Psychiatrists Under Attack: The Rebellious Dr. Szasz

The most outspoken critic of modern psychiatric methods is Thomas S. Szasz, a practicing psychoanalyst and author of several controversial books about the practices of his colleagues. Edwin M. Schur, a sociologist and Yale-trained lawyer, who teaches at Tufts University, assesses Dr. Szasz's criticisms, including the charge that many psychiatrists willfully abuse the constitutional rights of their patients. Mr. Schur is the author of CRIME WITHOUT VICTIMS and other books.

by EDWIN M. SCHUR

AT THE 120th annual meeting of the American Psychiatric Association, held in Los Angeles in May of 1964, a leading psychiatrist, Dr. Henry A. Davidson, delivered a paper entitled “The New War on Psychiatry.” Readers may be surprised to learn that the “war” in question was felt to emanate not from religion, not from nonpsychiatric medical colleagues, nor even from the social sciences, but rather from a fully qualified and practicing psychiatrist, Thomas S. Szasz, professor of psychiatry at the State University of New York’s Upstate Medical Center in Syracuse. Szasz has proclaimed that mental illness is a “myth,” and warned that America is drifting steadily and ominously toward the “therapeutic state.”

Reaction to his charges has varied widely. His Law, Liberty and Psychiatry (1963) was termed “interesting and provocative” by Arthur Goldberg, then a Supreme Court Justice, in a lead review for the American Bar Association Journal. Lawyer Edward de Grazia, writing in the New York Times Book Review, called it “an informed, inspired credo of fair treatment for all persons charged with being mentally ill.” Novelist George P. Elliott lauded it in Commentary. Yet the same work was described as “pernicious” and its author charged with “reckless iconoclasm” by Manfred S. Guttmacher, an eminent forensic psychiatrist, in an article devoted entirely to a critique of Szasz’s writings. Another psychiatrist, Bernard Diamond (who teaches at the law school of the University of California), termed it “irresponsible, reprehensible, and dangerous.”

Szasz, who many feel is making a major contribution to psychiatric thinking, came to this country in 1938 from his native Hungary, graduated from the University of Cincinnati, where he also received his medical degree in 1944. He later took psychoanalytic training at the Chicago Institute for Psychoanalysis. He has been at Syracuse for nine years, and maintains a part-time private practice in psychiatry and psychoanalysis.

Szasz perhaps first gained national prominence with the publication in 1961 of The Myth of Mental Illness. The basic argument of his book — that both our uses of the term “mental illness” and the activities of the psychiatric profession are often scientifically untenable and morally and socially indefensible — was bound, as its publishers claimed, to “create great professional furor and public controversy.” Far from dying down, this controversy has been vigorously fanned both by the angry retorts of the professed defenders of psychiatry and by the further writings of Szasz himself. He has since published Law, Liberty and Psychiatry, The Ethics of Psychoanalysis (1965), and Psychiatric Justice (1965), and has written more than one hundred articles, for professional journals and general periodicals.

It is no exaggeration to state that Szasz’s work raises major social issues which deserve the attention of policy-makers and indeed of all informed and socially conscious Americans. What exactly is he trying to say?

Perhaps the kernel of Szasz’s theory is the assertion that mental illness is in its most significant aspects different from rather than similar to conventional (organic) illnesses. Basically, Szasz insists, most of the conditions we now label “mental illness” are in fact “problems of living.” Since they do not involve organic pathology, but instead most crucially relate to patterns and problems in the area of interpersonal relations, their “diagnosis" as pathological does not really involve the same sort of scientific enterprise as the diagnosis of, say, a broken leg or a ruptured appendix. On the contrary, a kind of “judgment” enters into most psychiatric diagnosis; the diagnoser, in effect, “decides” that the person is “sick” rather than simply different, confused, difficult, or unhappy. The fact that such “decisions” are possible means that there is considerable leeway for arbitrary, excessive, and even biased labeling of people as mentally ill. Furthermore, if mental illness is not like physical illness, why should we assume that the medically trained psychiatrist is pre-eminently qualified to treat it? Partly because of their vested interests, Szasz claims, psychiatrists have glossed over the differences between physical and mental illness, and have insisted on the humaneness and efficacy of treating mental disturbance as a strictly medical problem.

Particularly offensive to Szasz is the assertion that whatever the psychiatrist does must be accepted as being “in the best interests of” the “patient.” Here, he feels, we must distinguish between different types of allegedly therapeutic situations. Because of its open, free, and confidential nature, and through techniques aimed at increasing self-knowledge, insight, and interpersonal competence (in short, autonomy), private and purely voluntary therapy, particularly psychoanalysis, holds out real hope for helping some people who themselves feel that they have serious “problems of living.” On the other hand, “involuntary therapy” is a contradiction in terms. You cannot help a person against his will; and above all, it is quite specious to insist, when you attempt to do so, that it is for the person’s own good. For these reasons, the public “uses” of psychiatry — primarily in providing expert testimony in criminal trials, and in arranging the involuntary and indefinite commitment to mental hospitals of persons who have not committed any crimes — go well beyond the scientific bounds of the psychiatrist’s legitimate understanding-andhealing role and constitute an immoral lending of psychiatric authority and power to the nonscientific task of social control. In the process of operating to the individual’s general detriment, such action may often produce serious violations of his basic constitutional rights. The danger of abuse is heightened, Szasz warns, by the tendency nowadays to seek psychopathological explanations of many social problems; this may even encourage individuals to “play the sick role” and to convince themselves that they are not in any way responsible for their own behavior.

Tans background may be helpful in clarifying some of Szasz’s major themes. Among his most effective points is the reminder that elements of conflict and relationships of power are involved in many psychiatric decisions. Szasz hammers away at this theme repeatedly in both Law, Liberty and Psychiatry and Psychiatric Justice, particularly in those sections where he discusses the nature and uses of court proceedings leading to involuntary mental hospitalization. Since around a quarter of a million Americans are committed to mental institutions each year, these proceedings obviously constitute a highly significant mechanism of social control.

Quite apart from the allegedly “scientific” assessments involved in commitment proceedings, it must be recognized that the participating individuals — the “patient,” relatives or others petitioning for commitment, the psychiatrists in the case, and the judge or jury — are engaged in a web of social interaction. They are doing things which affect other people; furthermore, they have interests of their own which in one way or another they seek to further. As Szasz correctly notes, people “put away” other people partly because they don’t want them around. Unfortunately, as in much of his writing, the impact of significant and undeniable assertions tends to be undercut by his rather extreme way of stating them. For example: “Quite often, husbands and wives who commit their mates act like the bosses of crime syndicates. They hire henchmen — psychiatrists — to dispose of their adversaries.” Nonetheless, there clearly is some truth here. We also know that however well intentioned its imposition, “mental illness” is a socially discrediting label to pin on anyone. These facts, together with the deplorable conditions and inadequate psychotherapeutic facilities existing in most public mental hospitals, force us to question whether the proceedings are really in the best interests of the committed individual.

Szasz, however, seems to take the position that such commitment can never be for the good of the patient, a stand which certainly may be questioned. The possibility that the behavior for which the person is committed might reflect an unconscious cry for help is apparently vitiated, in Szasz’s view, by the extreme unlikelihood of any useful therapy being provided within the context of involuntary commitment. Szasz also disagrees strongly with the “dangerousness” rationale often cited in discussions of commitment. He would not accept dangerousness to oneself as a legitimate basis for curbing individual freedom: “In a free society, a person must have the right to injure or kill himself.” As for dangerousness to others, Szasz notes that not all dangerous people are incarcerated (for example, drunken drivers). A person’s “dangerousness” becomes a matter for legitimate public control, Szasz argues, only when he actually commits a dangerous act. Then he can be dealt with in accordance with regular criminal law. Any curbing of individuals for potential dangerousness is unwarranted. Obviously, very thorny moral issues are involved here.

At any rate, compared with the suspected or acknowledged criminal, the person declared to be or even thought to be mentally ill fares very poorly in the courtroom. Szasz vividly demonstrates that the rights we would ordinarily accord to an “accused” are largely ignored in proceedings involving involuntarily labeled mental patients. Such a person may be indefinitely confined in a mental hospital without having committed any criminal offense, and without a court trial. far from having a “privilege against self-incrimination,” he may have been incarcerated on the basis of information he had himself given a psychiatrist. He may be committed to a mental hospital without adequate specification of the charges against him, without being adequately apprised of his legal right to challenge the proceedings. Often, no psychiatrist speaks “for” him, and no lawyer represents his interests. Once committed, he may not be adequately informed of his right to seek release. Legalists may insist that many times the proceeding for commitment is a “civil” one; nobody is “charged” with anything, nobody is being “proceeded against.” Surely Szasz is right in arguing that such distinctions are more rhetoric than fact. Incarceration in a mental hospital is a form of punishment; indefinite involuntary commitment may be quite analogous to a “life sentence.”

SZASZ is especially disturbed about the use of psychiatric diagnosis as an alternative to criminal prosecution and conviction. In Psychiatric Justice he shows how a person charged with a criminal offense may be denied the right to trial as a result of court-ordered pretrial psychiatric examination. If declared unfit to stand trial, he may be incarcerated in a mental hospital indefinitely, while the prosecution need not bother proving his criminal guilt. In effect, “The individual subjected to such an examination is imprisoned first and tried later, if at all.” His “sentence” under this “humane” procedure may well be greatly in excess of the maximum sentence he could have received if proceeded against on the criminal charge.

Through lengthy case studies Szasz reveals the dangers of abuse inherent in this procedure. Consider the case of Mr. Louis Perroni (a fictitious name). Perroni felt he was being “pushed around” by real estate developers who sought legally to take control of a gasoline station he had leased for ten years. When agents of the developers attempted to take over the station, the enraged Perroni took out a rifle and fired a warning shot in the air. He was arrested but never brought to trial. At the request of the district attorney, the court ordered him to undergo pretrial psychiatric examination to determine his fitness to stand trial. Found incompetent by two court-appointed psychiatrists. he was committed to a state hospital. With the help of relatives he made continuous attempts to secure his right to be tried, but it took six years before he could get a judge’s order that he either be tried or discharged. He was arraigned. but instead of being either indicted or released, he was ordered to submit to another pretrial examination. At this point, Perroni’s family and lawyer sought the help of Dr. Szasz, who examined the “patient” and determined that he was competent to understand the charges against him and to assist in his own defense. Despite indications that Perroni did know what was going on in the courtroom and the fact that he did participate in preparations for the hearing, on the testimony of the two doctors for the state he was again found incompetent to stand trial and recommitted to the hospital. At the time Szasz wrote, Perroni (who before the shooting incident had had neither a police record nor any contact with psychiatry) had been incarcerated for nearly ten years.

Also strange and frightening is the case of General Edwin Walker, the right-wing retired military leader who played a dramatic and controversial role in the resistance to the enforced enrollment of James Meredith, a Negro, at the University of Mississippi in 1962. There is some dispute regarding Walker’s actual behavior in these events; perhaps all one can say with certainty is that it was both vigorous and anti-desegregationist. Walker was arrested and charged with various violations of federal law, but while being held pending the posting of bond, he was suddenly whisked off by federal plane to the U.S. Medical Center for Federal Prisoners in Springfield, Missouri. This step was taken on the basis of an affidavit made by the medical director of the Federal Bureau of Prisons, who attested (without ever having examined Walker, but on the basis of news clippings, past testimony of Walker before a congressional committee, and past military medical reports on him) to indications of “sensitivity and essentially unpredictable and seemingly bizarre outbursts of the type often observed in individuals suffering from paranoid mental disorder.” Because of his standing and the publicity the case received, Walker was able to obtain his release from the hospital on bail, to choose the psychiatrist who would examine him, and eventually to take his case before a jury, which failed to indict him. As Szasz notes, these “breaks” are most unusual; “anyone but a Very Important Person is defenseless against the prosecution’s ostensibly benevolent ‘suspicion’ that he is ‘too sick’ to stand trial.”

The Walker case is particularly disturbing because it seems fairly clear that the government was simply using psychiatry to “get” Walker for his views and activities. (The celebrated case of Ezra Pound, discussed in Law, Liberty and Psychiatry, was probably in some ways similar.) If one accepts such a move, the possibilities for declaring undesirables mentally ill would seem to be almost unlimited. It is a sobering thought for any politically committed person to consider his likely position under a regime in which his political opponent could freely wield the psychiatric ax. (This is a point Szasz brings out forcefully in a review of Valeriy Tarsis’ work Ward 7.) Considering the fact that we already hear psychiatric “interpretations” of social movements as variable as those for civil rights, student autonomy, peace, and sexual freedom, the lesson of the Walker case may not be learned any too soon.

I find myself considerably less taken, however, with another line of Szasz’s argument: his opposition to allowing a plea and finding of “not guilty by reason of insanity” in criminal trials. This is an issue that has plagued both lawyers and psychiatrists for a long time. Under what circumstances should the defendant’s state of mind at the time of the criminal act (as subsequently determined at the trial, of course) cause him to be held not criminally responsible for that act? For years forensic psychiatrists and others have complained of the rule, established in M’Naghten’s Case (1843), that “to establish a defence on the ground of insanity, it must be clearly proved that, at the time of the committing of the act, the party accused was labouring under such a defect of reason, from disease of the mind, as not to know the nature and quality of the act he was doing; or, if he did know it, that he did not know he was doing what was wrong. . . .”This right-or-wrong test, they have argued, has no sensible relation to generally accepted psychiatric terminology and diagnostic categories. An opinion of the Federal Court of Appeals for the District of Columbia, in Durham u. U.S. (1954), establishing a broader and more medically acceptable rule (“that an accused is not criminally responsible if his unlawful act was the product of mental disease or mental defect”), was widely hailed by mental health “progressives” as a step toward a more coherent handling of the insanity plea. If anything, this rule bothers Szasz even more than does the right-or-wrong test. It represents “a move away from a Rule of Law toward a Rule of Men.”

Szasz in fact insists that the insanity plea should be completely abolished. Mental illness, he asserts, “should never be accepted as a release from criminal responsibility. . . . Everyone accused of breaking the law should be tried.” The only exceptions would be for temporary postponement of the trial in cases involving especially severe psychiatric conditions (such as catatonic stupor) where a person is obviously unfit to stand trial. But once the trial takes place, it should not include an attempt at a reconstruction of the defendant’s earlier state of mind. One gathers that Szasz feels there is only one scientifically and morally honest procedure: a person found by a jury to be guilty of a specific criminal offense should be punished for it. Not only should the offender face up to this possibility, but the court also must accept its responsibility. It should not ask the psychiatrist “to give it assurance that it can proceed with punishment without feeling guilty” (a key function of the insanity defense, according to Szasz). In line with this last point, Szasz cites some instances in which the insanity defense was interposed by the prosecution, despite the apparent insistence by the defendant that he simply be tried on the issues and found either guilty or innocent.

Szasz wants all defendants held responsible even if they would choose to plead irresponsibility at the time of the offense. Partly this view rests on the realization that those found “not guilty by reason of insanity” invariably face indefinite incarceration in a public mental hospital. Because “treatment” cannot be meaningful in such a context, Szasz considers it more honest to place such people in prison; treatment facilities, where necessary, can be provided in the prisons. In his overwhelming contempt for compulsory hospitalization, Szasz may well exaggerate the potential benefits of imprisonment. Furthermore, he does not deal adequately with the fact that in most cases where insanity is voluntarily raised as a defense, not prison but execution may be the alternative. Szasz states that he is opposed to capital punishment too, but in the absence of its abolition his insistence on holding the defendant responsible would have harsh consequences indeed.

IF SZASZ frequently states his case in an extreme form, nonetheless he almost always challenges us to confront significant and perplexing issues. It has been said that a democratic rule of law is grounded in the “principle of legality" — sometimes summarized in the maxims “no crime without law” and “no punishment without crime.”Yet the traditional legal goals of specificity and uniformity have tended to fade into the background in recent attempts to take advantage of scientific expertise. “Individualized justice” has become the byword in many situations, including, for example, the juvenile court (where adjudication depends much less on proven guilt of a specified offense than on a total evaluation of the juvenile’s social and psychological makeup and potential). Although tailoring the “treatment” to the “total individual" sounds progressive, there are numerous possibilities for abuse. (The adjudicated “delinquent,” like the person declared “mentally ill.” can often be incarcerated for a term in excess of the maximum sentence he might have received if convicted of the same behavior under ordinary adult criminal law.) Szasz may be excessively fearful of psychiatric power-wielding, but the need occasionally to protect people from those who seek to “help" them is a real one. Some of the specific reforms urged in Szasz’s books, such as an increased role for the legal profession in this area, and an independent watchdog agency to look out for the interests of hospitalized individuals and those threatened with commitment, would probably help to provide a more reasonable protection of the mental patient’s rights.

It is one thing, however, to urge legal control over expert activity, and another to charge the experts themselves with duplicity and self-serving machinations. It is true that a good many psychiatrists earn their living through forensic work or in government employ. And it is also accurate to note that psychiatrists “need” patients both financially and to “validate” their professional role. Nonetheless, Szasz has exaggerated these factors in discussing psychiatric motivation.

He glosses over the crucial fact that most psychiatrists simply do not view mental illness the way he does (as primarily an imposed definition, rather than an objective fact); they are quite sincere finding psychopathology where he would argue they are creating it. Professional critics of Szasz’s work claim, in fact, that he comes close to denying completely the existence of “unconscious” motivation. Whereas some conventional psychiatrists may seem to assume the existence of mental illness whenever there is the slightest possible basis for doing so, Szasz goes to the other extreme of assuming the individual’s mental health, even in cases of extremely aberrant behavior.

The distaste Szasz feels for the public uses psychiatry seems to have led him into some broad statements which, at least on first glance, reflect a political philosophy that is extremely conservative. For example: “The spirit of the welfare state, inflamed by the therapeutic ambitions of the mental health professions, is inimical to individual liberties and the institutions of a free society that make such liberties possible.” According to critics, some of Szasz’s works have been cited with approval and even distributed by extreme right-wing groups. It must be admitted that statements such as that above and his frequent disapproving references “collectivism” (of which psychiatric injustices seem to him to be a symptom) provide considerable ammunition to those who oppose all government efforts to ameliorate social inequities and to provide for the general welfare. One gathers that Szasz conceives of his position on psychiatric injustice being apolitical; his sole concern is protection the individual. Certainly his efforts to protect the civil liberties of mental patients are in a fine libertarian tradition. Furthermore, in some of his writing he seems implicitly to endorse as alternatives to psychiatric intervention a broad range of welfare measures: “The poor need jobs and money, not psychoanalysis. The uneducated need knowledge and skills, not psychoanalysis.” But his gratuitous gibes at the welfare state, together with his call for less imposed “helpfulness” and more individual responsibility, could well play into the hands of those who would require every individual, whatever his capacities and whatever his resources, to fend for himself in all matters. In his efforts to challenge the complacency of conventional thinking about psychiatry, Szasz may indeed have let the heat of the argument get the better of him.

At the same time, by forcing psychiatry acknowledge the moral dilemmas and social relations involved in its activities with “patients,”Szasz has performed an important service. Quite probably he has done more than any other man to alert the American public to the potential dangers of an excessively psychiatrized society.