Thomas Szasz Takes on His Critics

Is mental illness an insane idea?

Szasz Under Fire: The Psychiatric Abolitionist Faces His Critics, edited by Jeffrey A. Schaler, Chicago: Open Court, 450 pages, $36.95 paper

In 1980 Thomas Szasz testified for the prosecution in the trial of Darlin June Cromer, a 34-year-old white woman charged with kidnapping and murdering Reginald Williams, a 5-year-old black boy. There was no question that Cromer, who attracted suspicion because she had a history of talking about "killing niggers" and trying to lure black children into her car, had abducted Reginald from an Oakland, California, supermarket, strangled him, and buried his body near her home. She had told police as much when they questioned her. Neither was her motive in doubt. She explained that "it is the duty of every white woman to kill a nigger child," telling a jail psychologist she hoped to ignite a race war.

But as the San Francisco Chronicle reported, Cromer's attorney argued that "his client killed because she is consumed by schizophrenic paranoia --not hate for blacks." Or as the lawyer put it, "This case does not involve racism; it involves insanity." To help undermine this claim, the prosecutor enlisted the assistance of Szasz, the iconoclastic psychiatrist famous for rejecting the insanity defense, involuntary commitment, and the very concept of mental illness. At the trial, Szasz explained the difference between a medical diagnosis and a psychiatric diagnosis: "Medical diagnoses deal with objective and demonstrable lesions of the body, broken bones, diseased livers, kidneys, and so on. Psychiatric diagnoses deal with behaviors that human beings display, and they have to be interpreted in moral, cultural, and legal terms and, therefore, different interpreters will arrive at different judgments." He pointed out that "homosexuality was recognized as a mental disease until a few years ago" and that smoking, previously considered a habit, had recently been classified as a mental disorder.

Asked "what [Cromer] was suffering from, if anything," on the day of the murder, Szasz offered the following opinion based on her records: "She was suffering from the consequences of having lived a life very badly, very stupidly, very evilly....From the time of her teens, for reasons which I don't know...whatever she [has] done, she has done very badly. She was a bad student....She was a bad wife. She was a bad mother. She was a bad employee insofar as she was employable. Then she started to engage [in taking] illegal drugs, then she escalated to illegal assault, and finally she committed this murder....Life is a task. You either cope with it or it gets you....If you do not know how to build, you can always destroy."

Szasz did not really try to explain why Cromer killed Reginald. Indeed, the main strength of his testimony was his acknowledgment of how difficult it is to get inside the head of a criminal--or anyone else. Cromer was the way she was and did the things she did "for reasons I don't know." By contrast, the defense experts confidently asserted that her crime was caused by a mental illness.

In Szasz Under Fire, a new collection of exchanges with his critics, Szasz, a Reason contributing editor and an emeritus professor of psychiatry at the SUNY Upstate Medical University in Syracuse, explains why, unlike the defense experts, he did not conduct a "psychiatric examination" of Cromer. "I regard the practice as the epitome of junk science and refuse to participate in it," he writes. Not only is there "no objective test for mental illness," but psychiatrists are supposed to determine a defendant's state of mind at the time of the crime by talking to him many months later, a pretense Szasz considers "prima facie absurd." This was one of the main points he made in his testimony, which was condemned by psychiatrists outraged that he had dared to question the premises of their profession. The jurors, who convicted Cromer, apparently agreed with Szasz about the reliability of psychiatric testimony.

As illustrated by the case of Andrea Yates, whose 2002 conviction for drowning her children was recently overturned because of false testimony that may have undermined her insanity defense, the questions raised at Cromer's trial are as relevant today as they were a quarter century ago. Do some people have mental impairments, either temporary or permanent, that prevent them from controlling their behavior? If so, how can such people be identified, and how should they be treated?

Although insanity pleas are offered in only about 1 percent of criminal cases and are usually unsuccessful, they have played a role in a number of sensational trials, including those of would-be presidential assassin John Hinckley and D.C. sniper Lee Boyd Malvo. Furthermore, issues of mental impairment are important not just in cases where defendants offer insanity pleas but in every context where there is potential for psychiatric coercion, including legally mandated addiction treatment and civil commitment of people deemed a threat to themselves or others. Each year in the United States more than 1 million people are committed to mental hospitals; some two-thirds of these commitments are officially voluntary, but that status can change once a "patient" tries to get out. Since mental illness is a widely accepted rationale for both relieving people of responsibility and depriving them of liberty--the twin dangers to which Szasz has been alerting us for more than four decades--the psychiatric is unavoidably political.

Szasz Under Fire, edited by the Szaszian psychologist Jeffrey Schaler, appropriately focuses on this theme. Szasz's debating partners include psychiatrists, psychologists, bioethicists, and legal scholars, most of whom seem to have reservations about psychiatry's tendency to treat every facet of human behavior--happiness and sadness, energy and lethargy, neatness and sloppiness, shyness and boldness, inattentiveness and obsessiveness, thievery and honesty, promiscuity and celibacy, thinness and fatness--as a symptom of mental illness. At the same time, they ostensibly part company with Szasz when it comes to "severe" mental illnesses, which are usually said to include schizophrenia, bipolar (manic-depressive) disorder, and major depression. I say "ostensibly" because the contributors to Szasz Under Fire generally seem to believe that schizophrenia and a few other disorders that psychiatrists diagnose are in fact brain diseases, which would mean they are not "mental illnesses," any more than a brain tumor or Huntington's disease is.

"I struggle with ambivalence about [Szasz]," confesses E. James Lieberman, a professor of psychiatry at the George Washington University School of Medicine. "He's on the right track, but he goes too far and too straight." This book mainly deals with the ways in which Szasz's critics think he "goes too far," and in doing so it illuminates vital questions about the nexus between psychiatry and the law.

Discussions of Szasz's ideas tend to begin with his insistence that mental illness is, strictly speaking, a contradiction in terms, a literalized metaphor that confuses more than it clarifies. Not surprisingly, much of Szasz Under Fire continues the conceptual and semantic battles provoked by Szasz's 1961 classic The Myth of Mental Illness. His critics offer various alternatives to the Szaszian perspective, which insists upon an objectively measurable bodily defect as the sine qua non of a true disease. Among other things, they argue that some so-called mental illnesses are genuine brain diseases, although their precise etiologies have not been figured out yet; that if mental illness is a myth, so is physical illness, because both categories have fuzzy boundaries and are to a large extent culturally determined; that viewing mental illness as a myth is a fiction that is necessary to maintain the integrity of psychotherapy as a moral enterprise; and that the distinction between mental and physical disease is misleading, since (as the American Psychiatric Association puts it) "there is much that is 'physical' in mental disorders and much 'mental' in 'physical' disorders."

This book is the first in an Open Court series featuring debates between important thinkers and their critics, and Szasz should be commended for responding directly and at length to people who disagree with him, given how easy it is for a writer of his stature to retreat to an echo chamber populated by loyal followers. He sticks to his guns and scores many points, but his responses are not always completely satisfying. That's a shame, because many readers will look to this book for an introduction to his ideas and may be put off by the questions he neglects or only partially answers.

Consider Szasz's response to the late Robert E. Kendell, former president of the U.K.'s Royal College of Psychiatrists. Kendell writes that "it is impossible to identify any characteristic feature of either the symptomatology or the etiology of so-called mental illnesses which consistently distinguishes them from physical illnesses." This assertion seems to go to the heart of Szasz's insistence that mental illnesses are not real diseases. But rather than refute it, he replies, "This is true, but not enough." Enough for what isn't exactly clear. Szasz then cites three distinctions between physical and mental illness that are generally valid but do not hold in every case: 1) "Typically, physical illnesses are identified by observing the patient's body," while "typically, mental illnesses are identified by observing the patient's verbal pronouncements." 2) There are "objective, physical-chemical markers" to ascertain whether someone has a particular brain disease but "no such markers" to ascertain whether he has a particular mental illness. 3) "The typical medical patient" is treated only with his informed consent, while "the typical mental patient" is treated without his consent.

Although that last claim does not apply to the millions of Americans who voluntarily seek antidepressants or psychotherapy as a way of improving their lives, it arguably describes hospitalized mental patients, keeping in mind the blurry line between voluntary and involuntary commitment. The combination of subjective diagnosis and involuntary treatment poses obvious dangers. As Szasz says, "There is no way that someone can disprove the 'diagnosis' that he 'suffers' from schizophrenia." Still, the hallmarks of true disease that Szasz mentions do not always apply. In his contribution to Szasz Under Fire, Ronald Pies, a professor of psychiatry at the Tufts University School of Medicine, cites migraine headaches as an example of a physical condition that is diagnosed based entirely on "the patient's verbal pronouncements" (complaints of pain, nausea, light flashes, etc.). Then again, migraine sufferers are not treated against their will.

Amid all this terminological disputation, it is important, though not always easy, to keep in mind the real-world consequences of these ideas. Defenders of psychiatry can be remarkably blithe about those consequences. The American University sociologist Rita Simon, co-author of a book on the insanity defense, uses barely two pages of Szasz Under Fire to defend the practice, which she does simply by asserting that "a few individuals," because of "a mental disability or disease," lack "the minimal capacity for rational and voluntary choices on which the law's expectation of responsibility is predicated." She leaves unexamined the question of how the legal system should determine whether it is confronting such an individual. At the end of her very brief essay, she offers more cause for doubt by approvingly quoting legal scholar Alan Stone's statement that the insanity defense "purports to draw a line between those who are morally responsible and those who are not, those who are blameworthy and those who are not, those who have free will and those who do not." As Szasz notes in his reply, purport usually suggests a pretense of some sort.

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