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The Manufacture of Madness (1970)

This book can be considered a sequel to and complement of The Myth of Mental Illness. In it Szasz expounds on his position that mental illness is an objectionable concept for social reasons. “In the present work, I shall try to show how and why the ethical convictions and social arrangements based on this concept constitute an immoral ideology of intolerance” (p. XV). Before setting himself to this task, he differentiates between two kinds of psychiatry, contractual and institutional. This differentiation has fundamental significance for understanding his entire oeuvre. His motivation was discussed in 4.1.

The term mental illness mystifies and conceals “man’s struggle with the problem of how he should live.” (Ideology and Insanity, p. 21, Szasz’s italics) That which is called mental illness is in fact human conflict, which can be between individuals or between an individual and the group. In Szasz’s view psychiatrists deal in interpersonal conflict, thus they are comparable to practitioners of law. Like practitioners of law, they have three alternatives: they can side with their client (as do lawyers); they can side with the other party, who could be a spouse, the family, the employer, the neighborhood, or society (comparable to public prosecutors); or they can attempt to remain neutral and fulfill the role of mediator (as do judges).

Szasz describes the paradigm of the relationship between psychiatrists and patients in which the psychiatrist sides with the patient as follows. The patient volunteers himself for treatment, being fully informed about the possibilities, limitations, and risks. He pays the psychiatrist for his services, dedicates time and energy to the treatment, and swallows the humiliation of being unable to solve his problems by himself (at least, if that is how he perceives it). He does this explicitly in the expectation that the psychiatrist will serve him and help him solve his problems as he himself sees them. The psychiatrist offers his services and treats the patient in such a way as to serve the patient’s interests as that patient sees them, for as long as and to the extent that the psychiatrist is able to agree to them. Both are free to sever the relationship should the other not hold to the contract. In addition, the patient is free to discontinue treatment whenever he wishes. In this relationship the patient’s interests are the only ones, other than his own, that the psychiatrist serves. As the psychiatrist is defending the interests of his patient, and thereby could possibly damage the interests of others, he must avoid a situation of conflicting loyalty. This means that he must be in private practice and receive his income directly from the patient. It also means that he cannot treat patients with conflicting interests at the same time. The psychiatrist-patient relationship is a contractual relationship in which both sides retain their autonomy. It emanated from psychoanalysis. Szasz calls this form of psychiatry contractual psychiatry.

The other type of psychiatry Szasz calls institutional psychiatry. In this type of psychiatry, patients do not seek the relationship with the psychiatrist, but it is imposed upon them in one way or another, for instance by an employer threatening the sack, or a spouse threatening divorce, or – typically – by a court order. This means that clients have little to no influence on their participation in the relationship with the professional. The epitome of institutional psychiatry is involuntary commitment to a mental hospital. The patient’s situation is characterized by lack of freedom.

In institutional psychiatry psychiatrists assume the double role of therapists to their patient and defenders of the interests of other parties. Even though the interests of patients and their environments are not necessarily always conflicting, and even though it can sometimes be extremely complicated to determine to what extent psychiatrists’ interventions are advantageous to which party, nonetheless we can assume, according to Szasz, that institutional psychiatrists are always agents of the community and defend the interests of the community. It is dangerous and deceptive to maintain that anyone is capable of defending conflicting interests, and that is even more dangerous when the client’s adversary is a powerful group, society on the whole, or public order. In such cases the imbalance of power is extreme. In institutional psychiatry, psychiatric jargon serves to oppress patients. Conflicts are concealed, interpreted, and explained away as patients’ illnesses. Thus patients are automatically blamed, even though the word illness implies that they cannot be held responsible for this blame. Influencing patients in such a way that they again fit into the social rut and behave as their adversaries wish is called treatment. This leads Szasz to call mental hospitals jails, and therapies such as involuntary drugging, electroshock, and lobotomy, oppression and torture. The purpose of the label of mental illness is treatment and recovery. The true aims “…include such penalties as personal degradation, loss of employment, loss of the right to drive a car, to vote, to make valid contracts, or to stand trial – and, last but not least, incarceration in a mental hospital, possibly for life.” (p. XXVIII)

In The Manufacture of Madness Szasz compares institutional psychiatry to the Inquisition. He does so most expansively, comparing psychiatrists to inquisitors; patients to witches, heretics, and Jews; and the science of psychiatry to the Catholic faith. See also Chapter IV, 4.1.

His premise and conclusion is that a far-reaching structural similarity exists between both complex social phenomena, and that their social significance is identical. He views both social institutions as an expression of the fundamental human need to confirm one’s self as good, innocent, and normal, by designating individuals or groups who deviate in any way as bad, sinful, or abnormal: the “scapegoat” theory. (See 4.2.4) Everywhere that people live or lived in a community, this phenomenon emerges more or less clearly, according to Szasz. The community “purifies” itself, maintains its integrity and stability by seeking out scapegoats, shaming them, and sacrificing them. The scapegoat is the symbolic personification of guilt and sin; sacrificing the scapegoat absolves the others of sin. This is epitomized by the scapegoat in the Old Testament. The most honored scapegoat is Jesus, who took the sins of humanity upon himself and atoned for them by his death. Anthropologists and historians reveal similar scapegoat histories in various cultures. Szasz views the Inquisition as one example of the scapegoat phenomenon, and institutional psychiatry as another example. All forms of discrimination, whether based on race, skin color, different life styles, or other religions, are in essence variants of the same phenomenon. In this way all subjects of discrimination, whether on grounds of congenital attributes (such as race or skin color), acquired attributes (such as religion), or no attribute at all but only a quirk ascribed to them by others (such as witches and the mentally ill) are lumped together in one group, namely, that of scapegoats. So for Szasz institutional psychiatry is an age-old, integrally human phenomenon in a new costume. It emanates from a human trait that is so fundamental that he states, “Man’s refusal to sacrifice scapegoats – and his willingness to recognize and bear his own and his group’s situation and responsibility in the world – would be a major step in his moral development.” And, “In the rejection, or transcending, of the scapegoat principle lies the greatest moral challenge for modern man. On its resolution may hinge the fate of our species.” (p. 285)

In The Manufacture of Madness, several examples of the fabrication of insanity are given. One example is masturbation as a cause of insanity. In 1710 a book by an anonymous priest turned physician appeared: Onania or the Heinous Sin of Self-Pollution. This was the first time in history that attention was directed to masturbation as a medical problem. Apparently the book satisfied a demand, as by 1765 it reached its eightieth printing. In 1758 Tissot – a prominent Lausanne physician – gave his name to a book about onanism and its dangers. By the beginning of the nineteenth century belief in the danger of masturbation as a generator of all sorts of diseases was so widespread in medical practice that it can be considered a dogma, according to Szasz. Masturbation was in particular regarded as the cause of insanity in masturbaters themselves or their progeny. Practically everybody in the medical world believed in it, preceded by such famous men as Benjamin Rush in the United States, Esquirol in France, and Maudsley in England. Medical descriptions of those days were a mixture of psychiatric and moral views. This prompts Szasz to point out that there is no confusion, because moral and psychiatric views are identical. “Calling masturbation an ‘addiction’ is really no different than calling it a sinful or bad habit: the former is to condemn it in the language of medicine, the latter in that of morals.” (p. 195)

In the second half of the nineteenth century belief in the evil of masturbation began to wane. Freud blew new life into the declining belief in the pathogenic power of masturbation by suggesting a connection between masturbation and neuroses. In psychoanalysis, masturbation long retained its meaning as infantile sexual activity that ought to disappear during sexual maturity.

Gradually the picture changed, and physicians, initially still hesitantly, began to say that self-stimulation is perhaps not harmful. In Sex by Prescription (1980) Szasz adds the latest chapter until now on the history of the significance of masturbation to health. He describes the transformation of masturbation from originally evil and heretical, through a neutral transitory stage of harmlessness, to its current status as a laudable habit that is endorsed in sex education. Not only that, but it is recommended as therapy for people with sexual problems. The cycle is pretty much completed now that Masters and Johnson invented a new disease, “masturbatory orgasmic inadequacy.” This is defined as when a woman (they say that it occurs only in women) is orgasmic during coitus but not during (mutual) masturbation.

The point, to Szasz, is that illness suggests an objective defect (to him, physicochemical), whereas in reality there exists only an unverifiable belief, originally, in the harm, and currently, in the healthfulness of masturbation. Every such belief, regardless whether religious or scientific, has the same credibility. It is impossible to objectively determine what is deviant, sick, or normal. This means that limiting the rights or freedom of others on the basis of such a belief is wrong. It also means that each person must decide for himself how he wishes to lead his life and what he wants to make of it. If others object, this doesn’t mean that they have the right to label the undesired behavior (originally, masturbating, and now, not masturbating) sick, and even less to turn the said person into a scapegoat.

Finally, The Manufacture of Madness was translated into Dutch with the title De waan van de waanzin [The delusion of madness]. This translation of the title is not only incorrect, but is even an expression of that which in the book is so thoroughly contested. When the fabrication of madness is called a delusion, that fabrication itself is being declared a mental illness, as delusions are the most classic symptom of mental illness. So those who fabricate mental illness are turned into mentally ill people. Such psychiatrization is exactly what Szasz opposes so vigorously in this book. The word “manufacture” implies that something that does not really exist is fabricated. Szasz considers that wrong and worthy of rejection, but not sick. By the way, the English title also does not seem to me to do justice to the author’s intention. Szasz is not concerned with the fabrication of madness, but with the fabrication of mental illness. Probably his choice of this title was influenced by his love of alliteration. (See Chapter IV, 2.)
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