Sunday, May 20, 2018

Comments by Mark L. Ruffalo, LCSW

Showing 14 of 14 comments.

  • Merry Christmas to you, as well, Slaying. I must point out that Szasz never wished to abolish psychiatry–he only wished to abolish coercive psychiatry. This is what differentiated him from others in “antipsychiatry.” Szasz recognized the value of an autonomous talking arrangement with a skilled helper. He said that it was for this reason that he continued to practice and teach as a professor of psychiatry. A quote from the Ethics of Psychoanalysis demonstrates his appreciation of Freud: “Freud’s great contribution lies in having laid the foundations for a therapy that seeks to enlarge the patient’s choices and hence his freedom and responsibility.” Szasz rightly saw that Freud created a new role for the psychiatrist as an agent of the patient rather than agent of society. And a quote from Freud which demonstrates agreement with Szasz on his basic premise: “All neurotics are malingerers; they simulate without knowing it, and this is their sickness.” There is more agreement here than most care to realize. I think this is what Dr. Kelmenson is asserting. Best wishes.

  • Slaying–we are, for the most part, on the same page and fighting the same “enemy.” Szasz did indeed practice “psychotherapy” and employed analytic techniques. He realized that people can and do have “problems”–some of them, in fact, are “crazy.” You are right in your assertion that later in his career he distanced himself from all things Freudian and saw Freud as just another psychiatric charlatan. However, I do find value in some of his earlier writings which do apply some analytic ideas.

  • Throughout the Ethics of Psychoanalysis and much of Szasz’s early writings, he praises Freud for his development of a contractual, autonomous helping arrangement which was in stark contrast to the authoritarian psychiatry of his time. Freud’s contributions–as Szasz routinely pointed out–consisted of a conceptualization of human suffering as being driven by inter- and intra-personal conflicts. Szasz deviated from the analytic assertion regarding the existence of the “unconscious,” but he nonetheless agreed with the emphasis placed by psychoanalysis on personal autonomy and self-direction. In Ethics, Szasz even states that his method is very much consistent with Freud’s and other great psychoanalytic thinkers. Dr. Kelmenson rightly points this out.

  • Thank you, Dr. Kelmenson, for this well-written and insightful article. I agree with you that many in our profession are far too quick to dismiss Freud as a psychiatric flat-earther, and many in the so-called antipsychiatry movement overlook the lessons he could teach about the medicalization of human suffering. Not even Szasz negated the problems faced and posed by those described as mentally ill. As you assert, the Freudian model–with all of its flaws–is consistent with an approach that sees human beings as moral agents, arbiters of their own happiness–not biological organisms at the mercy of their genes and brains. In many ways, Szasz’s Ethics of Psychoanalysis is an attempt to return psychiatry to this original Freudian model. It is vitally important for us in the field–and for those allied with us in the so-called antipsychiatry movement–to realize Freud’s vast contributions to human understanding and “mental illness.”

  • Like Francesca above, I use the term “mental illness” (and other synonyms) out of convenience. A much better term to me is “problems in living” (a Szaszian phrase). Surely, the experiences exist. And in many cases those experiences are problematic, either for the person himself or those around him. But “mental illness” is a metaphor; the mind is not an organ and thus cannot be diseased. There is no inherent harm in using metaphors to describe human suffering except for the risk that some people take the metaphors literally.

  • Thank you for your comment. You are right that drugs treat disease. But drugs have also been used for thousands upon thousands of years to ease suffering. I never said that psychiatric drugs “do nothing.” To the contrary, many people seem to find relief in them, although the reasons for this are complicated. Unlike many associated with “anti-psychiatry,” I believe in an unregulated free market in psychiatric drugs. If a person wants Prozac or lithium, he should be able to walk to the pharmacy and buy it without a prescription. The reason for this is simple: I believe in freedom. This is the view of Thomas Szasz, who said the same thing for electroshock, lobotomy, etc. Any other view infantilizes the patient (person) and limits his autonomy even further. There are no psychiatric diseases, and psychiatric drugs don’t treat diseases. But this is not sufficient justification for restricting them from people.

  • We are in agreement there that most “anti-medication” psychiatrists are actually just “anti-excessive medication.” I am not a drug doc. In fact, I am not even a psychiatrist–I am a psychoanalyst. What you say about Szasz is actually mistaken. He believed people should be free to seek psychiatric drugs, just as they should be free to seek alcohol, cocaine, or marijuana. He just did not want any part in prescribing them. I am of a similar belief. Some people may find some relief in medication, and who am I to keep that from them? Szasz had no interest in banning psychiatric drugs, unlike some of the others associated with “anti-psychiatry.” His book Antipsychiatry: Quackery Squared reveals these beliefs.

  • Thank you for your comment. We may disagree here. I would much rather have outpatients who are free to refuse medications than inpatients who are civilly committed and unable to refuse drugs, electroshock, etc. While Kline’s work opened up the door for what later became an out-of-control biological psychiatry, he alone cannot be blamed for this, as he was very clearly cautious about the widespread use of psychotropics.

  • Thank you for the comment here. I am in agreement that most psychiatrists do not enter the field with the intention of doing harm or controlling their patients. As someone who teaches psychiatry residents, I think most are sincerely looking to help the human condition. My position on drugs is simple: as long as the patient consents to them and is informed that they are not treating any known diseases, I am okay with them. In my opinion, any other position negates the patient’s autonomy and self-responsibility.

  • Excellent article. Do you see the pendulum swinging back towards a more psychosocial psychiatry in the coming years, or do you believe the biopsychiatric approach will predominate indefinitely? I teach young psychiatry residents and supervise them on their psychotherapy cases, and many (but not all) seem to recognize the limitations of the reductionistic somatic approach and yearn for instruction on the basics of psychodynamics and psychotherapy. Some even recognize the utility of psychotherapy in working with so-called schizophrenic patients. The history of the field is marked by major paradigmatic changes. Could we see one occurring in the next thirty or fifty years?

  • Thank you for your comment. While I agree that the problems we label “psychiatric disorders” are metaphorical in their nature (and nondiseases), like Szasz I resort to the traditional terminology out of convenience. A much better term is “problems in living.” And the use of the term “patient” is intentional. A person need not suffer from any disease to be a patient, though the term “prisoner” is more appropriate for those cast into the patient role unwillingly.