Wednesday, November 30, 2022

Comments by Mark L. Ruffalo, LCSW

Showing 21 of 21 comments.

  • Thanks, Steve. “You appear to experience a lot of feelings of anxiety, and it seems you want to find a way to make sense of and get a handle on those experiences?” is precisely what I say–almost verbatim! To answer your question: I believe we need a concept called “mental illness” because a careful philosophical inquiry into the meaning of “disease” reveals, in my opinion, that a person can be ill in the literal sense in the realm of “mental”–Szasz’s interpretation of Virchow notwithstanding. However, I agree with you that diagnosis often does more harm than good–and sometimes much more harm. I do believe that some people can be aided by diagnosis in the sense that they can conceptualize their problem more easily and identify with others who have similar experiences. And calling it something might give them hope that some “treatment” might help. I don’t believe that either of these points necessarily undermines personal responsibility, though a practitioner who operates from a solely medical-paternalistic or deterministic approach can very easily use the disease concept to justify coercion. This widespread practice must be stopped.

  • Slaying, you have stated here a few times that Ethics of Psychoanalysis was one of Szasz’s worst books. But did you know that Szasz ranked it as his favorite book? He says so explicity in the preface of the Syracuse University Press edition released in the 1980s. This also says to me that his thoughts on “psychotherapy” really didn’t change all that much in those 20 or so years. I get the sense that the reason you dislike the book so much is that it gives credence to the idea that Szasz actually felt like there was some benefit to “psychotherapy,” despite his later writings, which I am aware became very hostile and critical towards Freud.

    I believe a careful reading of Szasz–as well as listening to him lecture and interview–reveals pervasively his game-theoretical approach to the problems called mental illness. In other words, Szasz saw the so-called mentally ill person as communicating in a somatic protolanguage that needed to be–if voluntarily undertaken–explored and decoded in a psychoanalysis.

    Despite what you have insisted, I have read nearly every book Szasz ever wrote, from Pain and Pleasure and his early psychoanalytic work, to Psychiatry: The Science of Lies. Whether you feel that I understand them is a different matter, of course.

    Also, my comments above about congestive heart failure reflect my own opinion and deviate substantially from what Szasz offered.

    Steve, I appreciate your words and I also appreciate the cordial manner of debate here. This discussion is much needed and like I said above, I think we mostly agree in principle.

  • I will end here with a few remarks. I believe that most of us here–Slaying, Steve, Frank, Richard, and some of the others–are 90% in agreement. I think that where we disagree is that I tend to read and cite Szasz’s earlier works, e.g. The Ethics of Psychoanalysis, whereas Slaying seems to be most familiar with Szasz’s later works–which admittedly did become much more radical and “anti-psychiatry.” I think that earlier in his career, Szasz was trying to find a balance between mainstream psychoanalysis and libertarianism.

    See Szasz’s quote on page 16 of Ethics: “Freud’s great contribution lies in having laid the foundation for a therapy that seeks to expand the patient’s choices and hence his freedom and responsibility.” Later in the same book, he states that what is addressed in autonomous psychotherapy is very much along the same lines as what was proposed by Freud and the other pioneering analysts. The book even concludes with a chapter giving advice to therapists. Clearly, Szasz believed in psychotherapy as a form of helping and believed that certain “problems in living” could be helped by human conversation.

    I have come to diverge from Szasz on the issue of metaphor since I believe Szasz erroneously asserted that “mental illness” and “brain disease” are mutually exclusive categories. Anyone who has worked in consultation-liason psychiatry knows that a whole host of neurological diseases present with mental symptoms. Such symptoms are no less “mental” than those produced by psychiatric disorder–but none of us question them as legitimate symptoms of disease. Additionally, I do not believe that an entity only becomes disease once its pathophysiology becomes demonstrable. If this were the case, quite of few diseases readily accepted as such would be declassified as disease.

    Furthermore, and in closing, I don’t think one has to fully accept Szasz’s claims about metaphor to reject involuntary hospitalization and coercion in psychiatry. One could leave room for the existence of a category of disease called “mental illness” and still believe that the only ethical approach to these problems is to assist the patient in becoming more autonomous and free.

  • Since Slaying’s comment is mostly filled with the typical anti-psychiatry rhetoric, I will address what I see as his (or her) main errors in critique.

    1.) While it is true that Szasz’s ideas on psychotherapy evolved over the course of his career, his early book The Ethics of Psychoanalysis very clearly outlined Szasz’s approach to working with patients. In it, he praises Freud on multiple occasions for opening the door to a completely voluntary helping service and talks about mental symptoms as resulting from unacknowledged conflict. He also speaks of so-called symptoms as a method of communication and applies game-theoretical principles to understand their nature. Any claim to the contrary is simply an attempt to appropriate Szasz for anti-psychiatry purposes. Slaying seems to allege that Szasz completely rejected “psychotherapy” (as in human conversation). This is blatantly false. He practiced it for half a century.

    2.) Szasz would routinely comment on the fact that if schizophrenia were found to be brain disease, it would leave the domain of psychiatry. In these statements and others, he leaves the door open to a biological understanding of what is called schizophrenia. It has been alleged that Szasz’s views on schizophrenia were much more nuanced in private conversations than in his necessarily polemical writings.

    3.) The idea that what is called “schizophrenia” is simply the result of institutional psychiatry has been thoroughly and repeatedly debunked by historians of psychiatry. It is like saying “congestive heart failure” wouldn’t exist without cardiologists. Perhaps the term would not exist, but people would still be dying of heart failure. “Schizophrenia” has an ontological reference that would exist regardless of psychiatry.

    4.) Please see my comments above regarding metaphoricity. Here is a paper by Pies published a few years ago in the Journal of Psychiatric Practice that expands on these ideas:

    5.) Regarding Szasz’s disavowal of anti-psychiatry: Szasz repeated throughout his career some variant of, “If a person wants a lobotomy, he should be able to get a lobotomy.” He never sought to ban anything. Rather, he was committed to the principles of liberty and contract in psychiatry as in his political philosophy. The claim that Szasz would support “modern anti-psychiatry” is not supported by any evidence and is debunked by virtue of the fact that he wanted nothing to do with the movement in the years preceding his death.

  • Richard, thank you for your reply here. I quote Pies because I think he offers the most significant and thoughtful counterargument to Szasz’s claims. To submit that there have been no reputable studies demonstrating brain changes in patients diagnosed with mental disorder runs counter to reality. One can question why the changes have occurred (biological vs. psychosocial), or why they do not occur in all patients, but to state that there is no research demonstrating some biological changes is false and misleading. The genetic research also points very clearly to biological involvement.

    A point that has been reiterated here by several commenters in various forms is Szasz’s assertion that once pathology is discovered, the entity ceases being a mental disease and instead becomes a neurological disease. Thus, it follows that there is no such thing as mental illness.

    However, this claim rests on the faulty assumption that mental disease and brain disease are disjunctive categories. Just as some mental illnesses, such as schizophrenia, may be considered “brain diseases,” some brain diseases–such as Alzheimer’s disease–may manifest as “mental illness.” Mental illness and neurological disease are complementary, not contradictory, terms.

    See, for instance, a 2006 article by Orth and Trimble titled, “Friedrich Nietzsche’s Mental Illness–General Paralysis of the Insane vs. Frontotemporal Dementia”:

  • Thank you for your reply. I agree wholeheartedly with your (and Szasz’s) assertion that language matters. Regardless of how we conceive mental illness, the problems exist and have existed long before institutional psychiatry. Pies calls Szasz on the fallacy that psychiatry invented schizophrenia. The term, yes. But the “condition” (as in human condition), hardly. The question then becomes what do we do to help such people. Szasz and I (and I am sure you) are in agreement that coercion must be rejected. And drugs are rarely an answer.

  • Since a few people have commented here, I figured I would attempt to clarify some of the statements made in the article. Thank you to those who have taken the time to read and critique the piece.

    Regarding the concept of metaphoricity: When Szasz states that “mental illness” is a metaphor, he implies also that it is “fake disease” (see Insanity: The Idea and Its Consequences). However, Pies perceptively notes that even if mental illness is a metaphor, the person diagnosed as mentally ill may still be ill in the literal sense. If, for instance, we say that “Night’s curtain fell upon the village,” we may indeed be speaking metaphorically, but not falsely–assuming that it did actually go dark in the village. Similarly, even if we speak metaphorically in saying, “Joe suffers from mental illness,” it would not follow that we were making a false statement. On the contrary, Joe might be quite disturbed in the realm of “mental.”

    I encourage you to take a look at the following paper authored by Pies in 1979:

    Regarding my statement on the growing research on the pathophysiology of mental illness: surely, even the purest Szaszians would admit that there has been an abundance of research in the past few decades linking what is called “mental illness” with certain biological changes–to a greater or lesser degree depending on the condition. Without going into the causes of such findings, one must admit that the problems called mental illness are much more complex than simply claiming “metaphor” and alleging that all mental patients are malingering (as Szasz did).

    I have great respect for Thomas Szasz, communicated with him on multiple occasions, and thank him immensely for his contributions to the cause of freedom and for pointing out the many pretensions of psychiatry. But I believe his argument eventually came to rest far too heavily on language.

  • 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.