Thomas Szasz Takes on HisCritics

Is mental illness an insane idea?

Jacob Sullum from the May 2005 issue

(Page 2 of 3)

In any event, how should a court decide whether someone like Darlin June Cromer is a paranoid schizophrenic or merely a racist murderer? And if it decides she is a schizophrenic, is that diagnosis enough to show that she should not be held responsible for strangling a 5-year-old-boy? In theory, the jury in her case could have decided that she was a schizophrenic but still responsible for her actions, since the legal definition of insanity--which generally requires that the defendant either did not know what he was doing, did not know it was wrong, or could not stop himself--is not the same as the criteria for a psychiatric diagnosis. Cromer's repeated attempts to kidnap black children, her explanation of her motive, and the fact that she tried to hide the body all suggest she knew what she was doing, which presumably helps explain why the jury found her guilty. But the defense argued that her appalling actions and statements all were symptoms of her disease--indeed, that they were so appalling they had to be. "If she isn't crazy," one of the expert witnesses asked, "who is?"

Similarly, Lieberman complains in his essay that, when it comes to individual responsibility, Szasz "makes no exception for a woman who drowns her five children." This reference to Andrea Yates implies that the nature of her act proves she was not responsible for it--a standard that would give a pass precisely to those guilty of the most horrendous crimes.

Still, surely there are people who commit what would ordinarily be considered crimes when they are mentally incapacitated: a sleepwalker who assaults a stranger while acting out a dream, say, or a Huntington's patient who throws a dish at his caretaker. Szasz's reply to Simon would have been stronger if he had explained how such cases should be handled. And if some people diagnosed as schizophrenics do in fact suffer from an incapacitating brain disease--a possibility Szasz concedes --presumably they too should be held less culpable than people in full possession of their faculties.

But as Szasz notes, if psychiatrists were interested merely in identifying and treating the brain diseases underlying certain forms of insanity, their field ultimately would be swallowed by neurology. Their agenda is far more ambitious than that, as illustrated by their attachment to the calculatedly ambiguous term mental disorder, which the American Psychiatric Association continues to use even while complaining that it "unfortunately implies a distinction between 'mental' disorders and 'physical' disorders that is a reductionistic anachronism of mind/body dualism." Given the sweep of the APA's Diagnostic and Statistical Manual of Mental Disorders (DSM), which takes in misbehavior ranging from rudeness to murder, it's fair to read this caveat to mean that anything bad people think, feel, say, or do can be interpreted as a symptom of a disease. In practice, psychiatrists often distinguish between "severe" disorders thought to have a physiological basis and the myriad sins, foibles, bad habits, and eccentricities cataloged by the DSM. But their training, terminology, diagnostic framework, and billing practices imply that all these are medical problems appropriately handled by physicians. As Kendell notes, "the inexorable expansion of the concept of mental illness" despite a "fragile empirical basis" leaves psychiatrists "vulnerable to accusations of unjustified medicalization of deviant behavior and the vicissitudes of daily life."

The DSM's broad scope is consistent with a perspective that sees brain defects at the root of all misbehavior and psychological problems. According to this view, the contents of the mind are determined by the structure of the brain; that structure, in turn, is shaped by genetics and experience. When something goes seriously wrong with either or both, the result is a disorder that is just as rooted in biology as a so-called physical disease. In this light, it makes perfect sense for Harvard psychiatrist Alvin Pouissant to argue that "extreme racism" should be considered a mental illness. So far the APA has rejected this suggestion, which would render racist murderers like Darlin June Cromer insane by definition and open the door to psychiatric treatment of unconventional opinions, � la Soviet Russia and Communist China. On the brighter side, the equation of broadly defined mental disorders with physical illness has the potential to let everyone--not just the Darlin June Cromers of the world--off the hook (although the legal system might continue to punish for the sake of deterrence, as opposed to justice). If we consistently apply the assumption that bad behavior is caused by defective brains, the question is not whether a particular murderer has a brain disease but whether there can be such a thing as a murderer who doesn't.

The breadth of the territory claimed by psychiatry would not be nearly as troubling if it were not so often settled by force. In addition to peering backward in time to determine a defendant's state of mind when he committed his crime, psychiatrists are expected to predict the future, assessing whether a given individual is likely to harm himself or others. Based on that judgment, innocent people can be forcibly "treated" and deprived of their liberty indefinitely. As with the insanity defense, defenders of psychiatry tend to minimize both the frequency of civil commitment and the importance of the psychiatrist's role in it.

Lieberman, for instance, casually remarks that "one rarely hears of someone being committed involuntarily to a mental hospital." Szasz rightly calls this an "astounding assertion," citing an estimate from the 1996 book Mental Health and Law that "each year in the United States well over one million persons are civilly committed to hospitals for psychiatric treatment." The book adds that "it is difficult to completely separate discussions of voluntary and involuntary commitment because voluntary status can be converted efficiently to involuntary status, once the patient has requested release."

Given their defense of involuntary treatment as not only justified but morally mandatory, psychiatrists seem weirdly reluctant to acknowledge their role in it. Pies approvingly cites a passage from Robert Simon's Psychiatry and Law for Clinicians that says "mental health professionals must understand that it is not they who make commitment decisions about patients. Commitment is a judicial decision that is made by the court or by a mental health commission. The clinician files a petition or medical certification that initiates the process of involuntary hospitalization." A prosecutor might with equal plausibility deny that he is the one who puts a defendant away for life; after all, it's the jury that convicts and the judge who imposes the sentence. True enough as far as it goes, but the prosecutor plays a crucial role. The same is true of the psychiatrist who "initiates the process of involuntary hospitalization"--even more so, since people who are committed do not receive the same protections as criminal defendants. "How do judge and mental patient meet?" Szasz asks. "The psychiatrist introduces them to one another. How does the judge know whom to commit? The psychiatrist tells him."

To get a sense of why psychiatrists might want to disclaim responsibility for civil commitment, consider the case of Rodney Yoder, an Illinois man whose cause Szasz has championed. Yoder, who completed a prison sentence for assaulting his ex-wife in 1991, has been locked in a mental hospital ever since, based on a series of dubious and contradictory diagnoses. To judge by a 2002 report in Time and other press accounts, Yoder's "illness" boils down to an abrasive personality that rubbed the wrong people the wrong way. Ostensibly, he is kept behind bars because he represents an intolerable threat to the public, even though a psychiatrist who examined him in prison said he wasn't a danger and did not meet the standard for involuntary hospitalization. In a 2001 letter about Yoder to then�Illinois Gov. George Ryan, the psychiatrist Loren Mosher said "the state is practicing preventive detention in the guise of mental-health 'treatment.'"

As Szasz notes, in 1997 the U.S. Supreme Court endorsed such detention for sex offenders who have completed their sentences but who, because of a "mental abnormality" or "personality disorder," are deemed likely to commit new crimes. These offenders, who are confined indefinitely in mental hospitals after serving their time, are considered sane enough to be convicted and punished but not sane enough to be released. Given the plethora of mental abnormalities and personality disorders identified by psychiatrists, this practice could be extended to many other criminals--for example, those suffering from antisocial personality disorder, "a pervasive pattern of disregard for and violation of the rights of others." The Bureau of Justice Statistics estimates that 16 percent of prison and jail inmates are mentally ill, and that includes only those who "reported either a mental condition or an overnight stay in a mental hospital."

Civil commitment does not require dangerousness to others; dangerousness to oneself will do. A diagnosis of schizophrenia, which is said to afflict about 1 percent of the population, is much more likely to result in hospitalization (or, as Szasz would say, imprisonment) than is a diagnosis of, say, major depression: Data from the Substance Abuse and Mental Health Services Administration indicate that in 1997 schizophrenia accounted for more than a quarter of in-patient psychiatric admissions of people with "serious functional impairment," compared to 38 percent for affective disorders and 12 percent for substance-related disorders--both of which, according to the DSM, are far more common than schizophrenia in the general population. Still, the rationale for most of these admissions presumably is the patient's own welfare, as opposed to public safety. And since psychiatric diagnoses, unlike the typical medical diagnosis, generally imply that the "patient" either does not properly understand his own interests or is not capable of acting on them, the threat of involuntary treatment always hangs in the background.

Although Szasz emphasizes the contrast with medicine proper, which usually is predicated on the patient's consent, there are exceptions based on competence: Children, the severely retarded, and patients in the advanced stages of Alzheimer's do not make their own medical decisions. In North Dakota, the children of former federal judge Bruce Van Sickle, who has Alzheimer's, are engaged in a legal battle over whether he should remain in a nursing home. One of his sons says Van Sickle wants to go home, while his other three children say he is too far gone to know what he wants. Elsewhere Szasz has acknowledged the need for a legal process to determine competence in such cases. Some discussion of that issue would have been appropriate in response to Pies' hypothetical question regarding an elderly man who begins to behave strangely after falling and hitting his head. If involuntary treatment can be justified in such a case, can't it also be justified for a schizophrenic? Szasz's failure to address that question leaves him open to the charge of dodging an important issue. I think he would have to say that the two cases should be handled in a similar way--provided the schizophrenic's brain injury can be demonstrated as readily as the old man's.

But as Richard Bentall, a psychologist at the University of Manchester, shows in his contribution to this volume, the science regarding the etiology of schizophrenia is not nearly as clear as psychiatrists often imply. Bentall points to several weaknesses in the leading theory, which holds that schizophrenia is caused by an excess of the neurotransmitter dopamine. He notes that antipsychotic drugs that block dopamine receptors within hours do not affect behavior for weeks; that some drugs considered effective in treating schizophrenia do not zero in on dopamine receptors; and that antipsychotic drugs do not work for all schizophrenics but may work for people with different diagnoses. Perhaps most important, "an expensive and sustained search for dopamine abnormalities in schizophrenia patients has so far drawn a blank." Kendell likewise concedes that "in schizophrenia a structural abnormality can only be demonstrated in populations, not in all or even most individuals." By comparison, while the etiology of Alzheimer's disease remains murky and its initial diagnosis depends partly on behavior (along with brain scans and cognitive tests), the diagnosis can be confirmed in autopsies by the presence of brain plaques and tangles. The postmortem evidence, which confirms the initial diagnosis about 85 percent of the time, gives physicians confidence that they are looking at a discrete condition with a common physiological cause.

To a large extent, then, the issue of involuntary treatment comes down to a question of where the burden of proof should lie and how heavy it should be. Even those who are skeptical of psychiatric pretensions cannot easily dismiss Pies' invocation of "the young man, rocking back and forth in a pool of his own urine, responding to voices from 'a CIA computer' that are instructing him to kill himself." If such a person is indeed suffering from an incapacitating brain disease, it should be possible to allow his family to make treatment decisions on his behalf. At the same time, anyone who cares about liberty has to hesitate before imposing treatment on someone who insists he does not want it.

The psychiatrist E. Fuller Torrey, once a Szasz admirer, is now one of his most vocal critics, having concluded that "schizophrenia is a disease of the brain in the same sense that Parkinson's disease and multiple sclerosis are diseases of the brain." Yet Torrey, a prominent advocate of involuntary psychiatric treatment, concedes "there is no single abnormality in brain structure or function that is pathognomonic for schizophrenia" and therefore "we do not yet have a specific diagnostic test."