by Thomas Szasz
Syracuse University Press, 1988
Review by Constantinos Athanasopoulos, Ph.D. on Jul 31st 2001
This book deserves a place in all psychiatry and psychology related libraries next to the greats of Freud, Skinner, Laing, Bleuler and others. What we will attempt here is try to chart the main arguments and consider their validity .
Szasz begins the book by making a very interesting parallel of the history of psychiatry (as related specifically to the treatment of schizophrenia) to the one of usual medical science (and more specifically the one related to the sexually transmitted disease of syphilis). He finds that the two people who coined firstly the word in the modern times (Kraepelin and Bleuler) were not physicians but "wardens" who justified their control and power on the inmates of their prison-asylums by turning them into "patients" (mainly p.38). His argument in this (the first) chapter of the book is quite impressive in its detail and thoroughness of research as to the specific circumstances related to the views Kraepelin and Bleuler advocated. He points out that Rudolph Virchow (1821-1902) was the one who initiated a paradigm shift in the model of medical science that was predominant up to that time. So from the medieval model of "humoral pathology" we have with Virchow a shift to "cellular pathology". With Emil Kraepelin (1855-1926) we have the first coinage of the term dementia praecox or schizophrenia "as we now know it". The term covered initially three "conditions" of the mind: catatonia (stupors), hebephrenia (silly behavior) and vasania typica (hallucinations and delusions). With the contributions of Eugen Bleuler (1857-1939) the application of the term became broader and included cases such as psychoses and even the cases of "normal" people who had no severe symptoms (latent cases) (pp.10-11). Szasz's argument stresses the fact that Kraepelin and Bleuler thought that schizophrenia was the outcome of pathological, anatomical, or chemical disturbance in the brain (following here the phrasing of I.R.C. Batchelor). According to Szasz, Bleuler, being more honest and straightforward, acknowledges this himself in his later work with the title Autistic Undisciplined Thinking in Medicine and How to Overcome It (1919), in which he emphasizes the fact that "the concept of mental illness, especially as it is used in institutional psychiatry, is not a medical concept at all" (p.29). Szasz actually uses many views the later Bleuler adopts and ends his admiring discussion of the later phase of the "repented" psychiatrist by claiming that the "repented" psychiatrist gained his early recognition on a quite different basis for which he is guilty of the "eternal damnation" which all "conquerors" and "colonizers" deserve! (pp. 22-44). But let us see in detail Szasz's critique on the early Bleuler. Szasz's argument is that even though Kraepelin and Bleuler sought to find the pathological, anatomical, or chemical disturbance in the brain on the basis of which they would treat efficiently the relevant disease (schizophrenia), they went ahead and described the disease and treated it as if they had found such a pathological, anatomical and chemical disturbance (histopathological lesions or pathophysiological processes) in the brain (p.9). In fact, instead of finding the lesions and processes in the brain which they originally thought were responsible, they ended describing only the "alterations in thought processes" during the progress in the illness (p. 13). Bleuler in Dementia Praecox or the Group of Schizophrenias (1911) stresses according to Szasz the fact that Schizophrenia is a "thinking disorder" manifested in a "language disorder" (Szasz, ibid.): "Blocking, poverty of ideas, incoherence, clouding, delusions, and emotional anomalies are expressed in the language of the patients. However, the abnormality does not lie in the language itself, but rather in its content." (Bleuler, ibid., p.147). However, and here Szasz again is basing his argument on the sincerity of Bleuler's confessions, Bleuler finds that at times these "linguistic abnormalities" and "schizophrenic logic" can not convince his audience in clinical demonstrations of the related disease pathology (Szasz, ibid., p.14; Bleuler, ibid., p.148). Szasz claims that this is due to the fact that Bleuler considers as "inappropriate figures of speech" metaphorical expressions or even poetic symbolizations which "normal" people have (pp.14-15). Szasz thinks that Bleuler tried hard to "invent" a disease and justify on this basis his status as a psychiatrist and his power on the "patients" cum inmates. In such an attempt Bleuler, according to Szasz, never bothered to ask a set of very important questions which are evident to any logically or libertarian inclined honest psychiatrist: "If what makes 'schizophrenic' utterances 'symptoms' is that they are incomprehensible, do they still remain 'symptoms' after they are no longer incomprehensible? If the utterances are comprehensible, why confine those who utter them in madhouses? Indeed, why confine persons even if their utterances are incomprehensible?" (p.16). According to Szasz, these never-asked-for and never-answered-to questions are not only an evidence of Bleuler's hastiness to characterize his inmates as "patients", but are also the questions which contemporary psychiatrists also do not ask and never answer, so that they can also keep their social and medical power on those they wish to incarcerate in the closed walls of the today's asylums (ibid.). To Szasz, the psychiatric conception of mental illness is what to Roman-Catholic Christians is the notion of transubstantiation: a literalized metaphor! (ibid.). After a brief investigation in the Freudian interpretations of schizophrenia and the World Health Organization's definition of the illness of schizophrenia (and its purported "inclusion criteria": delusions, inappropriate or unusual behavior, hallucinations and over-and-under-activity) Szasz concludes that the process which was followed in the definition of the illness was the same as Bleuler's: "define the madman as sick and discover in what way or for what reason he is sick!" (p.20). He finds that this "symbolization of the symbol" is essentially the psychiatric tool which provides the necessary doctrinal and "sacramental" support for psychiatry's success and predominant role in our societies (in much the same way as the sacrament and doctrine of transubstantiation gave to the Roman-Catholic Christianity its necessary support).
As I mentioned at the start, it is in this, the first, chapter that we find Szasz's most valid arguments and points. Even here however, there are a couple of points that a careful reader might find problematic. For example, it is highly suspicious that someone who claims at the back jacket of the book to be "both a practicing psychiatrist and a professor of psychiatry" also claims that "the psychiatrist treats healthy people as if they were sick patients, imprisons them as if they were convicted offenders, and uses the name of 'schizophrenia' to conceal his deeds" (p.42) and that the psychiatrists are colonizers, religious-political leaders and conquerors (mainly pp.18-35). One of the obvious points against Szasz here might be that he is just discrediting his colleagues just to drive his opposing "religious-political leaders" out of business! Also, his distinction between "real" and "fake" medicine based on the fact that "real" medicine treats and cures and "fake" medicine influences and controls "fake" patients (p.39) seems equally suspicious, especially after the recent debates between physicians and practitioners of homeopathy: homeopathy followers claim that physicians try to control their "patients" and make them pay for expensive surgery treatments and medicine, while what is really needed is complete fasting and cheap herbs!
As we progress in the book however, the motives and arguments that Szasz employs go from bad to worse! Take for example the second chapter. This chapter is dedicated to a critique of his chief opponent in his crusade against established forms of psychiatry: the anti-psychiatry movement led by R.D. Laing. He begins his attack by rejecting the very term of "anti-psychiatry": "I reject the term anti-psychiatry because it is imprecise, misleading and cheaply self-aggrandizing" (p.48). He also clarifies what is against to: "I am against involuntary psychiatry, or the psychiatric rape of the patient by the psychiatrist -but I am not against voluntary psychiatry, or psychiatric relations between consenting adults" (p.49). In the same page he justifies his claim by insisting that if one is against all psychiatric practice (this is implied by a "non-analytic" interpretation of "anti-psychiatry") this is "patently absurd". Since the main thrust of his argument in this chapter is against R.D. Laing and his theory I will not discuss in detail his rather problematic claims about his own position; I have to make two points however, which I believe warrant the attention of the serious reader: a) Since when "voluntary" psychiatry differs in its methodology from the "involuntary"? The methods are exactly the same. And Szasz himself claims this by insisting on the distinction between "real" and "fake" medicine. If the psychiatrists are "fake" doctors then the police should arrest them for fraud. One can see the point if one considers what happens in the case of real "fake" doctors: if a doctor does not have a license (has not passed the required tests, paid his fees, etc.) or he has been disqualified due to a misconduct then he/she may even be put to prison (depending on the service he/she provided). Perhaps what Szasz has in mind is that the voluntary psychiatry is more ethical. But I dare him to explain what is ethical in a case where someone claims that he/she is something that he/she is not and that he/she will do something that he/she knows that he/she cannot do: since when fraud is ethical? b) Why is it "patently absurd" for someone to reject all of psychiatric practice? If psychiatrist are highly paid criminals why not reject everything they do? Is it because they are effective in some of the cases they treat? Well, so is the placebo-sugar-pill they give in some illnesses to find a cure for them. However, no one thinks that it is "patently absurd" if someone makes a ban on sugar-pills! Actually I would suggest a test: banish all psychiatrists and forbid all psychiatric practice for 10 years and see what happens! This neither "patently absurd" nor irrational. It would be a good test to see what parts of the Szasz hypothesis is valid and what parts are not.
But let us turn our attention to the main thrust of Szasz's argument against Laing's theory. Szasz sees that the main problem with the anti-psychiatrists and especially Laing's theory is that they seek to raise the "insane" above the "sane" influenced by their communist and leftist ideologies which in general elevate the proletariat above the capitalists (p.49). The founders of the anti-psychiatry movement (R.D. Laing and David Cooper), according to Szasz, do not differ much from the psychiatrists they sought to oppose. Szasz sees that the differences in terminology (i.e., the term "patient" is transformed to "traveler", the term "psychiatrist" is transformed into "guide" etc.) are just euphemisms. The main drive of the movement is to keep the "travelers" chained in their incapacity to "guide" themselves through the "journey of their madness". As Szasz claims in his own view there is no "journey" or treatment since there is no illness to be treated. The term "schizophrenia" or "divided self" in Laing's terminology is just a word, a label for a non-existent illness (chiefly p.44). Thus Szasz sees two major problems in Laing's and Cooper's movement: a) they do what regular psychiatrists do, but in addition, they trick their patients into accepting their treatment more than the regular psychiatrists', attracting in the same way the state funds which should be directed into research, better facilities etc.; b) they do not differentiate between involuntary and voluntary treatment, and thus are no better from an ethical and libertarian perspective than the regular psychiatrists (pp.49-83).
Finally in this chapter, Szasz sees that the anti-psychiatrists just replace the negative symbol of "schizophrenia" with the positive of "authenticity". With the first the regular psychiatrists debase socially and morally the patients who are deemed as unfit to be free in society. With the second the anti-psychiatrists elevate the patients into "authentic" persons who try to find their own "authentic" way out of the dead-end situations which "normal" people have chosen to adapt to with their hypocrisy and inauthenticity. Regarding the arguments against Laing's theory and the anti-psychiatrist movement one may see Szasz's perspective equally suspiciously: Szasz in places engages in ad hominem arguments (see mainly p.70, where he claims that Laing is conceited and full of self-importance), and in other places the reader misses the point of what exactly his main point is. For example in p.74 in a footnote (!) Szasz explains his own view regarding schizophrenia and maintains that "whatever helps a person to achieve that goal [put one's life in order] will be "therapeutic". Now this is supposed to explain the difference between Szasz's view on therapy and the one Laing and the anti-psychiatrists put forward. However, the reader cannot understand what is this supposed difference: both the anti-psychiatrists and Szasz claim here the same thing. Finding one's own way is putting one's life in order! As regards the above mentioned bi-partite main thrust against Laing I think that the only thing worth mentioning is the difference between voluntary and involuntary treatment. Szasz seems to be right here. This seems as a serious difference between Laing and Szasz. However, a Laing supporter might equally well claim here that Szasz does not see the fact that the "traveler" will not travel and will not be guided by his "guides" unless he/she also wishes to travel in the proposed direction. I mean by this, that in the absence of any serious detention and torture measures (such as straight-jackets, isolation chambers, electroshocks, incapacitating medication etc.) the "traveler" is more free to follow or not follow the directions given. In this way the distinction between voluntary and involuntary seems not a serious one. However, Szasz even with this response seems to still be right, since consent plays and should always play a part in treatment (the problem remains however, if this consent is impossible, as, for instance, when the patient cannot communicate with the environment).
The final two chapters "Schizophrenia: Psychiatric Syndrome or Scientific Scandal?" and "Psychiatry and Matrimony: Arrangements for Living" are elaborations of the basic theory expounded in the first two chapters. In these final chapters we can see Szasz's rhetoric at its best dealing first with the scientific basis of psychiatry and secondly with a parallelism between the relationship of a married couple (typical of a pre-arranged marriage) and the relation between a psychiatrist and his/her patient.
The book ends with two very interesting appendices (one on "The view of mental illness as brain disease: A chronology" and one on "Psychiatry and Anti-psychiatry: The superior virtues of the oppressor and the oppressed").
As I said in the start the book is and will always be a necessary item in all libraries related to psychiatry and philosophy of psychiatry. By far, the first chapter supersedes all the rest in clarity and force of argument. And one can see, based on this chapter alone, why the book is considered one of the great books in the area: it has changed the way psychiatrists see themselves and the way they treat their patients. I just hope that many other great books such as this are written soon (preferably with more coherent and valid arguments and analysis throughout their length), so that the field does not remain stagnant in the achievements of the last 20 years!
© 2001 Constantinos Athanasopoulos
About the reviewer:``Dr.Constantinos Athanasopoulos has``a Ph.D. from the University of Glasgow (on the topic of The Metaphysics``of Intentionality in the Philosophy of Language and Mind of Sartre``and Wittgenstein). He has also studied philosophy, psychology``and religion at Brandon U., Canada, and Moral Philosophy at the``University of St. Andrews. Currently he writes books for the Greek``Open University (one on Medieval Philosophy and another on Byzantine``Civilization) and teaches part-time philosophy courses at the``University of Athens and Patras, Greece. His many research interests``include metaphysics, philosophy of mind and language, Continental``and Analytic, and Medieval and Byzantine Philosophy, moral psychology,``ethics, environmental philosophy and ethics, political philosophy,``philosophy of education, philosophy of psychology and psychiatry.``Parallel to job-hunting his other hobbies include Byzantine Music,``Orthodox Theology and going to the movies.