Written by and shared with the permission of Alan Forrester.
Thomas Szasz has done more than anyone else to try to clear up popular misconceptions about involuntary psychiatry and promote liberty and taking responsibility for mental patients. What popular misconceptions does Szasz address? Most people have the idea that there are some kinds of behaviour that are caused by illnesses called mental illnesses. Mental illnesses can be treated by medical specialists in those illnesses - psychiatrists. Sometimes a person who is mentally ill doesn’t understand that he is mentally ill so psychiatrists have to treat him against his will. Furthermore, sometimes a person who committed a crime was mentally ill. The justice system allows mentally ill criminals to get treatment from psychiatrists rather than go to prison. To most people questioning these ideas would be like questioning that bears shit in the woods. Szasz not only questions those ideas, he also refutes them and shows that are anti-liberal.
Szasz argues that mental illness does not exist. He admits that there is a set of phenomena that people call mental illness: some people complain that others are mentally ill, some mentally ill people act oddly by conventional standards, and psychiatrists say that some people have schizophrenia or attention deficit disorder. However, an illness like diabetes is a change in the structural or chemical properties of the human body that cause undesirable consequences. There are ways to test whether such a change has taken place independently of any unpleasant consequences of the change. For example, if a person has some of the symptoms of diabetes, like peeing a lot and feeling thirsty, a doctor can check if he has diabetes by blood and urine testing. Mental illnesses are described solely in terms of behaviour, not in terms of structural or chemical changes in the human body. So they are not illnesses in the same sense as diabetes is an illness.
Mental illness is a metaphor that psychiatrists use to stigmatise people by saying their actions are not motivated by ideas. Rather, their actions are a result of biology somewhat like what happens if a person has an epileptic fit and hurts himself or other people. Having thus stigmatised a person, psychiatrists can then ‘treat’ him without his consent, either by forcing him to take certain drugs or by locking him up in a building called a mental hospital. Psychiatric treatment is not like treating an unconscious or delirious patient. Doctors treat unconscious patients to try to get them to survive and recover consciousness. When an unconscious patient wakes up and starts expressing his preferences doctors treat him in accordance with his preferences. A mental patient will often clearly express preferences to be released from a mental hospital, but the psychiatrist will ignore the mental patient and keep him locked up.
Many of Szasz’s critics object that we may yet find that schizophrenia, say, is caused by some currently unknown change in the structural or chemical properties of the body. And indeed, they must discover such changes: how else can we explain very odd behaviour of a person diagnosed with a mental illness? There are two other explanations. The first explanation is that a person can lie about his own beliefs and actions to get committed, or he can lie about the beliefs and actions of other people to get them committed. The second explanation is that a person might actually hold odd beliefs. Most people throughout most of history have held beliefs that are now considered odd, e.g. - the idea that Jews or witches poison wells, or drink blood, or murder children en masse.
The coercive actions of psychiatrists are a threat to the rule of law in several ways. (1) They allow psychiatrists to imprison their patients without trial and without an opportunity to defend themselves: this undermines due process. (2) Both involuntary commitment and the insanity defense are instances of the rule of men rather than the rule of law. There is no publicly available set of rules you can obey to make sure a psychiatrist will not deem your behaviour to be mental illness because there are no objective criteria for judging mental illness. (3) There is no law specifying the exact term for which a patient may be imprisoned by psychiatrists, so the sentence is also subject to the rule of man.
Szasz has recommended many reforms to deal with these problems. He has recommended abolition of the insanity defense and of involuntary treatment. He has also recommended that people should be allowed to sign a legal document indicating that they do not want involuntary treatment under any circumstances. Szasz recommends that people should be able to engage in voluntary psychotherapy, and has suggested guidelines for such therapy. These include the idea that patients should pay for their therapy because otherwise the therapist will have to take account of the wishes of the people paying the bills, e.g. - the government, or the patient’s employer, or their insurance company. What is presently called voluntary treatment is not voluntary because a psychiatrist may change it to involuntary treatment at any time without the patient’s consent. Indeed, a psychiatrist may have legal problems if he refuses to engage in involuntary treatment. None of Szasz’s
proposals has been implemented.
Many critics have blamed Szasz for deinstitutionalisation, i.e. - forcible eviction of mental patients from mental hospitals. Szasz never advocated this policy, rather he has criticised it. The government has used force to put mental patients in a position of dependence, so using force to evict them without making any effort to help them adapt to freedom is a bad policy.
Szasz objects to the arguments of many people who are ostensibly on his side. Some people say that particular psychiatric treatments, like electroshock therapy, are inhumane but do not object to involuntary commitment or the idea of mental illness per se. Others say that some of the people in psychiatric hospitals are not mentally ill and do not belong there. Both of these positions take it for granted that involuntary psychiatry has some legitimate uses and that the real problem is that sometimes people abuse it. Szasz disagrees: involuntary psychiatry is inherently abusive, regardless of how particular treatments or patients are selected or used. Some people also say that involuntary commitment is wrong but that mental illness does exist. But mental illness is an idea that has no use except as a term of abuse and denigration: it implies that a mental patient is not a moral agent and so that his preferences and rights need not be respected. Szasz also
objects to the ideas and work of anti-psychiatrists like Ronald Laing. Szasz points out that Laing and his followers treat patients involuntarily despite claiming that they don’t want to do so. In addition, the anti-psychiatrists diagnose their patients with mental illnesses and so admit that those illnesses exist. The only difference is that anti-psychiatrists recommend different drugs and blame the patient’s family and society for all of his problems.
Szasz’s ideas are an indispensible part of the rational and liberal worldview for we cannot be free if we tolerate anti-human scapegoating of people who have arbitrarily labelled as mentally ill.
Thomas Szasz, The Myth of Mental Illness, Harper and Row, New York.
Thomas Szasz, Law, Legislation and Psychiatry, Syracuse Univeristy Press, New York.
Thomas Szasz, Insanity: The Idea and its Consequences, Syracuse Univeristy Press, New York.
Thomas Szasz, Cruel Compassion: Psychiatric Control of Society’s Unwanted, Syracuse University Press, New York
Thomas Szasz, The Ethics of Psychoanalysis, Syracuse University Press, New York.
Thomas Szasz, Antipsychiatry: Quackery Squared, Syracuse University Press, New York.
Thomas Szasz, The Manufacture of Madness: A Comparative Study of the Inquisition and the Mental Health Movement, Syracuse University Press, New York.
Thomas Szasz, Schizophrenia: The Sacred Symbol of Psychology, Syracuse University Press, New York