Towards the psychopathology mental health
Hans Keller
Ever since 1961, the year of the publication of Thomas Szasz's The Myth of Mental Illness, the professional world — psychiatrists, anti-psychiatric neurologists, psychoanalysts, analytical psychologists, psychotherapists, extra-medical psychologists, sociologists, crusaders for Mental Health, and sundry other loafers — has been divided into those who think that Szasz is a raving if psychiatric lunatic, and those who don't think so. But those who don't think so, don't think that he is right; they think he has a point. I have not encountered a single professional who, in public, has accepted Szasz's simple basic thesis that the concept of mental illness is a metaphor— though I did encounter an orthodox psychoanalyst (now dead) who told me, in private, that for him, after Szasz, professional life never was the same again: he faced his patients in a different frame of mind.
In one respect, then, Szasz has flawlessly succeeded: there are no Szaszians, and so he does not find himself as the founder of one of those schools he detests. You may say, .how could he, since he detests them — but compare Jung (in a letter dated 14 January 1946): 'I can only hope that nobody becomes "Jungian". I stand for no doctrine I abhor "blind adherents".' In which case, he shouldn't have invented 'analytical psychology', thus starting a religion.
There are, to be sure, a few psychiatrists who view Szasz's endeavours with considerable public sympathy— and not radicals either: Anthony StOrr, for instance, has done much towards getting the bad boy of psychiatry an unprejudiced hearing. But the fact remains that even sympathisers are firmly agreed that Szasz has gone too far — that his anti-fanaticism has turned him into a negative fanatic.
I, on the other hand, submit that in two well-definable dimensions, he has not gone far enough. For one thing, that is, he hasn't gone far enough into the past to trace man's irrepressible addiction to the concepts of mental health and illness. When he dives into antiquity or the early Middle Ages, he confines himself to 'the ceremonial destruction of scapegoats for "therapeutic" purposes' (The Manufacture of Madness, London 1971, p.263): psycho-therapeutic purposes don't come into it.
Yet the obsession with what we call mental health — with viewing the mind as we view the body — must have been there all along: the fact is demonstrable. At about the time when Jesus Nazarenus, Rex Judaeorum was sentenced to death for admitting to this description (see Haim Cohn, The Trial and Death ofJesus , London 1972) — an admission which would now adays land him in a mental hospital — a Roman satirist was born whose very sneers threw his moralism into relief when he insisted that 'if you must have something to pray for,' it should be `mens sana in corpore sano', a sound mind in a sound body (from Juvenal's Tenth Satire).
Two all-important considerations here force themselves upon us. First, if Juvenal expected his readers to know what he was talking about, the metaphorical use of the concept of health must have seemed quite natural — even at that stage of pre-natal psychiatry, not to speak of pre-natal neurology. Secondly, the moralisation of bodily and mental health, likewise, could be depended upon to 'click' with his audiences: the Tenth Satire does in fact conclude with the unsatirical reminder that there is only one value, which is virtue.
The intervening history of modern mankind has tended to show that Juvenal's dictum is a load of rubbish, even though you will find the odd neurologist, and the still odder psychiatrist, who hasn't got far beyond it. On the other hand, the proposition enraged Bernard Shaw (Man and Superman): Wens sana in corpore sano is a foolish saying. The sound body is a product of a sound mind.' But whether somato-psychic (Juvenal) or psychosomatic (Shaw), the urge to moralise about body and mind in the same terms seems as ineradicable as is the urge to moralise about each.
Which brings me to the other dimension in which Szasz hasn't gone far enough — in width, as it were: he objects to the medicalisation of psychiatry, but leaves the moralisation of medicine itself alone. In a letter of 25 November 1928 to that remarkable psychoanalytic pastor, Oskar Pfister, Freud says that psychoanalysis needs protection 'from the doctors' — but, complains Szasz, 'the psychoanalytic counterrevolution overtook his movement' (Ideology and Insanity, London 1973, p.235). And by last year, having, in his own mind, successfully banished medicine from psychiatry, Szasz had virtually sanctified Rudolph Virchow's medical philosophy as such (1858): 'What cells are out of order and what can be done for them?"This', comments Szasz, 'remains the basic concept and model of disease' (Schizophrenia, New York 1976, p.9); and since the mental diseases don't conform to the model, they were not discovered, but invented.
Well and good, but who says that the medical evaluation of physical disorder, disease, disturbance, is justifiable — the automatic assumption that illness is bad? We have all met people in whom an unsound body has produced a super-sound mind: the aforementioned Nazarene paranoic may, according to latest research, have been one of them — if, that is, you like his ideas, and plenty of distinguished people seem to. In any case, what was, perhaps, mankind's greatest, clearest, 'sanest' mind altogether needed, for its ultimate discoveries, the disorder of those very cells which it seemed to need most: the late, deaf Beethoven stands or falls with his total acoustic independence of contemporary sound. Wise after the event, we might even venture that his sound mind helped him to produce, with prophetic prowess, his unsound body.
In short and in logic, Szasz ought to extend his critique from the metaphor to the model, from Juvenal's sound mind to Juvenal's sound body: science can tell whether something functions badly, but it becomes unscientific in proportion as it implies that bad function is bad. Szasz would allow that if schizophrenia, whatever it was, could be shown to be due to histopathological lesions and/or pathophysiological processes, it could qualify as a disease. If genius, whatever it is, could be shown to be thus determined or promoted, could it likewise qualify as a disease? Down the ages. mediocrity's desire to pathologise genius has always been passionate anyway. Let us not pretend, however, that moralistic pathology has not had its uses: much malfunction is in fact bad in any en' cumstances, and for most of us, to live is at least marginally better than to die. The trouble is that while Virchow's cellular pathology is verifiable, the criteria of psychopathology are such that they themselves can be used towards pathologising what we regard as mental health, and thus leading our intellectual world's ruling virtue —mens sana —ad absurdum. By not permitting himself to talk in terms of psychological malfunction, Szasz renounces the opportunity of beating psychiatric evaluations of life and art with their own weapons — a rationallY honourable undertaking to the extent to which psychological malfunction can be defined, however abstractly. In a forthcoming book, 1975 (1984 minus 9),1 have made a modest beginning in this direction; here is my second step. The Kleinian D.W. Winnicott once remarked that Western civilization was predominantly 'depressive'. Well, for one thing, count me out; for another, I'm not alone: nobody is. If we define psychological malfunction as a failure to adjust to reality and intellectually to conquer it, then indeed depression has been our culture's leading pathological sympton. But if, on the other hand, we concentrate on the psychology of our culture's main achievements, its intellectual conquests of external and internal reality, we find that it has been predominantly obsessional: inspect the lifestyle and working methods of any of our history's geniuses and of most of its major talents, and you will have to admit that but for what they have discovered and produced, you would be tempted to class them as sharply diagnosable obsessional neurotics, whether you accept Freud's anal history of the condition or not — and he himself was, of course, a prize specimen of obsessionalism; otherwise he couldn't have got his writing done on top, or rather at the bottom, of his practice. Personally, on the basis of patient investigation, I would go so far as to say that what we regard as major cultural achievement, invariably the result of ruthlessly sustained effort, is impossible Without obsessionalism.
Came the psychoanalytic revolution and, in its trail, the secondary revolution of analytical psychology, none the less potent for being secondary: intellectual mankind's original sin seems to be the cordial welcome it offers to the second hand, at the expense of the first. Both camps, in any event, have stigmatized obsessionalsm out of existence, With residual justification: unlinked to talent, it removes you from reality. But nowadays, you can't meet anybody who's been analysed, and never mind by which brainlaundrette (analyses are getting shorter), who won't bore you with references to his (ex-)obsessionalism, and that goes for the analysts themselves too, Freudian or Jungian. You thank them for being punctual; they make a wry, unfunny joke about their obsessionalism. You admire them for having given up drinking or smoking; they stress the real achievement — which was to have done it without obsessionalism, the clear implication being that it is better to do nothing without obsessionalism than to do something with it. It is this implication that, as an unarticulated maxim, has come to dominate the stratosphere of our culture which, as it loses its obsessional spirit, is becoming sick with mental health — well supported by the ever-green, ever-mouldy permissiveness of our troposphere. Why bother?On the lower levels, bothering is old-fashioned discipline; on the higher levels, it is unhealthy, obsessional.
Nor is it only sustained effort that is on the way out. After all, once there is talent, any sustained effort, helped though it is by' obsessionalism, is not due to it: the causa tive basis is sustained, extended thought — which, in its turn, is helped by obses sionalism, as indeed is sheer intelligence, the compulsion to think logically. And it is extended thought itself which is in mortal danger: how much of it can we trace in the last few decades? Where are their philosophies, their psychologies — their symphonic structures in and outside the arts? When you do go something long, it's an easy-going accumulation of aphorisms, most of which, unobsessionally, contradict each other: who cares?
The third member of the original psychoanalytic triumvirate has been brutally forgotten — Alfred Adler, the later founder of Individual Psychology (a worthy name for a religion if ever there was one). In his Study of Organ Inferiority and its Psychic Compensation (1907!), he postulated the 'law of compensation and overcompensation'*, of which my simple illustration would be the tenor Julius Patzak: a boy with a crippled hand who wanted to be a pianist grew into one of the greatest singers of our age without ever taking a single singing lesson.
Organs compensate, but the mind — obstinate obsessionalism — is needed for over-compensation: a sick mind in a sick body produced one of our civilisation's soundest mental and physical feats: the myth of physical illness?
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