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Leading up to The Myth of Mental Illness (1957 – 1961)

Szasz attempts to describe what psychiatry is actually about in several articles that appear before The Myth of Mental Illness. During this period, contrary to his later works, he repeatedly mitigates his criticism, for instance by commenting that his intention is not to attack psychiatry per se, but to suggest additional considerations and improvements. In these articles he rejects the traditional, institutional description of psychiatry as a branch of medicine that is concerned with studying and treating mental illness. He calls these descriptions, “…generally comforting, and often useful, in a practical sense. It is inadequate, however, from the viewpoint of scientific accuracy.” Instead he chooses two instrumental premises. The first is the question of which methods and frameworks of reference serve psychiatry in theory. The second is the – operational – question of what psychiatrists do in practice. The first question leads, according to Szasz, to scientific theories; the second to a closer examination of the social circumstances in which psychiatrists work, and an analysis of psychiatrists’ social roles. In answer to the question on methods and frameworks of reference, in “Language and Pain” Szasz describes psychiatry as that which the British call medical psychology: “…the science and practical application of those disciplines which use the psychological method and language (in a medical setting). Their object is man as a social being, his development, social identity, self-concept, and his relationship with his fellowmen. The idioms appropriate to such discourse are what Woodger aptly called the ‘person language’ and the ‘community language.” The same is reflected in his description of psychiatry as “the science of human feeling, thought, and action.”

In an article in 1958 he explains that there are two kinds of psychiatrists. One kind uses physicochemical treatments such as electroshock, drugs, and psycho-surgery. They are to be considered physicians as they work within a physicochemical framework, but they are not psychiatrists. The other kind utilizes socio-psychological methods of research and treatment. This is the type he means when he refers to psychiatrists.

This means that that which he considers desirable in Pain and Pleasure, namely divorcing medicine that resorts to physicochemical methods of research and treatment from psychiatry that uses socio-psychological methods, has become a necessity, and even de facto reality. “Now, it is clear that medicine is concerned with the workings of the human (and animal) body as a physicochemical machine.” Thus a choice unavoidably has to be made. “We cannot have both or a combination of the two, either by simply wishing or by coining a word like “psychosomatic.”

This duality based on method used, frame of reference, and object, implies to me the drawing of a dividing line that runs straight down the middle of medicine and psychiatry as they are defined, organized, and practiced nowadays. The result of this division to him is that medicine is on one side of the line and psychiatry on the other. This duality is and remains essential for Szasz. For instance, when he discusses the family doctor in days of yore, he states that this figure “combined the social roles of physicochemical scientist vis-à-vis the body and psychotherapist vis-à-vis the person.” From the text we learn that Szasz means that the family doctor of the past maintained an ethic of caring about his fellow man. His goal was to provide humane care at least as much as medical treatment, which he was often powerless to provide. These two social roles reflect the duality that Szasz establishes in medicine and psychiatry.

Once this duality is established, it is apparently unimportant to Szasz to divide up the socio-psychological sciences any further. It is often quite difficult to find a clear difference between psychiatry, psychoanalysis, and psychology in his work. Repeatedly words like psychiatrist and psychotherapist are used interchangeably. His description of psychotherapy is so broad as to include psychological influence. (See Chapter II, 2.) The difference has become unimportant to Szasz for two reasons. The first is that as he declares the concept of illness invalid in psychiatry (see also 4.2), the most important reason for separating psychiatry from psychology is eliminated. The second is that also in this period Szasz ascribes an extraordinarily essential role to psychoanalysis for psychiatry as well as psychology. Regarding the latter, this is reflected best by his statement: “Various branches of modern psychology, such as physiological psychology, learning theory, experimental psychology, clinical psychology, psychometrics, social psychology, and so forth have no common denominator other than psychoanalytic theory. In so far as they do not lean on, nor borrow from psychoanalysis each of the foregoing disciplines remains relatively isolated from the others…” About psychiatry he says, “Modern psychiatry is said to consist of a body of knowledge upon which there is more or less general agreement. This knowledge consists of, or is derived from, the theory and practice of psychoanalysis.”

An operational definition of psychiatry should not cover only frames of reference, method, and object. The social position and purpose should be included as well. Thus the question arises: in which social roles are psychiatrists cast? What do they do? These questions in turn beg the questions: What is the nature of the psychiatrist-patient relationship? What are the moral implications of that relationship? Finally, we can gain operational insight into psychiatrists’ intentions when we examine their attitude towards various social developments. Szasz does so mainly regarding law and justice.

Psychiatrists have very differing roles. Szasz names some in an article in which he analyzes how they classify and diagnose patients:
  • ­ Psychiatrists in state mental hospitals decide whether the patient is psychotic. If so, an involuntary commitment and various, sometimes highly invasive therapies could be justified;
  • ­ Psychoanalysts use the term psychosis in a totally different way, namely as referring to certain mental mechanisms or relationship patterns. The word thus bears no reference to observable behavior or social judgment;
  • ­ Psychiatrists testifying in legal cases have to choose their diagnoses in a way that enables them to assign one of two classifications to the defendant: punishable or not punishable. I believe Szasz’s use of the word “punishable” in this sense is erroneous. He means responsible. He discusses the role of the psychiatrist as expert witness further in other articles;
  • ­ Psychiatrists in military service and child psychiatrists have other social roles with various corresponding preoccupations regarding the classification of their patients. Obviously, in each situation, the object of their intervention is different.
His conclusion is that absolute classifications of psychiatric disorders that are applicable in all these different situations are impossible.

In another article Szasz describes the intense distress that parents experience when their baby cries. The need to help the infant is generated partly by the parents’ feelings of guilt over his distress. Szasz concludes that parents find it difficult to tolerate their children’s unhappiness. He transposes this feeling to psychiatrists whose patients are threatening to commit suicide. Psychiatrists feel distress and the need to act so that they will not have to continue bearing their patients’ unhappiness, even when doing nothing would be better. Such “help” could be an involuntary hospitalization of the patient. However, that cannot be done without turning those patients into inarticulate children, to whom all sorts of things are done without consulting them. This is a dilemma: either patients are respected and nothing is done with them, or they are involuntarily hospitalized and thus are treated like children. This dilemma is repeatedly referred to in Szasz’s work. So treating others as competent adults who are responsible for themselves precludes involuntary commitment and treatment, as such unavoidably infantilizes, dehumanizes, and devalues them. This dilemma remains, no matter how much those others express verbally or through their behavior that they no longer wish to be (or are incapable of being) responsible for themselves.

In various articles Szasz emphasizes the difference in the relationships between psychiatrists and their voluntary patients versus psychiatrists and their involuntarily committed patients. In the former case, patients consider the psychiatrist as their ally and helper; in the latter, as their adversary, precisely because the patient role is imposed upon them against their will. Therefore involuntarily committed patients resemble someone suspected of a crime more than they resemble a sick person who wishes to be helped. However, when the position of involuntarily committed patients is compared to that of suspects in detention, the comparison is unfavorable to the patients. Suspects’ rights are clearly defined: they are to be informed as to the nature of the accusation, who accuses them, and what their rights are. They are explicitly told that anything they say can be used against them. In the case of psychiatric patients, the fact that the psychiatrist is the accuser and the patient is the accused is camouflaged by the rhetoric of illness and treatment. That is why hospitalization, no matter how much the patient resists, is regarded as in his best interest. Therefore in 1960 Szasz advocated a “Bill of Rights for the Mentally Ill” – not so much as a practical proposal, but in particular to draw attention to the loss of civil liberties and protection of the law of fellow citizens. That same year Szasz declared his rejection of any and all involuntary commitment. (See also 6.1 and 6.2.)

Regarding both types of relationship – voluntary and involuntary – Szasz asks the question, whose interest do psychiatrists serve? In the case of the contractual relationship (see 4.2.2) psychiatrists clearly act in their patients’ interest. Patients who do not think so (anymore) will discontinue the relationship. In the case of psychiatrists who write reports on the basis of which someone will be involuntarily committed, the situation is less clear. Aspects such as the interests of the family, environment, and public order come into play. An equally complex pattern of interests comes into play when the patient is a child, regardless whether that child is confined by court order. Szasz generalizes that in all cases of involuntary commitment the interests of others, society, and social order are served rather than those of the patient. He clarifies that not only by pointing out the dehumanizing and discriminating deprivation of civil liberties, but also by postulating a central connection between interpersonal conflict and mental illness (see 4.2.2).

So according to Szasz, psychiatrists who hospitalize patients against their will are categorically acting against what those patients regard as their interests. Such psychiatrists set the interests of the environment as their priority, and identify with that environment, to the detriment of their patients. When they claim to be acting in their patients’ best interest in such a situation, they are being deceitful. They can do that only on the basis of the authority and power invested in them, so their actions are characterized by “force and fraud.”

One implication of this position, according to Szasz, is that psychiatrists serve the conservative forces in society. Any unrest or unusual behavior can be delegitimized by psychiatrists by calling that behavior a symptom of mental illness. Psychiatrists take on the role of “social tranquilizer.” This happens in particular when they are protecting certain social institutions, such as marriage, a profession, or the criminal justice system. They defend the illusion that these institutions are good and harmonious at the very moments that these institutions are cracking under their own weight or contributing to people’s problems. To clarify this, two examples follow:

­ Not infrequently involuntary hospitalization of patients is requested by a member of their family. That is not surprising, as deeply depressed housewives, paranoid psychotic men, and increasingly demented grandfathers can pose serious risks for the other members of their family. Aside from the misery and suffering that strikes the entire family in such situations, it can be stated that such patients fail to fulfill their necessary social function in the family. The family can keep requesting the patient to change his behavior, they can abandon him, or they can appeal for medical assistance. When such medical assistance consists of involuntary hospitalization, it can be concluded that the integrity of the family prevailed over the autonomy of the individual. Insofar as the involuntary commitment comprises a solution for an unbearable family situation, it can be concluded that the institution of family is being protected, even at the expense of the individual. The family is a social structure that is far from optimal, as unbearable stresses often occur in it. Involuntary hospitalization conceals that. Thus people are hindered from facing their social roles, and, by changing them, creating better and more satisfying social structures.

­ In the criminal justice system sentencing delinquents arouses judges’ feelings of guilt and anger. In order to reduce these unpleasant feelings as much as possible, judges feel the need to know whether defendants can be held responsible for the crimes of which they are accused. Psychiatrists express their opinions about this in their expert evaluations, making it easier for judges to decide whether to sentence particular defendants. Thus by way of their expert-evaluations psychiatrists conceal a sore point that could lead to changes and improvements in the criminal justice system, forming an obstacle to improvements. The result is that judges no longer make punishment fit the crime, but the person who committed it. In addition, “…the oracular pronouncements of eminent psychiatrists have taken the place of publicly verifiable fact (and of scientifically acceptable theories).”
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