Perspectives

Art of medicine
Thomas Szasz: rebel with a questionable cause
See Obituary page 1380 Thomas Szasz challenged mental health practice perhaps Szasz first criticised “mental illness” as a legal term in a 1958
more than any other American psychiatrist in the decades issue of the Columbia Law Review. At the time of publication,
after World War 2. He did so by turning against his own five US states restricted involuntary commitment of people
specialty. In addition to contemporaries R D Laing in the UK, with mental illness to those deemed “dangerous”. The other
the Canadian sociologist Erving Goffman, and the French states generally permitted commitment for anyone with
philosopher Michel Foucault, Szasz provided much of the mental illness who had a “need for treatment”. By the end
high octane intellectual fuel for the genesis of the anti- of the 1970s, every state had either changed its statute or
psychiatry movement that burgeoned on both sides of the interpreted its pre-existing statute to narrow criteria in the
Atlantic during the 1960s and 1970s. In particular, Szasz direction Szasz first advocated. The number of patients in
promoted doubts about whether mental illness existed at public psychiatric hospitals or “asylums” fell from an all-
all with his publication of The Myth of Mental Illness in 1961 time high of more than 550 000 in the mid-1950s to fewer
and The Manufacture of Madness: A Comparative Study of the than 150 000 by the end of the 1970s.
Inquisition and the Mental Health Movement in 1970, along The downstream results of these reforms were stark and
with many other writings, lectures, and public appearances. disturbing. In the 20 years that spanned the bulk of this
Szasz is perhaps best known for his view that without a deinstitutionalisation, the chronically homeless population
diagnosis of neurological disease or damage, a psychiatric in the USA ballooned to more than 300 000, many of whom
diagnosis was meaningless. He argued that for most people lived with serious mental health disorders or substance
categorised as mentally ill, a more appropriate classification dependency. The USA witnessed a concurrent exponential
of their behaviour would be “problems in living”. Szasz’s increase in the prison population. A 2006 report by the US
unyielding critique of psychiatry helped to alter the Department of Justice indicated that, depending on the
trajectory of the field. In the second half of the 20th century correctional setting, between 40% and 80% of American
many psychiatrists began to rethink their rationale for inmates are considered to have mental health disorders;
disease nosology and to more aggressively search for the the Los Angeles County Jail, for example, is now one of the
underlying biochemical, genetic, and physiological bases of largest inpatient psychiatric care facilities in the USA.
mental health disorders—a strategy bearing fruit today. Part of the reasoning that allowed for such sweeping
Szasz’s attack on psychiatry was most controversial in change in the USA can be traced through three key court
the realm of the treatment of severe mental illness, and cases. These cases and the political push of some patients’
his influence was most profound with regard to what advocacy groups that reinforced them were greatly inspired
happened to such people in the USA. Szasz’s greatest by Szasz’s thinking. The first, a federal district court case
admirers were American civil libertarians. They took up in the state of Wisconsin, Lessard v. Schmidt (1972),
Szasz’s anti-psychiatry cause with an enthusiasm that had was the beginning of the end for vaguely worded, broad
mixed results for those with severe mental illness, their commitment statutes. The early Wisconsin law allowed
families, and society. The combination of American respect commitment to a psychiatric hospital for anyone who
for individualism, doubts about the efficacy and decency was simply deemed a “proper subject for custody and
of psychiatric treatment, the rise of an anti-paternalism treatment”. In Lessard, the court felt the law too easily
movement with respect to medicine, and a shaky early jeopardised the liberty of those with mental illness. Citing
foundation for some psychiatric diagnoses led to a dramatic Szasz, Lessard shifted the basis for inpatient commitment
shift in US health care: the delegitimisation of the field of from a need for treatment to dangerousness. The court
mental health care in favour of a philosophical response to did so by discounting the distinctly therapeutic aim of civil
mental illness that focused on autonomy and rights. commitment, thereby questioning whether psychiatry
Szasz was cited repeatedly within prominent American could treat people deemed mentally ill at all. If mental illness
law journals spanning mental health law topics from civil couldn’t be treated, why should someone be admitted to
commitment to the insanity defence. These law review hospital unless they posed a risk in the community?
articles, written by libertarian academic lawyers and their 3 years later, the conflict over the autonomy of people
students, informed certain legal reforms and key judicial with mental health disorders and the power of their
decisions in the USA. The court rulings created a unique treating physicians reached the Supreme Court of the
legal framework for managing people with mental health United States. In O’Connor v. Donaldson (1975), the Court
disorders, shifting decision-making power for patient ruled that involuntary commitment must be limited to the
care away from health professionals and into the hands of imminently dangerous mentally ill since, “A State cannot
rights-oriented lawyers and legislators. constitutionally confine, without more, a non-dangerous

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 Perspectives

individual who is capable of surviving safely in freedom

by himself or with the help of willing and responsible
family members or friends.” The ruling was used by the
American Civil Liberties Union and others to restrict the
use of involuntary commitment to psychiatric hospitals
nationwide. O’Connor reflected Szasz’s view and maintained
what psychiatrist Paul Appelbaum later described in Almost
a Revolution as a “discourse on mental health law reform…
shaped in important ways by doubts about the nature of
mental disorder…permeating the cultural milieu of the era”.
After curtailing the ability of doctors to commit patients
to psychiatric hospitals, US courts faced a new generation
of issues concerning people with mental illness: the right

Los Angeles Times

to refuse treatment when hospitalised. In 1978, the case of
Rennie v. Klein was heard by a United States district court in
New Jersey. The ruling in Rennie helped establish the right
of patients to refuse treatment by requiring third party Thomas Szasz (1920–2012)
review over decisions by the treating physician if a patient
refused treatment. Patients with mental illness, even if rights movement Szasz spawned makes it possible for people
severely ill or “dangerous” enough to be admitted to the with mental health disorders, as the American Psychiatric
hospital, could, out of respect for their “autonomy”, refuse Association began to lament, “to ‘choose’ a life on the streets
treatment. Citing Szasz in their conclusions, the Justices without consideration for their physical health or the extent
wrote, “Only where the government shows some strong of their competence to make such a ‘decision’”. Or to put Further reading
countervailing interest can the right to refuse be qualified.” the point starkly, as Paul Appelbaum and Thomas Gutheil Appelbaum P. Almost a
The need for treatment was no longer sufficient. have argued, post-Szasz many people with mental illness are revolution: mental health law and
Szasz’s philosophical activism was not intended to “rotting with their rights on”. Honouring the “autonomous” the limits of change. New York:
Oxford University Press, 1994
improve the treatment of people affected by mental illness behaviours of some of these individuals has been a
Appelbaum PS, Gutheil TG.
as much as to block involuntary treatment. The philosophical contributing factor to chronic homelessness and mass
“Rotting with their rights on”:
leap required to make sense of this position was premised incarceration in the USA. Are people with serious mental constitutional theory and clinical
on the idea that mental illness did not exist and that even disorders who are confined to these settings any better off reality in drug refusal by
than their pre-Szaszian predecessors who once filled asylums? psychiatric patients.
if it did exist, the individual’s refusal of treatment was still
Bull Am Acad Psychiatry Law
reflective of their authentic self-interest. The premise that Szasz undoubtedly helped psychiatrists better understand 1979; 7: 306–15
even individuals with severe mental illness are capable of the importance of what they were doing. While it was Caplan AL. Why autonomy
choice and self-direction dovetailed nicely with America’s commonplace through the 1950s to commit patients to needs help. J Med Ethics 2012;
love of autonomy, respect for individual difference, and inpatient treatment for months or even years at a time, published online Feb 15. http://
dx.doi.org/10.1136/
doubts about paternalism. People with severe mental illness, there was little reflection on associated deprivations of their medethics-2012-100492
however, differ in a fundamental way from other, historically liberty. The legacy of psychiatry before the mid-20th century Gaylin W, Jennings B. The
marginalised populations. A key aspect of mental illness is is one marked by scandal, neglect, and brutality. Sadly, that perversion of autonomy: coercion
that it affects integral aspects of an individual’s personality: horrific legacy continues in many parts of the world. Szasz and constraints in a liberal society.
Washington DC: Georgetown
cognition, emotions, and behaviour. One’s skin colour facilitated efforts to re-examine the tendency to commit University Press, 2003
or gender does not interfere with neurophysiological patients to indefinite periods of hospitalisation with little Isaac RJ, Armat C. Madness in the
processes influencing self-direction. Roughly half of oversight and no recourse for review. Tipping the scales in streets: how psychiatry and the
patients with active psychotic illness are thought to have the direction of patients’ rights was long overdue. However, law abandoned the mentally ill.
New York: The Free Press, 1990
anosagnosia—no insight into their disease. Serious mental this philosophically driven reform to indiscriminately
James JD, Glaze LE. Mental health
illness often competes with the individual’s capacity to protect autonomy hindered providers’ ability to treat some
problems of prisons and jail
make balanced, informed decisions and can sabotage an patients with serious mental illness. Ironically, it did as much inmates. Special Report NCJ
individual’s true interests when left untreated. to undermine autonomy as it did to protect it. 213600. Washington, DC: US
Department of Justice, Bureau of
Szasz established a non-evidence based, philosophical
Justice Statistics, 2006
foundation for the practice of mental health that prioritised Arthur R Williams, *Arthur L Caplan Lamb RH, Bachrach LL, Kass FI,
the views and preferences of individuals with serious mental Department of Psychiatry, New York University School of Medicine, eds. Treating the homeless
disorders above the true interests of a person not in the grip Bellevue Hospital Center, New York, NY, USA (ARW); and Division of mentally ill: a Task Force Report
of mental illness. Consequently, some mental health laws of the American Psychiatric
Medical Ethics, Department of Population Health, New York
Association. Washington, DC:
in the USA now better protect the preferences of a patient’s University Langone Medical Center, New York, NY 10016, USA (ALC) American Psychiatric
psychosis than the patient. To some extent, the philosophical [email protected] Association, 1992

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