Revealing the truth about psychopolitics
Following the death of Thomas Szasz, we republish an extract from Peter Sedgwick’s critique of anti-psychiatry’s leading light.
Dr Michael Fitzpatrick writes: Thomas Szasz, who died on 8 September aged 92, was an American psychiatrist of Hungarian Jewish origins, a consistent and courageous critic of mainstream psychiatry and medicine for more than 50 years. In the 1960s, his argument that mental illness was a ‘myth’ and his opposition to the coercive character of psychiatric diagnosis and treatment led to an association with the ‘anti-psychiatry’ movement popularised by the British psychiatrist RD Laing, the French philosopher Michel Foucault and the Canadian sociologist Erving Goffman, though Szasz’s approach had little in common with these authors. Szasz also pursued a wider critique of the ‘medicalisation’ of life by the medical profession (and the pharmaceutical industry) and coined the term ‘therapeutic state’ to characterise the collaborative interventions of medical and political authorities. Despite offering significant insights into psychiatric and medical practice, Szasz had a lifelong tendency to spoil a good case by overstating it and pursued an ill-advised collaboration with the Scientology cult (on the basis of a shared hostility to mainstream psychiatry).
What follows is an extract from Peter Sedgwick’s book, PsychoPolitics, a critique of the anti-psychiatry movement, published in 1982. Sedgwick was a left-wing British activist and intellectual, best known for his translations of the works of Victor Serge. He died in 1983 at the age of 49, a year after the publication of PsychoPolitics. This extract, discussing the work of Szasz, is reproduced with the permission of the publisher, Pluto Press.
For over two decades, Thomas S Szasz has been conducting a continuous, single-minded and stylish battle against mental-health ideologies and institutions, along a gamut of media from the scholarly to the popular, between the covers of 15 books and across the pages of some hundreds of articles and reviews. Erving Goffman began his influence in counter-psychiatric theorising at the same starting point as Szasz – ie, the later Fifties – but is better known as a general sociologist of the small-scale encounter than as a theoretician of mental-health issues. RD Laing came into public attention during the psychedelic Sixties, arriving with a sensational impact that has faded given the ensuing changes in modern cultural styles and in Laing’s own personal outlook.
Michel Foucault now reigns almost supreme in the modish avant-garde of Paris, London and New York, having achieved his eminence through the passing of the revolutionary or radical social aspirations that structured intellectual life in all three centres after 1968. In these successions of ideological fortune, Szasz’s stance as a critic of psychiatry has been unwavering. He is at the same time the doyen of the movement of mental-health revisionism and the herald of the newer orthodoxies of right-wing thought on welfare in the post-collectivist epoch of Ronald Reagan and Margaret Thatcher. From a position of apparent marginality, situated on the fringe of the right-libertarian grouplets associated with American individualism, Szasz has emerged as a thinker fully concordant with the mainstream of conservative thought on social policy; and, paradoxically, in his transition from fringe figure to conservative luminary, he has often received the approbation of the socialist or radical New Left, which has seriously misunderstood the implications of Szaszian anti-collectívism.
Yet any reader in the literature of mental-health revisionism will find Szasz’s work uneven, occasionally lacking even in the structure of a schematic overstatement. Two books by Szasz may be taken as the pillars of his theoretical edifice: The Myth of Mental Illness, published back in 1961, and The Manufacture of Madness, which appeared in 1970. The former consists of a fundamental attack on the logic of the concept of mental illness, in terms remote from any purchase on the actual institutions of psychiatric treatment; the latter is a critique of the operating social and political functions of psychiatric ideology.
Yet the two works fail to form a natural complement to one another. The Myth of Mental Illness is only seldom militant despite its polemical title. In the main, it fulfils the promise of its sub-title, ‘Foundations of a Theory of Personal Conduct’, providing a re-working of psychoanalytical categories of normal and abnormal behaviour along the lines of a game-playing model of social interaction which is zestful and insightful, but neither particularly uncommon nor particularly iconoclastic by the standards of recent social-psychosocial theorising. The text is enriched with a host of clinical and conceptual observations whose value stands independent of whether one accepts the author’s main case: that ‘mental illness’ is an invalid and perilous idea.
For instance, Szasz perceptively points out that the orthodox-psychoanalytic ideal of ‘genital primacy’, as a desirable goal for adult functioning, omits to state whether the successful genitality of ‘king and concubine, master and servant, soldier and prostitute, or husband and wife’ is considered the model to be followed. Again, the observation that much personal misery arises not simply through loss of a person or persons but also and even more through ‘the loss of game’ neatly integrates clinical empathy with the sociological discussion of ‘anomie’ (loss of norm) which is usually applied to whole groups of the displaced rather than to individual victims. Much of Szasz’s text is concerned with elucidating the many cases in which people can be said to be following rules, or learning to follow rules, in either a socially acceptable or a socially deviant manner; it would be relatively easy for an adept of psychoanalytically guided psychotherapy to accept Szasz’s general theoretical discussion of game-playing and rule-following without thereby concluding that the argument had destroyed the utility of ‘mental illness’ as a structuring concept.
Since in this work Szasz is more concerned with the construction of a game-analysis of human action than with the destruction of the pretensions of medical psychiatry, many polemical ideas which will later be developed much more vigorously are to be found stated here in less bellicose fashion. The targets of his critique are large, portentous and heterogeneous. Marxian ‘historicism’, health-insurance schemes, causal explanations of human behaviour and religious injunctions toward meekness and submissiveness are among the many stopping-posts in a waspish itinerary. Despite the author’s famed hostility towards psychiatry, only one school of psychiatric thought, the extreme ‘organicist’ trend which regards all mental illnesses as brain diseases, requiring no understanding of the patient’s motives and goals, receives sustained critical attention. The theory and profession of psychoanalysis gets off relatively lightly. It is made clear that Szasz’s own transactional approach towards psychological disturbances is a development from suggestions formed from within classical psychoanalytical theory (Sullivan, Ferenczi, Fairbairn and Freud himself) and the book as a whole bears something of the character of a neo-Freudian internal document, penned in order to persuade fellow analysts of the value of a fresh language to encompass their existing practice.
Human action is governed by intentions or motives; these motivations interlock predictably from situation to situation within various bundles of social rules; and behaviour in accordance with such rules may be seen in the light of an analogy with the playing of games of the ordinary and common kind. Such, too briefly it is true, is the explicit content of what Szasz terms ‘foundations of a theory of personal conduct’. The gameplaying analogue is deployed liberally and with gusto: thus, within the Judaeo-Christian religious tradition, one plays a ‘game of “I-am-not-happy” against a “partner-opponent” , God’; a hysteric patient is playing a game of coercion with her or his relatives and even with her or his therapist; modern society is involved in a ‘medical game of life’ – with prizes for the handsome and healthy winners and penalties for the old, ill and deformed – which has replaced the heaven-bent ‘theological game of life’ characteristic of the Middle Ages.
Szasz has the capacity to restate the commonplace within a vivid context that heightens the truth value of old truisms. But the apparently radical context can often be discarded as a cover. For example, it is easy to agree with Szasz that the assignation of mental illness undermines the patient’s responsibility and actually increases the burden of individual helplessness; the point can be taken as a salutary warning, but does not constitute a theoretical objection to the category of ‘mental illness’ as such. Where the work engages in a really controversial case – eg, in its large claim for the virtues of individually conducted and privately paid psychoanalysis – one is likely to find the argument oddly skimped. Such moot points lie embedded in a more graceful and detached discourse which has to do with ‘everyday life as a mixture of metagames’, ‘impersonated roles’, ‘coercive rules’ and similar ironies.
In contrast, the rising curve traced by Szasz’s later publications, with its early peak in The Manufacture of Madness, amounts to the escalation of a crusade rather than the development of a theory. Every differentiation required by Szasz for the establishment of his initial case is rendered into the sharpest and most unqualified dichotomy. In The Myth of Mental Illness, it could be admitted that the institution of private psychoanalysis might itself need some suspicious scrutiny, or that psychosomatic illnesses presented some unsolved difficulties for his analysis. Increasingly, however, the practice of psychiatry becomes divided by Szasz into two, and only two, functional types, forming respectively the utmost in totalitarian despotism and the best of all possible therapeutic worlds.
The totalitarian pole is termed ‘Institutional Psychiatry’; it is characterised by involuntary incarceration in mental hospitals, the use of psychiatric concepts for the extralegal punishment of deviants, and the state’s investiture of employed physicians as agents of social order rather than of their patients’ welfare. The opposite, benevolent extreme is offered in Contractual Psychiatry: an arrangement founded on an informed consensus between two freely choosing individuals, one a therapist and the other a client, the former providing a service in the unravelling of certain moral problems and the latter, in return, a monetary fee. Neither branch of psychiatry has anything to do with medicine, whose interventions should be limited to cases of ‘demonstrably bodily illness’.
Szasz has earlier insisted that doctors should even avoid concerning themselves with those social conditions that can precipitate demonstrably bodily illness; it is no part of their job to function as ‘attorneys for the poor’ since nowadays the poor have enough attorneys and other representatives of their own. But in the latter works social medicine, like social psychiatry, turns into anathema: a simple liberal call from an American public-health administrator asking doctors to join with community leaders ‘to eliminate known producers of stress such as urban slums and rural depressed areas’ is enough for Szasz to invoke the spectre of the Psychiatric Purge. ‘But who or what might be “producers of stress”? Negroes? Jews? Communists? Fascists?… These possibilities are by no means far-fetched.’ An organically defined medical science, blind to the most obvious connections between social environment and personal ailment: an equally individualistic psychoanalytic framework, avaìlable only for those patients who are well enough (and well-off enough) to pay cash: such are Szasz’s positive therapeutic ideals.
We must now tum to Szasz’s negative example of medical misuse, especially to ‘Institutional Psychiatry’, a phenomenon which he repeatedly states to be the twentieth-century equivalent of witch-burning and the Inquisition.
Medicine is defined by Szasz in terms of an objective subject-matter: the human body and its disorders. Within psychiatry, however, other criteria for definition are employed. Contractual Psychiatry is defined in the terms of an ethic, that of a voluntary exchange between doctor and patient, while Institutional Psychiatry is delimited in terms of a particular procedure, ie, the certificated delivery of a mental patient into hospital care through a legal process undertaken against his or her will. Involuntary hospitalisation is for Szasz the central paradigm of modern psychiatry – even though it is a minority procedure in Britain (where entry into psychiatric treatment usually presents no greater legal complexities for the patient than admission into any other form of medical care) and of decreasing importance in the United States.
Szasz’s method is thus to take a particularly disputable type of psychiatric action and define the rest of psychiatry around it. The most indefensible compulsory hospitalisations are presented as though they were typical hospitalisations. And, in order to forestall any possible apologia for an unjustified committal into hospital, the reader’s foot is shackled to a chain of linked universal prohibitions and injunctions, so that it can never once be set on the slippery slope that leads from diagnosing a patient to lobotomising him or her; from preventing a suicide to locking up a rich relative; from treating a homosexual who desires potency with women to castrating one who is content with partners of his own sex; from regarding delusions as evidence of illness to interpreting masturbation as evidence of insanity.
All psychiatric concepts are pragmatically re-fashioned by Szasz around the issue of compulsory hospital treatment. Thus, the distinction between neurosis and psychosis which is ordinarily founded on a variety of clinical, behavioural and phenomenological considerations is taken by Szasz simply to represent the difference between voluntary treatment and coercive certification, ‘neurosis’ being a covert justification for consulting-room psychotherapy and ‘psychosis’ for forcible retention and punitive treatment in hospital. In actual practice, of course, there are a great many psychotics who enter and leave hospital voluntarily, or who live out a mainly out-patient career on mood drugs and professional sympathy, and correspondingly a fair number of neurotics who get detained on compulsory orders, eg, as serious suicidal risks.
Szasz’s theoretical enterprise in anti-psychiatry is thus essentially one of tracing every thread in the web of psychopathological logic that could, under some construction and in some conceivable situation, facilitate the deprivation of the subject’s liberty through involuntary hospitalisation. Any unnecessary coercion of psychiatric patients is a scandal which, of course, deserves whatever public exposure it manages to receive. But Szasz identifies the scandal as any compulsory hospitalisation whatsoever, and his remedy – the outright abolition of compulsory procedures in psychiatric hospitalisation and the replacement of public-health psychiatry by fee-paid two-person psychotherapy – is useful more as a provocation than as a programme.
The Szaszian case contains both the force and the fragility of any analysis of social evils undertaken from the standpoint of a single absolute moral principle, be it Gandhian non-violence, Cold War parliamentarianism or – as in this case – civil-libertarian individualism. Like all such absolutist standpoints, it is capable of moral fervour and narrow sensitivity to certain intolerable wrongs, and a power to demolish more eclectic, more qualified positions. But its absolutism renders it impotent to calculate the complex relations between means and ends, risks and benefits which hold in real life. It seeks legal guarantees against injustice and abuse, and can find them only in the realm of ideas, since history itself contains no possibility of such warranties. By a Contractual Psychiatry, Szasz means a psychiatry which is guaranteed, safe, pre-designed to pose no serious ethical problems for therapist or client. It after all consists of a free exchange between approximately equal partners: ‘The relationship between contractual psychiatrist and patient is based on contract, freely entered into by both and, in general, freely terminable by both.’ Only the mildest mental disorders could possibly be handled within this framework, for one well-known consequence of emotional illness is an extreme dependency that is often manifested towards the therapist. Consequently, Szasz is saying that the only defensible psychiatry is that which can be practised with those who need it least.
Towards those who are in most need of psychiatric (as of ordinary medical) treatment – the chronically ill who cannot earn the fee that ignites the engines of Contractual Psychiatry – Szasz offers nothing. Thus Szasz never states how an adequate psycho-geriatrics would be possible within an individualistic fee-paying structure. In the first place, the old and indigent are hardly in a position to compete, in the therapy-purchasing market, with clients who are at their peak of earning capacity. Secondly, the Szaszian market model of free psychiatry assumes that a discrete, specific service – that afforded in the ‘analytic hour’ – is rendered in return for the client’s fee. But intensive, person-to-person analysis is only one of many psychiatric services; one, moreover, which is unlikely to prove useful to the most disabled elderly (who can provide for one another the experience of the ‘student of human living’ that Szasz claims as the special expertise of the analyst).
What old patients in mental difficulties need and want are such services as a supportive residential environment, social stimulation, an easing of such physical burdens as the necessity to cook, help in moving about, and assorted medications which may well be necessary in the psychological as well as in the physical accompaniments of old age. Quite apart from their difficulty in paying for these amenities – an obstacle which could theoretically be by-passed through issuing the aged and other poor vouchers in lieu of money – we have the even greater impediment of supposing that mental patients in a state of emotional distress and lowered attentiveness are going to be able to shop around for a number of psychiatric amenities, picking different items off the shelf of the therapeutic supermart in accordance with their chosen utilities, and presenting themselves to some terminal cashier with a list of purchases which has, through the exercise of a rational-consumer sovereignty, fallen within their available budget.
The market model of medical servicing is, in general, one which fragments the work to be performed along the requirements of a costing system for separate items, whereas the patient’s need is for an integrated structure made up of a number of servicing components. The sick person cannot engage in separate contracts with a physician, an anaesthetist, a nurse, a radiographer, a lab technician and a psychoanalyst. In any case, only a few of the therapeutic trades have any tradition of a fee-paying contractual relationship with the patient: nurses and social workers seem content to be part of the salariat, and their aspiration towards ‘professional’ status does not include any demand for individual-contract methods of payment. The individual chit for services rendered, despatched by one petty-bourgeois to another, is a prerogative claimed only by the more glamorous and status-anxious professionals like doctors and analysts. Thus Szasz’s demand that fee-paying practice be made the cornerstone of the therapeutic relationship can only accentuate the already excessive inequalities between different classes of therapist.
Whatever the bureaucratic disadvantages of a salaried health service, the employment of doctors and other professional helpers by public agencies does at least provide the foundation for a flexible and integrated delivery of the goods. However the workload is arranged – and a much greater variety, with different team structures, target populations and facilities, is possible with public-agency funding than with the individual-contract structure – the public exchequer is there to pick up the tab at the end, up to limits whose extent can be made a matter for social debate and decision. Szasz’s ‘freedom’ amounts to the dissolution of treatment services, atomising the situation of individuals who, whether as therapists or as patients, are already too much atomised.
But then, it is never clear whether Szasz is engaged in a theoretical reconstruction of psychiatric facilities, or in a series of defensive special pleas designed to avoid certain particular barbarities. When we total up all the psychiatric contingencies that he denounces – the evasion of legal responsibility through diagnostic tags, the persecution of homosexuals, and his own central paradigm (in The Myth of Mental Illness) of the hysteric, a type of patient who has lost considerable standing from the days when he or she took pride of place in Freud’s and Breuer’s consulting-rooms and has indeed almost disappeared from the literature – it cannot be said that anything like a comprehensive range of clinical material or psychiatric situations has been given to us. Phobics, depressives, manics, schizophrenics and anxiety-neurotics – in short, the general run of psychiatric patients who, in addition to having ‘life-problems’, do happen to feel distinctly unwell, rarely if ever enter Dr Szasz’s casebook.
In short, despite the voluminousness of Szasz’s work, we remain without any sense either of the complex and concrete reality of personal problems that come to the attention of psychiatrists and psychotherapists, or of the nature of the communications from therapist to patient and back that would comprise a valid and effective mode of treatment. Even in unmasking the hypocrisies of the analyst’s most intimate ideology of treatment – as he does supremely well in his paper on ‘transference’ – he is curiously mute on the type of learning that the analysed client undergoes. We are never told what does count for Szasz as a state of affairs where the patient has learned something rather than merely deluded himself or herself. His distinction between ‘therapy’, which is supposed to be good and libertarian, and ‘treatment’, which is wickedly coercive, remains a purely verbal solution.
All that Szasz’s Contractual Psychiatry does is to state some legalistic ground-rules for a psychiatric ethic; and this, in the absence of some detail as to what therapists are supposed to be up to in practice, can only constitute a pious but empty hope. The issue of coercion in therapy, for instance, cannot be resolved without thorough discussion of that much-recorded process in psychoanalysis whereby the patient displays a filial dependency upon the therapist. The immense authority held by psychoanalysts over their patients affords fantastic opportunities for the unequal exercise of power upon or even against the helpless client. At its crudest, this exploitation may be financial in its consequences, as when the analyst goes on milking customers for years, persuading them that enough ‘progress’ is being made to continue the sessions, while those living nearest to them find their problems as intractable as ever.
Szasz provides neither a convincing paradigm of the psychoanalytic relationship nor even an interior reconstruction of the vicissitudes of the client. His game-playing, behavioural analysis deals only in what the patient does to other people, never in the personal anguish, alienation or stupor which predates the sufferer’s communication with others. Mental illness is a language, but it is also the sick one’s miserable inability to use a language. It is, to be sure, a social status, but, before that, it is a private hell. Szasz attains his role as proxy spokesperson for the rights of the mental patient by ignoring, simply, what it is to be a mental patient.
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