The clinical wisdom of Thomas Szasz

Besides Szasz’s controversial views are brilliant contributions to clinical practice, including the following examples: (1) He elaborated the physician-patient relationship with three models—“activity-passivity,” “guidance-cooperation,” and “mutual participation.” (2) In The Ethics of Psychoanalysis (1965), he promoted “autonomous psychotherapy,” which involved noncoercive dialogue between therapist and patient that would lead to education and growth for the latter. (3) He argued that transference is part of the analyst’s judgment and the patient’s experience, and that there is a relationship between transference and learning. (4) He used principles of “object relations” theory to explicate deeply the signs and symptoms of schizophrenia. Contrary to popular belief, he was not “antipsychiatry” simpliciter. As a theorist, he clarified language and tried to understand pain. As a practicing clinician, he advocated ways to help people in distress, urged embracing the freedom and autonomy of patients, and treated them as persons with abilities to help themselves.

Szasz, suicide, and medical ethics

Szasz objected to the medicalization of suicide, the legalization of suicide prevention, and especially the coercive role of psychiatry in this realm. He declared that, by medicalizing suicide, we banish the subject from discussion. What is meant by acceptable and unacceptable “suicide”? Who has a right to commit suicide? How does suicide implicate freedom? Does it reflect abortion jurisprudence? How do psychiatrists become suicide’s gatekeepers? Current phenomena (e.g., new physician-assisted suicide legislation) illuminate these and other issues (e.g., euthanasia, informed consent, informed refusal, the “right to die,”), all suggesting how Szasz would react to each. Suicide is legal, but is almost always considered a result of mental illness. Courts approve psychiatrists who want to commit “suicidal” patients involuntarily. Granting physicians prospective legal immunity for prescribing lethal drugs is, at best, a strange and tangential reaction to our inability to discuss suicide (and dying) rationally. Szasz got it right.

Epilogue

This epilogue summarizes and interconnects the chapters of the book, particularly with regard to Thomas Szasz’s views on the insanity defense and the concept of mental illness. The epilogue’s author knew Szasz personally and shared an office with him for nearly a decade, thus gaining many opportunities to discuss ideas with him.

Szasz’s legacy and current challenges in psychiatry

Szasz’s legacy involves two issues in current psychiatry: First, he criticized the concept of mental illness. The DSM-5 debate shows that psychiatry still suffers from unresolved conceptual problems. The definition of the general concept of mental disorder remains unclear. Specific classificatory entities (e.g., autism spectrum disorder) are notoriously contested. Second, he criticized coercive psychiatric practice. Recent developments suggest an ongoing identity crisis of psychiatry as a medical institution. Psychiatry’s tasks are partly related to societal interests (e.g., dealing with dangerous persons). Two psychiatric forms of intervention are therapeutic coercion and compulsion to prevent harm to others. Whether the latter can be squared with therapeutic purposes is unclear. To justify paternalistic interventions such as therapeutic coercion is difficult. Hence, there is enormous pressure on psychiatry’s medical identity. Szasz asked the right questions, not necessarily providing the most convincing answers. Psychiatry would benefit from a thorough, less prejudiced assessment of his publications.

Myths, projections, and overextensions: The conceptual landscape of Thomas Szasz

This chapter distinguishes among myths, projections, and overextensions as they occur within the practice of psychiatry—adding to the conceptual complexity of Szasz’s own analyses and reflecting on how his focal concept of autonomy may itself fall prey to myth, projection, or overextension. Szasz offers detailed explications of his use of the term “myth,” yet many questions remain regarding his application of that term and its relevance to psychiatry. How is a metaphor “literalized,” and when is this problematic? What terms, in addition to the term “mental illness,” serve to support the myths of psychiatry? How do myths relate to the projections and overextensions that can also be found in the language and practice of psychiatry? With these distinctions in mind, it is appropriate to ask whether Szasz’s own reliance on the notion of autonomous agency might itself qualify as a myth, a projection, or an overextension.

Suicide prohibition: Shame, blame, or social aim?

Szasz’s final book, Suicide Prohibition: The Shame of Medicine (2011), covers the medical, legal, and philosophical aspects of suicide. The question of suicide goes straight to the core of the human condition. Szasz’s fearless wisdom brought this ostensibly taboo—yet historically popular and philosophically rich—topic into a brighter light. However, this topic is too complex to be resolved by confining it to an overly simplistic dichotomy of autonomy versus paternalism. A critical examination of “rational suicide,” sociological and psychological research on suicide, and various legal opinions concerning several forms of suicide, reveal both agreement and disagreement with Szasz’s detailed, nuanced, and heavily existential position on the matter. His emigration analogy fails because suicide, whatever its benefits, is life-negating, while emigration is typically life-affirming. Throughout this examination runs an implicit juxtaposition of the rational and the normative, from both individualistic and sociopolitical points of view.

Philosophical influences on Thomas Szasz

We would naturally expect Szasz, a libertarian conservative, to have been influenced by, for example, Rousseau, Burke, Hayek, von Mises, Thoreau, Socrates, Camus, Sartre, Mill, Mencken, Seneca, Nietzsche, Stirner, and individualism in general. But this is not entirely the case. As somewhat of a philosophical rogue, his influences were subterranean, selective, and so eclectic that we could almost accuse him of cherry-picking. He could not use many philosophers to his advantage since they mostly accepted the reality of mental illness. Yet in Szasz’s works we detect Popper’s rejection of historicism and social determinism, Russell’s linguistic analysis, Reichenbach’s logical empiricism, Bridgman’s operationalism, Langer’s and Cassirer’s systematic understanding of non-linguistic expressions such as symbols, Kierkegaard’s indirect communication, and Hobbes’s idea that government may not legitimately take away any individual’s rights unless the individual has first freely empowered the government to do so.

Rights, responsibilities, and mental illnesses: A chronology of the Szasz decades

Szasz’s influence through the intellectual history of individual responsibility is powerful. If mental illness is a myth, then ethical consequences follow, although some ethical developments have ontological, very Szaszian, implications. Szaszian writing is replete with his ethical conception of individual responsibility, emphasizing rights, freedom, autonomous agency, and human dignity for persons with aberrant behaviors. Themes of individual responsibility may be sorted into four variants, loosely identifiable by decade: (1) stress on mental patients’ rights (1970s); (2) application of identity politics to the mentally disabled (1980s and 1990s); (3) emergence of self-help approaches through recovery, rehabilitation, and other “consumer” and “survivor” movements (1990s and 2000s); and (4) trend toward public mental health as prevention, associated with global mental health policy (2000s to the present). Each may be critically evaluated in relation to personal responsibility. The idea of prevention reverts to ontology. Revised public mental health models mirror Szasz’s ontology of mental illness.

Bringing psychopaths into the moral community: Reassessing agency cultivation and social participation

Manuel Vargas’s philosophical account of moral responsibility does not tell us how we ought to hold responsible those who lack capacities for detecting moral considerations, for self-governance, or both. This account problematically makes psychopaths seem to exist outside the moral community. The argument pursued in this chapter is, instead, that psychopaths are inside our moral community insofar as they participate in our interdependent social practices and their actions elicit reactions from us. We can make a strong case for holding them accountable for their specific harmful deeds. However, instead of asking whether we should hold psychopaths morally responsible, we could ask in what way they could be held morally responsible. Thus, the emphasis shifts from their inner psychology to their agency and social participation. This shift aligns with Szasz’s concerns with our approach to mental disorders, and furthers his proposal to transform psychiatry from speaking of illness and disease to speaking of agency and responsibility.

Thomas Szasz and the insanity defense

Szasz stoutly opposed the use of the insanity defense. This chapter considers the persuasiveness of Szasz’s arguments against it, which fall into three broad categories: (1) arguments that the insanity defense is immoral; (2) arguments that it relies on a nonexistent entity, namely mental illness; and (3) arguments that the sciences of psychiatry offer no grounds for supporting it. Each category of argument is explored in its various forms. The most persuasive type of argument is found to be the third. Unlike the other two, it does not require us to buy into strong and broad beliefs which are indeed characteristically Szaszian (such as that mental illness is a myth), but which lack widespread acceptance. In contrast, Szasz’s argument that the sciences associated with psychiatry (such as psychology) do not offer grounds for the existence of the insanity defense appeals to a commonly held and highly plausible multifactorial account of the causes of human behavior. In short, analysed carefully, Szasz’s writing provides more persuasive grounds for taking exception to the insanity defense than his own best-known views offer.