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.