosenhan published a landmark study in Science in 1973. He broke every rule in the clinical trial handbook of today, but it worked in 1973. The study was called “On being sane in insane places”. Eight volunteers pretended to hear voices, and were soon admitted to psychiatric hospitals, whereupon they immediately behaved in a completely sane manner. This is not the forum to describe their inpatient experiences, the report is easily available, but seven were finally discharged with a diagnosis of ‘schizophrenia in remission’.
And the previous year, in 1972, Thomas Szasz published one of the great iconoclastic medical books of last century, The Myth of Mental Illness. To give you an idea of his approach, right at the beginning, on page 11, he writes: ‘bodily illness stands in the same relation to mental illness as a defective television receiver stands to an objectionable television programme’. Szasz then applied a scalpel to entrenched psychiatry, working his way from Hysteria of the 19th Century
My copy. 1972 edition
through rules and societal acceptance and odd behaviour and game-playing and everything else that psychoanalysts said. I once attended a meeting in the nineties on somatoform disorders mimicking allergy. I asked the guest psychiatrist about his views on Szasz. He replied: ‘Well, Szasz was an essayist’. I think he meant that Szasz was to psychiatry as Nietzsche was to philosophy. Both had the ability and desire to write about complex matters in a populist manner. I also thought that it was a backhanded compliment. But I had, and continue to have, a lot of time for Thomas Szasz. He wrote that the incarceration of the mentally ill was a crime against humanity. He felt that most people labelled as mentally ill were dealing with the personal, social and ethical problems of life in a manner that was different to the majority. He reserved restraint only for those who would harm themselves or others. And Szasz was one of the first psychiatrists to challenge the idea that homosexuality was a form of ‘mental illness’ or ‘disease’.
I remember being especially shaken by his statement that ‘mental illness is a metaphor‘. He believed that minds can be ‘sick’ only in the sense that jokes can be ‘sick’. His assertion that true mental symptoms arise from physical abnormalities in the brain has, of course, proved correct. And, what’s more, neuroscience will sort out those physical abnormalities for us. At the moment, however, we still use the term mental illness, albeit in a non-pejorative way. That’s progress, but until we do away with the term completely, and assert, like Szasz, that it is indeed a metaphor, we will still be hamstrung by history.
Postscript: Thomas Szasz died on September 8th, 2012. He was a man of his time, forgotten by those who assume that automatic incarceration of mentally disturbed people was something that stopped in the 19th Century, or that homosexuality was only thought of as a mental illness in the Middle Ages. But I remember him, and I re-read ‘The Myth of Mental Illness’ regularly to remind myself of the power its words had over me as a young doctor. I can forgive his anti-psychiatric stance that continued to his death. I can forgive his dalliance with Scientology (he was never a member). He, and others like him, liberated tens of thousands of people from institutionalization, and thus paved the way for a more humanistic approach to psychiatry. Is mental illness a metaphor? In his time – yes. He was trying to change a corrupted (as opposed to corrupt) system. Is mental illness still a metaphor today? I’ll let you judge that.
