by Ron Powers
Despite the many controversies and contradictions, there are now established facts about the neuropathology of schizophrenia. The disorder is associated with ventricular enlargement and decreased cortical volume. The pathology is neither focal nor uniform, being most convincingly demonstrated in the hippocampus, prefrontal cortex and dorsal thalamus. The pattern of abnormalities is suggestive of a disturbance of connectivity within and between these regions, most likely originating during brain development.6
A trio of researchers at the Harvard Medical School reported in 2010:
Between 1984 and the present there has been a burgeoning of MRI studies in schizophrenia. Further, during this 26-year time period there are more definitive findings with respect to brain abnormalities in schizophrenia than have been documented in any previous time period in the history of schizophrenia research.7
So, did the advent of brain-scanning technology and its findings move Szasz to concede that schizophrenia lesions did in fact exist—and thus, so did mental illness? Not really. “The evidence is not scientifically compelling,” he insisted late in his life. “And if it were, then these patients should be described as having brain diseases, not ‘mental illnesses,’ and should be treated accordingly. Neurologists don’t accept the ‘mental illness’ model”—though they do, as Harrison and the others quoted above affirm, by their use of the very term “schizophrenia”—“so psychiatrists try to invent ‘neuropsychiatry.’ Most of the brain correlates of psychopathology are descriptive, not explanatory, and give no evidence of causation. There is also much inconsistency entailing false positives and false negatives.”
Among the most unsparing critics of Szasz has been Rael Jean Isaac, who herself has written for many libertarian publications and a number of books both supportive and critical of libertarian ideas. Writing several days after the psychiatrist’s death, Isaac rebuked Szasz’s contributions with cold-eyed clarity: “Szasz serves as a powerful testament to the proposition that ideas have consequences—and that terrible ideas, no matter how demonstrably false and even absurd, can not only survive, but shape our institutions, in the process doing untold damage to human lives and the social fabric.”8
But what if Isaac and every other detractor has been misinterpreting Szasz? And what if that universal misinterpretation has been a key to his extraordinary legacy?
The American literary critic Alfred Kazin once wrote of Ralph Waldo Emerson that he “was always to have a positive effect on people who did not know what he was talking about.”9 Change the word positive to powerful, and you just might have Thomas Szasz. As one reads through the voluminous inventory of Szaszian criticism, it can begin to seem that no one understood him—not his detractors, and not his admirers. It can further seem that this very opacity of his fed a great deal of the intellectual clashes over his work.
History has certainly provided other examples of how people can project their own meanings onto abstruse texts. Reading his works, I sometimes felt that Szasz was attacking not psychiatry, or even “mental illness,” so much as he was attacking language itself. Viewed from this angle, Szasz might have had less in common with the diagnostics of mental illness than he did with the approaching era (roughly, the 1980s) of post-structuralism and deconstructionism.*
Szasz himself made several statements during his career that seem to bear this out. He offered a couple of them early on, as brief asides, in his introduction to The Myth of Mental Illness:
A psychiatry based on and using the methods of communication analysis has actually much in common with the disciplines concerned with the study of languages and communicative behavior, such as symbolic logic, semiotics [the science of signs], semantics, and philosophy.
And, even more explicitly:
My writings form no part of either psychiatry or antipsychiatry, and belong to neither. They belong to conceptual analysis, social-political criticism, civil liberties, and common sense.10
What comfort is this, then, to the countless sufferers of mental illness, most of whom in the acute stages of their disorder are demonstrably bereft of self-awareness and self-control, who have been left to survive as best they can on their own, their symptoms untreated and their blurry impulses unchecked by the courts, hospitals, psychiatrists, or law enforcement officers? What of the lengthening list of sufferers who have been shot dead by officers who saw their movements as threatening and had no training in the restraint of people in psychosis—in part because such training has been deemed unnecessary, given that “psychosis” is a “myth”?
Szasz’s impact was well and bitterly recognized by those in the profession he despised. Lawrence Hartmann, a former president of the American Psychiatric Association, remarked in 1992, after Szasz’s retirement: “He gave patients the opportunity to deny they were sick, and he gave legislators the opportunity to deny they were responsible.”11 And writing in 2001, the psychiatric researcher and author E. Fuller Torrey declared:
The major reason… why increasing insanity became a non-issue in the latter half of the twentieth century was the emergence of historical theories that appeared to negate it. If there had been any hope of seriously examining the question of epidemic insanity, that hope died in 1961 with the publication of three books: Michel Foucault’s… Madness and Civilization, Thomas Szasz’s The Myth of Mental Illness, and Erving Goffman’s Asylums.12
It is true enough (as we have seen, and will see again) that the mental institutions of Szasz’s early career—and many throughout his life—were hardly the answer to the care of the mentally ill, shot through as they were with filth, neglect, starvation, ignorance, and outright sadism. No one, not even Szasz himself, drove these truthful images into the nation’s perception as forcefully as did a novel published a year after The Myth of Mental Illness and the movie adaptation of it that followed thirteen years later.
One Flew Over the Cuckoo’s Nest, Ken Kesey’s scathing novel of sadistic abuse and brutalization inside an Oregon insane asylum, became an international best seller when it appeared in 1962. (Kesey had not read The Myth of Mental Illness before writing his novel, but he and Szasz later corresponded with mutual admiration.) The book’s effect grew exponentially with the film version released in 1975, in which Jack Nicholson gave a virtuoso performance as “Mac” McMurphy, an inmate who throws himself between his fellow patients and the totalitarian cruelty of Nurse Ratched, played by Louise Fletcher. One Flew Over the Cuckoo’s Nest swept the major Academy Awards, winning Best Picture, Best Director (Milos Forman), Best Actor, Best Actress, and Best Adapted Screenplay—only the third American film ever to claim that array of awards.
Thus the potent cocktail of Szasz’s denunciatory book, Forman’s cinematic fireworks display, and the fiery antiauthoritarian mood of the culture in general succeeded in damning psychiatry to a hell from which it has never entirely emerged. The new antipsychiatry movement also powerfully reinforced the conviction held, especially but not exclusively by the political right, that imposing medications or restraints on anyone going through a psychotic episode was a categorical violation of civil rights.
And now consider the story of a couple I know personally, Livy and Frank McClellan and their son Martin, a rare victim of pediatric, or “child-onset,” schizophrenia. (I have changed their names, and I have not met Martin.)
Livy is a slim, handsome woman in her sixties who wears her graying red hair piled atop her head. Three decades of virtually nonstop anxiety over her son have given her a hyperintense manner. She speaks rapidly yet in perfectly formed sentences. Her husband, Frank, a husky businessman, is agreeable and more laid back, yet clearly depleted by the recurring crises surrounding Martin since his childhood.
Martin, who turned thirty-one the summer of 2016, is a walking casebook of nearly everything that can go wrong for a person with schizophrenia in this country. Since childhood, Martin has suffered from the failure of child psychiatrists to recognize certain subtle but critical symptoms in early-phase schizophrenia; the rigidities of a misgui
ded legal system; the helplessness of legally and financially compromised care systems on the level of the US state; the catch-22 legal idiocy that prevents people from receiving medical care until they become “an imminent danger” to themselves or others (a condition they frequently demonstrate via actualizing some imminent danger or another); prolonged waits for treatment in hospitals without medication; and, ultimately, being prosecuted as a criminal. Any of these blows would be enough to aggravate, rather than heal, the cruelty of schizophrenia itself. In their aggregate, these systemic failures embody the continuing, jumbled, post-Szaszian atrocity that our society calls “mental health care.”
As is the case with countless parents of children with schizophrenia, Livy’s life in many ways has merged with Martin’s. Her waking and sleeping hours, often jumbled together, are filled with thoughts for his safety and fears of his possible actions, with accompanying visits to courtrooms and hospitals, legal advocacy at various hearings, and her volunteer work for the National Alliance on Mental Illness.
None of Livy’s efforts on behalf of her son have produced improvement in Martin’s condition beyond the medical prescriptions she and his inpatient psychiatrists have wrung from hospitals in the state, which Martin can be convinced to take only sporadically, and the safe harbor she and Frank have created for him, thanks to a small apartment on the farmhouse grounds. His future remains devoid of much possibility beyond just existing.
Yet Livy’s efforts have produced results in one respect: they have made her enemies. Because of her intensity and her untiring advocacy, Livy has often felt the sting of harsh criticism and vituperation from people associated with antipsychiatry, and the pointed, supercilious indifference of most state political figures from whom she has sought help for her son and others with mental illness.
“Martin’s signs and symptoms, in retrospect, became manifest in his early childhood,” Livy told me on one of my visits to the McClellan house. “He showed physical aggression toward other children by age one. He’d hit them for no reason—though he was never spanked or hit by either of us.” The young child was irritable; worse, he progressively lost empathy toward other people. (However, he was uncommonly tender toward animals and even insects.) He grew paranoid, blaming others for his problems and things that went wrong. “For example, if he couldn’t find something, he’d say that another family member took it,” Livy said. “By mid–elementary school he thought teachers and other children and family were trying to harm him. He was verbally hostile and unkind to others, including my mother. He called her a murderer when she killed an ant.”
Terrifyingly for his parents, the child developed what his mother at first called “the Evil Eye.” (When she and Frank came to understand his affliction, Livy changed that designation to “the Stare.”) She later learned that such a gaze is a common symptom for those with schizophrenia. From around age six on, Martin rarely seemed happy. In the years leading up to his eighteenth birthday, he was verbally fluent, “but he would rant on and on, often not making sense, and usually angry and hostile.” He hated loud noise and the scratch of tags on shirt collars. He could not perceive extreme cold, and he went outside in winter without a coat or gloves. He slept through the day and was active at night.
When Martin began exhibiting these reactions and behaviors, Livy took him to a child psychiatrist and recounted his symptoms to her. The woman listened, then asked Martin’s mother whether her son had reported hallucinations. When Livy said no, the doctor concluded that he was not schizophrenic. Livy’s next visit was to a child psychologist, who agreed that “something is terribly wrong,” and wondered about Asperger’s syndrome, an autism-spectrum disorder that afflicts children. This consultant tried to get the first psychiatrist to see Martin again, but she refused, insisting he did not need to see a psychiatrist.
Livy took it upon herself to add a working knowledge of schizophrenia to her already thorough physician’s education. She believes that her son was negligently or at least imperfectly diagnosed for many crucial years. On his eighteenth birthday, Martin suffered a severe psychotic break and entered the early stages of catatonia. The irony was that this birthday established Martin as a legal adult. Thus, on the same day he finally showed irrefutable evidence that he was in dire need of treatment, he gained the legal status to decide whether anything should be done about it, from medications to a hospital stay for treatment. Martin predictably ruled out each option.
“There is no flexibility in the system whatsoever,” Livy said. “The eighteenth birthday is seen as a definitive line of demarcation between a child brain and an adult brain. This cutoff was intended, I suspect, to allow for the drafting of males” into the military, “as soon as they are of full adult physical stature regardless of mental development. We could not get him appropriate medical care until he became ‘an imminent danger,’” Livy repeated bitterly. “By the time he proved it, he’d been psychotic for about three years at a minimum. There is evidence that duration of untreated psychosis [DUP] does have a bad effect on long-term outcomes.” To risk oversimplification, the schizophrenia entrenches itself ever more deeply.
“So Martin is an example of how care is in essence denied for years to someone so brain-diseased they don’t even know they’re diseased—denied for years under the guise of ‘civil liberties.’” Livy paused to take a deep breath before continuing, “Our system has failed to face the fact that when schizophrenia has done this to a person’s brain, it has already robbed him of that liberty. Our society needs more adult professionals to help these people, and protect them, not let them roam ‘free’ until they are jailed for their behavior.”
Martin’s catatonia was contained, but he was far from healed. In 2006, at age twenty, his mother said, the affliction caused him to commit crimes, including felonies. “He broke through glass into the office of a former employer and did thousands of dollars of damage,” Livy said. “Then he left, bleeding from several lacerations, and tried to hijack a car by trying to strangle the driver, who mercifully escaped. I think this was during an ‘excited’ phase of his catatonic state.”
Police arrested Martin and transported him to the emergency room at a nearby hospital that was associated with a medical school. At first he was combative, but shortly he fell into a catatonic stupor. When he regained consciousness after a few hours, he could barely speak or move. His parents gave him water and he was put in a wheelchair and transferred to the local jail without treatment. Livy called the jail several times and provided the relevant medical history. Only when he attacked a guard did the jail transfer him to the state psychiatric hospital. After several criminal hearings, which added to Martin’s psychic agonies, Livy was able to find a private lawyer who convinced the prosecutor that because of his insanity, Martin was not guilty of the charges leveled against him.
The lawyer was able to keep Livy’s son out of jail. But nothing, Livy feels, could undo the damage to his brain that resulted from his long stretches without medication. “The literature indicating that there can be toxic effects of protracted untreated psychosis on the brain concerns me,” Livy said.* “For the most part Martin has barely been able to mutter for years. He cannot advocate for himself. We must do that for him.” Martin has been hospitalized seventeen times as of this writing. In several of those admissions, he waited from sixty to eighty-eight days for involuntary treatment. The hospitalization that started with the eighty-eight-day wait lasted a year and a half.
To judge from Livy’s account, the network of courts, psychiatric hospitals, and law enforcement agencies that dealt with her son has done its collective best to keep Martin in full possession of his rights since his affliction was first diagnosed. Livy and Frank live with the galling belief that their son’s protracted suffering, and worsening condition, is due in part to a court system that for decades has been buffeted by the conflicting claims of psychiatric professionals on the one hand and, on the other, the hypervigilant mental health deniers and civil libertarians who often seem
more concerned with sustaining an ideology than with relieving the suffering of those in psychosis.
Martin remained mired in a catatonic state for several months, enjoying his rights somewhere in the deep woods around his rural home. His physician mother fears that he is approaching malignant, or lethal, catatonia.
Thomas Szasz’s personal life and relationships, while undoubtedly circumspect, are generally not discussed by surviving friends. It is easy to assume that he scarcely had a private life apart from his writing, teaching, talks, debates, and interviews.
In 1951 he had married a Lebanese woman named Rosine Loshkajan, whom he mentioned once in his autobiographical writings. She bore him two daughters. Szasz and Rosine were divorced in 1970. Rosine died by suicide in a motel the following year. Schaler believes that it was Szasz’s skyrocketing notoriety that “pushed Rosine over the edge.”
Thomas Szasz died in 2012 after a fall down a staircase. The coroner ruled it a result of a severe injury to his spine. The direct cause of his death, according to the Kaddish delivered by Jeffrey Schaler, was suicide.
12
Surcease
The prodromal stage of Dean’s schizophrenia, I believe, was triggered by the sustained trauma of the accident and the pressures he absorbed in its brutal aftermath. Prodromal investigation has a relatively short history in studies of chronic mental illness, dating for the most part to the early 1990s. Prodrome is from the Greek meaning “running ahead of”; and in neuroscience it bespeaks a shift from focusing exclusively on a cure for schizophrenia—still a hope, yet far from imminent—and toward identifying the early, “subclinical” behavioral signs that psychotic illness lies in a person’s future. This identification could lead to early intervention in the disease’s progress toward “frank” psychosis and a lessening of the patient’s lifelong struggles. As a paper published in 2010 by the National Center for Biotechnology Information explained: