Episode 34: Mental Illness Denialism Part 1 - The Godfather of Anti-Psychiatry, Thomas Szasz

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In the first installment of their mental illness denialism series, Dylan, Brent, and Forrest cover the psychiatric landscape in the 1950s that gave birth to the Bible of anti-psychiatry: The Myth of Mental Illness by Thomas Szasz. Along the way they debunk the more common Szaszian arguments and discuss their own personal experiences with mental illness.

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Asylums and The Psychiatric Climate

Compared to today, where only 22,000 Americans are involuntarily committed to psychiatric institutions, more than 500,000 were committed to mental asylums in the 1950’s, reaching an all time high of 533,000 in 1953. Most patients committed suffered from dementia, seizure disorders, paralysis, and advanced neurosyphilis.Medical knowledge at the time had no way to treat these conditions, so the only approach was long-term commitment.

Asylums thus became long-term homes for chronic patients whose care consisted of restraint, sedation with medications, such as bromides and chloral hydrate,7 or experimental treatment with opium, camphor, and cathartics.

This made sense given the idea at the mentally ill were incapable of making decisions on their own. Thus, there was only involuntary commitment. To further compound the immorality, since most asylums were private and there was little regulation of their activity, families could essentially pay to have an annoying relative committed. Even if someone managed to be declared sane by an asylum and released, they often lost many civil rights, including property and custody rights. One example of this is Elizabeth Packard in the 19th century, who was committed for “moral insanity” by her husband (because she was exploring religions outside Presbyterianism). Once released three years later, she discovered she had lost custody of her children and ownership of her property.

Enter Thomas Szasz

The Godfather of mental illness denialism. Thomas Szasz was an Hungarian-American psychiatrist. Szasz spent most of his professional career as professor of psychiatry at the State University of New York Upstate Medical University in Syracuse, NY. He was a lifetime fellow of the American Psychiatric Association and a lifelong member of the American Psychoanalytic Association.

According to RationalWiki, “Szasz was an ideologically motivated doctor with little real-world experience who used his post to attack the workings of the legal system. In fact, he admitted he was never really interested in psychiatry or psychology.” Szasz once said, “these things called mental illnesses are not diseases at all but part of the vicissitudes of life”.

Szasz wrote a book called The Myth of Mental Illness: Foundations of a Theory of Personal Conduct in 1961. This book became the Holy Bible for mental illness denialism. This wasn’t the only book Szasz wrote. He graced this world with over ten books in which his main argument was that mental illness was a “literalized metaphor because the mind was not a physical scientific object and therefore could not be subject to a biological disease.”

Here are some of Szasz’s beliefs he discussed in his many books:

He did not support the insanity defense.

He thought people who were depressed should be allowed to kill themselves if they wanted to.In fact Szasz didn’t believe in depression as a mental disorder. In an article in The New York Times magazine it states, “Once in a classroom Szasz asked his students, ‘Has she got an illness called depression, or has she got a lot of problems and troubles which make her unhappy?’ Szasz turns and writes in large block letters: “DEPRESSION.” And underneath that: “UNHAPPY HUMAN BEING.” “Tell me,” he says, facing the class, “does the psychiatric term say more than the simple descriptive phrase? Does it do anything other than turn a ‘person’ with problems into a ‘patient’ with a sickness?” He puts down the chalk so hard that a cloud of dust rises. There is a low muttering among the students as he returns to his seat.”

He was an advocate for the legalization of all drugs.

He didn’t agree with involuntary commitment, which is when a court orders someone into treatment at a psychiatric hospital. He considered admitting anyone to a psychiatric hospital “a form of brutality”.

He was a critic of the idea that homoseuxality was a disease.

He thought psychiatry was a pseudoscience and called psychiatrists “doctors of the soul” and witch hunters. During the 1970’s Szasz referred to psychiatrists as witch hunters. In the 1980s he often referred to them as slave owners and Nazis. Szasz once said that,

Psychiatry [is] in the company of alchemy and astrology … Let us suppose that there is no such thing as mental health or mental illness, that these words refer to nothing more substantial or real than did the astrological notions of the influence of planetary positions on personal conduct. What then?

Szasz Gets Annoying

New York’s commissioner of mental hygiene, Paul Hoch did not want Szasz at Syracuse Psychiatric Hospital anymore. Szasz was moved to the Veterans Administration Hospital, just a few blocks away. At first Szasz was fine with this transfer, but eventually decided that it was a bunch of bullshit saying, “I don’t want to belabor this metaphor, but it was as if Marc told me: You have to wear a yellow star,”

Colleagues and students of Szasz protested this transfer by boycotting staff meetings and classes. Some of the local newspaper don’t sensationalize this in any way shape or form when one reporter, T. Lee Hughes wrote, “One of the most flagrant breaches of academic freedom in the history of the school,” Szasz is “the victim of a virtual academic crucifixion.”

In the end Szasz tells us what he really thinks about his own legacy to mental health denialism,

I really don’t think I am falsifying it when I say I never had much hope of having an impact on psychiatry, I viewed psychiatry all along as more like the Catholic Church. What impact did Voltaire make on it? If you think about what happened since then, nothing! No I didn’t expect to make any difference.

So, what is a disease anyway? The Medical Model

Szasz’s primary complaint is the so-called “medical model” of psychiatry. Just as podiatrists are feet doctors and nephrologists are kidney doctors, psychiatrists are mind doctors. But even amongst proponents of the medical model, there are two competing versions

The minimal interpretation treats treats mental illnesses “as the observable, regular unfolding of a suite of symptoms.” They make no claims about neural underpinnings and treat diagnostic categories as useful heuristics rather than natural kinds like SODIUM CHLORIDE or ELECTRON.

The strong interpretation  argues that mental illnesses should ultimately depend on neural anatomy and physiology. Mental illness will be explained in terms of underlying neurobiological systems. In other words, “a strong interpretation commits psychiatry to a view of mental illness as a medical disease in the strongest sense, that of a pathogenic process unfolding in bodily systems.”

Szasz is committed to the strong interpretation, and is essentially an error theorist. If claims about mental illness are true, then they refer to discrete kinds of neurobiological pathology. They don’t so refer, so all such claims are false. Szasz even goes one step further. ALL disease, for him, is based on one kind of pathology, namely tissue lesion, which in medical speak is any tissue damage or abnormality.

But this doesn’t even work as a definition if we only consider physical ailments, as R.E. Kendell explains. He lists plenty of diseases which are defined in all sorts of different ways. Including by syndrome (a cluster of related symptoms and signs with a characteristic evolution), Morbid anatomy (The Szasz definition), Histology, Infective organism, Physiological abnormality, Biochemical abnormality, Chromosomal abnormality, Molecular abnormality, Genetic abnormality. Given all these different ways of defining disease, we are probably in a better position to throw out Szasz’s myopic definition than to agree that mental illnesses aren’t real.

Demolishing the Straw Man

If you type into Google “there’s no such thing as mental illness”, you’re likely to see rise near the top of search results an article called “Reviving the Myth of Mental Illness” by Steven Morgan of the so-called Wellness Recovery Action Plan, or WRAP, owned by Advocates for Human Potential, Incorporated.

Now, normally, at None Dare Call It Ordinary!, we’re not in the business of “debunking”, as it were. But I’m going to make a slight exception for this one, only because the stakes are too high not to utterly annihilate these idiotic arguments. Morgan writes,

What do we mean when we say someone has a mental illness? If we are to take the phrase literally, we mean that someone’s mind is ill. But can a mind be ill with disease? To believe so, one must make two serious assumptions: one, that the mind is a tangible object with discrete boundaries and two, that the health of that object can be measured. Both of these assumptions are wrong. Since nothing called a mind exists that can be looked at under a microscope, the former assumption is wrong. The mind is not an object. It follows that the latter assumption is also wrong because only objects with discrete boundaries can be objectively measured.

Thus, it is important to note that mental illness in itself – the idea that a mind is ill, is actually a categorical error, like saying the sky is ill or the color green is healthy. There is no such thing as mental illness except by metaphor. It may seem like trivial semantics, but the mistake that mental illness is something concrete has led to an epidemic of mythology. Every day, someone is told they have a thing inside them called mental illness that must be contended with long-term in order to achieve health.”

I would agree with Morgan that it’d be foolish to think of the mind, or mind processes, in the exactly same sense as one typically thinks of, say, the brain and brain processes. But it’s simply false to believe that modern psychiatry defines mental illness in such a sense. Take this characterization of such a definition from the DSM-IV, the second to latest edition of the standard classification manual of modern psychiatry, wherein it states,

… although this manual provides a classification of mental disorders, it must be admitted that no definition adequately specifies precise boundaries for the concept of ‘mental disorder.’ The concept of mental disorder, like many other concepts in medicine and science, lacks a consistent operational definition that covers all situations… Each is a useful indicator for a mental disorder, but none is equivalent to the concept, and different situations call for different definitions… Despite these caveats, the definition of mental disorder that was included in DSM-III and DSM-III-R is presented here because it is as useful as any other available definition and has helped to guide decisions regarding which conditions on the boundary between normality and pathology should be included in DSM-IV.

The following is the updated definition itself from the DSM-V,

A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.

The DSM’s nuanced, open, and highly hedged definition is absolutely nothing like what Morgan is pretending to argue against. One can only conclude, therefore, that Morgan has built a straw man.

Morgan goes on to say that mental health experts,

...claim that each mental illness correlates to a specific neurological disease. Yet you do not need to read studies or have a medical degree to rest assured that mental illness does not correlate to specific neurological diseases. You need only know that there is not a single reliable test for any of the 297 disorders listed in the current diagnostic manual, and not a single reliable test for any of the disorders being proposed for an expanded manual. Not one.

This claim is absolutely false. No modern psychiatrist worth their salt will tell you that mental illness correlates to any specific neurological disease such as, say, Alzheimer’s. However it’s beyond question that there are frequently neurological correlates, even though they may not fall into a neat 1:1 ratio between the “mental” and “physiological”, nor would it be right to classify mental illnesses as only identifiable as neurological disorders, but usually as containing behavioral and emotional elements as well, as stated in the DSM.

From the DSM-V,

Approaches to validating diagnostic criteria for discrete categorical mental disorders have included the following types of evidence: antecedent validators (similar genetic markers, family traits, temperament, and environmental exposure), concurrent validators (similar neural substrates, biomarkers, emotional and cognitive processing, and symptom similarity), and predictive validators (similar clinical course and treatment response). In DSM-5, we recognize that the current diagnostic criteria for any single disorder will not necessarily identify a homogeneous group of patients who can be characterized reliably with all of these validators. Available evidence shows that these validators cross existing diagnostic boundaries but tend to congregate more frequently within and across adjacent DSM-5 chapter groups.

Now, I am by no means an expert in psychology or psychiatry, but I do suffer from OCD, or Obsessive Compulsive Disorder, and I know enough about it to speak with some limited authority on the subject. In OCD, there’s an issue of hyper-connectivity between the orbital cortex of the brain, responsible for error detection (i.e. the feeling that something is wrong), and the caudate nucleus, responsible for the regulation of thoughts entering into consciousness. A malfunction of the caudate nucleus causes people like me to be unable to simply dismiss crazy or distressing thoughts. Rather, the thought simply stays in one’s mind and, the more one tries to dismiss the thought, the more highly activated the orbital cortex becomes, and therefore, the more anxiety there is. The only way to ward of the anxiety for an OCD sufferer is to create something of a ritual, the compulsion aspect of the disease. For example, OCD sufferers that think they’re being contaminated by whatever nefarious real or imagined substance feel they cannot function at all after having thoughts about contamination unless they wash their hands, nor will they be able to stop thinking about contamination until they do so. Though this development of rituals offers temporary relief, ultimately it only strengthens the pathological neural connections and only helps perpetuate the cycle of madness. So, while it would be wrong to think that mental illnesses are simply neurological diseases, or correspond to neurological diseases in some simple 1:1 ratio, almost nobody of true relevance is saying this, and so the straw man continues.

Morgan writes,

Let us not forget that psychiatry once proclaimed homosexuality a disease. And let us not doubt that if the cultural zeitgeist was still against homosexuality, that biopsychiatry would be hunting for it in the brain and proclaiming it as a legitimate, diagnosable brain disease. What has changed are social values, not scientific evidence.

What Morgan is saying is partially true, but misleading. It’s true that changing social norms is what caused homosexuality to no longer be viewed as a mental disorder. Be that as it may, the neurological, behavioral, and genetic realities that might be associated with homosexuality, if they exist, would remain unchanged. It’s not like those correlates go away just because society decided to be nicer to gay people.

Speaking of the belief in mental illness, Morgan continues,

...let’s not pretend this perspective is empirical – “just like having diabetes” – and therefore applicable to all subjects who have similar experiences. Nor should we ever build far-reaching policies and laws upon such a porous foundation. Let us instead call the brain disease hypothesis what it is: a worldview, a theory with contradicting evidence, and a cultural bias. We can then make room for other perspectives, for one person’s shrunken amygdala is another’s child abuse is another’s combat experience is another’s religious mission is another’s salvation. What is important is how we build the most connection between people. Talking about experiences in non-clinical, everyday talk provides a bridge between people that is otherwise drowned by psychiatric jargon. I cannot relate to someone who is having a symptom of schizophrenia called paranoia, but I can relate to someone who is really scared. And if I can relate, maybe I can align, be real, and open up with my own learned wisdom instead of parroting prescriptive treatment modalities.

This is where Morgan’s ideas really become dangerous. Someone suffering from schizophrenia isn’t simply “scared”. If you think, say, your neighbor is a ventriloquist dummy, and God commands you to put your neighbor’s head on a pike on your front lawn, that’s not just being “really scared”. In all seriousness, it is such idiotic and simplistic thinking as this that trivializes the seriousness of schizophrenia. One thing that is a truism of mental illness is that it’s extremely hard, if not impossible, to give someone else a good sense of what it’s like subjectively. The point is that the mentally ill and the non-mentally ill cannot relate on a fundamental level, so Morgan’s idea here is pure folly.

Morgan ends his stupid screed with this,

Patients should remember that a medical degree does not denote an understanding of consciousness, that people of all stripes have been trying to make sense of the mind forever, and that however unfortunate for industries that stand to make record-breaking profits otherwise, we cannot yet siphon the Great Mystery down into neuronal patterns and genetic variants.

And that encapsulates this dangerous attitude perfectly: distrust experts, material science is dehumanizing, consciousness is eternally supercalifragilisticexpialidocious and, at the bottom of it all, it’s all about the shadowy “They” making money.

Is there a strict line between neurology and psychiatry?

One premise Szasz needs for his argument to work is a strict demarcation between the psychiatric and neurological. But is there such a line? We already noted that there isn’t a 1:1 correlation between psychiatric criteria for mental illness and discrete neurological diseases. To speak stupidly, it’s not like we are going to find the OCD or Bipolar region of the brain.

BUT! We have to be careful here. There is a worry of thinking of the neurological strictly in terms of anatomy and physiology, as though we can only speak of long-term potentiation and action potentials.

As we get to a more abstract level, when we talk about neural function and dysfunction, lower level anatomical and physiological functioning can underpin cognitive, perceptual, and affective dysfunction. Let’s use the computer analogy again. You can write a computer program which has bugs in it and doesn't’ work. This can happen (in fact, mostly happens) even if each individual line of code is working properly, they have just been put in the wrong order or the wrong kind of code is brought into do a job. The same happens with the brain: individual neural processes which are working properly in isolation can add up to a cognitive process which is dysfunctional.