No One Cares About Crazy People

by Ron Powers

  The third wave, its crest ridden by myopic politicians and cynical bureaucrats, achieved a bungled liberation of the mentally ill. It sent hundreds of thousands of patients streaming from the imperfect custody of state-run asylums and into the fickle mercies of the nation at large with wonder-drug prescriptions in their pockets and purses, on the complacent assumption that small care centers and the new meds would make everything just fine. The small care centers and the new meds didn’t. Instead, and counter to the American myth of “progress,” the three waves combined to touch off more than a half-century of crisis in American mental health care, a crisis unimaginable even in the dark days of lobotomy and genetic experimentation.

  The first wave stepped off a steamship in Hoboken, New Jersey, in 1938, with his brother at his side.

  Thomas Szasz was one among a scattering of Eastern European Jews who had managed to get out of Hungary ahead of the Nazi Wehrmacht and the eruption of World War II. Adolf Hitler’s regime was just then pulling tiny Hungary into an alliance with the Axis powers. In 1944 the Nazis would violate this alliance via occupation. German soldiers rounded up some 440,000 Jews and sent them away on trains—most of them to Auschwitz, the remainder to dig trenches on the Austrian border.

  Hungary was trapped in a pincers of totalitarianism—a fact that left an imprint on the mind of Thomas Szasz. To its northeast, on the far side of Ukraine, sprawled the vast Soviet Union. And indeed, following its liberation from the Nazis, Hungary suffered occupations by the Russians in 1949 and again in 1956, when the Red Army invaded to crush a revolution. The last Soviet troops left in 1991.

  Neither Thomas nor his brother George spoke English when they disembarked at Hoboken. Each was small and lean, with wavy hair, a high forehead, and an air of continental assurance. Their father, Julius, a lawyer and businessman, had secured emigration visas for the family. Julius and his wife, Livy, would shortly join their sons in exile. The family would make its way to Cincinnati, Ohio, where the boys’ expatriate uncle Otto was a research professor in mathematics at the University of Cincinnati. George Szasz would attain a PhD in chemistry at the university and live a quietly productive life.

  Thomas Szasz taught English to himself in less than a year. He mastered the new and complex language to such a high degree of sophistication and nuance—and occasional sophistry—that intellectuals who had been speaking English all their lives would, in later and more contentious years, shy from engaging him in debate. He read deeply into European and American history, philosophy, psychology, medicine, religion, political science, literature, and linguistics. He remembered what he’d read. He took a degree in physics at the University of Cincinnati and graduated from the medical school in 1944. In his spare time, he refined his grander ambitions until they comprised what would become an assault on American psychiatry and the very notion of mental illness. Thomas Szasz saw in psychiatry the same coercive will to power that fueled the annihilating threats to his native country. He planned to expose its adherents, from Sigmund Freud onward, as mere poseurs—as profit-driven opportunists at best, and, at worst, as para-agents of a governmental state bent on shrinking the civil liberties of its citizens. He intended to mock and proselytize the field of psychiatry out of existence.

  Szasz earned a diploma at the Chicago Institute for Psychoanalysis in 1950, at age twenty-nine, and joined its staff. He enlisted in the Navy and was assigned as a psychiatrist at the US Naval Hospital in Bethesda, Maryland, where he found himself repelled by “the dehumanized language of psychiatry and psychoanalysis,” as he told his close friend and acolyte, the psychologist Jeffrey Schaler. He took a position as a professor of psychiatry at the Upstate Medical Center of the State University of New York in Syracuse, where he remained until he retired in 1990. He taught psychiatry, he told Schaler, as an atheist might teach theology.

  Szasz was to churn out thirty-five books before his death in 2012 at age ninety-two, but none matched the bombastic influence of The Myth of Mental Illness, published in 1961. The book, which nearly cost him his tenured position at Syracuse, declared that what people called “mental illness” was simply a range of behavioral choices that others found annoying or threatening. Mental illness was the stuff of metaphor, given that “the mind” was itself a metaphor. Therapeutic psychiatry was nothing more than “an arm of the coercive apparatus of the state.”1

  He challenged the very psychomedical establishment—just then emerging from the dark ages of asylums, lobotomies, and the wholesale application of electroshock therapy—and avowed that “all of medicine threatens to become transformed from personal therapy into political tyranny.”2 Hospitalizing a person in the midst of psychosis against his or her will, said Szasz, was a gross violation of civil and human rights, and amounted to a crime against humanity. In fact, it was worse than that: “Involuntary mental hospitalization is like slavery. Refining the standards for commitment is like prettifying the slave plantation. The problem is not how to improve commitment, but how to abolish it.” Ditto for medicating a psychotic patient without consent. Hysteria (an important early subject of Freud’s interest) was for Szasz hardly a symptom of madness; it was merely a form of communication, a “non-discursive language,” and need not be diagnosed. The unconscious, a cornerstone of Freud’s great fame, did not exist: Freud and his disciples invented it as a metaphoric explanation for why people could not remember traumatic events in their lives. Nor did the United States government have a right to prohibit illegal drugs, according to Szasz. It was prescription “psychotropic” medications that needed banishing; as Szasz expounded in a later book, The Medicalization of Everyday Life, “The dogmatic view that mental diseases are brain diseases, treatable with chemicals, dehumanizes the… patients.”

  Regardless of our evaluation of Szasz’s assertions—and evaluations have been legion, both pro and con—it remains impossible to dismiss them, even nearly sixty years after they first appeared. In spite of the persistence of the mental illness establishment and the evidence that people get depressed or manic or suffer delusions and cannot connect with others in a consistent and loving way, Szasz’s indictments of psychiatry and of the definitions of mental illness have knocked over pillar after pillar of received truth, as well as some pillars of actual truth. They have worked their way into public policy and into the fabric of mental health opinion and mental health care debate. A United States Supreme Court decision in 1975 established that involuntary hospitalization and treatment violate an individual’s civil rights. It now generally requires a court order—and a waiting period of days or weeks, and sometimes months—before doctors can enforce the treatment of a patient in psychosis who resists receiving care. As recently as the summer of 2015, the governor of Texas vetoed a bill passed with bipartisan support that would have allowed hospitals to detain a patient in psychosis for a brief period, until law enforcement officers could arrive and determine whether the patient was a danger to himself or others. The governor acted on the advice of several lobbying groups dedicated to the conviction that mental illness does not exist, and he explained that his veto was an effort to protect patients’ civil liberties.

  The most powerful group among the advisers was the Citizens Commission on Human Rights (CCHR), formed in 1969 by Szasz and L. Ron Hubbard, another mental illness denier and the founder of the Church of Scientology. Hubbard was a science-fiction writer and a believer that when human beings die, flying saucers transport them to Venus, where the locals retool them like so many extraterrestrial Mr. Goodwrenches and send them packing back to earth, where they are dumped into the Pacific Ocean, wading ashore on the California coast to go looking for new human bodies. Hubbard’s theory has yet to undergo peer review so far as it is known, but if it is true, it might explain a few things about Californians.

  In the 1950s and 1960s, Szasz’s ideas gave form and substance to a crystallizing “antipsychiatry” movement, a loose yet enduring affiliation of citizen groups in every state dedicated to the abolition of involuntary mental he
alth care. CCHR quickly formed international branches as well as associations. These groups included many former and current schizophrenia patients who found in Szasz a rare voice that explained to the world how they felt about themselves and the crushing diagnoses imposed upon them. Small in absolute numbers, over the last fifty years these groups have been highly effective in legislative hearings around bills such as the Texas measure—and often influence their outcome.

  Besides promising to curb the “abuse” of psychiatric patients and offer them “consumer protection,” the CCHR in recent years has pushed the claim that a category of high-selling “second-generation” psychotropic drugs—such as Abilify, Risperdal, and Zyprexa, all marketed for the treatment of schizophrenia and bipolar disorder—is partly responsible for the depravities of school shooters, mass murderers, and terrorists. Rather than ameliorating the symptoms of mental patients who might become violent, these drugs impel people into violent acts—at least according to the latest generation of Szasz’s acolytes. This position, to say the least, seems inconsistent with the Szaszian notion that mind-altering drugs of other sorts—hallucinogens, for example—should be freely available to everyone. But then, Thomas Szasz was an elusive thinker.

  Much of the support for the antipsychiatry movement has come from people who have been themselves diagnosed with schizophrenia—or who have not been diagnosed but might have symptoms of the disease—and found in the movement a ratification of their own beliefs, which had previously been hard for them to articulate. They got further reinforcement from disaffected members of the psychiatric profession, such as the charismatic New Age Scotsman R. D. Laing, who had been a psychiatrist in the British army when he developed a fascination for talking with disturbed patients. This led him to a philosophy expressed in his most famous work, The Divided Self, written when he was thirty and published in 1960, just a year before Szasz’s Myth of Mental Illness. Laing famously proclaimed that what society calls psychosis is in fact a bursting-free from the “false self” that individuals construct in order to survive under the world’s coercive, repressive norms. He had a gift for provocative, often gnomic aphorisms (“Insanity: a perfectly rational adjustment to an insane world”; “Life is a sexually transmitted disease, and the mortality rate is one hundred percent”).

  As the 1960s progressed, a coalescing counterculture greeted Laing’s emergence with unquestioning glee; it is possible that had he not been swept up in the adulation, his supple intellect might have produced deeper, more profound works. Young refugees from the 1950s avid for any ideas that attacked settled wisdom and authority also lionized the French philosopher and “militant intellectual” Michel Foucault. Foucault had already published Madness and Civilization, which challenged the social construction of madness and posited “rationality” as a pretext for confining and punishing undesirable people.

  It was soon clear that Szasz had drilled into a gusher. Though his early groundswell of endorsements came mostly from the ideological left, Szasz himself was anything but a bleeding heart. “I’m as far right as you can go,” he remarked. He dismissed Laing as “a preacher of and for the soft underbelly of the New Left.” Before his death, Szasz had supplanted Karl Menninger, the Kansas-born doctor who had Americanized psychiatry in the 1950s and made it safe for the home folks, as the most famous psychiatrist in the world.

  Szasz was perfectly equipped to spearhead a one-man revolt against the orthodoxies of psychiatry, which by the 1950s (and in spite of much American suspicion that it was either pointy-headed European hogwash or just an excuse for having as much sex as you want) had finally struggled to the legitimacy and status—and power—that it had craved since Freud’s visit to the United States in 1909. Psychiatry’s prestige was never quite the same after Szasz’s insurrection. “Mental illness” never again went unchallenged as an explanation for human behavior.

  A solicitous friend to those in his circle, scrupulous and polite in responding to readers who wrote to him, Szasz transformed himself into a stinging force of nature in debate or at the keys of a typewriter. No barrage of argumentation could sway him from his adamantly crafted line of reasoning, which again and again equated efforts to reach people in psychosis, particularly government-supported efforts, with the menace of state-sponsored coercion.

  He had a whimsical side, and he enjoyed constructing aphorisms, as did Laing. Szasz’s were deadlier. “If you talk to God, you are praying. If God talks to you, you have schizophrenia,” he famously quipped. And, “Formerly, when religion was strong and science weak, men mistook magic for medicine; now, when science is strong and religion weak, men mistake medicine for magic.”

  Szasz’s analogies were equally caustic, and effective. He used analogy in ways that too often substituted for proof. He likened psychiatry to alchemy and astrology. The Inquisition was to heresy as psychiatry is to mental illness. Therapeutism recapitulates paternalism. Psychiatry is medicalization. Psychoanalysis is medicalization squared.

  And then there was his reliance on pronunciamento: the flat assertion, delivered without expectation of rebuttal, and usually without substantiation, that

  suicide is a fundamental human right. This does not mean that it is desirable. It only means that society does not have the moral right to interfere, by force, with a person’s decision to commit this act. The result is a far-reaching infantilization and dehumanization of the suicidal person.

  And: “Psychiatry is probably the single most destructive force that has affected the society within the last sixty years.” World War II apparently had slipped his mind.

  And, most descriptively of his abiding philosophy:

  The more aggressively I reminded psychiatrists that individuals incarcerated in mental hospitals are deprived of liberty, the more zealously they insisted that “mental illnesses are like other illnesses” and that psychiatric institutions are bona fide medical hospitals. The psychiatric establishment’s defense of coercions and excuses thus reinforced my argument about the metaphorical nature of mental illness and importance of the distinction between coerced and consensual psychiatry.3

  Declarations such as these carry the whiff of absolutism, a hallmark of the same totalitarian political regimes that Szasz abhorred—and apparently feared might prevail in the United States. His untiring attacks on psychiatry—books, papers, lectures—are peppered with phrases and terms such as “coercive” (a favorite), “violent,” “wicked” (to describe the aims of the medical ethicist Peter Singer, for instance), “agents of the state” (to describe medical doctors), and “therapeutic ideology,” which seems to imply that Szasz himself was a neutral broker, not beholden to ideology. He was beholden, and the ideology was libertarian.

  His adherents worshipped him, and the surviving ones still do. Jeffrey Schaler, a gray-bearded, burly, and soulful man, a psychologist and teacher himself, has spent the last thirty-odd years of his life upholding his mentor’s ideas in talks, books, and websites. If Szasz were Don Quixote, the gentle Schaler was his Sancho Panza.

  For Schaler and others, qualifying one’s understanding of Szasz, or merely attempting to explain him, seems always to require a line of reasoning that can strike the layperson as convoluted. “Thomas Szasz is not opposed to psychiatry,” Schaler has said. “He is opposed to what is done to people in the name of psychiatry. He has always differentiated between crazy persons and those labeled by psychiatrists and politicians as ‘mentally ill.’ He does not deny that people do very strange things for even stranger reasons: He refutes that people do strange things because they are sick. He denies they lack free will.”4 This statement starts off on solid ground—Szasz is opposed to what is done to people in the name of psychiatry—but then veers into the marshlands of vagueness, seeming self-contradiction, and unanswered questions. What, exactly, is a “crazy person” if mental illness does not exist? What are some of those “stranger reasons” for strange behavior? And why do those “stranger reasons” categorically exclude “sickness”? And why is “free will”
an issue if the psychotic person, by her own compass, is acting in free will?

  Or consider this statement by another of Szasz’s adherents:

  Many psychiatrists to this day believe that Szasz denies that mental illness exists and even denies that mental suffering and disturbance exist. On the contrary, Szasz does not deny the existence of suffering. How foolish for anyone to think so. Szasz acknowledges the existence of mental illness, but differs from the conventional view of it. The critical point is that mental illness is not a disease that exists in people, as pneumonia exists in lung tissue. Mental illness is, rather, a name, a label, a socially useful fiction, which is ascribed to certain people who suffer or whose behavior is disturbing to themselves or others.5

  So, Szasz “acknowledges the existence of mental illness,” but only as “a socially useful fiction.” That seems a long way from acknowledging “the existence of mental illness” but simply differing “from the conventional view of it.” If certain people “suffer,” and they’re not suffering from insanity, then what are they suffering from?

  Early in his career, Szasz relied heavily on his “lesion” argument for discrediting attacks: while illness and injuries left their traces on or in the body—scars, organ enlargement or shrinkage, cysts, blindness, and so forth—no such irregularities could be ascribed to so-called “mental illness,” despite Emil Kraepelin’s and Eugen Bleuler’s visionary predictions from a century earlier. This was because, for Szasz, mental illness was a metaphor, and an illegitimate one at that. As for lesions in the brain—well, that was called “brain injury,” and was in the province of neurosurgery, not “mind-healers.”

  But from the 1980s onward, a series of dramatic advances—various types of magnetic resonance imaging (the MRI scan); positron-emission tomography (the PET scan); and computerized axial tomography (the CAT scan)—did make it possible for researchers to identify, in living human bodies, such persuasive lesion evidence as enlarged ventricles in the brains of schizophrenic patients. As Paul Harrison, professor of psychiatry, editor, writer, and head of the Translational Neurobiology Group at the University of Oxford, wrote in 2015: