Thomas Szasz and the Myth of Mental Illness - In Brief

Solid reasoning to reconsider the ethos of diagnosis and treatment, yet the medical model and chemical imbalance narrative rolls on

Who was Thomas Szasz

“Mental illness is a metaphor. Minds can be ‘sick’ only in the sense that jokes are ‘sick’ or economies are ‘sick.’”
— The Myth of Mental Illness

Thomas Szasz was a Hungarian-born American psychiatrist and scholar best known for his radical critique of psychiatry and the concept of mental illness. His most influential book was The Myth of Mental Illness (1961). In it, he argued that what we commonly call “mental illness” is not an actual disease, but rather a metaphor used to explain problematic or non-normative behaviors or experiences.

Szasz’s central argument was that mental illnesses are not real diseases in the same way that physical diseases are. He believed labeling behaviors or emotional distress as “illnesses” medicalizes problems. These problems are better understood as moral, social, or existential issues. This is why he fervently argued that mental ‘illness’ is just a myth. Diseases, such as cancers or diabetes, he argued have biological causes, and can be measured or observed, whereas mental illnesses cannot meet this standard. You cannot biopsy for an attention-deficit, prolonged grief, or a bad case of neurodiversity.

Since the days of Freud, the field of psychiatry has created labels and categorised less desirable behaviours. In Kids These Days, we wrote about how it’s the youngest child in the classroom who is most likely to be diagnosed with ADHD. Are we medicating for immaturity or a “real” disorder?

He explained in the short video below that, based on modern psychiatry, if we are too sad, we have a disease, if we eat too little, we have a disease, if we eat too much, we have a disease…and on and on. He finished medical school when there were only six mental illnesses, and at the time of this video, the DSM (Diagnostic and Statistical Manual—psychiatry’s bible) had over 300. He asks cheekily if 294 diseases were “discovered” in the time since he attended medical school.

If so, how were they discovered?

The "Therapeutic State" and the Role of Psychiatric Medication

Szasz coined the term the therapeutic state to describe a society in which medical and psychiatric institutions collaborate with the government to enforce conformity under the guise of health and therapy. He warned that psychiatry could become authoritarian, substituting clinical judgments for legal or moral ones. Szasz spoke out often against involuntary commitment and forced treatment, issues we have dealt with in our own field of research and practice. He asked if the mental illnesses cannot be scientifically tested for, what evidence should justify institutionalization outside of a criminal judgment?

We must point out, he was much more eloquent and effective in his arguments although the broader field of psychiatry did not hold him in high esteem. We assume the positive deviants did quietly though.

What Chemical Imbalance?

While not entirely opposed to the use of psychiatric medication, Szasz was skeptical about their overuse and the way they were used to suppress symptoms rather than address deeper issues. Again, this was more than 50 years ago and today we find traces of antidepressants in water runoff and the fish we eat. He believed that medications were often used to make people more “manageable” rather than to help them heal. Consider the above example about kids in the classroom. Some of his critics argued that he downplayed the suffering of those with severe mental disorders and underestimated the benefits of treatment, although reading his work suggests otherwise.

While Szasz wrote before the “chemical imbalance” theory became widely popularized in the 1990s and 2000s through pharmaceutical advertising, his general critique of biological psychiatry clearly applies:

“There is no blood or other biological test to ascertain the presence or absence of a mental illness, as there is for most bodily diseases.”
— The Myth of Mental Illness

Today, many psychiatrists, neuroscientists, and researchers now reject the “chemical imbalance” theory as a scientifically valid explanation for mental illness. Serotonin was hypothesized to play a significant role in depression, and hence, corresponding pharmaceuticals were developed to regulate the “chemical balance” in the brain. This has never been “proven” and several large-scale reviews, including a 2022 study published in Molecular Psychiatry, found no consistent evidence that serotonin levels or activity are different in people with depression. Moncrieff and colleagues explain in detail the realities of depression as a human emotion versus a brain chemical balance issue. The science is just not there to support the premise of the medical/chemical argument for mental health disease.

NOTE: This 2022 review paper cannot be found online, although its abstract can be seen on Google Scholar. Moncrieff et al. (2022), "The serotonin theory of depression: A systematic umbrella review of the evidence" – Molecular Psychiatry

Their conclusion was simple: the chemical imbalance theory lacks empirical support and should not be the foundation for understanding depression. And, we assume most psychiatric professionals do not endorse the chemical imbalance model but rather recognize the interplay of social, economic, biological, genetic, and the impact of life events on one’s ability to cope psychologically.

Take our previous Substack, You Are the Placebo. The chemical intervention appeared inert when patients believed they were taking a placebo pill. Despite living in evidence-based times, the simplest and easiest to administer intervention finds its way to the top…even when the best available evidence suggests otherwise.

Thomas Szasz was a provocative and influential critic who challenged fundamental assumptions about mental health and psychiatry. He challenged the dominant narratives about mental health. Whether one agrees or disagrees with his work, it remains a cornerstone in discussions about the ethics of psychiatric practice, the definition of mental illness, and the boundaries of medical authority. Listening to him is a treat as he can easily express the issues of validity within his own profession of psychiatry.

“If you talk to God, you are praying; if God talks to you, you have schizophrenia.”
— The Second Sin (1973)

Disclaimer: We are not saying medications do not work. We are not qualified to do so. We wanted to share the work of Thomas Szasz and highlight his efforts to speak up in his field about what he saw as political and economic forces overriding the work of humans supporting other humans. Despite weak support for the chemical imbalance theory, antidepressants and other psychiatric medications can still be effective for some people.