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Szasz presents a theory that redefines mental illness as "problems in living". He believes that an historical review of mental illness as well as an examination of its etiology, symptoms and treatment demonstrate that the concept of mental illness as practiced by the medical profession is based on erroneous beliefs. Although some reasoning based on the historical evidence seems weak, there seems to be some validity to his arguments concerning diagnoses and treatment. The history of mental illness is relatively short in the lifespan of humans. As recently as one hundred years ago the vast majority of what is presently defined as mental illness was either unheard of or labeled as other problems. Szasz forwards the hypothesis that what is presently treated as mental illness was first labeled hysteria one hundred years ago (Szasz, 1974). Previous to that, women with the same behaviors were identified as witches (Murray, 1988;Bootzin, & Acocella, 1984; Szasz,1960). Szasz notes that Jean-Martin Charcot (1825-1893), a French neurologist, pathologist, and professor was responsible for patients at the Saltpetriere, an asylum for women, most of whom were poor and suffering from diseases of the brain and nervous system. Charcot's work at the Saltpetriere was to "identify, describe and classify neurological diseases among the women who were considered to be incurably ill" (Murray, 1988; Szasz, 1974). Charcot did some work with epileptic patients but noticed that some women who did not have epilepsy began to experience convulsions similar to epilepy. There appeared to be no physical cause for the convulsions these women experienced. Charcot labeled these women as hysterics and by the mid 1800's the term hysteria came to be "a very general term used to describe excessive emotional upset, but which even then could involve disturbances of the body with no obvious physical cause." (Murray, 1988). Szasz believes that these "emotional upsets" do not constitute mental illness. He makes the distiction between diseases of the brain, (such as epilepsy), and diseases of the mind, (such as an erroneous beliefs that one's body is already dead), and states that the two are not equally "illnesses". According to Szasz these "emotional upsets" are better termed "problems in living" (Szasz, 1960). To Szasz. erroneous or irrational beliefs cannot be explained by means of physical defects or diseases and therefore cannot be called illnesses. A second point that Szasz makes is that if physical disease is diagnosed through particular signs and symptoms (fever and pain respctively) then the same should hold true for mental disease. However, when we try to consider what these mental signs and symptoms might include Szasz states that the physician has only the words and behaviors of the individual being examined and the physician must make a judgement call on the validity of the complaints made (Szasz, 1960). This would require the psychiatrist to set aside his own values and beliefs and be able to assess the signs and symptoms within their social context (Szasz, 1960). Szasz' next point is that mental illness is wrongly defined as "a deformity of the personality" (Szasz, 1960) and is responsible for many of the problems that people have in relation to one another. He asserts that it is unfair to define a person's behavior in abstract terms and then to blame the abstraction for social problems. It is inconsistent to refer to mental illness as a social problem and to judge its extent using ethical standards and to then treat this problem as a medical issue. Szasz believes that just as physical problems are medically defined, diagnosed and treated, (Szasz, 1974) other problems should also be defined and treated using one modality not several. Social problems should be defined and treated socially and ethical problems should be defined and dealt with philosophically (Szasz, 1960). The final and major point that Szasz (Szasz, 1960) makes is that it is impossible for a psychiatrist to make an impartial judgement of a person's thought processes and behaviors without the psychiatrist's own beliefs affecting how the patient is perceived. In the practice of medicine value judgements are put aside in favor of evidence of pathology (Szasz, 1974). In mental illness the only evidence that exists is that which the psychiatrist is told or is shown behaviorally. The psychiatrist is left to place a value judgement on whether the thoughts and/or behaviors are within "acceptable" limits (Szasz, 1960). Critique Szasz makes a valid point when he discusses how psychiatric diagnoses are made. Too frequently psychiatrists treat people as if they were working on an assembly line. They are anxious to see as many people as possible in a short period of time making it impossible for them to properly assess the patient. The psychiatrists that I have met, are generally not interested in finding the source of the problem and helping the person to cope with the their feelings, but rather try to medicate the person's feelings away. This, I believe sets up a dangerous situation where certain feelings are not allowed. If then, a person experiences these feelings to an extent that someone outside of the person with little knowledge of that individual, defines those feelings as wrong, or not healthy, then little will really be done to help the person. In my own practice, I have met psychiatrists who refused to consider an opinion that differed with their own. In one case a psychiatrist diagnosed one patient with three different mental illnesses in the span of one week. Interestingly, these three diagnoses could not co-exist. He refused to see his inconsistency or to accept another possibility to explain the confusion. Each of his diagnoses were based on a five to ten minute interview with the patient (which involved a few brief questions about her behavior) and at no time was the patient asked about the context of those behaviors. Other clients have told me similar stories. It seems that the psychiatrist has memorized a textbook - if they answer this--then this is the diagnosis - without ever considering the social environment where the behavior was learned. This can be an important factor in the development of a problem in an individual. For example, it has recently been well documented that Multiple Personality Disorder is caused by traumatic experiences suffered as a young child (Braun,1985; Peterson, 1991). An interesting finding, however, has been that in order to cope with a parent who has multiple personalities a child may develop signs of the disorder as a learned behavior (Braun,1985; Coons, 1985). One conclusion that could be drawn from this, is that the children of people with multiple personality are not themselves mentally ill but have developed coping strategies to enable them to live with a parent who keeps changing. Finally, in his book the Myth of Neurosis, Wood (1986) makes the point that if there is an illness then there should be a treatment [although it may not yet be discovered]. However, he found that "a series of studies on the effectiveness of therapy for psychoneuroses concluded that `approximately two-thirds of "severe neurotics" would improve anyway, on their own and without the benefit of systematic psychotherapy'" (Wood, 1986). If, then, two-thirds of the patients got better without treatment, then what exactly were they supposed to be suffering from, if anything except "problems in living". Defining an individuals problems as illness only encourages them to lose hope. As a therapist, I believe in the importance of normalizing a person's experience, helping them to accept and deal with their feelings and in helping them to cope with their "problems in living".
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