The Myth of Thomas Szasz
By the 1960s, American institutional psychiatry was a very large elephant caught in a seemingly inexhaustible growth spurt. “Nothing of human concern is really outside psychiatry,” proclaimed Dr. Karl Menninger, the profession’s unofficial dean. “So in one sense I have no hobbies. They are all part of my work.” This was to be the beginning of a golden age in psychiatry’s relationship with the American public. Psychoanalysis was busily remaking psychiatry after its own image — a new medicine born equally of natural and spiritual sciences. Practitioners were more than mere medics, they were soul doctors. The profession, as one practitioner predicted, would become “the integrator that unifies, clarifies and resolves all available medical knowledge ... into one great force of healing power.” The number of psychiatrists in the U.S. was increasing at roughly twice the rate of the population. In turn, practitioners were christening some five new mental illnesses every year.
Well, overconfidence will inevitably curdle, and in this case fairly quickly. In November 1982, a New York Times article was already describing “Psychiatry’s Anxious Years.” Some time in the early 1970s, the number of incoming practitioners as a percentage of all medical students had fallen by half. “Some psychiatrists conclude that the decade-long plunge ... reflects a disillusionment on the part of medical students over the scientific validity and practical effectiveness of the discipline,” the Times reported. The article went on to cite “the withering criticism” of one “outspoken” Dr. Thomas Szasz, “who has argued for years that ‘these things called mental illnesses are not diseases at all but part of the vicissitudes of life,’ dismissing psychiatry as a specialty without a medical cause.”
It was twenty years earlier, somewhere near the peak of psychiatry’s promise, that Szasz published his declaration of war, called The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (1961). His title was not hyperbole. “Psychiatry is conventionally defined as a medical specialty concerned with the diagnosis and treatment of mental diseases,” he wrote. “I submit that this definition, which is still widely accepted, places psychiatry in the company of alchemy and astrology and commits it to the category of pseudoscience. The reason for this is that there is no such thing as ‘mental illness.’” Szasz’s attack targeted the cornerstone of modern American psychiatry: the marriage of mind and molecule, the notion that behavior can safely be classified as “sickness” and that the mind can safely be “treated” just like any other organ. In calling that marriage a sham, Szasz mocked the efforts of almost every major American psychiatrist back to Benjamin Rush, the profession’s founding father. “The subjects [mental diseases] have hitherto been enveloped in mystery,” Rush wrote in the late eighteenth century. “I have endeavored to bring them down to the level of all other diseases of the human body, and to show that the mind and the body are moved by the same causes and subject to the same laws.” This was the error Szasz aimed to correct.
Some hailed The Myth of Mental Illness as a work of genius; others saw it as a pernicious attack or foolish waste of time. The book made Szasz a public figure, and by the late 1960s he was perhaps the most famous psychiatrist in America. Among peers, he was also the most despised and most feared — a bitter, well-educated critic with a sharp pen. He was, above all, a master of the analogy. “To put it succinctly,” he wrote, “Guillotin made it easier for the condemned to die and Charcot [early champion of the disease model of mental illness] made it easier for the sufferer, then commonly called a malingerer, to be sick. It may be argued that when dealing with the hopeless and helpless, these are real accomplishments. Still I would maintain that Guillotin’s and Charcot’s interventions were not acts of liberation but were rather processes of narcotization and tranquilization.”
Today, of course, Szasz is mostly remembered, if he is remembered at all, as the great silly, a flat-earth adherent in the time of telescopes and globes. Most medical students graduate without ever hearing his name. Peers who once grappled fiercely with his ideas are now surprised to find out he is still alive. His voluminous writings largely gather dust in libraries and used book stores. At a 1996 debate, well-known psychiatrist E. Fuller Torrey summed up the sentiment nicely with a joke that began: “Let me ask an important question. And this is a question that will be asked by future generations. The question is: Who was Dr. Szasz?” Few in the audience needed a punch line. The question itself was dénouement enough. “If he is unable to acknowledge his big mistake,” Torrey finished, “I think the answer to the question will be: ‘Dr Szasz was the man who wrote The Cat in the Hat, Hop on Pop and Horton Hatches the Egg.’” The audience roared.
One can hardly be surprised if Szasz has assumed the role reserved for all failed revolutionaries — a marker of backwardness against which to measure our enlightenment, his name a synonym for error. The disease model of mental illness is now so central to American medicine and culture that the most common response to Szasz — aside from utter disregard — is typically something like: “Just look around — anguished teenagers, depressed adults, distracted children. Only a fool would believe that mental illness is a myth.” Indeed, to the modern psychiatric mind, rejecting the legitimacy of mental illness is not just an error but an act of inhumanity, leaving the sick without the hope of a cure. The Szaszians of the world are not just fools but monsters.
Like most war stories, the Szasz story has passed into legend, bearing little resemblance to reality. A reconsideration of this piece of psychiatry’s forgotten history might shed some useful light on psychiatry’s present, showing us the excesses of both Szasz and his adversaries.Psychiatry on Trial
One place to begin such a reconsideration is by returning to a minor New York county courthouse in May 1962. Dr. Thomas Stephen Szasz, a first-generation Hungarian-American and newly tenured professor of psychiatry at the State University of New York Upstate Medical College in Syracuse, was there to testify on behalf of Michael Chomentowski, a second-generation Polish-American and seven-year veteran of various state mental institutions.
Chomentowski’s story provides a rare inside view of mid-century American institutional psychiatry, the milieu from which The Myth of Mental Illness sprang. The pertinent history begins seven years earlier in June 1955, on the morning Michael Chomentowski slung a rifle over his shoulder and took to patrolling a patch of ground in front of his gasoline station in Fairmont, New York. He was, as he would later try to explain, “walking his post in a military manner.” At some point, he also fired two shots into the air — successfully frightening two men who had come to erect a sign on the station’s property. The sign advertised a new shopping center. Construction was to begin soon. The developers had done their best to convince Chomentowski to vacate and Chomentowski was doing his best to convince the developers that he meant to stay.
Later that day, an officer idled into Chomentowski’s station. He asked for an oil check and Chomentowski, a mechanic in World War II, obliged, setting his rifle down and stepping toward the car. The officer then stepped forward and placed Chomentowski in handcuffs. He found a dysfunctional French machine gun in the trunk of Chomentowski’s car and subsequently booked Chomentowski for unlawful possession of a dangerous weapon — a charge for which he would never be tried or convicted.
Two weeks after his arrest, Chomentowski was transferred from the Onondaga County Jail to the Syracuse Psychopathic Hospital, where two court-ordered psychiatrists conducted an examination. The transfer was in accordance with the New York State Code, Sec. 658 which states: “If at any time before final judgment it shall appear to the court ... that defendant is in such a state of idiocy, imbecility or insanity that he is incapable of understanding the charge ... the court may order such defendant to be examined to determine the question of his sanity.”
At the hospital, Chomentowski sat quietly, responded affably and insisted that he had only been “walking his post in a military manner.” He was a thin man of average height. He wore a beard and he believed the beard was bringing him closer, both in nature and appearance, to Jesus Christ. His neighbors often greeted him derisively with a “Hello, Davy Crockett,” which Chomentowski was content to take as a compliment. When the arresting officer asked Chomentowski what he was doing, Chomentowski told him: “I’m a soldier for the people walking my post in a military manner. The people now have the original Davy Crockett. This will be the biggest story in history and I’m glad that it happened.”
During that initial interview, Chomentowski told the psychiatrists: “There are two stories that I can’t tell because they belong to my father.” He told them anyway. The first: There was gold buried under his gas station. The second: Jesus Christ had been born somewhere on the property. He also described a recent experience in front of his station. “I realized I was nailed to the cross,” he said. “I wasn’t actually nailed, but I was frozen to the cross. I was sitting with my feet crossed and my hands outstretched and then it began to rain. I sat in the rain for over an hour, unable to move.” The diagnosis of mental illness was fairly straightforward. The American Psychiatric Association had recently published its first diagnostic manual. The two psychiatrists deemed Chomentowski “grandiose and mildly euphoric.” They considered his “affect inappropriate.... The patient states that he does not think he is Davy Crockett but that because of his belief in re-incarnation, he might well be Davy Crockett.... Patient is oriented in all spheres.... Recent and remote memory unimpaired, retention and recall good. Insight and judgment impaired. Intelligence, probably average ... bizarre delusions ... suffering from schizophrenic reaction.”
Around the same time, Thomas Szasz faced imminent unemployment. His two-year tour of duty as a psychiatrist at the Bethesda Naval Base would end in 1955. He was considering private practice but his burning desire was to demolish American institutional psychiatry, and hopefully feed his family while doing so.
Szasz traced his opposition to modern psychiatry to his teens. At eighteen, when he left Hungary for the United States, he knew that “incarcerating people and talking to them were not medicine,” as he later wrote. “Any intelligent child would have known that. Of course, such simple-minded clarity had to be educated out of people to make them normal members of society, especially American society.” Szasz studied both Freud and his critics, but he was especially taken with a prominent Hungarian writer named Frigyes Karinthy. In one particular short story, Karinthy included the following dialogue between two psychiatrists, one of which is having a delusion of insanity:
Psychiatrist: So, am I insane?
Colleague: Well, since you have a delusion, evidently you are.
Psychiatrist: Oh, no, there you go again! Now you say that if I have a delusion, I am insane. But you just said that I am insane. In that case, my belief is not a delusion, but a correct idea. Therefore I have no delusion. Therefore I am not, after all, insane. It is only a delusion that I am insane; hence I have a delusion; hence I am insane; hence I am right; hence I am not insane. Isn’t psychiatry a magnificent science?
Colleague: The most magnificent, my dearest colleague! But of course it’s necessary to master it as well as only you or I have.
In 1956, Szasz accepted a post at SUNY-Syracuse. The offer came through Marc Hollender, a close friend from the Chicago Institute for Psychoanalysis, where he and Szasz had previously studied. Hollender hired Szasz hoping the two would implement Chicago’s curriculum and grow the school into a premier psychiatric residency. Szasz, for the most part, went along with the plan. He was quickly popular in and outside the classroom. His doubts regarding his own profession did not deter potential residents. Indeed, his lectures, often dramatic and seldom dull, drew crowds and eventually newspaper reporters. During the course of one routine hour in 1971, a student recommended drugs as the best treatment for a woman’s “chronic, severe depression.” The New York Times Magazine was there to record the subsequent scene, which Szasz has spent the majority of his career reproducing:
“So you would treat this ‘sickness’ she’s got with drugs?” There are several uncomfortable, uncomprehending laughs from around the room. “But what, exactly, are you treating? Is feeling miserable — and needing someone to talk things over with — a form of medical illness?” Szasz gets to his feet, walks over to a blackboard and picks up a piece of chalk.
“I don’t understand — we’re just trying to arrive at a diagnosis,” protests the student, his voice confused.
“Of what?” demands Szasz. “Has she got an illness called depression, or has she got a lot of problems and troubles which make her unhappy?” He turns and writes in large block letters: “depression.” And underneath that: “unhappy human being.” “Tell me,” he says, facing the class, “does the psychiatric term say more than the simple descriptive phrase? Does it do anything other than turn a ‘person’ with problems into a ‘patient’ with a sickness?” He puts down the chalk so hard that a cloud of dust rises. There is a low muttering among the students as he returns to his seat.
Of course, Szasz aimed for more than a low muttering, and outside of class he devoted himself to his typewriter. He soon began publishing at an envy-inducing pace. As one of his former colleagues recalls: “Tom came here as kind of the fair-haired boy of Marc Hollender.... He was expected to write and be smart.” That he did quite well. In 1958, the Columbia Law Review commissioned a piece on the increasingly controversial relationship between psychiatry and law. Szasz remembers: “I thought, ‘Well, I was invited, this is the Columbia Law Review, I can really say something.” Titled “Psychiatry, Ethics, and the Criminal Law,”the essay revolved around the following argument: “Disregarding even the most obvious doubt concerning exactly what the expression ‘mental illness’ is supposed to denote, it denotes a theory (if it denotes anything) and not a fact.... It is no more — or less — a fact than it would be to assert that the accused is possessed by the devil; that is another ‘theory’ now discarded. To believe that one’s own theories are facts is considered by many contemporary psychiatrists as a ‘symptom’ of schizophrenia.” Though short of his subsequent assault, the essay was clearly meant to pick a fight. In the end, it failed to do anything of the sort. While his arguments may have influenced a few lawyers, among psychiatrists they were almost completely disregarded or ignored, a fact that served mostly as further motivation for Szasz.
A year later, in May 1959, Szasz typed a brief letter in which he spelled out the rest of his career. “I have put aside for the time being ... my manuscript on the theory of psychoanalytic technique,” he informed Arthur Rosenthal, head of Basic Books. “Instead, I am now well on my way toward finishing a book on what is really an attempt to examine, in extense, the idea of ‘mental illness.’... I think no really meaningful work on psychotherapy is possible until the nature of the alleged illness which is so being ‘treated’ is fully examined and clearly defined.”
It was a minor prelude and Rosenthal’s eyebrows surely arched three months later when he received the manuscript, tentatively titled Human Behavior and the Myth of Mental Illness: Foundations of a Theory of Psychiatry. “Let us suppose that there is no such thing as mental health or mental illness,” Szasz wrote, “that these words refer to nothing more substantial or real than did the astrological notions of the influence of planetary positions on personal conduct. What then?”Insanity’s Guises
Szasz never knew exactly how the Chomentowski family first heard of him. It may have had less to do with The Myth of Mental Illness than with his testimony at a 1961 U.S. Senate hearing titled “The Constitutional Rights of the Mentally Ill.” By then, Chomentowski had languished for years in a psychiatric institution, and Szasz’s testimony seemed tailored to his situation. “The crucial issue in all of these situations is whether the psychiatrist is to be considered the agent of the patient or of someone else,” Szasz told the Senators. “We must constantly ask ourselves questions such as these.... Is he a therapist or a custodian? Is he a ‘doctor,’ or is he a ‘warden’ of an institution which, although it is called ‘hospital,’ functions as a prison, inasmuch as patients cannot leave it at will?”
At the time, Szasz found himself in fairly good company criticizing psychiatry’s relationship with the law. In 1961, an exasperated Circuit Court Judge (and later Chief Justice) Warren Burger complained: “No rule of law can possibly be sound or workable which is dependent upon the terms of another discipline whose members are in profound disagreement about what those terms mean.... [The term ‘mental disease’] which has no fixed, agreed or accepted definition in the discipline which is called upon to supply expert testimony and which, as we have seen, is literally ‘subject to change without notice’ is a tenuous and indeed dangerously vague term to be a critical part of a rule of law on criminal responsibility.”
Chomentowski’s predicament seemed to prove the point. By 1962, he had been hospitalized for seven years, some five years longer than the prison sentence he would have received if convicted of his crime. After the initial diagnosis, Chomentowski’s family quickly appealed. The appeals, however, simply resulted in confirming psychiatric opinions. Walter Chomentowski soon advised his younger brother simply to stop speaking with the psychiatrists. The counsel must have seemed quite prudent, and Michael was content to shut his mouth. But the tactic wildly backfired. By the time his family contacted Szasz, Chomentowski had been declared legally insane by seven different psychiatrists. While the repeated confirmations served to stamp the first with authenticity, mostly they illustrated an institutionalized dependence on precedent and a disturbingly broad definition of “insanity.” A close review of the case history reveals a kind of galloping guesswork. In each of the subsequent examinations, the prime evidence of continuing insanity was the fact that the patient refused to speak with the psychiatrists.
A few examples will suffice. The following conversations are excerpted from a series of psychiatric examinations in late January 1957, two years after Chomentowski’s initial diagnosis. The psychiatrists are Dr. H and Dr. S. The echo of Frigyes Karinthy is uncanny. First, from the examination of January 24, 1957:
Dr. S: Well, first of all to have a jury trial, there has to be a charge of some kind. Now, the charge ... was that you were carrying a dangerous weapon and I think you fired it as I recall it. Did you? You were marching up and down with a gun on your shoulder and were threatening somebody who came out there to put up a sign. Do you remember that? All you have to tell me is, do you remember?
Chomentowski: I’ve got nothing to say.
Dr. S: Well, I would say that is in evidence that you’re not really well, that you should at least answer innocuous questions that I’m asking here.
Dr. H: That doesn’t show very good judgment, does it?
Dr. S: All I asked you, for instance, was what my name was. You remember what [Dr. H’s] name is? I introduced you to him. Do you remember that?
Chomentowski: I’ve got nothing to say.
Dr. S: You wouldn’t even tell what date this is, I suppose? Or would you?
Dr. S: When did you come here? You know the name of this place don’t you?
Dr. H: Do you know why they send people up here?
Dr. S: Well, I don’t suppose we could do very much about this, he isn’t going to talk. This, in itself, is in evidence of a suspicious, paranoid attitude, isn’t it Dr.?
Dr. H: I should think so. Very definitely....
From January 30, 1957:
Dr. S: Are you willing to discuss your case with us today?
Chomentowski: Only at the proper time.
Dr. S: I understand you protected Dr. Brew the other day when she was attacked by another patient.
Chomentowski: Dr. Brew has never done anything to me and I’m always glad to help out.
From January 31, 1957:
Dr. S: Are you willing now to discuss your behavior of July 1955?
Chomentowski: I’m not talking until the proper time.
Dr. S: You know that Dr. H and I have been appointed by the court to determine whether you are sick or well. How can we tell what is going on in your mind unless you talk freely with us? From that standpoint, I believe this is the proper time to talk.
Dr. S: What is for you the proper time to talk?
Chomentowski: When ever the judge decides.
Dr. S: Why would you appear before a judge?
Chomentowski: I want him to tell me the crime I have committed. I haven’t committed any crime.
Dr. S: You admit you had firearms?
Chomentowski: I’m not committing myself to anything.
Dr. S: Did you fire two shots over the head of two men?
Chomentowski: I’m not committing myself to anything.
Dr. S: Do you think your mind is or has been upset?
Chomentowski: Just what do you mean by that?
Dr. S: You have been here before haven’t you?
Chomentowski: That’s right.
Dr. S: At that time you wore a full beard?
Chomentowski: That’s right.
Dr. S: What was the purpose of wearing a full beard?
Chomentowski: This is the first time I found out that it is a crime having a beard.
Dr. S: That alone is not the crime, but at the time you said you were emulating Christ.
Dr. S: Do you remember telling me in 1955 that you get your orders from above?
The resulting diagnosis was, as ever, a masterpiece of qualified conviction. “In view of the refusal to fully cooperate, it is difficult to determine the presence of any definite delusions at this time,” Dr. S concluded. “However, the patient’s attitude and manner have been of a stilted character and the fact that he refuses to answer, indicates a suspicious and paranoid attitude ... he is without question, a case of dementia praecox of the paranoid type in a state of partial remission. Moreover, we are convinced that he should still be considered unpredictable with a possibility that he should still be considered potentially dangerous and that therefore, further institutional care is indicated.”
That last part bears repeating in light of Szasz’s critique: The doctors were “convinced” of the “possibility” that Chomentowski was “potentially” dangerous. Moreover, Chomentowski’s 1957 diagnosis, along with a subsequent diagnosis in 1962, was identical to that of 1955, even though the latter two were based on symptoms that were not only different but precisely opposite. In 1955, Chomentowski was “grandiose,” “mildly euphoric,” “over-productive and spontaneous.” In 1962, “His stream lacked spontaneity; he was negativistic with delayed reaction time and psychomotor retardation and his affect was blunted.” In both cases, it was “undoubtedly” a schizophrenic reaction; Chomentowski was in such a state of insanity as to be incapable of understanding that he had been caught with a dysfunctional French machine gun.Szasz on Trial
When Szasz agreed to testify on Chomentowski’s behalf, news of the impending hearing spread quickly through the small but influential group of psychiatrists populating upstate New York, many of whom had been waiting for an opportunity to confront Szasz. By the time the hearing actually rolled around, what was supposed to be an inquiry into the mental status of Michael Chomentowski had quietly become an inquisition into the philosophy of Dr. Szasz.
The idea was mostly that of Dr. Abraham L. Halpern, the newly appointed commissioner of mental health for Onondaga County. For his part, Halpern believed Michael Chomentowski was neither sick nor violent. This, however, was not his prime concern. At the time of the hearing, Halpern was also an associate professor of psychiatry at SUNY-Syracuse and thus in fairly routine contact with the man who was making his life difficult. “See, he had just written his book,” Halpern remembers. “Here I was trying to tell the community, ‘Hey, you know you ought to allocate tax funds for the development of psychiatric units in the general hospital.’ And people would say, ‘Why should we do that when mental illness is a myth?’ You can see why I would oppose some of his ideas, only from a practical point of view.”
Halpern, now in his eighties, considers himself a close friend to Szasz, so he cringes at the manner in which he went about denouncing him. “I mean, here’s my dear friend Tom Szasz, I feel almost embarrassed in retrospect. But at that time, this was an opportunity for some of his extremist positions to be exposed in open court. Not where he has a bunch of medical students to indoctrinate, but a lawyer who was well prepared to challenge a lot of his ideas.” Halpern coached Onondaga County Assistant District Attorney Jack Schultz before the hearing; at the hearing itself, he sat near the prosecution’s bench, passing notes and recommending questions.
The event itself lasted two days, with Szasz’s testimony comprising the bulk of it. Szasz assured Chomentowski’s lawyer that he considered the defendant capable of understanding the charges against him, at which point the D.A. began his cross-examination. Schultz’s inquiries ranged from the theoretical to the comical, often in no particular order and with no apparent reason. In addition to seeking Szasz’s opinion on Chomentowski, the D.A. sought the doctor’s views on democracy, religion, the Bible, charity, and his own legacy as a psychiatrist. At one point, near the middle, Schultz stopped and said: “Doctor, let me ask you this. This will take the process off your mind, but I would like to ask it. There was a time when Sigmund Freud was told that he was all wrong ... people didn’t ascribe to his theories. Now he is looked upon by a great many eminent psychiatrists as the ‘Father of Psychiatry’.... Do you feel you are in the same position — do you feel you are ahead of your time, doctor, with all due respect to your natural modesty?”
Between the non sequiturs, Schultz returned to the topic of mental illness. “Now doctor, you call it the ‘myth’ of mental illness. In my layman’s terms, would that mean that mental illness does not exist?... Could anyone be mentally ill, doctor?... If somebody is directing traffic on Salina Street naked, would you say that person is mentally ill?... Is there any such thing as mental disease?” Szasz was content to expound, at one point explaining exactly what he meant by “myth”:
You seem to think that a myth refers to something that doesn’t exist.... A myth is not a word properly used that refers to something that doesn’t exist. It refers to a kind of collective reasoning that people make; that odd things which are variably upsetting to people — odd things that people do, such as killing their mothers or mothers throwing their children out of a seventh-story window, all sorts of terrible things — these things that exist, they very much exist. I am trying to do as much about these things as anybody else. I think a little bit more. The issue is what are these things? The myth refers to the fact that the people say they are illnesses that doctors can cure. I say they are wrong. They are not illnesses people can cure. They are using the term mental illness mistakenly.... People who drink and beat up their wife — I don’t like them any more than you do — but I don’t think they are insane. I think they are badly mistaken, ignorant, stupid, misled, upset — but they are not sick like with pneumonia. If that isn’t clear I will be glad to answer it further.
Shortly after that response, Halpern’s effort to discredit Szasz — the subtext of the whole hearing — met with success. In response to another series of repetitive questions, Szasz said that he “would not be caught dead” in a mental institution, and eventually he declared institutional psychiatry a form of “brutality.” “[B]eing called a psychiatric patient when one does not want to be called a psychiatric patient, being given drugs — psychiatric drugs — when one doesn’t want psychiatric drugs. I would consider all of these things together as brutality, yes.”
In truth, nothing Szasz said at the trial was new. He had published it all before in academic journals and in The Myth of Mental Illness, then already a year on the shelf. The only new element, the only reason to take action, was the fact that Szasz was now addressing the general public. “Saying this in an open courtroom and not in a textbook means that newspapers pick it up; and the Syracuse newspapers picked this up and played Tom as the heretic of Upstate Medical Center,” recounts Al Higgins, a sociologist at SUNY-Albany who worked with Szasz in Syracuse at the time. “At this point Tom’s colleagues in the medical profession said, ‘We got you.’ And they did! They made it terrible for him.” Higgins discusses the events with the barely suppressed excitement of an academic describing a very conclusive round of lab results: “The reaction of the medical profession, the reaction of his fellow psychiatrists is a wonderful, wonderful example of the ways in which a profession controls its members.” (Chomentowski, for his part, was eventually released, but only after the U.S. Supreme Court deemed certain aspects of involuntary commitment unconstitutional.)
Paul Hoch, New York’s commissioner of mental hygiene, wanted Szasz banned from the Syracuse Psychiatric Hospital, which was then functioning as the hub of Hollender’s department. Hollender’s temporary solution was to move Szasz from the psych hospital to the Veteran’s Administration Hospital a few blocks away. Szasz initially went along with the transfer, but then decided he wouldn’t stand for it. “I don’t want to belabor this metaphor, but it was as if Marc told me: You have to wear a yellow star,” Szasz says. Colleagues and protégés eventually protested the banishment, boycotting class and staff meetings. Local newspapers provided breathless color commentary: “One of the most flagrant breaches of academic freedom in the history of the school,” wrote reporter T. Lee Hughes. Szasz is “the victim of a virtual academic crucifixion.” Szasz appealed to the American Association of University Professors and to the American Civil Liberties Union. His attorney met with the officials in charge and asked, “What are you going to tell the federal judge when I tell him you tried to silence a professor’s academic freedom?” Eventually, however, the crisis dissipated.
For Szasz, the events served mostly as an education. He was soon publishing abbreviated versions of his books and papers in prestigious, non-professional outlets including Harper’s, National Review, and The New Republic. A piece in The New York Times Magazine titled “Mental Illness Is a Myth” reportedlyinduced more reader response than any article in the magazine’s history. If he had preached from the pulpit with The Myth of Mental Illness, he had now nailed his thesis to the church’s front door.
In1964, two years after the Chomentowski trial, the American Psychiatric Association invited Szasz, for the first and last time, to present his arguments at their annual conference. It was a heresy trial. Six APA psychiatrists presented papers denouncing Szasz. Howard Rome, a future APA president, accused him of extending “an unquestioned constitutional freedom to an impermissible degree,” the equivalent of shouting fire in a crowded room. Dr. Henry Davidson read from a paper titled: “The New War on Psychiatry.” “The net result of Dr. Szasz’s writing,” he argued, “has been to make people think that we psychiatrists are a menace to our patients. His views have had considerable effect on the less sophisticated elements of the public.” Another psychiatrist rose to say: “Certainly on our staff of a hundred we have some who would treat a certain type of patient largely through insight psychotherapy, others who would use pharmacotherapy, and still others who would use electroconvulsive therapy. But the public cannot be educated to these differences of opinion.”
Ironically, in this attempt to dismiss Szasz, official psychiatry was helping to make his case. In his writings, Szasz often echoed Max Weber’s The Sociology of Religion, which states: “Understandably, all magic lore originally has the character of secret knowledge, to protect the professional interest of the guild.” Szasz was a threat to the guild, both its lofty self-image as “doctors of the soul” and its practical interests as the beneficiaries of public esteem and largesse. And in the battle between Szasz and institutional psychiatry, each side moved the other to ever-greater extremes.The Limits of Psychiatry
It is hard to doubt the reality of mental illness, especially when the suffering of affected individuals is so complete and the impairment so extreme, when psyche and identity are crippled almost beyond repair. But it is also remarkable how much of modern psychiatry is still theoretical rather than empirical, and how many of the supposed mental illnesses that appear (and multiply) in the Diagnostic and Statistical Manual of Mental Disorders have no known biological underpinnings or explanations. Although Szasz’s critique often became a caricature, his intuition about the limits and deformations of modern psychiatry cannot be ignored. Many sick people have surely benefited from psychiatric treatment, both “talk therapy” and pharmacotherapy. But psychiatry’s long history of error — from snake pits to ice baths to spinning chairs to electroshock to lobotomy — should give us pause. Skepticism is not backwardness, even if Szasz often took his skepticism to rhetorical extremes.
At his best, Szasz actually clarified the Sisyphean predicament in which psychiatry remains largely stuck. For almost half a century, he has obstinately argued that a mind can only be sick in a metaphorical sense. And all this time, psychiatry has been desperate to prove what it claims to have already proven — to bring mental illnesses “down to the level of all other diseases of the human body, and to show that the mind and the body are moved by the same causes and subject to the same laws.” In response to the image crisis that psychiatry had suffered at Szasz’s hands, past-APA President Robert Felix offered the following cure: “More of us must intensify our efforts to become more identified with the mainstream of American medicine.” In other words, the legitimacy of psychiatry’s refutation of Thomas Szasz rests entirely on the profession’s ability to prove Benjamin Rush right. This was the goal implicit in Felix’s proposed merger with “the mainstream of American medicine.”
Not surprisingly, over the last four decades, psychiatry has systematically placed its greatest hopes in the biology of mental illness. We are led to believe that new disciplines like neuroscience are putting old ambiguities to rest. We hear of “explosions in scientific knowledge of the brain” and “remarkable advances in understanding the human mind.” Evidence of the biological basis of mental illnesses would seem to be so overwhelming that to doubt is akin to doubting evolution. Yet a review of the facts fails to reveal the sort of breathtaking advancement commonly claimed.
In her 2001 book Brave New Brain: Conquering Mental Illness in the Era of the Genome, Nancy Andreasen writes 174 pages before offering this tellingly brief and couched confession: “Because we cannot yet point to a specific lesion or a specific cause ... some critics (most notably Thomas Szasz of the University of Syracuse) have argued that mental illnesses must be myths.” Considering its context, the confession’s delay is disconcerting. In her introduction, Andreasen lauds the “powerful new technologies” that have already illuminated “the causes and mechanisms of mental illnesses on many different levels.” The reader must either assume that the technology is over-hyped or that mental illnesses are veritable black holes, reflecting very little of the blinding light we have apparently thrown on them. (Meanwhile, Szasz’s superfluity somehow continues to supersede the need for historical accuracy. Contrary to Andreasen’s description, he has never worked for the University of Syracuse.)
If mental illnesses truly begin in the brain, no psychiatrist on earth can conclusively say when, where, why, or how. Nearly one hundred years after Eugen Bleuler invented the word “schizophrenia” to describe, among others, the “irritable, odd, moody, withdrawn, or exaggeratedly punctual,” those who “vegetate as day laborers, peddlers, even as servants,” and “the wife ... who is unbearable, constantly scolding, nagging, always making demands but never recognizing duties,” the only way to diagnose this “disease,” or any other mental illness, remains the observation of behavior. Given the complexity of the human psyche, this makes sense: we can hardly expect the many moods and miseries of human life, even the most extreme, to have simple neurological explanations. But given the grand ambitions of modern psychiatry — to explain the human condition, to heal every broken soul — the reliance on behavioral observation has led to the medicalization of an ever-growing range of human behaviors. It treats life’s difficulties and oddities as clinical conditions rather than humanity in its fullness.Szasz’s Uncertain Legacy
For Szasz, the extreme induced by his war against psychiatry was both equal and opposite to that of his profession. When psychiatry failed to shut Szasz up, it went about forgetting him. When Szasz failed to persuade his peers, he seemed to devote his career to enraging them. In 1963, shortly after the crisis at SUNY, Szasz wrote: “To maintain that a social institution suffers from certain ‘abuses’ is to imply that it has certain other desirable or good uses.... My thesis is quite different: Simply put, it is that there are, and can be, no abuses of Institutional Psychiatry, because Institutional Psychiatry is, itself, an abuse.” By the 1970s he was comparing psychiatrists to witch hunters. By the 1980s it was slave owners and Nazis. While such extreme rhetoric made Szasz a public figure for a while, his polemical excess eventually ensured his professional obscurity.
Yet we are also right to give the earlier Szasz his due. “Quite probably,” wrote Edwin Schur in The AtlanticMonthly in the 1960s, “he has done more than any other man to alert the American public to the potential dangers of an excessively psychiatrized society.” A fellow psychiatrist put it thus:
We no longer have the right to be offended by what Szasz says. It is too late for Aesculapian arrogance. Szasz has been telling us over and over again that the ways in which we comfortably define behavior as “sick” ... can be more devastating to the human spirit than any persecution. He has been telling us over and over again that whatever “health” is, it is closer to whatever “freedom” is, than any other two conceptualizations that we push aside in our little black bags.
Perhaps the most remarkable tribute, however, came in 1989, when an ailing Karl Menninger, the long-time patriarch of American psychiatry, wrote Szasz the following:
I am holding your new book, Insanity: The Idea and Its Consequences, in my hands. I read part of it yesterday and I have also read reviews of it. I think I know what it says but I did enjoy hearing it said again. I think I understand better what has disturbed you these years and, in fact, it disturbs me, too, now. We don’t like the situation that prevails whereby a fellow human being is put aside, outcast as it were, ignored, labeled and said to be “sick in his mind.”
For his part, Szasz seems ambivalent about his legacy. “I really don’t think I am falsifying it when I say I never had much hope of having an impact on psychiatry,” he told me. “I viewed psychiatry all along as more like the Catholic Church. What impact did Voltaire make on it? If you think about what happened since then, nothing! No I didn’t expect to make any difference.”
Today, Szasz lives alone in a suburb of Syracuse where he continues to write. He has already published one new book this year — “My Madness Saved Me”: The Madness and Marriage of Virginia Woolf — and he recently finished a draft of yet another critical history of his profession. If the trend continues, the books will be read by few and endorsed by almost none. After forty years of comparing psychiatrists to the scum of the earth, Szasz now stands as one of the biggest obstacles to his own ideas. It is simply too easy to dismiss himas an axe-grinding zealot, a “musician who does not like music,” as one critic put it. “The atheist who cannot stop speaking about God.” But perhaps a new generation of critics will arise — aware of psychiatry’s achievements but also its limits, leading us not to extremes but to a much-needed reformation of psychiatry from within, and a much-needed de-medicalization of human life in the culture as a whole.
Jeffrey Oliver is a freelance journalist in Colorado. He recently returned from a Fulbright Fellowship in Taiwan.
Jeffrey Oliver, "The Myth of Thomas Szasz," The New Atlantis, Number 13, Summer 2006, pp. 68-84.
Now only an expert can deal with the problem because half the problem is seeing the problem.
- Laurie Anderson
In the animal kingdom, the rule is, eat or be eaten; in the human kingdom, define or be defined.
- Thomas Szasz
In Christopher Moore’s novel, The Lust Lizard of Melancholy Cove, we watch the cartoonish results of a town going off their antidepressants. When a local housewife commits suicide, the town psychiatrist becomes upset, believing that her tranquilizing medications might be insufficient in preventing such tragedies. She blackmails the local pharmacist into dispensing placebos instead of Prozac. Cold weather approaches and the town gets the blues. They start singing the blues. They also get their sex drive back, which coincides with the arrival of an aphrodisiacal sea monster. It’s all quite absurd and strange. Though his intent is more comedic than moral, it does push us to wonder about our reliance on professionals to manage our personal troubles and the influence of psychiatric experts in our lives.
If there ever was a critic of our enchantment with psychiatry, it was Thomas Szasz, MD, who died this past week at the age of 92. His 1961 book, The Myth of Mental Illness, provided the philosophical basis for the antipsychiatry and patient advocate movements that began in the 1960s and have flourished ever since. Szasz (pronounced “zoz”) argued that a disease model was a category error when it comes to accounting for “problems in living.” The New York psychiatrist, who was born in Budapest and immigrated to the United States in 1938, was originally trained as a psychoanalyst and was on the faculty of SUNY Upstate until retirement. He shunned the medical model of psychiatry, which he saw as inherently coercive. He was an early critic of psychiatry’s former disease model of homosexuality. He argued vigorously against the use of involuntary hospitalizations, the insanity defense, and the psychiatric control of psychotropic medications. His influence has permeated both clinical psychiatry and psychology, leaving the profession with a stronger emphasis on social justice and a legacy of psychiatric skepticism.
One of Szasz’s basic arguments is that mental illness is a myth. He was highly critical of the so-called medical model for understanding human struggles and difficulties. He saw the uses of diagnostic systems (such as the DSM) as wrongly implying the presence of actual disease. Furthermore, he saw such efforts as medicalizing morality and the typical dilemmas and struggles of human life.
To be sure, Szasz was not without his critics. His central view that mental illness is a myth has been dismissed, if not outright rejected, by the American Medical Association, America Psychiatric Association, and National Institute of Mental Health. Even Dr. Allen Frances, himself a critic of the modern diagnostic approach in psychiatry, has said that Szasz “goes too far.”
Still, the critique offered by Szasz deserves careful reflection, even if some of his views seem radical. We will soon witness a new, fifth revision to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). It is widely assumed that the DSM-5 represents an advancement in knowledge that will further our understanding in treating psychopathology. The experts have said we should not be concerned. In fact, we should applaud because we have come so far. There is less stigma associated with having a mental illness. Treatment works and suffering is reduced. And so on.
And what could possibly be controversial? At the most basic level, the American Psychiatric Association maintains a kind of monopoly on what constitutes a mental illness. As pointed out recently by Allen Francis, M.D., chair of the previous DSM-IV, the new manual has become a victim of its own success. It has become the chief arbiter of who is ill and who is not, and such decisions affect everything from access to school services to disability payments and insurance eligibility. The benevolent view would be that there will be more access to treatment for everyone. A more cynical view suggests an increase in pathologizing normal experience (e.g., converting shyness into social anxiety disorder) . With the addition of many new diagnoses and a broadening of diagnostic criteria for existing diagnoses, the DSM-5 could shape notions of normality and illness in ways that cannot possibly be anticipated. What is clear is that Its continued dominance as psychiatry’s sacra scriptura ensures a continued deference to experts when we are troubled.
If Szasz would have us question our fidelity to experts, psychoanalysis gives us a language for talking about why we might be drawn to experts in the first place. Freud reminds us that there is something intrinsically unmanageable about being human. We struggle to bear what seems unbearable. Our turning to experts is a self-cure for what we cannot tolerate or explain. But is it easier to bear if it can be explained and potentially alleviated by experts? If one is experiencing a persistent and stubborn shyness, is it usefully viewed as social anxiety disorder–a treatable mental illness (complete with psychotherapies and medications)? Thus, we thrust our fears about what we can’t seem to bear into the arms of experts.
If Freud would have us be critical of what we assume to be true in our nature, William James would push us to decide on the usefulness of what we’ve come up with. Would it be more or less helpful to think of one’s introverted nature and social fearfulness as a mental health condition? If we think of severe shyness as a treatable illness, am I more likely to seek some solutions rather than others? What are the side effects of a medical metaphor?
It would be hard to argue against the idea that we are better off with the kind of compassionate, non-discriminatory, science-based approaches we enjoy for conditions like autism, cognitive impairments, and severe depression. We no longer live in a demon-haunted world. We would also have a hard time imagining the kind of world that J.G. Ballard described in his futuristic short story, “The Insane Ones,” where psychiatrists and psychologists have been outlawed in a kind of libertarian utopia (under the fictitious Mental Freedom legislation) that Szasz might relish. “Discharging their self-hate and anxiety onto a convenient scapegoat, the new rulers, and the great majority electing them, outlawed all forms of psychic control, from the innocent market survey to lobotomy...the mentally ill were on their own, spared pity and consideration, made to pay to the hilt for their failings.”
There is surely a middle path–somewhere between Moore’s parody and Ballard's libertarianism. Our conceptions about what is normal or sane involve a much bigger project than the DSM, and perhaps we will see the DSM take its place alongside other relics we no longer need (lobotomies come to mind). Similarly, our ideas about self-improvement surely go beyond the language and treatment methods of psychiatry. While appreciating evidence-based practices in psychotherapy and medical advances in psychopharmacology, we need to be alert to a full range of avenues for self-help. Szasz would also remind us not to “mistake medicine for magic.”
* An earlier version of this article did not include the photo credit. My apologies to Jeffrey Schaler for not including this in the earrlier draft.
© 2012 Bruce C. Poulsen, All Rights Reserved