JMS Pearce
Hull, England

“[Mental illness] is a myth, whose function it is to disguise and thus render more palatable the bitter pill of moral conflicts in human relations.”
—TS Szasz (1920–2012), “The myth of mental illness”¹

In a discipline as diverse as medicine, it should occasion no surprise that odd characters, eccentrics, and unorthodox adventurers emerge from time to time. When their methods yield advances or improvements, they may be praised in retrospect. But in a profession bound by convention, their efforts are often disparaged, and sometimes their personalities are reviled because they do not fit in with contemporary attitudes to medical ideas or practices. Thomas Szasz’s vehement criticisms of his own discipline were unusual and provoked scorn, rejection, and hostility in his lifetime. For this reason, his views may have melted into thin air.

Born in Budapest, he was the son of a Jewish businessman, Julius, and his wife Lily.² Thomas Szasz graduated MD from the University of Cincinnati and studied psychiatry at the University of Chicago. He was appointed professor of psychiatry at the Upstate Medical University of New York. Szasz passionately espoused human freedom and was critical of any intrusions on civil rights and liberties.

He believed that psychiatric patients from the dawn of psychiatry had no opportunity to free themselves from a protective-oppressive relationship with psychiatrists, which he termed an abusive relationship with the psychiatric profession.³ According to Szasz, “The ethical dilemmas of psychiatry cannot be resolved as long as the contradictory functions of healing persons and protecting society are united in a single discipline.”⁴

The nature of mental illness

Being miserable, discontented, or unhappy did not necessarily constitute mental illness. Happiness, he believed, was an imaginary condition, “formerly often attributed by the living to the dead, now usually attributed by adults to children, and by children to adults.”⁵ He uses the word psychiatry “to refer to that contemporary discipline which is concerned with problems in living (and not with diseases of the brain, which are problems for neurology).”¹

He was keen to separate the normal ups and downs of human experiences and their emotional sequelae from conventional medical illnesses:

We call all manner of human problems “(mental) diseases”, and convince ourselves that drugs and conversation (therapy) solve such problems. Solutions exist, however, only for mathematical problems and some medical problems. For human problems, there are no solutions. Conflict, disagreement, unhappiness, the proverbial slings and arrows of outrageous fortune are challenges that we must cope with, not solve. Only after we admit that our solutions are illusions can we begin to develop more rational and more humane methods for dealing with “mental illness” and the “dangerous mental patient”.

Yet, we punish people—albeit we call it “treatment”—for annoying family members (and others) with behaviours they deem “dangerous” and also for “being suicidal”. Psychiatrists offer to relieve the disturbed person of the burden of coping with his disturbed relative by incarcerating the latter and calling it “care” and “treatment”.⁴

Discussing the moral conflicts of psychiatry, he commented:

We have failed to accept the simple fact that human relations are inherently fraught with difficulties…. I submit that the idea of mental illness is now being put to work to obscure certain difficulties which at present may be inherent—not that they need be unmodifiable—in the social intercourse of persons. If this is true, the concept functions as a disguise; for instead of calling attention to conflicting human needs, aspirations, and values, the notion of mental illness provides an amoral and impersonal “thing” (an “illness”) as an explanation for problems in living.⁶

Szasz, with logic difficult to refute, argues that “in actual contemporary social usage, the finding of a mental illness is made by establishing a deviance in behavior from certain psychosocial, ethical, or legal norms.”¹ “The phenomena—the human behaviors which some people call mental illnesses—do indeed exist,” he writes. “But I think that calling them mental illnesses is about as accurate as to call them witchcraft, which they used to be called.”⁷ He said that

judgment may be made, as in medicine, by the patient, the physician (psychiatrist), or others. Remedial action, finally, tends to be sought in a therapeutic—or covertly medical—framework, thus creating a situation in which psychosocial, ethical, and/or legal deviations are claimed to be correctible by (so-called) medical action. Since medical action is designed to correct only medical deviations, it seems logically absurd to expect that it will help solve problems whose very existence had been defined and established on non-medical grounds.⁸

He was particularly outraged by legal strictures⁹ commonly applied to mental illnesses. In his book The Myth of Mental Illness, he claimed that the idea of mental illness implies dangerousness, and in this conception, requires and justifies psychiatric coercions.⁸ “To civilly commit a person, a psychiatrist (or physician) must certify that the subject suffers from a mental illness and is dangerous to himself and/or others. Many psychiatric patients are denied the right to refuse treatment they don’t want,” he wrote also.³

He fearlessly challenged his own profession:

The avowed desires of patients and doctors conflict more often in psychiatry than in any other branch of medicine. People known as “mental patients” are routinely subjected to “diagnostic” and “therapeutic” interventions against their will. Many such people see being committed (sectioned) and treated against their will as a personal violation—a “psychiatric abuse”—and want to protect themselves from future involuntary psychiatric hospitalisation and treatment. At present former psychiatric patients, even when legally competent, have no means to defend themselves from such a contingency.³

“Doctors, politicians, and journalists assert that mental illnesses are real diseases and that psychiatrists are regular doctors. If that were true,” he said, “there would be no need for psychiatric protective orders.”³ Szasz later wrote, “I submit that we use phrases like ‘dangerousness to self and others’ and ‘psychiatric treatment’ as apotropaics* to ward off dangers we fear, much as ancient magicians warded off the dangers people feared by means of incantations, exemplified by ‘abracadabra’.”⁴ He compared conventional psychiatry to magic:

…when religion was strong and science weak, men mistook magic for medicine; now, when science is strong and religion weak, men mistake medicine for magic.”⁵

It is often overlooked, however, that he said psychotherapy based on the equality of therapist and patient, with the patient’s consent, was one of the most worthwhile things in the world. He also respected Freud, who had opened up searching conversation between consenting adults. But details of Szasz’s treatments are not clear.

Szasz was kinder to British psychiatrists, some of whom shared at least some part of his concerns. He noted that John J Sandford, a forensic psychiatrist, complained:

The preventive detention of those with untreatable mental disorders is already widely practised in England. Under the Mental Health Act (1983) people … [are] detained indefinitely in hospital regardless of response to treatment and on grounds of risk to self as well as others. Secure and open psychiatric hospitals are full of such patients.¹⁰

Derek Summerfield, a distinguished psychiatrist, similarly commented:

The growing pressures on them [psychiatrists] to deliver public protection was perhaps inevitable, given the rise of biopsychomedical paradigms as explanations for the vicissitudes of life in modern Western society. Psychiatrists have played their part by assuming the authority to explain, categorise, manage, and prognose in situations where well defined disease (arguably their only clear cut remit) was not present.¹¹

Summerfield also dismissed the fashionable label post-traumatic stress disorder, whose story he rightly says “is a telling example of the role of society and politics in the process of invention rather than discovery.”¹²

Szasz’s views were also justified by Roy Porter, the director of the Wellcome Institute for the History of Medicine. In A social history of madness: Stories of the insane, Porter noted:

The pontifications of psychiatry have all too often excommunicated the mad from human society, even when their own cries and complaints have been human, all too human.¹³

It is not easy to put Szasz’s opinions into perspective because though elegantly written and undeniably honest and logical, they are largely protestations; he does not detail how he treated his mad, depressed, and anxious patients.

Perhaps we should not too rapidly dismiss eccentrics driven by passion, even though like Szasz, some overstate their case, and some are misguided. Within their heretical outbursts, there may be hidden nuggets of essential and valuable truths.

Note

* Greek apostropaios, to turn away

References

1. Szasz, TS. The myth of mental illness. American Psychologist 1960;15(2):113-118.
2. Stadlen A. Thomas Szasz obituary. The Guardian 4 Oct 2012.
3. Szasz TS. The psychiatric protection order for the “battered mental patient.” British Medical Journal 2003;327(7429):1449-51.
4. Szasz TS. Psychiatry and the control of dangerousness: on the apotropaic function of the term “mental illness.” J Med Ethics 2003;29:227-230.
5. Szasz TS. The second sin. Garden City, NY: Doubleday, 1973, 128.
6. Szasz, TS. Moral conflict and psychiatry. Yale Rev 1960; 49:555-566.
7. Szasz, TS. Psychiatric justice. New York: Macmillan, 1965.
8. Szasz TS. The myth of mental illness. New York: HarperCollins, 1974 (first published 1961).
9. Szasz TS. Law, Liberty and Psychiatry. New York: Macmillan, 1963.
10. Sandford JJ. Public health psychiatry and crime prevention [letter]. BMJ 1999;318:1354.
11. Summerfield D. Public health psychiatry and crime prevention. BMJ 2001;322:95.
12. Summerfield D. The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. BMJ 2001;322:95.
13. Porter R. A social history of madness: Stories of the insane. London: Weidenfeld & Nicolson, 1987, introduction, 1.