It has been 10 years since psychiatrist Thomas Szasz died on September 8, 2012 at the age of 92. During his lifetime he published 35 books, and more than 700 articles, most of which were highly critical of both the theory and practice of psychiatry, which has long claimed to be a legitimate medical specialty (See Szasz, “Publications List, 1947-2009”). Depending on who is speaking, Szasz was either the heroic liberator of the so-called “mentally ill,” or a vicious critic of well-intentioned psychiatrists who only sought to restore the “mental health” of the “mentally ill.”
While other medical specialties have not had to defend their legitimacy, psychiatry has spent the last two hundred years trying to convince both medicine and the public of its medical bona fides. In the last sixty years, this has involved ignoring, attacking, misinterpreting, censoring, slandering, defaming, and smearing Szasz and his adherents. From the very beginning, psychiatry has engaged in myriad ad hominem arguments as a means to discredit his ideas.
That psychiatry has been successful in its attempts to shore up its reputation is a credit to public relations and a discredit to valid scientific inquiry. For as Szasz noted decades ago, psychiatrists are simply the high priests of the ideology that he termed the “Therapeutic State,” which is supported by one of the most violent social movements America has ever known. Szasz’s comparison of the mental health movement with the medieval Inquisition in his book The Manufacture of Madness (1970) threw flames on the raging fires of psychiatrists who did not take kindly to being compared to Inquisitors. Like politicians who claim they never said something impolitic, psychiatrists ignored that they had invited this comparison by blaming the victims (the so-called witches) through retroactively labeling the witches as “mentally ill” and thereby excusing the crimes against humanity of their persecutors (the Inquisitors).
A decade after Szasz’s death, it is time to ask several questions: (1) Has the vast research enterprise of biological psychiatry proven Szasz wrong? (2) Was Szasz successful in changing either the ideology and/or the practice of psychiatry? (3) If his viewpoint was valid, and if he was unsuccessful, what could still be done to further his vision of a non-medical, truly voluntary, confidential practice of personal “counseling” in America?
The Myth of Mental Illness
Starting in 1956, Szasz begin laying the groundwork for his attack on psychiatry with a series of articles and one important, but often overlooked, book, Pain and Pleasure. His first book in effect dealt with the crux of his lifelong crusade: the mind-body problem.
Szasz has succinctly summarized the major themes of his work in at least three places. His short 1960 article, “The Myth of Mental Illness,” contains the seeds of many of his ideas that he developed throughout his career. The 1974 revised version of the book The Myth of Mental Illness (1961) contains a “Summary” with ten major points (pp. 267-68). And Jeffrey Schaler’s website Szasz.com contains “Thomas Szasz’s Summary Statement and Manifesto” (1998) with six points.
Since Szasz has summarized his views so clearly, I see no need to dwell on them here. For those who wish a more detailed introduction to his work, please see my article, “Thomas Szasz’s History and Philosophy of Psychiatry,” in my anthology, Thomas Szasz: Moral Philosopher of Psychiatry (Seattle: Review of Existential Psychology & Psychiatry, 1997, pp. 6-69).
Modern scientific medicine is based on the idea that disease is something that affects the body, which is based on the deterministic laws of physics and biochemistry. Yet psychiatry claims that human behavior that violates social and cultural norms is caused by something in the body or brain and is treatable by the ordinary means of medicine such as drugs, electroshock, and surgery.
Szasz believed that the concept of “mental illness” was a metaphor that became literalized due to the category error of applying disease to social, moral, and political behavior. The people who are labeled mentally ill do not in fact have anything demonstrably wrong with their bodies or brains, and the standards from which they differ from others are not biological, but social, norms.
Beginning in his teens, Szasz believed that psychiatrists do not act the way that other doctors do. In treating freely chosen behavior as though the individual was not responsible, psychiatrists have violated the major principles of medical ethics and proven themselves to be adversaries of the people they claim to “help.” People whose conduct deviates from social norms are not diseased, and psychiatrists are serving the role of the state in functioning as extra-legal enforcers of social mores.
Psychiatry’s history is quite distinct from the history of medicine. In Madness and Civilization, Foucault traced the origins of psychiatry to the establishment of the Hôpital general in Paris in 1656. These were not hospitals in our sense of the word, but rather public asylums for les misérables. Szasz traces psychiatry’s origins to the widespread use of private madhouses in England, where relatives would send their unwanted family members (see Parry-Jones’s (The Trade in Lunacy).
In his Preface to the first edition of The Myth of Mental Illness (1961), Szasz wrote that he had a twofold purpose:
My first task, accordingly, is to present an essentially “destructive” analysis of the concept of mental illness and of psychiatry as a pseudomedical enterprise….My second task is to offer a “constructive” synthesis of the knowledge which I have found useful for filling the gap left by the myth of mental illness (p. x).
The Pseudomedical Model
It has become commonplace to refer to the “medical model” of mental illness characteristic of psychiatry. But Szasz’s point is that psychiatry is a pseudoscience that has adopted a pseudomedical model.
In short, real doctors do not invent fake diseases and fake diagnoses. Real doctors do not violate informed consent. Real doctors do not violate patient confidentiality. Real doctors do not violate their patients’ autonomy and treat their patients involuntarily. Real doctors do not imprison their patients. Real doctors do not force medications on their patients. Real doctors do not shock their patients involuntarily. Real doctors do not operate on their patients involuntarily. Real doctors do not invent diseases to excuse their patients for criminal behavior such as murder.
If psychiatry had in fact adopted the medical model, it would do none of these things either. Yet psychiatrists do all of these things.
Since its founding, America has been subject to scores of social movements. Some, like the abolition of slavery and the civil rights movement to end racial segregation have been considered positive.
But others have stained our history. Craniometry, eugenics, and alcohol prohibition were once popular, but have now been discredited.
Phrenology was once widely practiced and nearly cost the world the theory of evolution. Charles Darwin was nearly rejected when he applied for the five-year trip around the world of the HMS Beagle. Captain FitzRoy was an adherent to phrenology and he told Darwin that he had nearly decided to turn him down him due to the shape of his nose (Janet Browne, Charles Darwin: Voyaging, Princeton: Princeton University Press, 1995, pp. 160-61.)
In The Mismeasure of Man, Stephen Jay Gould deconstructed several pseudosciences guilty of biological determinism, including craniometry, the hereditarian IQ movement, and sociobiology. In his Introduction, Gould writes:
The general argument may be called biological determinism. It holds that shared behavioral norms, and the social and economic differences between human groups—primarily races, classes, and sexes—arise from inherited, inborn distinctions and that society, in this sense, is an accurate reflection of biology. This book discusses, in historical perspective, a principal theme within biological determinism: the claim that worth can be assigned to individuals and groups by measuring intelligence as a single quality (p. 52).
In Not in Our Genes Richard Lewontin, Steven Rose, and Leon Kamin unpacked the reductionistic ideas of biological psychiatry and what Szasz would call its “sacred symbol”: schizophrenia. In the Preface to the Second Edition (2017) of their work, these scientists write:
Yet for all the intense research in universities and the gigantic pharmaceutical companies (Big Pharma), and despite the huge advances in genetics, the genes and biochemistry believed to cause schizophrenia and depression remain elusive (p. xii and xiii).
In my article “No Proof Mental Illness Rooted in Biology” (2003), I said:
Psychiatrists have yet to conclusively prove that a single mental illness has a biological or physical cause, or a genetic origin. Psychiatry has yet to develop a single physical test that can determine that an individual actually has a particular mental illness. Indeed, The Diagnostic and Statistical Manual of Mental Disorders uses behavior, not physical symptoms, to diagnose mental illness, and it lacks both scientific reliability and validity.
In “No Evidence Low Serotonin Causes Depression,” Mad in America’s Peter Simons reports on the recent analysis by Joanna Moncrieff and her associates, and quotes the authors:
This review suggests that the huge research effort based on the serotonin hypothesis has not produced convincing evidence of a biochemical basis to depression. This is consistent with research on many other biological markers. We suggest it is time to acknowledge that the serotonin theory of depression is not empirically substantiated.
In “The Fruitless Search for Genes in Psychiatry and Psychology” (Genetic Explanations: Sense and Nonsense, ed. Sheldon Krimsky & Jeremy Gruber, Cambridge: Harvard University Press, 2013, pp. 94-106), Jay Joseph and Carl Ratner point out the methodological problems of twin, adoption and family studies in biological psychiatry’s research on genes. While many psychiatrists have claimed to find a gene or genes associated with mental illness, none have survived scrutiny and been replicated.
I have shown that family, twin, adoption, and molecular genetic studies have failed to provide scientifically valid evidence that genes play a role in causing depression. Combined with the recent findings by Moncrieff and colleagues that serotonin is not associated with depression, the idea of MD as a medical condition is in serious trouble. Psychiatry’s longstanding major depression chemical imbalance and brain disease claims used to support the medical model are now crumbling. The longstanding and related “depression as a heritable disorder” claim awaits its turn.
The concept of mental illness is a brand of biological determinism. It is the attempt to explain differences in freely chosen human behavior as deterministically caused by a disease in the individual that renders the person not responsible for their conduct. Since they are deemed unresponsible, psychiatrists claim they are justified in treating the person against his or her will.
As Szasz stated for many decades, “mental illness” is the ideology used to justify a myriad of crimes against humanity in which people who have not been afforded due process and convicted in a court of law for a specific offense and imprisoned for years, tortured against their will, and released only if they agree to continue to take “chemical straitjackets” once they are out.
Szasz believed that “mental illness” was not possible, that “minds” cannot be diseased, only bodies can. If medicine was to discover that some constellation of symptoms were to be caused by a bodily disease, then this would be added to our known compendium; it would no longer be treated by psychiatrists, but by regular doctors. The prime example of this is neurosyphilis.
It should not be surprising therefore that psychiatry has not been able to produce any credible, replicable, valid evidence that any “mental illness” has a biological or genetic cause.
Biological Psychiatry Strikes Back
During the 1960s and ‘70s, Szasz had a tremendous impact on psychiatry, politics, the law, and public opinion. A seminal 1982 New York Times article by Bryce Nelson was titled, “Psychiatry’s Anxious Years: Decline in Allure; As a Career Leads to Self-Examination.”
Nelson pointed to a “disillusionment on the part of medical students over the scientific validity and practical effectiveness of the discipline,” with the number of medical students applying to psychiatry falling by half. Nelson says:
As for the general decline in psychiatry, some blame the withering criticism the field has received in recent years. One of the most outspoken critics is Dr. Thomas S. Szasz, a professor of psychiatry at the State University of New York at Syracuse. Dr. Szasz has argued for years that “these things called mental illnesses are not diseases at all but part of the vicissitudes of life,” dismissing psychiatry as a specialty without a medical cause. “In the smoke-filled rooms,” Dr. Szasz says, “time and again I’ve heard the view that Szasz has killed psychiatry. I hope so.”
Psychiatrist Stuart Yudofsky told Nelson that “there was too much emphasis on social theory rather than on the biological and pharmacological triumphs of psychiatry.”
The Diagnostic and Statistical Manual of Mental Disorders (DSM)
Largely in response to its declining reputation in the 1960s, psychiatry had already been at work making itself appear more like regular medicine. This involved replacing many academic Freudians with biological psychiatrists.
In 1952, the American Psychiatric Association (APA) developed its own manual called the Diagnostic and Statistical Manual of Mental Disorders. The first edition was developed chiefly with psychiatrists who worked in mental hospitals and was designed in large part to deal with many of the problems posed by veterans of World War II.
Like the first edition, the second (published in 1968) was spiral-bound and only about 130 pages in length. It was designed to mirror the World Health Organization’s International Classification of Diseases (ICD-8, 1966). It added a section on “Behavior Disorders of Childhood and Adolescence” that included “Hyperkinetic reaction of childhood (or adolescence),” which “usually diminishes in adolescence.” In the next ten years, nearly 350,000 copies of this edition would be printed by the APA, indicating they had a moneymaker on their hands.
The third edition, published in 1980, marked a dramatic turn, as documented in Stuart Kirk and Herb Kutchins’ The Selling of DSM. This book ran to nearly 500 pages. The two-page section on childhood diagnoses in the second edition was now expanded to 64 pages and the number of disorders from 7 to nearly 50. The third edition sold 350,000 copies in only three years’ time. In 2016, STAT claimed that “Each edition of the DSM has sold over 1 million copies….”
The biggest scientific claim of the DSM III was that it had achieved a great degree of inter-rater reliability, that is, the likelihood that different psychiatrists would diagnose the same individual with the same disorder. But as Kirk and Kutchins pointed out, there were two problems with this claim.
The first was that they had to fudge to produce their result. For example, there are several different types of “Anxiety Disorders.” But if different psychiatrists diagnosed any one of the various anxiety disorders, reliability was rated as complete agreement. In other words, they enlarged the target from the small bullseye to the entire face of the target!
The second problem was that the claim for high reliability was false, despite many statistical shenanigans. In “The Myth of the Reliability of DSM” (“Challenging the Therapeutic State,” Part Two, ed. David Cohen, Journal of Mind and Behavior, Vol. 15, nos. 1 & 2, 1994), Kirk and Kutchins write:
No studies of the reliability of DSM as a whole when used in natural clinical settings…have shown uniformly high reliability….If, as the developers of DSM III insisted, an unreliable diagnostic system could not be reliable, there is ample reason to conclude that the latest versions of DSM as clinical tool are unreliable and therefore of questionable validity as a classification system.
In fact, reliability and validity have nothing to do with each other. You can have 100% reliability and 0% validity. And no versions of the DSM have been or can be tested for validity.
In order to test for validity, you would need to have a comparison test and there is none. Since psychiatry has never shown any mental illness to have a biological cause, there is no physical test to determine if anyone actually has such an illness. All diagnosis is done only from symptoms that are made up by groups of psychiatrists. Neither the DSM nor psychiatry itself have any validity.
Mental Health Insurance
Prior to the 1980 DSM III, it was likely that a person could see a psychiatrist or enter into voluntary psychotherapy without receiving a diagnosis. But the DSM III was designed in large part to meet the needs of insurance companies, who had been expanding their mental health coverage as a result of employee demand. It was cheaper for companies to grant expanded health coverage than raises, so many collective bargaining agreements ended with expanded health coverage.
The DSM III had given each “mental disorder” a discrete number so that insurance could be billed and reimbursement obtained. It soon became common for mental health providers of all types to give psychiatric diagnoses and to seek to collect money from insurance companies.
And mental health providers, their professional associations, and lay groups such as the National Alliance on Mental Illness (NAMI) began to push for state and federal “mental health insurance parity” laws. The major arguments used to convince legislators to expand insurance for mental health services were (1) mental illness is just like any other illness; (2) it will not cost anyone anything to provide mental health coverage; and (3) mental health treatments will save the economy money in the long run by increasing worker productivity.
Suffice it to say in brief that all three of these things are false, as David Cohen and I wrote in “Mental Health Insurance Parity Is An Empty Notion”:
The mantra of the mental health movement—whose major lay and professional branches, such as the National Alliance for the Mentally Ill and the American Psychiatric Assn., have deep financial roots in the drug companies—has been that mental illnesses are just like physical illnesses and therefore should be covered by insurance. But mental illnesses are precisely not like physical illnesses in at least two fundamental ways: Their diagnosis bears no resemblance to diagnosis in any other branch of medicine, and mental patients routinely get treated against their will.
There is no doubt that health insurance costs have continued to increase, yet no one has even bothered to ask how much of this is due to the new coverage of mental health treatments.
In “Majority of Psychologists Dissatisfied with DSM, Unaware of Alternatives,” Ashley Bobak cites recent research that shows that psychologists’ attitudes toward the DSM have not changed in the last four decades. As Kirk and Kutchins pointed out, the American Psychological Association threatened to develop its own diagnostic manual if the American Psychiatric Association did not remove its claim that all mental disorders were biological in nature. The psychiatrists acceded, and the psychologists went along with the DSM. But Bobak writes,
Despite overall negative views of DSM, with concerns expressed related to the diagnostic categories included and its medicalization of psychosocial issues, at least 88% of psychologists surveyed use DSM at least once a month primarily for practical, billing reasons.
However much psychologists and other mental health providers may grouse about the DSM, they are still happy to use it, to collect insurance money, and to be considered part of a medical enterprise.
Is Voluntary, Confidential Counseling Still Possible?
It has been more than sixty years since Thomas Szasz laid out his twin goals of the destruction of the ideology of psychiatry and the mental health movement and the construction of the idea of a voluntary non-medical “counseling” enterprise.
In his essay, “Whither Psychiatry?” Szasz saw two possible futures for the field:
one is the neurologic-medical approach to mental illness, which, combined with the custodial, has become our contemporary community psychiatry; the other is psychoanalysis, which, together with the work of many psychotherapists and students of man, has become our quest for a science of moral man, or for a moral science (Szasz, Ideology and Insanity, Syracuse: Syracuse University Press, 2nd edition, 1991, pp. 227-28).
It is clear that psychiatry has chosen to continue down the road of force and fraud.
But Szasz saw in psychoanalysis, despite the many shortcomings of Freud and his followers, the value in seeking out the guidance of another person in dealing with what he called “problems in living.” He laid out his positive ideas in many books and articles, most notably The Myth of Psychotherapy (Syracuse: Syracuse University Press, 2nd edition, 1988).
A few years before he died, Szasz was asked to contribute an article to an anthology called Existential Therapy: Legacy, Vibrancy, and Dialogue (London and New York: Routledge, 2012), edited by two British existential analysts Laura Barnett and Greg Madison. Since he had been cutting back on his writing, he demurred and suggested that I write the article summing up his views on existentialism and psychotherapy, which I did in my contribution, “The Existential ‘Therapy’ of Thomas Szasz: Existential, Yes; Therapy No” (pp. 127-40). Szasz himself commented on several drafts of my article, and chose the title himself.
In my conclusion, I wrote (pp. 136-37):
His own dialogical “cure of souls” can only be metaphorically—not literally—likened to “therapy,” and only with qualifiers. But if we understand “therapy” in his terms as the ethical practice of a philosophical dialogue, then I think it fair to say that Szasz has developed an exemplar of existential “therapy” that remains true to the principles of existential philosophy. He has, however, deliberately broken with all of the vestiges of the pseudomedical model. He wants nothing to do with the idea that psychotherapy of any type belongs within the health professions: “the psychiatrist qua health care professional is a fraud” (Szasz, Antipsychiatry: Quackery Squared, p. ix).
In his recent article, journalist Robert Whitaker has argued that psychiatry, as an institution, committed fraud with its promotion of the chemical imbalance theory of mental disorders, and called for a class action lawsuit largely based on the routine denial of informed consent (“Psychiatry, Fraud, and the Case for a Class Action Lawsuit”):
The chemical imbalance story of depression violated that obligation of honesty, and egregiously so. In lieu of information necessary for a depressed patient to give informed consent, patients—and the public—were told a false story that benefitted guild interests and the financial interests of pharmaceutical companies. In essence, a marketing story was substituted for a scientific one….A class-action suit would serve society well. It would put teeth into the legal obligation for doctors to provide “informed consent,” and for a medical discipline to provide society with information that met this standard too.
A class action suit would go far (1) to recover damages to those who have been harmed by psychiatry’s lies, and (2) to put a stop to further lies and further harm.
France faced a similar problem with a fraudulent doctor in the late 1700s. The King appointed a Royal Commission including Benjamin Franklin and the chemist Antoine Lavoisier to give a scientific opinion on the craze rocking Paris at the time: Mesmerism. After a thorough examination, the commission concluded there was no such thing as “animal magnetism” and that Mesmer’s “cures” could be attributed to the power of suggestion, or what we today would call the placebo effect. Mesmer left Paris in disgrace.
Ideally, the American Medical Association (AMA) ought to convene such a panel, since its reputation is also being harmed by the fraudulent claims that psychiatry is one of its legitimate specialties. Psychiatry is the worm in the apple of medicine.
But the AMA has in fact embraced psychiatry, with its general physicians routinely prescribing antidepressants and other drugs based upon the faulty ideology and research of psychiatry.
So it will have to be another group to put together the appropriate, unbiased experts to examine the claims and research of psychiatry and issue its report as to whether psychiatry not only has a valid medical basis, but whether this basis justifies the widespread violation of medical ethics and the routine use of imprisonment and torture.