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VOLUME 1, ISSUE 1 PSYCHNEWS INTERNATIONAL APRIL, 1996

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SECTION B: THE FIFTH COLUMN

PSYCHOSIS

Jeffrey A. Schaler, Ph.D.

The term psychosis is used to define and explain mental "illness." People labeled mentally "ill" are said to be "psychotic" and are usually labeled "schizophrenic." Public and clinical policies are implemented toward these people based on the definition and explanation of psychosis. Mentally "healthy" people are not considered psychotic. This distinction between mental health and mental illness is false. People considered mentally healthy can bepsychotic as well. That is not to say that they are mentally ill. There is no such thing as mental "illness"; the mind can be sick only in a metaphorical sense (Szasz, 1987).

Disease refers to physical processes or conditions. The word psychosis comes from the Greek _psukhe_, which means "soul." Combined with the suffix -osis, which means "process" or "condition," it is defined as "giving of life." The suffix -osis is also used to refer to physical disease conditions, as in tuberculosis, sclerosis, and so on.

We label mental confusion as psychosis. Confusion means "to pour together," "to mistake one thing for another." In the same sense, psychosis refers to a way of thinking and speaking. It depicts an _apparent_ failure to differentiate between the symbolic and the real.

People are labeled psychotic when they refer to mental representations of the world (thinking) as if they were substantive and real. Magritte addressed this concept in his painting of a pipe entitled "Ceci n'est pas une pipe" ("This is not a pipe"). Another example of confusion is the description of the "voice of conscience" as the literal voice of another being (known as "hearing voices").

People are also labeled psychotic when they claim that something metaphorical is literally true. An example of this is a person who makes a certain kind of false claim, i.e., a socially unacceptable one. Such claims might include statements such as, "I am Jesus," "the tree is crying," or "the dog is speaking to me." To ascribe this type of confusion to mental illness is tautological; the confusion is considered the putative "illness" by those who view the mind as capable of being literally sick.

Moreover, the failure to differentiate between the symbolic and the real may be intentional (artistic license) or strategic (lying). It may also be the function of a neurological reflex or a lack of cognitive ability to differentiate between fantasy and reality. Organic psychoses are characterized by cognitive deficits. Functional (non- organic) psychoses are characterized by false claims (ibid.).

People also describe psychosis in prescriptive ways or in terms of what "should be." For example, they may say that a person is mentally ill _because_ he is in a mental hospital: "He is psychotic, therefore, we should deprive him of his constitutional rights and 'treat' him." Here, assault and battery is labeled treatment. Calling things and people by the wrong names allows institutional psychiatrists to circumvent constitutional protections (Isaac and Jaffe, 1996). These strategic maneuvers are called "factual assessments" (Szasz, 1988).

Thus, there are at least three ways of using the term psychosis to refer to people speaking and behaving in certain ways. (1) Psychosis is used to refer to the state of mind wherein symbolic representations of the world (and metaphors) are confused with the real (literal) things they represent. This is a descriptive use of the word psychosis. It implies neither mental health nor mental illness. (2) Psychosis is also used when one ascribes confused speech to something else. Here, psychosis is said to be characterized by lack of intent. The confused speech and concurrent behavior labeled psychotic are attributed to a non-organic mental illness or an organic neurological disorder. Either of these disorders allegedly causes confused thought and speech reflexively. From that perspective, however, the confused thought and speech cannot be classified as behavior. It is actually a reflex, a function of the involuntary nervous system. Examples of a reflex are epileptic seizures and the contraction of the pupil in bright light. Intention has nothing to do with these reflex processes.

(3) Finally, the term psychosis is also used to prescribe speech and behavior. People who use the term in this way define "what is" in terms of what should be. The confused speech and behavior is labeled psychotic because it _should_ be different from what it is. Suicidal ideation, self-destructive behavior, and suicide are examples. They are considered psychoses, not choice or intentional conduct, i.e., based on values. Speech and behavior must abide by societal conventions.

Defining psychosis by ascribing it to something else or prescribing what it should be is a strategic maneuver on the part of the labeler. It allows some people to justify doing certain things to certain other people. For example, criminals are absolved of responsibility for their actions (the insanity defense). Some people are denied due process of law based on psychiatric declarations of incompetence. Those who have committed no crimes are treated as if they were criminals, e.g., with civil commitment, (Schaler, 1996).

ANGELS AND ALIENS

Psychosis is not a thing or an entity. It is a label describing identity. That identity is self-assumed or assigned by others. Moreover, reifying psychosis _is_ psychosis. (Again, this is not to suggest the existence of mental "illness.")

What do we mean by "identity" here? In his acceptance of the Henry A. Murray award from the American Psychological Association Theodore R. Sarbin said:

For simplicity and brevity I define identity as the composite of answers that an actor constructs to the 'who am I' question. Implicit is the caveat that the answers are always context dependent ... It is important to emphasize that one's identity is a construction that arises in dialogue ... with others ... including imagined others ... (Sarbin, 1995).

Qualitatively, there is no difference between psychosis considered mental illness and psychosis considered mental health. Schizophrenia is said to be characterized by hallucinations, i.e., self-reported imaginings. Belief in God is a socially acceptable self-reported imagining. Belief in Satan is a socially unacceptable self-reported imagining. The first is considered normal and is not an indication of mental illness, whereas the second is considered abnormal but is an indication of mental illness (Sarbin, 1990). Another example of self-reported imaginings, i.e., hallucinations, is the popular belief in the existence of angels. This belief is considered normal by mentally "healthy" people. Belief in the existence of aliens is considered abnormal and is a sign of mental illness. Yet, insofar as angels and aliens are both hallucinations (that is, self-reported imaginings), there is no difference between believing in angels and believing in aliens. Moreover, people who believe in angels are just as adamant in claiming the reality of angels as are those who insist on the reality of aliens. The difference between these two hallucinations has to do with the effect of these self-reported imaginings on others. That effect is determined by the values of the culture or context within which the self-report occurs. Because just as identity is a function of context, so too is the identity bestowed on us by others. Both are labels. Psychosis as a process of confusion (descriptive sense) is not context dependent. What is context dependent is whether or not we categorize it as a disease process. Identity is context dependent. I regard myself as male within the context of gender. I do not cease to be male simply because I am not defining myself as such within that context. A person is cast in the role of "patient," but that doesn't make him or her literally sick. We do not construct reality. We can distort our _perception_ of reality, but we cannot distort _reality_ itself. When self-reported imaginings conflict with socially accepted norms of belief, speech, and behavior, the claims are considered psychotic, ascribed and prescribed. When self-reported imaginings are consistent with socially accepted norms of belief, speech, and behavior, the claims are considered normal, although perhaps eccentric.

The December 27, 1993 issue of TIME magazine depicts an angel on its cover with the following caption beneath it: "The new age of angels. Sixty-nine percent of Americans believe they exist. What in heaven is going on?" Answer: Most people in the United States are psychotic.

All self-reported imaginings of a religious nature come under the heading of psychosis. The symbolic is mistaken for the real, the metaphorical for the literal. _Mutatis mutandis_. All self-reported imaginings labeled psychosis are essentially religious, animating. To label religious claims as psychotic is no more derogatory than to label psychotic claims as religious. Calling things by the wrong names may be intentional or strategic behavior not only among those who label psychosis mental illness but also among those who are labeled psychotic, who are just as likely to behave that way for their own strategic purposes.

VOICES

I'll conclude by giving two complementary examples of confusion about psychosis. The first concerns the mistaken notion that "hearing voices" is a form of psychosis. The second concerns the mistaken notion that "curing" psychosisis not in itself a form of psychosis.

Hearing voices is often considered a sign of psychosis as a mental illness. I submit that _not_ hearing voices in one's head is undoubtedly the more bizarre phenomenon. Hearing voices in one's head is normal. We generally call it our conscience.

In the movie _The Gods Must Be Crazy_, a woman asks if the voices in her head are bothering the person next to her. The belief that others can hear the voices in one's head is psychosis, as is the belief that the voices in one's head belong to another person.

In our discussions of the deconstruction of mental illness, my students inevitably ask, "What about those persons who are schizophrenic? They hear voices telling them to do certain things."

"Everyone hears voices in their head," I respond. "There is nothing unusual about that. Perhaps you don't want to admit it. Think about it. Don't you hear voices in your head? For example, I've told you what you need to study for your examination, and I've suggested that you'd better not wait until the night before the exam to start. If you wait until then, don't you think you will hear a voice in your head? Perhaps even _my_ voice? And if you get a bad grade in this course, don't you think you'll hear your mother's or your father's voice in your head? Especially when you think about how much money they're spending so that you can attend this university."

"What about people who hear voices commanding them to commit criminal acts?" someone usually asks. "Why is it," I tell them, "that just because people say they hear voices, we think it means that they have to obey those voices? If I told you to commit a criminal act, would you do it? You may hear my voice or that of your parents 'telling' you to study, and you may refuse to do it. Just because people hear voices does not mean that they have to obey them. There is a choice. And _you_ are in charge of making the choice."

What never ceases to amaze me is how surprised students are when I say that to them. They have usually been brainwashed into believing that hearing voices is a sign of psychosis and that the voices must be obeyed. The denial of voices-as-self is an attempt to deny the truth. It is a way of saying "this is not me." Pretending that the self is split or dissociated is a way of avoiding responsibility. What about people who claim that hearing voices in one'shead is a sign of psychosis? Do they _not_ hear voices in their own head? Are they not thinking? Are they denying the existence of their own thoughts? (T.S. Szasz, personal communication, 1995).

WHO'S ON FIRST?

Here is a scenario described by a practicing psychiatrist who believes not only in the existence of mental illness but also that he can successfully "treat" it. He described a person walking across a busy road who thinks that he will not be struck by a car because he is Jesus. The psychiatrist considers such a person psychotic (mentally ill) because (1) he believes he can alter events external to himself by thinking in a particular way and (2) he believes he is Jesus. The psychiatrist then went on to say that he believed that he could "restore autonomy" in that individual by administering certain neuroleptic drugs. But that's a contradiction in terms. How could he restore autonomy by administering drugs?

In the first case, the person crossing the road makes a false claim about himself ("I am Jesus") and believes the real world ("cars will not hit me") is consistent with his symbolic world ("because I am Jesus"). In the second case, the person makes a true claim about himself ("I am a psychiatrist") and believes that the symbolic world ("I can restore autonomy by the use of drugs") is consistent with his real world ("because I am a psychiatrist"). The person labeled psychotic is confused in his thinking because he believes the real world is in effect his symbolic world. The person labeled psychiatrist is confused in his thinking because he believes the symbolic world is in effect his real world. What's the difference?

CONCLUSION

While psychosis as mental illness is a myth, psychosis as confusion is not. Accurate perception of reality is the antithesis of psychosis, i.e., the person with accurate perception can clearly differentiate the symbolic from the real and the metaphorical from the literal. Accurate use of the term psychosis in effecting public and clinical policies must consider the validity of the distinction between socially unacceptable forms of psychosis--designated mental illness--and socially acceptable ones. That difference is a function of mores, not objective science.

REFERENCES

Isaac, R.J. & Jaffe, D.J. (1996, January 29).

Committed to help. National Review, 34-38.

Sarbin, T. R. (1995). (Speaker). The poetics of

identity (Cassette Recording No. 95-187). Washington,

DC: American Psychological Association.

Sarbin, T. R. (1990). Towards the obsolescence of the

schizophrenia hypothesis. In David Cohen

(Ed). Challenging the therapeutic state:

Critical perspectives on psychiatry and the

mental health system. The Journal of Mind and

Behavior, 11 (Nos. 3 & 4), 259-284.

Schaler, J.A. (1996, March 6). Medicine can do without

religion or state. The New York Times, A20.

Szasz, T.S. (1989). Law, liberty and psychiatry.

Syracuse, N.Y.: Syracuse University Press.

Szasz, T.S. (1988). Psychiatric justice.

Syracuse, N.Y.: Syracuse University Press.

Szasz, T.S. (1987). Insanity: The idea and its

consequence. New York: John Wiley & Sons.

Acknowledgment: I am grateful to Amos M. Gunsberg

for suggestions regarding a draft of this article.

Jeffrey A. Schaler, Ph.D., a psychotherapist in

private practice since 1973, received his doctorate

in human development from the University of

Maryland College Park, and lives in Silver Spring,

Md. He teaches at American and Johns Hopkins

universities and created NUVUPSY, SMARTREC, and

MM at sjuvm.stjohns.edu

Email: jschale@american.edu