This book is a recent installment in Thomas Szasz’ crusade against mental health care in its many guises, and in particular, against the use of coercion in psychiatry. The author says that the victims of psychiatry are coerced in many ways. They are hospitalized against their will, they are forced out of hospitals and into the streets when the state decides to desinstitutionalize them, and they are nearly always made to follow some kind of invasive treatment, ECT, lobotomy, or psychotropic drugs.

Szasz’ approach is nearly genealogical, in Nietzsche’s sense. He looks at compassion, the so-called virtue which motivates the infamous treatment of those we diagnose as mentally ill, through its historical, economical and political manifestations. Historically Szasz shows how we have striven to ‘store the unwanted’ i.e. those unable to support themselves because they cannot work (the indigent) or because they’re homeless, those unable to pay debts, children whose parents are unable or unwilling to bring up, and relatives who constitute an embarrassment, merely because they are different (Szasz discusses the fate of the epileptic). In all cases, the disposal and slavish treatment of the unwanted masquerades as compassion, and the real motive, i.e. the embarrassment they cause to others, is unspoken. The same goes for the political and economic analyses. The American government’s efforts to solve the problem of homelessness is, according to Szasz, not an example of compassion of the haves for the have nots, but a ploy to win more votes. Similarly, every instance of psychiatric reform is depicted as a money saving scheme wearing a compassionate mask. Even if this compassion were real, Szasz says, it would not constitute a sound foundation for deciding what to do with the homeless and the mentally ill, as it is a passion and therefore cannot be a virtue. Szasz questionably attributes this view to Aristotle, but it has a strong Kantian odor. In any case, it does not preclude that some psychiatric reform could have been motivated by a genuine desire to help, if not compassion, then a sense of duty to others (As a libertarian, Szasz does not emphasize duties).

Szasz’ analysis is fascinating – even if some of his pronouncements and conclusions are somewhat unsavory, for instance, his claim that schizophrenics who break the law should be treated as criminals. People diagnosed as mentally ill are stripped of their liberty. They also loose something, which for Szasz is equally important: their responsibility. People diagnosed as mentally ill cannot be held responsible, and therefore should not be punished for the crimes they commit against other people’s person or property. Yet, paradoxically, they often are punished even more than they would be if society deemed them sane. They are condemned to a life long dependency on institutions and drugs the result of which is that it is nearly impossible for them to become well adjusted independent adults. Therefore, they would be better off, and society’s treatment of them would be less hypocritical, Szasz says, if they were treated as common criminals. Szasz does not take it into consideration that if psychiatric institutions make people mad, the prison systems in many countries, including the US, make them criminals. It is a myth that one comes out of prison with a just sense of retribution, and cured of the criminal impulse which put us there in the first place. Moreover, since what Szasz objects to is the coercive element of psychiatric ‘help’, why not address this issue, and ask whether mentally ill people who break the law could not be offered drugs, counseling, or even temporary hospitalization?

One does not need to share Szasz’ philosophical and political views in order to share his indignation at the treatment meted out to those diagnosed as mentally ill, nor to recognize our tendency to ‘store’ away those we cannot interact with. This leads to the question whether the political and philosophical views in question form an important part of Szasz’ arguments. In particular, his claim that there is no such thing as mental illness (undefended in this book) is not needed to conclude that schizophrenia (the condition he focuses on) is a spurious category, or that being diagnosed as mentally ill does not justify having one’s liberty taken away. Separating the points that really matter from those that merely form part of Szasz’ libertarian propaganda is necessary in order to make the most out of this book. It is an important work and should teach us much about how we go wrong in treating mental illness. But for some of us at least, it will be necessary to be able to separate the main arguments from the political agenda of the author. Nevertheless I must say that the indignation I felt at some of his most extreme views kept up my interest in the book and made me finish it a lot quicker than I normally would.

Sandrine Berges is a member of the Department of International Relations, University of Bilkent, Ankara, Turkey.

Categories: Philosophical, MentalHealth