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Szasz's book Insanity is a lucid and passionate restating of the case that Szasz has been continuously trying to make for the best part of forty years. In all that time Szasz has continuously motivated an argument that begins from a notion of libertarianism and individual autonomy and which simultaneously challenges the medicalization of mental health as a strategy for control. In many respects Szasz is very close to the line of thought put forward by Foucault whereby the discourse surrounding mental health, insanity and schizophrenia masks a wider discourse of control and power.
Of course the similarities with Foucault are only partial and occur in the historical accounts of the way in which insanity is dealt with in society. Szasz and Foucault would no doubt part company around the issue of 'individual autonomy' which Szasz seems to hold onto as an almost absolute principle and which Foucault would no doubt see as, at least in part, constructed in the same way as society constructs definitions of mental health. Szasz's strength, however, comes from the way in which he deconstructs the myth of mental illness and it is in this realm where his arguments have most power. Insanity is a thorough and thought provoking introduction to this aspect of Szasz's work.
To reconstruct the arguments in the book is not the job of a reviewer but to indicate their relative importance is. Szasz's arguments operate with a 'conventionalist' theory of meaning and go directly to the heart of the 'scientific' aspect of mental health, the medicalization of insanity, which could perhaps be said to have started with Kraepelin's 'discovery' of schizophrenia. The idea of a pathogenic basis for psychiatry is countered with arguments which begin by denying such a possibility to mental illness. If it is pathogenic mental illness it becomes brain disease, in exactly the way in which epilepsy has been removed from the realms of the psychiatrists and placed into the realms of the neurologists. The legitimacy of neurological science is not in any way dismissed by Szasz. It is, in fact, the assumption of the status of science that Szasz suggests is invalid for psychiatry. Psychiatry as a medical science is impossible, Szasz would argue, since at the point at which it becomes scientifically able to articulate the pathological basis for mental illness such illness is no longer mental but neurological. The distinction has radical consequences when faced with the concrete patient rather than the abstract disease since at that point social control comes to the fore. In fact, for Szasz, the distinction between neurological and psychiatric could be said to rest precisely on a social role rather than on a medical or scientific basis.
Szasz claims that the facts of pathology as the basis of medicine, rather than healing, have been metaphorized to establish the grounds for psychiatry as a medical discipline rather than a social one. Psychology rests equally upon such a metaphorical basis, as does the whole of what Szasz calls the 'therapeutic state' which is a term he uses to indicate the growing medicalization of behaviour, a process indicated most clearly by the replacement of the category of evil or bad with the category of sick. Mental health, Szasz argues, rests upon what the English philosopher Gilbert Ryle called a 'category mistake'. Just as the logical positivists declared that 'metaphysics doesn't exist' so Szasz declares 'mental illness' not to exist.
Szasz's skill in Insanity is in single-mindedly and at times almost repetitively attacking the arguments of legitimacy put forward by psychiatry. From the idea of a 'future discovery' of pathogenic causes of schizophrenia and mental illness to the much vaunted idea of an already discovered 'brain chemistry' underlying mental illness, Szasz is incessant. If you think there is any medical basis to mental illness then, quite simply, you are wrong. That is Szasz's claim. If it is correct the consequences are, literally, devastating - if we were to accept Szasz's arguments it would utterly remove the social role and power of psychiatry. We would be forced to take apart a long-standing practice of western medicine and redefine, quite radically, our behaviour towards each other. Of course, to even make such a claim is to warrant an interest since anyone with 'the patients interests' at heart is obliged to at least listen to such claims. To refuse to do so would be to engage in a dangerous denial of discussion. When such a claim comes from a psychiatrist and is, moreover, backed up by an insistence and weight of argument that spans some forty years of practice and theory it is no longer dangerous but perhaps even insane not to listen to such a case. This simple fact is enough to make me recommend Szasz to anyone with any interest in mental health, psychology, psychiatry or insanity.
At its heart a book like Insanity suffers from its own consequences. If Szasz is correct and 'mental illness' is an illegitimate metaphorization of disturbing behaviour, then the practice of mental health professionals can only be understood within a paradigm of social control. At this point the debate around 'mental illness' is no longer a medical and scientific debate but is instead political and social. Szasz' strength, and the strength of Insanity lies in making a strong case for understanding insanity socially and politically - its weakness, then, lies not in its own arguments but in the ability of such arguments to effect our practices. One of the major problems the book leaves the reader with is quite simply what to do if Szasz is correct. Working from the basis of a principle such as 'do no harm' we are forced, when faced with someone like Szasz who declares that we are doing harm, to fully engage with his arguments, particularly when they have such strength, lucidity and determination as those contained within Insanity.
Matt Lee, University Of Sussex (PhD researcher, Philosophy)