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

(Page 3 of 6)

Reason: Since you criticized involuntary hospitalization in the '60s, legal reforms have changed the standards for locking people up. To what extent have those changes been in line with what you wanted to see?

Szasz: They have been diametrically opposite. This whole deinstitutionalization process was just as involuntary as the institutionalization process. First the patients were placed in the institutions against their will. Then they were kept there for a long time, and generally they became desocialized. They had no way of making a living, and their families didn't want them; they had no particular place to live. Instead of being allowed to stay in the hospital, which the majority of them probably considered their home, they were forcibly evicted and placed in other institutions run by the state but which are no longer called hospitals. So this is a huge deception. The number of people who are now maintained by the state as mental patients is probably no smaller than it used to be.

Reason: Where are they now?

Szasz: They're in so-called transitional living quarters, in group homes, in nursing homes, in prisons, on the street, maintained on Social Security. In the old days, you didn't get money for being schizophrenic. Now you get a lot of money for it. They are now maintained like pets rather than being locked up in a zoo.

Reason: The deinstitutionalization of mental patients has been criticized for putting helpless people, sometimes dangerous people, on the streets. How would you have handled it differently?

Szasz: There are two things that I would have done very differently, and they really have to do with my passion against coercion, especially unnecessary coercion and especially coercion outside of a due-process legal system. The first thing I would have done is to stop all further involuntary psychiatric interventions. This is unthinkable stuff, because this means stopping the fundamental social function of psychiatry, which is partly to relieve society, families, physicians of unwanted people and partly to "prevent suicide." "Dangerousness to self": This to me is the keystone in the Roman arch. Until it is knocked out, it's impossible to destroy the edifice. People should not be protected from themselves by involuntary psychiatric interventions. Psychiatrists should play no more of a role in this than priests do.

Reason: And after involuntary psychiatry was ended, people would have been free to leave mental hospitals, but they would not have been forced to leave?

Szasz: They would have been free to leave, and they would have been free to stay. They could have simply got room and board. That option was never given to anyone. I wouldn't give that to anyone except those who have already been victimized. They should be given every chance to get out insofar as they want to get out.

By the way, this brings us back to the old, pre-war system, when there were as many as 15,000 patients in a single state hospital. Nothing was easier than escaping from these places; they were not surrounded by barbed wire. In fact, escape--"elopement"--was the standard way of being discharged from the hospital. The hospital didn't go after you. But the fact that most people didn't leave indicated that they had no place to go, and that in fact this place was not all that bad for them, especially before there was any treatment

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Reason: When a crime is committed by a homeless person who has been diagnosed as a schizophrenic, critics of deinstitutionalization say it's too hard nowadays to commit people to mental hospitals. They say the standard of dangerousness to yourself or others is too demanding. Are they right?

Szasz: No, they are not right. But this brings us back to what else I would have done: Not only would I have stopped on day one all further involuntary mental hospitalization--commitment--I also would have stopped on that same day the insanity defense. The psychiatrist simply would not be allowed in the court to give expert testimony, any more than a priest is allowed to give testimony about heaven or hell.

So I would have stopped both of these [commitment and the insanity defense], as a result of which, I think, 99 percent of the people who now commit crimes would be and should be in jail and punished, probably by long prison sentences. Because in every one of these cases we learn that the person who has committed the crime--let's say this fellow who pushed the woman under a subway train in New York--has a long record not only of mental hospitalization but of violence.

Typically, what people call severe mental illness begins with some sort of violence in the family: A 17- or 18- or 19-year-old boy attacks his mother with a kitchen knife. Well, he should go to jail for five years, right away. This is a potentially fatal attack on a person. But these things are usually swept under the rug via diagnosis. And then people wonder five years later what happened.

Reason: What about people who haven't actually committed violence but are simply behaving in a bizarre and perhaps threatening way? Last year I was walking with my wife and daughter in Manhattan, and we saw this guy in camouflage pants who was running down the street, holding a piece of concrete pipe over his head, pumping it up and down, and cursing at nobody in particular. What, if anything, can you do about someone like that?