Thomas Szasz, MD: Philosopher, Psychiatrist, Libertarian
By Eric v.d. Luft, Ph.D., M.L.S.
Curator of Historical Collections
Health Sciences Library
Forty years ago a remarkable book appeared that immediately made its author the most famous, and perhaps also the most notorious, member of the Upstate faculty. This book, The Myth of Mental Illness by Thomas S. Szasz, claimed that there is no such thing as mental illness, and that what we call mental illness is really a contrivance of the medical community, government, and organized religion to control, oppress, and manipulate people. Reaction was swift and multifaceted. Traditional psychiatrists and psychologists were generally aghast, but the future guru of psychedelia, Timothy Leary, not yet fired from the Harvard University psychology faculty, wrote in a letter to Szasz on July 17, 1961:
The Myth of Mental Illness is the most important book in the history of psychiatry. I know it is rash and premature to make this early judgment. I reserve the right later to revise and perhaps suggest it is the most important book published in the twentieth century. It is great in so many ways scholarship, clinical insight, political savvy, common sense, historical sweep, human concern and most of all for its compassionate, shattering honesty. I have already contacted several of my colleagues and intend that everyone I meet will be exposed to your work. I am in charge of the first year graduate training at this Center and while I dont believe in required reading I shall certainly suggest with enthusiasm that this book be read and re-read. Your text states most eloquently, convincingly, systematically what a group of us here have been attempting to communicate.
Even during his 1960s heyday, Szaszs views on mental illness were always part of a small minority opinion. His influence on psychiatric and social theory has diminished since then. One of his most severe critics, Paul S. Appelbaum, wrote in Almost a Revolution: Mental Health Law and the Limits of Change (New York: Oxford University Press, 1994), p. 7:
Now, more than three decades later, [Thomas J.] Scheff, Szasz, [R.D.] Laing, and their colleagues are no longer fixtures in psychology and sociology courses. Most college and graduate students have never heard of them or their argument that mental illness is a socially derived myth. Academic critics have picked their arguments apart, and though Szasz, for one, is entirely unrepentant, many theorists who denied the existence of mental illness three decades ago are somewhat embarrassed now about their former beliefs.
But Appelbaum overstates the case. Szasz continues to represent a viable, albeit extreme, alternative to mainstream sociopolitical philosophy of medicine. Alvan R. Feinstein, Sterling Professor of Medicine and Epidemiology at the Yale University School of Medicine, writes that Szaszs most recent book, Pharmacracy, continues his long quest ... to comfort the afflicted and afflict the comfortable. ... Whether you agree or disagree, and whether you are pleased or enraged, Szasz will provoke you into an increasingly rare modern activity: critical thought.
Childhood in Budapest
Thomas Szasz was born in Budapest, Hungary, on April 15, 1920, to Julius Szász, a wealthy businessman and lawyer, and Lily Wellisch Szász. His uncle was the prominent mathematician Otto Szász (1884-1952), who did important work with continued fractions, Fourier series, and power series. Szasz enjoyed a wonderful, idyllic childhood. Not that he was happy to be a child, but he was happy to be a child in Budapest. He attended one of several academically excellent secondary schools in Budapest, the Minta Gymnasium, also called the Trefort Gymnasium because of its location on Trefort Street. Among its other famous alumni are Tódor von Kármán, Father of Supersonic Flight; Franz Gabriel Alexander, Father of Psychosomatic Medicine; Edward Teller, Father of the Hydrogen Bomb; Nobel Prize winning chemist George de Hevesy; and physicist Leo Szilard.
Fed by liberal turn-of-the-century attitudes and a long tradition of first-rate schools, Budapest in the 1910s and 1920s was a bustling center of art, science, research, and culture. Contributors to its greatness, all of them future exiles, included mathematician John von Neumann, future Nobel laureate physicists Eugene Wigner and Dennis Gabor, philosopher Michael Polanyi, and filmmaker Alexander Korda. Life in Budapest was then so vibrant that right-wing dictator Admiral Miklós Horthy, who ruled Hungary from 1920 to 1944, called it The Sinful City. George Cukor, director of The Wizard of Oz; Michael Curtiz, director of Casablanca; and so many other early Hollywood moguls, directors, and actors were born in Hungary that one of them, Adolph Zukor, had a sign in his Hollywood office: To Be A Hungarian Is Not Enough. The story goes that he would sometimes add in a whisper: but it might help.
Szaszs original ambition was to be a Hungarian poet. He had no inclination to leave his beloved Budapest. But between 1933 and 1939, with fascist winds blowing across central Europe, most of Hungarys intellectual and cultural leaders emigrated. The extreme right gained power in Hungary in November 1919, and by the end of 1920 most Hungarian Marxist, communist, and socialist intellectuals, such as the philosopher György Lukács, had fled the country in fear of their lives. Moreover, some, such as Szilard, left the country just to find jobs. Julius Szász took his family out in 1938, after the Austrian Anschluss. In the 1920s and 1930s the best universities and research centers of the west were suddenly populated by a significant number of incredibly intelligent Hungarians. During World War II, the most subtle insights at the Princeton Institute for Advanced Study and for the Manhattan Project would be discussed by their formulators in Hungarian, not English. The Hungarian mathematician John G. Kemeny, inventor of the BASIC computer language, later joked that the reason for Hungarian excellence in science and mathematics is the Hungarian language, being so much easier to learn, speak, read, and write than English, leaves Hungarian children more time to study other subjects.
Szasz received his A.B. with honors in physics in 1941 and his M.D. in 1944, both from the University of Cincinnati. He trained in medicine at Boston City and Cincinnati General Hospitals, in psychiatry at the University of Chicago, and in psychoanalysis at the Chicago Institute for Psychoanalysis. From 1951 to 1970 he was married to Rosine Loshkajian, by whom he had two daughters, Margot and Susan. From 1954 to 1956 he served in the U.S. Naval Reserve. From 1956 until he retired in 1990, he was a member of the Department of Psychiatry at the SUNY Upstate Medical Center, as it was then known, and maintained a small psychiatric practice. He gratefully recalls the camaraderie and benevolence of many of his faculty colleagues at Upstate, especially Eugene Kaplan, M.D. 57 and Robert Daly, M.D. 57 in Psychiatry; Robert King, M.D. and Charles Hodge, M.D. in Neurosurgery; and Ellen Cook Jacobsen, M.D. 50, Arlan Gottlieb, M.D., and Paul Kronenberg, M.D. 69 in Medicine. When the psychiatry offices were in University Hospital, Szasz would often eat lunch with Dr. King in the hospital cafeteria.
Szasz was the most exciting teacher in the psychiatry department from the 1950s to the 1970s, and very popular with residents. About 25 per cent of Upstates psychiatric residents at that time came to Syracuse specifically to study under him. He taught two advanced courses for residents, one on psychoanalytic theory, the other a review of contemporary psychiatric thinkers. Briefly in the 1960s he was head of the medical school teaching program in psychiatry.
Disbelief in Mental Illness
Even in retirement, Szasz generously gives his time to student groups. In a session jointly sponsored by the Humanistic Lecture Series and the Center for Bioethics and Humanities on February 22, 2001, he held an open conversation with medical students about bioethics, not lecturing, but fielding any question they asked him. When challenged about his disbelief in the reality of mental illness, he said, Show me 100 brain CAT scans, blind, that will show which patients have mental illness as reliably as 100 leg x-rays, again blind, will show which patients have fractures, and then I will believe that there is mental illness. He contends that mental illness does not exist because the medical criterion for illness is the physical lesion, which the mind, not being a material object, not being equatable with brain, is not capable of having.
Szasz decided long before he went to medical school that there is no such thing as mental illness. Some people are just plain nutty or even mad, but that does not mean that they are diseased, or indeed, that anything at all is wrong with them. The concept of mental illness evolved in Europe in the sixteenth and seventeenth centuries. Many cultures, such as the Native Americans, have no such concept, and would regard as divinely inspired or specially insightful those whom the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) would classify as sick.
There are fashions in medicine, and we need, Szasz says, some knowledge of the history of medicine in order to understand ethical issues in current medical practice. Before the Civil War, drapetomania, the tendency of slaves to run away; dysaethesia Aethiopis, the lethargy of black slaves; and negritude, the very condition of having dark skin; were all classified as diseases by many respectable American physicians. Both masturbatory insanity and homosexuality were considered legitimate diseases when Szasz was in medical school. In the former U.S.S.R., the desire to emigrate was officially designated schizophrenia. The current pervasiveness of Ritalin implies that contemporary American society regards hyperactive boys as diseased; but, Szasz observes, high levels of activity are normal for boys.
From the nosology of François Boissier de la Croix de Sauvages (1706-1767) and William Cullen (1710-1790) through DSM-IV, the systematic classification of diseases as entities is artificial and does not advance the cause of medicine, but allows physicians to pigeonhole and depersonalize patients, and assists physicians only in underserving or malserving their patients. Worse, it provides means for societal or governmental oppression of certain kinds of patients, notably the young, the old, the poor, the politically undesirable, and the socially offensive. Such people, Szasz says, tend to be abused by society, but when doctors do it, it is called treatment. He urges abolishing both the insanity defense because it excuses the guilty and involuntary hospitalization because it punishes the innocent.
Psychiatry, Szasz frequently reminds us, does not deal with diseases, but with conflicts between people. Psychiatric treatment, because it deals with unwanted behavior rather than disease, is not medical treatment, but a personal service if voluntary and a method of social control if involuntary. Psychiatrists should presume that people each have good reasons for behaving the way they do; that is, psychiatrists should feel professionally and morally obligated to respect the autonomy of each patient, rather than hastily assume that there is something wrong with the patient. Yet it remains each psychiatrists own decision whether or not to, on the one hand, help the patient, or, on the other hand, help integrate the patient into society.
Response to Critics
For Szasz, there is only one way to understand ethics, either medical ethics or ethics in general, and that is by asking the classic Roman question: Cui bono? Whom will this action benefit?
Szaszs lifes mission is to wrest artificial controls on natural individual freedoms away from politicians, clergy, physicians, lawyers, insurers, bureaucrats, etc., and return those freedoms to the individual. In this quest, he shares some territory with several prominent philosophers, such as Socrates (470?-399 B.C.E.), who was always willing to listen to what others had to say while guiding them gently toward the truth; Jean-Jacques Rousseau (1712-1778), who lamented that we are born free, but are everywhere in chains; Edmund Burke (1729-1797), who warned of the danger of liberty being gradually nibbled away by evil governments while duped citizens stand by and watch; Max Stirner (1806-1856), the anarchist individualist of the Young Hegelians; John Stuart Mill (1806-1873), the liberal utilitarian author of On Liberty; Henry David Thoreau (1817-1862), the champion of civil disobedience in defense of individual liberty; Friedrich Nietzsche (1844-1900), who urged us to use our own legs if we want to rise high and not allow ourselves to be carried on the backs of others; and Ludwig von Mises (1881-1973), the libertarian economist.
Szasz agrees with the ancient Roman stoics that suicide is a question for each individual alone to decide, without influence or coercion from any external agent. In the July 1999 issue of Ideas on Liberty, he writes that suicide is our ultimate, fatal freedom. ... For a long time, suicide was the business of the Church and the priest. Now it is the business of the State and the doctor. Eventually we will make it our own business, regardless of what the Bible or the Constitution or Medicine supposedly tells us about it. Szasz believes that suicide would include the voluntary stopping of eating and drinking (VSED), because that is entirely the decision of the patient, but would not include physician-assisted suicide (PAS), because the physician is an autonomous agent, not the moral equivalent of Brutuss slave ordered to hold the sword while Brutus runs on it. Thus Szasz holds that PAS is murder, because helping to kill the patient, even if in accord with the patients wishes, is ultimately the doctors decision, not the patients.
Szasz has published hundreds of articles, letters, comments, interviews, debates, prefaces, and rejoinders, as well as the following 25 books:
Pain and Pleasure (1957) The Myth of Mental Illness (1961) Law, Liberty, and Psychiatry (1963) Psychiatric Justice (1965) The Ethics of Psychoanalysis (1965) Ideology and Insanity (1970) The Manufacture of Madness (1970) The Second Sin (1973) Ceremonial Chemistry (1974) Heresies (1976) Karl Kraus and the Soul-Doctors (1976) Schizophrenia: The Sacred Symbol of Psychiatry (1976) Psychiatric Slavery (1977) The Theology of Medicine (1977) The Myth of Psychotherapy (1978) Sex by Prescription (1980) The Therapeutic State (1984) Insanity: The Idea and its Consequences (1987) The Untamed Tongue: A Dissenting Dictionary (1990) Our Right to Drugs: The Case for a Free Market (1992) A Lexicon of Lunacy (1993) Cruel Compassion (1994) The Meaning of Mind (1996) Fatal Freedom (1999) Pharmacracy: Medicine and Politics in America (2001)
To understand his thought, Szasz especially recommends The Myth of Mental Illness, Insanity: The Idea and its Consequences, and Fatal Freedom.
On April 15, 2000, Upstate hosted Liberty and/or Psychiatry?: 40 Years After The Myth of Mental Illness, a well-attended symposium in honor of Dr. Szaszs 80th birthday, and on May 20, 2001, at commencement, it presented him an honorary D.Sc. degree.
Additional information about Thomas Szasz, his theories, works, life, critics, and adherents may be found online at <www.szasz.com> or <www.enabling.org/ia/szasz/>.
The major repository for Szaszs papers, manuscripts, and correspondence is the Syracuse University Department of Special Collections on the sixth floor of Bird Library <libwww.syr.edu/information/spcollections/index.html>, which holds his donation of about 50 linear feet, mostly from 1949 to 1992. A small amount of historical and biographical material about Szasz is on deposit in the Special Collections Vault on the second floor of the Upstate Health Sciences Library. For access, please contact the Curator of Historical Collections by phone 464-4585, fax 464-7199, or e-mail <email@example.com>.