Head Games

What are the rules for defining mental illness?

Jacob Sullum from the January 2003 issue

Pharmacracy: Medicine and Politics in America, by Thomas Szasz, Westport, Conn.: Praeger, 212 pages, $24.95

Creating Mental Illness, by Allan V. Horwitz, Chicago: University of Chicago Press, 289 pages, $32.50

I've never met Zacarias Moussaoui, but I have a feeling we would not get along. At a hearing in Alexandria, Virginia, last spring, the accused terrorist said he prayed for "the destruction of the United States of America" and "the destruction of the Jewish people and state." He also had harsh words for Russia. As an American Jew descended from Russian immigrants who has close relatives in Israel, I've got four strikes against me.

Moussaoui not only hates total strangers; he is not exactly gracious toward people who try to help him either. He denounced his court-appointed attorneys as a "blood-sucking death team" of "Jewish zealots." He accused U.S. Judge Leonie Brinkema, who patiently guided him as he struggled to represent himself, of "preparing me for the gas chamber." He refused to meet with an attorney hired by his mother, saying, "My mother has no means to find this lawyer. He has been found by someone else."

Naturally, the FBI was in on the conspiracy too. Moussaoui said the bureau had him under surveillance from the moment he entered the country in May 2001 and therefore knew he did not participate in the planning for September 11. He claimed the bureau bugged his motel room by hiding a microphone in a fan that was "mysteriously left on my car."

Based on such remarks, Moussaoui's original defense attorneys, who officially continued to serve as his advisers even though he refused to speak to them, argued that he had crossed the line between fanaticism and mental illness. They said he was therefore incompetent to represent himself, and perhaps even to stand trial. "Mr. Moussaoui's ideology appears to be interlaced with serious psychopathology, the nature of which is unclear," they told Judge Brinkema.

Two psychologists they hired speculated that "Mr. Moussaoui's decision to waive his right to counsel may be the product of a mental disease or defect rendering the decision involuntary." They cited "considerable evidence that Mr. Moussaoui's thinking is dominated by irrational and unrealistic persecutory beliefs." One of them claimed Moussaoui's behavior was "far more consistent with a paranoid psychosis than with being an extremist Muslim."

But the prosecutors had an expert of their own, a court-appointed psychiatrist who interviewed Moussaoui for two hours and concluded that he was capable of deciding for himself how to proceed with his defense. "His actions and attitudes are not the product of mental illness, but are based on his view of the world," the prosecutors said. "He is a fanatic, a jihadist, but he is not mentally incompetent to stand trial or waive his right to counsel."

Brinkema initially agreed, finding that Moussaoui was mentally competent to fire his lawyers. But later she indicated that she might reconsider that decision. She said she would allow the defense attorneys to continue looking for evidence to impugn their former client's sanity. In a handwritten motion filed after that ruling, Moussaoui tried to turn the tables on his examiners, saying Brinkema displayed "acute symptom of Islamophobia with complex gender inferiority." He recommended "immediate psychiatric hospitalization" in the "UBL Treatment Center," explaining that UBL -- the government's shorthand for "Usama Bin Laden" -- "of course...stand[s] for unique best location."

The dispute over Zacarias Moussaoui's mental health illustrates the two main dangers that Thomas Szasz has long emphasized in his criticism of psychiatry. Defining behavior as the symptom of a disease can excuse the guilty, something attorneys did in the case of John Hinckley, tried to do with Ted Kaczynski, and might have accomplished with Moussaoui if he had been more cooperative. It can also punish the innocent, since a psychiatric diagnosis may be imposed on someone against his will as a way of limiting his freedom. In Moussaoui's case, the court-appointed attorneys tried to take away his right to fire them. In other cases, someone who is not charged with a crime but who is deemed a threat to himself or others because of his mental illness may be locked up indefinitely and forcibly treated.

At the extreme, a psychiatric diagnosis may simply be a cover for suppressing dissent. An article in the Fall 1999 Journal of Asian Law describes a retired Chinese coal miner who was diagnosed with "paranoid psychosis" -- one of the labels floated in the Moussaoui case -- because of his political writings. A diehard Maoist, he criticized Deng Xiaoping's reforms and presented himself as "the leader who would guide the international communist movement during its third high tide." This case of "political lunacy" was presented in an official training manual for Chinese forensic psychiatrists published in 1994. "It was thus presumably seen as a typical illustrative case," the law journal article noted, "the concluding diagnosis being one fully appropriate for study and emulation by others in the legal-psychiatric profession today."

This does not mean that American psychiatrists routinely lock people up because they disagree with their politics. But any diagnostic system that leaves so much room for interpretation, with such serious implications for liberty, ought to be scrutinized carefully and skeptically. Even those who are convinced that some of the conditions treated by psychiatrists are genuine brain diseases should be concerned about a profession that seems bent on cataloging and curing every unpleasant or disapproved thought, emotion, and action.

Szasz, a reason contributing editor and a professor of psychiatry emeritus at the Upstate Medical University in Syracuse, has been warning us about the implications of this sweeping agenda for many years. In Pharmacracy: Medicine and Politics in America, he offers a concise summary of his views, along with observations about the government's broader involvement in health care.

"Disease reveals itself in the abnormal activity of the body, not of the person," Szasz writes. "When a lesion can be demonstrated, physicians speak of bodily illnesses. When none can be demonstrated, perhaps because none exists, but when physicians and others nevertheless want to treat the problem as a disease, they speak of mental illnesses. The term 'mental illness' is a semantic strategy for medicalizing economic, moral, personal, political, and social problems."

Rutgers sociologist Allan V. Horwitz is not nearly as strict with his terminology. He argues that "a valid mental disorder" can be a true illness even if it is not caused by a physical abnormality. But in Creating Mental Illness he nevertheless presents a devastating critique of the classification scheme embodied in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (or DSM), which he portrays as arbitrary, arrogant, and pseudoscientific. His history of how the current system came to be is illuminating and provocative. Unfortunately, the alternative he suggests has serious problems of its own, replacing faux precision with admitted vagueness and subjectivity.