A Long and Controversial Career: Thomas Szasz, MD

I found out about the death of Dr Thomas Szasz from a former student of mine whom I introduced to Dr Szasz’s writings during her college seminar with me last spring. I thought it ironic but appropriate that a student should be bringing this news to her teacher, rather than the other way around. That at least one young person from that small class of 15 learned enough about Dr Szasz to take notice of his death means that he will be remembered for a while longer. With most of us destined for oblivion within a generation, this may be something.

It would not be overstating matters to say that during his long career, Dr Szasz has been one of the most controversial figures in the psychiatric profession. Since the original publication of his book, The Myth of Mental Illness,¹ he has aroused a great deal of passionate debate within and outside the profession, along the way gathering many more critics than sympathizers. As someone with rather categorical and uncompromising views, he provoked similar responses in his audience. Hardly anyone familiar with Dr Szasz-and the number of those who are is likely dwindling-carries a dispassionate view of his beliefs. To the end Dr Szasz defended his ideas with an unbending will, but with the passing of the years, his message has appealed to fewer and fewer psychiatric practitioners. In a way he outlived his own teachings and died a person of apparently little relevance to most contemporary psychiatrists.

Even to those who cared to listen to him, Dr Szasz was an enigma. He called himself a psychiatrist and yet stated explicitly and unyieldingly that he believed neither in psychiatric illness nor in the legitimacy of psychiatry as a medical specialty. In his own books, Dr Szasz compared himself with “a theologian who does not believe in God.” As a hired psychiatric expert witness at the trial of Darlin June Cromer, he refused to examine the defendant on the grounds that a psychiatric examination could yield no useful information because no such thing as mental illness existed. He challenged all of us who practice psychiatry as MD’s not to practice better, or more cautiously, or more humbly; he challenged us to surrender our very identities as medical practitioners-ironically, without giving up his own public persona as a psychiatrist.

Dr Szasz hit many psychiatrists where they were most vulnerable. Having spent years proving that one was no less a physician than an internist or a surgeon, hearing Dr Szasz deny one’s professional identity was insulting, to say the least. At a time when much psychiatric practice consisted of psychoanalysis or analytic psychotherapy, Dr Szasz’s beliefs may not have aroused such a strong reaction. However, as the field changed into one built on a medical model and standing on an avowed biological basis, Dr Szasz’s claims that psychiatry was not a legitimate medical specialty became especially charged. Still as time passed, Dr Szasz’s voice appeared to be of one crying in the wilderness, eventually drowned out amidst the loud campaigns for public awareness of mental illness and the successful marketing of medications that became the most widely consumed in the history of pharmaceuticals.

And yet, if we put away the sense of being betrayed by one of our own, if we look past his transparent polemics, if we avoid mirroring the rigidity of his views, can we find something of value in what Dr Szasz had to say? A related question is whether we can put aside the sense of being always right long enough to examine the possibility of being sometimes wrong? I suggest that despite his many weaknesses, Dr Szasz asked the kind of questions that should be borne in mind not only by practicing psychiatrists but also by anyone in a position to help those with mental discomfort. What are our definitions of mental illness and mental health? How do we distinguish ordinary human suffering from pathological mental phenomena? What is the legitimacy of coercive treatment? To what extent is the patient responsible for his predicament? Who benefits when problems in living begin to be seen as illnesses requiring treatment?

In addition, Dr Szasz reminds us that to date psychiatry has not been able to escape the subject-object predicament. Whereas non-psychiatric specialties focus on observable lesions of the body, the object of psychiatric inquiry is the internal experience of the patient, something for which no reliable and patient-specific biological correlate has been found. Like it or not, that we deal primarily with the internal experience of human beings makes psychiatry more related to philosophy than to neurology. This is a far cry from Dr Szasz’s conclusion that the internal experience, by virtue of being subjective, cannot be diseased. However, it also makes patently false the claim that current psychiatric diagnosis stands on the same footing with diagnosis in other medical specialties. One important difference is that a medical diagnosis can be made in an asymptomatic patient or in one who is dead. Dementias and other organic illness aside, no “functional” psychiatric illness such as bipolar disorder, major depression, or schizophrenia was ever diagnosed on autopsy. Although there are some medical disorders such as epilepsy that can only be diagnosed in a living person, such examples are exceptions in non-psychiatric medicine but the rule in psychiatry.

We do not have to agree with all of Dr Szasz’s conclusions to profit from his inquiry into our field. After all, he, too, was only human-sometimes right, and sometimes wrong. His lasting legacy and value to the field lie in examining the very foundation of what we believe as psychiatrists. Without placing these philosophical building blocks on more or less firm ground and without noticing where cracks between them still remain, the structure we erect will crumble easily. Whereas Dr Szasz concluded that there was no emperor, we may insist that one exists while admitting that he may sometimes be found without his clothes. This will, at least, be an honest start to clothing him appropriately at all times. Rest in peace, Dr Szasz.

Reference1. Szasz T. The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. New York: Paul E. Hoeber; 1961.