Revisiting Szasz: Myth, Metaphor, and Misconception
The famous and controversial psychiatrist rejected mental illness.
Posted Jun 14, 2018
No figure in the history of American psychiatry has proven to be more contentious—and perhaps more misunderstood—than the late Thomas Szasz. Best known for his 1961 classic The Myth of Mental Illness: Foundations of a Theory of Personal Conduct, Szasz was a prolific writer of 35 books and countless articles, publishing right up until his death at the age of 92 in 2012. He served his entire career as professor of psychiatry at the State University of New York Upstate Medical Center in Syracuse, was honored as a distinguished lifetime fellow of the American Psychiatric Association, and at one time was the most well-known psychiatrist in America.
This essay is an attempt to elucidate some of Szasz's major contentions regarding mental illness, identify some of the common misconceptions about Szasz and his ideas, and to offer some personal reflections on Szaszian ideology and psychotherapy. I have written about and taught Szasz for several years and maintain a full-time private practice of contractual psychoanalysis informed, in part, by Szasz's contributions. I had personal correspondence with Dr. Szasz during my graduate school training and kept in contact with him early in my career.
Szasz's ideas on psychiatry and mental illness can roughly be summarized as follows. First, mental illness is a metaphor for human problems in living expressed as "symptoms" via a somatic protolanguage. There are no biological tests for mental illness; thus, mental illness is not disease in the literal sense. Secondly, it follows that if mental illness is not literal disease, then persons should not be deprived of liberty and responsibility in the name of mental illness. Szasz opposed all forms of involuntary treatment and the insanity defense. Sociologically, he saw psychiatry as a state-sanctioned mechanism of social control and an omnipotent threat to civil liberty. He termed this association between government and psychiatry "The Therapeutic State".
It is important to note that Szasz's views on psychiatry were influenced by his libertarian political ideology, formed as a child growing up in Nazi-era Budapest. During his psychiatry residency and later during his psychoanalytic training, Szasz avoided all contact with involuntary psychiatric patients. He never committed a patient involuntarily to the hospital and never prescribed a psychiatric drug. Morally opposed to coercion in psychiatry, Szasz maintained a private practice of psychoanalysis where he practiced what he termed "autonomous psychotherapy", outlined in his 1965 book The Ethics of Psychoanalysis.
Szasz penned his early writings at a time when more than a half a million Americans were locked up in state mental hospitals—many of them for life. Abuses of psychiatric commitment were common. Basic civil liberties of mental patients were denied. These realities led Szasz, along with George Alexander and sociologist Erving Goffman, to form in 1970 an organization named the American Association for the Abolition of Involuntary Mental Hospitalization.
Historians of psychiatry note that Szasz's early work, in part, led to the mass deinstitutionalization of psychiatric patients in the 1960s and 1970s and to a broader legal recognition of their rights and civil liberties.
It should also be noted that Thomas Szasz was the first American psychiatrist to speak out against the classification of homosexuality as a mental disorder, and although it is Robert Spitzer who is frequently credited with the removal of homosexuality from DSM, it was Szasz who initially challenged psychiatry's medicalization of human sexuality nearly 20 years earlier.
While much has been written about Szasz in both mainstream academic and anti-psychiatry circles, misconceptions abound, particularly as they relate to Szasz's view on the nature of mental illness. It is hoped that an investigation of these ideas will yield some common ground and shed light on the contributions Szasz offered the field over a span of more than 50 years. I will then offer some challenges and personal reflections as a practicing psychoanalyst.
Szasz is frequently alleged to have denied the reality of mental symptoms, but a careful reading of his works reveals that this is a mischaracterization. While Szasz did not see psychiatric symptoms as something that happen to a person, as in physical disease, he recognized that they can cause great suffering—even if they are being driven by the person's own motivations. His ideas in this sense were actually quite similar to Freud's, who himself asserted that psychiatric symptoms result from underlying psychological conflict and often manifest symbolically as means of communication. What Freud termed "unconscious", Szasz termed "unacknowledged". In fact, Szasz (1965) contended that his "autonomous psychotherapy" was an expansion and refinement of Freud's original vision for psychoanalysis.
Szasz's belief in a thoroughgoing free will—even in patients deemed mentally ill—led him to conceptualize mental illness as resulting from unacknowledged internal motivations. This belief is expressed most eloquently in his statement, "People often say that this or that person has not yet found himself. But the self is not something one finds; it is something one creates" (Szasz, 1973, p. 49).
Psychiatric patients, unable to express themselves via conventional means, resort to a "somatic protolanguage" which is interpreted by psychiatrists as "symptoms of mental illness". The metaphor of mental illness is literalized, and the patient is said to be suffering from disease of the nervous system, despite the fact that no histopathological or pathophysiological abnormality has ever been consistently demonstrated in patients said to be mentally ill.
In order to treat a person suffering from mental illness, the patient's self-determination has to be supported and expanded. Since the defining feature of all mental disorder is a loss of a sense of control, treatment should focus on reestablishing the autonomy of the patient. To Szasz, this could not be achieved by accepting control for the patient's life or his behavior—even in cases where the patient poses a threat of danger to self or others. Indeed, this is the basic premise of Szasz's version of psychotherapy—the patient remains responsible for himself at all times.
Szasz's application of game-theoretical principles to the treatment mental illness bears semblance to the approach advanced by psychiatrist Eric Berne, author, most famously, of the 1964 bestseller Games People Play. In fact, Berne cites Szasz favorably in that classic book. I have written elsewhere about the overlap between Berne's transactional analysis and Szasz's contractual psychoanalysis (see Ruffalo, 2017).
While Szasz asserted that mental disorders are only metaphorical diseases, he never closed the door entirely on the possibility that one day the biological origin of a mental disorder will become known. However, he insisted that once the physical origin of a mental disorder becomes known, it ceases being a mental disorder and instead becomes classified as neurological disease. To Szasz, to deprive someone of freedom for a putative disease is tantamount to imprisonment.
This leads us to the theoretical possibility that what is called schizophrenia—for instance—is caused by a yet-to-be-discovered physiological disease of the brain. Szasz (1976) called schizophrenia the "sacred symbol" of psychiatry because he saw it as a post-hoc justification, morally and philosophically, for both the use of involuntary treatment and the classification of psychiatry as a branch of medicine. If schizophrenia, hypothetically, is a disease of the brain, would this justify involuntary treatment? Furthermore, does an entity only become disease when its pathophysiology becomes known?
Szasz maintained throughout his career that even if schizophrenia was proven to be brain disease, this would not negate his argument about the metaphorical nature of mental illness, and it would also not justify involuntary treatment—since patients with neurological diseases, such as Parkinson's disease, cannot legally be treated against their will.
But psychiatrist Ronald Pies, a student of Szasz's in the 1980s and now a professor in the psychiatry departments at SUNY Upstate and Tufts, argues that Szasz's contentions regarding mental illness rest on several conceptual errors. Pies (1979) asserts that Szasz erroneously equates metaphoricity with falsity. Simply because something is described using a metaphor, it does not logically follow that it is an inaccurate depiction of the state of affairs in the world. If mental illness is indeed a metaphor—and Pies does not think it is—the person said to be mentally ill may still be ill in the literal sense.
Pies (1979) also points out that Szasz's contention that mental illness and brain disease are mutually exclusive categories runs counter to the medical reality. Many neurological diseases manifest with mental symptoms, and some mental disorders, such as Alzheimer's disease, have known neuropathology but remain classified as psychiatric illness. The discovery that all mental disorders are actually brain diseases would not eliminate the category "psychopathology", nor would it discount the use of psychotherapy or the appropriateness of the term "mental illness".
Additionally, Pies has argued that Szasz's position on the meaning of "disease" resulted from a misreading and misunderstanding of the work of German pathologist Rudolf Virchow, whom Szasz cited frequently. While Virchow certainly viewed lesions and cellular pathology as the basis of specific diseases, it is not clear that he saw such pathology as equating disease in the broader, conceptual sense. To be sure, Virchow saw disease as afflicting persons and not simply bodies (Pies, 1979).
Szasz's brilliance lies in his pointing out the many pretensions of psychiatry, the risk of psychiatric diagnosis as an interpersonal and political weapon, and in his application of game-theoretical principles to psychotherapy. No one in the history of psychiatry advocated more tirelessly for the civil liberties of the mentally ill and no one challenged the (often misguided) conventional psychiatric wisdom more skillfully than Thomas Szasz.
When psychiatry is practiced consensually, as should almost always be the case, it can do a great deal of good. Unlike some others associated with the so-called anti-psychiatry movement (which Szasz perpetually disavowed), Szasz never sought to ban psychiatry or psychiatric treatment. Instead, he believed that people should remain free to seek any help they desired.
But Szasz's unwavering focus on the autonomy and self-determination of psychiatric patients may have led paradoxically to the deprivation of their freedom. Instead of half a million in state mental hospitals, we now have 350,000 mentally ill in prison and 250,000 homeless—the majority of them unable to obtain decent help even if they want it. And the growing research on the pathophysiology of severe mental disorder paints a more complex picture than Szasz let on.
Sixty years ago, Thomas Szasz did the profession—and the world—a great service by pointing out the gross abuses of power perpetrated in the name of psychiatric treatment. His influence on the humane treatment of the mentally ill forever changed the landscape of American psychiatry. But his claims regarding the nature of mental illness seem to be based on flawed logical and epistemological assumptions. They certainly seem to run counter to the clinical reality.
Pies, R. W. (1979). On myths and countermyths: More on Szaszian fallacies. Archives of General Psychiatry, 36(2), 139-144.
Ruffalo, M. L. (2017). The meaning of mental illness. International Journal of Existential Psychology and Psychotherapy, 7(1). Published online April 25, 2018. Retrieved from http://journal.existentialpsychology.org/index.php/ExPsy/article/view/217
Szasz, T. S. (1961). The myth of mental illness: Foundations of a theory of personal conduct. New York, NY: Harper and Row.
Szasz, T. S. (1965). The ethics of psychoanalysis: The theory and method of autonomous psychotherapy. New York, NY: Basic Books.
Szasz, T. S. (1973). The second sin. New York, NY: Anchor Press.
Szasz, T. S. (1976). Schizophrenia: The sacred symbol of psychiatry. Syracuse, NY: Syracuse University Press.