Thomas Szasz: An Appraisal of His Legacy

Book Review

Edited by C.V. Haldipur, James L. Knoll IV, and Eric v.d. Luft; Oxford, UK: Oxford University Press, 2019
324 pages • $44.95 (hardcover)

I was a first-year psychiatric resident at Upstate Medical Center, at the SUNY in Syracuse. I would be dazzled and envious sitting in a seminar with the by then legendary, Dr Thomas Szasz. Everyone seemed to regard him in either a hallowed or contentious way since his book, The Myth of Mental Illness, was published almost 10 years earlier. My envy, by the way, came from wanting to have a mind like his: I was ready to make a deal with the devil if I were suddenly able to think as well as he did. His capacity to formulate, articulate, and argue ideas was as keen as was this lean, diminutive (in size) Eastern European who never lost his accent.

The seminar would end, as would my academic cocoon. It was time for me to leave the classroom and run a few blocks to the state psychiatric hospital, where my on-call would begin at 5 pm. Breathless, I arrived at the admitting office to find the Syracuse police waiting for me. They were surrounding a 250-pound agitated, psychotic man. Sometimes there would be two patients. However many, patients were generally exceptionally displeased to be held against their will. The local cops smiled and said, “Hey Doc, you’re late. Here’s your patient. We’re outta here.”

“Myth” certainly confronted the reality I experienced at that moment. As it did throughout my career as a psychiatrist. I have had to wrestle with Szasz’s ideas, especially during my years as Medical Director of McLean Hospital, Mental Health Commissioner for NYC, and, for the past 12 years, as Chief Medical Officer of the largest state mental health agency in the United States. I am grateful for Szasz’s influence on me, which has insisted that I take no ideas for granted, recognize the social power I can exercise, and try to do the right thing, even if that sometimes meant running counter to his teachings.

C.V. Haldipur, James L. Knoll IV, and Eric v.d. Luft have written what might be considered, in the best sense of the term, an encyclopedia of the work of Thomas Szasz. They have compiled an extraordinary group of psychiatrists, philosophers, ethicists, social scientists, researchers, humanists, and forensic experts-many who knew Dr Szasz personally or who had debated him in public or on paper, or both. Yet this edited compilation is not hagiography; instead, it is a penetrating, deep, and intrepid exploration of Szasz’s oeuvre, and the indelible impact he has had on the practice of psychiatry, in this country and abroad. Even if younger members of my profession (and philosophers of history and science) do not know his work, they live under its long and fulsome shadow.

Szasz’s intellectual tools were history, philosophical argument, ethics, logic, and humanism. He was a master at demonstrating how metaphor can take on the power of fact, and how it was used in ways that could erode liberty. The most renowned, and enduring, of his metaphors is the “myth of mental illness.” His work in the book so titled, and some 30 volumes and hundreds of papers that followed, brought him the mantle of being “anti-psychiatry.” But he was not; he was a libertarian who held the importance of freedom over everything else (and he was clear to also say that with liberty came personal responsibility).

Haldipur and colleagues unbundle Szasz’s vast range of intellectual productions in 19 chapters divided into three book sections in Intellectual Roots of Szasz’s Thought; The Concept of Mental Illness; and Szasz’s Larger Impact, as well as a superb summary epilogue by Dr Haldipur. The writings consider not just the material Szasz produced but the man and his compelling, often disruptive, rhetoric. The chapters draw from psychiatry, psychoanalysis (Szasz was formally trained as an analyst in Chicago before moving east), forensics, social contract theory, values, ethics, language, communications theory, and good old clinical wisdom.

The contributors do not shy away from some of Dr Szasz’s most contentious claims, including: his highly vocal opposition to involuntary hospitalization and treatment of people with mental illness; his unwavering position that suicide was a right, not to be denied people under any circumstances (hard to bear since we know the compulsion to kill oneself is usually transient-not necessarily in thinking but in action, which can result in an irrevocable act-and that those who do not die are almost always grateful they survived); that “doctoring” was inimical to helping people with “problems in living,” as was prescribing psychoactive medications; to allowing people with mental disorders to “die with their rights on”¹; and the inanity of the insanity defense.

Thomas Szasz was born in Budapest, Hungary. His educated, Jewish parents fled their native country to the United States in 1938, when Hitler invaded Austria. They understood that Hungary was next in the Nazi’s sights (as it later would be oppressed by Communism). Szasz was 18 and multilingual when he arrived in this country, speaking French and German in addition to his native Hungarian, but he spoke not a word of English. You would never know because it was in the English language he immediately excelled in medical school and medicine.

Tom Szasz, whom I knew and learned from for 50 years, was a man whose persona was warm and engaging, except when publicly delivering his polemical arguments. He meant to admonish about the unintended consequences of would-be good intentions-that individuals needed to be protected from the power of the collective. His aim was to stir, not lull, the minds of all of us entrusted with the privilege of serving people with mental (and addictive) disorders. You may not have agreed with him, but he would surely put your assumptions and conventions to the test. There was no such thing as casual thinking or parroted instruction when in a conversation with him. That was a gift, whether you felt it or not, to all who knew, read, and debated him over the decades of his intellectual prowess.

Dr Thomas Szasz died in 2012 at the age of 92. I wonder what he would think of this comprehensive, intellectually challenging, carefully and clearly written analysis of his work? While I cannot imagine what he might say from a podium, I believe, privately, he would have appreciated the rigor, range, and intelligence brought to bear in this book. For those who knew or read this extraordinary man, your reading Thomas Szasz: An Appraisal of His Legacy will light up your remembrances. For those who barely know him or his work, you will surely be amazed by his contributions, whether you think them right or not (or some of both).

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Dr Sederer’s most recent book, The Addiction Solution: Treating Our Dependence on Opioids and Other Drugs (Scribner, 2018), is now available in paperback.

For more on this topic:

Mental Illness vs Brain Disorders: From Szasz to DSM-5

In Memoriam-Thomas Stephen Szasz, MD

This article was originally published 4/24/19 and has since been updated.

Disclosures:

Dr Sederer is Adjunct Professor, Department of Epidemiology, Columbia University Mailman School of Public Health, and Distinguished Psychiatrist Advisor to the New York State Office of Mental Health (OMH). The author reports no conflicts of interest concerning the subject matter of this article.

References:

1. Appelbaum PS, Gutheil TG. “Rotting with their rights on”: constitutional theory and clinical reality in drug refusal by psychiatric patients. Bull Am Acad Psychiatry Law. 1979;7:306-315.