Thomas Szasz died last month at age 92. You may not have heard of him, but you have almost certainly seen the effects of his landmark 1960 book, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct, wandering the streets of your city. It was, at least in part, due to his influence that asylums opened their doors and incarcerated mental patients were left to fend for themselves.
Born in 1920, Szasz (pronounced “Sahss”) was a Hungarian Jew who escaped the horrors of Nazism. He emigrated to the United States at age 18, finished college in two years and graduated first in his medical school class. Eventually he qualified in psychiatry and became a psychotherapist.
However, Szasz was more closely aligned to John Stuart Mill than Sigmund Freud. He was a libertarian who contended that people who appeared to be mentally ill were still responsible actors. It was wrong to lock up schizophrenics in mental hospitals, he argued, and it was equally wrong to allow them to plead insanity in criminal trials.
This was a radical attack on his own profession, which was moving more and more towards treating mental illness with drugs. Szasz became typecast as an anti-institutional rebel. What Jack Nicholson was doing inside the cuckoo’s nest, Thomas Szasz was doing inside the American Psychiatric Association.
After his death, the media sensationalized caricatures of his beliefs. The headlines about Szasz illustrated an unimaginative groupthink in the media. The New York Times described him as the “Psychiatrist who Led Movement Against His Field.” The Los Angeles Times labeled him a “Psychiatrist Who Attacked His Profession.”
Former New York Times blogger Judith Warner began a rant against Szasz with a story from the bad old days. She remembered a 17-year-old Caucasian girl who came home pregnant in 1970. The father was her Black boyfriend. The girl was whisked away to a mental institution and forced to have an abortion. The lawyer who told Warner the story lamented, “There were no laws we could use to protect her.”
If the story had taken place in the old USSR or China, even Warner might have seen that this was an abuse of human rights similar to the imprisonment of dissidents. Instead, she frames the problem as psychiatric treatment. But the pregnant teen was no more a patient with mental illness than Soviet dissidents.
Although she concedes that Szasz was an inspiration for the “patient rights movement”, Warner accuses him of leaving a “legacy of denial of the seriousness of mental illness that has done more damage than good.” She is happy to leave Szasz in the past with the bad old days.
But, really, Szasz was not against psychiatry or treatment. His target was government oppression, even if the oppression used soft beds and pills instead of jackboots and guns. He felt that psychiatry and psychiatrists – which hardly existed 150 years ago — had made themselves indispensable. We are living, he said, in a Therapeutic State:
“The concept [of mental illness] has become so essential to modern society that millions of people are living on mental illness disability; I mean there are whole mental health lobbies, mental patient lobbies who say there is no mental illness but they are collecting money for mental health disability. It’s so much a part of the law, you see it would be difficult to administer the law tomorrow if there was no mental illness. So this is no simple matter: mental illness could no more be abolished tomorrow morning than religion could be abolished in the Vatican—what would it be then, a bunch of beautiful buildings? This is part of what our society is.”
Szasz’s personal style did not endear him to his colleagues. He was bombastic and combative. He compared involuntary hospitalization to slavery and regarded himself as an abolitionist. This, of course, was hyperbole. As important as his work was for modern society, asylums are not slave plantations. Good intentions didn’t motivate slaveholders.
However, the bad old days of psychiatry offer an enduring lesson. The zeal to help is easily corrupted by a need for control. Szasz inspired a civil rights movement which ensured that everyone accused of lunacy and threatened with incarceration would receive a semblance of due process and rights. Even if you are crazy, you have the same rights as thieves and murderers have.
Szasz began his self-proclaimed abolitionist movement against involuntary hospitalization by attacking the problem at its root. In the Myth of Mental Illness, which initially appeared as a paper in the American Psychologist and later as a book published in 1960, Szasz argued that mental illness is a metaphor. It is not the same as physical illness. He noted that the symptoms of mental illness do not correlate to any neurological deficits. Moreover, mental symptoms are linked to a social context while bodily symptoms are not.
For Szasz, mental illness describes problems of living. By labeling psychosocial, ethical and legal problems as diseases, society was trying to resolve psychosocial issues with medical treatment.
While in some respects Szasz is clearly wrong, psychiatrists have still failed to respond adequately to his criticisms. Former APA President Lawrence Hartmann has defined mental illness as a complex bio-psycho-social phenomenon. But this is an intellectual cop-out which allows us to define mental illness as whatever we want. All human behavior is a complex bio-psycho-social phenomenon. This definition has been good for business but not for science.
Another vocal defender of the status quo, Dr Ronald Pies, has defined disease as simply suffering. But if disease is only suffering then what determines which suffering gets into psychiatry’s Book of Suffering, the Diagnostic and Statistical Manual?
But Szasz’s contribution was not simply destructive. One of his key themes was that human beings have to take control of their own lives. They need to feel responsible. Free nations depend upon people being responsible for their own behavior. If all troublesome desires and behaviors are due to diseases of the brain then people have no responsibility for their lives. They will need governments to step in and take over.
Like many libertarians, Szasz was resolutely atheist and hostile to religion. Many of his ideas can be traced back to his thorough-going materialism. But by attacking psychiatry from this angle, he had some creative insights. The Enlightenment, he argued, had banished God from the altars and substituted the worship of reason. So those who reject conventional reason – the madmen – are treated as heretics and criminals and locked up. Society had swapped a theocracy for a pharmocracy, a therapeutic state where psychiatrists pulled the strings.
In the end, Szasz’s sledgehammer rhetoric did not bring down the walls. The myth that there was a pharmacological answer to every problem could not be demolished and as Big Pharma pumped out tiny round solutions to those problems of living, it grew stronger.
Szasz was too blinkered in his libertarian rhetoric to be taken on board completely. After all, many suffering people are able to lead a normal life thanks to their medication.
Nonetheless, I sympathise with the broad thrust of his critique. Szasz reminds us that psychiatry and medicine are human inventions, not divine institutions. He recognized that in our culture, the tyrant will not wear a religious collar or Nazi uniform. The tyrant will wear a white lab coat.
Theron Bowers MD is a Texas psychiatrist.
