Thomas Szasz, R.I.P.

The Cato Institute is sad to report the death of the trailblazing and iconoclastic critic of psychiatry Thomas Szasz, professor of psychiatry emeritus at the Health Science Center, State University of New York and Cato adjunct scholar. He was 92.

Szasz advocated for individual liberty from a substantially different point of view than most libertarian intellectuals. Rather than focusing on economic arguments or political philosophy, Szasz focused on personal responsibility and how the institutions and practices of modern psychiatry fundamentally undermine the rights and responsibilities of individuals.

In the 1950s and 60s, psychiatry was in a dark place. Thanks to movies like One Flew Over the Cuckoo’s Nest, people are now aware of the profoundly disturbing practices that took place within the walls of mental institutions: lobotomies, electro-shock treatments, and involuntary medication. At the time, however, the practices were part of a profession that saw itself in a golden age. The emerging science of the brain disorders—which had been neatly categorized in the first edition, 1952, of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I)—seemed to promise the slow systemization and categorization of divergent behaviors into a predictable and scientific study of human behavior. Vague words like “neurosis” and “psychosis” were casually thrown about by doctors as objective classifications. If a doctor deemed someone to be “neurotic,” then he could be involuntary committed and subjected to the aforementioned tortures.

In some ways, this “golden age” of psychiatry parallels the false “golden ages” of other disciplines—times when too much knowledge was presumed and too much power granted. The command and control economies of the 20th century are an obvious example: Brilliant people “cracked the code” of the economy and all they needed for a more rational social order was better data and more control. Such overestimations of knowledge often precede claims for broader power. In some sense, Szasz’s war against psychiatry can be viewed in the same light as Hayek’s war against planned economies: an opposition to state-backed conglomerations of power masquerading under the pretense of knowledge.

The psychiatry profession has a lot of power. They can exonerate murderers by deeming them insane. They can institutionalize people against their will. And they do this all based on the trust the “system” has in their subjective determination of what is or is not an aberrant behavior.

Szasz had a problem with this system. As he wrote in the in the preface to the 50th anniversary edition of his most famous book, The Myth of Mental Illness:

I insisted that mental hospitals are like prisons, not hospitals; that involuntary mental hospitalization is a type of imprisonment, not medical care; and that coercive psychiatrists function as judges and jailers, not healers. I suggested that we view and understand “mental illnesses” and psychiatric responses to them as matters of law and rhetoric, not matters of medicine and science…If all “conditions” now called “mental illnesses” proved to be brain diseases, there would be no need for the notion of mental illness and the term would become devoid of meaning. However, because the term refers to judgments of some persons about the (bad) behaviors of other persons, the opposite is what actually happens: the history of psychiatry is the history of an ever-expanding list of “mental disorders.”

To expand on why Szasz believed mental illness to be a “myth”: If we call someone “mentally ill” without reference to a physical brain disorder but only as a “problem” with her behavior, then we are describing something that is difficult, if not impossible, to objectively quantify. We must invoke some norm to make our diagnosis more than a subjective opinion about “divergent” behavior. If homosexuality is a mental illness, then the norm of heterosexuality is presumed. If marital infidelity is a mental illness, then the norm of fidelity is presumed. Without any appeal an objective criterion we will inevitably institutionalize people based on our opinions about their personalities. As Szasz says, the obvious question always arises: “What kinds of behavior are regarded as indicative of mental illness, and by whom?”

Perhaps the most famous example of misusing the term “mental illness” is drapetomania, or “runaway slave syndrome.” But drapetomania was not the first misuse of mental illness, nor would it be the last. Szasz’s unique contribution to psychiatry was to continually refocus the question on whether there is a scientific, objective basis for asserting that certain “kinds of behavior are regarded as indicative of mental illness.” His unique contribution to libertarian thought was to focus on personal responsibility as the proper response to claims of “mental illness,” to be concerned about the involuntary incarceration of the “mentally ill” as an immoral deprivation of liberty, and to criticize the state as the most significant “whom” that defines mental illness.

Because of this focus on the state’s effect on social and scientific areas, rather than in just the economic and philosophical realms, Szasz’s work encourages libertarians to look to broader social criticisms of government. Szasz wisely questioned the implications of letting the government define “mental illness” and trusting the political forces that affect those determinations. As he wrote in The Myth of Mental Illness, “Debate about what counts as mental illness has been replaced by legislation about the medicalization and demedicalization of behavior. Old diseases such as homosexuality and hysteria disappear, while new diseases such as gambling and smoking appear, as if to replace them.”

There is something profoundly unsettling about the state having any say in defining “normality.” The state is never a passive player in these situations. Government officials have concerns and interests of their own that can fundamentally distort the perception of mental illness and “divergent” behavior. And, perhaps most importantly, the state has vast amounts of money it can use to fund research and institutions that skew the playing field in its favor. The medicalization of Attention Deficit Disorder in American public schools is perhaps the best recent example of this phenomenon. In retrospect, the mass overdiagnosis of ADD seems the inevitable result of a recalcitrant and monolithic public school system combined with a state-backed mental health establishment obsessed with psychopharmacology.

Despite the scathing criticism given to the book-length version of The Myth of Mental Illness (1961), Szasz’s critiques were arguably at the forefront of major changes in psychiatry that followed. Although many current psychology students have not heard of Szasz, they have assuredly read about the famous Rosenhan experiment. As documented in the essay “On Being Sane in Insane Places” (highly recommended), the Rosenhan experiment had eight sane, normal people admit themselves to mental institutions complaining of auditory hallucinations. They were then told to behave normally and try to convince the doctors that they were, in fact, sane. This proved nearly impossible to do. All behaviors were immediately categorized as manifestations their subjectively diagnosed “neuroses.” Moreover, whereas many of the other patients sensed that the subjects were planted there, the doctors could not be convinced.

As a result of Szasz’s work, One Flew Over the Cuckoo’s Nest, the Rosenhan experiment, and other work, American mental hospitals are no longer the horrific institutions of the 1950s. But things aren’t too much better. The most disturbing development is the total politicization of the mental health profession. As Szasz wrote in 2011:

Since that time [1961], the formerly sharp distinctions between medical hospitals and mental hospitals, voluntary and involuntary mental patients, and private and public psychiatry have blurred into nonexistence. Virtually all medical and mental health care is now the responsibility of and is regulated by the federal government, and its cost is paid, in full or part, by the federal government. In short, psychiatry is medicalized, through and through. The opinion of official American psychiatry, embodied in the American Psychiatric Association, contains the imprimatur of the federal and state governments.

Even as his scientific studies slowly go out of date, Szasz’s work will always underscore the fact that the state does not only control, it distorts. Sometimes it distorts so much that the world starts to look, well, kind of insane.

He will be missed.

For more, see Szasz’s 2003 address at the Cato Institute: Are Libertarian Principles and Psychiatric Practices: Are They Compatible?, and the Libertarianism.org lectures On Psychiatry and Religion and On Socialism and Health Care. Also, find more on Szasz at Reason here.