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Mental Illness as Brain Disease: A Brief History Lesson

Thomas S. Szasz

A 1999 White House Conference on Mental Health concluded: “Research in the last decade proves that mental illnesses are diagnosable disorders of the brain.” President William Clinton was more specific: “Mental illness can be accurately diag­nosed, successfully treated, just as physical illness.” Persons who reject the view that mental illnesses are physical diseases are dismissed by today’s opinion-makers as intellec­tual troglodytes, on a par with “flat­earthers.”

That the claim that “mental illness­es are diagnosable disorders of the brain” is a lie ought to be evident to anyone who thinks for himself. Here I want to show that the claim that “research in the last decade proves [this]” is also a lie, one more in a very long list in the history of psychiatry. The contention that mental illness is brain disease is as old as psychiatry itself: it is an integral part of the grand lie that psychiatry is a branch of med­icine and healing, when in fact it is a branch of the law and social control. Hannah Arendt was right when she observed: “There are no limits to the possibilities of nonsense and capricious notions that can be decked out as the last word in science.”

The idea that mental illness is a bodily disease dates back to the premodern medical conception of disease as “humoral imbalance,” comically prefiguring the mod­ern, supposedly scientific conception of it as “chemical imbalance.” In the United States, the idea of mental ill­ness as humoral imbalance was famously espoused by Benjamin Rush (1746–1813), the founding father of American psychiatry. Rush did not discover that certain behaviors are diseases; he decreed that they are: “Lying,” he declared, “is a corporeal disease.” In a letter to his friend John Adams, he wrote: “The subjects [mental dis­eases] have hitherto been enveloped in mystery. I have endeavored to bring them down to the level of all other diseases of the human body, and to show that the mind and the body are moved by the same causes and subject to the same laws.”

In the nineteenth century the sci­entific concept of disease as lesion replaced the Galenic concept of dis­ease as humoral imbalance. Now, physicians postulated that mental dis­eases are diseases of the brain. From about 1850 until past World War I, German (more precisely, German-speaking) psychiatry ruled the field. The very term psychiatry (Psychiatrie) was a German invention, coined in 1808 by Johann Christian Reil (1759–1813). Reil, not an alienist (psychiatrist), was one of the out­standing medical scientists and physi­cians of his age. He was a friend and physician of Johann Wolfgang von Goethe. In addition to coining the term “psychiatry,” he also coined the term “noninjurious torture,” to describe the methods of frightening mental patients that he con­sidered effective and legitimate “treatments.”

It is important to keep in mind that the German asy­lum system was created, in 1805, by the autocratic Pruss­ian state: specifically, by Karl August von Hardenberg (1759–1822), a Prussian statesman. Hardenberg declared, “The state must concern itself with all institutions for those with damaged minds, both for the betterment of the unfortunates and the advancement of science. In this important and difficult field of medicine only unrelenting efforts will enable us to carve out advances for the good of suffering mankind. Perfection can be achieved only in such institutions.”

Writing in 1917, at the height of World War I, Emil Kraepelin (1856–1926)—creator of the first system of psychiatric classification, today widely considered the father of modern “scientific” psychiatry—offered these revealing remarks about Hardenberg’s achievement: “The great war in which we are now engaged has com­pelled us to recognize the fact that science could forge for us a host of effective weapons for use against a hos­tile world. Should it be otherwise if we are fighting an internal enemy seeking to destroy the very fabric of our existence?”

Kraepelin’s remarks make clear that he regarded psy­chiatry as an arm of the state, similar to the military forces, whose duty is to protect the fatherland from “an internal enemy” that, like a hostile army, seeks to destroy it. The evil genius of psychiatry lay, and continues to lie, in its ability to convince itself, the legal system, and the public that, in matters defined as psychiatric, there is no conflict between the legitimate interests of the indi­vidual and the legitimate interests of the political class in charge of the state.

Of course, the German psychiatric pioneers had to answer the question, “What is mental illness?” Answer it they did. Wilhelm Griesinger (1817–1868), considered one of the founders of German psychiatry—and also of the famed Zurich insane asylum, the Burghölzli— declared: “Psychological diseases are diseases of the brain…. Insanity is merely a symptom complex of var­ious anomalous states of the brain.”

Theodor Meynert (1833–1892)—a German-born Viennese neuropsychiatrist and one of Freud’s teach­ers—began his textbook, Psychiatry (1884), with this statement: “The reader will find no other definition of ‘Psychiatry’ in this book but the one given on the title page: Clinical Treatise on Diseases of the Forebrain. The his­torical term for psychiatry, i.e., ‘treatment of the soul,’ implies more than we can accomplish, and transcends the bounds of accurate scientific investigation.”

In a review of Swedish psychiatry in the nineteenth century, historian of science Roger Qvarsell states: “In the 1860s, the debate among psychiatrists about the real nature of mental disease was over…. Almost all medical scientists and medical authorities were at this time convinced that mental diseases were of the same nature as somatic disorders.” Plus ça change, plus c’est la même chose.

Infringement of Freedom

What inferences did and do doctors draw from their concepts of mental illness as brain disease? First, as Carl Wernicke (1848–1905), a prominent nine­teenth-century German neuropsychiatrist observed, “The medical treatment of [mental] patients began with the infringement of their personal freedom.” In addi­tion, it began with “benevolent tortures,” such as fright­ening them by throwing them into a pit of snakes, the origin of the term “snake pit” for insane asylum. More specifically, the humoral-imbalance theory led Rush to employ “bleeding, purging, low diet, and the tranquiliz­ing chair.” The tranquilizing chair was a chair-like contraption for confining the patient and rotating him until he became dizzy or lost consciousness. This was supposed to rebalance the circulation in the brain. It was but a small step from the nineteenth century’s tranquil­izing chair to the twentieth century’s tranquilizing drug, supposed to rebalance the chemical imbalance in the patient’s brain.

Psychiatric practice today requires that doctors and patients ignore evidence and be ignorant of history. There was no evidence for a humoral imbalance causing illness, but the doctrine prevailed for two thousand years. There is no evidence for a chemical imbalance causing mental illness, but that does not impair the doc­trine’s scientific standing or popularity. Neither the American Psychiatric Association nor American presi­dents remind people of the caveat of the great nine­teenth-century English neurologist John Hughlings Jackson (1835–1911): “Our concern as medical men is with the body. If there be such a thing as disease of the mind, we can do nothing for it.”

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