Thomas Szasz is an enigma. He is a trained psychiatrist who spent decades railing against psychiatry. He said that mental illness is a myth, compared involuntary psychiatric treatment to slavery, and made a case that all drugs – including psychiatric ones – should be available on the free market. Szasz wrote a lot of books – 33 to be exact – making these arguments.
But as a writer, this – at least in my view – nuanced thinker is hard to understand, for two main reasons. His writing is both crystal clear and highly rhetorical. Reading Szasz feels like reading someone like Thomas Paine, a very adept writer who sees himself as engaged in an existential battle. So, Szasz can often be misunderstood, taken as more extreme than perhaps he was, the nuances missed. In this video, I want to give you my articulation of the anti-psychiatric writings of Thomas Szasz.
First, a warning. I am not a medical doctor, but a philosopher interested in ideas. So, I’m not here to give any sort of medical advice. My aim is to explain the arguments of Thomas Szasz, who had very controversial ideas about psychiatry. If you are struggling with mental health, then Szasz be damned: you should talk to a professional who is equipped to help you. I’m not that person.
Myth of Mental Illness
In most of his books, Szasz starts in the same way: arguing that mental illness is a myth and that psychiatric language – things like diagnosis and treatment – involves a bad metaphor. He first gained popularity with a book-length version of this argument that he published in 1974 appropriately called The Myth of Mental Illness. Here’s the argument.
Medical fields diagnose disorders that have identifiable bodily causes. When you go to a doctor complaining of an ailment, the doctor listens to your symptoms but can follow up with x-rays and blood tests to look for the physical root or marker of that ailment. And while the doctor can and will treat the symptoms, they will often be able to treat the physical cause of the disorder with medicine that acts on you physiologically.
Szasz notes that this is not how psychiatry works. First, psychiatry has not been able to trace a single one of its disorders to a pathogen as cause. Psychiatrists deal only in symptoms, and while psychiatrists may have occasion to request blood tests – for instance, to monitor patients with drug dependencies – they can often do all of their job without ever examining a patient’s physiology. Even when prescribing psychiatric drugs that work on the patient’s physiology, these are generally monitored by talking with the patient, listening to her self-report about how the treatment is working.
Szasz makes a subtle but important point here. If we look at the books psychiatrists use to make patient diagnoses, each disorder is a collection of symptoms only, with no reference to pathogens at all. Put it this way: if I come to the doctor complaining of chest pains, the doctor can do tests to figure out the bodily cause of my chest pains. If I go to a psychiatrist complaining of anything from unwanted irritability to hallucinations, the doctor can’t and generally won’t try to figure out a physiological cause, because psychiatric diagnoses don’t require inquiry into causes.
Szasz adds to this: oftentimes, those with what we call mental illnesses can benefit significantly from talk therapies, or meditation, or things that work on one’s psyche first and only indirectly on physiology. If I have a broken leg or a skin disease, I can’t be talked into good health; my physiology must be directly acted on. But if I have an anxiety or depression, talking to a counselor or psychologist can significantly impact my treatment.
This leads Szasz to conclude:
My point is that to speak of elevated blood pressure and hypertension, of sugar in the urine and diabetes, all as “organic symptoms,” and to place them in the same category as hysterical pains and paralyses is a misuse of language; it is nonsensical; and it creates a linguistic and epistemological muddle which no amount of “psychosomatic research” can clarify (Myth of Mental Illness).
Therefore, Szasz argues that calling things like ADHD, depression, or schizophrenia mental illnesses is a bad analogy between psychology and medicine. Psychiatrists do not diagnose illnesses but detect what Szasz would call problems of living. They do not treat disorders but help clients alter their thoughts and behaviors in productive ways.
I should pause because Szasz has been heavily criticized for these views. The main criticism is that Szasz has a restrictive understanding of medicine and a misinformed view of psychiatry. Szasz says that medical diseases require pathogens as their cause, his many critics suggest otherwise. Doctors diagnose migraines, fibromyalgia, and irritable bowel syndrome, all disorders without known pathogenic causes, called idiopathic conditions Critics also suggest, against Szasz, that psychiatry does have to do with the physical brain. Schizophrenia, for instance, both seems to have strong genetic predictors and correlates to identifiable differences in brains. Also, talk treatments can work with or for certain psychiatric problems, but others often require and respond well to medical treatment. Why would that be if psychiatric problems were not illnesses?
To this, Szasz responds with a reminder that where medicine is pretty value neutral, psychiatry is always laden with value judgments. Here’s Szasz again: “While it is generally accepted that mental illness has something to do with man’s social or interpersonal relations, it is paradoxically maintained that problems of values – that is, of ethics-do not arise in this process” (Ideology and Insanity). Take homosexuality, which was listed in the DSM as a psychiatric disorder until 1973. Why? Presumably, the nature of homosexuality didn’t change. Rather, society changed, and people were less willing to call homosexuality a problem that should be fixed, instead recognizing it as a legitimate human variation. Or take Attention Deficit Hyperactivity Disorder. Looking through the DSMV’s diagnostic criteria, having it doesn’t just come down to having difficulty focusing for long periods or hyperactivity, but having these things in inappropriate settings or ways. But won’t different doctors judge that differently? And since there is no identifiable pathogen that tells us whether a patient “has” ADHD, it’s really a judgment about whether certain behaviors are inappropriate, inconvenient, or unreasonable.
Mental Illness as a Tool for Social Control
When Szasz calls mental illness a myth, he doesn’t mean that psychological trouble doesn’t exist or that it shouldn’t be taken seriously. He means that psychiatry misrepresents itself as being a value-free science when in reality, says Szasz, it is a technique of social control. People, according to Szasz, will always have distress, and because we are individuals who exist among other individuals, we will always have interpersonal conflict and, well, people who need to be kept to the rules of society. Psychiatry, he says, is our modern way to keep those people in check while looking like we are doing neutral medicine. Again, take ADHD. In our society, we have deeply centered childhood around modern schools. Schools require that students pay sustained attention to the material even when they’d rather do other things. And it requires that teachers don’t spend all their time getting students’ attention. Put these conditions together, and only then does ADHD become a disorder. Not because the student has a pathogen in them we must treat, but because they have a behavior about them that is inconvenient. Or take the various addiction disorders. Part of diagnosing them has to do with whether they get in the way of a patient’s normal or appropriate functioning. But what is that, and how will that judgment be made without the psychiatrist abiding by the dominant values of the society? Why is there internet addiction disorder but not book addiction disorder? Because our society looks at books as a sign of culture and the internet as a possibly dangerous mixed bag.
Societies need social control; ways to make sure that everyone is abiding by norms that make society possible. But at the very least, psychiatry needs to be honest that this is what it is doing, not the neutral practice of medicine.
For these reasons, you can probably see why Thomas Szasz has huge issues with involuntary psychiatry, the idea of committing someone to treatment or therapy against their will in the name of bettering them. He goes so far as to compare the practice to witch-hunting, religious inquisitions, and even slavery. Here’s Szasz again: “Formerly, the inquisitor accused the citizen of witchcraft and proved him to be a witch… Today, the institutional psychiatrist accuses the citizen of mental illness and diagnoses him as psychotic” (Manufacture of Madness).
Religious inquisitions were hunts for people who deviated from the ways of the prescribed religion. Something inside the heretic, it seemed, compelled the deviation, in which case, the person was justifiably restrained or punished. Slavery has often been rationalized by appeals to something about the slave that rendered them unsuitable to freedom that justifies coercing them, allegedly for their own good. Szasz says it is not hyperbole to see involuntary psychiatry as the same in its basics. Speculate that there is something inside the person that causes undesired behavior – something we can’t detect by a physical pathogen, behavior only – and use that as the basis to hold and treat them against their will. And if they try to defy the treatment, that too becomes evidence of their unfitness for freedom.
The Therapeutic State
Lastly, all of this adds up to what Szasz calls the psychiatric state or pharmacracy. We have so internalized the language and ways of psychiatry that we build it into our self-images and our institutions. Someone who repeats the same behavior a number of times might joke “Oh, that’s just my OCD,” even if they have no official diagnosis. A child who persistently can’t or refuses to pay attention to school assignments will be quickly suspected of ADHD. Those who commit murder can evade a full conviction if they plead insanity and can convince a psychiatrist that their rage fits the profile of a psychiatric disorder. Illegal street drugs can alleviate anxiety, and so can fully legal psychiatric medicines. If you can convince a psychiatrist to prescribe you the latter, you are treating your anxiety disorder. If you use the former instead, you’re just getting high.
For Szasz, the problem starts when we mistake a metaphor – mental illness – for a description. Once we treat mental states as medical diseases, we can easily justify all of the above things. We spot more and more mental diseases we can treat, treat problems of living with medical solutions, and expand the role of psychiatric treatment into more and more areas that need social control.
What is Szasz For?
Here’s where Szasz is most often misunderstood. He’s not saying that there are no such things as psychological problems, that using drugs to aid behavior change is bad, or even that therapy is bad. So, what is he for? What’s his version of how we should treat mental health issues? In Ethics of Psychoanalysis, Szasz describes his view of the therapeutic process. Here’s what he says:
In brief, then, the psychotherapist observes people, not minds. To be sure, people are often unhappy and unsuccessful, however, if we choose to call them, for this reason ‘sick,’ we use language metaphorically and rhetorically…. Accordingly, the psychiatrist does not ‘treat” mental illness, but relates to and communicates with a fellow human being).
For Szasz, the language of illness and treatment degrades the relationship between therapist and client. It tells the latter that she is broken and the therapist that her job is to fix. For Szasz, the therapist’s job is to listen to a client, and help the client figure out how to change in ways the client wants to change. Those may involve listening, suggesting, analyzing problematic situations, or yes, even drug therapies. But none of this should be seen as a medical transaction.
Also important for Szasz, the therapist’s allegiance should always be with the client. One of Szasz’s problems with the therapeutic state is that the therapist is often the agent of the state, the family who wants the client committed, the insurance company who will only pay for certain treatments or recognize certain diagnoses, or the government who is deliberating on how to deal with the client’s troublemaking behavior. These situations mean that the therapist is acting less as the client’s agent than as society’s agent. It amounts to practicing social control as if it is medicine. Szasz’s ideal therapist always follow the lead of the client.
Szasz also thinks that psychiatry is too often a way to avoid hard political and social problems. Some people’s lives do not go well; we often have unwanted thoughts and behavior. Social conditions can often interact with us in anxiety- and depression-inducing ways. But these are problems of living – both as individuals and as social units. Treating these medically is a convenient way to avert our conversations away from tackling hard ethical, social, and political problems. Instead of changing schools and how we teach, diagnose and medicate kids who have trouble in the system. This is Thomas Szasz. If anything, he has been a lightning rod. He’s inspired other critics of psychiatry like Gary Greenberg, Sami Timimi, and Joanna Moncrieff, while infuriating others. But I think his message is subtle and interesting; regardless of whether we accept it, he poses some meaty challenges not just to do with psychiatry, but with the nature of liberty, coercive power, human diversity, and justice. Sometimes, the best critics of a profession come from inside the profession, and entrenched professions – psychiatry is surely one – needs those critics if only to cause periodic rethinking. But will we accept that challenge?