Dr. Thomas Szasz, who passed away in 2012, was (and still is) widely admired in libertarian circles. He was given a platform in libertarian journals and periodicals, and was the subject of numerous accolades upon his passing. He merits a full 11-page discussion (pp. 499-509) in Brian Doherty’s chronicle of the libertarian movement, Radicals for Capitalism (PublicAffairs, 2007). Although it easy to fathom the reasons for this fame and respect, it is misplaced. Even from a purely rights-based perspective, Dr. Szasz is no hero.
Szasz is admired for his battle against what he called the “therapeutic state,” i.e. those laws that authorize the courts to impose medical (specifically psychiatric) treatment on adults against their will, including involuntary commitment to mental institutions. Over the course of his long career, starting most famously with his The Myth of Mental Illness (1961), he argued that schizophrenia, bi-polar disorder, severe clinical depression, and other conditions commonly thought of as mental diseases are only “metaphoric diseases…They are problems, but they are not medical problems, in that they do not involve somatic, organic etiologies, and are thus not amendable to somatic organic resolution.” See “Curing the Therapeutic State: Thomas Szasz Interviewed by Jacob Sullum” (July, 2000), http://reason.com/archives/2000/07/01/curing-the-therapeutic-state-t.
Libertarians are united in wanting to limit the powers of the state to the greatest practical extent, or to eliminate it altogether. If the disease metaphor is inappropriate, then involuntary commitment, authorized and enforced by the political authorities, is a gross insult to human autonomy; a morally impermissible effort to control and repress unconventional thoughts and behavior. But autonomy is not an attribute possessed by every human being. In its absence, paternalism is not only appropriate, but often a duty.
For example, libertarians will (admirably) fight fiercely for the right of competent adults to own firearms, and to practice with them; to inject themselves with heroin; to take their own lives; and so on, but it would be criminally irresponsible for parents to allow their five-year child to own and use a firearm as he pleased, inject heroin, etc. If the state interferes with the supervision and discipline exerted by responsible parents in such matters, it violates their rights.
Parental rights and responsibilities do not end with respect to children who reach the age of majority, but for any number of reasons are still not able to rationally decide such things for themselves. And, subject to reasonable procedural safeguards, parents (or spouses, or others with this duty) should be permitted to protect their child (or spouse, etc.) against his or her severely self-destructive choices.
The issue then is clear: should we regard (say) schizophrenics as autonomous agents, who simply exhibit unconventional or disturbing behavior, or are they more akin to children in need of benign intervention? The overwhelming weight of the evidence is that this condition has a physiological component, which leaves the subjects in need of psychiatric care, even if it is unwelcome. Some of this evidence is scientific and technical, and thus outside of my competence to fully evaluate. Nevertheless, the critiques by Kendall, Shorter and Clarke presented in the Wikipedia entry on schizophrenia (http://en.wikipedia.org/wiki/Schizophrenia), are devastating.
Moreover, even the layman should recognize the implausibility of Szasz’s thesis. According to the Wikipedia entry, about 80% of patients given anti-psychotic drugs have a complete or partial positive response, i.e. a reduction in typical symptoms. If the behavior of schizophrenics is autonomous, why do medications typically alter it in predictable ways, rather than having no effect or random ones?
Similarly, why is there a strong genetic component to this condition, such that, according to Wikipedia, “If one parent is affected the risk is about 13% and if both are affected the risk is nearly 50%.” If what is called “schizophrenia” is simply the misdiagnosis of unconventional or “strategic” behavior, as claimed by Szasz, its distribution should be much more random, unless one wishes to adopt the implausible theory that schizophrenia is a learned behavior, passed from fathers to sons like political loyalties.
Finally, there is this. Anyone with a close relative or friend afflicted with this disease knows that Szasz is wrong, and dangerously so. Those of us who have heard the absurd, crazy, paranoid conspiracy theories expounded by a schizophrenic friend recently off his meds can never be convinced that he has suddenly and inexplicably changed his perceptions and feelings about everything and everyone around him, rather than being in the grip of something physiological. Delusions which “miraculously” end when (really, if) he goes back on his medications.
Such unfortunates often end up homeless and miserable; robbed of their human dignity and properly objects of pity. No caring person would knowingly treat a dog this way. But this is the cruel fate of many of the mentally ill.
There is no doubt that innocent persons have been, and to a much lesser extent, continue to be harmed by involuntary commitment. But this fact hardly makes mental illness a “myth,” or justifies the almost insurmountable barriers that now exist before those with severe mentally illness can be helped on a nonconsensual basis. Szasz and his followers have, in the service of a bankrupt idea, done far more harm than good.
This topic is very complex, and there are many arguments, research findings, clinical observations, and interventions. The above article does not go into these in enough depth to make a new contribution.
Two of my favorite “case studies” are “I Never Promised You a Rose Garden” and “Dante’s Cure” each of which leads readers far beyond a reductionist medical model.
Dr. Szasz wrote about cases he was personally involved in, c.f. PSYCHIATRIC JUSTICE and LAW, LIBERTY, AND PSYCHIATRY.
These books, not loved by psychiatrists, are loved by attorneys!
Always the objection comes to us Szaszophiles regarding the atypical individual with a genuine brain disease of schizophrenia, albeit less than 1% of the human population qualify, with \dangerous\ schizophrenics even far less than 1%. My friend Tom Szasz always allowed that in the tiny number of cases wherein a proven brain disease compromised agency and innocent victims were at risk, then we have a different debate.
Hi Richard:
Thanks for the comment. It would be helpful if you could supply the actual quote from Szasz on which you base this statement. Also, the relevant percentage regarding schizophrenics with genuine brain disease clearly seems to be the portion of purported “schizophrenics” correctly diagnosed as such by the medical establishment (versus false positives), not the percentage of the general population.
Finally, to the extent that Szasz acknowledges brain disease as a real cause of mental illness, then to that extent he is less a revolutionary figure, and more a doctor quibbling with other professionals regarding false positives in the diagnosis of schizophrenia (as conventionally understood).
Mark (if I may): The number of times that Tom stipulated that the discovery of brain disease wherein “mental illness” was diagnosed verified his claim that mental illness was merely a metaphor is legion. He is indeed quite a revolutionary figure, and parenthetically, he is a much plagiarized individual (not by you, of course), plagiarized by many conventional psychiatrists who claim their exceptions to mental health orthodoxy were discovered by themselves, even though they were first argued by Tom Szasz.
From /ThePsychiatric Bulletin/ 2011: “The proposition that mental illness is not a medical problem runs counter to public opinion and psychiatric dogma. When a person hears me say that there is no such thing as mental illness, he is likely to reply: ‘But I know so-and-so who was diagnosed as mentally ill and turned out to have a brain tumour. In due time, with refinements in medical technology, psychiatrists will be able to show that all mental illnesses are bodily diseases’. This contingency does not falsify my contention that mental illness is a metaphor. It verifies it. The physician who concludes that a person diagnosed with a mental illness suffers from a brain disease discovers that the person was misdiagnosed: he did not have a mental illness, he had an undiagnosed bodily illness. The physician’s erroneous diagnosis is not proof that the term mental illness refers to a class of brain diseases.”
Hi Richard (if I may):
I appreciate your supplying this quotation from Dr. Szasz. However, I do not see how it advances his argument. He states that when a physician comes to realize that a patient does not have “mental illness,” but instead suffers from “an undiagnosed bodily disease,” this “verifies” that “mental illness is a metaphor.” I’m sorry, but I can’t follow this logic. If somehow it turned out to be the case that ALL people (mis-)diagnosed with mental illness really suffer instead from a bodily disease, it seems to me that this would prove the truth of the conventional view that mental illness is caused by specific physiological conditions, i.e. it really is a disease or illness, and not autonomous, if strange, behavior.
Of course, as Szasz says, “The physician’s erroneous diagnosis is not proof that the term mental illness refers to a class of brain diseases,” but nor is it evidence to the contrary. Just to be clear, I do not deny that many people diagnosed with “mental illness” are not actually afflicted with a physiological disease, but this fact does not make mental illness a myth, it merely shows that doctors are prone to error (as are we all).
Not that this will change anyone’s mind, but: http://www.usatoday.com/story/news/nation/2014/09/15/genetic-cause-schizophrenia/15535557/.
I thank David Herman for bringing this essay to my attention. It is a part of a more extensive symposium on involuntary treatment, Szasz, and mental illness posted by the Cato Institute: http://www.cato-unbound.org/2012/08/22/editors/letters-libertarians-proposal-reform-involuntary-commitment
Would your same contention have applied to pre-1970s homosexuals, Mr. Friedman? Were they not thought to engage in appallingly anti-social and irresponsible behaviors? Is it not possible that their brains are different, as some have argued? They were classified among the most irredeemably mentally ill. They were deprived of their rights. They were treated on a nonconsensual basis.
I don’t know how you would exempt heavy drug and alcohol users, or chronic tobacco smokers, from your list of people to be deprived of rights given that the official medical (and pseudomedical) view is that they suffer from the disease of addiction, a type of mental illness considered to have a biological basis.
Although it is not uncommon, it gobsmacks me to be reminded that someone claiming to be a libertarian could endorse the empowerment of physicians to decide who gets to keep his rights, and who can be “helped on a nonconsensual basis.” What a perfectly Orwellian phrase.
“We’re from the government, and we’re here to electroshock you.”
Following Robert Nozick, I identify the source of individual rights in the human characteristic of rational agency, possessed by all competent adults. Homosexuals possess this attribute to the same degree as all other persons. Thus, in general they form friendships and intimate relationships, hold jobs or self-employ, pursue intellectual and cultural interests, enjoy hobbies, and so forth. These are objective facts. That society wrongly persecuted homosexuals in earlier times does not alter them.
Those addicted to alcohol, heavy drugs, and tobacco are still rational agents, although if the addiction and its effects are severe enough this capability may be substantially impaired. They may no longer be able to flourish in most of the ways described above. Nevertheless, because they possess free will, are still rational and thus able to understand the consequences of the choices they are making, they are able, albeit often with great effort, to overcome their addiction if they choose. Thus, as a society we wisely stay our hand. Sadly, those suffering from severe mental illness have lost rational agency altogether. They have lost their free will, and their reason. Often they are incapable even of rational conversation, let alone rational choice. This is the key distinction.
Moreover, nowhere did I say or suggest that is should be up to “physicians to decide who gets to keep his rights.” What I actually said was, “subject to reasonable procedural safeguards,” parents or other loved ones should have the right to seek a court order for involuntary commitment. This would typically involve an adversarial proceeding, with counsel, examination of witnesses, etc. Finally, your unfounded outrage is unbecoming.
You embrace the therapeutic state when it suits you, and eschew it when it doesn’t. The fact is that homosexuals were held by psychiatry to be mentally ill for many years. You descend (or ascend, depending on how you see it) this time into waxing philosophical rather than consulting and quoting the profession you believe should be empowered with determining who has agency and who doesn’t. If you think that psychiatrists will not be decisive participants in the “reasonable procedure” for depriving people of liberty, then you don’t know how it already works. Most people who are involuntarily committed have low incomes, and so are uniquely ill-equipped to hire the guns who will keep them out of psychiatric prisons. Your scheme is directed disproportionately at the poor and particular minorities.
So-called addicts are assumed to have lost agency by mental health professional, as have habitual smokers. Since Wikipedia seems to be your primary (exclusive) source, I’m sure it will confirm that.
A few years ago there was a small study of people who have been diagnosed as “schizophrenic” to determine if they were happy. Thirty-seven percent said they were happy all or most of the time. That is strikingly similar to many polls of the general public. I doubt they will be made happier upon being subjected in involuntary treatment and incarceration. But you don’t want to make them happy, you want to make them healthy.
Epileptics were another group of people imprisoned based on comparable neuropsychiatric assumptions that you apply to “schizophrenics.” Small comfort it would have presented to them to have been able to defend their liberty in adversarial proceedings.
It’s revealing that in your original post you include not a single quote from anything that Szasz wrote, which doesn’t engender confidence in your depth of knowledge of his beliefs. I don’t know why someone who posts an ostensibly serious critique of any author would do so without actually quoting from that person’s detailed writings.
Given that I’m responding to someone who advocates the imprisonment and torture of innocent people, my outrage is subdued.
Okay, I believe I have said all I need to say to you in my original post, my earlier response to you, and my replies to other, more civil, interlocutors. In the future, you will have to take your rants elsewhere, as you have worn out your welcome here.
It is interesting to me that at my public library Prof. Nozick’s book THE EXAMINED LIFE is right next to Szasz’s book THE MEANING OF MIND. So they do share common ground.
I am sure this is true. They both were staunch defenders of free will and generally opposed state coercion, unless required to protect the innocent. For better or worse, what makes for the most interesting conversation are their differences.
As a sibling of people who have endured debilitating schizophrenia, I applaud your that assertion that guardians and society as a whole have a responsibility to make decisions for adults who lack the capacity to protect themselves. However, i question the conclusion that the effect of anti-psychotic meds are proof that something is a disease or dysfunction. It’s only proof that mental condition is a biological process. Sadness at the death of a loved one is a biological process, which may be soothed with anti-depressants, but that’s not proof that sadness at the death of a loved one is a “disease”. Sadness in response to loss and tragedy, if framed appropriately, has vital therapeutic benefits to those in mourning. To drug appropriate sadness is an affront to humanness, and healthy emotional coping process. In the same way, “schizophrenia” may, sometimes, be a completely appropriate response to environmental stressors (such as abuse), and not a brain disease. Drugging it into submission may also be an affront to humanness and appropriate emotional coping. You may ask, what possible therapeutic benefit could there be to paranoid schizophrenia? We may find answers in non-Western, pre-industrial societies who intentionally, ritualistically induce a psychic break with reality as a form of collective healing.
Hi John:
Thanks for dropping by my blog and for your thoughtful comment. I’m glad we agree that those incapacitated with mental illness should not be left to suffer grave deprivation in the streets in the name of “liberty.” I’m not sure we really disagree on much. The relationship between mind/body is a complicated and undefined one, and I do not dispute that the “mind” can play a role in the onset or severity of various diseases, especially but not limited to, mental illness. However, when we typically refer to a “disease” we are adopting a physiological model, as articulated in this dictionary definition, the first one I found: “a disorder of structure or function in a human, animal, or plant, especially one that has a known cause and a distinctive group of symptoms, signs, or anatomical changes.” Example = “bacterial meningitis is a rare disease.”
So, the causation is usually, “physiological cause” brings on mental disease/illness, as in Alzheimer’s. No one, except perhaps extreme followers of Szasz, would deny that the dementia caused by Alzheimer’s has a physiological cause and is thus a disease that affects the mind, and therefore a form of “mental illness.” Again, I do not deny that extreme mental states can also cause physical illness or prolong it, including mental illness. I believe that Schizophrenia is typically like Alzheimer’s, but I agree it can be triggered by emotional factors. However, Szasz denies that Schizophrenia is ever a “disease,” and I think this is plain wrong, for the reasons set forth elsewhere in this thread.