Thomas Szasz died on September 8, 2012. For over 50 years, he argued against the ever-increasing medicalization of everyday problems. His argument was simple, yet often misunderstood. Because minds (unlike brains) are not physical, they cannot suffer from diseases in any literal sense. Thus, when people talk of “mental” illnesses, they are using language metaphorically (Szasz, 1974). Illnesses, in Szasz’s view, are limited to dysfunctions or breakdowns of the body.
Of course, the language of illness is powerful. It often provides a compelling way to express concern about how others are living their lives. When we disapprove of other people’s behavior, we simultaneously explain and negate their actions by attributing them to illness: “They did what? Wow, that’s sick!” Somewhere along the way, people shifted from seeing such exclamations as declarations of disapproval and started literally believing that those they called sick actually were. Hence, the medicalization of everyday life began.
Simply give a problem a proper name and—presto!—it becomes a recognized illness. As a result, it is now common practice to transform most every problem that people experience into a disorder. Sad people have major depressive disorder; angry people, oppositional defiant disorder; distractible people, ADHD; those who have a hard time after experiencing the horrors of war, PTSD; and so on. Of course, Szasz acknowledged that those with so-called disorders experience genuine difficulties and deserve empathy. He just did not see why this necessarily meant they were diseased. Life is hard, and sometimes people struggle to deal with it. This makes them human, not sick.
Importantly, Szasz wasn’t merely interested in these issues from a detached intellectual perspective. He was concerned about the real-world implications of pathologizing everyday conflicts and behaviors. As the title of one of his books said, ideas have consequences (Szasz, 1987). Once we call a person ill, it is easy to justify intervening—even when the person rejects our attempts to help. This is true in cases where what we label as illness doesn’t seem to affect psychological functioning, but becomes even more relevant when it does. After all, if a person is so psychologically confused that he or she cannot “think straight,” it only makes sense for others to jump in and take charge. Yet, there is a danger in this, which Szasz wisely saw. As the old saying goes, the road to hell is often paved with good intentions.
Sometimes what we see as benevolent help is experienced as paternalistic and intrusive. Involuntary treatment runs the risk of having mental health professionals impose their ideas of what is normal on others (Szasz, 1963). Though many patients have been helped by psychiatric interventions, there is no shortage of instances where the psychiatric establishment merely reflected the biases of the wider society. This is why homosexuality was once considered a mental disorder. Only in hindsight can we see that “curing” it was not about treating illness, but imposing a particular moral worldview. How confident are we that at least some of our current treatment efforts won’t one day be viewed similarly?
Unfortunately, Szasz’s position was often misinterpreted. He was castigated for being unsympathetic to the plight of the mentally ill. He was told he was backward and unscientific in rejecting the exclusively biological perspective of modern psychiatry, a perspective in which almost all human problems are assumed to be reducible to defective brain processes. He was even accused of being mentally ill himself—an unintended illustration of his own point that calling those who disagree with us sick makes it easier to dismiss and demean them. The unfortunate result of this is that Szasz grew angrier and more bellicose over the years in how he expressed his opinions. People began to respond to not just his positions, but his style of argument. This allowed his adversaries—those who had mocked him as uncaring and possibly crazy for challenging the fundamental assumptions of his profession—to win the public opinion battle over who was most sympathetic to the plight of psychiatric patients.
The irony is that Szasz cared deeply about those diagnosed as mentally ill. He wanted to make sure that, in our haste to benevolently intervene to protect them from themselves, we did not mistreat them. He wanted to make clear that the vast majority of problems dubbed mental illness are not best construed as illnesses at all, but as complicated human problems that lead to unhappiness and suffering. He wanted us to be more humble. Instead of asserting that particular problems people have are inarguably brain diseases and nothing but brain diseases, he urged us to acknowledge that even diagnoses that we suspect of having a biological component—schizophrenia and manic depression, for example—are, at this point, only putative brain diseases (Szasz, 1987). That is, we suspect biological underpinnings, but because we currently can’t diagnose these disorders using biological markers, good science demands that we be honest about the limits of our understanding. Humility requires acknowledgement that we still diagnose “mental disorders” based on how people act. While brain researchers have some promising leads, the schizophrenias remain putative, rather than proven, illnesses. If we admit this, then it becomes incumbent upon us to be careful in how we treat those so diagnosed. The disruptions they cause—the extent to which they disturb, scare, and upset those of us who have to deal with them—are social problems as much, if not more, than medical ones.
There is nobody who can take the place of Thomas Szasz. To the extent that he was willing and able to eloquently put forward the argument that mental illness is a metaphor gone awry—a metaphor whose widespread acceptance oftentimes yields disastrous yet unintended consequences—he was a true original. It takes courage to defend positions that challenge or upend the status quo. If doing so for more than 50 years while being mercilessly attacked and misrepresented resulted in his becoming shrill and angry in how he sometimes expressed his views, I think he warrants forgiveness.
The question is who now will stand up for the issues and concerns he cared so deeply about? Who now will cut through the many contradictory and questionable assertions of the increasingly medicalized helping professions? Szasz may have passed, but if enough people go back and examine and engage the elegant arguments at the heart of his work, his ideas will certainly live on. Yet, having his ideas alone live on would likely not satisfy Szasz. Applying his ideas to how we work with those experiencing problems in living—making sure we avoid coercion and don’t become enforcers of social conformity—are the real reasons why Szasz insisted it was so important to clarify the hazards encountered when we turn metaphorical illnesses into real ones. If we use that to guide our practice, then we will truly be honoring Dr. Szasz’s work and memory.
Szasz, T. S. (1963). Law, liberty and psychiatry: An inquiry into the social uses of mental health practices. New York, NY: Macmillan.
Szasz, T. S. (1974). The myth of mental illness: Foundations of a theory of personal conduct (rev. ed.). New York, NY: Harper & Row.
Szasz, T. S. (1987). Insanity: The idea and its consequences. New York, NY: John Wiley.
— Jonathan Raskin