Karl Kraus and the Soul-Doctors, by Thomas Szasz, Baton Rouge: Louisiana State University Press, 1976, 180 pp., $9.95
Schizophrenia: The Sacred Symbol of Psychiatry, by Thomas Szasz, New York: Basic Books, 1976, 237 pp., $10
Psychiatric Slavery, by Thomas Szasz, New York: Macmillan, Free Press, 1977, 159 pp., $8.95
The Theology of Medicine, by Thomas Szasz, Baton Rouge: Louisiana State University Press; New York: Harper & Row, 1977, 170 pp., $9.95/$3.95
It is now over 15 years since Dr. Thomas Szasz published The Myth of Mental Illness (1961). The campaign he opened with that first splendid barrage had already, by the beginning of 1976, included nine further battling books, among them Law, Liberty, and Psychiatry (1963, 1968), Ideology and Insanity (1970), The Manufacture of Madness (1970), and The Age of Madness (1973). Now another four honors have been added to the list: Karl Kraus and the Soul Doctors, Schizophrenia: The Sacred Symbol of Psychiatry, Psychiatric Slavery, and The Theology of Medicine.
I imagine that many REASON readers will have at least one or two of these works on their shelves, will be familiar with the general line, and will welcome the entire campaign as being fundamentally as good as it is important. So my job here and now must be, first, to describe the special contribution made by the four latest and then perhaps to raise some questions.
The first book is historical. The satirist, poet, and polemicist Karl Kraus was a major figure in Vienna from the turn of the century until early 1930's—the place and period in which so many of the influential ideas of our century were forged. As Szasz notes in his preface, "A history of the formative years of psychoanalysis without Kraus—which is how all such histories have so far been written—is like the cultural history of Europe during the French Revolution without Edmund Burke, or the political history of America without the Antifederalist Papers…or the contemporary history of Russia without Aleksandr Solzhenitsyn."
The second part of Karl Kraus and the Soul Doctors consists of translations of almost everything Kraus had to say about psychiatry and psychoanalysis. Among the many minor memorabilia of Szasz's essay in the first part are: that the Cambridge philosopher Ludwig Wittgenstein was a faithful subscriber to Kraus' magazine Die Fackel and was concerned to discover his opinion of the Tractatus Logico-Philosophicus, and that Freud in 1933 inscribed a presentation copy of one of his books to Mussolini with the words, "From an old man who greets in the ruler the Hero of Culture." The only reference to that Italian dictator in the Ernest Jones biography of Freud is the report that Mussolini intervened to protect Freud from Nazi persecution after the German occupation of Austria.
Much more important and more relevant than either of these two tidbits is that Kraus seems to have been a consistent libertarian in the tradition of John Stuart Mill, believing in "the greatest amount of freedom for each individual, limited only by consideration for the freedom of others." It was this basic commitment that led Kraus to oppose both "police harassment of prostitutes and homosexuals" and the "incarceration in a madhouse" of the Hapsburg princess who wanted to divorce her blue-blooded but unwashed husband in order to marry a commoner. The psychiatric agent in this latter affair was, incidentally, a future Nobel prize winner. He was also later to boast of the effectiveness of the "electric shock treatments" employed under his direction against malingerers in World War I.
One very small point: Szasz should not have spoken toward the end of his essay of only "two book-length studies in English on Kraus's life and work," ignoring my former colleague Frank Field's The Last Days of Mankind: Karl Kraus and his Vienna (1967)—especially not after describing that book earlier as "one of the few major works in English on Kraus."
Psychiatric Slavery is in its own way another fairly particular book. It deals with the Donaldson case. Against all the professional psychiatric interest groups presenting amicus curiae briefs to the Supreme Court, Szasz wants to offer his remarks "as an inimicus curiae to that august body." Kenneth Donaldson was, on the initiative of his father, incarcerated in the Florida State Hospital at Chattahoochee in January 1957 and released in July 1971. The stated grounds for this incarceration were that he was a paranoid schizophrenic. The criteria for this condition are: that subjects maintain grossly false beliefs and that they insist that they are in fact sane and not mentally ill. Donaldson had been complaining that someone had been putting something in the food he was given in his parents' house. Once in Chattahoochee, he refused both electroshock treatment and other conventional forms of medication on the grounds both that he was a Christian Scientist and that anyway he was not ill. In his years there he made 18 separate approaches to get his release, but always refusing to admit that he had been ill and was now cured. Thus, when his daughter wanted to sign him out in 1966 he insisted that he was "not going to be subjected to indignities ladled out by a bunch of goddamned mammy-jamming honey-dippers." I hope on my next visit to America to discover what these magnificently abusive words mean. I shall then find my own employments for them!
But no sooner had Donaldson gotten out of Chattahoochee than he reversed his position and began to complain not only that he had been wrongfully committed and detained but also that he had been denied his rights to treatment of his mental illness. This subsequent litigation was apparently financed by the Mental Health Law Project, which is partly sponsored by the American Civil Liberties Union. Not surprisingly, the initial first complaint was progressively submerged under the second. The newly discovered constitutional right to treatment which was demanded in this case would be a right that the patient had no right to refuse. It would, therefore, be a right of the State or, more particularly, of State-employed psychiatrists—and hence a right, not of, but against the individual citizen.
In the final two chapters of the book Szasz discusses "right to treatment" versus "right to treat" and develops an analogy between "chattel slavery" and "psychiatric slavery." Not to be missed in the former are two chilling statements quoted from Judge Bazelon, author of the Durham Rule, which allows pleas of irresistible impulse to defeat charges of criminal responsibility. In the first statement, Bazelon by implication rejects every idea of individual responsibility and choice, suggesting that all crime is an expression of mental disease and that all delinquents should be indefinitely detained at the psychiatrists' pleasure. "Human behaviour is caused rather than willed," he says. "What is…required of the expert is a statement in simple terms of why the accused acted as he did." Given this he may—indeed, surely he must—"under the Durham Rule…be seen as a sick person and confined to a hospital for treatment."
Not surprisingly, Bazelon earned a great welcome as a member of an American mental health mission to the USSR. There, he was delighted to report: "Even if a patient opposes hospital commitment, it is deemed voluntary if it is sought by the patient's family, his trades union, business organization, or polyclinic doctor. The Russian attitude seems to be that under these circumstances the patient himself would want hospitalization if he could make a rational decision. As a result, only three or four percent of all commitments are termed involuntary. I must hasten to add that many of our own psychiatrists share the same underlying attitude." No need, Bazelon, no need. We know.
In Schizophrenia, Szasz takes up again, with particular reference to the most common of all psychiatric diagnoses, the general thesis first broached in The Myth of Mental Illness—a thesis which has played some part, larger or smaller, in every succeeding battle in the continuing campaign. The thesis, expressed in the very title: that really there is no such thing as mental illness, that not just some or most but all people diagnosed as mentally ill are nothing of the sort. If this is true, then the objections to compulsory psychiatric treatment must be stronger and more fundamental than those to compulsory treatment for (at any rate noninfectious and noncontagious) physical diseases or disabilities. If this is true, then whatever proper function the psychiatrists—"the soul doctors"—can still be allowed to have, what they cannot honestly pretend to be is a kind of medical doctors.
Some psychiatrists, and rather more of those parapsychiatrists who practice as psychiatric social workers and the like, hope to minimize the significance of this second and shattering corollary. They suggest, often in an irritatingly knowing tone of voice, that they "do not accept the medical model." This will not do, though. For all the professional activities of psychiatrists and parapsychiatrists, their whole standing in society and their financial rewards, are based upon precisely this "medical model," which cannot be so easily jettisoned. These things are all based, that is to say, upon the assumption that there really are mental diseases, which these people are qualified to treat. Furthermore, both the Durham Rule and similar rules in other legal jurisdictions are accepted both by the generality of lawyers and by the lay public only insofar as it is believed that victims of these putative conditions must be in some way as much incapacitated thereby as sufferers from cholera or yellow fever.
It is at this point that I have to declare an interest. I believe that there can be, and in fact are, conditions sufficiently similar to paradigm cases of physical disease and physical illness to deserve to be described as mental diseases and mental illnesses. So, although these crucial expressions are nowadays continually misemployed to label conditions that are nothing like the physical paradigms, they do nevertheless have a more limited but entirely legitimate application. There is, therefore, a proper and traditionally medical place for psychiatrists. I have argued for this important reservation, in a penal context, in my Crime or Disease? (1973). I can and do go along with Szasz only, but fully, insofar as his campaigning is consistent with such modest admissions.
At one point in one of the essays reprinted in The Theology of Medicine, Szasz seems to be ready to concede. He proposes to respond to "the most important objections to my contention that mental disorders are not bona fide diseases." The second of these objections is that "the term mental illness often designates a phenomenologically identifiable and hence valid category of conduct." Szasz says: "But I do not deny that." How could he? Unfortunately, this formulation of the second objection fails to specify any criteria for mental illness. In particular, it fails to insist that, if the mental conditions are sufficiently to resemble the physical paradigms, then they must be both essentially incapacitating and typically unwelcome to their victims.
Szasz proceeds: "I object to psychiatric diagnostic terms not because they are meaningless, but because they are used to stigmatize, dehumanize, imprison, and torture.…I oppose involuntary psychiatry, but I do not oppose voluntary psychiatry, or psychiatric activities between consenting adults." But what are these adult activities, conducted no doubt in decent seclusion, if they are not treatments of genuine mental illnesses, "on the medical model." Yet, if so, what has become after all these years of the surely overbold original suggestion that mental illness is simply a myth?
The basic contention of Schizophrenia is narrower and therefore weaker, yet still very strong. It is that the concept of schizophrenia is a shambles, with no application to any identified disease. This drastic contention seems to me to be, on the evidence deployed here, correct. Szasz, following Sir William Osler, takes syphilis as his paradigm of disease. He then challenges that "version of the history of psychiatry" that holds that, "as some medical investigators discovered and identified diphtheria, so others—in particular, Kraepelin—discovered and identified dementia praecox; as some discovered and identified syphilis, so others—in particular, Bleuler—discovered and identified schizophrenia."
Szasz objects that each of the three conditions included by Kraepelin in the first of these two syndromes "refers to behavior, not disease; to disapproved conduct, not histophathological change [tissue change characteristic of disease]." Bleuler then created the second syndrome by extending the scope of the first and introducing a Greek name to replace the original Latin. Both these innovators believed, and the successors have continued to believe, in the words of Henderson and Gillespie's Textbook of Psychiatry, that dementia praecox and schizophrenia are "the outcome of a pathological, anatomical or chemical disturbance of the brain." Noting that this guilty disturbance has not been (though it is always about to be) identified, Szasz comments: "Paresis is a disease for one reason only: because the paretic patient suffers from a demonstrable abnormality of his brain." He also notes that "in the main, so-called schizophrenics or psychotics do not regard or define themselves as ill and do not seek medical (or, often, any other kind of) help." Significantly, too, it is some form of schizophrenia that KGB psychiatrists diagnose in dissidents, and, where Western psychiatrists seek funds to discover the genetic cause of this ghastly disease, their Soviet colleagues gleefully report "the 65 percent improvement rate" produced by starvation treatment.
In all this Szasz gets warm, yet not quite warm enough. Thus he contrasts behavior with disease. But the symptoms of the most purely physical illness may include, for example, uncontrollable trembling or shaking or the inability to make certain normal movements in any but some abnormal way. The true crux is the antithesis between uncontrollable behavior and controlled conduct. Again, it is only half right to oppose "disapproved conduct" to "histopathological change." Certainly the criteria actually employed by contemporary psychiatrists, and not only by KGB men, seem to refer to disapproved conduct or disfavored convictions rather than to any kind of acquired incapacity. But neither "histopathological change" nor "demonstrable abnormality" in the brain is a necessary or a sufficient condition of either physical or mental illness. People had to be able to identify illness independently before it could become possible for medical researchers to discover that certain illnesses are in fact due to certain internal conditions of the organism. It is therefore entirely conceivable, though not in fact likely, that for some undoubted illness no such hidden condition ever could be found.
Even if we were able to point to genetic or other physiological preconditions of some syndrome currently rated schizophrenic, still, this discovery would have no tendency by itself to show that syndrome to be, or be part of, an illness. If schizophrenia is to be established as a kind of illness, then someone has got to specify the incapacities and discomforts to which patients become subject by falling victim to it. And, if the psychiatrists are to make good their prerogative claim to it as mental, then they will have to show that the relevant incapacities are either intellectual or psychologically caused.
The first of these alternatives chimes with the traditional popular conception of madness. The second fits Freud's account of "obsessional neurosis and hysteria,…the two forms of neurotic disease upon the study of which psychoanalysis was first built up, and in the treatment of which also our therapy celebrates its triumphs." Here the symptoms precisely are incapacities: the incapacity to make bodily movements that the healthy person can make or not make at will or the incapacity to stop behaving in ways in which the healthy person does not normally but always could behave. The patient, Freud claims, "simply cannot help himself." The warrant for distinguishing these syndromes as mental is the claim that their constituent incapacities are psychologically caused: "The proposition that symptoms vanish when their unconscious antecedents have been made conscious has been borne out by all subsequent research." (From Freud's Introductory Lectures on Psychoanalysis.)
It must here be remarked both that Szasz gives little attention in any of his writings to genuine cases of madness and that in The Myth of Mental Illness he suggests, even if he never states outright, that the hysterics and obsessional neurotics of Charcot and Freud were all in fact malingerers. These are, of course, both questions of fact, of a kind upon which I have no special qualifications to speak.
Another point to remark is that Schizophrenia contains a useful chapter assailing Ronald Laing, David Cooper, and "the so-called anti-psychiatry movement." The central theme of the Szasz polemic is that this fashionable movement, like most contemporary intellectual radicalism, is corrupted through and through by pervasive and total bad faith. This unlovely and too rarely noticed fact is most visible to those of us who had close personal acquaintance with the idealist extreme left of the late thirties and forties. In such circles it was usual to begin by pointing to actual or supposed evils in capitalist societies and then to labor to show that in the USSR, under full socialism, these evils had disappeared or were disappearing. But today radical criminologists, for instance—while insisting that the evils of crime and punishment are due to capitalism and while supporting Leninist revolutionary policies—make almost no attempt to deny, what they know as well as we do, that the first Leninist state has kept more of its people in worse prisons than any other ever; or that their adored 'Fidel', even after forcing a vast emigration, still has, proportionately a far bigger prison population than the worst of the much-denounced military dictatorships further south. Whatever motivates radicals of this all too familiar type, it certainly cannot be the humane concerns that they both so loudly profess themselves and so bitterly excoriate their opponents for not sharing.
Finally, a few words about The Theology of Medicine. These twelve papers include two especially valuable pieces, "The Ethics of Addiction" and "The Ethics of Suicide." The overwhelming impression I take away from the first is how much cheaper than present U.S. drug-abuse policies any of the more libertarian alternatives would be. The second essay examines the ideal, classic case of misrepresenting unconventional choice as a symptom of mental disease. Szasz quotes Ari Kiev, speaking for the Cornell suicide prevention clinic: "We say, look, you have a disease, just like the Hong Kong flu.…Most of the patients have never admitted to themselves that they are sick." Well, fancy that! Since they are not, why should they?
Antony Flew is professor of philosophy at the University of Reading. He is widely published in philosophical journals and has written numerous books. His A Rational Animal will be published by Oxford University Press in 1978.
This article originally appeared in print under the headline "Against Mind Medicine".
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