A short critical introduction to the work of grandfather of psychiatry Thomas Szasz.
American psychiatrist and academic Szasz is probably best known for his controversial claim that mental illness doesn't exist, summed up in the title of his best-selling book The myth of mental illness (1974). Despite being known as a psychiatric abolitionist and the grandfather of anti-psychiatry, Szasz scorned that movement as an alternative to psychiatry that didn't go far enough (reserving special scorn for RD Laing). Here I will provide a short critical introduction to his work on mental illness and psychiatry from an anarcho-communist perspective.
The meaning of the claim that mental illness is a myth or metaphorical story has been much discussed and is often misunderstood. Szasz is not claiming that the "schizophrenic" experience isn't real but that the idea that this experience is an illness to be understood as a biological disease is false, unless we take it metaphorically. Psychiatrists are first of all physicians, and Szasz was keen to remind his fellow doctors that a disease is a biological process that can be observed in and on bodies. As he puts it
Diseases are malfunctions of the human body, of the heart, the liver, the kidney, the brain (Szasz 2004).
If mental illnesses were real biological events then they would fall under the purview of neurologists and psychiatry would vanish over night. The only way that mental illness can be spoken of as a disease is by borrowing the language of medical science to describe experiences and observed behaviour that really consists of interpersonal, social, ethical and political 'problems in living'. The now classic example would be that of homosexuality. Up until 1980 American- and thus Western- psychiatry considered being gay to be a mental illness. To want to fuck someone of the same sex was evidence in itself of some pathological process in the biological make-up of the person who held such a desire. We can see how this was really an attempt to police sexuality, pleasure and desire, to make it sit within the a Christian morality that condemned homosexuality as an offence to God. Really, the pathologisation of queerness was a neat way to manage the perceived moral and social threat that gay culture and sexuality was presented as being by conservative forces.
For Szasz the adoption of a metaphorical language of disease isn't a neutral decision but a political one. The idea runs that by claiming a behaviour or a way of living is a disease state then one can strip the diseased person of moral responsibility and agency and thereby control them through medication, detention and other methods of "cure". It should be clear that this process is far from disappeared: recent activities in Russia, the constant discussions about "gay genes", the debates around the legalisation of civil partnerships and gay marriage, and the continued pathologisation of trans-people are all evidence that lurking behind public discourse on LGBTQ groups is the idea that they are somehow aberrant, abhorrent or otherwise unnatural. In the 1960s Szasz was among the first psychiatrists to challenge the notion that homosexuality was a disease.
Szasz's view is thus that psychiatric diagnoses are scientific sounding justifications for the control of individuals that, far from being normatively neutral, have to be seen as normative value judgements. To claim someone is mentally ill is to evaluate them as a morally depraved and to do so in terms that will effectively hide the fact that this is a judgement used to support the use of psychiatric power.
All of this would clearly chime well with anarchist communists. Psychiatry is a tool for the state to apply its power to individuals in order to deprive them of liberty and to establish a kind of fear of the mad other, thereby internally dividing classes from themselves. The problem is that the idea of class doesn't enter into Szasz's account of things. As I said in my first post, Szasz is a right-wing libertarian. For him the unit of political and social life is the individual. The individual only ever turns up in a social context but nonetheless isn't conditioned by the materiality of that context in Szasz's work. Writing about the practice of psychotherapy, Szasz (1961, p.61)stresses that
better education and economic security favor the conditions necessary for a two-person therapeutic contract.
Added to this he claims that psychotherapists shouldn't be 'distracted' by the class of their patient. Taking inspiration from psychoanalysis, Szasz (1988, pp.17-18) writes that psychotherapy
is a model of the human encounter regulated by the ethics of individualism and personal autonomy.
While anarchists are also concerned with personal autonomy, it becomes clear that Szasz's critique is inspired by his commitment to individualism. In therapy, an individualism who has problems in living comes to an individual who doesn't and the two individuals work together to instil new values with the aim of relieving the first individual of their distress. Despite the radicalism of his critique, Szasz thus thoroughly accords with that aspect of the person-centred approach to therapy that acts as if there were no wider social, economic or political context or causes of mental distress. As a consequence Szasz simply reasserts the primacy of the individual and locates the origin of problems with living as with the individual's grasp on and response to the world, rather than with that world itself. Szasz believes the strength of psychotherapy lies in its ability to individualise the individual and expand her realm of person autonomy without ever having to address capitalism or the state. By acting as if these things didn't exist, Szasz merely reproduces the psychiatry he is so averse to but in place of psychiatric power he would install psychotherapeutic power.
As a right-wing libertarian Szasz doesn't believe we need to radically overhaul psychiatry or psychotherapy. Instead, he wants both to become entirely voluntary. He reminds us that 'the typical relationship between doctor and patients rests, and has always rested, on consent' (Szasz 2007, p.) and states that his real problem with psychiatry is its legal power to override questions of consent. The psychiatrist is the only medical professional- and this includes neurologists- who can confine and treat a patient against their will. Again, this seems like a concern that all anarchists would share, and it even has echoes of Bakunin's (1882) statements on authority:
Does it follow that I reject all authority? Far from me such a thought. In the matter of boots, I refer to the authority of the bootmaker; concerning houses, canals, or railroads, I consult that of the architect or the engineer. For such or such special knowledge I apply to such or such a savant. But I allow neither the bootmaker nor the architect nor the savant to impose his authority upon me.
The obvious difference here is that Bakunin wasn't Szasz's kind of libertarian but an anarchist. For Szasz, people are free to consult the psychiatrist, take the pills, endure electroshock therapy or to undergo psychosurgery if they chose to. For Szasz (2007, p.151)
the state is primarily an apparatus of coercion with a monopoly of the legitimate use of violence
thus if you remove coercion and the monopoly on violence, by emphasising responsibility and choice, the situation magically resolves itself. Thus the state disappears whilst remaining in place.
Running alongside his rejection of class analysis is Szasz's ahistorical and offensive characterisation of psychiatric relations as '"psychiatric slavery" and "psychiatric rape"' (2009, p.ix). Not only are these ahistorical but they also reveal how little concerned Szasz was with considering patients as bodies, specifically as racialised and sexed bodies. To suggest that taking a pill is the same as slavery or rape is offensive to people who have been or suffer the threat of being enslaved and/or raped whilst also deshackling slavery and rape from their own proper analytic frames. For Szasz, psychiatric subjects seem to have no class, no race, and no sex; which is to say, his idea of psychiatric patients is the post-ideological white, middle class, sexless individual. His lack of understanding of racial bodies is repeated over and over again, but most clearly in his straight faced admission that 'chattel slavery and psychiatric slavery are not identical' (Szasz 1977, p,135) but that they are close enough simply because both involve science, economics and power- precisely excluding the existence and experience of black people, and also missing an opportunity to show how black people are disproportionately diagnosed as schizophrenic.
My contention would be that it is not the abuse of psychiatric power that is problematic, as Szasz thinks, but that psychiatric power is always abusive, and that it often deployed especially to target particular populations (homosexuals, women, PoC). In those situations were some kind of detention is required (I'm thinking about florid and violent psychotic episodes and some cases of suicidality) detention isn't an abuse simply because there is no question of consent. The person in these circumstances cannot give reliable consent and lacking that ability shouldn't mean that people undergoing these experiences should be left to fend for themselves in a condition where they are in great danger. The emphasis on consent in the cases where it was impossible to give wouldn't just be metaphysical libertarian/liberal nonsense, it would also be reckless and dangerous. I'm not advocating that anarchists accept detention as it is currently conceived and if I use the word "detention" it is only because we lack the language to speak about an alternative.
We also find Szasz's position as one that ends up supporting the idea that people who have acted in violent or dangerous ways while experiencing acute and disorienting mental distress ought to be treated as criminals. He writes that
Because being accused of mental illness is similar to being accused of crime, we ought to presume that psychiatric ‘defendants’ are mentally competent, just as we presume that criminal defendants are legally innocent Individuals charged with criminal, civil, or interpersonal offences ought never to be treated as incompetent solelyon the basis of the opinion of mental health experts. Incompetence ought to be a judicial determination and the ‘accused’ ought to have access to legal representation and a right to trial by jury (1998).
Szasz intends this as a kind of liberation from psychiatric oppression, but its hard to see it as anything other than the criminalisation of incredibly vulnerable people. Whether it is a psychiatric assessment of capacity or a trial by jury the patient is processed as the object of one or another kind of law. As a right-wing libertarian it is unsurprising that Szasz ends up by endorsing the state, via the juridical processes, as arbiter of sanity, insanity and responsibility. Rather than understanding "moral responsibility" as something held in common, Szasz locates it in the "accused" in order to render them just like everybody else. The very idea of diminished capacity is thrown out the window. The "accused" becomes doubly responsible: responsible for their actions whilst distressed, and responsible for that distress. Szasz's version of liberation is thus an exaggerated or accelerated version of what we already have today: the individualism of mental health.
This individualism would be completed by the 'pharmacological autonomy' of a free market in drugs in which the patient would become the consumer free to consume any number of medications to "treat" any number of psychic maladies (Szasz 1992a; 1992b). Again, Szasz's vision is already with us in most high GDP countries, especially in the US where drug companies can advertise direct-to-consumers. Szasz's abolition of enforced psychiatry amounts to little more than the kind of deregulation that has characterised neoliberalism carried into the realm of mental health service provision. A combination of individualism, moralism and faith in market capitalism- and its material root in private property- which he declares as 'a beacon that lights the way for persons and social cooperation' (Szasz 1992, p.2), sounding like a so-called "anarcho-capitalist" or, in other words, a capitalist.
To draw this together, I think this shows that a renewed anti-psychiatry that was anarchist could take a lot from Szasz's critique in also viewing the disease-model of mental distress as spurious and as a justification for the exercise of power and processes of normalisation. As communist it would need to reject Szasz's emphasis on individualism and take account of the common production of mental distress and how it relates to capitalism. The two-person therapy model would also need to be rejected as it embraces the idea that therapeutic change is necessarily divorced from social change. As anarchist, it would accept concerns about involuntary treatment, medical cognitive authority and extra-legal power of detention and restraint without fetishing consent and choice as the only important considerations. Szasz's insistence on choosing to believe in psychiatry is akin to the false choice of deciding between political parties or consumer products, especially given his defence of a free market for psychiatric drugs.
Finally, an anarchist anti-psychiatry would need to make clear that while psychiatric reform is welcome and can only be a good thing for people exposed to its services, the idea that people experiencing extreme states of consciousness should be subjected to criminalisation is extremely dangerous, damaging, remarkably statist and in no way liberatory. Szasz talks about separation of psychiatry from the state and in the spirit of a neoliberal capitalist psychiatry whereas we should argue for the supersession of capital, the state and psychiatry.
Bakunin, M. 1882. What is authority? Online.
Szasz, T. 1961. The myth of mental illness: foundations of a theory of personal conduct. London: Hardper and Row.
Szasz, T. 1977. Psychiatric slavery. New York: Syracuse University Press.
Szasz, T. 1988. The ethics of psychoanalysis: the theory and method of autonomous psychotherapy. New York: Syracuse University Press.
Szasz, T. 1992.a. The fatal temptation: drug prohibition and the fear of autonomy. Online.
Szasz, T. 1992.b. Our right to drugs: the case for a free market. New York: Syracuse University Press. [Incidentally, the cover of this text comes is adorned with praise from Milton Freidman, telling in itself].
Szasz, T. 1998. Thomas Szasz's Summary Statement and Manifesto. Online.
Szasz, T. 2004. Remarks at the 35th Anniversary and Human Rights Award Dinner Citizens Commission on Human Rights International Beverly Hilton Hotel, Beverly Hills, California. Feburary 28th 2004. Online.
Szasz, T. 2009. Antipsychiatry: Quakery Squared. New York: Syracuse Press.
Szasz, T. 2007. Coercion as cure: a critical history of psychiatry. London: Transaction Publishers.