No Excuses: The Reality Cure of Thomas Szasz
by Phil Barker and Poppy Buchanan-Barker And you thought Tom Szasz was yesterday’s hero? This paper brings us up to date.
Future historians may well cast Thomas Szasz as an intrepid campaigner for the blindingly obvious: people do not have "mental illnesses" but experience a wide range of moral, interpersonal, social and political "problems in living." All such problems concern, or have an impact on, our sense of who and what we are and could just as easily be called spiritual crises. However, despite his prodigious scholarly output, Szasz might well be written out of history, as punishment for his single-handed and persistent exposure of the greatest hoax of the modern age – the construction of the "myth of mental illness" and psychiatry's ludicrous attempts to "treat" it.
In the best Socratic tradition Szasz has been, for over 50 years, the gadfly of psychiatry. In his classic book, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (Szasz, 1961), he contended that, contrary to the professional and public opinion of the time (the late 1950s) the mind – an abstract concept – could only be considered "sick" in the same sense that a joke or a building might similarly be described. This mind metaphor functions as a powerful myth, like many fictions, offering comfort to all who embrace the idea as a way of explaining the "inexplicable."
At the end of the 20th century religion, especially Christianity, was furiously debunked by radical secularists like Richard Dawkins, Daniel Dennett and Christopher Hitchens. They exposed not just its mythical nature but the harm and injustice associated with its practice down the ages. Ironically, their glaring sin of omission was to ignore psychiatry – by far the most potent and influential religion of the past two hundred years.
Psychiatrists might feign offense at their portrayal as "high priests," believing that they offer a complex and compassionate form of psychological medicine, worshipping at the same altar as scientists like Dawkins. Historically, the facts tell a very different story, as Szasz's works have vividly illustrated.
Traditional religions can hold sway over large sections of any population, and may be considered a force for good or evil. However, such "myths" are, at the very least, embraced by the faithful; who gain socially, culturally or spiritually from their allegiance; and are free to rejoin secular society whenever they wish. The same could never be said of "psychiatric patients." The open secret of the 20th century was that modern psychiatry became a "church" founded on hocus-pocus masquerading as science, and promoted a range of means of detaining and restraining its "patient" flock. Today, as psychiatry rebrands itself as a branch of neuroscience, it seeks to colonize "developing nations," despite its near-bankrupt status in its Western world of origin. Parallels with the Christian missionaries seem wholly apposite.
Over the past 60 years Thomas Szasz has published over 30 books and around 700 papers and articles, all focused on exposing the logical weaknesses of psychiatric thought, and the moral bankruptcy of its practice. Heidegger proposed that every great thinker thinks but one thought. Szasz's singular, original thought concerns the moral bankruptcy of expecting (far less forcing) people to see psychiatrists; to be admitted to so-called "mental hospitals"; to take psychiatric drugs; and otherwise to comply with the capricious fashions of psychiatric religion. His diverse and remarkably accessible writings around this single proposition have led many to view him as the foremost, contemporary moral and existential philosopher of psychiatry and psychotherapy: the psychiatric equivalent of the boy obligated to point out the Emperor's nakedness. In his 90th year, the uncompromising fury of Szasz's scholarship shows no sign of waning as three of his latest books attest.
Coercion as Cure (Szasz 2007) has a "classic" feel providing, as its subtitle makes clear, a much-needed "critical history of psychiatry." Szasz acknowledges that, from his first day in medical school in the early 1940s, his understanding of the physician's role was to try to relieve the suffering of individuals who asked for, and accepted, medical help. He quickly formed the view that psychiatrists were committing a grave moral wrong by imprisoning and coercing people who neither sought nor wanted their "help." This simple, yet profoundly humanist view became, and remains, his raison d’être.
Szasz opens with his assertion that "the typical relationship between doctor and patients rests, and has always rested, on consent," returning to this moral imperative in his conclusion. Between these moral bookends he lodges a highly original thesis, which frequently makes for painful reading. His intentions, like his writing style, are clear from the outset:
In the days of the insane asylum, the nature of psychiatry was clear: the madhouse was a snake pit and snake pits could be found only in insane asylums. Today…. "snake pits" are everywhere, from the kindergarten to the hospice and the reality of psychiatric coercion and dehumanization is camouflaged by a façade of fake diagnoses, outpatient commitment, the renaming of insane asylums as "health care facilities" and a lexicon of euphemisms concealing the exploitation and injury of so-called mental patients as "treatments." Szasz's critics argue that, today, involuntary commitment is rare. Szasz disagrees. The use of force has simply become, for the most part, covert; as shown by the proliferation of "community treatment orders" and the lingering threat of involuntary treatment, should people refuse to "volunteer." That said, in many countries, like the UK, "commitment" is again on the rise.
The comparison with religion is obvious. Psychiatry "is a belief-system impregnated with rules and values, permissions and prohibitions." The theory and practice of psychiatry is irrefutable and inviolable "not because they are true or good, but because it is taboo to deny or reject them." St. Augustine said that "religion binds us to the one Almighty God." It is no accident that the most popular diagnostic manual – the DSM – is commonly referred to as the "psychiatric bible." It binds psychiatrists, other "mental health" practitioners and even the "patient" to the spurious ideology of the psychiatric faith.
Sadly, most "mental health professionals" have little knowledge of the scandalous history of their discipline; insulated from the warts of their history by a cavalcade of hagiographers. Those with any awareness, either blindfold themselves with the psychiatric flag, or reframe coercion as compassion: "in the patient's best interests."
Psychiatric history is riddled with charlatans and megalomaniacs, who peddled bogus remedies either in the name of medical treatment or scientific progress. All were welcomed as messiahs, if not by patients, then certainly by the families fed up with the patient's behavior. Szasz's critical history follows this messianic pathway: tracing the development of the asylum system, with its various pretenses towards "humane treatment"; adding a wealth of detail to established accounts of "shock treatment" (iatrogenic epilepsy); the "cerebral spaying" of lobotomy; and the ethical disingenuousness of "moral treatment." He reminds us that "neuroleptic drugs" were not developed to "treat" any lesion but were, in the words of Laborit – "inventor" of chlorpromazine – "a veritable medicinal lobotomy." All "side effects" associated with such drugs are – in truth – "intended effects." Today's "new generation" of psychoactive drugs perform much the same function. There is no disease to treat, only persons to be managed and muted.
Szasz's detailed account of the career of Walter Freeman, the serial lobotomist, is one of the many high (or low) spots in this remarkable book. Freeman heralded, unwittingly, the era of the "celebrity patient." Operating brutally on thousands of patients, once he completed 228 "operations" in 12 days, often without gown, mask or gloves, turning his operating theater into a circus performance. Called on by the serial womanizer, Joseph Kennedy to "treat" his gregarious, free-spirited daughter, Rose, Freeman's lobotomy rendered her so passive that the family had to pass her off as "mentally retarded," and she spent the next 63 years in the care of nuns. In an attempt to hide the disgraceful butchery of his daughter, Kennedy and his family "donned the mantle of protectors of the mentally ill and mentally retarded, as if the two terms referred to similar conditions."
Today, many psychiatrists claim a neurological basis for mental illness – especially the "psychoses." Szasz has addressed such claims for decades, noting that if a "mental illness" emanates from some disease or disorder of the brain, then the patient needs a neurologist, not a psychiatrist. The difference is critical, as he notes at the end of Coercion as Cure. Over a century ago, the fledgling American Psychiatric Association invited S. Weir Mitchell, founder of the American Neurological Association to address their 50th anniversary meeting. With grave misgivings, Mitchell agreed. Szasz notes that Mitchell's scathing address has been remarkably neglected by psychiatric historians:
You quietly submit to having hospitals called asylums; you are labeled as medical superintendents ... You should urge in every report the stupid folly of this. You ... conduct a huge boarding house – what has been called a monastery of the mad.... I presume that you have, through habit, lost the sense of jail and jailer which troubles me when I walk behind one of you and he unlocks door after door.... You have for too long maintained the fiction that there is some mysterious therapeutic influence to be found behind your walls and locked doors. We hold the reverse opinion ... Your hospitals are not our hospitals; your ways are not our ways. Plus ça change! Contemporary neurologists do not coerce people with manifest brain disorders – such as Parkinson's disease or epilepsy – to accept treatment. Neither do they show any interest in pursuing people with hypothetical "brain disorders" – such as schizophrenia. Szasz concludes: "More than ever, the ways of psychiatry are not the ways of medicine."
In Psychiatry: The Science of Lies Szasz summarizes, pithily, the thesis he has been illustrating so vividly for five decades. His erudite and highly readable account underlines the scientific folly of talking of "illness" in the absence of physical pathology; bringing the sheer mendacity of both professional and political perspectives on "mental illness" to life through the duplicitous accounts of those like Tipper Gore, Kay Redfield Jamison and Lauren Slater, all of whom "built successful careers as celebrity experts on madness." Szasz views them all as "impostors...." "Being an expert about mental illness is like being an expert on ghosts or unicorns."
However, the best examples of impostors are to be found among the parcel of rogues called "antipsychiatry," especially its "guru" Ronnie Laing. Although he tried to distance himself from such an affiliation, Szasz's documentary account reveals how Laing created this "movement" with the South African psychiatrist, David Cooper, who later proposed that having sex with female patients would be "therapeutic." Szasz has frequently been associated with this grouping, so it is unsurprising that he should want, so vigorously, to explode its mythical nature; showing how "antipsychiatry" was merely a thinly veiled attempt to redirect power from the mainstream into the hands of Cooper, Laing and others.
In Antipsychiatry: Quackery Squared, Szasz begins by pointing out the foolishness of the title – who would call an obstetrician opposed to abortion, an "anti-abortionist"? More importantly, he reminds readers of his libertarian belief that people should be free to believe in "mental illness," just as they are free to believe in God, voodoo, alien abduction, or anything else about which he might be skeptical. People should also be free to consult psychiatrists; to accept or reject their diagnoses; to take drugs; to accept electro-convulsive therapy, or even submit to psychosurgery. His main concern has always been with the abuse of psychiatric power: where people are coerced, or otherwise manipulated, into accepting bogus "treatments" for their metaphorical "illnesses." All those associated with "antipsychiatry" – from Cooper and Laing, to Lacan, Basaglia and their various "disciples – never sought to challenge this abuse of power. Instead, they tried to wrest power from orthodox psychiatry, in pursuit of their own ideological prejudices.
Szasz begins his conclusion by quoting GK Chesteron who "wisely warned – do not free a camel of the burden of his hump, you may be freeing him from being a camel." In Chekhov's novella, Ward No 6, he reminded us that "what the inmates of psychiatric confinement need is freedom, not another set of careers." Szasz concludes with the reminiscence of Lenin's younger sister, who recalled that when the "great dictator" read Ward No. 6 "he felt like going out of his room and taking a breath of fresh air: it seemed to him that he had himself been locked up in Ward No. 6."
Psychiatric organizations and government departments alike now employ the ludicrous double-talk of "mental health problems/issues/difficulties"; acknowledging, however grudgingly, that the only "fact" is that people experience problems, in relation to themselves or others. In that sense, Szasz's original premise has been accepted. The outstanding problem lies in the consequences of such a worldview. When people experience problems they may or may not ask for help to deal with them. Nowhere is it written (except in the psychiatric canon) that people are obliged to accept "help" far less be penalized should they decide to ride out their fate.
None of this is "rocket science." Indeed, future scholars might wonder how Szasz managed to create such a fuss in the late 20th century, when the social significance of science and its inherent rationalism was being brought to widespread public attention; and support for mythology and faith-based ideologies teetered on the brink of collapse. Szasz's thesis has been simple and straightforward. If people have a genuine (i.e., biological) illness, then they may be offered appropriate medical help. However, as persons, they have the right not only to choose from various "treatment" alternatives, but can refuse them all, if they wish.
Szasz's emphasis on persons was and remains the critical stumbling point of Szasz's thesis: a veritable sin of commission. In The Myth of Mental Illness he stressed the centrality of "personal conduct" and ever since has written and talked only of persons. 40 years ago he wrote:
Modern psychiatry dehumanizes man by denying ...the existence, or even the possibility, of personal; responsibility of man as a moral agent...(The psychiatric mandate) is precisely to obscure, and indeed deny, the ethical dilemmas of life, and to transform these into medicalized and technicalized problems susceptible to "professional solutions" (Szasz, 1973. p. 11). There are no "patients, clients, survivors or service-users," only persons. This stubborn defense of personhood is ignored, not because it is flawed, but because of its implications.
Szasz's concerns are unashamedly political. Szasz has often quoted Lord Acton's dictum: "Power tends to corrupt and absolute power corrupts absolutely." In Psychiatry: The Science of Lies he recaps the story of its origin, in Acton's critique – as a Catholic – of Vatican-sponsored mendacity.
It cannot be faith in the true sense, which a man defends by immoral means... [B]elief is not sincere when the believer is not sincere. ...I have never found that people go wrong from ignorance, but from want of consciousness, Even the ignorant are ignorant because they wish to be ignorant in bad faith. (Acton cited by Szasz, 2008: p114–5) Acton concluded: "I find that I am alone...I cannot obey any conscience but my own." The parallels with Szasz are all too apparent. He too realizes how marginal is the position he has created for himself:
(Critics of psychiatry) who call themselves "antipsychiatrists," "critical psychiatrists," "ethical psychiatrists," "postpsychiatrists," "ex-mental patients," "voice hearers" and so on – oppose one or another psychiatric "diagnosis" or "treatment"; sometimes even psychiatric coercion. But they draw back from defending an ethic based on nonviolence, personal responsibility for public actions (as distinct from private actions called "thoughts"), and every person's inalienable right to his or her life and death – lest they appear uncompassionate and, perish the thought, unscientific and illiberal (in the modern, statist sense of "liberal"). A popular tactic employed by many of Szasz's critics is to dismiss both the man and his ideas on the basis that he eschewed the practice of mainstream psychiatry: refusing especially to work with so-called "non-compliant psychotics." Szasz reminds us that obstetricians are free to choose not to perform abortions and neurologists are not obliged to conduct so-called "psychosurgery." Indeed, despite its emergence as a response to the traumatic casualties of the Great War, most "plastic surgeons" are celebrated today for treating "patients" whose primary complaint is overweening vanity. Szasz chose to work only with those who asked for his help and who were willing to enter into a contract with him. The legal analogy, which Szasz first employed in Ideology and Insanity, is apposite.
In the practice of law...the objects of classification are not the attorney's clients, but the nature of his work. We thus have attorneys who specialize in corporation law, criminal law, divorce law, labour law, tax law and so forth (Szasz 1973, p. 238). Szasz chose to be a "psychiatric defense lawyer." The hostile opposition to any similar "division of labour" within its ranks "is a measure of the extent to which psychiatry has abandoned the liberal-rationalist values of science and the open society (committing itself) to their counterrevolutionary antithesis, the illiberal and irrational values of scientism and the closed society (Szasz, 1973:238)."
Much of today's radical thinking in mental health amounts to little more than footnotes to Szasz. From the "political correctness" of "mental health problems" to the emergence of "advance statements," most of our contemporary "radical thinking" is borrowed from Szasz. It may well become the historian's duty to make repay the debt.
Reprinted from The Journal of Critical Psychology, Counselling and Psychotherapy.
August 4, 2010 Phil Barker is Honorary Professor, University of Dundee, Scotland. Poppy Buchanan-Barker is Director, Clan Unity International, Fife, Scotland. Thomas Szasz is professor of Psychiatry Emeritus at the State University of New York Health Science Center in Syracuse, New York. Visit his website.
Copyright © 2010 Phil Barker and Poppy Buchanan-Barker
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