Thomas Szasz: An Evaluation

The extreme biological libertarianism of a refugee from totalitarianism.

Posted Jan 05, 2018

A few months ago, some colleagues asked me to write a foreword to a book about Thomas Szasz, written by his friends and associates in the department of psychiatry at the University of Syracuse. After I wrote the foreword, the editors rejected it. This action is uncommon for an invited essay, but I probably shouldn't have been surprised. The collection of essays in the upcoming book on Szasz ignores more than it discusses. To be critical is not necessarily a bad thing; criticizing ideas should not be seen as personal attacks; understanding a legacy has to take the bad with the good. 

I know there are many pro-Szasz ideologues out there, especially among some strident anti-psychiatry groups. My view of Szasz' ideas is not that he is simply wrong, but that when right, he is right for the wrong reasons; and when wrong, he is simply wrong. Since the foreword was rejected, I have decided to publish it here, in a slightly edited version so that it can stand alone, to make it available to interested readers: 

On Thomas Szasz

It is held that one should not speak ill of the dead, as they cannot defend themselves. Too often we err in the opposite direction, speaking well of the dead out of respect. Truth has its own exigencies.

Thomas Szasz famously was a polarizing figure, and he appeared to revel in it. He is seen by his supporters, mostly citizens who are critical of the psychiatric system,  as a courageous man who spoke out against the errors and excesses of his profession. Imagine a psychiatrist who claims that there is no such thing as mental illness. This would be like a surgeon who claims that cutting into bodies is wrong.  Or a cardiologist who claims that there is no heart disease. His opponents, mostly card-carrying members of the psychiatric profession, see him as a stubborn fanatic. 

It would be to easy to say that both perspectives are partly correct, though they likely are. Instead, I would be inclined to say that the story of Thomas Szasz can’t be understood outside of the context of how psychiatry evolved in the course of his career. When Szasz entered the discipline in the 1950s and became prominent in the 1960s with his famed book on the Myth of Mental Illness, psychiatry in the US lumbered under the hegemony of an extreme psychoanalytic orthodoxy.   1950s-60s US psychiatry was to the profession as 1950s-60s Soviet orthodoxy was to communism. The profession was led by psychoanalysts who stunted any free thought. Their opinions truly were myths. Schizophrenia wasn’t caused by cold mothers, as they believed. Mania wasn’t a reaction to depression, as they argued. Depression wasn’t a reflection of not-good-enough early childhood experiences, as they speculated. Hysteria wasn’t a fantasy of childhood libido, but a reflection, too often, of real-life sexual trauma. Homosexuality was not a perversion. The psychiatry that Szasz railed against in his most famous book was full of myths and was mostly false. But, as Ronald Pies describes well, it wasn’t false for the reasons Szasz thought it was false. (Pies trained under Szasz but developed an independent critical position of Szasz' views, while holding him in esteem personally). The problem wasn’t that all mental illness is mythical inherently, but rather that the mental illness concepts that Szasz had been taught in his education were false. There are other better concepts.

I will not assert that in the 1970s and 1980s, as it shifted to a more biological perspective, psychiatry got mental illness right. This would be the viewpoint of today’s apologists for psychiatry. The falsehoods of Freud were replaced by the falsehoods of DSM-III in 1980. Psychiatry in the 1980s and 1990s was wrong again, but not in the same ways as in the 1960s. It remains mired in falsehoods, and this is why some of Szasz’s critiques will remain relevant today. But a disciplined and reasoned critique of psychiatry today cannot rest on the same viewpoints Szasz put forward half a century ago. The problem is not the psychiatry is not medical enough, as Szasz argued; in fact today, there are plenty of pathological abnormalities in the brain that are connected to schizophrenia (like ventricular enlargement) and manic-depressive illness (like amygdala enlargement in mania and hippocampal atrophy with depression). These anatomic findings, along with strong genetic evidence of almost complete genetic heritability of these diseases (and clear genes associated with them in the human genome project), would meet some of Szasz’s requirements for claiming that one is dealing with a bona-fide medical disease. He would have to revise his claims so as to admit that schizophrenia and manic-depressive illness are medical diseases. Whether he would want to call them “mental” illnesses or not is a linguistic and conceptual matter, as Pies again describes. Szasz seems to engage in what philosophers call “eliminative materialism,” which is the view that once we have sufficient scientific knowledge, the language of the ordinary world (“folk psychology”) will be replaced by a scientific language. Instead of saying, “I’m angry,” we’ll say, “My amygdala is overactivated.” There is a large philosophical literature on this topic, and one can argue the matter in either direction. It is worth noting though that one can be materialist without being eliminative. One could still use psychological concepts even though one realizes that such notions are based in the brain.

In short, I think Szasz was right in many ways for his time, and for the right reasons; he is right partially today, but for the wrong reasons; and he is wrong if his views are used, as many of his extreme supporters use them, to deny any reality to any psychiatric disease, like schizophrenia or manic-depressive illness.

Besides his philosophy of disease, the other central feature of Szasz’ thinking is his libertarianism. Szasz was a biological libertarian in psychiatry. He accepted the existence of medical disease; he just denied such status to psychiatric diagnoses. Even if a disease existed though, whether psychiatric or not, he argued for a libertarian approach to practice. Patients should be allowed to do whatever they want; they shouldn’t be forced by society to do anything. This is the postmodernist perspective, enshrined in Michel Foucault’s work (also based in the psychiatry of the 1950s), of psychiatrists as policemen, mere agents of society’s laws. Laws are social constructions, not facts of nature. So if we accept that mental illnesses are social constructions, as Foucault and Szasz argue, then the psychiatric profession is a mere rationale for enforcement of society’s standards. All claims to science and disease and an external source of truth are false pretensions. This is simple postmodernism, held by Foucault most famously, among others, at the same time as Szasz came of age. It is based on a general philosophy of knowledge and science advanced by Heidegger in the 1920s and 1930s, with a foundation in the works of Nietzsche in the 19th century. Szasz is part of a larger postmodernist tradition, which one can accept or reject, but which is independent of him. 

This is the standard perspective of the “anti-psychiatry” movement, and Szasz participated in it, collaborating closely with Scientology-funded groups, and smiling broadly in pictures with the likes of Tom Cruise. Other groups among anti-psychiatrists have motivations which Szasz may not have shared (he wasn’t a Scientologist), but he shared their goals. Szasz’ motivation was libertarian, which has some value, just as an anarchist’s skepticism about government has value. Yet one is better off with a democracy than with anarchy. Szasz’ virtues can be obtained otherwise while avoiding his vices.

For instance, as some authors note, Szasz held a humanistic approach to work with patients. But Szasz was predated in this commitment to a humane approach to patients by the extensive existential tradition in psychiatry, inaugurated by Karl Jaspers in 1913 and extended in the 1930s and later by Viktor Frank and Ludwig Binswanger and Leston Havens, among others. This tradition took all the humane approaches to patients found in the writings of Szasz, and more, and yet it did not reject the basic concepts of mental illness or psychiatric disease in the way Szasz did. They agreed that many people seek help from psychiatrists for problems of living, not diseases. But they held that some people have psychiatric diseases. Szasz’ view was all-or-nothing, without allowing for this nuance. 

In sum, one can be quite humanistic in one’s approach to psychiatry without verging into the anti-psychiatric judgments, and extreme libertarianism, that characterized Szasz’ work. 

It probably is not irrelevant that Szasz was born in Budapest and left as an 18-year-old with his Jewish family just before World War II. He arrived in the US as an adult, whose whole character must have been stamped by his experience of totalitarianism. His libertarian approach to life must have grown out of this painful personal experience with the Nazism which displaced him from his homeland in 1938, and the Stalinism which famously repressed his nation of origin in 1956.

Psychiatry in the 1950s and 1960s was unhumanistic, and repressive in many ways, and it remains so to some extent today. But it does not compare to Nazism and Stalinism. For Szasz, given his personal biography, such differences may have been difficult to distinguish. 

Another personal aspect to Szasz’ life that is mentioned rarely is that his first wife likely had a psychiatric disease. She had severe psychological symptoms and committed suicide in 1971 after their divorce. Presumably, to be consistent Szasz would have to hold that she simply had a problem of living that led to suicide and that she freely chose to kill herself. On this theory, all 30,000 suicides yearly in the US are free choices of free citizens of the freest nation on earth. There’s no such thing as psychiatric disease even in such cases. This perspective was a reality in his own clinical work, where he famously refused to ever give a medication to any patient. One of his patients, himself a psychiatrist, committed suicide 6 months after beginning treatment with Szasz, who stopped the patient’s lithium for manic-depressive illness. Lithium is proven to prevent suicide based on double-blind placebo-controlled studies; it is the only drug proven to do so in our highest level of scientific research. Either all of the best clinical research in medicine is false since it is based on randomized placebo-controlled research, or Szasz is wrong. In a long lifetime, as with most human beings, he never changed his mind on this matter or any other major aspect of his psychiatric beliefs.

In the end, Szasz’ life and work reflect the vagaries of the psychiatric profession itself, as it has lunged from error to error, to the glee of its critics. As to the solutions for its errors, better guides have existed, like Jaspers and Frankl and Havens. Szasz’ role early in his career may have been beneficial, revealing the falsehoods of the profession, but his later and long-term effects were less benign. The good that men do may be interred with their bones, as Shakespeare's Marc Antony famously intoned over Caesar, but it also is true that the evil men do lives after them.