The legacy - or not - of Dr Thomas Szasz (1920-2012).

Dr Trevor Turner was asked to provide a commentary on the preceding paper in this issue, '"Freedom is more important than health": Thomas Szasz and the problem of paternalism', by Joanna Moncrieff.

During the 1960s and 1970s the arguments put forward by Thomas Szasz, a Hungarian émigré who established himself in the psychoanalytic world of the USA, becoming Professor of Psychiatry at the State University of New York in Syracuse, were widely discussed and even admired. His arguments, made most forcefully in his 1961 book The Myth of Mental Illness: Foundations of a Theory of Personal Conduct, essentially stated that psychiatry was an emperor with no clothes. He considered that physical health could be dealt with in ‘anatomical and physiological terms’, while mental health was inextricably tied to the ‘social’ (including ethical) context in which an individual lives. He regarded the term ‘mental illness’ as a metaphor, and used the analogy of a defective television set to explain his meaning. It was as if, in his view, a television viewer were ‘to send for a TV repair man because he dislikes the programme he sees on the screen’.

As outlined in the previous article in this issue, by Joanna Moncrieff (2014), Szasz held freedom to be more important than anything, seeing psychiatrists as paternalistic and imposing a myth on capacitous individuals whom they deem to have a ‘mental illness’, but who are actually suffering from degrees of social deviation rather than a formal disorder. He wrote numerous articles and books, and was popular at meetings. In the early 1990s, at a meeting of the European Association of the History of Psychiatry, he was quite charming, impervious to argument, and a little hard to understand because of his unique accent.

Szasz’s views over the 30 or 40 years of his working life never changed, the patient being someone who paid you money to receive discussion and advice. He worshipped at the throne of the contractual life, denying schizophrenia’s illness status, there being no organic factors. Detention under the Mental Health Act he saw as a threat to individual liberty, not a therapeutic event. Patients seeking help from psychiatrists he found perplexing. The logic of his view, therefore, would see Parkinsonism (when first described in the 19th century) as a non-disease, it being just a description of behaviours rather than linked to physical pathology. Martin Roth (1976) gave an excellent critique of his theories.

What did emerge from the antipsychiatry movement was the realisation that psychiatry needed to get its diagnostic house in order. The development of stricter criteria for defining schizophrenia, led by the World Health Organization, established a most reliable diagnosis. Perversely, this move away from the more psychoanalytic versions (of schizophrenia and hysteria, for example) to the first-rank and functional criteria of the modern period reduced psychiatry’s standing in the artistic and intellectual worlds. The psychotherapeutic doctor hero (Szasz, even?) in many 1960s and 1970s films has now become the white-coated figure in a secure unit, injecting people and giving them shock therapy, and even the ultimate psychiatric monster, Dr Hannibal Lecter (an ultra-Szaszian version of how he portrayed psychiatrists).

In her commentary on Thomas Szasz’ work, Dr Moncrieff has suggested that ‘Only when healthcare is designed and implemented by the community itself will it be able to foster the development of capable and autonomous individuals’. This view is quite Szaszian, in denying the specialist skills of psychiatry. But while, for example, a diabetic patient after 10 years of illness may know much about both his symptoms and his treatment needs, the extraordinary debate in the USA about health insurance for everyone (not just the rich) and the shooting of vaccination workers in Pakistan seem to indicate that ‘sensible’ beliefs about healthcare are not necessarily the norm. We do have intense debates about mental health in the UK (e.g. the 10-year discussion around a new Mental Health Act, an admirable social construction), and the battle against stigma is long and wearying.

Whatever psychiatry is, it is clearly a part of medicine in terms of taking a history, examining patients and reaching a diagnosis to provide treatment, and can be seen as one of the most thoughtful parts of medicine. Everyone has a right to treatment, the best available, and detained patients rarely take umbrage once they become well. Dr Szasz has had his time, and paying him privately is not (in my view) the way to construct modern doctor–patient relationships.