Curing the Therapeutic State: Thomas Szasz interviewed by Jacob Sullum

Thomas Szasz on the medicalization of American life.

Jacob Sullum from the July 2000 issue

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Szasz: I see psychoanalysis as a contractual conversation about a person's problems and how to resolve them. I tried to avoid the idea, which seemed to be particularly pernicious, that the therapist knows more about the patient than the patient himself. That seems to me so offensive. How can you know more about a person after seeing him a few hours, a few days, or even a few months, than he knows about himself? He has known himself a lot longer!

To me the whole idea of calling it "therapy" is crippling. So there was a kind of understanding between the other person and me that we were having a conversation about what he could do with his life. That obviously involves adopting different tenets of sorts--different ways of relating to his wife, his children, his job. The premise was that the only person who could change the person was the person himself. My role was as a catalyst. You are making suggestions and exploring alternatives--helping the person change himself. The idea that the person remains entirely in charge of himself is a fundamental premise.

Reason: You were trained as a psychoanalyst. How have your views on Freud's theories changed over the years?

Szasz: Freud had a very good idea which was very quickly abused. Bertrand Russell said that Christianity is a wonderful idea--it's too bad it's never been tried. That is my view of psychoanalysis. Freud had a wonderful idea, namely, that he was going to have a completely private, confidential, one-to-one conversation with another human being about his or her life. There's no coercion. It's entirely contractual. The patient pays. But as soon as he developed this, he sacrificed it by betraying confidentiality, by creating training analysis, by creating child analysis, and so on. It immediately became a thing where the premise was that the therapist knows more about the patient than the patient himself. There was a kind of manipulation, exploitation involved.

My feeling all along was that there was something wrong with the authoritarian, top-down stance. At the same time, I was very much impressed that this was a radical departure from "psychiatry," which was based entirely on an involuntary relationship. Traditionally, there is no such thing as a voluntary psychiatric patient. That's an oxymoron. If you are crazy, then you are locked up in a state hospital. So Freud's great departure was that, within medicine, you could go and talk about your problems and not be considered crazy, not be locked up.

Reason: In the 1960s people like R.D. Laing and Michel Foucault agreed with you that psychiatry was a form of social control, a way of stigmatizing and punishing unwanted behavior in the guise of therapy. Both of them identified themselves as men of the left, whereas you allied yourself with classical liberalism. What would you say are the basic differences between their views on psychiatry and yours, and how are those related to political ideology?

Szasz: Although we agreed on the criticism of traditional psychiatry, they somehow never made it clear that bodily diseases--pneumonia, cancer, and so on--are real, but mental diseases are metaphoric diseases, in the sense of a "sick" joke. They are problems, but they are not medical problems in that they do not involve somatic, organic etiologies and are not amenable to a somatic, organic resolution. They are essentially conflicts within oneself and conflicts between oneself and other people. So that would be the first distinction.

Secondly, Laing in particular was completely inattentive to the legal aspects, so he never really distinguished between involuntary and voluntary psychiatry. Here my classical liberal convictions are crucial, in that I firmly believe that there should be no interference in voluntary relationships between psychiatrists and patients. If the patient wants a drug, fine. If the patient wants electric shock, fine. If the patient wants a lobotomy, fine. Now that doesn't mean that I like it, any more than I would if the patient wants to have an abortion just because it's inconvenient to have a baby. I don't think that's a good idea either. But I don't think the law should interfere with it.

By contrast, with involuntary psychiatry, under no circumstances do I consider it permissible. Neither Laing nor Foucault made this clear. They offered a kind of a blanket condemnation of psychiatry which smacked of a socialist, left-wing indictment of capitalism. [In their view,] the whole thing is no good. Of course, in some ways the whole thing is no good, in that it's misconceptualized, but so is religion if you don't believe in religion. Yet you don't want to forbid it or interfere with it.

Reason: Since The Myth of Mental Illness appeared, it seems that more and more areas of life have been medicalized. But at the same time it seems that people are more willing to question the authority of psychiatrists and of physicians in general. On balance, do you think psychiatrists and physicians have more or less power than they used to?

Szasz: I think they have much, much more power, but it has become increasingly covert and subtle. If you focus on psychiatrists per se, then perhaps they have a little less power, but the power has been diffused among "mental health professionals": school psychologists, grief counselors, drug treatment specialists, and so on. It pervades society. Sixty years ago, when I went to medical school, this kind of activity was limited entirely to psychiatrists.

So traditional psychiatrists may have less power. They certainly don't have the feudal slave estates of the old state hospitals, where the patients were washing their cars. That's gone. On the other hand, there is a Tocquevillean kind of oppression--a softer kind of totalitarianism.

Reason: In some respects people do seem to be more skeptical than they used to be of psychiatry's attempts to medicalize behavior. Psychiatrists themselves often acknowledge that the Diagnostic and Statistical Manual of Mental Disorders is increasingly arbitrary and unscientific. It also seems that the use of the term disorder, as opposed to disease or illness, is designed to fudge the question of whether these conditions have a biological basis. Meanwhile, journalists are increasingly alert to controversies over what constitutes a bona fide disorder, as in the case of "multiple personality disorder," which has fallen into disrepute. Is this skepticism just temporary?

Szasz: Without seeming excessively pessimistic, my view is that this whole development subtly reinforces the basic error and the basic authority of psychiatry. People are saying that, of course, multiple personality disorder and social phobia are excesses, but schizophrenia, depression, and so on are real diseases and therefore justify involuntary hospitalization, outpatient commitment, wholesale drugging of children, of people in nursing homes, and so on.

I have always challenged the "psychoses." Why don't you have a right to say you are Jesus? And why isn't the proper response to that "congratulations"?