Deconstructing Antipsychiatry: Mental Illness Isn't Real

One of the core arguments in PBM is that mental illness isn’t a real illness, because it has no observable physical pathology. Or in other words, if you can’t point to something physical, it’s not an illness, and thus outside the scope of medicine.

This claim is used to bootstrap further arguments, e.g. if it’s not an illness, all these things you’re putting in the DSM are meaningless, and given that medications are designed to correct something physical, and by definition there’s nothing physical going on in mental not-really-an-illness, these medications are by definition not addressing any illness. And so on.

The Argument

The base argument is most pointedly made in Chapter 2 of PBM, in the section “Medical Advances, Professionalization, and the State,” in discussing the evolution of medicine at the point in the late 1800’s where studying of corpses allowed for a better understanding of human anatomy and disease. If I may quote extensively from PBM:

Continuing to study anatomy and inventing more and more instruments to extend its observation, it [medicine] further progressed as a science. What was particularly important—and the significance of this cannot be overstated—as Szasz (1976/1988) points out, it progressively conceptualized like a science. Most especially it put aside impressionistic concepts of what constituted a disease, adopting in their stead concrete criteria based on observation. Instrumental in this regard was physician Rudolf Virchow, who introduced a standard henceforth embraced by the medical community.

According to this new understanding, pain or discomfort per se no longer sufficed for something to qualify as a disease. Real lesion, real cellular pathology observable directly or by tests was to be the standard. While disease might be hypothesized and temporarily entertained in the absence of pathology, to be clear, it was discoveries of pathology alone which confirmed them. With Virchow criterion, medicine had essentially crossed the science threshold and found its “gold standard.”

The end of that passage concludes with a footnote reading “For highly informed commentary on the Virchow criterion and its significance, see Ackerknecht (1953) and Szasz (1976/1988).”

Sound convincing?

A lot seems to reside on that definition of “disease” and by implication whether the scope of medicine (and hence psychiatry) is determined by “disease” or not. And is “illness” the same thing as “disease”? And does medicine deal with illness or just disease? But isn’t illness something we all understand, and… well, the above thing about lesions and such sounds reasonable, and if that is the gold standard…

Definition Controversies

In the quoted passage, BB makes two claims supporting her position, “a standard henceforth embraced by the medical community” and “crossed the science threshold and found it’s ‘gold standard’.” These are her words.

These claims that Virchow’s ‘physical’ standard was then and continues to be the definition of disease, and that presence or absence of disease defines what is or is not medicine, is supported by references to “highly informed commentary” by Szasz, an early pioneer of psychiatric criticism referenced by most antipsychiatry works, but nothing else (selective reference).

Virchow was a pioneer for his time, though some of his positions didn’t work out so well over time (he was anti-evolution and did not believe in the germ theory of disease). How did this standard hold out?

Not well either unfortunately. In both medical practice and common usage, there is a lot of overlap between the terms “disease” and “illness,” sometimes used interchangeably. Some medical texts simply define “illness” as “disease.” Many dictionaries define illness as “being unhealthy in body or mind.”

The actual definition of “illness” has been an occasional matter of debate to this date. There were a lot of short back-and-forth letters and articles during the 80’s in the Canadian Medical Association Journal (CMAJ), including the ones by Szasz. The definitional debates continue more sporadically to this day in various professional medical journals, including CMAJ.

The Gold Standard?

Even taking “mental illness” out of the equation, does medicine today deal with illnesses or diseases that would not be identified by “real lesion, real cellular pathology”?

Has medicine evolved since the late 1800’s?

Our understanding today of germs, viruses and bacteria go beyond what Virchow proposed. Think of all the illnesses and diseases associated with those.

There have been thousands of medical discoveries between then and now which identified causes and treatments for various illnesses. Before the discoveries, were they not illnesses, managed or treated by doctors, even though the cause, physical or otherwise, was unknown? Absolutely.

Are there illnesses today, treated by doctors, for which we do not know the cause? Here are a few:

I could go on. But nobody would dispute that these illnesses are within the purview of medicine. Medicine even has a term for these: diseases (or illnesses, or ailments) of “unknown etiology.”

The bottom line is that medical doctors treat many illnesses and diseases in terms of their symptoms, as a regular and standard part of their practice. And to experts and the public alike, it’s not a question of whether they are real or not.

Summary

Defining a concept in a particular, narrow way is a common technique used in debating circles. Choosing a definition (“illnesses have physical causes”) that is so close to the conclusion you want to draw (“mental illnesses have no known physical causes so are not real illnesses”), is an example of a logical fallacy called “begging the question.”

The use of only selective references here, showcases an “appeal to improper/biased authority” fallacy. Yes, Virchow and Szasz have important contributions to make with regards to medicine and psychiatry. Yet, while the claims attributed to them carry some weight, they are not generally accepted in common practice today.

For this argument to work, you need to agree to a particular definition of a term that is at best controversial and at worse false in light of common practice.

A large chunk of the remainder of that chapter in PBM is dedicated to examples where psychiatry has assumed causes and adopted terminology suggestive of specific etiologies, without proper evidence of such. As suggested in a previous section, I agree with BB that psychiatry did itself no favours here.

The flawed notion that mental illnesses have no known etiology and therefore aren’t real illnesses is a foundation on which several other major arguments in PBM rest. We will also see the same attempts to persuade the reader to a false conclusion in other arguments shortly.

But really, if at some point in the future, a definitive underlying physical/biological cause for mental illness was discovered, do you really think the antipsychiatry community would admit that mental illness is real?