Thomas Szasz and the "Myth" of Mental Illness
Haag, Ernest van den
"Thomas Szasz and the "Myth" Ernest van den Haag Thomas Szasz and the "Myth" of Mental Illness Iam second to none in my admiration of Thomas Szasz. He has great merit in having drawn to our attention (in The Myth of Mental...
...The separation of psychiatric and moral diagnoses still is far from complete...
...and, by definition, they are not competent themselves to decide whether they are better off institutionalized...
...Szasz is often right in practice though for reasons other than those he gives: not because there is no mental disease as he thinks but because its presence does not usually permit us to predict behavior that, if it could be predicted, should lead to confinement...
...And so it goes through all the grades, involving mysterious techniques such as the "dual payline process," until it is finally concluded that an "across-the-board" pay increase is warranted, and it only remains for the president to sign it into law...
...So this year President Carter lost no time in signing on the dotted line just as soon as the dotted line was put under his nose, and now all federal workers are being paid 7.05 percent more than last year...
...So, in the fullness of time, these things came to pass...
...At that time the BLS investigators returned from the heartland and reported their findings: The salary for comparable jobs in the private sector was $10,100...
...In March 1977, a GS-5 clerical worker was paid $10,677 annually...
...Presidents Nixon and Ford were sometirfies a little tardy, stubborn, or unenthusiastic about signing, but when that happens such documents as the presidential income tax form 1040 are in grave danger of popping up on the front page of an important newspaper...
...Thus, a federal judge recently decreed that involuntary confinement of the insane without treatment is unconstitutional as though (a) treatment existed for a great number of conditions for which it does not exist, apart from judicial hallucinations...
...They still are: In the past disease often was regarded as immorality...
...Though I should hold drunks responsible for their acts for they contracted drunkenness voluntarily...
...Irrationality and lack of control are also found when the disorder is purely behavioral without a detectable physical or chemical cause...
...Surely this is seen when there is brain damage...
...and unlike Szasz, I believe we must institutionalize those insane persons who are totally incompetent or dangerous to others...
...it is not desired by the obsessed and hinders and defeats his activities and wishes...
...How does this work...
...If they do not have a reasonable capacity to make rational decisions and are a threat to themselves or others, such persons may be confined...
...Hartman comments: "This finding—which a hard-nosed type might regard as an Tom Bethell is Washington editor of Harper's and contributing editor of the Washington Monthly...
...The patient may lose all conscious control over his behavior and become unable to grasp or respond to rational communications, to judge the nature and effects of his acts, to be able to intend or control them...
...To be sure, such a patient, although he suffers from a mental disease, is "perfectly aware of his condition" and capable therefore of deciding on treatment himself...
...This need persists...
...GS-5s are thus transformed from being overpaid to being underpaid...
...I don't share this view...
...The confinement has nothing to do with whether we like the decisions confined persons make—suicide, homicide, or any other—but only with whether their decisions are made while compos mentis, capable of making rational decisions, decisions that are intended and likely to lead to the intended effects...
...The mental hospital is not better for him, or the community, nor more curative...
...No one back home noticed the difference...
...Which is unfortunate for he risks discrediting a justified position for the sake of what seems to me a seductively simple but wrong view...
...Mental diseases differ from physical ones in many respects...
...There you have a capitol idea in action...
...The Romans spoke of a person non compos mentis, who temporarily or permanently did not possess the rational ability required to exercise his rights as a member of society...
...So are suicides...
...Modern liberals feel uneasy with the notion of moral right and wrong, of moral norms (rules, laws...
...But they can be as involuntary, harmful, and incapacitating...
...But in practice, as Szasz points out so incessantly, moral judgments often were disguised as clinical diagnoses...
...Treatment need not depend on the presence of disease: Obstetricians or cosmetic surgeons treat conditions that are not diseases...
...Everyone who wants treatment, including institutionalization, for the sake of changing or controlling his feelings or behavior should have a right to arrange for it...
...You may not have known it, but federal pay is based on something called "comparability...
...Some wise old heads at the Civil Service Commission, or some such place, put their wise old heads together and said to one another: If we were to strike, no one would be any the wiser, or any the poorer, while for others life might actually be greatly simplified...
...Anyway, as a result of the pay raise, the Washington area is now richer to the tune of $700 million a year...
...The evidence...
...Thus, most suicides are temporarily deranged, but by no means all...
...Let us see how this works in greater detail (I am indebted here to Robert W. Hartman, an economist with the Brookings Institution, for these figures...
...Not all such persons need to be institutionalized...
...And how could treatment be voluntary if the confinement is not...
...Clearly obsession neither starts nor stops with a conscious (and voluntary) act...
...most homicides are sane and do not by themselves justify even a suspicion of mental illness...
...Consider Freud's vivid and accurate description of obsession: "...the patient's mind is occupied with thoughts that do not really Ernest van den Haag is professor of social philosophy at New York University, and lecturer in psychology and sociology at the New School for Social Research...
...is now $20,800...
...Szasz is quite right in insisting that psychiatry historically has confused, clinical questions and judgments—dealing with the presence of pathology—with moral ones—dealing with the rightness, propriety, or acceptability of the behavior of the patient...
...Thomas Szasz is right then...
...Confusion in this area is not limited to psychiatrists...
...Also, there is the danger that they may vote Republican next time...
...Thus, I agree with Szasz on the treatment of the insane who have committed crimes, but unlike Szasz I believe there is such a thing as mental illness, which Szasz believes is a labelling device...
...He has great merit in having drawn to our attention (in The Myth of Mental Illness) the scandal of forcible confinement of harmless, if eccentric, people who have been confined as mentally ill because they were a nuisance to their families, friends, or enemies, or to the community as a whole...
...To do so, I agree with Thomas Szasz, may be neither necessary nor useful...
...Obsession certainly does not call for confinement...
...But mental diseases may go further and affect other parts of the personality...
...therefore, let us not go on strike...
...Federal pay is then increased to make up the difference...
...b) treatment somehow could justify, or make constitutional, involuntary confinement, which clearly, if it can be justified at all, cannot be justified by involuntary treatment...
...Recidivists also may be dealt with without distinguishing between sane and insane...
...Murderers (or criminals in general) are "sick...
...Hence they may be confined involuntarily, on a basis other than their own decision, for the sake of either their own welfare—which they are no more competent to judge than an infant might be—or for the welfare of the community...
...But what affects the patient is a disease, or the symptom of a disease, and he and others, except Szasz, perceive it as such...
...Often "treatment" has been worse than punishment—more painful, indefinite, and confining—while depriving "patients" of the elementary procedural safeguards and rights that even the worst criminals retain before and after they have been found guilty...
...Why, they do what I don't approve of...
...If we could know for certain what the psychotic will The American Spectator February 1978 19 do, I—unlike Szasz—would not object to confinement to restrain the psychotic from acts that would be criminal if done by a sane person...
...On the other hand, if a person has committed a criminal act, I do not really care whether he is found "not guilty by reason of insanity" and confined in a mental hospital, or guilty and confined to a prison...
...But we are entitled, even obligated, to prevent what they cannot control...
...excuse for a pay reduction—was transformed into a pay raise under what is called the government's comparability method...
...thus they are not responsible and cannot be punished post facto...
...Helped by the growing effectiveness of chemical means in the management of agitation and depression, Szasz has greatly contributed to liberating literally thousands of patients—who should never have been confined in the first place...
...the bureaucracies ticked along quietly with the high absentee rate customary at that time of year...
...Hartman explains: "At GS-5, the private sector secretarial wage was combined with technical jobs paying $11,770, administrative posts at $12,346 and professional slots at $13,439, to reach an average survey salary for GS-5 of $10,736...
...In the case of psychotics we may not call what follows a guilty finding "punishment...
...But our ability to predict is much less than psychiatrists have pretended...
...Historically psychiatry attempted to separate the pathological, to be treated, from the immoral, to be condemned...
...From the true and lamentable fact that many diagnoses of mental disease are no more than disguised moral judgments of disapproval (and bad judgments at that, apart from being irrelevant) Szasz goes on to assert that there is no such thing as mental disease...
...I have always thought that that is why federal employees are not allowed to strike...
...Treatment should depend only on wishes and possibilities...
...This comes up every October...
...Sticks-dwellers, we give thee thanks...
...The average federal white-collar salary in D.C...
...Szasz would oppose the involuntary confinement of such persons, not only because he denies the existence of mental disease, but also because he feels that the disturbed person, like the sane, should be confined only for what he has done and not for what he may do...
...But the important thing is that the same processes be used to ascertain the facts and to protect thecommunity whether or not the offender is "sane...
...The theory behind "comparability," of course, is that if people are not offered enough money to work for the government, they 20 The American Spectator February 1978...
...Hence we may just as well use the same processes and outcomes regardless of whether the person was disturbed—and not responsible therefore—or sane and responsible...
...Tom Bethell Capitol Ideas The holiday season found Washington largely emptied of its busybodies...
...By way of compensation, however, the wise old heads said to one another: We shall pay ourselves at an ample rate of remuneration, and—because we do not wish to be sullied with the contamination of "politics"—we shall make it very difficult for any of our number to be fired...
...suicide attempts do not suffice for a diagnosis of illness, but they invite scrutiny...
...There is the danger that if federal workers are not paid more every year to keep up with inflation, they may sullenly decline, in the many ways open to them, to implement presidential programs...
...Government specialists from the Bureau of Labor Statistics set forth across the land each year to find out how much money people are earning in the private sector...
...Beyond the threat of a seeping scandal, there are other reasons why the president, whoever he is, can more or less be relied upon to sign this pay raise into law...
...This is cure by definition...
...Szasz has the merit to have drawn attention to abuses and confusions...
...There are 1.4 million federal white-collar workers, and it is a good bet that most of them vote Democratic...
...Armed with this data, they then return to Washington, and here they reliably find, year after year, that those laboring in the private sector are being paid more than those who work for the government...
...today immorality, including criminality, often is regarded as a disease...
...Szasz is right and meritorious in protesting the over-extension of the notion of disease—but he goes too far when he denies, by definition, the possibility of mental disease and the need, occasionally, for society to take decisions for those who are in no position themselves to take them...
...But he goes too far...
...But he has not persuaded me that mental disease is a hallucination —although I too wish the world were neater...
...Thus, there rarely is sufficient reason for preventive action...
...Only part of his psyche is affected by his ego-dystonic condition...
...Still, mere incompetence, if it goes far enough, may require institutionalization: We would not leave a four-year-old to his own devices and we cannot do so for a person no more competent, whatever his age...
...it does not help either the patient or society...
...interest him, he feels impulses which seem alien to him, and he is impelled to perform actions which not only afford him no pleasure but from which he is powerless to desist...he is perfectly aware of his condition...only he cannot help himself...
...They have not been able to quite dispense with these notions—it is impossible to have a society without them—but, because of their uneasiness, they have disguised moral judgments which now take the form of pseudo-clinical diagnoses...
...Or even when a person is functionally disabled, intoxicated by drink or drugs...
...In principle, disturbed persons may be confined qua disturbed, for the sake of their welfare, or that of the rest of us, since when they threaten to interfere with either, they cannot be said voluntarily, intentionally to do so...
...but (with one exception of which anon), no one should be forced to accept treatment or institutionalization against his will...
...But surely such persons exist...
Vol. 11 • February 1978 • No. 4
