We’re probably in for a fresh spate of critiques and reappraisals of the work of Thomas S. Szasz.

In 1961 Szasz published The Myth of Mental Illness (following an article with the same title, two years earlier). His many subsequent books would preach the same message, and most of these later volumes make much more entertaining reading than The Myth of Mental Illness.

Szasz’s reputation as a writer suffered on account of that early work. Because of its title and its key role in psychiatric controversies, it became the one work of Szasz to cite. People curious about Szasz would usually seek out that particular book. It’s rather dull compared to such sparkling later works as The Manufacture of Madness (1970), The Therapeutic State (1975), or Liberation by Oppression (2002). His Karl Kraus and the Soul Doctors (1976, later reprinted as Anti-Freud) is also captivating, but in this case partly because of the translated remarks of Kraus. Szasz’s own witty, oracular debunking style evidently owed a lot to the author of The Last Days of Mankind, as well as to Mark Twain, Ambrose Beirce, and H.L. Mencken.

Szasz argued that there is literally no such thing as ‘mental illness’. Mental illness is no more than a metaphor. If we speak of ‘a sick economy’, we know this is a metaphor. We don’t try to pretend that economics is a branch of medicine. It’s just the same with human behavior, human feelings, and human thoughts. These do not belong to the domain of medicine. But in this case, we may be tempted to think that there is a branch of medicine—psychiatry—which is competent to deal with problems of behavior, feeling, and thinking. This Szasz denied outright. He did not rule out as meaningless or useless everything that psychiatrists might do—he merely insisted that it was not medicine. He undoubtedly did believe, though, that psychiatry had done a lot more harm than good.

Szasz himself had a private practice as a psychotherapist, as well as being a professor of psychiatry. He defended being a professor of psychiatry by pointing out that few would object if an atheist were a professor of religion. He talked about his own practice of psychotherapy rarely and vaguely: he characterized it as having conversations with people in order to help them with their problems in living. As for helping them by giving them drugs, Szasz held that this should be permitted as long as it was entirely voluntary, but he himself was not a big enthusiast for the practice (and, for all I know, believed it was always wrong). He would say, for instance, that you don’t call in a TV repairman when you’re disgusted with the quality of the programs. This is an entirely typical Szasz bon mot. On the one hand, it strikingly clarifies one facet of the issue. On the other hand, there is a lingering doubt, is there not? For after all, if the entire scriptwriting and production process occurred inside the TV set, it wouldn’t be so obviously silly to get the repairman to fix up the script for It’s Always Sunny.

Szasz—an MD who knew quite a bit about medicine and the history of medicine—didn’t dispute that the realm of behavior often interacts with the domain of medicine. By drinking too heavily, a person may give himself cirrhosis of the liver, which is a medical problem. By bungee jumping a person may give himself a broken neck. What makes him take to drink or go in for bungee jumping is not, in Szasz’s view, a matter in which medical doctors have any special competence. What are commonly regarded as ‘mental illnesses’ are simply ‘problems in living’.

His books are eloquent in exposing and criticizing the absurdities which result when any and all human behavior is viewed in terms of health and disease. Even before such diseases as sex addiction, shopping addiction, and internet addiction had been invented, Szasz had accounted for them, and had pointed out the affinity of such afflictions with drapetomania (the disease diagnosed in some black slaves by a nineteenth-century doctor, the symptom of this malady being the slaves’ desire to run away from their owners) and the mental diseases identified by Soviet psychiatrists in people who criticized the socialist regime.

I first became aware of someone called ‘Szasz’ when I read R.D. Laing in the 1960s; at that time Laing was all the rage in England. At first the ‘anti-psychiatrists’ eagerly quoted their predecessor Szasz, but it soon became apparent that Szasz had nothing but contempt for the anti-psychiatrists. He didn’t like them because they were socialists and because he believed that they sought to glorify the mental states of designated mental patients. Szasz had no patience with those who imputed to mental patients wondrous insights denied to the rest of us. He tended to think of mental patients as, for the most part, a rather pathetic bunch who were often complicit in their own oppression.

Jonathan Engel (in his American Therapy, 2008) gets the chronology wrong and thinks that Szasz was a follower of the anti-psychiatrists. I have occasionally encountered people who suppose that since Szasz was a ‘radical’ in the 1960s and later says things that sound ‘conservative’, he must have undergone a political conversion. But the truth is that Szasz’s fundamental outlook was pretty much fixed by the 1940s and never changed. He was always a classical liberal, an anti-communist, and a ‘cultural conservative’ in lifestyle matters, though of course favoring the repeal of all prohibitions on drugs and victimless crimes. The biggest change he did undergo was from being a psychoanalyst (some said the crown prince of psychoanalysis) to being a hostile critic of psychoanalysis.

The volume Szasz Under Fire: The Psychiatric Abolitionist Faces His Critics (edited by Jeffrey Schaler, 2004), which includes a brief autobiography, also contains an exchange of letters between Szasz and Karl Popper (this is given by Szasz in his reply to the article by Ray Percival). Here, Popper says he thinks that Szasz is ninety-five percent right about the nonexistence of mental illnesses. What Popper meant was that while he agreed with Szasz that the extension of the medical metaphor to every type of human ethical or lifestyle decision is preposterous, we can still reasonably conjecture that there are some few cases where a typical brain malfunction is the cause of some typical cluster of emotional and behavioral problems (even though we can’t yet identify the brain malfunction in question).

Not that Szasz would have disputed the truism that Alzheimer’s and syphilis can cause mental deterioration, and that there are sure to be many other as yet undiscovered diseases of the nervous system that have mental and behavioral symptoms. But he took the position that we can’t describe these as diseases until we have ascertained their physical cause.

In a typically Szaszian crisp summary (and possibly oversimplification), he asserted that we’re not entitled to talk about a disease until a pathologist can identify its presence in a corpse. A corpse can have cancer, bunions, or atherosclerosis. A corpse can’t have schizophrenia, bipolar disorder, or paranoia, let alone shopping addiction or obsessive-compulsive disorder. No pathologist can detect the presence of these supposed illnesses by examining a cadaver. To Szasz, this meant that they could not be called literal diseases, even though he allowed that at some future date we might find that they corresponded, more or less, with some presently unknown literal diseases.

Szasz observed that once a genuine physical disease is identified, it tends to be taken away from psychiatry and given to general medicine, as occurred with syphilis of the brain and with strokes, and more recently with Alzheimer’s. Once these are classified as literal diseases with known physical causes, psychiatry can claim no special expertise in these areas. Szasz also pointed out the influence of ethical and religious fashion on psychiatric diagnoses: when Szasz started writing, nearly all psychiatrists held that homosexuality was a disease (this was the official position of the American Psychiatric Association until 1973 and the World Health Organization until 1990). Now most of them don’t. The switch is not in the least due to any new medical evidence, but purely to a re-adjustment of mores and ethical attitudes.

Although on occasion Szasz fully acknowledged that some human problems would eventually be attributed to presently undiscovered brain diseases, the general sweep of his rhetoric tends to give the opposite impression: “. . . we will discover the chemical cause of schizophrenia when we discover the chemical cause of Christianity and Communism. No sooner and no later” (The Untamed Tongue, pp. 215–16).

I agree with Szasz in opposing involuntary commitment of the mentally ill and I admire his exposure of much psychiatric silliness. But the route to those conclusions is not as simple as he believed. Szasz holds that there can be no literal disease of the mind, only a literal disease of the body or a metaphorical disease of the mind. This is strictly correct, but it does not have the sweeping implications he supposes. Szasz attacks people who employ the term ‘mental illness’, but his attacks fail if people are using the term to mean ‘a brain disease with mental symptoms’.

Various drugs can cause you to have hallucinations and infection by rabies will make you terrified of water. So we know that purely bodily changes can change your conscious states and your deliberate behavior in predictable ways, and we can’t rule out the possibility that some such bodily changes may happen without the intervention of drugs or of rabid beasts.

Szasz would say that until we have identified the physical cause (the lesion), we can’t assert the existence of an illness. But, as far as I can see, nothing prevents us from conjecturing that certain symptoms are accounted for by an illness whose existence we can’t yet observe directly. I know a lot less than Szasz did about the history of medicine, but I would even surmise that there have been such cases—consumption, epilepsy, and asthma spring to mind. But even if I’m wrong in thinking that there have been actual cases, it still wouldn’t follow that such conjectures are inadmissible. And if we can do this with physical symptoms, we can do it with mental symptoms: I can see nothing wrong in principle with hypothesizing that a certain cluster of emotions, thoughts, and behaviors is accounted for by a brain malfunction. It’s literally, pedantically wrong to call this a ‘mental disease’ just as it’s literally, pedantically wrong to say that the sun rises, but such casual expressions are inevitably rife throughout language.

Involuntary commitment and other pretexts for imprisonment and torture are very common in our culture, and so is the endless re-iteration of the claim that victims of state coercion are ‘ill’. Yet these two facts are not as tightly connected as Szasz supposed. I can easily imagine a change in semantic fashion, so that state paternalists would say: ‘Granted, these people are not ill, but they are still a threat to themselves and others and therefore need treatment whether they consent or not’. And I can also easily imagine some people coming around to the view: ‘These people are indeed ill, but even sick people shouldn’t be forcibly incarcerated or given drugs or electric shocks against their wishes’.

Szasz wrote about forty books, even one (Faith in Freedom, 2004) devoted to a critique of the views of libertarians on mental illness. The one I found most disappointing is The Meaning of Mind (1996). As you read most of Szasz’s work, you become conscious of an odd lacuna: he repeatedly draws a bright line between consciousness and physiology, as though these are independent realms. This is the more remarkable because he is an atheist with no theological commitments. So, you wonder what he thinks about the relation of mind and brain. With The Meaning of Mind, we find out that he has no coherent view of the relation between mind and brain and (while the book does have a sprinkling of his usual piercing insights) his uninformed comments on those who have carefully elaborated various theories often miss the point and are at times painful to peruse.

Following protracted illness, and a few days after a severe spinal injury due to a fall, Tom Szasz exercised his right to suicide. I never met him but had various phone and email exchanges with him over a number of years. If I had met him in the flesh, I might have mentioned some of my criticisms of his views, though his always thick Hungarian accent might have been a conversational impediment, and I have heard from a reliable source that in his last years he became testier and testier, disposed to see any disagreement as betrayal.

Szász Tamász István (the surname comes first in Hungarian). Born Budapest, 15th April 1920. Died Manlius, New York, 8th September 2012.