Review: C. V. Haldipur, James L. Knoll IV, and Eric v. d. Luft (eds.), Thomas Szasz: An Appraisal of His Legacy. Oxford: Oxford University Press, 2019. xv and 298 pp. ISBN: 9780198813491
Alexander Dunst, Paderborn University, Germany
70 years after the publication of The Myth of Mental Illness, the book’s enduring impact can seem puzzling. Built on a series of outrageous simplifications and argumentative slips, Szasz’s polemic generalized its denial of mental illness from an understanding of hysteria as “malingering“, never engaged with the intricacies of long-term care it sought to deny to patients, and upbraided the sick for cheating the healthy. Nevertheless, Szasz emerged as the pre-eminent critic of psychiatry in the United States. He at once relished this status and vehemently distanced himself from the left-wing practitioners and theorists, from Franco Basaglia to Michel Foucault, that he was often lumped with. Szasz’s distinction was to be the only conservative so-called anti-psychiatrist, and his writings were feted by right-wing intellectuals and the counterculture alike. For patients and radical psychiatrists, The Myth of Mental Illness promised to remove the stigma of disease and seemed to offer freedom from paternalistic institutions. Despite its numerous shortcomings, then, Szasz’s work proved useful to a wide range of readers and inspired an institutional practice of mental health that combined self-help, state neglect, and psychopharmacology under the aegis of personal autonomy.
Unfortunately, Thomas Szasz: An Appraisal of His Legacy fails to answer, or even seriously ask, how his flawed ideas could have such enormous consequences. The editors and authors are psychiatrists and analytic philosophers and have surprisingly little to say about the real-world contexts of their subject’s writing, either at the height of his career or in our present moment. Neither does the volume contain contributions by former patients, a particularly disappointing oversight because the social movements that formed against institutional psychiatry were an important locus of Szasz’s reception in the United States and abroad. Instead, the chapters largely focus on his philosophical influences, extend Szasz’s reflections on psychoanalysis, suicide, and schizophrenia, or apply his writings to legal and theoretical issues in contemporary psychiatry.
A historical appraisal of Szasz’s legacy must therefore move along the edges of the volume’s dominant concerns. Many of its contributors note the significant impact The Myth of Mental Illness had on their professional development and testify to their lasting friendship with its author, lending the publication the air of a posthumous Festschrift. Even the contributors that disagree most strongly with Szasz assert his importance to critical debates within a field dominated by biomedical assumptions. Such personal testimonies reveal Szasz’s continued appeal to a small minority of philosophically minded psychiatrists. Coming from a generation of researchers that underwent graduate training in the 1960s or soon thereafter, these comments also emphasize the historical situatedness of Szasz’s critique. Writing with real rhetorical verve, Szasz attacked institutional psychiatry where and when it was weakest, exploiting the uncertain etiology of major mental illnesses as the psychodynamic consensus of the postwar years unraveled.
Throughout his writings, Szasz built on the central opposition between physical and mental illness. Adopting Rudolf Virchow’s definition of disease as cellular pathology, Szasz denied that psychological suffering could constitute an illness, or that it involved any suffering to begin with. If all illness was physical in this purposefully narrow sense, then mental illness was merely a metaphor or myth—a rhetorical ploy “to force others to provide for one’s needs“ (Szasz 171). This notion of myth was inspired by Gilbert Ryle, who saw the mind as a philosophical category mistake. Yet, it seems to have been Szasz, rather than any of his conservative forebears, who reinforced this argument with a psychiatric voluntarism that was breathtaking in its lack of empathy: So-called mental illness was merely an abdication of personal autonomy and society owed little to those who shirked responsibility in this manner. There was one decisive exception for Szasz—involuntary treatment. In the late 1960s and early 1970s, he founded two organizations that fought forced hospitalizations in court. The results, coming as large psychiatric hospitals closed, were decidedly mixed. Although some wards were rife with abuse and the quality of treatment varied considerably, Szasz and his followers saw no need to extend care to those freed from hospitalization. The only person worthy of attention became the freely contracting participant in a capitalist marketplace, the individual who paid for therapy out of their own pocket.
Several contributions to the volume point to the fallacies of this philosophy—Szasz’s misreadings of Virchow, Thomas Hobbes and Ryle, and his naive positivism that at once idealized medical science and denied any role for public health. In a memorable passage, the psychiatrist Allen Frances recounts that Szasz refused to treat severely ill patients during his residency in Chicago. When ordered to do so, he moved to Syracuse where he exclusively saw outpatients for the rest of his career. The man who routinely dismissed mental suffering, who railed against the laziness and stupidity of people with severe psychological problems, never actually worked with them.
Given these accounts, it’s difficult to agree with the praise accorded Szasz throughout the book, from describing his unmatched analytical rigor to lionizing him as the greatest defender of patient rights since Philippe Pinel. In part, these adulations stem from shared commitments, such as rejecting “statist medicine” (60). This opposition to public healthcare is widely shared in the United States, where it extends to a medical establishment that benefits from the inflated costs charged by private hospitals and resident doctors, pharmaceutical and insurance companies. Although Szasz was often dismissed out of hand by mainstream practitioners, his program shares more with the psychiatric status quo than may be apparent. As early as 1961, Szasz advocated a mental health policy that married conservatism with libertarianism and anti-communism, the main pillars of the Republican party that emerged under Ronald Reagan. Reagan had already implemented drastic cuts for psychiatric care during his time as governor of California, and state budgets have only shrunk further since. On the one hand, these measures have instituted a modern version of laissez-fare capitalism, with intensive psychotherapy for wealthy individuals and cheaply produced but highly profitable medication for the masses. On the other hand, a punitive regime has built on the moral condemnation that Szasz personified, pushing the desperate and needy into poverty and homelessness. For thousands, prison terms have replaced the mental hospitals that campaigners decried as incarceration. Szasz himself might have found punishment more palatable than treatment. For their part, patients and mental health workers proved pawns in a cynical, yet effective, game of cutting costs while crying freedom.
References
Szasz, T. S. (1971) The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. New York: Harper & Row.