Curing the Therapeutic State: Thomas Szasz interviewed by Jacob Sullum

Thomas Szasz on the medicalization of American life.

Simply having one of Thomas Szasz's books on your shelf can lead to an argument. Explaining his most familiar contention--that there is, strictly speaking, no such thing as "mental illness"--almost invariably does. And the very mention of his name has been known to provoke a heated response from certain people. I once asked a psychiatrist I knew if he was familiar with Szasz's work. "Oh, he's crazy!" he exclaimed, inadvertently illustrating Szasz's point that such labels are often used to stigmatize people who offend or disturb us.

I don't think this psychiatrist was ready to have Szasz committed; he was expressing an intellectual rather than a clinical judgment. But Szasz's critique of psychiatry suggests that such distinctions are ultimately arbitrary. A psychiatrist could, if he were so inclined, diagnose as mentally ill someone with whose worldview he disagreed--which is essentially what it means to say that a person is "suffering from delusions." If the psychiatrist could make a case that the "patient" might harm himself or others (a prediction that many psychiatrists privately concede they are ill-equipped to make), he could have him confined and forcibly "treated."

In Szasz's view, this should not be possible. For decades, what he calls his "passion against coercion" has driven him to denounce involuntary mental hospitalization, while his insistence on individual responsibility has made him a dedicated opponent of the insanity defense. If someone commits a crime, Szasz says, he should be punished, not "treated." But if he has not violated anyone's rights, he should be left alone, no matter how bizarre his behavior.

As unpopular as such ideas are now, they were even more heretical when Szasz started to express them in the late 1950s. Born in Budapest in 1920, he immigrated to the United States in 1938 and attended the University of Cincinnati, where he majored in physics as an undergraduate and earned an M.D. in 1944. After a residency in psychiatry, he underwent psychoanalytic training at the Chicago Institute for Psychoanalysis, where he remained as a staff member for five years. In 1956 he took a position as a professor of psychiatry at the State University of New York in Syracuse, where he is now a professor emeritus. Shortly thereafter, he began to publish articles that questioned the basic premises of his profession, work that would lead to his classic The Myth of Mental Illness in 1961.

"I became interested in writing this book approximately ten years ago," he wrote in the preface, "when I became increasingly impressed by the vague, capricious, and generally unsatisfactory character of the widely used concept of mental illness and its corollaries, diagnosis, prognosis, and treatment. It seemed to me that although the notion of mental illness made good historical sense--stemming as it does from the historical identity of medicine and psychiatry--it made no rational sense." Szasz's bold attack on a concept that most people took for granted (and still do), bolstered by the efforts of civil libertarians and other social critics, encouraged skepticism about the justification for coercive psychiatry. That uneasiness led to legal reforms in the 1960s and '70s that made it harder to lock up people deemed to be crazy.

"Mental illness is a myth whose function is to disguise and thus render more palatable the bitter pill of moral conflicts in human relations," Szasz wrote in "The Myth of Mental Illness," a paper that appeared in American Psychologist the year before his book of the same name was published. "In asserting that there is no such thing as mental illness, I do not deny that people have problems coping with life and each other." Likewise, Szasz has never denied that organic conditions--say, Alzheimer's disease or untreated syphilis--can have an impact on thought and behavior. But he insists on evidence of an underlying physical defect, and he emphasizes that behavior itself is never a disease. "Classifying thoughts, feelings, and behaviors as diseases is a logical and semantic error, like classifying the whale as a fish," he writes on his Web site (www.szasz.com).

This error has serious consequences, Szasz argues: "The classification of (mis)behavior as illness provides an ideological justification for state-sponsored social control." As he put it in his 1990 book The Untamed Tongue, "What people nowadays call mental illness, especially in a legal context, is not a fact, but a strategy; not a condition, but a policy; in short it is not a disease that the alleged patient has, but a decision which those who call him mentally ill make about how to act toward him, whether he likes it or not."

The collaboration between government and psychiatry results in what Szasz calls the "therapeutic state," a system in which disapproved thoughts, emotions, and actions are repressed ("cured") through pseudomedical interventions. Thus illegal drug use, smoking, overeating, gambling, shoplifting, sexual promiscuity, pederasty, rambunctiousness, shyness, anxiety, unhappiness, racial bigotry, unconventional religious beliefs, and suicide are all considered diseases or symptoms of diseases--things that happen to people against their will. Szasz believes this sort of thinking undermines individual responsibility and invites coercive paternalism. A prime example is drug prohibition, an area where his work--especially his penetrating 1974 polemic Ceremonial Chemistry: The Ritual Persecution of Drugs, Addicts, and Pushers--has had an important influence.

As Szasz marks his 80th birthday this year, the misuse of the medical model and the literalization of the disease metaphor are rampant. But skeptical voices, often those of Szasz admirers, can be heard on issues such as criminal responsibility, the nature of addiction, and the reality of the mental disorder du jour. Szasz himself continues to drive home the dangers of surrendering our autonomy to physicians acting as agents of the state. Last year he published Fatal Freedom: The Ethics and Politics of Suicide (Praeger), in which he warns that "relying on physicians to prevent suicide, prescribe suicide, and provide suicide...is an evasion fatal to freedom." When I interviewed him by telephone in February, he was completing a book on the evolution of the therapeutic state. After that, he said, he'd like to write "a history of psychiatric misdeeds, from its beginning to the present."

Szasz, a REASON contributing editor whose work has also appeared in publications ranging from The Lancet to Playboy, has produced some 700 articles and two dozen books, including Law, Liberty, and Psychiatry (1963), The Ethics of Psychoanalysis (1965), The Manufacture of Madness (1970), The Myth of Psychotherapy (1976), The Therapeutic State (1984), and Our Right to Drugs (1992). Asked if he was working on a new book, he said, "What else can I do?" Asked if he had plans for another one after that, he said, "Always."

Reason: You've said that true brain diseases are the province of neurologists, not psychiatrists. I gather that what people call mental illness, which you understand as problems in living, would be something for psychotherapists to handle. Do psychiatrists have any legitimate role as physicians who specialize in psychological problems?

Thomas Szasz: That entirely depends on what sort of arrangement society allows and the economic system permits. There is no reason why physicians should be prevented from talking to people.

Reason: Do you see any benefit from having an M.D. in doing that sort of work?

Szasz: Yes, but not as a requirement. There are two aspects of life without which it's very difficult to [manage], and those are medicine and law. Knowing how the body works is beneficial for anyone. That could help you as a therapist because there are all kinds of personal complaints, and people who come to you may very well also be sick. [A knowledge of medicine] helps you in the same sense that it helps if you are familiar with law, because people are entangled in all kinds of legal problems too.

Reason: How would you describe your approach to therapy?

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    To me Dr Szasz is the most humanitarian person on this planet. I hope there are many like him everywhere but who are not expressing their views as well or at this time. To Dr Szasz: Thank you for your wonderful books as they will live on to perpetuate your exquiste understanding of the human conditions. I am nearing my 80's so will wish us both many more years to enjoy the time of our lives. Warm Regards Always.

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