Since the publication of The Myth of Mental Illness and Psychiatric Justice some 35 years ago, Thomas Szasz has battled the popular conception of mental illness as a disease “like any other.” He has long argued against the involuntary interning of the mentally ill, against denying the mentally ill their constitutional right to trial, and against exonerating criminals from responsibility for their actions on the basis of “temporary insanity.” Thomas Szasz is a professor of psychiatry at the State University of New York in Syracuse.
There is a strange and wondrous story by Edgar Allan Poe called “The System of Doctor Tarr and Professor Fether,” in which the reader is never quite certain, at least until the end, just who is the superintendent and who is the patient in a Maison de Sante outside of Paris in the first half of the 19th century. Indeed, there is sufficient role reversal taking place so that the reader is unrelieved of doubt on the doctor-patient role even after the story is concluded, hi the short story, Poe mixes terror and kindness, sickness is commingled with health, lucidity with imaginings of all sorts. Overall, we are left with grave doubt as to the relationships of people to each other—especially in confined settings, or what Erving Goffman preferred to call total institutions. The human condition is neither comedic nor tragic, but some ever-changing admixture of the two.
It is not that categories of sanity and insanity are fictitious, but that the human bearers of such categories are all too real. They operate from a mixed bag of motives which require explication. Poe’s story might well be the appropriate fictive tale to the quite real concerns of Thomas Szasz. For his interests range far beyond commonplace slogans about mental illness, into the painful ambiguities of everyday life—and the need to make decisions about what constitutes creative as well as destructive behavior, no less than what we mean by health and ailment. His work crisscrosses law, medicine, and the social sciences with frightening ease—frightening because Szasz is so knowledgeable, and even more, because he probes the sources of our intellectual boundaries in a challenging way.
If there is another living psychiatrist who has suffered more professional obliquity while sustaining great public recognition, this person escapes my recognition. To be sure, the work of Thomas Szasz has far greater support in allied disciplines such as sociology and political science than in his own native field. This is a two-way street, of course. For if people like Erving Goffman drew support in his Asylums from the earlier efforts of Szasz, so too has Szasz sought relief and comfort in the likes of George Herbert Mead and his Mind, Self & Society. To say the least, the life and career of Szasz are a tribute to the incredible moral spine of this individual, but also to the tangled web of professional relationships that have evolved over the century in the social and behavioral sciences.
Calling attention to the contributions of the social sciences may be the greatest sin committed by Szasz in the eyes of his critics. For it is the medical model of psychiatric practice that comes under the sharpest critique in his work. This is not because Szasz is against medicine—indeed his training and points of reference have always been the medical profession—but against the smuggling of categories of crime and punishment, for example, into the definition of mental illness. In a recent essay, Szasz adroitly sums up the dual edge to his critique of contemporary psychiatry: “The focus of my conceptual critique is the distinction between the literal and metaphorical use of language; and the focus of my moral-political critique is the distinction between dealing with grown persons as adults, possessing free will and rights and responsibilities, as against dealing with them as if they were infants or idiots lacking free will and rights and responsibilities.”
One might claim that even the conceptual critique is saturated with political judgment—since the literal and metaphorical use of language has, over time, been well understood to have a high political content. For what else has given George Orwell his permanent niche in the world of letters if not this deep appreciation of language as a symbolic tool of manipulation, no less than a prosaic tool in communication? It is the language of medicine—the certitude with which the idea of mental patients having mental diseases and medical claimants having scientific rigor that is a basic source of the politics of mental health—that is, the presumption that a subset of professionals can impose its will and judgments over a large set of medical practitioners.
The stakes in this intellectual struggle are so high—ranging from fees to be collected to worldviews to be protected—that it is little wonder that Szasz has been pilloried in a manner and with a drumbeat that surely would have sent a less determined individual to Coventry and back. Hardly a book or article he writes fails to produce a legion of critics. The lines of criticism seem to divide the political and the professional.
In the former category, we are told that Szasz does not represent a consensus of opinion and is therefore wrong, or he so distorts psychiatry that the normative foundations of society would be undermined by his judgments. On the professional level, the usual criticism is that he is mistaken on specific points of psychiatric practice, to the more recent and quite fashionable critique that psychopharmacology has given precisely the sort of chemical basis to neurosis and psychoses that Szasz’s work largely if not categorically denies. Since Szasz himself has responded at great length to these other charges, I shall eschew a defense of his work as such, and move on to the political and economic sources of those assaults. But before doing so, it might be worthwhile to explain what elements in his work have enraged his professional colleagues. At least in this way, the ethical battleground of psychiatric practice can perhaps be sharply etched.
Ultimately, Szasz’s achievement is his unique ability to bring into a discipline, which, ostensibly at least, has come to pride itself on its indifference to moral claims, precisely a sense of morality—an ethic of responsibility. In a universe in which everyone claims victim status, a liberal virus threatens to undermine a liberal society. When everyone from the street pusher to the university president can claim victim status, it is precisely this sense of ethical responsibility that vanishes behind a cloud of psychiatric smoke. Such vague notions as ethics are given meaning by Szasz, to wit, sufficient education to make distinctions as to what is right and wrong, good and evil, no less than true and false.
And while Szasz has been, improperly in my view, classified as anti-Freudian, he is perhaps the most Freudian of the present lot of analysts—for to rekindle the phrase of Philip Rieff, Szasz shares with Freud the “mind of the moralist” in defining the field and developing scenarios for the determination of neurosis and normalcy in the conduct of everyday affairs. For without a moral sensibility, prospects for the reconstruction of society become null and void. Egoism comes to replace civilization, and the discontents are able only to undermine, rather than restore, that sense of purpose that gives reason its place in the human mind.
This is not to deny that Szasz has been critical of many propositions within the Freudian corpus—from the Oedipal complex and notions of philogenetic memory traces to Freud’s judgments about the analytic setting of doctor-patient relations; this hardly makes Szasz unique. Indeed, there are many practitioners of psychiatry who are far more severe in their judgments of Freud, who nonetheless earn Szasz’s wrath. It is the singular merit of Szasz that his concerns extend far beyond the parochial boundaries of biography or, for that matter, the dangers of digressing from an established corpus of the master’s writings. Rather, in a sense of the goals of medicine; the prolongation of life, and even the goals of analysis, the ability of the person to make free and rational choices however such big words are defined, I find the two far closer in spirit, than those who believe that in attacking Szasz they are somehow protecting Freud.
For in reviewing the constancy over 35 years of his major themes, one senses the “ought” behind the “is”—the impulse to liberty as free choice even more than the lack of efficacy of psychiatric treatment and counseling. Indeed, in his most recent book, Cruel Compassion, which can be viewed as a final manifesto on his lifelong themes, there is a sharper polarity: caring for others by means of coercion, or doing so with their consent. The libertarian motif became text rather than subtext. To those who claim that a theory of consent is not feasible with those labeled as mentally ill, he reminds his critics that it is they who continually utilize and invoke the medial analogies. And if this analogy between the physical and the psychic is accurate, then, too, must the right of the patient to solicit treatment be viewed as inviolable by extension.
Perhaps certain levels of coercion are required. But Szasz’s answers—not always fully worked out—are two in number: if this be the case, then the analog to medicine in general must be abandoned or seriously revised. But more important, to argue the case for coercive practice is to move dangerously close to the identification of the scientific community with the police force. And here Szasz, in his full passion, returns to the ethical basis of all issues connected with health. It is worth quoting a passage from his Cruel Compassion, because it is both an apt summary of his ethical position and, no less, a warning to those with a monopoly of power—including the power to treat patients.
It is dishonest to pretend that caring coercively for the mentally ill invariably helps him, and that abstaining from such coercion is tantamount to ‘withholding treatment’ from him. Every social policy entails benefits as well as harms. Although our ideas about benefits and harms vary from time to time, all history teaches us to beware of benefactors who deprive their beneficiaries of liberty.
Of course, it might be argued that this is a straw man, that many individuals do indeed seek the very sort of treatment which Szasz finds reprehensible. But that is another matter— having to do with the empirical efficacy of specific techniques of treatment. One might say that there is an ethical break between psychiatric control of society’s unwanted, and psychiatric treatment of society’s elite. One might say that “The Myth of Mental Illness” may be common to all segments of society, while the reality of psychiatry as a mode of coercion is unique only to special segments of an advanced society. I am not sure that Szasz has worked out the parameters of this relationship of voluntary and involuntary patients, and libertarian and authoritarian psychiatrists. Perhaps this is a work yet to come.
My own view is that the gap between psychology and psychiatry in general, and to psychoanalyses in particular, will both widen and deepen. The uses of psychology—from testing and measuring individual performance to defining the structure of perception and conception—have expanded over time. And while this expansion may not always be uniform, or for that matter, even welcome, it is real enough. One might well argue that far too much reliance on psychologists has crept into everything from evaluating career capabilities to defining students as haying learning disabilities. Nonetheless, this aspect of professional psychology has expanded enormously—the size and outreach of professions and journals attest to this.
At the level of psychoanalysis, the situation is far different. It is a sub-branch of psychiatry, and one that has great strength only in isolated pockets—usually suburban areas where time and wealth conspire to permit its practice. The need to compress years into days has had a variety of consequences: much higher use of drug therapies on one hand and a reinterpretation of behavior to widen the area of the permissible and reduce that which is considered bizarre. And here it is not the moral assault by libertarian critics like Szasz that has proven effective, so much as the economic assault of the marketplace and the social assault of contemporary relativism.
So Szasz can be said to have scored some substantial victories in his crusade for a libertarian option, but also a few major setbacks. He himself realizes as much, since the rise of Medicare and Medicaid programs, inclusive of psychiatry, has expanded the payment basis for mental illness of all sorts; and this is coupled with the license given to psychiatrists to define huge numbers of society’s unwanted as mentally ill rather than physically dangerous. There are, in short, dynamics at work within the society that tend to subvert the very goals Szasz seeks. But there are also tendencies that reinforce his position. Just how these social considerations affect the theory and practice of psychiatry is beginning to occupy many talented people—including Szasz himself—for whom the larger context of the field has transformed the world of professional analysis into one of public discourse.
But quite beyond minoritarian fashions such as libertarianism lurks the mind of the moralist. And it is this which provides the umbilical cord between Szasz and Freud—one that cannot be severed, no matter how severe Szasz’s reservations might be about the therapeutic process itself, or the conduct of its practitioners. I am reminded of the fact that Philip Rieff, some 30 years ago, wrote a book on Freud: The Mind of the Moralist. It is in the dramaturgy of good and evil that Rieff saw the staying power of Freudianism as an ideology. While Szasz’s savage critique of “the manufacture of madness” by psychiatrists and witch hunters prevents him from exercising the power of an “ism” (nor I hasten to add would he desire such an appellation), the burden of his work is precisely to reannounce the dramaturgical aspects of psychiatry: the confrontation of oppressor and oppressed, of good and evil, of science versus mystification.
I would argue that this aspect of Szasz’s work—his morally centered critique of a branch of both medical science and social science—has led to certain shifts in his objects of wrath over time. But these have been minor in contrast to the shifts in those who support and oppose him. I know of few figures in modern intellectual history who can enlist the wrath and support of a conventional “left” and “right.” And thus it is that an Edgar Z. Friedenberg, a grand guru of the 1960’s and the anti-American generation, can praise “the depth of Szasz’s commitment to human freedom and the precision with which he perceives that psychiatry has created highly effective forms of human bondage” while an equally powerful voice in the conservative movement, Ernest van den Haag, can claim to have been “entranced by the originality of Szasz’s ideas and the brilliance and cogency of the presentation.”
But what links scholars like Friedenberg on the left and van den Haag on the right—if one can still use such tattered terms in a meaningful way—is their marginality. And that must ultimately be said of Szasz as well. For what we have with Szasz is an attack on the center of a profession, on its established habits of advancement and promotion no less than patterns of professionalization. While I have concentrated on the relatively well known aspects of Szasz’s critiques of the latter, it is his implicit assault on the former—on ways in which a profession awards and rewards—that so excites his opponents. This is not a pleasant academic discourse, but a bitter struggle over the fate of a science on one side and its economic foundations on the other.
For Szasz makes a direct appeal to a larger, intelligent public—the sort of individuals who might see a psychiatrist for better or for worse—to reconsider their basic notions of superordination and subordination. And to do so is a direct querying of trust. To pay money to an analyst, to allow the analyst to sit in judgment, whether through expert testimony in legal matters or direct decisions about incarceration in medical matters, are weighty concerns. I suspect that at the outset of his career, when he first started raising fundamental questions about the scientific status of psychiatry, Szasz thought little, if at all, about the politics and economics of such considerations. But as his analytic skills sharpened, and the target of his criticisms became increasingly focused, so too did the resistance of the psychiatric mainstream. This in turn fueled Szasz’s sense of the political. He became involved in the politics of libertarianism. For his work moved from a critique of a profession to a defense of the person, or as Szasz liked to put it, “to a struggle for self-esteem.” His approving citation of C.S. Lewis serves Szasz as a final judgment, not on the scientific pretenses of a profession, but on its moral claims: “Of all the tyrannies a tyranny sincerely exercised for the good of its victims may be the most oppressive. To be ‘cured’ against one’s will and cured of states which we may not regard as disease is to be put on a level with those who never will; to be classed with infants, imbeciles, and domestic animals.” But in claiming that “these words still apply to psychiatry today,” he only increased the level of his marginality. He became vulnerable to assaults in ways he could hardU’ have imagined in the late 1950’s, when The Myth of Mental Illness first appeared.
This is not aimed to provide a brief history of Szasz; not at all. It is rather to make clear the politics of psychiatry and the ethics of a psychiatrist. What emerges is hardly a pretty picture of professional and academic life in America. The best that can be said is that such a life is never dull; the worst that can be said is that those in charge of a profession are not by any means best fit to be the guardians of scientific considerations. The long and short of it is that Szasz has garnered the public rewards of his marginality, while at the same time paying a heavy price in terms of the professional emoluments.
Nonetheless, it might be said, more in sorrow than criticism, that the psychiatry and psychoanalysis of the mid-1990’s is radically different from that of the 1950’s. When Szasz started writing on fundamental themes, American culture, no less than medical practice, still accepted electroshock therapy as a norm, and took for granted the blessings of incarceration—forces and otherwise—upon those labeled mentally ill. While the humanization of treatment has not been entirely even or steady, it is sufficiently noteworthy to raise questions about the tactics of critical analysis. One would like to see Szasz take some credit for such new developments rather than flog a dead, or at least badly injured, pseudoscientific horse.
Given this combination of intellectual circumstances, it is little wonder that Szasz, in the twilight of his life, can boast fewer acolytes than far lesser figures, hi part, this is a consequence of the double edge of Szasz’s work: it devastates totalitarianism, in its fascist and communist varieties, with equal force, and it cuts down ideological humbug, however meliorate or humane its social intentions or scientific pretensions. Thus it is that Szasz must deal with the loneliness, the isolation, that comes from moralism as a personal posture no less than as an element in his analysis of a discipline. The “struggle for self esteem” which Szasz offers is a lonely struggle—and again, one that has a curious analog in Freud’s notions of self-liberation through rather than against the therapeutic process. Thus it is that Szasz cannot quite free himself from his adversaries within psychiatry —in part because of a magnificent obsession with the subject, but in great measure because he shares with a century of psychiatry, despite its own ambiguities and doubts, the search for human liberation—however fumbling that search may be at different times and different places.
In what might well be called the anomaly of success, Szasz now takes his place in the pantheon of the very psychiatric movement that he has so chastised and devalued over the years. But that is because the secret is out, due in part to Szasz’s own efforts: the function and structure of psychiatry, especially psychoanalyses, belongs more to the search for ethical moorings in a secular world than empirical science as such. The sooner the practice of psychoanalysis realizes this, the earlier we can all get on with the shared task of fashioning a new, and more modest, science of human nature. Curiously, Szasz put this search in quite elegant perspective in the preface to his first, and perhaps most enduring book. The Myth of Mental Illness: “I believe that psychiatry could be a science. I also believe that psychotherapy is an effective method of helping people—not to recover from an ‘illness,’ it is true, but rather to learn about themselves, others, and life.”
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