The Man Versus the Therapeutic State

Thomas Szasz's courageous defense of freedom and responsibility

The New York Times obituary for Thomas Szasz, who died this month at the age of 92, says his critique of psychiatry "had some merit in the 1950s…but not later on, when the field began developing more scientific approaches." That's a paraphrase of historian Edward Shorter, whose judgment reflects the conventional wisdom: Szasz called much-needed attention to psychiatric abuses early in his career but went too far by insisting on a fundamental distinction between actual, biological diseases and metaphorical diseases of the mind.

In fact, however, Szasz's radicalism, which he combined with a sharp wit, a keen eye for obfuscating rhetoric, and an uncompromising dedication to individual freedom and responsibility, was one of his greatest strengths. Beginning with The Myth of Mental Illness in 1961 and continuing through 35 more books and hundreds of articles, the maverick psychiatrist, driven by a "passion against coercion," zeroed in on the foundational fallacies underlying all manner of medicalized tyranny.

The idea that psychiatry became scientifically rigorous soon after Szasz first likened it to alchemy and astrology is hard to take seriously. After all, it was not until 1973 that the American Psychiatric Association (APA) stopped calling homosexuality a mental disorder.

More often, psychiatry has expanded its domain. Today it encompasses myriad sins and foibles, including smoking, overeating, gambling, shoplifting, sexual promiscuity, pederasty, rambunctiousness, inattentiveness, social awkwardness, anxiety, sadness, and political extremism. If it can be described, it can be diagnosed, but only if the APA says so. Asperger's, for instance, will cease to exist when the fifth edition of the APA's Diagnostic and Statistical Manual of Mental Disorders (DSM) comes out next year.

As Marcia Angell, former editor of The New England Journal of Medicine, observed last year in The New York Review of Books, "there are no objective signs or tests for mental illness—no lab data or MRI findings—and the boundaries between normal and abnormal are often unclear. That makes it possible to expand diagnostic boundaries or even create new diagnoses in ways that would be impossible, say, in a field like cardiology." In other words, mental illnesses are whatever psychiatrists say they are. 

How "scientific" is that? Not very. In a 2010 Wired interview, Allen Frances, lead editor of the current DSM, despaired that defining mental disorders is "bullshit." In an online debate last month, he declared that "mental disorders most certainly are not diseases."

Then what exactly are they? For more than half a century, Szasz stubbornly highlighted the hazards of joining such a fuzzy, subjective concept with the force of law through involuntary treatment, the insanity defense, and other psychiatrically informed policies.

Consider "sexually violent predators," who are convicted and imprisoned based on the premise that they could have restrained themselves but failed to do so, then committed to mental hospitals after completing their sentences based on the premise that they suffer from irresistible urges and therefore pose an intolerable threat to public safety. From a Szaszian perspective, this incoherent theory is a cover for what is really going on: the retroactive enhancement of duly imposed sentences by politicians who decided certain criminals were getting off too lightly—a policy so plainly contrary to due process and the rule of law that it had to be dressed up in quasi-medical, pseudoscientific justifications.

Szasz specialized in puncturing such pretensions. He relentlessly attacked the "therapeutic state," the unhealthy alliance of medicine and government that blesses all sorts of unjustified limits on liberty, ranging from the mandatory prescription system to laws against suicide. My own work has been powerfully influenced by Szasz's arguments against drug prohibition, especially his discussion of its symbolism and its reliance on a mistaken understanding of addiction, and his criticism of paternalistic interventions, such as New York Mayor Michael Bloomberg's recently approved soda serving ceiling, that conflate private and public health.

I will always be grateful for Szasz's courage and insight, and so should anyone who shares his passion against coercion.

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  • RBS||

    It's only a matter of time...

  • Hneckone||

    I've never heard of Szasz until this article. I'm looking forward to reading Sullum's book "For your own good: the tyranny of public health" and Szasz's books "Ceremonial Chemistry; the ritual persecution of drugs, addicts and pushers" and "Our right to drugs: the case for a free market". Thanks for the info Jacob.
    I wish our politicans would be rational about drug prohibition! Why can't they apply the same lessons learned from alcohol prohibition?

  • The Derider||

    Asperger's, for instance, will cease to exist when the fifth edition of the APA's Diagnostic and Statistical Manual of Mental Disorders (DSM) comes out next year.

    No, asperger's will be "subsumed by autism spectrum disorder".

    You can't even quote yourself accurately!

  • ||

    I dunno, but it seems to me that it is perfectly correct to say that "Asperger's, for instance, will cease to exist" when it won't be mentioned in the next DSM, no matter what category it is "subsumed by".

  • The Derider||

    Asperger's is already part of the autism spectrum, they're just calling everything on the autism spectrum "autism spectrum disorder" instead of differentiating between Asperger's, Pervasive Developmental Disorder, and Autism.

  • ||

    Have mistakes been made in diagosis some people? Of course they have! Have mistakes been made in treatments? Of course they have! But to claim that mental illness is a fiction is idiotic.

    It is also harmful. Look at a lot of the homeless who walk around, unbathed, smelling of urine, incoherent, and being victimized by thugs. They are the victims of Szasz, who insisted that people who are mentally ill should not be institutionalized.

  • Ron||

    I don't know about Szasz but the homeless are victims of the Democrats. For years they attacked Reagan claiming him to be some form of Nazi for keeping these people imprisoned in hospitals. When Reagan finally caved and said okay I'll sign your law and release them, now all we here,even to this day from the democrats is how evil Reagan was for releasing these people onto the public.

  • ||

    The laws deinstitutioanlizing mental patients predates the Reagan years by a decade. They were largely state by state issues and started with exposes of the kind of conditions that inmates in state hospital were subjected to.

    Since these changes were accopanied by the discovery of new treatments along with shutting down the ibnstitutions new outpatient regimes with regual and accessible treatment programs were supposed to be astablished. They weren't.

    But the biggest single contributor to homelessness were the extensive subsidies paid for "slum clearance" and "urban renewal" that resulted in the destruction of the cheap apartments, hotels and boarding houses (flophouses) that the kind of men of that era were able to afford, thus keeping a roof (however shabby) over their heads.

    The additional irony of the subsidies is that the kinds of buildings that replaced them are luxury hotels and commercial properties in shitty sections of town wher no one wants to stay or rent. They are neither able to make enough money to properly maintain themselves nor can they be made cheap enough for the "poor" to afford.

  • ||

    I was speaking of those homeless who were obviously mentally ill, who were thrown out of institutions for "benevolent" reasons, stemming to a large degree to the influence of Szasz.

    I read him during the 60s and like many others was captivated by his verbal virtuosity and his witty aphorisms. He was right on some points; on others he was full of crap.

  • Nick Stuart||

    You obviously did not understand a word you read of Szasz. He never stated that 'mental illness' is a fiction, only that behaviour that is toaday deemed a 'disease' is not actually a medical issue. He also opposed the de-institutionalisation of those in hospitals.

  • Robert||

    I'm glad you pointed out that Tom vigorously opposed all elevation of physicians (not just psychiatrists) and medicine to a privileged legal and societal status. Plus he was an all-round libertarian (and was for years on the Libertarian Party's national committee), just that his area of expertise meant he was associated mostly with health freedom -- or freedom from medical paternalism, more specifically.

    There are certain patterns of abnormal behavior that I think are too specific to have a cause other than a neurologic one. The phrase "mental illness" was an unfortunate one that distorts thinking, but there are certain undesirable conditions of the mind that are too stereotypic to have cultural causes rather than biologic ones. Unfortunately the tools we have now to modify them are too crude to get a good assessment in many cases as to whether the affected person would have wanted such modification or not.

  • Wizard||

    The literature and the DSM stereotype the behaviors. Start to spend some lengths of time with these people and they are not at all stereotypic. In fact there even has been arguments among those who are in favor of the 'biomental illness' model that they are hard to categorize as stereotyped and they use this as an argument as to why they have not been able to find biomarkers or genes.

  • C. S. P. Schofield||

    My wife has been in the mental health care subculture for a couple of decades. I would describe the spectrum of therapies she has tried as useful Arts.

    Just a thought.

  • ||

    Some of the mental illnesses are due to a chemical imbalance in the brain. Usually, but not always, they can be cured with psychotropic medication. A person with chronic depression is incapacitated to the point that she/he wants to commit suicide. A person with serious bipolar disorder is either depressed or is like a speeding car with no driver; his life is a wreck and his family is in turmoil. A person with schizophrenia is totally helpless and erratic in behavior. Tell those people that mental illness doesn't exist. I had one schizophrenic pt, who uncharacteristically, had a sudden onset during adulthood . He was babbling nonsense, could not sit still, had hundreds of tiny papers with notes and symbols. After 2 days of haldol Rx, he was back to normal. "Simon, what THE HELL happened to me?"

  • ||

    "Some of the mental illnesses are due to a chemical imbalance in the brain. "

    What chemicals?

  • Nick Stuart||

    The 'chemical imbalance' theory is known and accepted by both the APA and NIMH to be wrong and without foundation. You have patients? Wow! Without an agreed etiology there can be no 'cure' of a 'mental illness' despite the claims of Pharma and your personal anecdotes.

  • ||

    Stupid spam filters.
    a href = 'http://www.youtube.com/watch?v=Nkj4_-14Ra4' Just leave me alone

  • ||

    holy crap, aw fuck it.

  • jason||

    This is the one against the whole party which is ruling right now in the world strongest country,

  • Make money online||

    Thomas Szasz is one man that we all respect! RIP Thomas Szasz

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