Leaving Psychiatry Chapter 11; Liberty
Climbing Mt Szasz.
The FDA calls certain substances "controlled." But there are no "controlled substances," there are only controlled citizens.
Szasz
“In the animal kingdom, the rule is, eat or be eaten; in the human kingdom, define or be defined.”
Szasz
“Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies. The robber baron's cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience. They may be more likely to go to Heaven yet at the same time likelier to make a Hell of earth. This very kindness stings with intolerable insult. To be "cured" against one's will and cured of states which we may not regard as disease is to be put on a level of those who have not yet reached the age of reason or those who never will; to be classed with infants, imbeciles, and domestic animals.”
CS Lewis
Prologue; May 2023
As I look back on the typos of this draft chapter from 4 years ago, I am reminded of how prescient Thomas Szasz was. This year marks the 60th anniversary of a grave danger he coined “the therapeutic state”. It is to him this chapter is dedicated.
Climbing Mt Szasz. Oct 2019
Regrettably, Thomas Szasz was a man I never met or shared correspondence. I suspect we would not agree on everything, most especially his atheism replacing faith in God with an almost dogmatic commitment to libertarianism and laissez fare capitalism (a sure route on one hand to losing the battle to those who are more subtle in their aggression, and on the other by those “capitalists” who appear more free market than they will tolerate themselves). But these two ideologies of atheism and libertarianism informed his psychiatric critique, and we can hardly regret him being disposed to them. As Szasz was oft to mention, why is it sane for a man to talk to God but not to claim that God has replied? There are dangers lurking behind that question, not the least of which are the assumptions behind hastily dismissing it. Many materialist psychiatrists might conclude both men are insane, albeit only the second of the two can be subjected to treatment. Szasz saw both as living in a world of unreality, along with the cherished beliefs of the church of psychiatry also. He wished all to live and let live.
My own thoughts were well on their way to development before discovering Szasz. Still, the master comes before the apprentice and deserves the greater due. And he is one of the few coordinate points around which this apprentice formed his views (the others know who they are). Though Szasz disavowed the term “anti-psychiatry”, it’s difficult to deny its goodness of fit to the man himself. So for lack of a better term, he remains the gauge in extremis to measure how far you can go in a critique antagonistic to psychiatry. I call this adventure “Climbing Mt Szasz”. Consequently, he ought to be the mandatory reading for all would be psychiatrists, best read as a challenge to radical empathy as opposed to the secondary reading from those good for nothing but building straw men. Szasz was a polyglot polymath far brighter than the best of them.
Almost single handed Szasz took on American psychiatry as his star rose very high in the 1960’s and 1970’s only to burn dim long before the man himself reposed in 2012. We can attribute the fading only partly on account of psychiatry finally succeeding in ignoring him away (an early example of cancel culture), and many a career patient preferring his message not exist either. Indeed, it seems we moved from the 1960’s call to liberty from medicalized labels towards to a current infantilized want to be respected and cared for with or as a label. Now mental illness is variously held as excuse, a fashion or some twisted masochistic badge of honour. Like Rousseau, man everywhere is free and everywhere in chains, to which we might say he seeks both despite the contradiction, the freedom of the chains. When all the asylum walls were torn down, as many as were liberated then built their own. We even see the same in the otherwise brilliant 2019 cinematic take on 1980’s life, “Joker”. The character is downtrodden and deeply troubled, and even his reality is placed in question. And yet in a crucial climactic scene he asserts himself not as a downtrodden man, yet rather as the downtrodden sufferer of a “mental illness”, taking it on himself as a radical identity as opposed to being a man with problems and understandable responses to trauma. (any good psycho-dynamically minded practitioner will likely not diagnose pseudobulbar affect). His was thus never to be a freedom from psychiatry and those critics of psychiatry who would milk him for all the pathos they could get. He took it to his heart as himself. Ergo he can never escape his asylum. But neither can the audience who agrees with his self-identification leave the asylum of their worldview. “If only the world had treated this psychotic man better” they think to themselves. The joke really is on an audience who leaves the cinema believing in the mental illness of the protagonist more than a mental illness of the sick world in which he lived.
Returning to the conspired forgetting of Szasz, in my own psychiatric apprenticeship, his was not a name included on any prescribed text, and the sum total devoted to him was approx. 15 minutes in a single lecture where his arguments were straw manned, mischaracterised and irrationally bundled up in a quasi-diagnostic category known as “antipsychiatry”. Actually, though Szasz was a brilliant and witty polemicist, my own opinion is that he became lost in his own Ivory tower and partisan arms of the likes of the Cato institute, all too often failing to enter empathically into the minds of the swinging voters he wished to persuade. Or maybe that’s just me. That said, some posthumous attacks against the man still do persist. Even as an octogenarian he was fighting virtually the entire psychiatric establishment more or less single handed and, in a way, not shared by those who came to label or be labelled as “anti-psychiatry” or “critical psychiatry”. He rejected both. Championing a man outnumbered and who is no longer around to defend himself is a cause noble enough. To this end I will try and be faithful to Szasz’s own thoughts in the earlier parts of this chapter. The reader will forgive if I drift into my own ideas in places, and hopefully will discern the difference if or when it arrives.
As a final preamble, in this chapter as in others I’ll be faithful to not burdening the text with references. If the reader wishes to explore the matter further, I commend to them the excellent work “Szasz Under Fire” edited by psychologist and Szasz fan Jeffrey Schaler, along with of course Szasz own books (approximately 30 in number, I have read but 3) and also the published work of his key opponents, e.g. Robert Kendell, Edwin Torrey and, especially, Ronald Pies. These latter works are predominately to be found in the specialist journals, where each article will cost the lay reader more than this entire book and a lunch to read it with. Such is the sharing and caring socialist spirit of disseminating knowledge in science and medicines fourth estate. It is yours if you can afford it, at approx. 20-35 dollars per article .
Thomas Szasz; a Brief Biography
Tamas Istvan Szasz was born to wealthy atheist ethnically Jewish parents in Budapest April 15th 1920. Had his father not changed the family name a generation earlier he would have likely been born Tamas Schlesinger. By all accounts the home was a harmonious one, with much love shared between Tamas, his parents, his older brother and the beloved Nanny, herself essentially a de facto member of the family and not the only member of staff. There is no doubt that he did have recurrent serious infections as a child, this being an era before the antibiotic golden age, and he could well be stereotyped as the sickly homebody child with the precocious intellect. Szasz himself admits on reflection that the lessons he learned as a child he transferred into his later reflections on the psychiatric patient. For having been doted on when ill, he would later embellish symptoms and malinger in order avoid the gymnasium. The uncharitable formulation would then have Szasz as the consummate child liar, later projecting this negative character trait out into the world of the “mentally ill” in accusation, a callous call to make them responsible for what was obviously beyond them. The more charitable, and I would submit more realistic, formulation is that lying is a thing many a child does, and many an adult also. Further, ies can be so subtle as to be hidden even from the one who makes them. Anyone who works in psychiatry comes to see this as a pervasive fact of human nature. We cannot blame Szasz for his confession to introspection of himself let alone observation of others. Inferences from our own minds is a time-honoured technique in psychology. Szasz was an expert psychoanalyst all too aware that therapy of the other always involves checking oneself also.
Like many a continental European product of high learning in the Gymnasium, by the time of graduation Tamas was fluent in Hungarian, German, French, Latin and (I assume in virtue of his contact with the rabbis whose faith he saw as superstition), Hebrew also. Just as there is no substitute for interviewing a patient in their mother tongue and sharing an intimate knowledge of their cultural mores, Szasz was able build up a critical metanarrative of psychiatry from a reading of original psychiatric works in the authors mother tongues, availing himself of not simply the psychiatric literature itself, yet also the political and philosophical discourse of the time and place of the preceding 300 years. And he was a voracious devourer of it all. With the rising spectre of Nazism, Szasz left Hungary in 1938 as part of the Jewish Diaspora, arrived in The United States as anglo Thomas, added English fluency to his arsenal in an immersive couple years and managed graduate in physics with highest honours before attending medical school where he continued to excel. His claim to have topped the class has never been contested. Szasz chose medical studies even prior to leaving Hungary, not as a route to a vocation so much as a want to understand the body as the property in which his person lived. A walk through the body was a walk through his own most intimate backyard, and example of just how attuned he was to the body as a bio-political object, a first point to explore and embark upon the philosophy of liberty and private property. Despite Szasz never really intending on practicing medicine, he did flirt with becoming a physician before deciding on psychiatry, as was always fated to do. Szasz completed much of the training in an internal medicine residency in Harvard and Ohio before jumping ship to psychiatry. This was still the golden era of the asylum, and Szasz needed plan assiduously and use his all his guile to avoid being placed in a compromising position of forcibly hospitalizing and treating another human being. He chose a psychoanalytically orientated training program in Chicago with this express goal in mind and threatened to resign when they sought to seconder him to the state psychiatric hospital. He may quite well be the last psychiatrist to be able honestly say never used coercion. Of course some may see this as his Achilles heel, never being confronted face to face with someone so mad as to require the straight jacket and the like. How does he know what he would not have done, or know it ought not to be done unless he is there? However it is fair and true to say that Szasz did see an ample share of madness. And his principled objection was not to avoid a confrontation with hypocrisy so much as the upholding of principle for its own sake. He was going to always be honest to himself and others. After all, he had been scrupulously honest and acted against any selfish interests when turned down from numerous ivy league medical schools for admitting he was a Jew, an admission he did not need to make and which sabotaged entry at the final turn. Nonetheless he was shrewd enough to realise a manoeuvre of ducking and weaving the asylums were also strategic to avoid being placed in a conflict of revealing his hand against the state until his strength was up to the occasion. He needed complete training and find himself safe tenure. He had wisely taken stock of history and lessons learned, e.g. of a fellow Hungarian Semmelweis who became a pariah for speaking the truth about hand hygiene and lacked the political strength to stay in the game. By the late 1950’s, Szasz had arrived. He was a staff academic with stable income and time on his hands at the State University of New York. Now he could turn that time and those hands against psychiatry. For the next half century he would dig in, defend his tenure against sometimes ferocious attack and launch a salvo of a few dozen books and articles aimed at undermining psychiatry. Taking from the old adage that the enemy of the enemy is my friend, Szasz with atheist even sidled up with the anti-psychiatric cult come official religion scientology (made official religion when it barraged the IRS with complaints such that the IRS relented and granted it tax exempt status). The outcome was the founding of the scientology front group, the citizens commission on Human Rights (CCHR).
I said earlier that Szasz was trained in and incredibly well versed in psychoanalysis. He received his own analysis by fellow Hungarian Jewish ex patriot Therese Benedek, who in turn received analysis by Hungarian Jewish Sandor Ferenczi, who in turn received analysis by the unanalysed (or self analysed) master himself, the secular Jewish Moravian Sigismund Freud. Such is the way classical analysis was practiced and taught, a predominantly secular Jewish enterprise similar in some respects to the Kabbalah, requiring two adults to dive into the gnostic territory of the unconscious, and pulling out truths to set the world aright. Christian readers will see in the requirement for the analyst to be analysed a metaphor of catechism and baptism, or alternatively the anointing of the apostolic line of priests. Yet it would be a mistake to assume that Szasz saw psycho-analysis as Freud did. Rather he saw it simply as a conversation.
The Myth of Mental Illness
Szasz basic argument was aimed philosophically and practically at containing medicine to the matter of physical pathology of the physical body, and mental phenomena only if directly causally related to the pathology in question. All else that resides in the mental life and behaviour of the person is not medicine, and better left to be discussed as part of psychology to be sure, along with rhetoric, law, philosophy, ethics, politics, theology and plain old village life. Should we fail to observe and defend this boundary he warned, we run the risk not only of many a logical transgression, yet also one where the doctor becomes a political actor, a tool of tyranny if not a tyranny itself.
This was the gist behind the title of the article "The myth of mental illness," in the Feb 1960 issue of American Psychologist and followed up with the book of the same name, just as importantly subtitled “Foundations of a Theory of Personal Conduct”. The subtitle has much to say about the theory and is often ignored by critics and fans alike.
A simple example of the proposed demarcation is as follows. A man attends the doctors rooms, and may be subsequently diagnosed with emphysema. That such a pathology relates to smoking is a given in his case. Insomuch as the pathology is causally related to the behaviour, the doctor may advise the person to cease smoking, and even scale this up to mass public health campaigns encouraging the whole population to voluntary change. To be sure Szasz would endorse a certain compassionate attitude be had by the physician for his/her patient, as the diagnosis is delivered to a human being with a mental life. But Szasz would point out that the behaviour itself is a choice and outside the province of medicine beyond its limited scope to advise the one seeking the advice, or an invitation to change for the one or the many alike. To say that smoking involves the inhalation of chemicals with biological effects is also a given, as has been already recognised in the pathogenesis of the emphysema about which the doctor could elaborate and is expected to be expert. And all would acknowledge that the nicotine has certain psychotropic effects and a whole pharmacology that, within the narrow technical terms of art that the pharmacologist might use, is a substance which we might describe in terms of “tolerance” and “dependence”, though “addiction” is a different notion altogether. And yet whilst smoking might cause an illness and emphysema is usually a smoking related disease, there is no reality to the claim that the patient suffers from a smoking illness or a smoking disorder or tobacco use disorder, etcetera. Smoking is a choice, however much it might be a poor one. The disease of smoking is nowhere to be found except as a metaphor! And medicine has no place in forcing or coercing the smoker to quit. The next step towards medical overreach is to speak of a “gambling disorder” explained using an illness model (another behaviour without a bodily pathology), an antisocial personality disorder using an illness model (a character or person without a bodily pathology) and so on. Now several years after Szasz death, there is likewise a call now for health care workers to be at the vanguard against so called intimate partner violence (previously termed domestic violence), the explicit call being that intimate partner violence is “a public health matter”. When is assault more than a criminal matter, and how long until we pass from the victim being victim of a health matter to the perpetrator also a victim of an illness the psychiatrist will treat, perhaps a “domestic violence perpetrator disorder”? Or we might as well make divorce a public health matter also, and demand the nanny state step in and save us from what has become endemic. Surely there are symptoms (regret, sorrow, loss of sleep etc), signs and behaviours (visiting lawyers, arguments, scuffles over shared property) of divorce which may be descriptors of suffering, i.e. pathos. Is not suffering the province of medicine? And there may be attendant social and occupational dysfunction also. We could even develop a nosology of subtypes of divorce disorder and write them out on little gray cards a la Kraepelin. Presto, a new illness is born if we only want it to be so. But is divorce an illness? What place is the doctor in all this, and where will these incursions into good sense end? Shall voting for the wrong political party also be an illness, or at least a symptom? The psychiatrist may counter by condescending towards an explanation that the divorce can “trigger” a major depressive disorder, depression being something we are attuned to consider is a valid illness. But what is this major depressive disorder apart from its descriptiveness, it boundedness to precipitant and a turn of phrase for a divorce having passed an arbitrary threshold of what might be an acceptable impact upon the person and that which we wish were not the case (or what our values would morally proscribe as excessive). Where is the boundary between a healthy divorce and an unhealthy one, and how is “health” anything but a metaphor beyond medicine. If one is excessively troubled by the divorce you will be diagnosed, e.g. with major depressive disorder for example. If glibly untroubled you may be diagnosed also, with narcissistic or other personality disorder for example. But why diagnose with anything, when diagnosis implies disease? And what of bereavement? Perhaps an urban myth, I’ve heard it said many bird species mate for life and have a response to a mate’s death that may be said to be an equivalent of a severe major depressive disorder. And so what? Can no man or woman have a similar attachment without the psychiatrist’s invocations of illness? The DSM criteria permit a human to mourn the death of a loved one for a couple weeks and no longer. Are people not entitled to remain sad for life after the passing of a spouse without a psychiatrist saying they have major depression of the morbid grief variety? To all this and more madness Szasz would say a resounding “enough”. Disease (or illness) involves bodily pathology, this being the place where the line is to be drawn lest it project into absurdity and tyranny. In and of themselves, neither sadness, badness nor madness is disease.
Another example to illustrate the point is Nietzsche. Often prone to melancholy, one winters day in 1889 he simply became mad, flung his arms around a mistreated horse and from that moment his sanity never returned. Or did it, as after this fateful day he did continue to write for a time until he could write no more. Scholars have since read into his case the likelihood that his madness was neuro-syphilis, in this case the sequelae in the brain from an infection first acquired many years earlier in a brothel (pure speculation) or having been up to his elbows in syphilitic soldiers as a hospital orderly in the Franco Prussian War (a less likely means of transmission, and also speculative). Others have conjectured he had one too many strokes, a mercury poisoning or a slow growing brain tumour. Note that all these conjectures hinge upon a catastrophic physical event in the physical brain. My own money is on the syphilis. But what if it wasn’t and it were possible us prove this to be the case? What if it was just him? What if his brain, like any genius, appeared to the pathologist just like any of ours? What if he came to simply believe he was literally Dionysus, much as the Tibetan in exile to whom millions fawn believes he is the reincarnation of the Bodhisattva? And after Nietzsche’s failed attempt to liberate the horse, when he then wrote (also in 1889 mind you) that the world should attack Germany and all anti-Semites be cast out, does this make him any more insane than the perfectly sane yet evil man who 50 odd years later attempted to do the opposite? And when Nietzsche elevated himself to the person of the Godhead himself above the minor Dionysus, why ought we see this as any different to Jung with his sincerely believed pseudo-divination a mere 24 years later, and countless other Antichrists of the fin de siecle then and since? At the sheer arbitrariness of it all should we throw out an objective biological criterion for disease?
Szasz was fond of the line, that when you talk to God it is called praying, when God talks to you this is insanity. So people have beliefs about themselves and the world, sometimes very strange beliefs. People have emotions, sometimes powerful emotions. People make decisions, sometimes stupid and poorly considered ones. And sometimes these thoughts, emotions and attendant behaviours become a nuisance to themselves, and sometimes a nuisance to others, a state of being “at risk of harm to self and/or others” or “at risk of harm to reputation”. When such risk involves psychological suffering, we might be tempted to use all the same language of medicine and disease with none of the physicality as its ontologically necessary requirement. If so, we are using the language of medicine metaphorically. We can talk until the cows come home of “signs”, “symptoms”, “behaviours” all of mental “illness”, of psychiatrists “examining” persons whom they now refer to as “patients” to whom is administered “treatment” and so on. Yet this does not bridge the gap between real medicine (bodily disease) and counterfeit medicine (i.e. psychiatry). From the rubble of a fallen church and ministers to the soul who are disqualified from being ministers to the psyche, a whole new industry can breed these counterfeit medical specialists claiming to be experts over the mind and behaviour, along with guilds of these same individuals whose power is underwritten by the state, “hospitals” and “clinics” in which to “treat” the alleged illness of what people think, feel and do. It additionally acts as a filter capturing certain species of social deviance that do not obviously fit within criminal law. And when we believe these turns of phrase and use of metaphor, the belief elevates the new psychiatry to the status of tangibly real organic pathology that is the stuff of real medicine, of broken bones and tubercle bacilli. This bewitched belief, in the fallacy of its own misplaced concreteness, is the makings of a myth. In 2020 we now stand on the other side of many decades of sedimentation of metaphor into a superstructure of dissimulation that we believe is solid as a rock and yet crumbles when approached with a relentlessly critical mind. To those who would claim that the diagnoses in DSM 5 or ICD 11 are medical illnesses, Szasz would challenge them to prove the ethics and logic of the sense in which they carelessly use language. To those who say they are physical illnesses he would offer the same challenge, show me the bodily pathology, the stroke or the tumour etc. They had not succeeded in the late 1950’s when Szasz launched his attack, and they have not now 60 years later. And the hubris has taken us all in the entirely wrong direction he would say.
His formulation of mental illness and the appropriate place of the physician is encapsulated in the fifth Act of Hamlet, Shakespeare being just one of many literary luminaries who understood the mind far better than the psychiatrist. In the play, Hamlet calls for the physician to attend to Lady Macbeth; “Canst thou not minister to a mind diseased” he says and continues his plea “Pluck from the memory a rooted sorrow”, “….and “with some sweet oblivious antidote”. The physician of the play rightly diagnoses that pain of a tortured mind and its voices is not the stuff of medicine. It is conscience. It is coming from, and remedied by, a conversation between lady Macbeth and herself, if not the divine also.
And Szasz himself writes
“According to pathological-scientific criteria, disease is a material phenomenon, the product of the body, in the same sense that urine is a product of the body. In contrast, diagnosis is not a material phenomenon or bodily product: it is a product of a person, typically a physician, in the same sense that a work of art is the product of a person called an "artist." Having a disease is not the same as occupying the patient role: not all sick persons are patients, and not all patients are sick. Nevertheless, physicians, politicians, the press, and the public conflate and confuse the two categories”.
Now the contemporary reader will often see the word “medicalize” or “pathologize” and take it as a pejorative against more holistic care, suggesting that we ought to treat the patient already divested of autonomy and responsibility more humanely, with more than simply the “medical model” or “drug therapy”. That is to say we ought to care about them as people and not biological machines. Szasz went further to say medicalization in psychiatry is a logical fallacy, thus rendering the question of the “medical model” not simply excessive or myopic, but irrelevant. In its pretensions to be medical it is, a priori, harmful. We cannot have a humane person centered medicine for something that is not medical in the first place! Even to see the person as a patient with a mental illness is medicalization, regardless of the model of care.
But what did Szasz, and yours truly, both think of so called “symptoms” of psychosis, these being the most confronting challenge to the claim that mental illnesses do not exist as illness, except metaphorically. I have covered psychosis in the previous chapter (sanity). He thought delusions were like any other belief. In these cases, the beliefs are more often than not incorrect to be sure, and often very idiosyncratic and strange. Yet wrongness as such is hardly the licence to medicalize. Although critical in some senses of classical psycho-analysis, he considered the belief to be psychologically constructed according to some inner need. The need defends the belief as a lie to the self against seeing the reality of the world. And insomuch as so called delusions are a lie to the self or an error of thinking stubbornly held, it is a choice made by the person if to engage in a dialogue towards a flexibility to change their mind, where mind in turn is a verb and not a noun. I would see belief in less flexible, less libertarian, less consumerist pick and choose terms. Some beliefs we simply have. Autochthonous or semi-autochthonous they are what they are and their fixedness is more fate than pathology. Some of us even have beliefs we would wish we did not have yet cannot lie to ourselves and pretend we do not believe what we believe. Nonetheless and notwithstanding beliefs might have their mysteries, once again this is hardly licence to medicalise. Auditory hallucinations he saw as they are, conversations had with the self, disavowed and on an unconscious level chosen to be experienced as the voice of another. Even the voice of the other is the voice we speak to ourselves as from the other, what we think they are saying to us, or would say to us. And insomuch as the hallucination involves beliefs about the voice heard, I assert on some level they are inseparably bound up with the so called delusion, which is an alternative belief. My own transcultural and trans-historical view is that the externalization of such phenomena (the ego alien aspect) makes of voices and such the latter day equivalent of demon possession, and the psychiatrist the priest who will perform the exorcism.
The Therapeutic State and Pharmacracy
The therapeutic state is simply the power invested in psychiatry by the organs of government to police and engineer the desired thoughts, feeling and behaviours of the citizenry, with the authority to force their engineering upon the person if, according to the metrics of psychiatry, the mental state is beyond the pale. Obviously, the agenda of psychiatry must harmonize with the government in order for the state to run smoothly, and not be detected by the citizenry as averse to their own liberty. The project is aided by the cultivation of an attitude in the citizenry of actually wanting the shackles of the therapeutic state, as this will absolve themselves of personal responsibility, along with the burden and embarrassment of loved ones who are social deviants (or its euphemism “mental illness”). Psychiatry places all those parts of themselves they dislike as the other, the mental illness they suffer from. Though an international phenomenon, the therapeutic state could also be best historically formulated in that colossal ongoing social experiment known as the United States of America. Puritans and Masonic seals on dollar bills aside, the United States explicitly separated church and state. Nonetheless the same social unconscious was at work with the same needs for the same controls that the church provided in augmenting state power and providing meaning, just as it did in the old world. And so, when God died in America as in Europe psychiatry acted to fill the void, a different kind of church with a different kind of priest yet wedded to the state all the same. Where once the outcasts were managed by the Church, now we had psychiatry. Where once we had demonic possession, now we had psychosis or severe neurosis of borderline personality structures. Where once we had inquisitions as forced therapies for the soul, now we had forced psychiatric treatment, for the patient’s own good of course. As some might say, the content changed yet the form remained the same, a passing over of power from the papal ferula to the staff of Aesclepius (or worse still, the Caduceus of Hermes). Szasz neologism for this, dare I say, unholy collusion of (predominantly) psychiatry and the government he termed the Therapeutic State, or Pharmacracy.
In Ceremonial Chemistry, Szasz writes
"Inasmuch as we have words to describe medicine as a healing art, but have none to describe it as a method of social control or political rule, we must first give it a name. I propose that we call it pharmacracy, from the Greek pharmakon, for ‘medicine’ or ‘drug’ and kratein, for ‘to rule’ or ‘to control’”.
Szasz writes in the preface of his 1963 text Law, Liberty and Psychiatry” the following
“For the most part, psychiatrists are engaged in attempts to change the behaviour and values of individuals, groups and institutions, and sometimes even nations. Hence psychiatry is a form of social engineering. It should be recognised as such”
To which he added in the introduction to golden anniversary of the Myth of Mental Illness
“For the practice of pathology and for disease as a scientific concept, the person as potential sufferer is unimportant. For the practice of medicine as a human service, in contrast, the person as patient is supremely important. Why? Because the practice of Western medicine is informed by the ethical injunction, Primum non nocere! and rests on the premise that the patient is free to seek, accept, or reject medical diagnosis and treatment. Psychiatric practice, in contrast, is informed by the premise that the mental patient may be "dangerous to himself or others" and that it is the moral and professional duty of the psychiatrist to protect the patient from himself and society from the patient”
In this sense, psychiatrists might purport to care for individuals. Yet to imagine that this is the boundary of their concerns would be a subtle error on their part and ours. They are public health clinicians working on individual instantiations of public health problems. The question ultimately is not what a person wants but what society needs and proscribes. The psychiatrist sees through the former towards the latter, and will incarcerate the person to achieve collectivist goals. In a later interview Szasz spoke bluntly the obvious fact
“if you’re in a building that you can’t get out of, that’s not a hospital, it’s a prison”.
Psychiatry as a substitute for religion and a quest to socially engineer the man (or woman) by the powers that be is a bold claim. Yet one does not have to look far for the evidence of this. In the few short years before the release of chlorpromazine, take also the keynote speaker at the 1946 William Alanson Memorial lecture in Washington DC, lamenting at the state of man in the wake of the second world war
“the only psychological force capable of producing these perversions is morality”….
“the re-interpretation and eventually eradication of the concept of right and wrong which has been the basis of child training, the substitution of intelligent and rational thinking for faith in the certainties of old people, these are the belated objectives of practically all effective psychotherapy”
The speaker later continues
“if the race is to be freed from its crippling burden of good and evil it must be psychiatrists who take the original responsibility. This is a challenge which must be met. If psychiatrists decide to do nothing about it but continue in the futility of psychotherapy only, that too is a decision and the responsibility for the result is still theirs”….
In calling for the mobilization of a 10 fold increase in the army of psychiatrists and conscripting other doctors also in the war against human nature, he states
“shock, chemotherapy, group therapy, hypno and narco-analysis, psycho drama, even surgery, can all be used…”
And later still
"Psychiatrists “should be trained as salesmen and taught the technique of breaking down sales resistance”
Things get ominous when he asks
“should attempts be made by the profession to induce governments to institute compulsory treatment for the neuroses as for other infectious diseases”
Such were the words of none other than Brock Chisholm, the first director of the World Health Organization, celebrated humanist and (not surprisingly) psychiatrist, who in a fervent attempt to avoid a repetition of the first two world wars calls for a one world government and psychiatry at the vanguard of explicit micro and macro social engineering. Such is the progressive mania (see my abuse of metaphor) seizing a reflective moment following the war, a wholesale hatred of the world and all it has held sacred the likes of which one might read in a Robespierre or an unveiled Voltaire. One can hardly fail to perceive in such sentiments the palpable potential for totalitarian evils, all opportunistically cloaked in the knee jerk sentiment to avoid another Hitler. All rhetoric since has been a repletion of the same. Too much liberty, nationalism and uncomfortable conservative ideas leads to the oven and the pit. Chisholm’s speech was fawned over by powerbrokers in government and psychiatry alike. Present for example was Harry Stack Sullivan, one of the founding fathers of contemporary American psychiatry who described Chisholm as “a rarely wise man”. Stacks tone was more cautious, and his eye more widely and deeply scanned the psychodynamics of the situation, whilst retaining the same progressive drive nonetheless. As the dust settled after the war, psychiatry continued its aspirations and developed further its armamentarium. It caked upon this layers upon layers of public relations and the language of care.
Psychiatry isn’t the only participant in the therapeutic state of course. We have public health measures which might include seatbelt wearing and vaccination campaigns, and some coercive activities when persons drive intoxicated or mandatory notification or quarantine of persons infected with tuberculosis, plague or Spanish flu. Yet note these are usually either predicated on encouraging voluntary assent by the individual subject to the marketing, or coercion only when there is a clear and present danger to others from something beyond the control of the individual (no one individual can purify an aquifer and no willpower can resist ebola). What is under the control of the individual is potentially a crime and not a public health measure as such. Recklessly infecting another person with hepatitis or HIV can, for example, be rightly considered assault in my own, and other, jurisdictions. Another manifestation of the power of the state is as prohibitive nanny over what chemical substances the person wishes to take for their own private reasons, this the subject of another earlier chapter. Nevertheless, it is in psychiatry that we find the most pervasive, concentrated and contentious manifestation of the therapeutic state as running roughshod over autonomy. And we have metaphor heaped upon metaphor, from thoughts becoming illnesses to treatments and public health campaigns becoming a “war” on mental illness or a public health “campaign”. And yet who are the invading forces we are warring against? A person who may commit a crime on account of deviant thoughts? Do we not have a police force for that? A person who may harm themselves? Why not the right to be sick and damage one’s own property, i.e. the body that is theirs? Tyranny always invents the solution first, and then the emergency to justify the solution. Each generation as psychiatric power grows its claims to catastrophe also become greater. As the numbers treated with so called antidepressants increase, unlike with antibiotics or polio vaccination the cases of depression rise also.
Eventually even the jailors of the therapeutic totalitarian state become captives to its cause. As Szasz quotes Alan Leshner circa 1998, Head of the American National Institute of Drug Abuse involved in the majority of drug addiction “research”
“My belief is that today, in 1998, you [the physician] should be put in jail if you refuse to prescribe S.S.R.I.s [Selective Serotonin Reuptake Inhibitors, a type of so-called antidepressant medication] for depression. I also believe that five years from now you should be put in jail if you don’t give crack addicts the medication we’re working on now”
Strong words, yet hardly surprising or unusual. In my own practice, untreated “psychosis” and refraining from forcibly saving someone from the “mental illness” of suicidality can get the physician in hot water. But nurses, teachers, clergy and all public servants are being brought into the orbit of mandatory “duty of care”. Even the banking officer on the phone will call the police or paramedic if you threaten suicide in response to them threatening to foreclose on your mortgage, for neither you nor they are responsible for what you do. They are not responsible for taking your home and you are not responsible for taking your life. Indeed, they might be fired for what you do with your body. The health sociologists say health is human flourishing, disease is anything that obstructs the road to health. The health socialists say your brother is public property and you are his keeper, you being one of the million eyes of the therapeutic state. And should you not keep your brother well you are a criminal or traitor. These are the makings of a Pavel Morozov. It is all around us. Don’t believe me? Just start talking about hearing voices telling you to suicide.
To properly understand the danger posed by the therapeutic state requires an understanding of, and more to the point an affective leaning towards, libertarian principles. It won’t be to the liking of those red shirts of a more communitarian bent who believe that they are their brothers (or sisters) keeper and vice versa (or more accurately their brothers purifier using the state to re-educate). Liberty is not for those who wish to suck on the teat of the state and turn to the same at signs of trouble, expecting all facets of life to be politicized and the government to license approval, regulation and supervision of everything. It is not for those whose naivety would lead them into excessive trust in their leaders simply because they are not liquidating their own citizens, and always pointing the finger at those foreign regimes who are. The libertarian in principle sees the adult as a private person, not a public property. And the libertarian in principle sees government as inherently dangerous to individual freedom. Any elaboration upon state powers agreed on by the citizenry is a necessary evil, say for taxation of emergency relief or the mobilization of an army in times of genuine war. This always carries a risk of gathering gravitational mass and carrying us further towards the proliferation or more and more organs of government, regulation and oversight as we undoubtedly have today. Apart from possessing two eyes and two ears to see what is the truth, why might any person have so strong a view? For the simple reason that just as I have defined the psychiatrist on the basis of the power to coerce (chapter 1 on ontology), this too is exactly the sine qua non of government, i.e. the rapacious power to control the individual, the power to control you. You may like the roads upon which you drive and like the state health care you receive. Yet you do not like it that the tax that pays for x is also misallocated to y. You cannot choose either the amount taxed or its allocation. And in virtue of paying taxes you have less income available for your own philanthropy, though can always apply for a grant that nanny government will provide, and regulate, audit so on. You might finance via taxation the defence research programs from which smart phone and internet technology develops, yet pay twice over when the government gives the technology over to large corporations that charge you a fee for the product. And things get ominous when that same road that you paid for can carry you against your will to a technologized hospital which can admit you against your will, hold you down and inject state sanctioned drugs, all for the crime of thinking differently. Postmodern man can scarcely imagine a time or a possibility of things being otherwise. As George Washington himself stated
“government is not reason; it is not eloquence. It is force. Like fire it is a dangerous servant and a fearful master”
How can any open eyed student of history doubt the truth of this?
The purist form of libertarianism would imagine a rational agent stepping out of the Lockean state of nature into free assembly and voluntary contracts with other free individuals, voluntary contract being the atomic units from which even a national army may be assembled. You would pitch your tent or build your log cabin, fence around it, sell the tomatoes and prosper. Or you might worship the garden fairies if that was your great American pursuit of happiness. Alternatively, you could just drink yourself to oblivion. Every individual is free to do as they please up to the point of violence against another’s life, liberty and property. And actions always carried consequences, with no one to blame but oneself.
When considering the danger psychiatry poses, let us neither overstate the case (say with puerile and cliché comparisons to totalitarian states of the previous century) or understate the case (by viewing psychiatry only through rose coloured glasses). To state the ethical and moral case we need understand the gravitas of what deprivation of liberty is, along with the complement to liberty, i.e. personal responsibility. To apply this to the person whom we are indoctrinated to believe deserves to have their liberties taken from them, we need also enter into the mind of the other in an act of empathy that few can achieve. We need be bravely open to a process of unlearning, dwelling in a place of sceptical tension, resisting the drive to foreclose on a greater knowledge by prematurely falling back on the comforting prejudice and bewitching language of our current selves (i.e. the myth of mental illness). Hopefully the bonds have already been loosened as I have addressed the matter of psychosis above and in a previous chapter. Hopefully you will forgive my repetitiveness. Here and there I’ve gone as far as I can to convince you of its arbitrariness, where arbitrariness is defined in terms of an autocratic system which operates according to power over persons, not having won the argument of either the moral warrant behind the power, nor the logical use of it. A similar case is made with respect to suicide and the myth of addiction, also in previous chapters. Its moralism using the language of medicine.
So let us say for the moment that you have a belief, any belief, and this places you in a position of conflict with others (“social and/or occupational dysfunction”). If this belief is to cast aside your own personal property that is your choice is it not? If this belief leaves you in a predicament where you fail to flourish as the society would like, is it not your responsibility to take or reject what help may be offered? If this belief involves infractions upon others liberty, this is criminal is it not? And let us take a leaf out of Rawls book and assume that you do not know what the ensemble of your beliefs might be before you are thrown into the stuff of life and the world, only that there is a state mechanism to take certain deviant beliefs from the street, hold the bearer of the belief down (i.e. you), forcibly inject you with medication and up the ante with forced hospitalization if it chooses for an indefinite period. This mechanism exists to augment the police and judiciary to capture and control the other fraction of social deviance violating the criminal code. Are you comfortable with such an augmentation, simply because the odds are in your favour that your beliefs won’t be the one arrested? Or might there be the faint stirrings of some principled qualms against even the existence of such a mechanisms of control?
The reader might be interested to know that on the basis of psychiatry and its predicates existing (i.e. what Szasz would call metaphor and myth), that police and psychiatry act hand in glove in the service of the therapeutic state. All over the world police and paramedics have the legal authority to detain and transport a person for psychiatric assessment. Certain jurisdictions may even have instantiated into law that a psychiatric assessment will first need be a) available and b) provided in a timely manner for c) the police or emergency services worker to bring them in and hospital staff to keep them there. That is to say, the emergency services worker’s authority is bound up with the existence and function of the psychiatrist, the process analogous to due process in criminal law where a defendant has the right to a timely trial. Police and paramedics cannot function on their own with their own concepts of mental illness and what they do now legally depends on what is available later. They are essentially deputized by psychiatry and their powers to detain contained within acts of legislation that are explicitly health (not criminal) related. This first point of arrest and detention is underwritten by the law to be sure, with use of legal terms of art that might not be entirely part and parcel of the clinical praxis of psychiatry. Actually, my own experience is that emergency services workers actually exercise excess power, detaining people for trivial reasons or as a ready mechanism to dump the person (and responsibility thereof) into a substitute jail (hospital) for acts that do not obviously fall within the chapters of the criminal code (non criminal deviance). Nonetheless these observations aside, psychiatry is the pneuma of the assault to liberty from the outset.
The length of time the person may be detained for involuntary assessment is not trivial. Even an hour or a day may matter to the patient themselves as it may also matter to you, most especially if you are a principled reader who takes umbrage to even an unjust moment in jail. With psychiatric seizure, what will follow is a paranoia against the state and ever more ardent attempts to evade psychiatric surveillance, this assuredly making a diagnosis of a paranoid psychotic illness more likely. But what happens next after the ambulance brings the person to the hospital is certainly not a trivial bite out of a patient’s (qua ex person’s) life. Depending on the jurisdiction, having been assessed by the psychiatrist as being a danger to self and/or others and this informed by a mental illness, patients might be detained for several days to several weeks before having the opportunity to present their case for freedom to an “independent” tribunal. Such a tribunal always involves a legal professional of some standing, essentially a presiding judge who chairs the tribunal and who makes the final adjudication. It may or may not involve an alleged “independent” psychiatrist whose function is perhaps to question the “treating” psychiatrist claiming the person requires ongoing involuntary hospitalization and/or treatment. The proceedings may or may not involve independent state appointed legal counsel representing the patient, counsel who notionally plays an adversarial role against the designs of the psychiatrist come jailor. From all this there arises a sense whereby the psychiatrist might attempt to weasel out of responsibility for the incarceration of persons in psychiatric hospitals by deferring responsibility to the judge or more diffusely still, claiming they are simply part of a due process. However, the judges in such cases, and the state appointed legal counsel, are both supremely ignorant of psychiatry, and supremely trusting of the same. Moreover, psychiatry is not itself on trial. The legal professions only role is to referee the correct application in law of what psychiatry has decided is the reason to detain and/or treat according to the assumed reality of the psychiatric constructs. The myth of mental illness is itself not placed on trial and so is inviolate and beyond the law. One can imagine a counterfactual history where an independent court of arbitration were to sit between the witch and her executioner. A witch is one who dances, yes. And this woman was dancing yes. Ergo she is a witch. Her soul is to be freed by a benevolent burning she, needless to say, does not want for herself. But what pray tell is witchcraft? It is what the witch hunter tells the legislature it is, this the principal determinant of her being declared a witch. The reasoning is circular with a linear outcome.
Now a minority fraction of those in psychiatric hospitals are there notionally on a voluntary basis, I say notionally as this too is the world of mendacious appearances. If I tell you that you can remain voluntary on the proviso that you agree to the admission and you agree to stay, are you truly free? Have you freely chosen? Not at all! This demarcates the difference between an overt deprivation of liberty and coercion, between the fist of power that falls upon the patient and the first held high and ready lest it is needed. In a great number of cases the voluntary admission is fraudulent. In my own practice I always attempted resist the temptation to coerce. If I was not going to take no for an answer, I saw no need to ask the question. Or at least no need to use the answer to deny the inevitable.
We cannot understate just how powerful this collusion is between state and psychiatry. And I must parenthetically restate here the central point of the second chapter, i.e. that the necessary and sufficient variable that defines a psychiatrist is the power over persons freedom on matters of mental health. Moreover, it is not possible for the trainee psychiatrist to become the specialist or “board certified” consultant without exercising the use of this power and endorsing the same on guild exams. Psychiatrists, especially inexperienced ones, may be anxious when approaching tribunals and even the rare independent adversarial lawyer who a patient may retain. Yet the psychiatrist need not be afraid. The power is theirs for the taking. They just need become experienced in what to say in addressing the criteria under law for involuntary detention and treatment. I once observed in my own jurisdiction that almost all tribunals result in upholding the designs of the psychiatrist to extend involuntary treatment/civil commitment. Why this massive bias in outcomes I thought, when the tribunal ought to serve an adversarial role and play devil’s advocate in the service of the patient (or "mental health consumer") who was once a person? I compared this to data from the criminal legal system (which is often necessarily adversarial) and found similar numbers, most are found guilty. The prima facie conclusion from this would suggest psychiatric tribunals are doing their job well and psychiatrists playing their own devil’s advocate. The allegedly unwell are unwell in fact, the allegedly guilty are guilty in fact. However, the devil is in the detail. The majority of “crimes”, be they misdemeanors or felonies, are crimes to which the defendant pleads guilty. Take the fraction where the cashed up defendant “lawyers up”, claims to be innocent and fights the case. Then the odds substantially shift in favour of the defendant. Compare this to the case of our hapless psychiatric patient. To a man (or woman) they all want their freedom and all deny the crime of mental illness. They are all fighting the charges made against them and they all protest their innocence of the crime that their thoughts, feeling and behaviours ought to be separated out for persecution by drugs and psychiatric confinement. And yet despite universal protest they almost universally lose their case.
Insanity Defence
Szasz next concern was the so called insanity defence, and he was an expert witness for some high profile criminal trials of his day. Forensic psychiatry and the insanity defence is a huge subject beyond the scope of this book. Suffice for now to include certain of Szasz’s key observation along with my own. I have worked in emergency room psychiatry longer than anyone else I know, and lost count of the number of times I’ve been called on to psychiatrically assess those who have made threats to kill another, simply on the basis that they have at some time in the past have attracted some kind of psychiatric diagnosis and involvement, whatever that may be. It is as if once labelled, be it with schizophrenia, ADHD, anxiety or PTSD or whatever, the person is forever more assumed not to be a rational actor. Or worse still, very often someone is brought into the hospital by police or paramedics as they have “thoughts to harm others” and “afraid they might act on these thoughts”. Non-psychiatric physicians regularly make similar referrals. I invite the reader to let that sink in, that collectively these educated and ostensibly responsible highly intelligent professionals even countenance the idea, let alone introject it as a given of the human condition. They believe that thoughts of violence suggest mental incapacity unless and until proven otherwise. It is as if the whole of society ardently wishes free will and personal responsibility not to exist, or rather wishes such quaint notions of free will to be real only up to the point where praise stops and punishment starts, where good becomes bad. Sanity it seems is a diagnosis of exclusion when someone may be violent. And no clearer an example of repression is this, that man does not wish to know that he personally is capable of evil without being possessed by disease. He wants the excuse for the other such that it can be held in reserve for himself. One hardly needs even approach the vexed issue of the forensic psychiatric patient to have learned the lesson, though forensic psychiatry is the most deluded psychiatric subspecialty of all.
Next of course we have the frank commission of acts of criminal behaviour. To the materialist, they may if they like turn the tables on Szasz. They might say that all mental phenomena of necessity must have a basis in brain activity. And so any dysfunctional behaviour is material in its basis. So every bad act means a bad brain state. But then every single fact of the human condition can be vulnerable to being disease, and so no one can be blamed and no one can be praised either. Such would be a facile and fatuous argument, as there is not a basis of disease the likes of which is substantially discriminative from the normal anatomy (or physiology) of the brain. As was the case of the third chapter (epistemology), this little catharsis of a book cannot answer the mind body problem. Nor can this chapter address the many problems in forensic psychiatry that remain veiled to a critical eye and especially veiled to a laity who believe there are experts into the mind of the criminal. Suffice it to say that criminal behaviour almost by definition has often violated the non-aggression principle of libertarianism, and this ought to be the basis of consequences that operate on an exclusively criminal axis. Ought these consequences ever be psychiatric? Szasz controversially would say no, never, and for reasons laid out towards the beginning of the present chapter. If the criminal act was not informed by a physical illness which removed from their person the capacity to do otherwise, then they ought to be respected with the responsibility to face the consequences of their actions, regardless of how strange the co-occurring beliefs and motivations. The argument of course is that in the absence of severe physical illness to provide an objective attribution and mechanistic explanation for the criminal act, then it was informed by beliefs and behaviours which were objectively antisocial in their manifestation, if not intention. In his time Szasz did, as I could, marshal example after example where expert witness psychiatrists would argue that the defendant was mad and not bad, these psychiatrists being little more than hired sophists oblivious to the obvious fact that the defendant knew exactly what they were doing contra the law. Consequently, there ought to be no place in law for forensic psychiatry and the insanity defence. In my own experience, it is very rare patient indeed who does not recognize the relation between their desired behaviour and the law and its consequences, i.e. it is exceedingly rare a person lacks the awareness of criminality (the mens rea) of the criminal act (the actus reus). Even rarer still is the individual who will not modify their behaviour (even “psychotic” behaviour) should they fear and have personal experience of a law actually applied against them by a willing police and judiciary. I’ve even personally observed a patient with a supposedly rare form of epilepsy resulting in explosions of violence have the trajectory of their “disease” radically altered not by anti-convulsant drugs, but by the police knocking on the door and delivering a punitive treatment. It is worth pointing out in closing that much of the prosecution of insanity by forensic psychiatry rests not upon physical evidence, as opposed the mental state of the defendant at the time of the crime. The delay between the crime and the assessment of mental state may be delayed days, weeks or months, and is always inferred by what the patient tells the psychiatrist at the time of the review. Good jurisprudence is about evidence. How does a psychiatrist know the mental state of another in the here and now, let alone in the past? How can they know what they really thought and felt at the time?
Contra Szasz
An honest psychiatry would be acutely aware that is has failed to find the biological basis of the vast majority of its diagnoses. It was so in the 1950’s, 1960’s and 1970’s, and remains unalterably the case in 2019 despite the propaganda to the contrary. Accordingly, psychiatry’s only ham-fisted lines of defence are philosophical and hermeneutic. It ought not to be lost on the reader that when they throw everything they have at Szasz, and they did throw everything at Szasz, this is not the work of dispassionate enquiring minds. Surely, they must be motivated by a strong desire for his thesis not to be true, it being something they wish not to believe.
On the Historical Breadth of the Disease Concept.
Much of Pies and Kendell’s attack relied on finding examples from antiquity where disease was defined as more than on anatomical and physiological terms, even suffering in the broadest possible sense. Consequently, they are arguing that if an historical quantum of precedents be found where the doctor was granted authority over more than mere physical pathology, then this ought to continue. Not surprisingly many examples are to be found, for there were not many MRI scanners or EEG suites found in the ancient world, to say nothing of sophisticated chemical pathology laboratory. Diseases might only have been known as constellations of signs and symptoms clustering together (syndromes), which might only have been known eponymously. And so for perhaps millennia Kendell writes that disease was
“…essentially an explanatory concept, invoked to account for suffering, incapacity, and premature death in the absence of obvious injury, and suffering and incapacity are still the most fundamental attributes of disease”
To which Szasz responds
“until the nineteenth century, and beyond, illness meant a bodily disorder whose typical manifestation was an alteration bodily structure” or “physicians distinguished diseases from non diseases according to whether or not they could detect an abnormal change in the structure of the persons body”
He is then stating that modern psychiatry invented the non-physical suffering as illness. His detractors state that this was not possible, as the epistemic question of what was known as to the organic pathology was not known, yet these were diseases nonetheless.
How do we reconcile these two positions? There is no controversy, and both are correct in their way. The question was not what was known, yet what was inferred. Hippocrates humoral theory was said to interface with the body and indeed constitute the body in the physicality of its pathology. That was Hippocrates account of all mental life. All eponymous syndromes of continental and British medicine were assumed to be bodily diseases with yet to be discovered pathophysiology, however much matters might involve attendant psychological distress or social dysfunction. In the America’s, Benjamin Rush was of the belief that mental illness would be explained as brain vasculopathy, this being his proposed road to legitimize mental illness as medicine. And as any medically minded feminist knows, hysteria in antiquity was the migration of a delinquent uterus around the body, perturbing the humours of the mind in its travels. Uterine expeditions could be cured, inter alia, by being grounded by sexual intercourse. Nowadays a hysterectomy would offer the most fulminant cure.
Szasz was a voracious reader of history. Though not having read more than a fraction of the corpus of his work, I trust he knew only too well all the uses and abuses of appeals to traditional thought employed against his own anachronism. He makes short work of such argument, in being dismissively incredulous to the journey down the memory lane of medical history. We live in modern times Szasz will say and must have a modern measure of disease. To Szasz, Pies and Kendell both use the deficiencies and myths of primitive medicine to defend the myth making of the psychiatrist. They want to use the mistaken assumptions of old to justify the psychiatry of the present.
Or to put it another way; it ought not to be lost on the reader that at precisely the historical age when medicine was turning to biological roots for both its epistemology and ontology of disease, psychiatry was hoping to do the same of course. But early and contemporary psychiatry also insured itself against failure by simultaneously seeking to shore up a definition of the disease concept that defined itself entirely in functional and phenomenological terms, this only increasing to the current day. It wants to eat its biological cake and have it too in ever more nebulous and inclusive, though ultimately disjunctive forms. It wants to say that when a bodily pathology cannot be found, one day it will be found. Just have some faith.
Psychiatry attempts claim legitimacy not simply from trawling the history of the disease concept, yet also to find examples of modern constructs of mental illness in antiquity, as if to imply that what has always been is part of the psychiatric triumph in having been discovered. Now there is no denying that such descriptions approximating schizophrenia or psychotic depression can be found in times past. So what? This will not challenge Szasz thesis one iota. No one would suggest that the kind of social deviancy and personal distress whose liberty he wished to protect had never been seen or documented in times past. This is obvious, for nothing is new under the sun and ours is a cycling through another iteration of the human condition. Yet we must be cautious of just how dull our keen eyes can become when looking back through time. Time and again I have read of even Hippocrates himself describing the “mania” of bipolar disorder and “melancholia” of severe major depressive disorder. But beware. A commonality of terms does not an equivalence of diagnosis make. Actually, what Hippocrates likely described was what we might call today noisy and quiet delirium. We would wish today to transport Hippocrates manic and melancholic patients over two millennia into the future of our intensive care wards and pump them full of antibiotics and cancer chemotherapy, not into the arms of psychiatrists.
A finally “ought not be lost” ought not be lost on the reader, and that is that social deviancy, distress and dysfunction can also come to be defined and partitioned to the experts as disease and illness on purely utilitarian grounds. In other words, psychiatric illness comes into being and is said to exist when the psychiatrist can do something about that which might previously have been considered part of the human condition. This is pure pragmatism, and unashamedly Kendall hangs his banner high in his submission to the book “Szasz Under Fire”. If the dreamy or rambunctious child can be made docile and a good cog in the machine by stimulant medication, we have both the invention of ADHD and with it necessarily the disappearance of both personality as an attributing formulation, along with the deficiencies of the school system, if not the family system. ADHD exists if we can do something to control the behaviour, same for schizophrenia. The reader too might be inclined to define others mental illness on the grounds of the utility of controlling another’s symptoms and unwanted behaviour. But beware that something in yourself does not go against the social grain. For you too might be the one for which psychiatry has the label and coercive answers. I can only be true to myself, to state and restate. Philosophical pragmatism is the privation of principle, the turning ones back to the will towards the good, the beautiful and the true. Ergo it is evil.
On Disease Only for the Living
The next line of attack is the definition of disease as made by the pathologists themselves. Pies quotes the pathologist Krehl for example, who in tones suggestive of a postmodernist social worker stated that there is no such thing as illness at all.
“there is no illness, there are only sick people. In principle, nothing biologically different happened to a sick person than a healthy one”.
This is to say that illness is not an abstraction apart from the one who suffers it, and so cannot be found in the cell, tissue, organ or organ system without consciousness, only in the suffering person. Or when Szasz holds up his beloved Virchow and says that disease has its being in the anatomical lesion, this readily observable in the cadaver, psychiatry quotes Virchow to have said that disease can only exist in a living cell in the living person.
“Disease presupposes life. With the death of the cell, the disease also terminates”.
Only cells (or organ systems) in their living state are functionally perturbed by the lesion, and only the living person is the one “suffering” the disease. Ergo dead men do not have diseases and none can be found in the cadavar. This is a small quibble, for what Virchow (and Szasz) were saying was that the basis and meaning of medical disease is its physicality. Moreover, this can often and in paradigmatic cases be ascertained posthumously, or in dead tissue obtained via biopsy of the living person. To be sure, it is a simple truism that there is no such thing as a sick corpse any more than there is a healthy one. Yet if disease were to cease to exist in an ontologically radical way upon death, then what need do we have for the forensic or anatomical pathologist? The cause of death and all that is of interest to Virchow writes its signature upon the corpse. You see death and disease is like a marriage. Though marriage is said to be until death do us part, death is neither divorce nor even a negation of the past, for the corpse still wears the ring. In pocketing the ring, even an illiterate grave robber could make the correct diagnosis as to what afflicted the living re their matrimonial state of affairs. But note that Virchow did not consider bad music or a bad marriage to be a disease either, though the music be obviously only played by a living human being, and music too ceases to be played upon death. Neither music nor marriage were medical matters that ceased to be of interest to the physician upon death. They were never of professional interest to the physician when the patient was alive, and would not be of interest to the pathologist after. Virchow and indeed the whole triumphant metanarrative of pathology as Aesclepius vs Hippocrates was an implicit logical defence of Szasz, if not an explicit one. One need be wilfully ignorant or a sophist engaging in great mischief to ignore the obvious. In their little quibbles the critics seek to charge Szasz with a fallacy of ignoratio elenchi, when it seems that this is what they themselves are eminently guilty of. But who can blame psychiatry in its feebleness. All over the world of mental health today we will hear not of patients with symptoms but of “clients” or “consumers” with “lived experiences”. Well, to the best of my knowledge the dead don’t have experiences do they? And so why the need to qualify the term as if to distinguish the lived experience from that of the dead? I could deliver my own petty little metaphysical blows against the notion of a lived experience (past participative) as opposed to a living experience, the latter being the better of what would still be a ridiculous tautological term. Regarding the “lived experience”, this from an industry which might criticize Szasz for suggesting a corpse can have a disease, we might reply that his was the lesser fallacy. We might also ask ourselves if we have ever known of a consumer or client forced by the state to purchase a product or service? Why then call them consumers or clients?
On Dissolving the Boundaries of Disease Within the Body
The next line of attack is the distinction between anatomy (i.e. the structure of the body) and physiology (the functional dynamism of the anatomical structures). The metaphysical distinction between what something is and what something does could make for a whole book, though won’t be required here. Suffice to say that there are pathologies of bodily function that are not conceived of in the same sense as an observably dead piece of organ or a fracture of a bone, or the pathogenic bug grown from the patient’s sputum and the like. This manifestation of disease might only be said to have a material manifestation and be known to us in perturbation of concentrations of chemicals in the blood, or via the output on a machine that measures the dynamism of the body. And so if psychiatry thinks or implies Szasz (and Virchow et al) argues that disease is anatomical pathology alone, pathological physiology is shown up as a common sense exception. I cannot speak of course for Virchow, having not read his work. But Szasz was not at all averse to defining disease in physiological terms, as his argument was to defend physicality per se. But Anti-Szazsians are more subtle here. They are arguing not simply that disease can be defined by perturbation of physical dynamics, yet also defined by abstractions and numbers that might seem prima facie arbitrary and pragmatic, and yet are sound markers of disease nonetheless.
Kendall for example is quoted in the Pies article in Szasz Under Fire as follows
“There is no single set pattern of either structure or function….even in health, human beings and their constituent tissues and organs vary considerably in size, shape, chemical composition and functional efficiency”
What Kendal is saying is that if Szasz cannot fix normality within certain boundaries, then Szasz is denied a reference frame from which to argue psychiatry violates the boundaries in the overplay of metaphor. But what he (Kendall) is also implying is that we can define disease by other means, by a holistic and pragmatic calculus of bodily (dys)functioning, suffering and other more diffuse arguments with which to appeal. There is no set pattern, and so anything goes so long as suffering and dysfunction are involved. This is to open up the cognitive door a little wider such that the mental world can, in its apparent non physicality be also considered pathological. Anything can be pathology.
With a quote the likes as having been made by Kendall (vide supra), we could be forgiven for thinking that psychiatry does not care at all about the bodies physicality as the defining ground from which diagnoses grow and ultimately have their being. And this would be true. Yet psychiatry is desperate to find the brain lesion or pathophysiology of schizophrenia and bipolar disorder, of major depression and ADHD, or anorexia and PTSD. With very little exception what they have found is essentially nothing. They do delude themselves about concepts such as “duration of untreated schizophrenic illness” leading to "brain damage, ironically oblivious to the fact that macaque monkeys treated with antipsychotics suffer brain shrinkage in the order of that which is thought caused by the schizophrenia itself, and against which the drugs are mendaciously marketed as “neuro-protective”. Presumably these poor monkeys were not schizophrenic before the drugs, though no one asked the monkey any questions. Perhaps they heard voices when no one was there. Perhaps the CIA had been stealing their bananas also. I doubt both. Likewise, we have had psychiatry peddling for decades the notion that depression and schizophrenia both were chemical imbalances in the brain. When no imbalance was found, the strategy was to wait one generation and then deny the claim was ever made in the first instance. Much have been written about this intentional forgetting. Pies himself began an article in 2011 with a (presumably) materialistic quote by Will Durant
“Mind and body do not act upon each other, because they are not other, they are one.”
Pies continues…
“ I am not one who easily loses his temper, but I confess to experiencing markedly increased limbic activity whenever I hear someone proclaim, “Psychiatrists think all mental disorders are due to a chemical imbalance!” In the past 30 years, I don’t believe I have ever heard a knowledgeable, well-trained psychiatrist make such a preposterous claim, except perhaps to mock it. On the other hand, the “chemical imbalance” trope has been tossed around a great deal by opponents of psychiatry, who mendaciously attribute the phrase to psychiatrists themselves.2 And, yes—the “chemical imbalance” image has been vigorously promoted by some pharmaceutical companies, often to the detriment of our patients’ understanding. In truth, the “chemical imbalance” notion was always a kind of urban legend- - never a theory seriously propounded by well-informed psychiatrists.”
If Pies, qua an experience of loss of temper, is one with his limbic system, pray tell what/where/who is the separate subjective “I” that “experiences” limbic activity? And just who were these psychiatrists who believed the claim to be preposterous and railed against the big pharma companies, where big pharma (and doubtlessly also family physicians) are scapegoated as spreading the chemical imbalance lie. I’m all for a good bashing of big pharma when they deserve it. Yet here they are at worst minor accomplices, and perhaps being honest in a sense. Pharma was being true to themselves as profit orientated free marketeers as opposed to alleged promotors of scientific truth marching to the beat of the physician’s ethical drum. It would be charitable to say Pies is playing the Scotsman fallacy. For he would have it that the minority of stupid ones who might have promoted the chemical imbalance myth aren’t the real psychiatrists, the smart “well informed” ones, the ones like him. They are an urban myth he would say. Then why 32 years earlier in the landmark article of 1979 to which this chapter is largely addressed and in which he attacked Szasz did Pies write
“But now let us suppose that hallucinations and delusions are caused by an excess of dopamine in the brain-a thesis Szasz has never refuted. It would not be absurd, or silly, or wasteful to ameliorate these symptoms with dopamine antagonists”.
Actually Szasz never bought stock in the chemical imbalance theory and was one of the few never found in bed with the pharmaceutical industry. And we might ask why Pies raised this particular supposition contra Szasz if Pies and his limbic system never took the chemical imbalance seriously? In point of fact, institutional psychiatry (yes the intelligentsia of psychiatry, the guilds themselves and their thought leaders) were up to their elbows in promotion the chemical imbalance theory. The remainder less biologically inclined psychiatrists were busy with other nonsenses such as psychoanalysis or the satanic panic, or stayed silent not rocking the boat of their industry. We might be reminded by Orwell
“Who controls the past controls the future. Who controls the present controls the past”.
Let us not let them get away with rewriting history.
We also have perinatal psychiatrists claiming, with a straight face, that depression in pregnancy (where depression by all accounts is a non-physical state of being) causes birth defects, the implication being that SSRI’s will protect the foetus against the teratogenicity of its mother’s mood. And yet why then are SSRI’s (undeniably physical substances), associated with a doubling of risk of birth defects (undeniably a physical outcome), if they are so protective?
Returning to the matter at hand, many examples of nominal and statistical “diseases” can or have been provided by anti-Szazians. On the nominal side we have nominal examples such as “essential hypertension”. When a physician consistently reads a blood pressure as 145/85, they might inform the patient of a mild hypertension. This is related to the patient in terms of them rightly having attended the doctor’s rooms, of having the “disease” of hypertension and perhaps requiring medication. There is not necessarily any anatomical lesion diagnosed and none was looked for. In point of fact, what was observed was a machine, and inferences made about the body from the numbers on a dial. And were the medical student to ask the significance of a boundary between what might be called normal blood pressure of 139/79 and the systolic hypertension of 145/85, the answer would be “not much, the cut off is semi arbitrary and a convention informed by risks. We have to set a limit somewhere”. Many other biological abnormalities are given medical labels despite being explicitly informed directly only by convention or statistical norms. If your blood level of a chemical constituent falls in the upper or lower fifth centile, you might have “hypo”-this or “hyper”-that. This does not in any way negate the notion as to the physicality of disease a la Szasz and Vichow.
Even Kendells as quoted above (in the Pies article) is only true in the most superficial and inconsequential sense. Surely we shan’t charge him with a relativism such that “there is no single set pattern of either structure or function..” can be used in turn to argue physical disease is anything we want, and that Szasz has no frame of reference whatsoever to define a disease as a physical abnormality of a specific kind. But then why raise the argument? The fact is that Szasz has every right to demand a firm objective frame of reference with which to label someone as mad and deprive them of their liberty, and the onus is on psychiatry to provide it. As a former lecturer in embryology, I might say that some persons are born with several extra small accessory kidneys, this being a normal variation. Another common variation is the absence either unilaterally or bilaterally of a small muscle in the forearm called the palmaris longus. Neither are diseases. Yet compare this with the following little personal anecdote; once as a medical student one of our pathology professors spoke of a recent case he had, the case of the unexplained death of a child. The post-mortem had collected tissue samples, including brain tissue that had been processed to be observed under the most powerful of microscopy, the electron microscope (an instrument only found in large tertiary university hospitals articulated with large universities). And so, one night he was up into the wee hours painstakingly scanning the tissue field by field in the darkened room. And then he found it, a single sarcomere, the functional unit of skeletal (and cardiac) muscle. You see even a single sarcomere in the brain is radically out of place, and pathognomonic of a malignant tumour (a rhabdomyosarcoma). This an example that the exceptions prove the rule as a refutation of Kendals relativism in defence of psychiatric pragmatism. It is ok to lack a forearm muscle or two. It is ok to have a little third kidney (or even a fourth or fifth). It is never ever ok to have skeletal muscle growing in the brain. Variation is not the relativistic solvent within which to rid ourselves of Szasz
Or think of plasma pH (a measure of acidity/alkalinity). Take all the therapeutic bicarb soda or apple cider vinegar one wishes, and the plasma pH will remain within a very narrow range indeed. Though one healthy person might have a plasma pH of 7.35 and another 7.45 (these being the boundaries of the normal range by common convention), and though we might reason correctly that one does not suddenly die when the pH is 7.34 or 7.46 (in fact there’s a margin of error in the machines measure as to what the plasma level actually is), none would argue that a level of, say, 7.15 or 7.65 is compatible with life. Plasma pH is thus immensely informative as to the reality and acuity of bodily disease states. Relativism loses again.
Or let us return to the matter of hypertension. It is obviously true that physicians arbitrarily define high blood pressure as, for example >140mm Hg systolic and/or >90mm Hg diastolic, and these numbers relates to a physiological process which is not in and off itself a pathological anatomical state. In a sense pressure is an abstraction and only exists in circular relation to physical concepts such as force per unit area or in relation to flow and resistance. Nevertheless, it would be misleading to detach hypertension from even the hard Virchowian idea that pathology is anatomical pathology. The reason is very simple. For the numbers to have any meaning at all, they must inform a risk of developing an anatomical pathology that is conceptually linked in its physicality to the blood pressure itself. The endothelial lining of the vasculature is not like a sturdy wall of tiles that can withstand all pressure. On a molecular level it is more like a delicate coral reef. This delicate reef, this complex ecosystem if you will, is pressure sensitive. And in a less subtly conceptual level, the walls of vasculature are sensitive to pressure in the same way that one could strip the paint off, and ultimately blast through, a plaster wall with a high pressure water cleaner. If one were to have a blood pressure of 225/120, death would be sooner rather than later. Elevated blood pressure relates in its physicality to all the sequelae that might result from it, be it stroke, renal failure, an aortic dissection, arteriosclerosis or whatever. One can seamlessly link the conceptualization of the physicality of one process (i.e. hypertension) to all the others (e.g. the stoke). If we were to find tomorrow that we were wrong all along and blood pressure bears no relationship whatsoever to the matter of anatomical pathology, then hypertension would cease to be a concern to doctors. The argument must also be made what makes a state of mind a disease if not causally related in a strong sense to a disorder of the body.
We could say the same for blood glucose levels, calcium levels and countless other examples as we have for blood pressure and plasma pH. Even height is the same. Great height is only disease marker and only of interest to the doctor if it is a manifestation of a pituitary tumour for example. A healthy giant, if one exists, is none of the doctors business. Neither is the water supply the business of the doctor if not contaminated by Vibrio cholerae and the like.
Statistically abnormal, deviant and interpersonally (even intra-personally) distressing thoughts, emotions and behaviours in the absence of any anatomical correlate with strong causal inference sit within an entirely different category to the above examples of blood pressure and the like. Granted what is called schizophrenia indirectly impacts on physical health. Typically, this cohort of persons smoke and otherwise poorly attend to their health, dying prematurely from most of the diseases common to the western world. But schizophrenia is not like syphilis with its multi-organ manifestations and a pathophysiological narrative to link them all together. It is not a multi-organ disease manifest by emphysema or obesity (in the so called schizophrenic who smokes, is sedentary and who is administered fattening psychiatric medication).
On the Dissolution of Szasz Disease Concept into a Language Game
Pies, in his debate against Szasz (In “Szasz Under Fire”) makes the surprising turn to use Wittgenstein. I too had my proto-Wittgensteinian revelation as outlined in a previous chapter, i.e. the shocking realization that psychiatry can only define delusion on the basis of the use of the term, without appeal to any essentiality, i.e. that the patient does not have a delusion before the psychiatrist gives it to them as its existence is bound up in the use of the word. An understanding of Wittgenstein is like Feynman’s formulation of quantum physics. Those who claim to understand him (or quantum physics) are likely not to, and anything I write here is likely not improve on things. But one formulation of the so-called latter Wittgenstein is to say that language does not directly point to anything in the world. It refers only to itself as its use in a “language game”, i.e. a practical system between persons as to the use of a word. It is impossible to fix ourselves upon a definition that is impervious and a priori, of a word that represents a thing in the world the way we might aspire to being like Adam, when God charged him with naming things as they are in a strong sense. Pulling out Wittgenstein is Pies way of devaluing Szasz’s biophysical definition of disease as a proposal to elevate just another rival language game. But does it escape the mind of Pies that that in using Wittgenstein as a weapon, he embarks on a philosophical suicide mission as the weapon also explodes onto himself. For Pies himself cannot escape being captured in the orbit of admitting his own psychiatry to be a language game, where Pies only claim to have the greater game could be in its having greater political power. Actually, I suspect that Pies, as a philosophical pragmatist amongst pragmatists, is all too aware of the manoeuvre and could frankly not care less. His is a language game where mental illness is spoken of as existing, of being diagnosed as it is, of being treated as it is, this including deprivation of liberty. They would love for it to be reified as physical pathology. But they are just as happy if they cannot. Either way they wield power. The game played is psychiatry’s game. And that is that.
On Suffering and Dysfunction as Illness/Disease
In something of an extension of the use of historical notions of disease under which the doctor has authority, the anti-Szaszian might then say that any and all suffering and incapacity with a predominant (or exclusive) mental component could be termed mental illness. We might look at contemporary formulations of disease such as the World Health Organization which defines health as
“a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”
Such a definition appeals to sentiment and aspiration, also had in certain quarters of clinical psychology where the absence of neurosis does not necessarily imply that one is living to the best of the psychological and social potential. It’s a sentiment that has given rise to thousands of positive psychology practitioners and life coaches working with otherwise unremarkable people who are at least not cutting themselves or hearing voices. The WHO definition is superficially sound enough and uncritically accepted by almost all medical students who hear it. Their reaction, if critical at all, will be simply a recognition of its tedium by the “health sociology” lecturer when all they really want is to learn the “real” medicine. Yet it should not be a definition considered only by tired and disinterested eyes. Lurking beneath the surface of the WHO definition is the potentiality of a medical overreach of totalitarian proportions. Is this health vs illness a spectrum or a dichotomy? If someone lacks disease, can they ever be teetering in a neutral state of lacking wellbeing either? That is to say, what do we call a state of falling short in the goal of “complete wellbeing”? If this is not health and it is not disease, what is it? Is it partial wellbeing or partial disease? We might argue that the definition implies what would be incoherent if formally stated; that the absence of perfection is a disease of a kind, for it is something that we wish to change and defined as disease by the WHO (not Szasz or I). In any case, this is the WHO definition. And who has responsibility towards the other in respect to reaching the goal of the health that is their right? Who has authority as advocate, architect (and enforcer) of the health of this new world order, where it could be argued that almost everyone falls short of it, particularly all in the developing world and the world of so-called mental illness?
The American Psychiatric Association DSM and psychiatry in general avoids the use of the term disease, preferring the term “disorder” (which is synonymous with illness and equivalent in practice to that of disease), and defining a mental disorder including the following; “behavioural, psychological or biological dysfunction” manifest in terms of "social or occupational dysfunction" and excluding “deviant behaviour” or conflicts between the individual and society. This is also a muddle. Definitions or elements of definitions such as the above do nothing to resolve the matter of whether the individual in front of us is mentally ill/disordered and in what sense these terms might have meaning. Any conflict between an individual and their world necessarily involves some manner of dysfunction in social and/or occupational terms, this being experienced in any conscious person as a psychological phenomenon (collectively mind and behaviour). It places the individual in a place where the dividing line between the mentally disordered and the socially deviant is arbitrary and known only by the common customs. In “Szasz Under Fire”, Kendall realizes this in outlining certain other definitions of disease, including to single out one by Scadding
“the sum total of the abnormal phenomena displayed by a group of living organisms in association with a specified common characteristic or set of characteristics by which they differ from the norm for the species in such a way as to place them at a biological disadvantage”.
Kendall continues to suggest a disease concept meaningful to psychiatry might involve an impairment in fertility or life expectancy, both of which might be the case in the patient with schizophrenia. Collectively, Scadding and Kendall both seem to view disease (or illness or disorder) in some kind of neo-Darwinian frame where a human being, a person, is a function within a social whole, measured against a species norm. Presumably social functioning also is a Darwinian epiphenomenon. How to possibly escape the conclusion that the urban homosexual male and the ascetic monk in the Syrian desert are both, in their own opposite ways, as diseased as the one who talks to the green aliens in their roof crawl space? Both are exceptions to the norm. Both might well have reduced fecundity in serving the needs of the species or the tribe to reproduce its kind. Or maybe not. Maybe we might be eugenicists and see the value in their degeneracy dying out, if degenerate is what we decide they are.
In ever more expansive nebulous and protean definitions of disease, illness and disorder, many a psychiatrist seems to have both a romantic and imperialistic notion of who the doctor is as physician over the mind and soul of person and village, for Psyche seems to have divorced herself from Eros and demanded her new psychiatrist bridegroom be worshiped in her stead. They imagine themselves like the rural family physicians of some amalgam of all the clichés of a certain genres of fiction. And so up across the porch and under the hanging shingle of the M.D. walks the troubled teen who might get advice form the sage as to what life is and how to be. Why not receive some advice as to the sufferings of his unrequited love? Or maybe he is suffering some poor grades in mathematics and its attendant suffering drives him to the kindly family doctor, whose mathematical aptitude is the stuff of village legend. In between lancing boils and delivering babies the doctor might work towards ameliorating the other sufferings of the community such as organizing a grain depository against famine or running for mayor. Or he might take up with an amateur detective and tour around with Sherlock Holmes solving the suffering of murder and injustice. In an earlier chapter I described a time when psychiatrists battled the social suffering of Satan worship. Doctors today might take up their righteous place as “scholar”, “expert” and “advocate” and preach who the people ought to vote for, and what their opinion ought to be in the fight against this or that social or climatic suffering that has usurped real bodily disease in the pages of any Pravda that was once a bone fide medical journal. Life is suffering and so the psychiatrist sage is the master over life on the way to its un-suffering perfection
Now we might say that such a fanciful vision of the physician (or psychiatrist) is a fiction. In a limited sense it is, though not far from what the psychiatrist thinks they have the God given right to be and to do should they choose, given their infinitely plastic notions of suffering to which they minister as the sage of the village. Currently we have the custom of leaving that kind of suffering that is known as burglary to the police and the judiciary. We leave that kind of suffering that is homelessness to the social worker, and kind of suffering that is educational underdevelopment to the teacher. We leave the kind of suffering that is the fracture to the orthopaedist and that kind of suffering that is the heart attack to the cardiologist or emergency physician. And we leave that grab bag of other kinds of suffering about which the village elaborates labels such as “depression” and “PTSD” to the psychiatrist. But what licence does the psychiatrist have to be master of anything at all? Is it because certain kinds of suffering appear to be better served by diagnosis and medication? This is the world of appearances only, and not enough to argue the case of reifying mental illness and elevating to the ontological status we might accord physical pathology. We must come to see the dangers of a profession that considers itself to have expertise over undefined suffering, as this places the profession as masters over the human condition and all persons.
Really, we must challenge ourselves to the notion of how and why our psychiatric customs have developed, whether they be good or bad, right or wrong and what problems we have with them in the sense they represent an economy of power over knowledge and person’s bodies, an economy within which certain power structures seek to expand or consolidate according to their own purposes.
Or what is next? We might formulate popular culture and art as informing health. We might then see appreciation of the ugly as a symptom and manifestation of the ugly in contemporary art (as sign) as aesthetic forms of a new kind of mental illness. Believing in the wrong political ideology (symptoms) and voting incorrectly (sign) is could also be argued to be a manifestation of mental illness, for this too can be interpreted as the furtherance of suffering about which the citizen (patient) lacks insight (symptom). And will loneliness (which is suffering) be the province over which psychiatry demands its place as the expert? What of the mystic who has the suffering of the dark night of the soul? Is Kierkegaards despair (supposedly shared by us all) an undiscovered mental illness? What of divorce as mentioned earlier and to repeat here, childhood temper tantrums, writers block? Choose your diagnostic definition where suffering is the necessary and sufficient factor and I can work any and all of these into it, and so much more besides. Moreover, I’ll guarantee to find a functional MRI difference somewhere between those who suffer these pseudo-diseases and those who do not. These examples are not lexicographic or semantic ad absurdum to the notion of suffering and functional incapacity as sufficient to diagnose “illness”. These are always within reach of a psychiatry which might make opportunistic and pragmatic use of them if the political conditions ripen. The only means by which the individual can assure its own protection is by an in principled killing psychiatry first. And the individual has ample precedent as to the dangers it faces.
Szasz insight is in recognizing that the definition of a psychiatric doctor are the limits of the doctors power over persons liberty. His most consistent bulwark against all these slippery slopes of “suffering = illness” equations is the insistence that mental illness must be related to a physical disease as its antecedent and cause. Only then could medicine even consider making a claim over the territory of the person. And so we now turn to the synthesis of the myth of mental illness and the therapeutic state.
Divide and Conquer; The Indivisibility of the Argument
Much of the problem with the anti-Szaszian lay in their reductively splitting at the outset a) his philosophy of mental illness on one hand (the myth from metaphor of illness), and b) use of psychiatric authority on the other to force “health” upon others (the therapeutic state). The critic of Szasz usually insists on first defending the flank of the construct of mental illness. Thinking to a) have resolved the answer of mental illness as a valid concept, this being a belief they held all along and were destined to “prove” one way or the other via various sophist manoeuvres, they then b) feign openness to humanely exploring the limits of coercion upon the mentally ill. Then and only then might they pay a trifle respect to Szasz as a misguided defender of human rights, all the while believing that curtailing the freedoms of the mad is self-evident, this being cloaked in the language of care and of course for the patient’s own good. A token of respect is itself self-indulgent, for it is the granting to oneself the appearance of a peace maker, a condescending nod to that tiny piece of wisdom possessed by one whom we believe to be a fool. Szasz will have none of a backhanded compliment predicated on the myth.
In any case this reductive approach is a mistake, one of many made by the anti-Szasz camp, and inverse to the order the matters ought to be approached if to be separated at all. It is impossible to properly do justice to Szasz if to myopically cast him as a psychiatrist critical of psychiatry or as a philosopher of language wishing to peel wide open the analytic/synthetic divide. Although conversant in the practice and philosophy of science and medicine, he was instead a moral philosopher and political activist, and perhaps the most radical exponent of libertarianism specifically. Part historical accident and part his own choice, psychiatry was simply the city in which he built his church to liberty. Were life to have taken a different turn or were he incarnated in another form, he might well have been an American race liberator or anti-socialist dissident behind the iron curtain had he remained in his native Hungary. To be sure, “The Myth of Mental Illness” is his chef d’ouve. Yet it is his more political works such as “Faith in Freedom” that give us a better window to his project, and he is quoted to have said that were he to have succeeded in killing off psychiatry that he would devote himself entirely to political philosophy. His attack on mental illness as myth is robust enough. But always he views this question through the lens of liberty and the place of the state as matters of first principle, hence my earlier dwelling on the subject. Always the question is approached for Szasz also through a genealogical lens which, like Foucault, was to examine what diagnoses are as products of history. One needs to approach his argument in its totality or not at all. One needs to understand that the political is always involved.
Consequently, when the anti-Szaszian contends that a) many illnesses in times past have been known only by their singular or collective symptoms, behaviour or pathos and not by their organic cellular pathology (e.g. migraine and epilepsy in the 19th century), they will assert that b) any physical or mental discomfort and abnormal behaviour alone are reason enough to assume genuine disease is involved and c) what might be called illness ought to be seen as falling under the authority of the doctor as an agent of the state. Such a non sequitur trades on three appeals to make it stick. The first is on the reader knowing what we know now only in retrospect, that these precedent example diseases are indeed pathophysiological events in the brain, and we are asked to then consider it wrong epilspey was ever considered anything else. There is no shortage of other examples either. I have lost count of how often the modern medical triumphalist parades out the corpse of that young man in the gospels allegedly exorcised of a demon as really having an epilepsy. The truth is we shall never know. Tourette’s syndrome, like epilepsy, also has gone the way of the brain, as has migraine, albeit even in the 21st century migraine especially remains poorly understood. It should not be lost on the reader that these and other discoveries of disease are deliberately chosen as historiographic tools of argumentation. From diseases once poorly understood or thought not to be disease, the anti-Szaszian attempts take the reader on a cognitive and affective journey to uncritically identifying all so called mental illness as also being biological pathologies, albeit with mechanisms yet to be discovered. And from here there are further appeals to the triumph of science and materialism. The reader, in their conscious or unconscious weddedness to materialism, is left in a position of not wanting to appear the fool when science one day finds that psychopathologies a la the DSM 5 or their criterion symptoms are found to be caused by anatomical lesions or pathophysiological processes.
The problem is that medicine in general and psychiatry in particular also has a history replete with failed hypotheses and assumptions masquerading as certainties. Psychiatry has invested literally billions without establishing the physicality of mental illness. Essentially all it has a grab bag of drugs found by serendipity and having largely non-specific effects to blunt emotionality, drives, initiative and attention (or inattention). Unlike psychiatry, on balance internal medicine and surgery can certainly take a stance of optimistic verisimilitude, though even in these disciplines at the it is not entirely clear which medical facts of today will be disproven tomorrow. Even as a post millennial medical student, our more professors would say we would end our career knowing that half of what we said or did at the start was wrong. we were doomed not to know what half except by use of the retro-spectoscope. A knowledge of the history of psychiatry does not grant us warrant for even a guarded optimism, and the discipline lurches along either in stasis or quiet crisis.
The second anti-Szaszian hook is to assume he is proximally interested in whether a physician has ever considered migraine or epilepsy a disease before its pathology was elucidated. They assume that Szasz might have believed that medicine and surgery could and should not have existed before the days of Rokitansky, Virchow and Morgagni, of Leeuwenhoek, Jenner and Pasteur. They might even attempt to paint Szasz in absurdity, to imply he would be forced to admit that by the lights of own logic that before modern medicine and the pathophysiology we now know, there could be no disease. “if a tree falls in the forest and no one is there to hear it, does it make a sound”, they would have it that Szasz would answer “no”.
Both arguments would be a misreading of Szasz, who argued libertarian axioms of freedom and responsibility are a priori with the onus placed upon the illness monger to prove the case. However, Szasz is not a blind ideologue. He admits that if it were one day discovered that what we call mental illness is a physical disease in the way he reasonably defines it and which overturns free will in a way discriminating the brain of the ill from the masses, then he too would admit the same. And who wouldn’t? But such a discovery is heretofore elusive. Should it come to pass it would provide no vindication to the psychiatrist of today. Given that in science a hypothesis has at best meagre value until the day proof is found, there is no scientific sense in which one might speak of their cherished hypothesis “see I knew it all along”, for the knowing comes into being only with the discovery. Even then, from Hume to Popper to Kuhn we would say our proof is provisional. Granted we might praise the one who makes the discovery as being intuitive or a skilled evaluator of the prior evidence in the formulation of hypotheses. They deserve some credit. Yet this praise does not amount to an acknowledgment that they knew, especially when freedom is at stake. In any case, it does not take a genius to hypothesize correctly that migraine, epilepsy, Tourettes disorder, Parkinsons Disease etcetera are brain (or bodily) pathologies in the broadest sense, and so we shan’t inflate the value of those who claim the same, this especially when they stand on the right side of history looking back. The much more difficult hypothesis is to guess ahead of the game the precise pathophysiology involved, the devil of both meaningful hypothesis and knowledge being in the detail (is duodenal ulcer stress related or bacterial, only the latter hypothesis gets you the Nobel prize). And yet we ought to accept nothing less than solid proof when liberty is at stake. Then and only then can we even countenance calling mental illness a disease for reasons of using coercive powers. For Szasz, the question was not simply whether mental illness was a disease in and of itself or of the flexibility with which we might use the word if we wish to use it, a freedom underwritten by the first amendment of his adopted nation. No, the question is of illness in being an argument in favour of violating the libertarian non-aggression principle. It was to defend the person who might have their liberty and responsibility taken from them when they make the statements “I feel..”, “I believe….” or “I desire…”, “I am being told…” or “I am going to do…”. And parenthetically, notwithstanding the notion that the physicality of the disease might be located diffusely within the ecology of the body (body, brain and gut microbiome included), the newly discovered brain disease with mental manifestations would likely then be considered a new chapter within the neurology textbook, and find itself in good company with delirium, the dementias, central nervous infections and toxidromes. Accordingly, such a hypothetical discovery would not breathe life into a psychiatry that never could exist outside its use as a political tool for social deviancy. It would merely expand the borders of neurology and internal medicine.
I will make a claim that hardly ought to be seen as controversial to any who have read Szasz work, yet may be read with disbelief by most anti-Szaszians; i.e. that is he was extremely obliging of aberrant behaviours and alternative beliefs being referred to as mental illness, and even assumed to be bodily disease, though he believed these to be vastly different categories. He was also extremely obliging of the use of psychiatric drugs, as he was supportive of persons having the free-market access to use drugs of all kinds, even if this were to place the user on the path of self-destruction. Insomuch as this is the case, he is not at all guilty of Pies imputation to having committed an exclusionist fallacy (i.e. that one cannot use the remedy of one kind of malady to treat a malady of a different kind). He repeatedly stated he was quite comfortable with two free persons coming together and involving themselves in a mutually consenting transaction where what troubles one is called a disease and the other assumes the role of doctor and seeks a cure by whatever means the patient assents to. The choice of language in such a case is a matter of individual taste in accord of the terms of the transaction, informed perhaps by science, yet informed also both by the prevailing ideologies and realpolitik of the time. As stated, Szasz even allied himself with scientology, all the while of the mind that Hubbard’s pseudo religion was ridiculous and contra his own atheism. He would have had no bilious eruption against a free citizen of Greece attending a consultation with Hippocrates or Soranus, the subject being the discredited paradigm of humoral imbalances. Returning to the current day, though mercilessly scathing of so called complementary medicine, he had no objections to people spending their hard earned own money in a free market economy to receive healings by sitting under a wire pyramid with a crystal in their hand and a homeopathic tincture under the tongue. Caveat emptor, live and let live he would say, and more fool them. And so Szasz the radical libertarian protected the rights of people to do what they want within the limits of the non-aggression principle. He would have even gone so far as not to obstruct anyone seeking to take major tranquilizers (what are now misleadingly called antipsychotics) or be lobotomized if they did so voluntarily and having been adequately informed of the risks, taking personal responsibility for whatever follows. He thought these drastic interventions would be wasteful and destructive, though not to be prohibited between consenting adults. The problem as he saw it arises when the myth that is mental illness is coupled with infractions upon individual liberty and a means to avoid responsibility (the insanity defence much more pervasive than that which goes on in the court room). That was the myth he thought monstrous. In a sense we might then think of Szasz as attacking a triune myth of the mental illness/therapeutic state/insanity defence as a collective political exercise. Though not often employed, the insanity defence he saw as crucial to his thesis of the ideology behind psychiatric power plays. Psychiatry divests the one who is insane from freedom whilst attempting to divest the criminal from responsibility. Freedom and responsibility both are the targets. One cannot have one without the other. One cannot destroy one without destroying the other. The insanity defence was a conceptual wedge into which all responsibility would eventually be dissolved, this being the tendency of the larger project.
Climbing Mt Szasz
Though I would argue all the above to be critically important, quibbles over words and their meaning could be considered an exercise in intellectual masturbation missing the obvious realities of life. When confronted with the question if eccentricity in extremis is equivalent to madness, we might just say a rose by any other name…..
That is to say, the proverbial rubber hits the road when you or I encounter the other who sits across from us, and in this other is represented the extremes of social deviancy that might be described as stark raving mad. What are the boundaries to liberty here when someone is obviously “insane”? Below are several examples and a more radical Libertarian (i.e. Szaszian) ways in which they might be approached. Only in sitting comfortably with, and accepting the rightfulness of, such an approach might we claim to agree with him. And if we shan’t then his case, though perhaps correct in a sense, has failed to be convincing in advancing his cause.
Firstly, we have the child with the various signs and symptoms that suggests perhaps a bacterial meningitis at play. The clock is ticking here, with life and limb dependent upon diagnosis and treatment which requires restraining the howling, hostile and obviously “noncompliant” young person who rejects the poking and prodding and the lumbar puncture. Even Szasz would have no compunction in doing what needs be done, for every child, in lacking adult responsibility likewise lacks adult liberty. The parent can conscript whomever they wish, who if likewise acting in good faith can do what is in the child’s best interests to diagnose and cure an illness that is by definition physical. The doctor, operating in parens patriae, has a proper place in this scenario to even usurp the authority of the parent in certain vexed cases. It is not a paradox that Szasz saw child psychiatry as a form of child abuse, as it trades on the myth of mental illness and treatment which the child lacks the maturity to assent to. Szasz prescription to troubled children was a loving gradual training into the world of adult responsibility, this by the parents or those appointed by the state if the parents are grossly inadequate for the task. Simple.
Secondly, we have the adult patient. They have a modest elevation in white blood cells and certain other biological markers of inflammation, though all other investigations are normal. The previous evening, they were suddenly and uncharacteristically violent, “seeing things” and unable to attend to a conversation despite being notionally aware of where they are. Today they have a residual of the same perturbation to mental state, and they are unreasonably anxious to leave hospital. The most parsimonious conclusion is that there is something physically untoward informing both the deranged mental state and the physical markers, a delirium that in its nature they are not yet enduringly free of. It is just as likely as not that in the minutes to hours that follow, they will succumb to the delirium again, as they have partially succumbed now. Given we infer a) that their mental state is affected by the physical illness and b) that in better times they might prefer upon a course of action maximizing their chance of survival and future exercise of rationality, we might c) detain them for a reasonable time to complete the observations, investigations and treatment. It is the d) physicality of the basis of their mental change and e) our not unreasonable optimistic hope when their sensorium clears they will retrospectively assent to what we did that f) we feel justified in our strong paternalism. The doctor naturally has a proper place in this scenario. The only caveat is that we must consult with whatever pre-existing legally binding record they have of treatment preferences. Simple.
In a similar vein, we have the elderly patient with a dementing illness (or those with either congenital intellectual disability or severe acquired brain injury). Presuming their faculties exceed whatever threshold is required to be the architect of their own destiny, they ought to be left to their own self-determination what is done with their body. Whether the outcome be good or bad and even unto their own death is their own choice. To be sure, the adjudication of where that threshold might be crossed is easier conjectured than identified and is somewhat arbitrary. (no easier than the very difficult question of when the child becomes the adult). Yet there would be a point where all agree that more of the mind is gone than can be trusted to make decisions in one own best interest, that in virtue of the diseases physicality the doctor might have right of place in these scenarios (often a futile role), and that liberty ought to be curtailed in the patients best interests.
Next, we have the drug addled (usually) young adult. They may present to hospital disorganized, raving nonsense and with some or all the hallmarks of what we might call “psychosis”. After the storm of intoxication subsides, some strange and maladaptive beliefs and behaviours might persist. What to do if they wish to leave hospital and be left to their own devices, at the first or any other point along this journey? Undeniably, the physicality of the scenario is clear, insomuch as drugs such as methamphetamine steer the brain towards a dysfunction that is manifest in what we call psychosis or intoxication or delirium or whatever we wish to call it. I’m not entirely sure what Szasz might say in such a scenario, though his response is likely be somewhat less conservative and authoritarian than mine. I for one have no problem that the prison cell or hospital or other suitably containing environment be provided by the village. Insomuch as the care may involve forced sedation, involving a doctor is a prudent inclusion in the response, though this is far from the makings of a pretentious argument that a special species of doctor is required (a psychiatrist). The more controversial question is what to do the next day, or the days after. Here Szasz and I still walk a little way apart, though relative to the rest of the psychiatric world still we march in step. Suffice to say that when the drug user has attained the is compos mentis and can navigate themselves in the world, that Szasz would certainly argue (and I agree) that involuntary confinement in a psychiatric hospital and/or forced medication ought to be seen as a criminal act. Whether the police and judiciary are involved to prosecute the drug use is another matter and none of the psychiatrist’s business any more than any other citizen. Yet what does psychiatry all too often do? It moves the goalposts of diagnosis. Where once there was “first episode psychosis” or “recurrent drug induced psychosis”, the shift is towards psychiatrists being called to treat “as if” the patient has schizophrenia. Now they are treated “as having” schizophrenia, potentially with loss of liberty and responsibility whether intoxicated or not. That or the psychiatrist will perversely formulate the patient as having a primary mental illness that drove them to use the substances, the drugs receding into the causative background. Gone altogether are antiquated notions of free will and personal responsibility. Another manifestation of the insanity defence.
Now we have the final couple of patients. Each are adult so, prima facie, liberty and responsibility ought to be recognized and respected. There are no attributing physical illnesses for their aberrant behaviour. However well-intentioned we are, they reject utterly our proposed interventions. The first patient, an extraordinary man who frequented mansion gardens under the fervent belief that these estates were his, granted to him by no less than her majesty Queen Elizabeth II herself. He was harmless enough. Despite threatening all and sundry with execution by Mi5 if they didn’t acquiesce to his demands, he never did take matters into his own hands when Mi5 didn’t show up. (As it happens, they never did). The previous psychiatrist refused to see him following these threats, I suspect more out of a fear of an extra patient on their list than out of fear of violence. The patient conveyed his fantastic entitlement with such poker faced sincerity (I believed his conscious mind to be sincere whilst the unconscious was lying through its teeth) that only I somehow managed to keep a straight face while the medical students quickly excused themselves from the room on account of laughter they could not contain. What struck me was that in every other way this grandiose man was normal. His thoughts were coherent and articulate, his dress sense stylish, his manner debonair and aristocratic. It was never clear whether he was “hearing voices”, though there were tell-tale signs that he possibly was. One Autumn Day he managed to abscond from hospital, and off he ran. Szasz would have argued that he did not abscond at all. In the sense that there was no moral legitimacy to having been detained in the first place. From time to time I thought of our pseudo-aristocrat and his fate, until one night a few years later I was working the graveyard shift when the same patient was brought in by police for the same otherwise harmless trespass, a trespass for which I might add he was never charged. Why would a police force dissuade someone from nuisance behaviour using the rule of law, when dumping them in the emergency department saves them the paperwork on a charge that would never be prosecuted or convicted anyway (the insanity defence once again). What was sadly poignant in this story was that now 3 years later he was facially disfigured, a shadow of his former self. You see in the interim years he took a gun to his head in a failed suicide attempt, an act that was documented as causally related to “schizophrenia”. The problem was this; did he put gun to head for the Queen? No. In the interim years he came under the clutches of another mental health service in another jurisdiction. They treated him with a medication causing a terrible sense of restlessness we call ‘akathisia”. It was this terrible side effect that drove him to attempt suicide.
The first thought of the psychiatrist would be to lament that an alternative less troublesome drug had not been forcibly injected into our patient instead. So utterly committed they are to the therapeutic state, psychiatry would not dream for a moment of giving him his freedom to believe what he believed and face a criminal consequence for trespass. My own thought then was as it is now. Here was a man with alternate beliefs. Startlingly alternate I’ll grant you. I shan’t for a moment myself believe that his beliefs had a basis in reality, a reality in fact open only to a few in the British royal family. His isolation is probably more severe still. Imagine being the only one in the whole world believing your own story. We ought to take pause here at just how catastrophic the blow to the self might be if he ever attained the insight the psychiatrist wishes him to possess. Such is the hazard of unintended consequences. After all, are always all people best divested of their false beliefs that we medicalise as “delusions”? Why are you so sure you are helping them by forcibly trying to change their mind? How might you know the content of a delusion is a stochastic accident vs a choice by the person’s unconscious that helps them preserve ego strengths and get through the day? Whether fact or not, the question is whether a doctor ought to have the power to forcibly restrain, detain and inject powerful tranquilizers all for the sin of failing to agree on the facts of self and world. I invite the reader to first encounter the arguments made in the earlier chapter on psychosis. Enough to say for now that we all encounter persons with beliefs we do not share. Some will make claims that flow from these beliefs, claims that may even imply a potential to infringe upon other person’s comforts and freedoms. Our electoral podiums, professorial lecterns and priestly pulpits are full of people with views in part or in whole we do not share. And whether its taxation departments, terrorists, police states or possessive ex partners, they may want what we have. They may believe with all their heart that that it is their due. Arguing about the relative strength of argument of what constitutes strong evidence is a dead end about which even seasoned philosophers may not agree. And the psychiatric drugs we use to dull the fervour with which a belief is held are nonspecific. These drugs can make a zombie of anyone and their drive to exercise beliefs if the dose is pushed high enough. They prove nothing as to the ontology of mental illness. These drugs are only useful as domesticating chemicals to dull the deviant.
So what is the alternative? The alternative is a dialectic, an unforced invitation to challenge this patient as to the validity of his beliefs and how he might better live in the world. In the majority of cases such a dialectic will not budge the mind of the person with the so-called delusion any more than that of engaging the strong political ideologue in argument. Hence psychiatry turns against the dialectical approach and makes many a non sequitur from it (the metaphor of illness and the construct known as insight lacking in virtue of illness when lack of insight really indicates difference of opinion). I hazard to add that challenging the so-called delusional patient with a vigorous dialectic has surprised me with many persuasive victories also, even those written off as irredeemably psychotic. But even if the one with the deviant belief is not convinced, what the proverbial 99% of patients will grasp is that their truth is not shared by others, the police included. They are very well aware they are alien to the mainstream and well aware of the consequences of their actions. That is to say, if we embark upon a learning process with repeated police involvement to extinguish the behaviour that is both criminal and “psychotic”, this non-medical approach is often successful. As one militantly opposed to thoughts and feelings being considered crimes or pathology, I often advise a patient thus; if they manage to keep their beliefs to themselves and some trusted others and not attract suspicion from the widner world that they are crazy, who should care what they believe? I remind them the wider world has not developed the tolerance and "so what" attitude towards highly unusual beliefs my experience has given me. Whether or not they choose to take my advice will be theirs to make. Theirs will also be the responsibility come the consequences should they fail to heed it. If they fall into the clutches of a less tolerant psychiatrist or other mental health clinician, it is only because they attempted impose their beliefs on the world.
Our final example case is that of a female patient. She was raised in a (more or less) normal household, enticed into adolescent rebellion and minor drug use as a teen and cavorting with the “wrong crowd”, a member or members of which more than likely raped her. Fast forward to mid adulthood and she had the bizarre delusion of being raped by bikers even when in a locked room in the psychiatric ward, with no one around to touch her. She would claim other staff raped her also, even in the open area where the accused staff member stood at one corner of the room and her at the other. Naturally all this was quite distressing to all involved, and though “psychotic”, hers were false beliefs echoing in her mind from traumatic events of the past that her mind could or would not shake. Hers was a case beyond PTSD, though one could argue PTSD was continuous with psychosis in this case, a testament to the contemptable stupidity of the DSM project in carving nature at the joints. Needless to say, she was not living the life of a productive contended tax paying compliant citizen. She had no need to work, as the state would support her for life as disabled with schizophrenia, this despite the fact that she could easily communicate, ambulate and navigate about town to her friends and cannabis dealer and to do the shopping etcetera. Despite her distress, there was no denying that our forced and very protracted psychiatric incarceration and treatment with clozapine ( a powerful tranquiliser) resulted in a significant lessening of the phenomena. With it we can claim to have achieved an objectively significant positive shift in her life. Readers who might be psychiatrists will not be surprised to be told however that our patient did not fall at our feet, wash them with her hair and worship us for saving her from the torments of her mind. Quite the contrary. She was bitterly opposed to the treatment program and the medication. She would attempt abscond and evade us as much as possible, not simply because of the assaults she believed happened to her in hospital as they happened much more so elsewhere. Rather she wanted freedom from hospital per se, and freedom also from our medications. And she wanted none of my Socratic conversation. How do we reconcile this? In a previous chapter I lament that as a younger man I flirted with the psychiatrist’s defence, i.e. we were saving the patient from the jail that was their own mind, a jail worse than the walls and ceilings of our ward, worse than the regular forced administrations of medication. We were saving her from false beliefs and her mental illness. We were lovingly attempting a mind transplant whilst leaving identity intact. We were doing what caring experts do. I, like the rest of the psychiatric machine, objectified compassion, this despite knowing that “objective compassion” could only hope to have conceptual coherence as a transcendental from which I could not be its source. And I also had a practice of imagining this gnostic other person within the patient who wanted to be freed, a kind of iatrogenic multiple personality disorder that I projected into the patient, the healthy woman who wanted to emerge victorious over the schizophrenic one. Sure, there is part of the patient who expressed their dissatisfaction with care and indeed wants none of it. But deep inside there is the other side of her which only the psychiatrist as seer into souls can see. She is (or they are) happier and perhaps one day will emerge and thank us. But such days rarely if ever arrive. In any case the conjecture is wishful thinking. It’s doomed to failure in the arena of argument. There is only a single identity before us in the present. That much we know is true. And that identity insists to be free from psychiatry. That identity insists that our equally insistent compassion is disguised tyranny, ours a pale mirror of her past trauma. For past trauma too was a deprivation of liberty. Now psychiatry will counter this and defend its benevolent tyranny with notions such as “she lacks insight” and so knows not what she does, or does not, want. We know better for her. We might even say she lacks “executive function” and has in theory the hypo-functioning frontal lobes typical of schizophrenia. Such science and psycho-babble are universal solvents into which we might place anyone who protests and disagree about anything, including every male under the age of approximately 30 years with unripe frontal lobes. Such appeals always appeal in turn to circular reasoning as to the relationship between the act of disagreement and the diagnosis we have placed upon the victim of diagnosis, a criterion being “lack of insight”. Still the reality of the political situation persists. The mind in front of us believes ours to be the greater torture and she wishes to be free of it. And part of my own mind (a part which I knew to exist as I was using it at the time, and long before I discovered Szasz), knew that psychiatry was wrong. I saw the dangers in the power it held was contained only by custom and sentiment and not from any deep engagement with ethics or philosophy of self or power relations. And yet I flirted with the moral fallacy that a) what I want for another, this being b) what they should have or want for themselves, mandates c) forcing this upon the person as somehow rescuing them from themselves. They would accuse Szasz of callousness and cruelty for wanting to let her go free and tortured by mental illess. Now for all the callousness we might accuse Szasz of, let us give him the benefit of the doubt that he also desires for this woman a life free of persecutory beliefs and distress. None of us should be comfortable with her pathos. Yet it ought not be our own sense of discomfort that we are treating using her psychiatric incarceration as a therapeutic object. It is not from a place of callousness that we might grant people their freedom to hazard the dangers in the world, along with the world of their own mind. Dare I say it is even an act of love to grant people freedom and responsibility. And it makes little difference whether we add into the equation that the examples above might be hearing voices whose counsel they take before ours. Nor does it negate the argument if they wish to kill themselves for reasons we cannot empathize with as being reality based. It is their life to take for the reasons they wish to take it. If you have come this far and allow this woman walk out past the hospital gates to the life and fate of her choosing within the constraints of her person and past, be that life sweet and long or bitter and short, then you too have climbed Mt Szasz.
Epilogue May 2023
No one of good sense and good will would argue against health and the wellbeing of our fellow man. We all should want to make the world a better place of fresh water and less malaria. To these ends, thoughts and emotions evoked from the words “military campaign” and “public health” or “war on mental illness” are very different from each other. Even placing “public health” in the same sentence of “totalitarian” would seem strangely histrionic. Yet it is precisely in these assumptions that dangers lurk. Psychiatry the canary in the coal mine. The prison, the camp, the locked down home or the psych ward., these are simply different colours on the same moral canvas.
When I wrote this chapter circa the time of event 201 of Oct 2019, I was not aware of the simulation exercise eerily like the pandemic to follow and the response to it. In these global (and globalist) sweeping draconian responses we have been given a taste of just how punitive and Maoist health programs can be. We cannot claim not to have been warned if or when they drop the boot come the next virus. Just as many a schizophrenic is permanently under state control and only able get about under conditions of treatment orders, the sane of the last three years have ben given conditional freedoms to be given or snatched away by health managerialists according to “danger to self and others”.
If only the danger of the therapeutic state was restricted to viruses of the mind and airways, we might have a fighting chance. The diagnosis (and perhaps prognosis) is far worse. Health vs politics vs morality vs capital vs the ecosphere vs the social sphere - these are just words now without meaningful referent where all manner of hysteria and agenda fuse them altogether. Now everything is a health matter. Bullying and misgendering is neurotoxic and causes suicide. Cash is unhygienic. Mis/information contributes to deleterious health outcomes, or so they say. What passes for democracy is healthy and what is propagandised as antidemocratic is not. The whole planet is a patient with climate change a symptom that causes us all dis-ease. Hence every movement, every transaction and every act of consumption somehow somewhere helps or hinders the Earths hypercapnia. All movements of all local collections of antigens, antibodies require monitoring as the internet of things becomes the internet of bodies becomes the internet of pure localisations of bio-information towards metrics of immunity and threat. The sky is the limit and don’t think new moon shots will not be made, some at project warp speed and some at less noticeable velocities. I have written on these matters elsewhere (see links below). If the agenda and grifts of the neoconservative war machine doesn’t get you the therapeutic state will. Thankfully for Szasz he isn’t around to see it.
https://rmachine.substack.com/p/whats-with-the-who
https://rmachine.substack.com/p/the-once-and-forever-state-of-emergency
Will this book be published in print?