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Selected Leifer Materials:
The Legacy of Ernest Becker
The Psychiatric Repression of Thomas Szasz: Its Social and Political Significance
By Ronald Leifer, M.D.
Thomas Szasz has been the leading critic of psychiatry for the past thirty five years. In this time, his relationship with psychiatry has been problematic and painful. Critics are rarely loved by the objects of their attention. Thomas Szasz has been hated, mocked, repressed, ignored, and ostracized by psychiatrists who fear his critical gaze. This period of psychiatric history, which is not well known, is highly significant for contemporary psychiatry and for the society in which it operates.
The reader should be informed at the outset that I, personally, have been strongly influenced by Szasz to both my benefit and my detriment. I first met him in 1956, when I was a senior medical student and he had just been appointed professor of psychiatry at the Upstate Medical Center at Syracuse. We have been friends and colleagues for--I am startled by the number-- almost forty years. In this time, both psychiatry and American society have undergone profound changes. Some people have blamed Szasz for some of those changes, for example, the deinstitutionalization of mental patients.(1) Others would deny that he has had any influence at all on psychiatric thought or practice. They say that progress in biological psychiatry has rendered his writings hopelessly obsolete.
It is incorrect and unfortunate, however, to dismiss the corpus of Szasz's work on the grounds either that he has been a negative influence or that his work is no longer relevant to modern psychiatry. Although Szasz has been in conflict with psychiatry because he is an individualist and a champion of individual rights, he is not an individual thinker. Strictly speaking, there is no such thing as an individual thinker in the sense that individuals think in the intellectual paradigms of their times. Thinking is a social activity. Thinkers think in the framework of thoughts articulated before them. They may interpret and express their ideas uniquely, but they nevertheless swim in the intellectual currents of their Zeitgeist. Szasz represents a current of intellectual history. The fact that most psychiatrists dismiss him as irrelevant means that psychiatry rejects and avoids that current.
If some people regard Szasz's work as wrong, obnoxious, or obsolete it is because it embodies a historical set of concepts and values with which they disagree or by which they are threatened. Szasz has written critically of psychiatry because he disagrees with fundamental psychiatric concepts and values. The relationship between Thomas Szasz and psychiatry is shaped by ethical and philosophical conflicts which are rooted in historical and political currents. Understanding these currents will help to illuminate some vexing problems of modern psychiatry and society.
THE HISTORICAL CONTEXT
Students of the sociology of knowledge have long understood that thought is a commodity. Karl Mannheim observed that thoughts have political and social value.(2) Some thoughts are enlightening and ennobling while others are false and degrading. Some ideas are congenial and supportive of our particular interests while others are contradictory and threatening. Mannheim, like most social thinkers after Marx and Freud, recognized that individuals and groups are motivated by their desires and interests and tend to support ideas which promote them and to oppose ideas which obstruct them.
History shapes and is, in turn, shaped by the dynamic conflict between competing desires and ideas. Until the seventeenth century of the Christian era, the prevailing ideology in the West was a cosmology which viewed the world hierarchically. The earth was perceived as at the center of the universe, orbited by the seven visible spheres: the moon, the sun, Mercury, Venus, Mars, Saturn, and Jupiter. Presiding at the pinnacle of this cosmic hierarchy was the Judeo-Christian Sky God, Lord of the World, who governed human affairs through His representatives on earth-kings and popes. They, in turn, ruled by divine right over the descending order of landed nobles and feudal chiefs, soldiers and knights, artisans and merchants, and, at the bottom, peasants and indentured serfs.
In the seventeenth century, this dominant ideology was challenged by the scientific discoveries of men like Giordano Bruno, Johannes Kepler, Galileo Galilei, Isaac Newton, and Rene Descartes. In their new, scientific world view, the earth was perceived as only one of six planets orbiting the sun in a universe governed indifferently by the laws of physics. The New Science threatened the knowledge and, therefore, the authority of the prevailing social powers who consequently opposed it and persecuted its practitioners. Bruno was burned at the stake for teaching that the earth revolves around the sun. Kepler and Descartes were intimidated. Galileo was forced to recant it. His works were censored by the Vatican's index of prohibited books until the end of the nineteenth century.
But the medieval cosmology could not withstand the assault of factual knowledge about the world. At the same time that the facts of the New Science were spreading across Europe, the Catholic Church and the monarchies of its Christian empire were disintegrating from the poisonous effects of their own corruption, cruelty, and hypocrisy. A ground swell of political unrest and revolution overturned the authority of the tyrannical rulers beginning in America in 1776, erupting in France in 1779, and continuing around the world until today.
The twin ideals of the intellectual and political revolutions of the European Enlightenment were science and democracy. Jurisdiction over the problems of human suffering and the pursuit of happiness were transferred from religion to science and from church to state. The new social order would no longer be guided by priests, Kings, and scripture toward a hoped for heaven after death. It would now be guided by scientists and politicians toward the utopian ideal of social progress here on earth.(3)
The decline of traditional religious authority, the rise of the city, and the corollary disintegration of the clan and family left the individual and the state as the new primary units of society. The democratic revolutions embodied a new political spirit of a community of individuals as expressed in the slogan "Liberty, Equality and Fraternity." This new ideology was fueled by the hope for social progress based on faith in science and an economic policy driven by enlightened self- interest under a minimalist state ruled by law. American constitutional government was designed on the template of this ideology. This is the current of history to which Thomas Szasz belongs. Szasz has been labeled a political conservative but he is, basically, a Jeffersonian liberal.
Szasz's valuation of the individual and of individual rights under the rule of law in an open society also has a personal context. He was born Jewish in Hungary in 1920 when anti- Semitic Fascism was on the rise. His family was educated and politically sophisticated. They knew that Fascism and Communism both meant the hypertrophy of the power of the state and the repression of the individual, especially the Jewish individual. Szasz fled Hungary in 1938 together with his beloved brother George. His parents followed later. They traveled overland to Paris and then overseas to the United States, to Cincinnati, Ohio, where relatives lived. Szasz attended the University of Cincinnati and graduated first in his class with a bachelor of science in physics. He then completed his medical education at the University of Cincinnati medical school.
Szasz's conflict with psychiatry has its historical roots in the growth and expansion of the power of the state over and against the individual. The eighteenth-century ideal of enlightened self-interest was, in practice, more selfish than enlightened. The gap between rich and poor grew wider than it had been under the old feudal and monarchic orders. The modern socialist state has hypertrophied to its present Leviathan proportions to mediate the conflicts between classes and groups, to replace the historical functions of the declining family and community, and to socialize, educate, and control its members.
As a social institution, psychiatry has historically functioned both in the service of the individual and in the service of the state. This is the root of the conflict between Thomas Szasz and modern psychiatry. Psychoanalysis and psychotherapy developed in the service of the modern, alienated individual to help resolve and relieve the psychological conflicts and emotional pain of secular life. In this manifestation, the psychiatrist is the heir of the priest, the moralist, the educator, and the critic. Szasz belongs to this tradition. He was trained as a psychoanalyst and, like Freud, was more comfortable in the role of the intellectual and literary critic than of the medical physician.
Psychiatry has another face, however. Psychiatry has also allied itself with the state as a covert agent of social control of the individual. This alliance of psychiatry and the state is a historical consequence of the limitations placed on the power of the state by the rule of law. The rule of law limits the power of the state over the individual. This limitation has motivated the invention of a covert, disguised means by which society can control the individual. Psychiatry has served this social function through its state sanctioned power to label certain forms of deviant or undesirable conduct as illness and by means of involuntary psychiatric commitment which enables the state to detain individuals against their will, without trial or conviction of a crime, in the name of their mental health.
The conflict between Thomas Szasz and establishment psychiatry began in the historical context of the conflict within psychiatry about whether it functions as an agent of the individual or as an agent of the state. Szasz's critique of psychiatry has two elements: first, the critique of the political function of psychiatry as an agency of social control; second, the critique of the ideology which justifies and facilitates this political function, namely, the medical model of psychiatry.
SZASZ'S EARLY WORK
Szasz inaugurated his critique of the medical model of psychiatry with the publication of the now classic Myth of Mental Illness in 1961. This seminal work has been widely misunderstood and misinterpreted. Many psychiatrists to this day believe that Szasz denies that mental illness exists and even denies that mental suffering and disturbance exist. On the contrary, Szasz does not deny the existence of suffering. How foolish for anyone to think so. Szasz acknowledges the existence of mental illness, but differs from the conventional view of it. The critical point is that mental illness is not a disease which exists in people, as pneumonia exists in lung tissue. Mental illness is, rather, a name, a label, a socially useful fiction, which is ascribed to certain people who suffer or whose behavior is disturbing to themselves or others.
Szasz developed this point of view while he was a student and teacher at the Chicago Psychoanalytic Institute under Franz Alexander. Alexander's work focused on the psychoanalysis of psychosomatic disorders. Szasz disagreed with his teacher on fundamental philosophical points which Szasz presented in his first book, Pain and Pleasure, published in 1957. In this book, Szasz critiqued the prevailing tendency to psychoanalyze body functions, imputing meanings to and motivations for physical diseases. Szasz's critique was based on the work of modern English philosophers such as Bertrand Russell, Gilbert Ryle, and Karl Popper.
Szasz's critique of Alexander's work was derived specifically from the empirical and logical dualism developed by Russell and Ryle.(5) Russell took the epistemological position that mind-body dualism is based upon an operational dualism. Mind and body are different because psychology and the physics (including biology) are based on different methods of investigation. Knowledge about the body is obtained by means of the methods of physics observation, description, measurement, and mathematical calculation. Knowledge about the mind is obtained by means of communication through language and the interpretation of meanings. Ryle supplemented this view with the argument that, since our knowledge of other minds is based upon the meaning of the actions and speech of other persons, statements about minds and statements about bodies belong to different logical categories of language.
Szasz applied this point of view to the critique of the medical model of psychiatry. The medical model is so called because it views the mind the way medicine views the body, as an object which is explained either in terms of neurophysiology and genetics or in the language of disease, medicine, and treatment.(6) In Pain and Pleasure, Szasz argued that it is logically permissible to talk about the meanings of physical disease, in the sense of our reactions to them and interpretations of them. But to talk about meanings as causes of physical disease is to conflate two operationally and logically different concepts. In The Myth of Mental Illness, Szasz moved from psychosomatic disease to conversion hysteria to demonstrate that the classification of thoughts, feelings, and behavior as diseases or as diseased is a logical error. It confuses the logical category of the body with the logical category of the mind. The term "myth," in The Myth of Mental Illness, refers to a category error as described by Gilbert Ryle. Ryle defined a myth as not a fairy story but as the presentation of the facts from one logical category in the language appropriate to another.
Szasz's first book was not attacked by established psychiatry. In fact, Franz Alexander was so impressed by Szasz's intellect that he offered to make him his heir as Director of the Chicago Institute of Psychoanalysis.(7) Szasz turned Alexander down for another offer, as we shall presently see. Szasz came into conflict with psychiatry not so much because of his ideas but because of his values. All his life, Szasz has been the emphatic champion of the values of individual freedom, dignity, and autonomy, which are in conflict with the psychiatric practices of involuntary psychiatric confinement and treatment. This is the basis of the conflict between Thomas Szasz and psychiatry.
CONFLICT IN THE DEPARTMENT OF PSYCHIATRY AT SYRACUSE
I can best tell the story of this historical conflict from my own point of view. I believe it is a story that needs to be told and reflected upon. It illustrates how and why intellectual thought is subtly controlled by academic power brokers and, in this case, how the repression of Thomas Szasz and his students reflects the ironic predicament of modern psychiatry.
After graduating from the medical school at Syracuse in 1957, I served a one-year internship in medicine and psychiatry at the Strong Memorial Hospital in Rochester, New York. The six-month psychiatry rotation was under John Romano, who was chairman of psychiatry, and George Engel, from whom I learned to read electroencephalograms. In 1958, I returned to Syracuse to do my residency training under Szasz. Dr. Marc Hollender had just been appointed Chairman of Psychiatry at Syracuse, by the good graces and influence of Dr. Julius Richmond, who was then Chairman of Pediatrics. Richmond was a Chicago-trained, psychoanalytically oriented pediatrician who became friendly with Hollender and Szasz when he studied at the psychoanalytic institute. He later became Dean of the Faculty at Syracuse and then Director of Head Start and Surgeon General. Later he moved to the post of Director of the Judge Baker Clinic in Boston. Hollender brought Szasz with him to Syracuse as full and tenured professor of psychiatry. The idea was to form a psychoanalytic training institute at Syracuse with Szasz as the leading intellectual. I was a resident in psychiatry at Syracuse from 1958 to 1961, and was fortunate to have read The Myth of Mental illness in manuscript form and to have discussed it vigorously with a brilliant group of co-residents in Szasz's seminars.
To understand the situation at Syracuse, it is important to recall the intellectual context of psychiatry at that time. Psychoanalysis was in ascendance. It had been increasingly popular among American intellectuals during the 1930s. In the postwar intellectual ferment of the 1950s, it became the guiding theoretical framework of psychiatry. Its derivative, dynamic psychotherapy, was the most popular therapeutic modality. Therapists who did not have psychoanalytic training but who were psychoanalytically-oriented practiced dynamic psychotherapy. Psychiatric faculties across the country were recruiting training analysts for chairmanships and professorships with the same enthusiasm, conviction, and exclusivity as they now recruit neurobiologists.
Hollender's idea, as I understood it at the time, was to found a unique psychoanalytic center at Syracuse, unique because it would seek to integrate an interdisciplinary faculty and curriculum. Attempts to integrate psychiatry and psychoanalysis with psychology and the social sciences were very much in the air at the time. Hollender's predecessor, Edward Stainbrook, who was a medical psychiatrist as well as a Ph.D. psychologist, had already invited a variety of social scientists and humanities scholars from Syracuse University to participate in the undergraduate and graduate psychiatry teaching programs at the medical school.
At the time, about thirty-five years ago, Hollender's vision was avant-garde. It was at the cutting edge not only of psychiatric thought but of the social sciences and humanities, which were heavily influenced by psychoanalysis. Stainbrook had invited Professor Douglas Haring, an anthropologist from Syracuse University, to teach general and psychological anthropology to medical students and psychiatric residents. When Hollender took charge, he hired Ernest Becker, who had recently completed his Ph.D. in anthropology at Syracuse under Haring.
Becker and I quickly became close friends, bonded to each other by a common background as first-generation Jews; by a mutual fascination with anthropology, psychoanalysis, and intellectual history; and a by a mutual love of Italian food and films. Becker attended Szasz's seminars for psychiatric residents and began to read extensively in psychoanalytic literature, hoping to integrate psychoanalytic theory with current work in psychological anthropology. In 1961, I completed my residency and, at Hollender's invitation, joined the full-time psychiatric faculty. Gradually, Becker and I shaped a common vision which seemed to be in harmony with Hollender's vision of an interdisciplinary psychoanalytic center, namely, to bring modern knowledge from the fields of psychology, anthropology, sociology, and philosophy to bear on a new understanding of the forms of mental suffering which are designated as mental illness. Toward this end, I took a master's degree in philosophy at Syracuse University and also taught the sociology of personal development and deviance under Paul Meadows.
The next few years were intellectually productive for Szasz, Becker, and myself. Szasz followed The Myth of Mental Illness with Law, Liberty and Psychiatry, the third of 25 books he has published to this date. Becker wrote the first edition of The Birth and Death of Meaning, in which he attempted to integrate psychoanalytic and anthropological concepts of human personality development. Next, he wrote a potentially seminal book which, tragically, has been widely ignored by psychiatrists, The Revolution in Psychiatry. In this book, Becker adopts the eclectic spirit at Syracuse and the spirit of Szasz's critique of the medical model by initiating a project for the development of a nonmedical, interdisciplinary view of such alleged mental illnesses as schizophrenia and depression. I recommend this book highly to those interested in a fresh and non- reductionistic view of depression and schizophrenia. Becker's hopes for the development of a new humanistic science were dashed by developments at Syracuse, but he continued to write as he pursued the painful career of a peripatetic intellectual.
For my small part, I published in two directions. I wrote a number of articles critical of the legal and social functions of psychiatry.(8) At the same time, I was working with Ernest, in the context of our friendship, toward an interdisciplinary, nonmedical understanding of the various psychiatric diagnoses. In this period, I wrote a nonmedical formulation of the problem of phobias.(9) I was in the process of developing an introductory textbook of psychiatry for a course taught to sophomore medical students. I was also writing a political and sociological critique of psychiatry, which appeared in 1969 as In the Name of Mental Health: The Social Functions of Psychiatry.
The dark clouds of conflict, soon appeared on the horizon, however, and the dream of a school of autonomous, interdisciplinary intellects striving together to understand the problems of human life vanished in the storm.
In 1962, after The Myth of Mental Illness had been published, Szasz testified in the Onondaga County trial of John Chomentowski. Mr. Chomentowski owned a small gasoline station which he sold to a prominent real estate developer. When the developer tried to take over the property earlier than had been agreed, Mr. Chomentowski threatened the company's agents with a shotgun which he fired into the air. He was arrested and the prosecutors, aided by testimony of government psychiatrists, convinced the court that Chomentowski was not mentally competent to stand trial. Chomentowski was then committed to Matteawan State Hospital for the Criminally Insane, in spite of the fact that he had not been convicted of a crime. Szasz testified at a habeas corpus hearing in which Chomentowski was suing to gain his freedom from confinement. The trial, which I attended, was a highly anticipated event in psychiatric circles, since for the first time Szasz was in an adversarial confrontation with conventional psychiatrists in a public forum.
Szasz's testimony was eloquent, witty, and bold. Testifying for the defendant, he stated frankly under questioning that he did not believe that mental illnesses are true medical diseases but, rather, are psychiatric fictions. He believed that mental hospitals are prisons and that, in effect, Mr. Chomentowski had been imprisoned without having been convicted of a crime. He translated the state hospital psychiatrists' psycho-babble testimony into ordinary language with devastating effect. What the psychiatrists called psychotic aggression Szasz called anger at false confinement. What the psychiatrists called psychotic withdrawal Szasz translated as the unwillingness to consort with one's enemies. What the psychiatrists called contractions of his blepharal and facial muscles Szasz called "blinking." The state psychiatrists from Marcy State Hospital in nearby Rome, where Chomentowski was being held for examination and trial, were humiliated and angered.
Present in the courtroom was Abraham Halpern, then Commissioner of Mental Health for Onondaga County. He sat at the prosecutor's table, coaching the District Attorneys. He felt outraged by Szasz's testimony and made his feelings known. His protests reached the ears of the State Commissioner of Mental Hygiene, Dr. Paul Hoch. Simultaneously, the state hospital psychiatrists complained to the director of their hospital, Dr. Newton Bigelow, who was also editor of the then prestigious psychiatric journal, The Psychiatric Quarterly. Bigelow published an article in his journal condemning Szasz, "Szasz for the Gander."(10) In response to the complaints by the state psychiatrists, Dr. Hoch issued an order banning Dr. Thomas Szasz from teaching psychiatric residents at the Syracuse Psychiatric Hospital. To understand the significance of this order, it is necessary to know how Hollender's department of psychiatry was set up.
Hollender had a dual appointment as both chairman of the department of psychiatry at the medical school and as director of the Syracuse Psychiatric Hospital, which was a state hospital. In addition, many of the faculty of the department of psychiatry also had joint appointments as visiting staff at the hospital, including Szasz. This arrangement was and is today quite common. Many of the faculty of medical school departments of psychiatry around the country are also directors of, or staff of, government-run hospitals. The critical fact in this case is that Hollender decided to locate his office for both positions at the state hospital. Using state funds, he constructed for himself a very comfortable office at the hospital from which he conducted departmental business. In addition, Hollender refurbished a meeting room at the hospital where the department held its weekly scientific and faculty meetings.
When Szasz was notified that his appointment as visiting psychiatrist at the Syracuse Psychiatric Hospital was terminated, he boycotted the hospital, including the departmental meetings which were held at the hospital, on the basis that if he was not permitted to teach there, he should not attend teaching clinics conducted there. This created a conflict between Szasz and Hollender which split the department apart. Several faculty members, including the psychologists Ed Engel and Charles Reed, Becker, and myself joined Szasz in boycotting the hospital. Those who joined the boycott did not all necessarily agree with Szasz's analysis of the concept of mental illness, but they all found unacceptable the attempt by an official of the state to censor and repress a member of an academic faculty.
Hollender responded by offering to move the scientific faculty meetings to the medical school. This did not satisfy Szasz or other members of the faculty, however. They believed that Hoch's and Hollender's repression of Szasz made it clear that the teaching faculties of an academic department of psychiatry must be autonomous and independent of the state or the freedom of inquiry and expression would be jeopardized. They requested that Hollender choose between being director of the state hospital or being chairman of the department of psychiatry. If he was to continue as chairman of psychiatry, he should resign as director of the hospital and move his office to the medical school.
Hollender declined to choose. He took the position that the state hospital was the flagship of the department and he was admiral of both. Interpersonal tensions in the department intensified. Szasz's supporters took seriously the threat by the state to intimidate and repress academic faculty. Most of the faculty who had joint appointments at the medical school and the Syracuse Psychiatric or the nearby Veteran's Administration Hospital, which also had a closed ward with involuntary patients, were hostile toward Szasz. They rejected his critique of the medical model and believed he was creating unnecessary conflict. Some people believed that Szasz should not even be allowed to teach the myth of mental illness to students, interns, and residents at the medical school. The conflicts were both personal and ideological, the one fueling the other until the department was divided into two hostile camps.
Some members of the faculty contrived a secret scheme to lure Szasz into insubordination so they could fire him in spite of his tenure. One principled member of the group, Dr. Richard Phillips, withdrew and notified Szasz of the attempt. Szasz hired a young lawyer from the local law school, George Alexander, later dean of the law school at the University of California at Santa Clara, to defend him against his accusers. The dean of the medical school, Carlysle Jacobsen, appointed faculty committees to investigate the conflict. The AAUP committee, chaired by Dr. Peter Witt, found that Szasz's academic freedom had, indeed, been violated.
Hollender was exasperated by this conflict, which had stalled his quest psychiatric empire. One day, Hollender telephoned Becker to request his appearance in Hollender's office at the Syracuse Psychiatric Hospital. Some medical students had asked Hollender whether the psychiatric teaching program had been compromised by the conflict between him and Szasz. Hollender asked the students where they had heard such a story. They told him they heard it from Becker. Hollender was indignant. He accusingly demanded to know from Becker whether he was warning prospective interns and residents away from the department.
I was present when Becker returned Hollender's call. We had discussed how he might respond. Becker told Hollender that he would not meet him at the hospital because he was not on the staff of the hospital, he was on the faculty of the medical school. The administrators of the hospital had banned a faculty colleague from teaching there and so he would prefer to meet Hollender at the medical school. Hollender refused and, once again, ordered Becker to come down to Hollender's office in the state Hospital. Becker refused. Hollender fired him on the spot!
On the one hand, Hollender might seem to have had some justification for firing Becker on the grounds of insubordination. On the other hand, Becker was one of Szasz's most vocal defenders. His ideas and writings were influenced by or were in harmony with Szasz's views. Becker was even interviewing a few patients by Syracuse Psychiatric Hospital under Szasz's supervision. Firing Becker was a way for Hollender to strike back at Szasz
After leaving the medical school, Becker had a tragic-glorious peripatetic career.(11) He spent 1965 in Rome writing what he thought would be his monumental work, The Structure of Evil.(12) He then returned for a one-year appointment in the department of anthropology at Syracuse University, sponsored by his close friend Professor Agehananda Bharati. This was followed by a second year in Sociology, hosted by his friend Professor Paul Meadows, who was chairman. The following year, Becker replaced Erving Goffman at Berkeley on Goffman's recommendation. He won a brief moment of fame there when he was written up in Time magazine because the student body at Berkeley petitioned for Becker to be rehired, and, in an unprecedented move offered to pay his salary out of the student organization's treasury. But the university refused. It would have been too dangerous for them to rehire a professor who was a social critic and also popular with the students at time of political protest and upheaval.
Becker then moved across the bay to San Francisco State University where he worked happily until 1968, when S.I. Hayakawa, then president of the university, called police on campus to repress student demonstrations against the war in Vietnam. Becker resigned in protest in a heroic gesture, since he had three children and no prospect of any job elsewhere. The only offer he received was from Simon Fraser University in Vancouver, Canada, where he remained in exile until his premature death from colon cancer in 1974.
Two months after he died, Becker was awarded the Pulitzer Prize in Non-Fiction for his book The Denial of Death. This highly prestigious award represents the recognition by the literary community of the high merit of Becker's work. Yet Becker has never been recognized by establishment psychiatry in spite of the fact that he wrote continuously on psychiatric issues from his days in Syracuse until he died. His work has been totally ignored. To establishment psychiatry, Becker was tainted by his association with the reviled Szasz. In effect, Becker was indexed and repressed. He was the victim of modern society's favorite method of repressing its critics--what the Germans call Todschweigen (Tod = death; schweigen = silence)--death by silence.
After Becker left, I continued as an assistant professor at the department of psychiatry, teaching, writing, and speaking my mind on a variety of psychiatric issues, including the social functions of psychiatry and nonmedical conceptualizations of the problems of human suffering. During this period, I completed the manuscript of In the Name of Mental Health. In 1966, frustrated by his hostile standoff with Szasz, Hollender resigned as chairman of the department and was replaced by Dr. David Robinson, an ally of Hollender's who even more vehemently opposed Szasz's critique of psychiatry and the concept of mental illness.
The department was still trying to continue its liaison with social scientists and other scholars from Syracuse University. A committee was formed, of which I was an appointed member, whose job was to nominate social scientists from Syracuse University to teach the psychiatric residents and interns. I taught at Syracuse and knew the faculties of the social sciences and humanities, and I nominated Ernest Becker and Stanley Diamond, an outstanding anthropologist who later became professor at the New School, as the best suited to teach medical students and psychiatric residents. My colleague on the committee, Dr. Robert W. Daly, now Professor of Medical Humanities at the Health Sciences Center at Syracuse, agreed on these nominations, as did Dr. Bradley Starr, chairman of the committee, although Starr was doubtful that Robinson would approve of either of these men.
A few days later, Starr informed me that Robinson had indeed vetoed both Becker and Diamond as candidates to teach the psychiatric residents. I could understand why he vetoed Becker. Hollender, although no longer chairman, was still in the department and it would have been awkward for him to face Becker. I could not imagine, however, why Robinson objected to Diamond, who had nothing to do with Szasz or the Szasz affair. I protested to Starr. The next day, Robinson burst into my office and announced that he did not intend to renew my appointment. Since I was a junior faculty member without tenure, this meant, in effect, that I had been fired.
I appealed to the local and national chapters of the AAUP on the grounds that, although I did not have tenure, the university did not have the right to dismiss me because of my views. They could fire me without reason, or for such justifiable reasons as insubordination, dereliction, incompetence, or flagrant immorality. But they could not fire me because the chairman opposed my views, my speech, or my writings.
In a meeting with Dr. Jacobsen, Dean of the Faculty at the medical school, Robinson said he would not renew my appointment because he "did not need two French professors in his department," meaning that he had been sufficiently provoked by Szasz and did not want another thorn in his side. In other words, everyone else in the department could share Robinson's views, but if I shared Szasz's views, I was excess baggage.
To my further amazement, Robinson boldly admitted that he did not want me on the faculty because he did not want my book published while I was a member of the department. He said that he was afraid that with both Szasz and me writing, publishing, and teaching our heretical views, the department at Syracuse might become known as "anti-psychiatry" and might not be funded by the NIMH, with obvious unpleasant consequences for him and the department. Jacobsen, acting in the great tradition of academic administrators, chose to avoid conflict with a department chairman. He imposed a compromise. He conceded that the department had fired me without adequate notice since Robinson had fired me in March effective the following September while AAUP regulations provided for one year's notice to give the rejected member time to find another job. So Jacobsen gave me a six-month extension on my appointment--a delay of execution.
On another occasion, Robinson arrogantly admitted to me that he did not want either Becker or Diamond to teach in his department because he believed both men were eastern radical-liberal troublemakers who were stirring up dissent by participating in civil rights and anti-war protests. The implication was clear that Robinson believed that I, too, was a member of this group of traitors.
Becker and I were both victims of the psychiatric repression of Thomas Szasz. In my view, Robinson, Jacobsen, and the State University abridged my First Amendment rights of free expression. If one believes in the value of ideas and the right to express ideas, which is supposedly protected by the First Amendment, this is a serious matter. I do not think that my experience is unique. I saw a generation of brilliant intellectuals driven off university campuses because they studied and talked about Marx or some other out of favor thinker, or because they fought in the civil rights and anti-war struggles of the 1960s. In my view, the same situation exists today in universities and medical school departments of psychiatry. I do not believe thought is free America. Thought is a controlled substance, repressed and regulated by representatives of various prevailing interests. Many of my friends on the medical school faculty were horrified by this situation, but felt powerless to do anything about it. The AAUP committee of the medical school, after painful debate, decided not to challenge the administration on constitutional grounds.
It was a painful experience, but my fate, or that of Becker or Szasz individuals, is relatively insignificant in the scheme of history. More significant, it seems to me, are the questions of whether the right to the free expression of ideas was violated at Syracuse and, if so, what are the motives and consequences of such repression?
We can only speculate what course psychiatric history might have taken had Szasz not been repressed and had Becker and I not been fired from the medical school at Syracuse. Our dynamic trio would likely have attracted at least a few interested students. And some of these students might have matured, made their own unique contributions, and, in turn, drawn more interested students. Possibly, a school of thought might have developed at Syracuse which would provide a critical alternative to the current ideological hegemony of contemporary medical-coercive psychiatry.
As it is, neither Szasz, Becker, nor I have had any students, in the sense that most university professors and elders of various intellectual traditions usually have the opportunity to teach and guide their heirs of the next generation. After the crisis with Hollender was resolved, Szasz remained at Syracuse as full professor, but out of the spotlight and off stage. He was not asked and did not volunteer to teach psychiatric residents. He no longer presented papers or participated in the discussion at faculty meetings. He wrote and published prolifically, traveled and lectured widely and frequently, but was silent at Syracuse.
I too was, in effect, blackballed from academic psychiatry. I applied for faculty positions elsewhere, but I was condemned by my association with Szasz and by the evidence of my own writings. I submitted the manuscript of In the Name of Mental Health to Basic Books. They accepted and I went to Mexico on an extended adventure. When I returned, the editor at Basic Books, Irving Kristol, called me and withdrew the offer. Basic Books would have to reject my book, he confessed apologetically, because the psychiatrists to whom they gave the book to review were so outraged by it that they threatened to boycott Basic Books if they published it. Todschweigen! I was repressed and negated by psychiatrists who threatened to boycott my prospective publisher.
I have spent the last thirty years in the glorious isolation of private practice, continuing to study and write, striving to develop a nonmedical view on the problems of mental and emotional suffering. Having been disillusioned by the coercive and repressive influences in Western psychiatry and psychology, I turned elsewhere for insight and understanding. Over the years, my interest has increasingly turned to a study of the Buddhist view of mind.
Over the past twenty years, I have studied under several distinguished Tibetan Lamas, particularly Khenpo Karthar Rinpoche, Abbot of Karma Triyana Dharmachakra, a Karma Kagyu monastery near Woodstock, New York. I was one of the organizers of the first Karma Kagyu Conference on Buddhism and Psychotherapy at International House in New York in 1987. I invited Tom Szasz and R. D. Laing to be two of the main Western speakers at this conference. For the past two years, I have been a student at the Namgyal Monastery Institute for Buddhist Studies in Ithaca, New York, which was founded by the Dalai Lama. I have just completed a comparative study of Buddhist and Western views on suffering and the causes of suffering, called The Happiness Project.(13) I am now working on a manuscript on the emotions as viewed from a combined Buddhist and Western perspective.
In my view, obviously textured by my own personal experiences, the events at Syracuse are significant because they represent the repression and abortion of a school of ideas. I believe that ideas are important. E. A. Burtt once wrote that the concept a people has of its world is its most important possession. How we see the world shapes how we act in it. The repression of Szasz at Syracuse is symptomatic of a society which, like Oedipus Rex, blinds itself to the truth it does not want to see.
Szasz was banned from the Syracuse Psychiatric Hospital because of his views and his values. In contrast to the followers of the medical model, Szasz acknowledges and appreciates the differences between mind and body, and does not try to reduce the former to the latter. Unlike most modern psychiatrists, Szasz opposed the common practice of oppressing individuals through psychiatric labeling and involuntary commitment.
Szasz was repressed because his critique of the medical model threatened the medical identity of psychiatrists. Becker and I were fired not simply because we defended the academic freedom of a colleague, or even because we were friends of Szasz. We were fired because we were writing and publishing prolifically and thus also represented a threat to psychiatric ideology and psychiatric identity. In my view, the events at Syracuse constitute the control and suppression of thought for social and political purposes, something we assume does not happen in this country, but which happens so persistently and inexorably that we choose to ignore it.
THE SIGNIFICANCE OF THE PSYCHIATRIC REPRESSION OF SZASZ
What is the significance of the repression of Thomas Szasz and the possible abortion of a critical school of thought in psychiatry? To probe this question, we must trace the recent history of psychiatry. In the early 1960s when Szasz was first repressed, psychiatry was at a crossroads, a crisis of identity. The psychoanalytic tradition had reached the zenith of its influence and several formidable problems had been exposed. Psychoanalytic therapy had become the most powerful and most popular form of treatment of mental illness. The problem was that it is a nonmedical treatment. It can be practiced equally well by psychologists, social workers, and other skilled nonmedical professionals as well as by physicians. The increasing number of non- medical psychotherapists not only threatened the medical identity of psychiatrists, they also threatened the economic interests of psychiatrists by competing for psychiatric patients at a lower fee. A second and related problem was that the basic sciences of psychoanalysis are psychology and the social sciences. A sophisticated spectrum of neo- psychoanalytic, non-medical theories of mental illness was under development by men like Erving Goffman, Norman O. Brown, and particularly by the French existentialists. Szasz, with his reinterpretation of conversion hysteria in The Myth of Mental Illness, Becker, with his new theories on schizophrenia, depression, and the neurotic sexual fetishes, and my contribution on phobias(14) were on the frontier of this development.
The problem for psychiatry was that its medical identity was being eroded by psychoanalysis. Szasz's critique of the medical model and of coercive psychiatric practices was perceived by medical psychiatrists as an added threat to their legitimacy. Medical doctors in other specialties were growing increasingly skeptical that psychiatrists were really kin under the sheepskin. Nonmedical therapists, often well trained and competent, were competing with medical psychiatrists for fees. Psychiatrists who worked for the state, particularly those who worked with involuntary patients in mental hospitals or clinics and who adhered to a Kraepelinian model of medical diagnoses, were becoming increasingly hostile toward psychoanalysis and psychoanalytically-oriented psychiatrists in private practice.
Over the years, psychiatric anger toward Szasz and those who agree with his point of view has been further provoked by the mental patient's survivor movement. The medical- coercive psychiatrists and their sympathizers have come increasingly under criticisms and attack by survivors of psychiatric abuse-- victims of involuntary confinement and forced drugging and electroshock.(15) We have recently become more sensitive to the endemic horrors of sexual abuse and child abuse, thanks to the media. However, we have not discovered, or have not yet been willing to admit, the degree of endemic psychiatric abuse by means of involuntary confinement and forced treatment. Our denial is reinforced by psychiatrists who regard the victims of psychiatric abuse as mentally ill and therefore incompetent to form valid feelings or complaints. This is similar to saying that a rape victim asked for it. The mental patient survivors and self-help movement is autonomous and driven by its own motives, but it has, over the years, been inspired and supported by Szasz, Peter Breggin(16) (a student of Szasz's and me at Syracuse), me, and other critics of coercive medical psychiatry. This has contributed to the psychiatric anger toward Szasz and his supporters.
Hollender embraced both sides of this inner conflict of psychiatry in that he was both a psychoanalytically trained chairman of an academic department of psychiatry and a director of a state hospital. The situation at Syracuse was representative of the conflict within psychiatry as a whole and, thus, was primed and ready for the explosion that occurred.
At the same time, other developments in psychiatry were strengthening the hand of those who subscribe to the medical model. The era of tranquilizers had arrived with the introduction of Thorazine in 1954. The success of the new tranquilizers in controlling the inmates of psychiatric institutions was exploited by medical psychiatrists to bolster their argument that mental illnesses have a biological basis. Increasing funds were invested by pharmaceutical companies to develop new anti- psychotic and anti-depressant drugs and the NIMH increasingly favored research to study the safety and efficacy of these drugs, thus underwriting the medical model.
As narrowly-funded research seemed to confirm and explain the efficacy of psychoactive drugs, the false impression was created that psychiatry had become an objective, quantifiable, "hard" biological science. As new generations of drugs were developed, the pharmacological treatment of mental illness appeared to be more cost- effective and became more popular. This trend has continued to the present day, when, under managed care, drug treatment of mental illness is the preferred modality and psychiatrists are now primarily trained as psychopharmacologists rather than as psychotherapists. Psychotherapy has largely been taken over by nonmedical therapist! This is the historical context of the conflict between establishmentarian, medical- model psychiatry and its critics such as Szasz, Becker, and me.
But the pendulum of history may now be swinging the other way. The biological approach to mental illness may have reached a point where its weaknesses, problems, and contradictions are becoming clear, just as they did after psychoanalysis was in vogue for a few decades. The biological model of mental illness has been successful, in part, because it has identified itself with modern science and, thus, basks in the prestige of modern science. Present-day psychiatric theories assert that mental illness is basically brain disease, that schizophrenia and depression are basically caused by genetic predisposition to "chemical imbalances"--excessive dopamine in the case of the former and insufficient serotonin in the case of the latter. This point of view helps to solidify psychiatric identity as medical and carves out for psychiatrists a monopoly on the pharmacological treatment of mental illnesses.
Present biological theories of mental illness, however, are highly problematic. In the first place, they are incomplete, because they are biological, reductionistic and ignore the psychological dimensions of human experience and thus ignore what is most characteristic of and fundamental to the human experience. Secondly, they are weak in themselves, having been deduced entirely, and not entirely logically, from the actions of tranquilizers and anti-depressants on neuro- transmitters.
The fact that Prozac, for instance, which boosts inter-synaptic serotonin, can help lift depression does not logically imply that the depression is cause by low brain serotonin. It may equally well be, and is in my opinion more likely, that the individual's psychological response to life events condition the levels of brain serotonin. In spite of the strident brain reductionism of modern biological psychiatrists, there is strong scientific evidence that experience influences the brain's physical structure and development. Spitz's famous studies showed that babies will die without sufficient love. Children will lose their capacity for speech if they have not learned to talk by a certain age. A crowd of sports fans in a frenzy over the last-minute victory of their team will undoubtedly have elevated blood catecholamines. Is their excitement due to the elevated catecholamines or to the thrill of victory?
While psychiatrists are publicly engaged in a media blitz to propagandize the idea that mental illnesses are medical diseases which are treatable with medications, privately they admit that their research is flawed and their theories are, as yet, unproved. Every few years they convene a committee to write a new diagnostic and statistical manual (DSM), in which the primary proof of the existence of the diagnostic categories of mental illness is that psychiatrists, who train each other to see them, believe they exist. Natalie Angier, science writer for the New York Times, says what no psychiatrist will publicly admit: that they "want badly to transform their discipline into a hard, quantifiable science that is on a par with molecular biology, or genetics, but they have often been frustrated. Every time they think they have unearthed a real, analyzable gene to explain a mental disorder like manic depression or alcoholism, the finding dissolves on closer inspection or is cast into doubt."(17)
To make matters worse, psychiatry bears the historical guilt of having purged itself of critics. No supporter of Szasz's views on mental illness would be appointed to full-time position by an academic department of psychiatry to teach psychiatric residents. I know this from my own personal experience. In spite of his international reputation, Szasz's papers are routinely rejected by psychiatric journals. He has, in effect, been excommunicated.
As a result of the persecution of Szasz at Syracuse and elsewhere, there are no critics of psychiatry from within its ranks. This, in itself, should disqualify psychiatric theory as scientific. The essence of scientific method is critical inquiry. The basic principle of scientific discovery is the null hypothesis, that is, the hypothesis which, when it is advanced, is presumed to be false and is subject to exhaustive testing, checking, and criticism before it is even accepted as provisionally valid.
Psychiatric thought more closely resembles political ideology than it does science in that it is presented and certified by a power elite, the psychiatric establishment, who promote and propagandize their views as official dogma and who dismiss, exclude, and persecute dissenters. Psychiatric thought is not the product of a free market of ideas. It is carefully controlled and disseminated. And it serves the economic and psycho-social interests of those who purvey it by promoting their medical identity and justifying their right to receive part of the national health care budget. This does not mean that the costs of alleviating the emotional sufferings of life should not be distributed equally through insurance programs, whether private or public. It means that if we distort our perception of the problems of life by viewing them as medical illnesses, we are disabling our abilities to deal with these problems effectively in order to justify the sharing of its costs.
The persecution and repression of Thomas Szasz and his school of thought, and the corresponding supremacy of the medical model of mental illness, presents two critical problems, one for psychiatry and the population it serves and the other for society as a whole. An exclusively biological approach to problems of mental suffering and disability is, at best, partial and incomplete and, at worst, disempowering and disabling to the consumers of mental health services. It sends the explicit message that people are not responsible for the forms of suffering which are labeled as mental illness.
There are certain kinds of suffering for which the individual cannot be held responsible, and others for which he or she can. Certainly, people are not responsible for their medical illnesses, except in cases where they are self-induced, like cancer of the lung from smoking cigarettes. On the other hand, there is a degree of suffering that we cause ourselves because of our ignorance, our selfishness, our greed, and our aggression.
Ancient wisdom teaches that portion of our suffering is the result of defects of moral character. The Greeks, too, knew that character is fate. Sophocles said that "the greatest griefs are those we cause ourselves.(18) The Judeo-Christian Bible is a book of ethics based on the belief that evil- doing is punished with suffering and virtue is rewarded with happiness. The moral teachings of the Judeo-Christian prophets, on which the values of Western civilization are based, tell us, in effect, that although life is a "valley tears" we are, nevertheless, responsible for some portion of our suffering.
We are responsible, at least, for how we suffer, for example, whether we suffer patiently, like Job, or with aggression. We are also responsible for that portion of our suffering that we cause ourselves. We are responsible for the consequences or our words and deeds. This is the law of Karma, or, as the saying goes: "What goes around comes around." These are profound moral teachings and they are compatible with the view of most modern psychotherapists, who, whether or not they believe in the medical model, practice therapy on the assumption that we can increase our measure of happiness through self-knowledge and self-discipline.
Innumerable patients have come to me with the complaint that they have a "chemical imbalance." They have been told by other therapists, or have heard in the media, or have read in misleading NIMH pamphlets, that their sufferings - their depression, their anxiety, their guilt, their anger, their enthusiasm, their addiction to drugs or food, their obsessions and compulsions - are due to biochemical imbalances in their brain. They have no idea what these chemical imbalances are. But they believe they are the cause of their misery. As a result, they have not the slightest insight into or interest in the way in which their mental attitudes, orientations, and responses to life events cause their suffering and symptoms. They have become blind to the human dimensions of their lives, to the nature of their own experience, and thus have handicapped their ability to deal with the problems of life.
By discouraging people from taking responsibility for themselves, for their own behavior, emotions, and modes of thinking, biological psychiatry contributes to the current political atmosphere of the dissipation of moral values and the abandonment of personal responsibility. In this century, we have seen the balance between individual freedom and state power swing away from the individual and toward the state. As it swings toward the state, the individual is deprived both of freedom and the responsibilities which are intrinsic to the exercise of freedom. Modern psychiatry has contributed to the momentum of this swing by promoting an ideology which is biologically reductionistic and explains human thoughts, feelings, and behavior on the basis of brain physiology.
After completing his presidency, Dwight Eisenhower warned the American people that the military-industrial complex, which was largely responsible for victory in World War II, was the greatest danger to peace. As we approach the millennium, we must be aware of a new danger. The State-Science Alliance, upon which our forefathers relied instead of religion for human progress, is now the greatest threat to that progress.
The psychiatric repression of Thomas Szasz is a symptom of the rise of the State-Science Alliance--the ascendance of the ethics and technology for managing and controlling people and the simultaneous decline of the ethics of individual freedom, dignity, and responsibility. In the context of history, the conflict is between a narrowly scientific, biological-reductionistic view of human beings, which interprets behavior as the product of brain chemistry and justifies depriving certain individuals of their freedom against their will, and a humanistic view which integrates biological science into a multidimensional perspective on the individual as moral agent. To humanists all over the world, Szasz is a hero who has fought long and hard and with great personal sacrifice for the values of individual rights, freedom, and dignity, and against the paternalistic state and psychiatrists who function as agents of the state to manage, control, and repress the individual.
The issue came to a focus recently when Darryl Strawberry, star outfielder of the Los Angeles Dodgers, quit playing baseball, reportedly because he had a problem with drugs and had to enter a treatment program for addiction. Tommy Lasorda, manager of the Dodgers, criticized Strawberry for his lack of moral character because he yielded to the temptation of drugs. Tipper Gore, wife of the U.S. Vice-President and champion of medical- model coercive psychiatry, chastened Lasorda for his ignorance. Every educated person today knows, Tipper Gore said, that addiction is a disease and that Strawberry, therefore, is the victim of mental illness. Perhaps only old Szasz fans and old Dodger fans like me believe Tommy Lasorda.