Dr. Thomas Szasz’s Campaign against Psychiatric Coercion and the "Therapeutic State"
During the Cold War, people were shocked to see the Soviet Union lock up dissidents in state mental institutions because being against socialism was “proof of mental illness.” Soviet psychiatrists were condemned for violating the Hippocratic oath, with one of the most important promises of that oath being “First, do no harm.”
While psychiatry in the United States has not gone as far as what happened in the former USSR, many psychiatric institutions in the US have nonetheless engaged in harm, and one brave—and often reviled—psychiatrist was not afraid to speak out against what he called “torture” and “kidnapping.”
Dr. Thomas Szasz was well known both in libertarian and professional circles for speaking out against what he called the “therapeutic state” and the use of coercion in treating people with mental disorders. His message was popular with many followers, but also earned him the enmity of others in his profession.
What Was Szasz Fighting Against?
An article published in Lancet Psychiatry in 2015 began with the following paragraph:
Have asylums disappeared, or have they simply changed their form? Over the past 50 years these notorious institutions have largely been closed down in the USA and Europe. But before modern society becomes too complacent about this apparent sign of progress, it should ask whether the asylum has been replaced with an environment that similarly constrains and damages vulnerable individuals—prison.
To the common layperson outside the fields of psychology and psychiatry, this might come as a surprise. “Mental asylums are an environment that constrains and damages vulnerable individuals as much as a prison? Impossible! They’re a place designed to help people,” one might scoff at the statement.
But no one can be helped unless they want to be helped, and even worse, one does not help someone by torturing them. Mental asylums were originally created by “social reformers” and “progressive” politicians in the latter half of the eighteenth century. These places were the definition of torture: multiple patients were crammed into a single room, screams were heard at night, common treatments were spinning, branding, and malaria, and patients had to fake wellness to be released, with many committing suicide soon after leaving. By the beginning of the twentieth century, nearly every state had at least one government-run mental asylum.
Szasz identified these institutions as part of the “therapeutic state,” a term that refers to government subversion of psychology and psychiatry to remove or correct those who do not conform to what the government deems socially good. For example, homosexuals have always been a target of state oppression, and for a long time the therapeutic state deemed them “mentally ill” people who needed to be corrected, involuntarily committing them to mental asylums. Women who defied their husbands and even “unruly” children were also committed involuntarily to mental asylums (where many died).
The therapeutic state still exists today around the world, causing immeasurable harm to humans, as noted by multiple studies (Cohen and Minas 2017; World Health Organization 2012, 2013; Human Rights Watch 2016; Irmansyah et al. 2009; Drew et al. 2011; Bass et al. 2012; Krishnakumar 2001; Carey 2015; Minas 2009; Minas and Diatri 2008).
But most of the care of those considered “mentally ill” has been transferred to outpatient care centers (no overnight stays), and mental asylums have been closing in droves for the last fifty years, to the point of near extinction. These are the results of an ongoing crusade against torture led by Dr. Thomas Szasz, whose legacy endures despite his having passed away in 2012.
Szasz’s Proposed Alternative View
Cofounder of the Citizens Commission on Human Rights and the American Association for the Abolition of Involuntary Mental Hospitalization, a distinguished lifetime fellow of the American Psychiatric Association, and a life member of the American Psychoanalytic Association, Dr. Szasz won many awards during his career, such as the Award for Greatest Public Service Benefiting the Disadvantaged (1974), the Martin Buber Award (1974), the Humanist Laureate Award (1995), the Great Lakes Association of Clinical Medicine Patients’ Rights Advocate Award (1995), and the American Psychological Association Rollo May Award (1998).
Szasz sought to analyze human behavior in terms of freedom, choice, and responsibility. The Hippocratic oath is a declaration of the rights of patients, which psychiatric institutions violated by declaring people “mentally ill.”
To Szasz, mental illness is a stigmatizing term invented to justify social removal of those who do not fit into the therapeutic state’s list of acceptable behavior. He describes these conditions as human behaviors rather than illnesses.
Until the middle of the nineteenth century, and beyond, illnesses meant a bodily disorder whose typical manifestation was an alteration of bodily structure: that is, a visible deformity, disease, or lesion, such as a misshapen extremity, ulcerated skin, or a fracture or wound. Since in this original meaning of it, illness was identified by altered bodily structure, physicians distinguished diseases from nondiseases according to whether or not they could detect an abnormal change in the structure of a person’s body.1
An illness is a disorder, a deviation from the normal. There are normal body structures, but what is “normal” human behavior? The very term mental illness already carries a social stigma. The illnesses of body medicine were discovered; those in psychiatry were invented.
It is important to understand clearly that modern psychiatry—and the identification of new psychiatric diseases—began not by identifying such diseases by means of the established methods of pathology, but by creating a new criterion of what constitutes disease: to the established criterion of detectable alteration of bodily structure was now added the fresh criterion of alteration of bodily function; and, as the former was detected by observing the patient’s body, so the latter was detected by observing his behavior.2
The agents of the therapeutic state observed the behavior of human beings, and if said behavior did not fit the procrustean mold of what they wanted in society, it was deemed a “mental illness.”
Human action is purposeful, goal-oriented behavior. It is desire put into motion. If a person is eating too much, they are using their will to employ means, seeking the achievement of their ends. An actor “bulking up” for a future role is not considered mentally ill, but someone that wants to increase their weight is. In both cases, the person is unsatisfied with their current body and is seeking to change it, but only the latter psychiatrists would claim they are mentally ill, claiming body dysmorphia, gender dysphoria, etc. The criteria used by psychiatrists are loosely defined and grounded solely on what behavior the therapeutic state wants in society.
Human suffering exists. Some behaviors can be self-damaging. But it is ultimately up to the person to seek help. This is by no means to suggest that those who suffer should be ignored. But it also does not mean that those who suffer should be kidnapped and put into a chemical bliss through forced drugging or taken to electroconvulsive therapy. The central argument in Szasz’s analysis is that coercion aggravates human suffering, while voluntary treatment mitigates it.
Why Szasz Is Correct
As someone who studies psychology, I have found that therapies and treatments only work when the client wants to undergo them. The first session of cognitive behavioral therapy (CBT), for example, is designed to make the person seeking help comfortable working with the therapist: the two set goals together, begin talking about the core beliefs that are causing harm, and start to build an environment in which the person feels safe talking about what has been bothering them.
Without the person’s consent and voluntary decision to cooperate with the therapist, CBT simply doesn’t work. Forcing the person to continue will only generate animosity and possibly even trauma, leading to an internalized phobia of psychologists, therapists, and professionals alike, and to the person closing themselves to any help. The person’s behavior can only truly be changed by choice, through willpower that comes from within.
Contrast the empirically proven and ethical methodology of cognitive behavioral therapy with the torturous and sadistic methods many psychiatric institutions continue to use to this very day. Instead of voluntarily undertaking an amicable and moral CBT treatment plan, people are kidnapped against their will, taken to electroconvulsive therapy, drugged, and then imprisoned in a mental asylum for the rest of their lives.
Szasz was a supporter of psychotherapy (which he correctly believed was more effective than compulsive treatment) and also of the right of people to freely buy drugs. But he did not disregard alternative treatment methods. If the patient wants to, for example, do a “primal scream” session and this helps them, then let them scream! If it’s done voluntarily, and it’s helping the patient, why interfere? If someone’s depression was cured by voluntarily going to the gym and taking cold showers instead of getting hooked on antidepressants, there is nothing wrong with it. Szasz thought that any method that helped mitigate human suffering was welcome as long as it didn’t violate the patient’s or others’ freedoms.
Szasz’s argument against the psychiatric method of his time is threefold: (1) coercion aggravates human suffering, while voluntary treatment mitigates it; (2) drugs aren’t the only way to help people—any voluntary method that helps reduce people’s suffering is welcome; and (3) no such thing as mental illness exists, but we should still help those who voluntarily seek help.