Szasz Under Fire: The Psychiatric Abolitionist Faces His Critics
Thomas Szasz was the enfant terrible of 20th-century American psychiatry. His 1961 book, The Myth of Mental Illness (New York, Paul B. Hoeber), and his searing intellect and take-no-prisoners rhetorical style defined the terms of the discourse. Szasz under Fire consists of 12 essays by critics, Szasz's replies to each, and a brief autobiographical sketch. The essays are uneven; Szasz is more interesting than his critics, and, right or wrong, he always wins the debate. The book provides a deja vu experience and stimulates reflection on what we were arguing about then, why it seemed so important, and how we think about it today. (Figure) Szasz was born in Budapest in 1920, and although he spoke almost no English, he emigrated to the United States in 1938. He ranked first in his medical school class, but he didn't really want to practice medicine. As he put it, "My true passion was literature, history, philosophy, politics -- or, put more plainly, how and why people live, suffer, and die." After a year of medical residency, he shifted to psychiatry in order to "be eligible for training in psychoanalysis, not to practice psychiatry." He sought a platform from which to attack "the immoral practices of civil commitment and the insanity defense." This book, some 60 years later, continues that attack. Szasz's psychiatric residency was unusual. He never worked on an inpatient unit, and when his chairman suggested that he should have experience with "seriously ill patients," he quit the program. Szasz makes clear that his views about mental illness, involuntary treatment, and the insanity defense were well established before his exposure to psychiatry, psychoanalysis, or even medicine and that he was unusually successful at avoiding any experience that might have been relevant to them. Szasz's views are entirely ideological; they have nothing to do with empirical data and are therefore immune to arguments on the basis of data; they are premises, not conclusions. Szasz's central thesis is that "disease" means an abnormality of the body, and since doctors treat bodies, there may be brain diseases but not mental diseases. Corollaries are that involuntary treatment of mental disease violates fundamental liberties, that mental disease should not be considered in assessing criminal responsibility, and that physicians should have no privileged role in the prescription of drugs or in assisted suicide. Several of his critics argue with his definition of disease. They point out that diseases happen to people, not bodies, and review the evidence that brain diseases underlie major psychiatric disorders. These arguments have no effect on Szasz, although they are probably the chief reason that his position seems so out of date. Szasz also seems out of step with contemporary practice. He states that "the typical mental patient . . . is hospitalized and treated without his consent" (which has not been true since years before Szasz's residency) and that there has been little progress in the diagnosis and treatment of mental illness (an assertion that would receive little support). For me, the underlying issue is Szasz's view of psychiatric patients as competent, autonomous adults who are different and who must be protected from a society that wants to infringe on their rights and uses that difference as a justification. It is an important perspective, and one that touches on fundamental values of our society, but tragically, it is less relevant to the seriously mentally ill than to almost anyone else. An alternative view -- that people with mental illness are childlike, helpless, and in need of our care and protection -- has little appeal to him. He even seems to question the view's premise; he speaks of the child's relationship to his parents as one based on domination and submission and argues that psychiatry rests on "a coercive pediatric model characterized by relations of domination and subjection." If one starts with the view that parenting is domination and pediatrics is coercive, the conclusion is that psychiatry is evil. In this book Szasz is called "the most influential ideologist of the `new' antipsychiatry of the 1960s and 1970s" and "a powerful intellectual ally of the civil liberties movement." He forced a sometimes reluctant profession to attend to the moral and ethical dimensions of its work, and though he is largely wrong, his arguments have been immensely valuable.Robert Michels, M.D.Copyright © 2005 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.