Insanity Defense

The central conceptual error of Szasz's metaphysical perspective is his failure to recognize that the brain and the mind are related, as are structure and function. There exists no mind, and hence no free will, in the absence of an adequately functioning brain. It would be odd indeed if the brain were the only bodily organ that has malfunctions which are fully understood. Yet that is Szasz's position. If one accepts his obviously flawed premise, his argument is as resilient and impermeable as a steel ball. He insists, over and over, that mental illness doesn't exist because he sees no evidence of brain dysfunction in common psychiatric diagnoses such as psychosis or depression.

This sweeping agnosia is unworthy of a man who holds himself out as a professor. He seems not to have looked carefully in the evidential archives. Since the publication of his first book, 46 years ago, there has been an explosion of understanding in the neurosciences. Genetics, brain imagery, neurophysiology, psychology, chemistry, and pharmacology together show this mounting evidence: The brain, like every other organ, may suffer from a wide spectrum of disorders. These may impair the cognitive and emotional functions upon which autonomy depends. While not fully understood, these disorders are nevertheless real and can, in many cases, be ameliorated. That is a fact. It is perverse to deny it. Yet deny it he does.

How, then, can we make sense of this half-century jihad for unfettered individual expression and autonomy? The book's introduction gives us a clue. Szasz informs us that "long before medical school, I suspected that mental illness was a medical fiction." He goes on to say that, by graduation, he had no doubt of it. He sees himself as a modern Voltaire, seeking to erase the infamy of coercion, as best enabled by psychiatry.

This is an example of an overvalued idea, a notion that is neither a delusion nor obsession, and not necessarily wrong in itself but that, for some personal reason, crystallizes as an all-consuming illumination, pushing aside all other considerations and becoming the ruling passion of one's life. A similar familiar example is that of Dr. Jack Kevorkian's advocacy of euthanasia.

This is, of course, the author's right. He may certainly express his autonomy with a lifelong rage against practices of which he disapproves. I doubt that the worst psychiatrist, on his worst day, would deny him the means to express himself thus. But I can express my ideas, too. Thomas Szasz is an enormously erudite and energetic man who has wasted his life on a silly fiction. In doing so, he has brought quite a lot of misinformation into the world, and enhanced the misery of a lot of troubled people.

He's a crank.

William Anderson, M.D., is a lecturer at Harvard and retired psychopharmacologist.