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Szasz as Theoretician

Szasz is a theoretician. The domain in which he works is the philosophy on which medicine and psychiatry are based. He studies situations that determine the relationships between people and in particular between physician and patient. He examines the fundamental aspects of the physician-patient relationship, and especially the psychiatrist-patient relationship, more so than daily reality. He also examines psychiatry more in its theoretical premises and assumptions than in its daily practice. The fact that he seeks out operational definitions does not detract from that. His study of actual practice is limited to examining publications by colleagues and others. Only rarely did he collect data himself, using the questionnaire method. That is revealing of his most important preoccupation. Not the patient but the person who does something to that patient is the center of his attention.

His interest in the practical aspects of problems concerning implementation and organization, if not totally absent, is scant. When he occasionally treads that area anyway his views are so general and simplistic as to be unconvincing. An example is his contention concerning “the right to health.” (The Theology of Medicine, Chapter 8) He claims that the government artificially creates a market of “demand,” ensuring high income for physicians and specialists by limiting the amount of people admitted to the practice of medicine.

His preoccupation with the theoretical rather than the practical and organizational sometimes detracts from what he aims and possibly could achieve through his points of view. For instance, in Psychiatric Justice he reports on a lawsuit in which he himself testified as a special witness. (pp. 85-144) However, his testimony was so confusing because of the many theoretical implications that the client whose interests he was defending lost his case. Something similar occurred in 1980 when Szasz testified at the Medical Ethics Board in Amsterdam. It was the only time that he raised his voice in the Netherlands in connection with such a matter. The complaint concerned a woman with a strong obsessive-compulsive disorder for which she was treated with LSD, and later with stereotactic surgery. Her condition did not improve.

By the way, in stereotactic surgery certain specifically localized connections are destroyed by electrocoagulation. It is, also internationally, a highly controversial treatment in psychiatry. For one thing, healthy brain tissue is damaged, whereas it is not known whether an organic disorder is involved in the particular psychiatric disorder. Secondly, it is not clear whether the treatment actually has a specific influence on the complaints and symptoms, or whether the treatment alters the patient’s personality in a way that renders him incapable of complaining, protesting, and resisting. As the treatment is reserved for extreme cases it is applied only to people who have pushed their environment, their doctors, and probably also themselves to utter despair. That is what makes it so difficult to be certain of the results of the treatment apart from the hopeless and desperate situation of all who are involved.

In the official report of the Medical Ethics Board’s hearing, Szasz’s testimony is summed up as follows. “Finally, it is noted, that the specialist, Szasz, who rejects the said treatment because of its possible mutilating effect, apparently assumes that it was wrong to deprive the patient of her compulsions because she needed them. He overlooks the fact that the patient and her environment seriously suffered from them, and longed for years to be freed from them.” The misunderstanding on the part of the Medical Ethics Board is so complicated that the translation of the theoretical concepts into practice seem to have led to an apparent contradiction. Anybody who is familiar with psychiatric practice appreciates that the request, “help me get rid of this complaint” can mean many different things. It is up to the diagnostician to determine what exactly this request means in each case. Besides, Szasz is not the only one who denies the existence of any psychiatric syndrome that justifies a mutilating treatment. In an article on Szasz following this case, it was mentioned that in the United States, psychosurgery is prohibited. Article 24 of the Mental Health Service Patients’ Rights Manifest, which was drawn up by the Dutch Psychiatric Patients’ Movement in 1981, states: “Psychosurgery and radiation in the framework of psychiatric treatment is to be prohibited by law.” The Vatican and the [former] USSR – in agreement for a change – have prohibited psychosurgery.

Szasz has said little about the exceptionally difficult terrain that lies between determining theoretically pure and morally correct premises, and the execution of a practical policy of mental health care in which these premises are actually carried out as they are intended. An exception to this is his elaboration on autonomic psychotherapy in The Ethics of Psychoanalysis.

Although the Libertarian Party in the United States has adopted Szasz’s views on psychiatry in its program, we cannot speak of extensive political support from political parties. This might be partially explained by the fact that his views are difficult to translate into direct, concrete policy. Another factor is his individualism which has precluded his forming a school of thought, although he does have some clear kindred spirits such as Leifer. Additional factors are his constant endorsement of social pluralism and diversity, making it difficult to join forces with others for certain social goals, and his skepticism, which he ascribes to “Moral Man,” and that is applicable to himself.
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