Madness, myth and medicine

Only after we abandon the pretence that mind is brain and that mental disease is brain disease can we begin the honest study of human behaviour and the means people use to help themselves and others cope with the demands of living (Szasz, 2007a, p.149).

Fifty years ago American Psychologist published a seminal article by the Hungarian-born psychoanalyst and psychiatrist Thomas Szasz, 'The myth of mental illness' (Szasz, 1960). The thesis was elaborated at length in a book of the same name a year later (Szasz, 1961). As the decade got into full swing, Szasz's critique of psychiatric theory and practice was herded into the same conceptual basket as the musings of Scottish psychiatrist R.D. Laing, and his erstwhile friend and collaborator David Cooper. The quite different ideas of these men came to be bracketed inappropriately under the rubric of 'anti-psychiatry' – an expression coined by Cooper though disclaimed by Laing and rejected outright by Szasz.

Since then biological psychiatry has developed a stranglehold on research, teaching and practice in the field of 'mental health', and Szasz's opposition to psychiatry and the basis for it has been mislocated in the art and culture of the day, its relevance for today denied. Szasz's view has become viewed by many as a supposed child of its time – a component in the social manufacture of the so-called anti-establishment Swinging Sixties. To let such misapprehension pass unchallenged into the history of the behavioural sciences would be a serious error, and Szasz for his part has constantly endeavoured to set the record straight.

First it must be said that Szasz's insights into the shortcomings of conventional psychiatry pre-date the 1960s by some considerable margin. In a brief autobiographical sketch Szasz makes clear that the absurdity of psychiatric fictions had dawned on him long before Fellini's masterpiece was highlighting the shallowness of La Dolce Vita:
'Everything I had learned and thought about mental illness, psychiatry, and psychoanalysis – from my teenage years, through medical school, and my psychiatric and psychoanalytic training – confirmed my view that mental illness is a fiction; that psychiatry, resting on force and fraud is social control, and that psychoanalysis – properly conceived – has nothing to do with illness or medicine or treatment' (2004, p.22).

Szasz graduated in medicine in 1944, having migrated to the US from his native Hungary in 1938, a fugitive from the looming menace of Nazism. He undertook a psychiatric residency and trained in psychoanalysis. The appeal of psychoanalysis, besides its intellectual and interpersonal attractions, lay in its ostensibly consensual and contractual nature. Less well known than his other works, his dissection of the nature of power in psychoanalytic relationships – published as The Ethics of Psychoanalysis (Szasz, 1965) – is central to his thinking and stands complementary to the assertions that mental illness is a myth. In this Szasz effectively provides a practical guide on how to ensure a level playing field in psychotherapeutic relationships, to the benefit of both parties. He is honest and open enough to explicitly explore the role that money may play in distorting therapeutic means and ends. As such, it not only stands the test of time but stands squarely against the numerous vested interests, both pharmaceutical-financial and professional, which dominate the mental health industry past and present

Anti-psychiatry or pro-consent?

Szasz is not 'anti'-psychiatry. He advocates the right to agree consensual contractual relations of any kind, including consensual psychiatry if that is what suitably informed people want. He has proposed, for example, the use of advanced psychiatric directives whereby people could agree to accept or refuse specific interventions to be made 'on their behalf' in the event of their becoming extremely distressed and 'irrational' in future. Such ideas have unfortunately been rejected outright by leading figures in both psychiatry and medical ethics, and accordingly Szasz sees little possibility of any kind of consensual psychiatry until the use of coercion, whether explicit or tacit, is relinquished.

As psychiatry continues to function for the most part as an extension of the criminal justice system, Szasz asserts that psychiatry in its current form must be abolished. This would require a concerted challenge to its support structures, premised as they are on the notions of behaviour as disease, the fear of dangerousness and the necessity for medical treatment under the guise of protecting the individual from his or herself. The championing of the latter notion in particular owes much to an ignorance of its origins. A careful reading of Szasz's historical analysis of the origins of the insanity defence in 17th-century England goes some way to clarifying where behavioural scientists got the idea from that people of 'unsound mind' were not responsible for their actions and could not be held accountable for them. In Coercion as Cure, he writes
With suicide defined as a species of murder, the persons sitting in judgment of self killers had the duty to punish them. Since punishing suicide required doing injustice to innocent parties…the wives and minor children of the deceased – eventually the task proved to be an intolerable burden. In the seventeenth century, men sitting on coroners' juries began to recoil against desecrating the corpse and dispossessing the suicide's dependants of their means of support. However, their religious beliefs precluded repeal of the laws punishing the crime. Their only recourse was to evade the laws; The doctrine that the self-slayer is non compos mentis and hence not responsible for his act accomplished this task (Szasz, 2007a, p.99)

And so a social practice became reified into an imaginary biological disease process ravaging through the brains of its unfortunate victims, necessitating psychiatric intervention!

The label of 'anti-psychiatry' that continues to be attached to Szasz is one which he has been at pains to condemn (Szasz, 2009), used as it is to stultify and nullify any criticism of contemporary psychiatry. While Laing saw himself as 'essentially on the same side' as Szasz (Mullan, 1995, p.202), Szasz sees considerable distance between them, for a number of reasons. Perhaps at the forefront of these Laing was known to have forcibly drugged one of his patients (Szasz, 2008) and for all his eloquence and insight into human misery his writings do not in principle condemn the forced treatment or incarceration of people against their will on psychiatric grounds. Finally whilst The Divided Self (Laing, 1960) and Sanity Madness and the Family (Laing & Esterson, 1964) amongst other outpourings proclaimed the intelligibility of going mad within a human rather than biological framework, Laing did not reject outright the notion of mental illness, which in Szasz's view remains at best a metaphor.  

Szasz has throughout his career stood firmly to his principles and steadfastly eschewed psychiatric practice in an environment where people have been deprived of their liberty. He has on occasion appeared in court both to represent individuals deprived of their liberty and to uphold the principle of criminal responsibility in murder cases where those accused have sought to evade it through the insanity defence (see Szasz, 2007b, chapter 13 in particular). Such consistent challenges to institutional psychiatry have been made at some professional cost. Szasz has not simply been the recipient of fierce criticism from the psychiatric fraternity, who feel betrayed by his actions, but has also endured attempts to limit his academic freedom. In the aftermath of the publication of The Myth of Mental Illness, for example, attempts were made to ban him from teaching at the state hospital medical school – citing his beliefs as 'proof' of his 'incompetence as a psychiatrist' (Schaler, 2004, p.xix).

Some confusion about Szasz's work has arisen through the quite different political cultures within which it is interpreted, even by those who oppose institutional psychiatry in its current incarnation. His work has been claimed and repudiated by those on both the 'left' and 'right' – deemed a liberal in some quarters and a fascist in others – with the claims and counterclaims rooted in the predilections of the critics for different configurations of state power. European intellectual tradition on the left, for example, clings to a belief and a desire that state power can be harnessed for the good. This means that while Szasz's attacks on psychiatric authority are applauded, his admonitions against the 'therapeutic state' (Szasz, 2001, 2002), with its merging of psychiatric and state power on the one hand and private and public health on the other, are glossed over. In truth, if such a thing can be said, Szasz's ideas belong to neither the right nor the left. His work challenges and questions all operations of organised power from the state downwards, as long as they are used to crush and oppress human freedom. His work implies unanswered questions concerning the forms of community and social organisation which people can harness for the individual and common good in order to enable them to deal elegantly with the insatiable demands of living.

Addendum

While preparing this article I encountered Philippe Petit's (2002) wondrous account of his high-wire walk across the twin towers of the World Trade Center in 1974. Immediately after performing his 'artistic crime of the century' Petit was arrested and subject to psychiatric examination. Petit was judged to be sane, but the outcome of the psychiatric interview is less revealing than the fact that psychiatrists were willing to play their part in a pseudo-medical intervention provoked by nothing more than social rule breaking of the highest imaginative order. It struck me that Petit – an imaginative, unusual and beguiling figure – exemplifies much that modern psychiatry stands in antipathy to. Petit cares not for the rules and regulations that structure and govern the lives of citizens and lives, in his terms, only to dream 'projects that ripen in the clouds' (Petit, 2002, p.6). There can be little doubt that psychiatry is an enterprise that is engineered to destroy these – that it cannot tolerate idiosyncrasies of thought, whether grandiose or mundane. Petit succeeded in his outlandish and highly improbable quest – but why should one have to achieve outlandish success to be embraced by society and enjoy the right to pop one's head in the clouds or spend the 'afternoons in treetops'? Szasz's efforts over the years can be seen in many lights, but without doubt he has toiled on behalf of the dream of human accountability and responsibility, for the freedom to be different and to take charge of one's life, free from the machinations of state-sponsored psychiatric interference.

Ron Roberts is a Senior Lecturer in Psychology at Kingston University

[email protected] 

References

Laing, R.D. (1960). The divided self. London: Tavistock.
Laing, R.D. & Esterson, A.E. (1964). Sanity madness and the family. London: Tavistock.
Mullan, B. (1995). Mad to be normal: Conversations with R.D.Laing. London: Free Association.
Petit, P. (2002). To reach the clouds. London: Faber and Faber.
Schaler, J. (Ed.) (2004). Szasz under fire: The psychiatric abolitionist faces his critics. Chicago: Open Court.
Szasz, T. (1960). The myth of mental illness. American Psychologist, 15, 13–118.
Szasz, T. (1961). The myth of mental illness. New York: Harper & Row.
Szasz, T. (1965). The ethics of psychoanalysis. Syracuse, NY: Syracuse University Press.
Szasz, T. (2001). Pharmacracy: Medicine and politics in America. London: Praeger.
Szasz, T. (2002). Liberation by oppression: A comparative study of slavery and psychiatry. New Brunswick, NJ: Transaction.
Szasz, T. (2004). An autobiographical sketch. In J. Schaler (Ed.) Szasz under fire. Chicago: Open Court.
Szasz, T. (2007a). Coercion as cure: A critical history of psychiatry. New Brunswick, NJ: Transaction.
Szasz, T. (2007b). The medicalization of everyday life: Selected essays. Syracuse: Syracuse University Press.
Szasz, T. (2008). Debunking antipsychiatry: Laing, law, and Largactil. Current Psychology, 27, 79–101.
Szasz, T. (2009). Antipsychiatry: Quackery squared. Syracuse: Syracuse University Press.