The correct paradigm may be that of evolutionary psychiatry

Dr Thomas Szasz repeats his view that psychiatric illness does not exist, and that people should be held responsible for their beliefs and actions. ¹ But what if we are presented with a mother who believes she has committed an unforgivable sin, and that she and her baby are infested with the devil, with the only solution being to kill herself and her child? We know that with treatment, or just with the passage of time, she will return to normal and realise that her ‘sinfulness’ was delusional. As I understand Dr Szasz, he would consider treating her to be ‘a grave violation of her basic human rights’ and he would advise us to let her ‘minister to herself’. Yet does she not have a basic human right to be treated, even if she has no insight into her need for treatment?

It is likely that evolution has prepared mental states for extreme situations and that it is possible to enter one either because a person is in an extreme situation, or by mistake, on the ‘smoke detector’ principle that it is better to be frightened to death a hundred times thinking there is a lion in the bush rather than ignore one real clue that a lion really is there. ² It may be impossible to tell whether a mental state is caused by a real danger or disaster, or is due to a psychic mistake. A depressed mother with a baby may be a member of one of those societies who try to maintain a constant population, whose surplus men go into monasteries and only one daughter per family is allowed to breed, and she may have offended against society’s rules by getting pregnant outside marriage. In the Book of Job, Job lost his children and all his cattle and became depressed, but why did his so-called comforters not offer their condolences on the death of his children? This may suggest that the text can be as easily read as a story of a man who, owing to psychotic depression, had the delusion of loss of property and death of loved ones. ³ In psychiatric practice we are often dealing with people who have entered states of depression and anxiety when there is no real cause - are we not to help them?

The paradigm here is evolutionary psychiatry. ⁴ It is not necessary to view these deluded and anxious people as either sinful or responsible - whether or not we treat them as ‘sick’ depends on factors such as eligibility for NHS healthcare and other practical matters. We have been fashioned by evolution to suffer inappropriate extremes of mental pain and delusional ideas - it is more important to help these people back to normality than to spend time discussing whether they are sick or bad or should bear responsibility for themselves.

I must acknowledge one debt to Dr Szasz. In my long career in working age psychiatry, I was often asked by troubled patients what to say when, applying for a job, they were asked whether they had ever had mental illness. Knowing of the stigma and prejudice that a positive answer would probably arouse, I was able to say to them with a clear conscience, ‘Think Szasz and say ‘No!’.’