The concept of impersonation refers to the assumption or imitation of someone else’s appearance, character, condition, or social role. Impersonation is a ubiquitous phenomenon and is not, as such, considered to constitute a psychiatric problem. Indeed, everyday speech offers numerous terms for a variety of impersonations or, more precisely, impersonators; for example, charlatan, confidence man, counterfeiter, forger, impostor, quack, spy, traitor, and so forth. Two impersonators, the malingerer and the hysteric, have been of special interest to psychiatrists. I have remarked on them both in the previous chapters of this book.
A definition of impersonation is now in order. According to Webster, to impersonate is “to assume or act the person or character of… .” This definition provokes some interesting difficulties: if role-taking behavior is universal, as Mead and others have suggested,1 how do we distinguish ordinary role-taking from impersonation? I suggest the following answer: role-taking refers to consistent or honest role-playing, in the context of a specific game—whereas impersonation refers to inconsistent or dishonest role-playing, in the context of everyday life. For example, taking the role of a vendor and approaching another person as a prospective customer implies that the seller either owns the goods offered for sale or is authorized to act in the owner’s name. When a person sells something he does not own, he impersonates the role of an honest vendor and is called a “swindler.”
Since role-taking is a permanent and universal characteristic of human behavior, it is evident that practically any action can be interpreted as a type of impersonation. The so-called Don Juan may thus be said to impersonate a man of acrobatic virility; the transvestite, the social role and sexual functions of a member of the opposite sex; and so forth. Simone de Beauvoir offers this account of role-taking as impersonation:
Even if each woman dresses in conformity with her status, a game is still being played: artifice, like art, belongs to the realm of the imaginary. It is not only that girdle, brassiere, hair-dye, make-up disguise body and face; but that the least sophisticated of women, once she is ‘dressed,’ does not present herself to observation; she is, like the picture or the statue, or the actor on the stage, an agent through whom is suggested someone not there—that is, the character she represents, but is not.2
If what de Beauvoir says is true about women, it is even more true about children, who spend much of their time impersonating others. They play at being fireman, doctor, nurse, mother, father. Since the child’s identity is defined in predominantly negative terms—that is, in terms of what he cannot do, because he is not allowed to do it or is incapable of doing it—it is not surprising that he should seek role fulfillment through impersonation. A child’s real identity or social role is, of course, to be a child. But in an achievement-oriented culture, as opposed to a tradition-and kinship-oriented one, being a child tends to mean mostly that one is unable or unfit to act in certain ways. Thus, childhood itself may be viewed as a form of disability.*
Let us now briefly reconsider the impersonations which children, say between five and ten, characteristically engage in. From the adult’s point of view, what is perhaps most striking about these play-acts is their transparency as impersonations. How could anyone possibly mistake a child playing doctor or nurse for a real doctor or nurse? The question itself is ludicrous—because the task of distinguishing impersonated role from genuine role is here nonexistent. A blank sheet of typewriter paper is not an imitation of a twenty-dollar bill; nor is a five-year-old playing doctor an impostor. In part, it is of course the child’s size that stamps a clear identity on him, and vitiates his effort at any credible imitation of an adult role: he is simply too small and looks too unlike an adult to be able to assume an adult role. He may, of course, possess the skills of an adult, and more—as, for example, a musical prodigy does; but he cannot possess the social role of an adult.
Although the child’s impersonations are so obvious as to present no problem at all for adults to recognize, there are others which are so subtle, or require such specialized informations and skills, that most adults are quite incapable of recognizing them. Many people cannot tell a quack from a licensed physician, or an art forger from a recognized artist. Similarly, most people cannot readily distinguish between a clinical psychologist and a psychiatrist, or a psychiatrist and a “regular” physician: to make these distinctions—that is, to see how psychologists impersonate psychiatrists, and psychiatrists regular physicians—requires that one possess certain kinds of specialized information not generally available.3
Impersonation, then, is an integral part of childhood. Another way of saying this is by asserting that children learn how to grow up by imitating adults and by identifying with them. For the reasons I have just noted, the problem of distinguishing between successful and unsuccessful impersonation does not arise until after the person has attained physiological and social maturity. Only an adult can fake another.
Nevertheless, psychiatrists and psychoanalysts have systematically failed to distinguish between impersonation, which is the general class, and imposturing, which is but one type of impersonation. Helene Deutsch, who has written extensively on this subject, actually equates, and thus confuses, these two concepts and phenomena.4 Some of her observations apply to impersonating, and others to imposturing, as the following passage illustrates:
The world is crowded with “as-if” personalities, and even more so with impostors and pretenders. Ever since I became interested in the impostor, he pursues me everywhere. I find him among my friends and acquaintances, as well as in myself. Little Nancy, a fine three-and-a-half-year-old daughter of one of my friends, goes around with an air of dignity, holding her hands together tightly. Asked about this attitude she explains: “I am Nancy’s guardian angel, and I’m taking care of little Nancy.” Her father asked her about the angel’s name. “Nancy” was the proud answer of this little impostor.5
Deutsch is correct that the world is full of people who act “as if” they were someone else. Alfred Adler noted the same phenomenon and called it the “life-lie.”6 In this connection, we might also recall Vaihinger’s important work, The Philosophy of “As If,”7 which influenced both Freud and Adler.
The point is that not all impersonators are impostors, but all impostors are impersonators. In illustrating impersonation, which she erroneously calls imposturing, Deutsch cites examples of the behavior of children. But, as we saw, children must impersonate others because they are nobodies. Deutsch concludes that the essence of imposturing lies in “pretending that we actually are what we would like to be.”8 But this is merely a restatement of the common human desire to appear better than one actually is. It is not a correct formulation of imposturing, which implies deceitful role-taking for personal gain. Impersonation is a morally more neutral name for a class that contains role pretensions which are both objectionable and unobjectionable, blameworthy and praiseworthy.
The desire to be better or more important than one is is likely to be strongest, of course, among children, or among persons who are, or consider themselves to be, in inferior, oppressed, or frustrating circumstances.* These are the same persons who are most likely to resort to various methods of impersonation. Conversely, those who have been successful in realizing their aspirations—who, in other words, are relatively well satisfied with their actual role achievements and definitions—will be unlikely to pretend to be anyone but themselves. They are satisfied with who they are and can afford the luxury of telling the truth about themselves.
Since, in principle at least, every human activity or role can be imitated, there are as many types of impersonations as there are human performances. From this rich variety of impersonations, I shall select and briefly comment here on a few which seem to me especially relevant to psychiatry and to the present study of it.
Lying is the logical example to begin with. The liar impersonates the truth-teller. We speak of lying usually in relation to verbal or written communications; and then only when there is an expectation that the communicants are supposed to be truthful. Poets speak in metaphor, and politicians in rhetoric, and we do not call their utterances lies. Witnesses in courts of law, on the other hand, are explicitly enjoined to tell the truth, and are guilty of perjury if they do not.
Cheating is like lying, but in the context of games. The cheat impersonates the honest player, to unfairly enhance his chances of winning. We speak of cheating only when the rules of the game are clearly codified and generally known. For example, a person may be cheated in a business venture, or a husband by his wife or vice versa. When the game rules are uncertain or unknown to the players, we give other names to rule breaking. In psychiatry, for example, instead of saying that persons cheat in the medical game, we say that they suffer from hysteria or hypochondriasis; in politics, instead of saying that office holders cheat, we say that they are patriotic or protect the general welfare.
Malingering, which I have discussed in detail earlier and elsewhere,9 is impersonating the socially legitimatized sick role. What constitutes being correctly sick depends, of course, on the rules of the illness game. If the medical game recognizes the legitimacy of the sick role only for persons who are bodily ill, then those who assume this role without being bodily ill will be considered to be malingerers; whereas if it also recognizes the legitimacy of the sick role for persons who are not bodily ill, then those who assume the sick role without being bodily ill will be considered to be mentally ill.
Although it may be obvious and a truism, I want to emphasize that a person who did not know the rules of the illness game could not malinger. This is like asserting that a person who did not know that a canvas by Picasso was valuable could not, and hence would not, try to sell a painting which he believes to be a fake Picasso for a large sum. This, then, lets us deal more clearly with the problem of error and self-deception in impersonation. In the case of illness, a person might sincerely believe that he is bodily ill when in fact he is not; and he might then represent himself as sick. Such an individual is like a person who has unknowingly purchased a fake Picasso, who sincerely believes that it is an original, and who then represents and tries to sell it as a genuine Picasso. Clearly, there is a difference between what this man is doing and what the forger is doing. In psychiatry and psychoanalysis, malingering has traditionally been seen as similar to a forgery, and hysteria as similar to the unwitting possession and sale of a forgery. It is, I think, helpful to see both as impersonations—of possessing a genuine Picasso in the one case, and of possessing a genuine illness in the other. Whether the impersonation is conscious and deliberate, or otherwise, is usually easily ascertained—by communicating with the potential impersonator and by investigating his claims and possessions.
So-called mental illnesses are best conceptualized as special instances of impersonation. In hysteria, for example, the patient impersonates the role of a person sick with the particular disease or disability which he displays. Many psychiatrists more or less recognize and admit that this is what the hysteric does, but hasten to add that the hysteric does not know what he is doing. This belief flatters the psychiatrists, for it means that they know more about their patients than the patients know about themselves—which is usually not true. The hysteric’s seeming ignorance of what he is doing may also be interpreted as his not being able to afford to know it, for if he knew it he could no longer do it; in short, that the patient cannot bear to tell himself the truth about his own life or some particular aspect of it. He must therefore lie both to himself and others. As I have indicated already, I consider this to be the correct view.
The so-called hypochondriac and schizophrenic also impersonate: the former takes the role of certain medical patients, whereas the latter often takes the role of other, invariably famous, personalities. The hypochondriac may thus claim that he has cancer, just as a quack may claim that he is a doctor. And the schizophrenic may assert that he is Jesus, just as a child may assert that he is a daddy. These examples also show why and when psychiatrists, and the public, resort to labeling persons crazy or psychotic: the more publicly unsupported a person’s impersonation is, and the more stubbornly he clings to it despite the attempts of others to reject it, the more he courts being defined and treated as a madman or psychotic.
Another type of impersonation is that exemplified by the confidence man who pretends to be trustworthy only to defraud his victim.10 This sort of impersonation is conscious, is frankly acknowledged to self and friends, and is concealed only from intended victims. In confidence games, the swindler’s gains and the victim’s losses are obvious, at least in retrospect.
There remains one particular type of impersonation which deserves special attention—namely, acting, or impersonation in the theater. In this setting, role-taking is explicitly identified as impersonation by the context in which it occurs. The actor who plays Lear or Lincoln is not Lear or Lincoln, and both actors and audiences know this. Theatrical impersonation is, in many ways, the model of all impersonations. Although such impersonation is characteristically confined to the theater, the actor being himself when he is offstage, the actor’s real life, or at least the public’s image of it, is often profoundly affected by his theatrical roles, especially if these are consistently of the same sort. I refer here to what in the theater and movies is known as “typecasting” and “being typed,” phenomena which, as we shall presently see, are of considerable importance for psychiatry and ordinary social relations as well. If actors or actresses appear in the same sorts of roles over and over again, they are likely to create the impression in the public that they are “really” like the characters they are portraying. One immediately thinks in this connection of the actors who are always the gangsters, or the actresses who are the sex bombs. To many Americans, Boris Karloff was Frankenstein, Raymond Massey was Lincoln, and Ralph Bellamy was Franklin Roosevelt. Moreover, the actors’ assumed identities may prove convincing not only to their audiences but to themselves as well. They may then begin to act offstage as if they were on it. Roles can and do become habits. In many chronic cases of mental illness, we witness the consequences of playing hysterical, hypochondriacal, schizophrenic, or other games over years and decades, until they have become deeply ingrained habits.
A type of impersonation of special interest and importance to psychiatrists is the so-called Ganser syndrome, which, simply put, is the strategic impersonation of madness by a prisoner. Yet for decades psychiatrists have argued about whether this alleged illness is a form of malingering, a form of hysteria, a form of psychosis, or whether it is an illness at all.11 I suggest that we regard the Ganser syndrome as a special kind of impersonation of the sick role, occurring under the conditions of prison life as defined by judges, wardens, and prison psychiatrists.
The Ganser syndrome was first described, or perhaps I should say was created, by a German psychiatrist of that name in 1898.12 He called it a “specific hysterical twilight state,” the chief symptom of which he identified as vorbeireden. Other psychiatrists subsequently named it “paralogia,” or the “syndrome of approximate answers,” or the Ganser syndrome. Here is the description of this alleged illness from a standard American text, Noyes’s Modern Clinical Psychiatry:
An interesting type of mental disorder sometimes occurring in the case of prisoners under detention awaiting trial was described by Ganser. It develops only after commission of a crime and, therefore, tells nothing about the patient’s mental state when he committed the offense. In this syndrome, the patient, being under charges from which he would be exonerated were he irresponsible, begins, without being aware of the fact, to appear irresponsible. He appears stupid and unable to comprehend questions or instructions accurately. His replies are vaguely relevant to the query but absurd in content. He performs various uncomplicated, familiar tasks in an absurd manner, or gives approximate replies to simple questions. The patient, for example, may attempt to write with the blunt end of his pencil, or will give 11 as the product of 4 × 3. The purpose of the patient’s behavior is so obviously to appear irresponsible that the inexperienced observer frequently believes that he is malingering. The dynamics is probably that of a dissociative process.13
It should be noted that, in this account, the person exhibiting such conduct is labeled a “patient,” and his behavior a “mental disorder.” But how has it been shown that he is “sick”?
Here is another interpretation of the Ganser syndrome—this one by Fredric Wertham:
A Ganser reaction is a hysterical pseudo-stupidity which occurs almost exclusively in jails and in old-fashioned German textbooks. It is now known to be almost always due more to conscious malingering than to unconscious stupefaction.14
If the Ganser “patient” impersonates what he thinks is the behavior of the mentally sick person—to plead irresponsibility and avoid punishment—how does his behavior differ from that of a person who cheats on his income tax return? One feigns insanity, the other poverty. Nevertheless, psychiatrists continue to view this sort of behavior as a manifestation of illness and to speculate about its nature, causes, and cures.
This fact is itself significant and points to the parallels between the impersonations of the Ganser patient and of the actor who has been typecast. Persons diagnosed as suffering from the Ganser syndrome have succeeded, to an astonishing degree, in convincing both themselves and their significant audience that they are, in fact, sick—disabled, not responsible for their “symptomatic” behavior, perhaps even suffering from some obscure physicochemical disorder of their body. Their success in this respect is exactly like that of the actor who comes to believe that he is, say, irresistible to women, and about whom others come to share the same belief.
When an actor has been typecast, he has succeeded in making his assumed role so believable and accepted that people will think he no longer “acts” but “plays himself.” Similarly, if a person diagnosed as suffering from malingering, hysteria, or the Ganser syndrome has been accepted as truly ill, as a sick patient (even if the sickness is mental sickness), then he too has succeeded in making his assumed role so believable that people will think he no longer “acts” but “is sick.” This phenomenon is actually encountered in all walks of life, and there is nothing mysterious about it. Our image of the world about us is constructed on the basis of our actual experiences. How else could it be constructed? The proverbs tell us that “Seeing is believing” and that “Four eyes can see better than two.” In other words, we build our world on the basis of what we see and what other people tell us they see. Complementary channels of information thus form an exceedingly important corrective of and support for our own impressions and experiences. For example, by listening only, we may not be able to distinguish a person’s voice from a recording of it; by looking at the source of the sound we can easily resolve this problem. When the complementary channel of information is another person, his agreement or disagreement with us can be similarly decisive in shaping our own experience and judgment.
We may state this more generally by asserting that the concept of impersonated role has meaning only in contrast with the concept of genuine role. The method for differentiating impersonated or false roles from genuine or real ones is the familiar process of verification. This may be a social process, consisting of the comparison of opinions from various observers. Or it may be a scientifically more distinctive operation, consisting of testing assertions or hypotheses against observations or experiments. In its simplest forms, verification involves no more than the use, as mentioned above, of complementary channels of information—for example, sight and hearing, checking the patient’s statements against certain official documents, etc. Let us consider the case of a person who claims to be Jesus. If we ask such a person for evidence to support his claim, he may say that he suffers and soon expects to die or that his mother is the Virgin Mary. Of course, we don’t believe him.
This, however, is perhaps too crude an example. It fails to confront us with the more subtle and difficult problems in validating the sick role, such as occur characteristically with persons who complain of pain. Here the question becomes: Does the patient “really” have pain—that is, is he a genuine occupant of the sick role? Or is his pain “hysterical”—that is, does he impersonate the sick role? In this sort of case we cannot rely on asking other people whether they think that the patient is “sick” or “malingering.” The criterion for differentiating between the two roles must be scientific rather than social. In other words, it will be necessary to perform certain “operations” or “tests” to secure more information on which to base further inferences. In the case of differentiating bodily from mental illness, the principal method for gathering further information is the physical, laboratory, and psychological examination of the patient.
Viewing impersonation and genuine role-playing in terms of games, they could be said to represent two fundamentally different games.15 In genuine role-playing, the actor commits himself to the game with the goal of playing as well as he can: for example, the surgeon tries to cure the sick person by the proper removal of the diseased organ. In impersonated role-playing, the actor commits himself to imitating the well-playing person: for example, the man who impersonates a physician tries to convince people that he is one so that he can enjoy the economic and social rewards of the physician’s role.
In impersonation, then, the goal is to look like the imitated person: that is, to effect an outward, or “superficial,” similarity between self and other. This may be achieved by dress, manner of speech, symptom, making certain claims, and so forth. Why some persons seek role imitation rather than competence and task mastery need not concern us here.
The desire for unnecessary surgical operations—”unnecessary,” that is, from the point of view of pathophysiology—is often a part of the strategy of impersonation. In this situation, the impersonator plays the illness game and tries to validate his claim to the sick role. The surgeon who consents to operate on such a person performs a useful function for him, albeit his usefulness cannot be justified on surgical grounds. His intervention legitimizes the patient’s claim to the sick role. The surgical scar is official proof of illness: it is the diploma that proves the genuineness of patienthood.
In genuine role-playing, on the other hand, the individual’s purpose, usually consciously entertained, is to acquire certain skills or knowledge. The desire for a certain kind of similarity to another person—say, to a surgeon or scientist—may be operative here also. But the goals as well as the rules of this game require that the similarity be substantive rather than superficial. The goal is learning, and hence an alteration of the “inner personality” rather than a mere “outer change” such as occurs in impersonation.
In the case of malingering, hysteria, and the Ganser syndrome—and, indeed, in all cases of so-called mental illness—psychiatrists actually confirm the patient’s self-definition as ill and so help to shape his illness. This psychiatric authentication and legitimization of the sick role for those who claim to be ill, or about whom others make such claims, has the most profound implications for the whole field of psychiatry, and beyond it, for all of society. When physicians and psychiatrists began to treat those who impersonated the sick role as genuinely ill patients, they acted much as an audience would if it treated Raymond Massey or Ralph Bellamy as Presidents of the United States. This sort of feedback to the actor means not only that he can no longer rely on his audience for a corrective definition of reality and his own identity in it, but also that, because of the audience’s response, he must doubt his own perceptions about who he really is. In this way, he is encouraged to acquiesce in the role which in part he wants to play, and which his audience wants him to play. While actors are sophisticated about the risks of typecasting, persons playing on the metaphorical stage of real life are usually quite unsuspecting of this danger. Hence, few persons who launch themselves on a career of impersonating the sick role reckon with the danger of being authenticated in this role by their families and by the medical profession. On the contrary, they usually expect that their impersonated roles will be opposed or rejected by their audience. Just as swindlers expect skepticism and opposition from their intended victims, so malingerers have traditionally expected skepticism and oppositions from physicians. However, as on the stage so also in real life, an audience’s resistance to an actor’s impersonated role is strongest when the play is first put on stage. After a run of initial performances, the actor is either accepted in his role—and the play goes on for a longer run; or he is rejected in it—and the play closes down. Moreover, the longer the actor plays his role, the less will his critics and audience scrutinize his performance: he is now “in.” This is a familiar process in many phases of life. For example, if a student does well early in his courses and becomes defined as a good student, his teachers will scrutinize his subsequent performance much less closely .than they will that of a bad student. In the same way, actors, athletes, financiers, and others of proven ability tend to be much more immune to criticism than those who are not yet so accepted.
The distinction between genuine and impersonated roles may be described in still another way, by making use of the concepts of instrumental and institutional groups and the criteria for membership in them.16 Instrumental groups are based on shared skills. Membership in them, say in a Davis Cup team, implies that the person possesses a special skill. We consider this role genuine because such a person really knows how to play tennis. Institutional groups, on the other hand, are based on kinship, status, and other nonfunctional criteria. Membership in a family, say in a royal family, is an example. When the king dies, the crown prince becomes the new king. This transformation from nonking to king requires no new knowledge or skills; it requires only being the son of a dead king.
Impersonation may be summed up in one sentence; it is a strategy of behavior based on the model of hereditary monarchies. Implicit in this strategy is a deep-seated belief that instrumental skills are unimportant. All that is needed to succeed in the game of life is to “play a role” and gain social approval for it. Parents often hold up this model for their children to follow. When they do follow it, they soon end up with an empty life. When the child or young adult then tries to fill the void, his efforts to do so are often labeled as some form of “mental illness.” However, being mentally ill or psychotic—or killing someone else or himself—may be the only games left for such a person to play.
In playing a role, the actor’s main task is to put on a good performance. If the role is genuine—by which I mean that it pertains to an instrumentally definable task, such as playing chess or driving a car—then successful role-playing simply means successful task mastery, and unsuccessful role-playing means unsuccessful task mastery.
If, however, the role is impersonated—by which I mean that it pertains to an institutionally definable task, such as convincing others that one possesses certain qualities whether one does or not—then the possibilities for failure are doubled. The person may fail, first, by putting on an inadequate performance and failing to persuade the audience to authenticate him in his impersonated role; and, second, by putting on a performance that is so convincing that the audience authenticates his impersonated role as his genuine role. I remarked on how this may happen to actors as well as to so-called mental patients. I might add here that this hazard is greatest for the competent and successful performer. In other words, those who play the games of hysteria or mental illness poorly or halfheartedly are likely to be repudiated in their roles by their families or physicians. It is precisely those who play these games most skillfully whose performances are likely to prove successful and whose identities will therefore be authenticated as sick—that is, as mentally sick. I submit that this is the situation in which most persons called mentally ill now find themselves. By and large, such persons impersonate* the roles of helplessness, hopelessness, weakness, and often of bodily illness—when, in fact, their actual roles pertain to frustrations, unhappinesses, and perplexities due to interpersonal, social, and ethical conflicts.
I have tried to point out the dangers which threaten such impersonators and those who accept their impersonations—the main danger being the creation of a culturally shared myth. I believe that “mental illness” is such a myth.
Contemporary psychiatry thus represents a late stage in the mental illness game. In its beginning stages—that is, before the end of the nineteenth century, when alienists aspired to be neurologists and neuropathologists—psychiatrists were violently opposed to those who impersonated the sick role. They wanted to see, study, and treat only “really” sick—that is, neurologically sick—patients. They believed, therefore, that all mental patients were fakers and frauds.
Modern psychiatrists have swung to the opposite extreme. They refuse to distinguish impersonated from genuine roles—cheating from playing honestly. In so conducting themselves, they act like the art expert, mentioned earlier,17 who decides that a good imitation of a masterpiece is also a masterpiece.
Conceptualizing psychiatric illness on the model of medical illness, psychiatrists leave themselves no choice but to define psychiatric treatment as something that can be “given” only to persons who “have” a psychiatric illness! This leads not only to further unmanageable complications in conceptualizing the true nature of so-called psychiatric diseases and treatments, but also to an absurd dilemma with regard to persons who impersonate the role of the mentally sick patient.
Once a role is socially accepted, it must, in principle at least, be possible to imitate or impersonate it. The question then is: How shall the person who impersonates the role of mental patient be regarded—as malingering insanity or as insane? Psychiatrists wanted to claim such persons as patients so that they could “treat” them. They could do so only if those who pretended to be mentally sick were also conceptualized and defined as “sick”; hence, they were.
Thus, without perhaps anyone fully realizing just what was happening, the boundaries between the psychiatric game and the real-life game became increasingly blurred. The lonely, romantic movie fan, enchanted with his idolized actress on the screen, may gradually come to feel that she is actually becoming a close, lifelike, and intimate figure. What is needed for this is a convincing performance and a receptive audience. And, indeed, just as men need a Marilyn Monroe, or women a Clark Gable, so physicians need sick people! I submit, therefore, that anyone who acts sick—impersonating this role—and does so vis-à-vis persons who are therapeutically inclined, runs the grave risk of being accepted in his impersonated role. And in being so accepted, he endangers himself in certain, often unexpected, ways. Although ostensibly he is requesting and receiving help, what is called “help” might be forthcoming only if he accepts the patient role and all that it may imply for his therapist.
The principal alternative to this dilemma lies, as I have suggested before, in abolishing the categories of ill and healthy behavior, and the prerequisite of mental sickness for so-called psychotherapy. This implies candid recognition that we “treat” people by psychoanalysis or psychotherapy not because they are sick but, first, because they desire this type of assistance; second, because they have problems in living for which they seek mastery through understanding of the kinds of games which they, and those around them, have been in the habit of playing; and third, because, as psychotherapists, we want and are able to participate in their “education,” this being our professional role.
Finally, the concept of impersonation is useful for understanding the role not only of the psychiatric patient but also that of the psychiatric practitioner. The two are engaged in a reciprocal impersonation, each fitting into the role of the other like a key and a lock. The psychiatric patient impersonates, or is impressed into, the sick role: the so-called hysteric acts as if he were sick and invites medical treatment; the so-called paranoid is regarded as if he were sick and treatment is imposed on him against his will. In both cases, the person is defined, by himself or others, as a patient. Reciprocally, psychiatrists, psychoanalysts, and many clinical psychologists engage in a complementary act of impersonation: by accepting the problems of their clients as the manifestations of an illness, or by assigning such problems to the category of illness, they assume the roles of medical practitioners and therapists. This professional impersonation occurs also independently of the conduct of clients: it is actively fostered and supported by contemporary psychiatric, psychoanalytic, and psychological organizations and their members, and by other institutions and individuals, such as courts and schools, lawyers and educators.
The upshot is the professional credo of mental health professionals: that mental illness is like medical illness, and mental treatment like medical treatment. In fact, however, psychotherapists only look like doctors, just as hysterics only look like patients: the differences between the communicational interventions of psychotherapists and the physicochemical interventions of physicians constitute an instrumental gulf that no institutional dissembling can convincingly narrow.18
Until recently, this impersonation of the medical role by the psychiatrist and psychotherapist has served the apparent interests of both psychiatric patients and practitioners. Hence, not many concerned parties were left to protest this modern variation on the ancient theme of the emperor’s clothes. I believe the time is now ripe to announce that the emperor is naked: in other words, that the medical aspects of psychiatry are just as substantial as was the fabric from which the emperor’s legendary cloak was fashioned. As will be recalled, that material was so fine only the wisest could see it: to claim that the emperor was naked was, therefore, an affront against a powerful person as well as a self-confessed stupidity. It has been, and continues to be, much like this with psychiatry, whose similarities to medicine are so subtle that only the best-trained professional can see it: to claim that these similarities are insubstantial or nonexistent is thus an affront against the powerful social institutions of medicine and psychiatry, as well as a self-confessed stupidity. I hasten to plead guilty to both of these potential charges.
* I do not wish to imply that children are always oppressed, or that their lack of a firm inner identity is due to oppression. Indeed, the role of being oppressed can itself be the core of one’s identity. The lack of firm personal identity in childhood is a reflection mainly of the child’s incomplete social and psychological development
* I do not wish to imply that this impersonation is always a consciously planned strategy, arrived at by deliberate choice among several alternatives—although often it is.
* Similar considerations hold for old age. As old persons become unemployed and unproductive, and particularly if they are economically and physically disabled, their principal role becomes being old.