n the light of some recent shootings and subway pushings, there's been much talk about how to handle mentally ill persons. The problem is the lack of objective criteria for diagnosis. If diagnoses are subjective, based solely on psychological testing and observations of behavior, there is nothing to stop society from imprisoning, drugging, and surgically mutilating people it finds inconvenient—or for people to insist their everyday problems and fetishes are medical in order to receive drugs, sympathy, or government benefits.
And that is exactly what is happening. We now have physicians giving powerful stimulants to schoolchildren to control their behavior. Others are working feverishly to find ways of medicalizing political dissent, so they can discredit their political adversaries. Still others are testifying in insanity defenses making retroactive diagnoses of a person already judged competent to stand trial. Quacks, all of them.
We also have to ask ourselves whether any such conditions are real diseases. Szasz says no. "Mental illness is not a condition, but a policy," says Szasz. A psychotic pushes another onto the subway tracks because that is what he or she wishes to do. Their bizarre excuses do not change the fact that they are eaten up with hatred and have committed a deliberate crime. "It is not an accident," says Szasz, "that in all of psychiatric literature, there is not a single account of voices that command a schizophrenic to be especially kind to his wife."
Szasz also criticizes other medical practices that have no scientific justification, such as calling the crime of pedophilia a "disease" and the routine circumcision of children. In the USA, 80-90% of male children are circumcised. Yet people criticize Middle Eastern cultures for female genital mutilation. Hypocrisy at its finest.
If psychiatry is the opiate of the people, the DSM-IV-TR (soon to be 5) is their bible, at least for those in the psych profession. Its contents are proof of Szasz's idea that mental disease is only a metaphor. But here he goes beyond psychiatry, warning that the "pharmacracy" we are creating with nationalized health care and rampant medicalization will give the state virtually unlimited control over every aspect of our lives: "By the time [people] discover that the therapeutic state is about tyranny, not therapy," he writes, "it will be too late." Finally, a cure for the tragic disease of Szaszophobia. If only we could cure the plague called APA.
Dec 30 2012
his classic work is the product of the 1960s, a period of ferment in psychiatry and a period of self-criticism in society. In this book, Szasz put forth his controversial belief that mental illness is only a metaphor, and that psychiatric disorders are not diseases, but are attempts by the patient at communicating distress.
Szasz focuses mainly on conversion hysteria, a disorder that preoccupied Freud and his contemporaries. In conversion hysteria, the patient develops physical symptoms because of a neurosis. Freud and others believed this revealed a connection between physical and mental disease. Neurosis was thus conceptualized as a sort of toxic substance that sought release and found its expression in the body.
Conversion hysteria is rarely diagnosed today, and it may seem strange to us that Freud focused on it. But in those days, Cartesian dualism was an important factor in people's thinking. The Freudians saw conversion hysteria as a clue as to how the mind and body are connected. Even today, the connections between the mind and brain remain poorly understood. Unfortunately, the early obsession with hysteria may have led doctors down the wrong path--a path many are still following a century later.
Most biologists today would agree that "mental illness" is a metaphor, and most would probably agree that the psychodynamic concepts on which psychiatry is founded have little or no scientific basis. Szasz considers mental illness to be political--a failure by the patient to abide by the social rules of behavior. The patient cannot be "cured", because he or she is not really sick, but has failed to adapt to the social rules using gamesmanship. There is much to be said for this view. However, Szasz leaves himself open to criticism when he considers all psychiatric disorders to be social constructions. Some disorders once regarded as psychiatric, such as depression, are now thought to be predominantly, if not exclusively, physical disorders of the brain. Szasz's characterization of these disorders as mythological has hindered acceptance of his other ideas.
Szasz performed a valuable service in pointing out that nonphysical disorders which cannot be measured, even in principle, cannot properly be classified as diseases; the general failure of psychiatry to make progress toward a cure of such disorders has convinced even those who disagree with Szasz that psychiatry has a faulty theoretical basis. The question of whether socially disruptive behavior in physiologically normal individuals should be medicalized (as is done routinely today, even in children) is one that society has still, fifty years later, not fully grappled with.
odern psychiatry," says Thomas S. Szasz in his most scathing indictment yet of the field of psychiatry, " ... is a monument to quackery on a scale undreamed of in the annals of medicine."
These words may earn him some choice comments from professional psychiatrists, and even win him a few free diagnoses. But over the past half century, Dr Szasz has convinced many that what we commonly refer to as "mental illness" has very little to do with disease, and much to do with social politics. At first, it appears that Szasz is finally going to take on a critical issue that his previous work overlooked: if mental illness does not exist, then what on earth is wrong with all those so-called crazy people?
According to Szasz, there might be many things wrong with them, none of them medical. In some cases, the patient could be pretending, out of a wish to be pampered as if he or she were sick and to be excused from ordinary social responsibilities.
One can easily envision other scenarios where ordinary social interactions result in a normal person being diagnosed with psychosis. For example, the person might simply choose to engage in behavior that, for one reason or another, annoys the heck out of other people. In response, they define his or her behavior as a disease in order to delegitimize the behavior and find a doctor who, they hope, will validate their assertions. If successful, they can then use the power of the State to further delegitimize the patient's behavior, imprisoning the patient and injecting him or her with incapacitating drugs. No matter how the patient responds to this treatment, it would be misinterpreted by the physician in terms of the prevailing orthodoxy, and would only confirm the doctor's initial diagnosis. If Szasz is right, and situations like this are what's really happening in schizophrenia, "quackery" would be a gigantic understatement.
However, The Science of Lies does not proceed along these lines, but instead returns to the main topic of Szasz's recent work: historical accounts of the charlatanry that suffused the works of the founders of psychiatry, including Freud and Charcot, and the later practitioners of psychoanalysis. Those interested in mythbusting will find this short book fascinating and engagingly written. Those who hope to hear an explanation of how such things as schizophrenia and depression can be imaginary will once again be disappointed.
s a medical researcher who has spent over twenty years studying the brain and its diseases (not counting one brief unproductive period where I got stuck in a lab studying the neurochemistry of the liver), I have found myself agreeing more and more with the ideas of the heretic Thomas Szasz, whose lifelong ambition has been to convince the world that "mental illness" is a myth.
My brief study of liver psychology was uneventful, but had one benefit: the realization that, in the absence of organic disease, the behavior of the brain--that is, the mind--can no more be in a disease state than the behavior of the liver. The mind is the software program that runs on your computer. Unlike the Windows software we're all familiar with, it's impossible for it to crash: the hardware can break, to be sure, but failing that, anything else is a value judgment on your behavior imposed by society. As proof, says Szasz in this devastating indictment of psychiatry, if the cause of a psychiatric disorder were ever found, it would cease to be a mental disease, and be reclassified as a real brain disease, for which incarceration and coercive treatment would be illegal.
Declaring someone in need of psychiatric treatment is society's way of saying that nothing that person does has any intrinsic meaning. It is the ultimate form of imposed irresponsibility. By general agreement, we are thereafter permitted to ignore anything that person has ever said or done. It is our way of declaring someone an "unperson." We can impose whatever treatment we wish on an unperson: surgically mutilating their brain, injecting them with behavior-suppressing drugs, electric shocks, and perpetual imprisonment. It is no exaggeration to call this, as Szasz does, a form of torture. Szasz provides a history of these treatments as seen by a skeptic: lobotomies, electroconvulsive therapy, toxic psychopharmaceuticals, forced drug treatment of misbehaving children, and involuntary confinement in conditions that are so far from therapeutic that it calls into question their stated purpose. Szasz reserves his harshest words for the atrocities committed by the Kennedy family on Rosemary Kennedy, the oldest sister of JFK. Rosemary Kennedy was involuntarily lobotomized solely because her mild mental retardation threatened the political aspirations of the Kennedy family.
Now, a new generation of pseudoscientists have entered the field, using every technique imaginable to search for evidence that political dissent is also a form of disease. It's easy to imagine where this could lead: the leaders of whichever party is out of power could someday find themselves subjected to surgical experimentation or to involuntary hospitalization, as was done in the Soviet Union.
It may seem incredible, but many patients actually crave being judged irresponsible as a way to absolve themselves from their past behavior and escape from the terrible social stigma placed upon them by their failure to conform, to obtain the medications they believe will make them happier, and to escape the blame for the behavior that so disturbs the people around them. For others, unstoppable emotional feelings seem to dominate every waking moment and suffocate their well-being: crushing depression, rage, and even delusions or hallucinations.
One such person of my acquaintance insisted that her depression and stress-related behavioral difficulties were part of a physiological disease that needed medication to keep it under control. This allowed her to blame her occasional bad behavior on the disease. Yet it was clear that what she really needed was relief from the oppressive judgment of others. Given a change in lifestyle, a suitable period of detoxification from the many prescription drugs she was taking, and an occasional pat on the back (or, perhaps, an occasional sock in the mouth, depending on which therapeutic doctrine you subscribe to), those "psychiatric" problems might have evaporated like the morning fog.
One need not be a libertarian to realize that when the State uses its enormous power to imprison people on the basis of what is essentially an arbitrary judgment of their behavior, it is a form of tyranny. Szasz says that people who complain about their own behavior are classified as neurotic, and persons about whose behavior others complain are classified as psychotic. There is no objective, scientific way of distinguishing either group from normal individuals. Psychiatry has made zero progress in understanding the causes or in finding cures for mental illnesses. Szasz argues that there is a very good reason for this: brain diseases exist; mental illness does not.
Yet some fundamental problems remain: Szasz seems to ignore the fact that some people appear to genuinely believe they are Napoleon or that the neighbor's dog is telling them they must sauté the postman in Béarnaise sauce. Surely there is more to such cases than a simple mistaken belief. Psychiatrists might also argue that, in the case of depression, temporary imprisonment might be justified if it prevents a person from committing suicide. Szasz's extreme, unqualified language allows others to dismiss his ideas as zealotry. Yet his main points remain valid and, indeed, are gradually becoming accepted within the scientific community.
Szasz is not calling for us to empty the psychiatric hospitals and allow homicidal lunatics to roam the streets. His courageous, and occasionally overstated, call is intended to remind us that it's wrong to forcibly treat patients, and to make researchers realize that we have been traveling the wrong path for over a century. As proof, we need only ask: what do we have to show for it?