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The debate over the existence of mental illness is into its third decade without any real progress toward resolution. Resolution is possible, however, if two wholly unrelated issues are separated from one another. These are (a) the conceptual status of the psychological variables determining deviant behavior and (b) the appropriate response of society to individuals exhibiting certain behavioral characteristics. Regarding the first issue, sound philosophy of science dictates that the psychological variables determining deviant behavior are not physical structures, but hypothetical constructs. Neither side of the mental illness debate seems to have any quarrel with this conclusion. Regarding the second issue, the two sides of the debate do not seem to have any fundamental disagreement over behavioral ideals. Moreover, they appear to agree that methods of achieving such ideals be selected for specific efficacy. The real disagreement seems to be over professional prerogatives and the legal/ethical status of the behaviorally aberrant. I suggest that these issues be addressed directly and the empty debate over the existence of mental illness be abandoned. Gorenstein, E. E. (1984). Debating mental illness: Implications for science, medicine, and social policy. American Psychologist, 39 (1); 50&emdash;56.

It will soon be a quarter of a century since Thomas Szasz (1960) advanced his controversial thesis that mental illness is a myth. During that time, Szasz's position has alternately been denounced (e.g., Ausubel, 1961; Chodoff, 1976; Kety, 1974) and applauded (e.g., Laing, 1964; Rosenhan, 1973; Sarbin, 1968; Scheff, 1966), but always, the issues have been intractable to resolution. As the debate continues to unfold (e.g., Szasz, 1982a), the mental health field is still unable to establish, except as a matter of faith, whether or not there is such a thing as mental illness.

Gradually, though, the views of Szasz and like-minded commentators have had a subtle but detectable impact on a field that remains staunchly medical in orientation. The standard terminology of the past&emdash;''mental disease,'' "insanity''&emdash; is now considered archaic by most mental health professionals. Even "mental illness," once considered the locution of enlightenment, is increasingly avoided in the scientific literature. In the psychiatric sphere, practitioners have begrudgingly resigned themselves to elections as the only feasible means of establishing the medical status of controversial behavior patterns. In education, textbooks on psychiatry and abnormal psychology now suggest that mental illness or abnormality, although it surely is real, is exceedingly difficult to define absolutely.

Thus, the mental health field has made uneasy adjustments to accommodate its most important contemporary challenge. But the basic issues do not go away (e.g., Szasz, 1982b), and one wonders why there has been no real progress in resolving so fundamental a debate as whether or not mental illness exists.

I think most who have studied this problem would agree that one of the principal difficulties has been the failure to isolate the separate questions that need to be addressed (cf. Sarason & Ganzer, 1968). However, I think this problem has been compounded by the failure of the various interested parties&emdash; science, medicine, and social welfare&emdash; to understand the limitations of their respective domains. The result has been such misrepresentation of the issues that opponents cannot even recognize those points on which they actually agree.

It is hard to tell if the debate over the existence of mental illness is ripe for a solution. It does seem clear, however, that this debate is ready to be reduced to manageable proportions. In so doing, we may examine some important issues that seem already to have been solved and identity the remaining issues and appropriate avenues to their resolution.

A protracted debate was set in motion by Thomas Szasz (1960) when he suggested that "mental illness," originally a summary term for certain behavioral phenomena treated by health professionals, had become reified as a cause of the very phenomena that the term had been coined to represent. In other words, the concept of a diseased mind was based on a logical fallacy. Not only could the concept of mental illness be criticized on logical grounds, but also, according to Szasz, some factual reasons why the notion of "illness" had doubtful application to mental phenomena. First of all, it was unlikely that organic brain damage could account for the content of an individual's thoughts (and, in any event, organic etiology would imply a brain disease, but not mental illness). Second, Szasz suggested that there was a fundamental distinction between the procedures used to diagnose physical diseases and the procedures used to identify mental disorders. In the former case, a diagnosis was based on objective criteria, but in the latter, completely objective judgments were demanded. Finally, Szasz proposed that mental illness functioned as a pretext for exonerating irresponsible behavior and was objectionable from the point of view of social justice.

Szasz concluded that the term "mental illness" had outlived its usefulness and suggested that deviant behavior patterns be recognized simply as "problems in living."

The responses to Szasz's statement were of many types. An initial rebuttal, offered by David Ausubel (1961), captured what was probably the predominant sentiment among mental health professionals at the time. To begin with, Ausubel offered plausible counter arguments to many of Szasz's factual claims. In addition, he denounced the moral implications of Szasz's proposal that the concept of mental illness be abolished. However, refutation of Szasz's central thesis, that mental illness did not exist, proved elusive. Ausubel was able to do no better than proclaim the existence of mental illness as a manifest truth. Mental illness could be defined, he declared, as "behavior that is either seriously distorted or sufficiently unadaptive to prevent normal interpersonal relations and vocational functioning," in other words, "a gross deviation from a designated range of desirable behavioral variability" (p. 72). This definition, of course, simply begged the question: What is normal? What is desirable?

To refute Szasz's position effectively, it seemed that an unequivocal definition of mental illness had to be formulated. However, Ausubel's failure to define the phenomenon in question foreshadowed certain difficulties that would be encountered in any attempt to specify the parameters of psychological abnormality. Subsequently, it has become standard practice for abnormal psychology texts to introduce the field by enumerating various means of defining mental illness- or abnormality and various deficiencies associated with each of them. (e.g., Bootzin & Acocella, 1980; Gottesfeld, 1979; Kazdin, Bellack, & Hersen, 1980; Sue, Sue,& Sue, 1981).

The so-called "statistical'' method-of defining mental illness is typically presented first as one plausible approach that inevitably raises more questions than it answers. According to this definition, mental illness is determined by the relative frequency of certain characteristics or behaviors in the general population. Phenomena that are relatively rate&emdash; in the case of a normal distribution this amounts to phenomena that are dimensionally extreme&emdash; are considered indexes of mental illness. For example, individuals whose level of trait anxiety is two standard deviations above the population mean might be considered abnormal or mentally ill according to this definition.

Needless to say, this method of defining mental illness is fraught with deficiencies, the most obvious, though probably the least problematic (see Rimland, 1969), being the dependence on arbitrary cutoff points. The greatest inadequacy is the definition's complete lack of content. On what basis are the psychological dimensions to be chosen? Is anxiety a relevant dimension? Is intelligence? The notion that some psychological characteristics are statistically rare obviously does very little to clarify the boundaries of mental illness.

An alternative method of defining mental illness, the textbooks have noted, is the use of social norms. The social definition is similar to the statistical definition in that statistical rarity usually characterizes those psychological features judged abnormal, but now the relevant dimensions of behavior are specified, in particular in terms of the values of society at large. Behavior that is beyond the bounds of social acceptability would be considered a manifestation of mental illness by this definition. The textbooks have generally been quick to emphasize the totalitarian impactions of this approach and suggest that it must ultimately be rejected on these grounds. Yet, the social definition seems to capture some essential ingredients in the way the concept of mental illness is applied.

A third means of defining mental illness is to draw on psychological theory. As the textbooks usually note, numerous theoretical persuasions have sprouted up in the mental health field, each with its particular notion of what constitutes psychological abnormality or mental illness. Although some schools of thought do not use the term illness explicitly, each identifies certain undesirable psychological states or behaviors that merit professional intervention. Unconscious conflicts dominating an individual's behavior are ''pathological" according to psychoanalytic theory; ineffective responding for reinforcers defines the patient for some learning theorists, among the humanists, it is marked incongruence of the introjected self-concept and the actual self; for the gestalt therapist, it is an excessive dissociation of components of experience. The list is virtually endless, and there is a tremendous variety of new points expressed. Unfortunately, the theoretical assortment is so great that it would be impossible to formulate any broadly acceptable definition of mental illness.

This is not to imply that all theories are equally meritorious. Clearly, some theories may be considered superior to others on either formal or empirical grounds. But even the most advanced psychological theory currently available falls far short of the kind of comprehensiveness and validation that could justify authoritative pronouncements regarding the parameters of abnormality. Were an adequate theory to be developed, it is still not clear -that a definition of mental illness would result. After all, a valid psychological theory would merely afford the explanation of psychological or behavioral outcomes in accordance with postulated causal mechanisms. Such outcomes would still have to be evaluated as positive or negative according to some criteria. Deciding on the relevant criteria entails nothing less than posing the original question: What is abnormal?

Most textbooks recognize, therefore, that theory-based definitions of mental illness amount to an alternate form of the social definition. The only difference is that the norms are derived from the implicit values of a particular school of thought as opposed to society at large, and of course, often there is more than casual correspondence between the two.

A fourth principal method of defining illness or abnormality is to use the criterion of subjective discomfort. According to this approach, individuals are identified as mentally ill by their own admission of psychological distress. of all the means of defining abnormality, this is perhaps the most analogous to the approach taken in the practice of physical medicine. Medical conditions are identified primarily because an individual seeks treatment for physical discomfort. Alternatively, a non painful condition is targeted for treatment because it is known ultimately to lead to physical discomfort (or death), and of course, some conditions are treated merely because the patient desires a change, as in the case of cosmetic surgery.

Psychiatry, however has been notoriously resistant to accepting a role for its patients in determining illness. Indeed, the traditional clinical lore held that a disorders severity was measured in direct proportion to the patient's lack of awareness of the underlying psychological processes. It is this theoretical-climate that enabled many in the field to accept uncritically a study in the early 1960s purporting to show that over 80% of an unsuspecting metropolitan population exhibited psychiatric symptoms and almost one quarter were ''impaired'' (Srole, Langner, Michael, Opler, & Rennie, 1962).

The textbooks have generally recognized some merit in the subjective discomfort definition but have concluded that it falls far short of a satisfactory definition of mental illness. As a sole criterion, it would exclude many of the so-called personality disorders as well as such psychotic states as mania and schizophrenia. A principal feature of these diagnostic categories is a lack of insight into the problematic nature of one's mental condition. More generally, the textbooks observe, almost anyone's understanding of mental illness includes the notion that the affected individual might have some impairment in rational judgment, especially as applied to himself or herself. Thus, a subjective discomfort definition of mental illness appears to violate certain intuitive understandings of the concept.

If the statistical definition, the social definition, the theory-based definition, and the subjective discomfort definition all fall short of an adequate representation of mental illness, it seems reasonable to wonder if we really know just what we are trying to define.

An opinion on this subject is offered by several theorists of a sociological bent who contend that the social definition of mental illness, for all its unsavory connotations of conformism, actually comes closer to the mark than we are willing to admit. To make their point, theorists such as Braginsky, Braginsky, and Ring (1969), Sarbin (1967, 1968), and Scheff (1966, 1970) have brought the full weight of Goffman's (1959, 1961, 1963) social identity theory into the mental health arena.

Scheff (1970), for example, published a statement in the then newly formed journal Schizophrenia Bulletin, denouncing its very rationale. Schizophrenia, he contended, is not an illness but an ideology, a label conferred on individuals who commit offenses against the public order. The nature of the transgression is the failure to maintain society's implicit standards of self-presentation in public encounters, a violation of "residual rules."

The social deviance perspective of Scheff suggests, perhaps, why the mental health field gropes so ineffectually for a definition of mental illness yet senses intuitively that the concept has some validity. A definition is elusive because deviance itself has no inherent properties; it is strictly a normative phenomenon. Yet, deviation from social norms is so deeply understood by every member of society that any conceptual abstraction to pin it down strikes a responsive chord. The illness or medical model enjoys currency because the contemporary approach to regulating deviance is through treatment by medical personnel.

It is important to note&emdash; and this is often not understood by the many detractors of Scheff and like-minded theorists&emdash; that Scheff's position acknowledges the potential role of psychological, environmental, and even genetic or biochemical factors in producing deviant behavior. Scheff's quarrel is not with the putative causes of behavior but with the identification and characterization of the outcome. Specifically, what is condemned is the application of medical terminology to a phenomenon identified by social criteria.

Despite these qualifications, many behavioral scientists, particularly those with medical training (e.g., Kety, 1974; Spitzer, 1975, 1976), bristled at the continuing insinuations by Scheff, Ssasz, and others (e.g., Laing, 1967; Rosenhan, 1973) that they had been devoting their careers to the research and treatment of a myth. Seymour Kely's (1974) paper, entitled "From Rationalization to Reason," took up the defense of the medical model as an empirical challenge. Specifically, he outlined the results of his investigation of psychopathology in the biological and adoptive rdadves of schizophrenic and control adoptees. The results indicated that schizophrenia (as defined by DSM-II), was three and a half times more prevalent among the biological relatives of schizophrenic adoptees than among all other groups of people, including those with whom the index case had actually been raised. If there were any doubts as to the implications of these findings, they could be dispelled by subsequent analyses restricted to paternal half-siblings (who do not share even their prenatal environment). Among these relatives, it was found that those related to a schizophrenic index case were seven times more likely then controls to be diagnosed as schizophrenic. The only factor that could conceivably account for this result is genetic overlap among biological relatives. As Kety was compelled to conclude, "If schizophrenia is a myth, it is a myth with a strong genetic component.'' (p. 961).

Kety's study was a classic contribution to the body of evidence now generally accepted as incontrovertibly demonstrating a genetic component of schizophrenia.

But did the study establish the existence of mental illness?

I suggest that Kety's study did not even address this issue, at least not in the way it had been formulated by Szasz, Scheff, and others. As we shall see, the principal reason that the myth versus illness dispute continues unresolved is that advocates of the two perspectives are actually in substantial agreement with each other on most basic points without realizing it. To understand this, we must first consider what is really means by the proposition that mental illness is a myth.

This proposition actually raises two very different questions, and unless they are separated, any systematic or rational analysis of the issues is completely obstructed.

The questions are, in effect: (a) What is the conceptual status of the psychological variables determining deviant behavior? and (b) How should society respond to individuals exhibiting certain psychological or behavioral characteristics?

The so-called medical model can speak to, though science can. Unfortunately, many theorists and researchers erroneously equate medicine with science, thus presuming that if the scientific validity of a term such as schizophrenia is established, then schizophrenia is automatically installed within the purview of medicine.

In fact, medicine has only a derivative relationship to science. It is a technology developed to deal with pragmatic problems as defined by individuals and social policy. Thus, when the genetic basis of schizophrenia gradually came to light, this no more established it as a medical condition than the genetic basis of eye color established brown eyes as a medical condition. That a particular phenomenon has a cause in no way implies it is a disease.

Disease and illness are not scientific concepts. They are merely categories that comprise the ever expanding range of conditions treated by health professionals As Meehl 1977) observed:

One can discern nothing obviously in common- in the postulated causal structure, in the statistical relations between signs or symptoms and the definitional etiology, and in the approach to prophylaxis and treatment- among the following conditions, all of which are recognized as "disease entities": Huntington's disease, pellagra, measles, rheumatoid arthritis, subacute bacterial endocarditis, congential aneurysm, idiopathic epilepsy, general paresis, dementia senilis, obesity, diabetic gangrene, appendicitis, gout, cerebral fat embolism following bone crushing trauma. So far I have been able to ascertain no general systematic clarification has been done within organic medicine on the metaquestion "When does a disease entity exist?" (pp. 194-195)

The conceptual status of psychological variables can hardly be eludicated by a so-called model, devoid of any unifying conceptual framework.

Some medically trained researchers might dispute such a characterization, suggesting that a basic model with substantial heuristic value does in fact exist. As Kety (1974) stated in defending the proposition that schizophrenia is a disease:

The medical model is an evolving intellectual process, consonant with the scientific method, which involves long periods of observation and description, increasingly sharper differentiation, and research rather than wishful thinking.

The medical model of an illness is a process that moves from the recognition and palliation of symptoms to the characterization of a specific disease in which the etiology and the pathognesis are known and the treatment is rational and specific. That process depends on the acquisition of knowledge and may often take many years or centuries. (p. 959)

But what process is it that Kety is actually describing here? Students of non medical fields will recognize it not as a "process consonant with the scientific method,'' but as the scientific method itself, as it is-applied in physics, chemistry biology, psychology, economics or any other empirical field. Atom, molecule, genotype, cognition, market value: Are these diseases? Indeed they are not. They are theoretical entities or constructs that have been inferred following systematic observation of their presumed effects. The scientific method maybe useful in discovering causes and developing cures for medical conditions, but this in no way implies the converse: that a particular state constitutes a medical condition because it is amenable to scientific analysis.

The point, then, is that the "medical model," as Kety uses the concept, is synonymous with the scientific method, which objectively does not provide recommendations regarding the necessity of treatment by medical personnel.

If medicine has nothing to say about the conceptual status of psychological variables, then where does science stand vis-a-vis the proposition that mental illness is a myth?

Far from disputing such a claim, science presents itself as a chief proponent. Science, after all, is built on myths. Its very progress depends on the development and refinement of the many outlandish creations&emdash; otherwise known as theories&emdash; that afford prediction and control of natural phenomena. Accordingly, the psychological variables determining deviant behavior are regarded by scientists (cf. Neale & Oltmanns, 1980), not as diseases but as theoretical or hypothetical constructs. (Cronbach & Meehl, 1955). Hypothetical constructs are not presumed to exist as physical structures (though the basis of their effects may be presumed to reside ultimately in physical mechanisms). Rather, they are conceptual abstractions that are developed to account for observable phenomena. Terms such as schizophrenia, depression, anxiety, psychopathy&emdash; in short, all the so-called mental disorders&emdash; are products of just such an inferential process.

Those who defend the illness model of mental disorders do so principally in the interest of preserving an enlightened scientific approach to the research and treatment of deviant behavior. Though their idiom is medical, we may presume that they do not intend to quarrel with sound philosophy of science regarding the conceptual status of inferred entities. Kety's own words, quoted earlier, clearly reveal his commitment to the tentative "evolving intellectual process" that scientific inference entails.

Therefore, regarding the conceptual status of psychological variables determining deviant behavior, there is no real impediment to a negotiated settlement between the medical and the myth ideologues. Both camps implicitly accept the proposition that psychological variables&emdash; mental conditions or diagnostic entities&emdash; are theoretical constructs subject to modification and refinement in accordance with acceptable standards of inductive inference (see Szasz, 1960, p. 1 13).

Where the two factions often differ, though the level of polemic rarely advances this high, is in their reading of the empirical status of specific diagnostic categories. Critics of the medical perspective have typically underscored limitations in the reliability and predictive validity of psychiatric diagnoses (e.g., Braginsky et al., 1969; Rosenhan, 1973; Scheff, 1970), whereas its advocates (e.g., Kety, 1974; Spier, 1975) have understandably sought to emphasize the successes.

But even this difference of opinion is not as great as it often seems. Sophisticated advocates of the medical perspective are acutely aware of the tenuous empirical status of most diagnostic categories. For example, in their analysis of the diagnostic reliability of DSM-II, Spitzer and Fleiss (1974) concluded that, even under the best of circumstances, levels of interrater agreement was quite unsatisfactory. Although reliability in the most recent DSM appears to be substantially improved, the authors of the manual recognize that the predictive validity of even reliable categories is hardly assured (see American Psychiatric Association, 1980, pp. 1-12).

The empirical status of current diagnostic entities is really beside the point. Even entities with proven construct validity (Cronbach & Meehl, 1955) are myths in the sense of their being abstract creations. Unlike other myths, however, valid constructs can lay claim to some measure of "verisimilitude"(Popper, 1972).

What of the second aspect of the myth versus illness debate: How should society respond to individuals exhibiting certain (deviant) psychological or behavioral characteristics?

Now we are in a realm to which science brings no special expertise, for this is a matter of social policy. Science can, of course, provide information that will aid the public in making an educated decision. But such formation conveys only the empirical relations between independent and dependent variables, that is, between therapeutic actions and behavioral outcomes. As to which actions or outcomes are desirable, cost-efficient, egregious, misguided, or anything else, these questions must be evaluated against of the public will that customarily is charged with formulating social policy in accordance with society's basic values. To some extent, we already have something of a codified policy in elfea, as reflected in competency hearings and insurance practices. though we need not dwell on the very controversial and very incomplete nature of such policy as it now stands.

By and large, the formulation and execution of policy for psychological intervention has fallen, by default, on the various professional groups claiming expertise in the modification of psychological or behavioral abnormalities: medicine, clinical psychology, social work, and pastoral counseling. Needless to say, such policy has never been explicitly delineated, and most mental health practitioners are hardly ever reminded that implicit values are espoused whenever a decision is made to initiate or terminate treatment of a given individual. The question of values is rarely raised because, by and large, members of society seem to agree fairly well what constitutes desirable versus undesirable behavioral outcomes. Occasionally (and not inconsequentially), conflicts do arise, as when a hospitalized patient (described as having "loss of insight'') refuses to accept treatnent or when a segment of society (e.g., homosexuals) is no longer willing to have its behavioral practices considered grounds for medical intervention.

But for better or worse, there seems to be minimal conflict over many fundamental ideals of human existence&emdash; for example, that one should be physically comfortable, emotionally happy, kind to others, and in touch with events&emdash; and these shared ideals are reflected every day in the treatment goals endorsed by patients and therapists alike.

By the same token, there is no real disagreement between the myth and the medical ideologues over behavioral ideals themselves. Neither group views the aimless wandering of hallucinating vagrants through New York City as a desirable behavioral outcome (however, see Laing, 1967, for a possible exception). Rather, the dispute has arisen over medicine's labeling as ''diseases those behavioral practices that fall short of consentually accepted standards. As we have already seen, this is an empty dispute in terms of its conceptual or scientific significance&emdash; there is no scientific basis for labeling a hypothetical construct " diseased.'' In terms of practical significance, proponents of the medical versus the myth position are in conflict essentially over the following question: What are the particular methods, both in terms of effectiveness and moral acceptability, that should be adopted to help individuals achieve levels of behavioral adjustment consistent with common values?

Supporters of the disease perspective have maintained that medical treatment is the appropriate strategy of intervention, whereas their opponents have insisted that deviant behavior be addressed as "problems in living'' (Szasz, 1960). But here again the difference between the medical versus the myth ideologues may be more apparent than real.

Indeed, how does verbal psychotherapy&emdash; a practice that has traditionally posed a medical treatment&emdash; really differ from alternative modes of intervention aimed at problems in living? We need not review the classic comparative studies of psychotherapeutic practice (e.g., Frank, 1973; Levy, 1963; Schofield, 1964) to surmise that the two approaches would not differ at all in any qualitative sense. Whatever its pretensions to the medical imprimatur, psychotherapy retains a verbal exchange between two individuals, intended ultimately to help one of the individuals overcome the very problems in living that Szasz has underscored.

Even the various somatic treatments advocated by medical psychiatry are not inherently anathema to the problems-in-living perspective. The antimedical movement is not bent on denying the palliative benefits of chemical compounds to those who suffer. The principal objection has to do with ultimate effectiveness: that such treatments are used as nonspecific custodial measures that fail to achieve any permanent remedy. The use of psychotropic medications is considered doubly injurious because these medications not only entail serious side effects, but also are far too readily (and fallaciously) interpreted as affirming a simple organic model, thereby dampening efforts to explore alternatives or adjuncts to medication that are more specifically effective (Szasz, 1976).

Despite these objections, Szasz and others do not articulate any absolute principle that would bar somatic treatment as a component of the therapeutic armamentarium if an undeniably positive contribution to alleviating problems in living could be demonstrated. By the same token, serious thinkers in psychopharmacology acknowledge that treatments are ideally devised to address proximate causes specifically, whether through somatic, psychological, or social means (Barchas, Berger, Ciaranello & Elliott, 1977).

If the myth and the medical ideologues are largely able to agree on behavioral ideals, and if they agree in principle that methods of achieving these ideals be selected for specific efficacy, then where does the dispute really lie?

By now it should be clear that the dispute lies in the only real meaning that the term "illness" has acquired when applied to an individual's emotions or behavior, namely, (a) the authorization of care by a physician and, in some cases, (b) the assignment of a legal/ethical status that denies certain freedoms while conferring special protections. Professional and regulatory practices like these (and ultimately, their social consequences, e.g.. Sarbin, 1967) are at the heart of the debate over the existence of mental illness.

The issues raised are enormously controversial, and the depth of disagreement between adversaries cannot be minimized. Szasz's position, for example, is fundamentally irreconcilable with that of the medical establishment. Whereas Szasz denounces involuntary commitment categorically, the medical establishment generally supports it as legitimate and even desirable (cf. Chodoff, 1976).

Society must come to grips with the many questions that are raised by its avowed intention not to ignore deviant behavior. For example: Who is entitled to conduct treatment? When can treatment be applied forcibly? When can an individual's rights be abridged? When is an individual absolved from responsibilities?

These are serious questions, difficult questions, but what ultimately must be faced is that they are not theoretical or empirical questions. They are questions of social regulation that must be addressed directly, not concealed within a specious debate over the existence of an undefined abstraction.

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