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Law, Liberty, and PsychiatryReview - Law, Liberty, and Psychiatry
An Inquiry into the Social Uses of Mental Health Practices
by Thomas Szasz
Syracuse University Press, 1989
Review by Stephen D'Arcy, Ph.D.
Aug 3rd 2004 (Volume 8, Issue 32)

Thomas Szasz has written more than a dozen books, most of them elaborations on the fundamental themes of his first major work, The Myth of Mental Illness (1961). That book became the intellectual basis for the phenomenon of "anti-psychiatry," which functioned both as an intellectual challenge to psychiatry's claims to scientific and medical credibility, and as the animus for a political movement aiming to oppose the power of psychiatrists and defend the rights of "psychiatrized" persons.

Two years after publishing The Myth of Mental Illness, Szasz followed it up with Law, Liberty, and Psychiatry. His earlier attack on the concept of mental illness is reiterated and extended in the sequel, but the relative emphasis now shifts from the status of mental illness as a supposed medical notion to the status of psychiatric claims as a basis for legal decision-making. In this more ethically and politically focused work, Szasz sets his sights on three major targets: first, as before, the very idea of mental illness; second, the use of that idea to authorize specific forms of legal or quasi-legal coercion and regulation, notably involuntary commitment; and third, the coalescence of psychiatry and other ostensible helping professions, supported by misguided judges and legislators, into a rising "therapeutic state," animated by "a spirit of do-goodism" (240), but posing a grave threat to the rule of law and the liberal traditions of constitutional liberty.

None of these concerns seems entirely groundless, but it is worth subjecting each one individually to critical scrutiny.

Mental Illness. On this question, Szasz certainly can't be faulted for fence-sitting, bluntly stating that "mental illnesses do not exist" (16). But we may wonder whether "existence" is quite the right concept for framing the question he intends to address. In particular, he concedes three points which, taken together, cast doubt on this approach. First, he admits that "the social and psychological occurrences so labeled" (as mental illness) do indeed exist (16). Second, he acknowledges that, like mental illness, "bodily" illness is a normative notion, implying deviation from some favored standard, although in the case of bodily but not mental illness the favored standard and the deviation from it "can be stated in anatomical and physiological terms" (14). Third, he concedes that finding oneself labeled as mentally ill, precisely because one deviates from a (non-anatomical, non-physiological) norm can have enormous implications for how one sees oneself, how one is seen by others, how one will be treated in the legal system, and so on. At this point, the reader will be led to wonder how much sense it makes to say that mental illness "does not exist" when we know that norm-violating behavior exists, the practice of labeling such behavior as mentally ill exists, and there follows upon such labeling a series of psychological, administrative, legal and interpersonal implications which are only too real concerning how one is treated and how one relates to oneself? Surely, Szasz is operating with an unnecessarily impoverished notion of existence here. Perhaps he means (or should mean) to say something different, such as that facts about mental illness unlike facts about bodily illness (including "neurological deficits," which Szasz accepts as a genuinely medical notion, on p. 12) are institutional facts, i.e., facts about a social status that is conferred on some people by members of a community (a status with specific implications for role-expectations and typical role-performances) rather than "brute facts" about the physical world. He could certainly claim, as one might nowadays put it, that mental illnesses are "socially constructed" in ways that the bodily illnesses addressed by what Szasz calls "medicine proper" are not. This claim would be easier to defend, and would not require Szasz to retreat from his ambitious political project of denying psychiatry access to the credibility and authority it derives from its "essentially misleading association with the practice of medicine" of the usual, non-psychiatric sort (23). No doubt there is, as Talcott Parsons suggested, a normative "sick role" for cancer patients or amputees; but so one could argue the identification of someone as having a Narcissistic Personality Disorder is really nothing more than a role-assignment effected by the imposition of a particular social status on a patient by psychiatric authorities. In any case, this is a line of thinking that Szasz did not pursue.

Coercion. Nietzsche points out that a society ruled by priests needs sin, because sin is the "handle" and foothold for power. Szasz makes similar points about the function of mental illness for psychiatry. The application of the "mental illness" label has the function of authorizing intrusions and coercions of various kinds, but in this book Szasz is primarily interested in one kind of intervention: involuntary commitment of the mentally ill to hospitals. According to Szasz, the fact that this phenomenon is widely thought to be tolerable, even in countries with liberal legal systems, arises out of two unquestioned but plainly mistaken presuppositions. First, there is the assumption that many people labeled as "mentally ill" are not responsible for their actions. And second, there is the tendency to regard the psychiatrist/patient relationship as non-adversarial. The first assumption often necessitates finding a proxy decision-maker; the second assumption makes it natural that the physician should be invited to assume that role, alone or in concert with others. Szasz tries to challenge both assumptions. Unfortunately, his case against the notion of non-responsibility "by reason of insanity" seems to rest almost entirely on his ability to cite several cases where the notion was in fact applied, but clearly shouldn't have been an objection that unintentionally invites readers to insist on a more rigorous and careful application of a principle that Szasz would rather have them discard altogether. By contrast, his case for dropping the assumption that psychiatrists are primarily advocates for the best interests of their patients, as opposed to advocates for the maintenance of social order (embodied in moral opinions about what kinds of behavior are "healthy"), seems essentially airtight. Above all, the notion that commitment, when demanded by a psychiatrist, should be presumptively taken to be in the patient's best interests, is here subjected to a withering and utterly convincing critique.

The Therapeutic State. For many readers, the least appealing aspect of Law, Liberty, and Psychiatry will be the association of Szasz's critical insights about psychiatry as a mode of social control (which often anticipate Michel Foucault's nominalist genealogies of "subjection" through identification) with a specifically "libertarian" approach to questions of political morality. Libertarians (most famously, Robert Nozick and Milton Friedman) tend to reduce political questions to questions about what should be done with property, whether property in one's person or one's resources, and then to assume that questions of that kind should generally be referred to the private preferences of the relevant property-holders taken individually. For Szasz, accordingly, the basic moral objection to psychiatry in particular, and to the therapeutic state in general, is that it usurps the function of self-ownership from individuals. Szasz draws attention to the plain fact that the demands made on the state, or made by the state, have expanded into previously private realms, such as helping citizens reach their full potential, relieving their suffering, and protecting them from misfortunes. In the face of this development, Szasz, like other libertarians, worries about the price that will have to be paid in personal liberty for every advance in social welfare. "If...the state assumes the roles of parent and therapist, the citizens will be forced to assume the complementary roles of child and patient. This is bound to lead to the parentification of the government, and the infantilization of the governed" (222). Of course, obvious objections will arise from other locations on the political spectrum. How beneficial is liberty from state paternalism to a person whose behavioral idiosyncrasies (for lack of a better word) make sustained gainful employment unlikely indeed? To be sure, infantilization at the hands of the state is not an appealing solution, but neither is abandonment to a libertarian labor market. One reason for the rise of the so-called therapeutic state is that markets "fail," in the sense that they produce victims. A libertarian like Szasz can accept such market failures for the sake of preserving liberty and maintaining the institutional basis for a society founded (he thinks) on respect for individual persons. But most of us will continue to find in libertarianism a simplistic and one-dimensional understanding of what it means to treat a person with dignity, with dubious appeal as a positive alternative to psychiatric or state paternalism, even when we agree with Szasz's critical objections to them.

But it is the latter, the "negative" side of Szasz's work, as a fundamental challenge to what others regard as obvious, that makes Law, Liberty, and Psychiatry worthy of serious attention, even four decades after its original publication.

 

2004 Stephen D'Arcy

Stephen D'Arcy, Ph.D., is Assistant Professor of Philosophy at Huron University College, in London, Ontario, Canada.


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