Psychiatrists Do Not Know What They Are Treating

AS A BOY, especially while lying in bed or suffering a fever, I was periodically troubled by harshly critical voices that vaguely charged me with misconduct and failures of character. As I grew up, the murmuring Greek chorus was replaced by a single voice, which by then I recognized as my own.

- JACOB SULLUM

If those seemingly external voices had persisted into adolescence and adulthood, I might have qualified for a diagnosis of schizophrenia. Instead, I became a garden-variety neurotic, assailed by self-recriminations that undermined my confidence and interfered with my happiness.

Are these two states of mind categorically distinct, or do they occupy different spots on a continuum of mental health? Is one properly classified as a brain disease requiring biomedical treatment while the other is a psychological condition amenable to talk therapy? Or are we talking about a difference in degree rather than kind? The renegade psychiatrist Thomas Szasz, a longtime Reason contributing editor, argued that "mental illness" was a metaphor that should not be taken literally. In his view, the patterns of speech and behavior that are seen as symptoms of schizophrenia, like less severe and more common disturbances of thought and emotion, could be traced to "problems in living" rather than an identifiable neurological lesion or biochemical defect.

Less radical critics of psychiatry's scientific pretensions tend to dismiss Szasz's take as implausible, clinically naive, and cruelly indifferent to the suffering of people diagnosed with schizophrenia. At the same time, they emphasize that psychiatry has never managed a satisfactory account of what schizophrenia is, let alone what causes it or why the treatments du jour can be expected to work. That ongoing failure with regard to schizophrenia, which Szasz called "the sacred symbol of psychiatry," epitomizes the field's broader crisis of credibility, which extends to the medicalization of nearly every human folly and foible.