Coercion as Cure

A Critical History of Psychiatry

by Thomas Szasz

Transaction, 336 pp., $34.95

No man is an island .  .  . any man's death diminishes me, because I am involved in mankind," said John Donne.

Not if Thomas Szasz can help it.

The underlying premise of his life's work is that all of us are, or ought to be, islands of individual autonomy and responsible only to our inner lights. This cornerstone supports a moral universe of elegant simplicity: No one should have the right or capacity to coerce anyone else.

Yet civilization requires that certain actions must be encouraged and others must be prevented. This is accomplished, all else failing, by coercion. To deny this is idle dreaming, an adolescent fantasy of anarchic Arcadia. Yet that is the world in which Dr. Szasz insists we should live.

For Szasz, professor emeritus of psychiatry, individual freedom and autonomy are not the most important values; they are the only values. This concept generates a morality with curious properties: There is no room for the possibility that autonomy may be compromised by illness, that such illness may be treated, and autonomy thus restored. There is also no room for brotherly love, charity, or assistance to those who may be impaired. The practice of psychiatry, he insists, represents the chief obstruction to the realization of his goal. Its practitioners are the shock troops of societal oppression. They are motivated by hubris, venality, folly--or perhaps simply malice.

Early in the 20th century, it should be noted, his concern about coercion was not entirely wrong. There were cases in which families, psychiatrists, and judges colluded to rusticate an embarrassing wayward scion, sometimes with tragic results. Since then there has been a societal trajectory toward recognition of individual rights. But perhaps this is now in danger of being overdone.

By my count, this is the 30th book by Szasz that argues this central theme. Since the publication of The Myth of Mental Illness (1961), he has tilted at the windmill of psychiatry, and not without a measure of success. This current incarnation of the polemic contains many familiar elements, but is organized around what he purports to be a "critical" history. And in a way, it is--if, by history, one means a catalogue of every ugly, stupid, evil thing that a profession may have allowed for the past 300 years, and which omits any activity that might have had some positive value. Psychiatry, no doubt, has its complement of knaves, fools, and mountebanks, but that is not the whole story.

Thus, the third sentence of Chapter One: Incarcerating people is what psychiatrists do. No, it isn't. Psychiatrists try to apply scientific medicine in the service of ameliorating disturbances of thinking, feeling, and action brought about by disturbances of brain function. Given a highly imperfect understanding of how the brain works, this is not an easy thing to do. Results are often less than satisfactory. Yet the alternative is to do nothing, and that is often worse.

Courts of law, however, do incarcerate people. Occasionally, they consider psychiatric opinion in their decision. Courts do this not to indulge a malicious desire to suppress autonomy, but to protect the public order and provide an alternative to tribal warfare. Courts also make errors, and yet we mostly agree that we need them.

Fifteen years ago, Larry Hogue was a well-known citizen who inhabited the streets of Manhattan. He had a proclivity toward the use of alcohol and cocaine as well as other eccentricities of brain function. He expressed his autonomy by breaking windows, assaulting passersby, and, most notoriously, by pushing a young girl in front of moving truck. (She was unhurt.) After seemingly endless wrangling, he was finally hospitalized involuntarily for psychiatric evaluation. Omitting the facts of the case, Szasz describes this episode as an example of oppression of a man who had "annoyed the city's mental health authorities." This is dishonest.

Jane, my friend of 30 years, died recently by her own hand. She was attractive, intelligent, energetic, and funny. She was a graduate of an Ivy college and medical school, with training in two specialties from teaching hospitals of the first rank. In her 58th year, she lost interest in work, became consumed with guilt over imaginary misdeeds, and progressively lost the ability to eat or sleep. She accepted hospital admission, and a first-rate psychiatrist began to treat her. But her illness was such that she declined to continue her treatment. The laws of the state in which she lived, informed by the principles of Thomas Szasz, insisted on what was, for her, a lethal dose of autonomy.

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.

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