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The Great Paradox of Psychiatry

by Mark L. Ruffalo

We are living in an era of supposed rapid progression in the development of newer, better, and more effective treatments for the human problems called mental disorders. The psychotropic drugs that are marketed today are said to be more effective than ever before, and we are told by the purveyors of psychotherapy that it too has become more refined and more effective in the treatment of mental distress. Yet, at the same time, the rates of mental illness continue to rise and in fact have never been higher. We are told by some authorities that there is an "epidemic" of mental illness in America. One out of four Americans is mentally ill, the oft-cited statistic goes. Some claim that the rate of mental illness is even higher. And herein lies the great paradox of psychiatry: while mental illness is said to be more effectively treated today than at any other time in history, we are also told, sometimes in the same breath, that it is more common than ever before and is, in fact, increasing at exponential rates. How could this be so?

The answer to the above question lies in the fact that mental illnesses are not objective histopathological or pathophysiological lesions, and, consequently, that the category of mental illness—unlike, say, the category of medical disease—can expand and constrict as a result of a variety of different moral, social, political, and economic factors and interests. Depression, anxiety, posttraumatic stress, and schizophrenia are not, have never been, and will never be "just like" cancer or diabetes or heart disease, despite the obfuscations of psychiatrists, mental health professionals, and mental health "advocacy" groups. There is, of course, no objective medical diagnostic test for any of the conditions currently categorized as mental illnesses, and, consequently, no way yet discovered to objectively determine who is or who is not mentally ill. As the late psychiatrist-psychoanalyst Thomas Szasz pointed out so eloquently in his writings, throughout the history of psychiatry, once the biological etiology of a so-called mental illness becomes objectively known and demonstrable, the condition ceases being a psychiatric disorder and instead becomes classified as a neurological disease. The fact that mental disorders are not objectively demonstrable bodily lesions has led to the broadening of psychiatric diagnostic categories and the progressive medicalization and pathologization of everyday life, as evidenced by the increased rates of mental disorder in society. When scrutinized more intensely, it becomes clear that the concept of mental illness is in actuality a literalized metaphor upon which the discipline of psychiatry rests.

What do I mean when I say that mental illness is a literalized metaphor? I mean, simply put, that although we can say that the human problems currently classified as mental disorders are like diseases—in the sense that they cause suffering, respond to certain interventions, are treated by doctors, etc.—they are not diseases in the traditional, Virchowian sense of the concept of disease, despite the fact that we treat them as if they are diseases. In a form of linguistic sleight-of-hand, organized psychiatry and the other mental health disciplines have literalized the metaphor of mental illness, a literalization which has served the purpose of justifying, morally and philosophically, both the classification of psychiatry as a branch of medicine and the involuntary detention and treatment of persons said to be mentally ill.

So, while there may (or may not) be better or more effective treatments for the human suffering defined as mental disorder, there is a range of vested interests—financial, moral, intellectual, political—influencing which deviations in human behavior and experience become defined as mental illness and resultantly phenomena for study and treatment. A distinction between literal and metaphorical entities is essential in interpreting the claims made by some about the treatment and prevalence of mental illness, and also in understanding the true nature of the human problems called mental disorders.


Mark L. Ruffalo, L.C.S.W., is a psychoanalyst in private practice in Tampa, Florida. He serves as an affiliate assistant professor of psychiatry and an adjunct instructor of social work at the University of South Florida and has previously served as membership chair of the Academy for the Psychoanalytic Arts.