Jeffrey A. Schaler, Ph.D.

PsychNews International

An Online Publication

Volume 1, Issue 1: Section B 
The Fifth Column 





The following is a regular, independent column written by 
Jeffrey A. Schaler, Ph.D. 

Opinions and comments are invited. Please send them 
to the PNI Mailbox 

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 be
psychotic 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&qu ot; ("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
n on-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
s ocietal 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 peo ple. 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).

Psychosis is not a thing or an entity. It is a label
describing identity. That identity is self-assumed or
assigned by others. Moreo ver, 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.

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" psychosis
is 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's
head 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).

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?

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.


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