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The Rhetorical Paradigm in Psychiatric History: Thomas Szasz and the Myth of Mental Illness

by Richard E. Vatz and Lee S. Weinberg

[Full Citation: Richard E. Vatz and Lee S. Weinberg, "The Rhetorical Paradigm in Psychiatric History: Thomas Szasz and the Myth of Mental Illness" in Mark S. Micale and Roy Porter, DISCOVERING THE HISTORY OF PSYCHIATRY, Oxford University Press, New York: 1994.

Note: This article may not be reproduced. The copyright is held by Oxford University Press. Contact Oxford University Press for reproduction permission.]

As even his critics acknowledge, psychiatrist Thomas Szasz is the preeminent and most prolific critic of psychiatric theory, practice, and participation in public policy and the law (Schoenfeld, 1976; Krauthhammer, 1985). Born in Budapest, Szasz and his family escaped Nazi Europe when Szasz was in his teens. While forsaking his original interest in internal medicine to specialize in psychiatry, Szasz was always skeptical of the medical pretensions of psychiatry, especially insofar as psychiatric hospitals were represented to be authentic medical hospitals. Instructed by his new department chair at the University of Chicago, where he did his residency, to spend a year of training at a state mental hospital, Szasz refused, saying, "I won't go because I don't believe in it" (Hirsch, 1992, p. A-7). Szasz had acquired early on an appreciation of the effects of language and metaphor on perceived reality, which led to skepticism and disbelief of psychiatric orthodoxy. After publishing a number of articles critical of psychiatric concepts and practice, in 1961 Thomas Szasz wrote his seminal work, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct, a book which challenged the medical identity of psychiatry (Szasz, 1961). This medical identity has constituted the dominant paradigm of madness since the inception of modern medicine in classical Greece, and continues as the dominant paradigm of American psychiatry, though "it has waxed and waned" (Szasz, 1987, p. 69) since the institutionalization of the concept of mental illness in America by the "father of psychiatry," Benjamin Rush, in the late 18th century, who certified madness as a medical concept in his 1812 publication, Medical Inquiries and Observations Upon the Disease of Mind, the first psychiatric textbook (Conrad and Schneider, 1980, p. 49). Most histories of psychiatry, E. Fuller Torrey has argued, are typified by Gregory Zilboorg's history of medical psychology in that they "are written by physicians with the assumption of the medical model as 'truth'. The history is chosen and synthesized to show how everything leads up to the contemporary physician-psychiatrist, 'treating' irrational behavior as mental 'illness'" (Torrey, 1974, p. 6).

The historic role and potential consequences of Szasz's revolutionary reconceptualization of the field of psychiatry can best be characterized as a major paradigm change. Thomas Kuhn's groundbreaking theory of paradigmatic change in scientific inquiry (Kuhn, 1970b) offers an illuminating framework for understanding the significance of Thomas Szasz in the evolution of psychiatry, as well as some basis for speculation about how Szasz's work will influence future developments in the field. Such an assessment requires an examination of the nature of Szasz's alternative paradigm, its implications for the extant psychiatric paradigm and its practitioners, and the prospect for bringing about a scientific or intellectual revolution. Thomas Kuhn's Theory of Paradigm Change

In his landmark Structure of Scientific Revolutions (1970b), Kuhn argued that scientific disciplines operate through agreed-upon paradigms, which constitute the "methods, problem-field, and standards of solution accepted by any mature scientific community at any given time" (p. 103). Crises occur when sufficiently penetrating anomalies, or dashings of "paradigm-induced expectations" (pp. 52-53) make the accepted modus operandi of the scientific discipline untenable. The success of an emerging paradigm, which Kuhn terms a "scientific revolution," requires the overcoming -- through persuasion -- of the presumption that adheres to the status quo. Moreover, the established paradigm can be replaced only "if an alternative candidate is available to take its place" (p. 77).

While Kuhn's concept of paradigm focuses on the competition among paradigms within scientific disciplines, Szasz's proposed paradigm differs in that it rejects the validity of psychiatric-enterprise- as science itself. Consequently, while the progression of Szasz's major paradigm change should follow Kuhn's descriptions of the progression of paradigm change, it should do so more intensely. Kuhn postulates the generation of genuine problem-solving accomplishments as the necessary criterion which distinguishes an enterprise as a "science" (p. 160). Yet, as elaborated below, Thomas Szasz's assertion that psychiatry has produced no genuine problem-solving accomplishment -- no progress, in Kuhn's terminology -- implicitly places psychiatry in a pre-paradigmatic stage, in which problems are created rather than solved.

For Kuhn, science involves the solving of puzzles, "that special category of problems that can serve to test ingenuity or skill in solution. . ." (p. 36), and "the assured existence of a solution" is a "criterion for a puzzle" (p. 37). But not all problems are puzzles. Indeed, in Szasz's new paradigm -- which we will call a rhetorical paradigm -- psychiatry has no clear puzzle to solve. Szasz's rhetorical paradigm implies that the deviant behaviors which constitute psychiatry's "puzzle" are, at least potentially, understandable, if not sensible or commendable, as game- playing and symbolic action strategically chosen as responses to varying social situations. Moreover, in Szasz's view, deviant behavior is not inherently problematic (unlike cancer, for example), and when it is most arguably problematic, as in behavior likely to harm others or oneself, it is not a puzzle because first, as in Kuhn's example of "a lasting peace" (p. 36), deviant behavior "may not have any solution" (p. 37), and second, because, in any event, it is potentially understandable as goal- seeking.

To Kuhn, an analysis of problem-solving capability is particularly revealing of the power of prevailing paradigms in a scientific community. For the practice of the traditional endeavors of a scientific enterprise, what Kuhn calls "normal science" (p. 52), the location of problems and determination of their solutions present an often self-validating and circular system, which militates against the production of "major novelties, conceptual or phenomenal" (p. 35). The instrumental value of the dominant paradigm is that it provides a "criterion for choosing problems that...can be assumed to have solutions" (p. 37).

In his rhetorical attack on the medical paradigm of psychiatry, Szasz was not only arguing for an alternative paradigm, but was explicitly saying that psychiatry was a "pseudoscience", comparable to astrology, two "instances of defining a science by specifying the subject matter of study...completely disregard[ing] method and ... based on false substantives" (Szasz, 1961, p. 1). Thus, the attack on the "normal science" of psychiatry -- what here will be termed the "medical model" - - constituted a more damning and disqualifying recommendation for change than is observed in the prototypical scientific revolution described by Kuhn. During scientific revolution, Kuhn finds the theoretical possibility of the new paradigm being practiced by practitioners of the old paradigm (p. 134), despite the tell-tale paradigmatic creation of a "different world" (p. 118) or new Weltanschauung.

But such accommodation to the rhetorical paradigm is quite unlikely. As described herein, the rhetorical paradigm represents so drastic a change -- indeed a repudiation of psychiatry-as-scientific- enterprise -- that the vocabularies of the two paradigms are completely different and incompatible, a degree of difference Kuhn maintains is not typical in paradigm change. Often, Szasz's use of rhetorical terminology to analyze the behavioral subject matter of psychiatry is dismissed ironically as a type of rhetorical legerdemain, or as one prominent critic called it, "word magic" (Schoenfeld, 1976).

As a further illustration of this frequent reaction, we are reminded of the audience reaction to a speech given by Szasz over a decade ago to the Pennsylvania Mental Health Association wherein we observed that few understood what he was talking about, let alone considered adaptation of their current methods to his proposed paradigm. In fact, Szasz's ideas of rhetorically created reality and the symbolic communication perspective of what is considered "mental illness" evoked reactions of confusion and embarrassed humor comparable to what one might witness from conventional theists listening to an evangelist speaking in tongues. Thomas Szasz's Rhetorical Paradigm

In Szasz's view the subject matter, method and promotion of psychiatry constitute a rhetorical enterprise masquerading as a medical/scientific one. Human behavior -- deviant and conventional -- consists of freely chosen, symbol-using, goal-oriented actions or games, in contradistinction to the psychiatric view of human behavior as determined motion. Psychiatry, in this view, functions rhetorically to accredit socially valued behaviors and discredit socially disvalued behaviors, ostensibly through medical analysis and cure, but in reality through the medical rhetoric of "diagnosis" and "treatment" of "mental illness" or "mental disorders." In doing so, Szasz argues, "psychotherapists are [base] rhetoricians" (Szasz, 1978, p. 20), rhetoricians who, in Richard Weaver's terms, use language to deprive people of their autonomy, as in the psychiatric efforts to prevent suicide, while simultaneously increasing their "own power [and producing] converts to [their] own cause..." (1978, p. 20). Nowhere is this latter motive more evident than in psychiatrists' writing of "psychohistory," wherein social and political preference masquerades as disinterested scientific analysis. Szasz describes such work as nothing but "[t]he vilification of hated, and glorification of loved, historical figures -- presented as the products of impartial psychiatric-historical research" (Szasz, 1990, p. 165). Psychiatry's hidden social and political agenda, among other things, disqualifies it from its claim of being in the category of a scientific enterprise.

For Szasz, psychiatry effects social control through the rhetorical imposing of definitions, but the "problems" it solves are more reasonably viewed as political. The alleged medical/scientific discovery of such "problems" amounts to no more than the rhetorical creation of problems through strategic defining, the "impos[ing of] their reality on each other and everyone else" (Szasz, 1984, p. 10). As Szasz argues in his epigrammatic book, The Second Sin, "The struggle for definition is veritably the struggle for life itself...In ordinary life, the struggle is [for symbols]...whoever first defines the situation is the victor; his adversary, the victim. For example in the family, husband and wife, mother and child do not get along; who defines whom as troublesome or mentally sick? ... In short, he who first seizes the word imposes reality on the other...." (1974, p. 24-25).

Szasz's rhetorical paradigm suggests that deviance has always been subjected to some sort of rhetorically justified forms of social control. As with the medical/scientific pretentions of psychiatry today, such control always succeeds through mystification which legitimizes it.

From Szasz's conception of the "Age of Reason," postulated by him to extend from the end of the Thirty Years' War (1648) to the present (as opposed to the conventional view of historians that the seventeenth and eighteenth centuries were the Age of Reason) the "dominant ideology of the West...has been scientific" (Szasz, 1973, p. 2), whereas it had previously been Christian. Moreover, Szasz sees this period also as the "Age of Madness," wherein social control is effected not through theological mystification, but by the "scientistic jargon" of psychiatric rhetoric. Thus, as science replaced theology, the concept of mental illness replaced evil, and forcible "therapy" replaced forcible conversion of heretics. Particularly in the Age of Reason, justificatory rhetoric was and is necessary to reconcile the resorting to punishment for those who commit the heresy of rejecting the Zeitgeist: "Man has always found it necessary to employ various methods for dealing with interpersonal and social antagonisms. All such methods [include] the use of force. However, [unlike animals, men] must also explain and justify it" (Szasz, 1970b, p. 293). The history of psychiatry and the Age of Madness is a history of the use of its armamentarium rhetorically to justify social control through involuntary "therapy" (e.g., mental hospitalization) and/or the "expulsion from the social order" (Szasz, 1973, p. 3) of those who violate the precepts of mental health, just as in the Age of Faith, rejection of the precepts of God were punished and/or discredited (Szasz, 1973; Szasz, 1970b).

Szasz argues that to understand both the behaviors called "mental illness" and the practices called "psychotherapy", one must understand not medicine, but rhetoric and metaphor: "Psychiatry, using the methods of communication analysis, has much in common with the sciences concerned with the study of languages and communicative behavior. In spite of this connection between psychiatry and such disciplines as symbolic logic, semiotic, and sociology, problems of mental health continue to be cast in the traditional framework of medicine" (1961, p. 3). Psychiatry is, therefore, ultimately a linguistic enterprise closely related in the tradition of Aristotle, to ethics and politics (Szasz, 1961, p. 212) and having as its end moral suasion rather than medical cures. Szasz states, "...what people now call mental illnesses are, for the most part, communications expressing unacceptable ideas, often framed in an unusual idiom" (1970, p. 19). Only if psychiatry is understood as rhetoric and persuasion rather than medicine can one begin to understand, for example, why: psychiatrists are seen as medical practitioners even though they don't practice medicine; people are seen as patients despite the fact they have no demonstrable illness; and psychiatrists' nonscientific and nonmedical opinions are seen as scientifically and medically based.

In Szasz's paradigm "mental illness" is a myth; that is, one cannot have a disease of the mind, since the mind is not an organ; it is an "abstraction" or a construct without physical referent (1965, p. 30). "Mental illness" is a literalized metaphor. Usually, literalized metaphors are recognized as such, and may be amusing, such as when a movie alien literally flies a kite when dismissively told to "go fly a kite." This central category error leads psychiatry into a wealth of category errors which create a pseudoscientific method of problem- solving wherein "we use language metaphorically and rhetorically and speak like the poet or the politician, not like the physician or scientist. Accordingly, the psychotherapist does not 'treat' mental illness, but relates to and communicates with a fellow human being" (1965, p. 30).

The prototype of the basic method of psychiatric treatment, Freudian psychoanalysis, is thus "communicat[ing] with patients by means of language, nonverbal signs and rules," as well as "analyz[ing], by means of verbal symbols, the communicative interactions which they observe and in which they themselves engage" (Szasz, 1961, p. 3). But, Szasz says, psychiatrists "talk as though they were physicians, physiologists, biologists, or even physicists" (1961, p. 3). Szasz sees in this not a scientific or medical method of healing, as Freud claimed, but rhetorical skills "in understand[ing] and decod[ing] the patient's communications" (1965, p. 38). To be authentic medical science, however, Szasz maintains that psychiatry would have to deal with its "core concept of disease" (1987, p. 23) medically, not rhetorically, but that foredooms it to failure since "man's sign-using behavior... does not seems to lend itself to exploration and understanding in these terms" (Szasz, 1961, p. 3). Thus, psychiatry's "normal science" uses a self- ennobling, but inappropriate, language of medical science, despite "using the methods of communications analysis [which have] much in common with the sciences concerned with the study of languages and communicative behavior" (Szasz, 1961, p. 3).

As exemplified in his analysis of the "establishing [of] hysteria as a medically legitimate illness" (1974, p. 17), Szasz views the history of psychiatry largely as a series of invalid, unscientific and non-medical assertions by physicians seeking to convince others "... to view almost any disability -- and particularly one, such as hysteria, that looked so much like a disorder of the body -- as illness" (1974, p. 24). These claims, Szasz asserts, have then been repeated, selectively interpreted, and largely accepted by psychiatrists who cite them as authorities whose earlier work justifies current psychiatric practices. Szasz points to Jean-Martin Charcot's "invention" of "hysteria" and its subsequent acceptance by Freud and others as the prototype for the creation of the concept of "mental illness." Szasz argues that Charcot, a physician specializing in diseases of the nervous system, simply "...decided by fiat that, in contrast to organic neurological disease, these people had 'functional nervous illnesses'" (1974, p. 22). As Szasz reads psychiatric history, Charcot's prestige as a neurologist allowed him to persuade medical and non-medical people alike that he could distinguish malingering from "hysteria", and thus he transformed hysterics into patients suffering from "illness" and enfranchised doctors to exercise control over their patients' lives. Subsequently, Freud and others built on Charcot's claim to be able to identify "hysterics." As Freud wrote, "...Charcot had thrown the whole weight of his authority on the side of the reality and objectivity of hysterical phenomena" (Szasz, 1974, p. 22).

By contrast, for Szasz, an "illness" is exclusively "a condition of the body...I define illness as the pathologist defines it -- as a structural or functional abnormality of cells, tissues, organs or bodies" (1987, p. 12). The elasticity of the definition of disease allows the subject matter and involvement of psychiatry to be nearly boundless. With its medical/scientific ethos, psychiatry engages in endeavors ranging from accrediting or discrediting of witnesses in court to involuntary psychiatric hospitalization, thereby regularly and systematically violating the "ideal" of the Szaszian paradigm: "to change patients only as they desire change" (1965, p. 45). Szasz maintains that the medicalization of personal and social problems simply "invites the use of medical rhetoric [to justify] resorts to coercive interventions to solve vexing social problems" (1987, p. 24).

Psychiatry's Promotion of the Medical/Scientific Paradigm

To Szasz, psychiatry has successfully, but inappropriately, claimed for itself special expertise concerning "man's journey through life" to the extent that "today, particularly in the affluent West, all of the difficulties and problems of living are considered psychiatric diseases..." (1970, p. 4; pp. 21-22). The identify of psychiatry as a medical science of behavior is engineered through the use of "the logic, the imagery and the rhetoric of science, and especially medicine" (1970, p. 4). Regardless of its authenticity, the promoting of psychiatry as science has long been critical to its economic and professional viability, though such a claim is not unique to psychiatry. Since at least the 1950's, Szasz notes, "every contemporary profession, unless based on art, is said to be based on science" (1965, p. 32).

Consistent claims by psychiatrists that psychiatry is a medical specialty are further belied by the fact that there is relatively little medical practice qua medical practice in psychiatry. As neurologist Richard Restak noted as recently as 1983, "Fewer than one percent of the nation's psychiatrists claim that their principal method is organic or biological. Only 213 psychiatrists in the United States have completed residency training in neurology" (Restak, 1983, p. 114). The same article reported that "a 1977 study by C.W. Patterson revealed that 81% of psychiatrists do not refer their patients to other physicians for such examinations. One third of those surveyed in another study admitted that they no longer knew how to perform a physical examination" (1983, p. 114). That psychiatry is not a science is evident in Karl Popper's observation of the impossibility of falsification of its claims (Popper, 1974); that is, as Szasz notes, psychiatry "cannot be proven wrong" (Szasz, 1987, p. 204). Moreover, conceptually, when viewed through a rhetorical framework, there can by definition be no medical or scientific authenticity to a field that focuses on nonmedical and nonscientific matters: the human mind and human behavior (1965, p. 30). Szasz argues further that use of the medical term "therapy" to describe the clearly nonmedical techniques of psychotherapy betrays the inauthenticity of any medical identity. Szasz concludes, if mental "illnesses" are real illnesses, how could nonmedical approaches be justified, and, if such "illnesses" are not really diseases, "then it makes no sense to adopt a medical approach to [them]" (1987, p. 87). As Szasz said to us in a 1991 conversation, "Would one speak of the 'medical model' of any real disease?"

From The Myth of Mental Illness to the present, Szasz insists on a new paradigm for thinking about what he calls the "problems in living" experienced by many or most people and about psychiatric practices aimed at helping people dissatisfied with aspects of their lives to "learn about themselves, others, and life" (1961, p. xvi). But to Szasz, psychiatry, which in its modern version constitutes nothing more than a form of strategic or persuasive communication, is a sub-topic of rhetoric, not medicine and not science. Szasz treats psychiatry as a rhetorical phenomenon, critiques it from a rhetorical point of view, and frequently resorts to a rhetorical vocabulary, a vocabulary often completely beyond the understanding of psychiatrists. The Incompatibility of The Rhetorical Paradigm and The Normal Science of Psychiatry

The Szaszian paradigm has brought about only a gradual change in the normal science of psychiatry. One explanation for this may be that it is not in the interest -- economic, social, or existential -- of psychiatrists to fully adopt the rhetorical model. But another explanation, which Szasz considers, is that a paradigm based on communication and metaphor is too radical a change for those socialized into the medical paradigm. In fact, Szasz notes, many physicians do not even know what a metaphor is. In one interaction wherein Szasz asked a group of medical students to define "metaphor," one said he knew but could not give an example. Szasz suggested he try to give an example. He replied, "My mind is a blank . . . and not a single student laughed" (1987, p. 135).

It is through the persuasive and mystifying literalization of metaphor, Szasz maintains, that institutional psychiatry exerts social control and enjoys tremendous social power. This is illustrated in the position for which Szasz is best known: his opposition to involuntary psychiatric hospitalization. Szasz argues that such forced imprisonment is not generally seen as such because of the therapeutic metaphors by which it is described. When psychiatrists support involuntary psychiatric hospitalization, it is incompatible with the ethics of medicine, says Szasz, which include the right of a patient to refuse service: "So intimate are the connections between psychiatry and coercion...[that] noncoercive psychiatry...is an oxymoron" (1991b, p. 117).

This focus on persuasive language in Szasz's rhetorical paradigm has significant ethical implications for both psychiatrists and mental patients. In rhetorical theory, language inescapably is linked to responsibility, and, Szasz argues, the "entire psychiatric enterprise hinges on [the notion] that human beings diagnosed as 'mentally ill' have a brain disease that deprives them of free will" (Lancet, 1991, p. 1576). Szasz's rhetorical paradigm, however, portrays these behaviors as freely chosen and transforms "victims" propelled by their neurobiological environment into free agents, perpetrators of actions for which they are fully responsible.

Rhetorical theorists further maintain that behavior can be seen as "agent" or "scenic," with the former implying free will and the latter implying determinism. The "scenic" approach dominates psychiatry which even its defenders portray as an essentially deterministic enterprise (APA, 1982), wherein patients are seen as not responsible for their behavior. Szasz sees this determinism in the "historicism" of psychoanalytic theory wherein "antecedent historical events [serve] as alleged determinants of subsequent behavior...[and thus] preclude explanations of valuation, choice, and responsibility in human affairs" (1961, p. 5). The exculpating rhetoric of forensic psychiatry in the insanity plea is illustrative of such rhetorical denial of responsibility. In Szasz's paradigm such a plea denies the responsibility of, say, a brutal murderer, through medical mystification and the consequential rhetorical redefinition which invalidly portrays the perpetrator as lacking the ability to control his behavior (Szasz, 1984).

Just as Szasz insists that psychiatric patients are moral agents, he similarly sees psychiatrists as moral agents. The medical paradigm implicitly argues that psychiatrists are not morally culpable for the consequences of their psychiatric practice. In the rhetorical paradigm the psychiatrist who deprives people of their autonomy would be seen as a consciously imprisoning agent, not merely a doctor providing "therapy," language which insulates psychiatrists from the moral responsibility for their acts. As rhetorical theorist Kenneth Burke points out, "One may deflect attention from the criticism of personal motives by deriving an act or attitude not from the traits of the [person] but from the nature of the situation" (Burke, 1969, p. 17).

Szasz's rhetorical paradigm denies psychiatry's claim to be a scientific enterprise and, equally significantly, transforms its practitioners from problem-solvers to problem-creators. If deviant behavior is only "disease" through rhetorical creation, then there can be no justification for undesired psychiatric intervention in people's lives. The rhetorical paradigm represents a significant threat to institutional psychiatry, for not only is Szasz arguing that psychiatry is non- scientific, and not only is the language inherent in the rhetorical paradigm foreign and unadaptable to psychiatrists practicing the "normal science," but without the medical model for protection, psychiatry becomes little more than a vehicle for social control -- and a primary violator of individual freedom and autonomy -- made acceptable by the medical cloak.

In this vein Szasz describes some psychiatric practices -- including forced hospitalization, electroshock therapy and drugging -- on involuntary victims (if they are not "patients," they are victims) as simply unethical (1974, p. 259-260). Elsewhere, and often, Szasz argues that such involuntary interventions are no less than criminal, violent, and terroristic actions and enslavement. The Myth of Mental Illness is written without the polemics of some of Szasz's later work, yet this first major book, according to Harvard psychiatrist Alan Stone, "earned the lasting enmity of his profession" (Hirsch, 1992, p. A-7).

In sum, Szasz's paradigmatic challenge represents an unusual type of paradigm exchange, one which by replacing the original paradigm, would invalidate the existing paradigm without opportunity or provision for new tools to provide similar status and remuneration for the current practitioners. The rhetorical paradigm is simply too different -- involving as it does semiotic and rhetoric, especially the defining of "mental illness" as semantics and symbolic action -- to assure current practitioners any clear role in its implementation. The Significance of Biological Psychiatry for the Normal Science

Psychiatrists have often depicted the domain of psychiatry as John Hanley, professor of psychiatry at UCLA did in the American Medical News in 1985, as "the brain and its system therein" (Szasz, 1987, p. 69). Thus, it has been a potential problem when psychiatric puzzle-solving has been unable to point to neurobiological correlates specific to "mental illnesses." In Szasz's view this constitutes psychiatry's "unredeemed promissory note," of more than a century's duration (1987, p. 51).

Kuhn argues that crisis in "normal science" can be stayed "so long as the tools a paradigm supplies continue to prove capable to solving the problem it defines; science moves fastest and penetrates most deeply through confident employment of those tools" (1970, p. 77). In Szasz's depiction, however, psychiatry lacks these tools, or "special instruments," to qualify it as a science (1965, p. 33). Thus, in the 1970's and 1980's psychiatry experienced the type of crises that Kuhn sees as the "necessary precondition for the emergence of novel theories" (1970, p. 77). Biological psychiatry, which assumes the neurobiological basis of mental disorders, and is accompanied by an emphasis on drug therapy, offered a rescue of psychiatry's medical paradigm that Szasz anticipated: "Whatever might be the effects of modern psychopharmacologicals on the so-called mentally ill patients, the effects on the psychiatrists who use them are clear, and unquestionably 'beneficial:' they restore to the psychiatrist what he has been in grave danger of losing -- namely, his medical identity" (1970, p. 222). Psychiatrists often grant this point themselves. Keith Russell Ablow, chief resident in psychiatry at New England Medical Center in Boston, states, "The burgeoning growth of biological psychiatry... [testifies] to how anxious we are to translate what we know about the human mind into something resembling objective science (1992, p. 9).

Thus, to Szasz, the rise of biological psychiatry in the 1970's through the present offered not a new paradigm, but an attempt at proof or authentication of the already existing medical paradigm. As one prominent practitioner put it, "The recognition that mental illnesses are diseases affecting the brain is the basis of the biological revolution in psychiatry" (Andreason, 1984, p. 8).

In the Szaszian paradigm, biological psychiatry has not and cannot resolve the conceptual crisis of psychiatry. Biological psychiatry cannot rescue the conceptual bind of focusing on a concept, the "mind." Moreover, any finding that some behaviors are entirely caused by brain disease "would destroy psychiatry's raison d'etre as a medical specialty distinct and separate from neurology" (1987, p. 70). Yet, in the persuasion used by some supporters of biological psychiatry, there has been an effort to transfer the widespread acceptance of a limited number of "mental illnesses" as bona fide brain diseases to an acceptance that all so-called mental illnesses constitute proven brain disease (Vatz and Weinberg, 1991, p. 14). But for the great preponderance of the wide range of behaviors called "mental illness," there is no comparable proof offered.

In addition, institutional psychiatry identifies a large plurality of Americans as mentally ill, only a tiny percentage of whom demonstrate the behaviors for which biological psychiatry claims to have found neurobiological correlates. The National Institute of Mental Health (NIMH) determined a few years ago through non-medical interviews by "lay interviewers" that up to 23% of adults in America have at least one "psychiatric disorder" (Myers et al., 1984), and that up to 38% experience mental disorders at some point in their life (Robins et al., 1984). Yale psychiatry professor Jay Katz conceded several years ago, "If you look at [the diagnostic manual], you can classify all of us under one rubric or another of mental disorder" (Szasz, 1987, p. 57).

Recognition of this conceptual bind is not hard to find, even in the establishment journals of psychiatry. An article discussing "conundrums" facing the APA's Task Force on the proposed newest revision of psychiatry's diagnostic manual (DSM-IV), authored by several members of the Task Force, admits that "unfortunately, in most instances, biological tests can not be used even as diagnostic indicators" since such tests are not specific to particular "mental disorders" (Frances et al., 1991, p. 408).

The same article reports that there has been heavy lobbying of the Task Force to influence its revisions for DSM-IV ("The zeal...is extraordinary") (p. 411), and the lobbying is largely based on financial and ideological motives. Financially, there is no more salient issue in mental health than insurance costs. While health costs are rising generally, the Employee Benefit Research Institute reports that the rise in mental health costs is over 40% higher than the rise in health costs in general. There is grave concern among mental health practitioners as a result of restrictions on mental health coverage through managed care and increased restrictions on mental health care in employers' health plans. In the past several years the APA's newsletter, scholarly articles on the revisions for DSM-IV, and the speeches of the APA's leadership are replete with discussions of concerns regarding insurance and reimbursement issues.

The link between psychiatry's definition of "illness" and the financial concerns attending its recognition through health insurance is inextricable. At the 144th annual meeting of the American Psychiatric Association, then-president Elissa Benedek warned that the threat of rising medical costs coupled with new restrictions on health-care insurance provisions for psychiatric care make "many feel that...the very future of psychiatry [is] in doubt" (Benedek, 1991, p. 1126). The insurance reimbursement issue also is linked to the issue of whether "mental illnesses" are real illnesses. The Task Force wrote that "...there are those who want some or all mental disorders designated as diseases in order to protect reimbursement and research funding...." (Frances et al., 1991, p. 409). The Task Force allows only that changes in DSM-IV "cannot be overly influenced by such considerations" (Frances et al., 1991, p. 410).

Resistance to the Rhetorical Paradigm

From Kuhn's perspective on scientific revolutions, the intense resistance to Szasz can be understood as an attempt to wean defenders of the "normal science" of psychiatry "whose productive careers have committed them to an older tradition...[and who are assured] that the older paradigm will ultimately solve all its problems" (Kuhn, 1970b, p. 151). Inasmuch as Szasz's proposed rhetorical paradigm constitutes a major paradigm change, Kuhn's theory leads us to anticipate and to find an even greater degree of animosity and resistance from traditionalists of the dominant paradigm.

Criticism of Szasz, for example, has gone well beyond scholarly debate. As Szasz recalls in his second edition of The Myth of Mental Illness: Foundations of a Theory of Personal Conduct, "Within a year of the [the publication of the first edition], the Commissioner of the New York State Department of Mental Hygiene demanded, in a letter citing specifically The Myth of Mental Illness, that I be dismissed from my university position because I did not 'believe in mental illness'" (1974, p. vii). Szasz's ideas met with considerable political resistance, as well, where he was teaching at the Health Science Center in the Department of Psychiatric and Behavioral Sciences. There, his job was threatened -- and some of his supporters, who, unlike Szasz, lacked tenure, were terminated -- because of Szasz's rejection of the normal science of psychiatry and his attacks on the ethics of psychiatry and psychiatrists (Hirsch, 1992; Leifer, 1990).

Among scholars the opposition to Szasz sometimes appears to ignore what he actually has written, perhaps because, as rhetorical theorist Richard Weaver notes, "Nothing is more feared by [the base rhetorician] than a true dialectic" (Szasz, 1978, p. 20). In fact, Szasz has written that Sigmund Freud was the ultimate "base" rhetorician who used "language to increase his own power, to produce converts to his own cause, and to create loyal followers of his own person" (Szasz, 1978, p. 20). Following Weaver, therefore, Szasz would not expect to find most psychiatrists engaging him in constructive dialogue. Some of the difficulty which psychiatrists have with Szasz's paradigm may be due to confusion about his claims. As psychiatrist/columnist Charles Krauthammer notes, "...Szasz is the kind of author no one reads but everyone knows about...." (1985, p. 70). It is not surprising, therefore, that from its inception the rhetorical paradigm has been met with resistance and misunderstanding.

A frequently repeated criticism of Szasz rests on basic misunderstanding of his position to the effect that, as C.G. Schoenfeld argues, he "fails to offer his readers detailed descriptions, case histories, and the like of a representative cross section of persons whom psychiatrists usually judge to be neurotic or psychotic, but whom he has interviewed or examined as a psychiatrist, and whom he has demonstrated to be completely normal" (Schoenfeld, 1976, p. 246). In one form or another many critics voice this objection. However, in offering such a criticism Schoenfeld and others who make similar objections demonstrate a lack of understanding of the fundamental assertion of Szasz that the very use of the language of medicine -- "neurotic or psychotic" versus "completely normal" -- constitutes a type of category error. Schoenfeld's demands make perfect sense within the existing paradigm, but no sense whatever from outside that paradigm. Viewing behavior from his paradigm, Szasz cannot possibly demonstrate "normality" anymore than he believes psychiatrists can demonstrate "mental illness."

Some of the initial response to The Myth of Mental Illness evidenced resistance to the proposed paradigm change but denied that it represented a revolutionary challenge. Writing in The American Journal of Psychiatry, Eugen Kahn observed, "[Despite that] this book is the work of a doubtless brilliant mind...[I]t damages this book that the author with a few terms of his own pretends to change psychiatry revolutionarily and fundamentally" (1962, p. 190).

But more frequently, the early critics of Szasz misinterpreted and rejected his claims, but did not dispute their revolutionary nature. Jurgen Ruesch's 1962 review of The Myth of Mental Illness sounded a familiar critical note: "Mental illness is not a myth to those who have experienced it" (1962, p. 190), a point which is still frequently made, but which erroneously implies Szasz's denial of the existence of the behaviors called "mental illness" (see below). Ruesch adds, "In an essentially new contribution, Dr. Szasz gives us a brilliant review of the ways of communication that hysterical persons employ" (p. 190) and concludes that this attack on psychiatric conceptions of hysteria may demonstrate the myth of "a mental illness" (p. 190), a conclusion which misses Szasz's point which was to use hysteria as a prototype for "mental illness" in general. At least one reviewer who did understand Szasz's intent concluded, "The reviewer knows of no psychiatrist who agrees with him, and is sorry to consider his book a total waste of time" (The Psychiatric Quarterly, p. 591). Not all response was marked by rejection, however. Very prevalent was the nonconcessionary allowance -- and variations of it -- that Szasz had raised important and provocative questions, but none with the potential to wholly vitiate the normal science of psychiatry (Frank, 1961; Mowrer, 1961).

Interestingly, reactions to Szasz's 1987 work, Insanity, a work Szasz (and we) consider his best, and a work wherein Szasz refines his arguments and engages his critics, received positive, but muted, response: "[Szasz] does an excellent job of answering all of the arguments against his position" (Bell, 1987, p. 269). There were some positive reviews in the elite popular press (Sobel, 1987). For the most part, however, it was -- and is -- ignored within (and without) the psychiatric community. Perhaps because of the new language presented by the rhetorical paradigm, Szasz has been consistently misinterpreted in the most elementary way as if he were denying the existence of the behaviors that are labeled "mental illness" despite his unambiguously stating, "While I maintain that 'mental illnesses' do not exist, I obviously do not imply or mean that the social and psychological occurrences to which this label is attached also do not exist" (Szasz, 1970, p. 21).

Such misunderstanding or misrepresentation of this basic tenet of Szasz's position remains prevalent both within and outside of psychiatry. In a 1989 interview Harvard law professor Alan Dershowitz said that while "...Szasz has had an enormous impact on psychiatry and the law...If you've seen somebody who is...troubled, you can't believe Szasz's arguments that there's no such thing as mental illness" (Shapiro, 1989). One well-regarded text recently attributed to Szasz's Myth of Mental Illness (1961) the view that "mental illness did not exist at all but was the product of hospitalization" (Gudeman, 1988, p. 715). In a recent issue of the APA's newsletter, Psychiatry News, one psychiatrist wrote that if Dr. Szasz "doesn't believe that drug addiction and abuse is a disease, he should go visit with some of the addicts on the street" (1992).

Szasz and Anti-Psychiatry

There are significant critiques of psychiatry, known as anti- psychiatry, but as E. Fuller Torrey points out, such critiques represent a wide variety of viewpoints (Torrey, 1974). Most prominent among the anti-psychiatrists has been R.D. Laing (Boyers, 1971; Dain, 1975). Szasz has often been mislabeled by supporters and practitioners of the "normal science" of psychiatry as belonging to the anti-psychiatry school of thought (Adelson, 1991; Isaac and Armat, 1990), whose views Szasz has expressly repudiated (1976). Indeed, Szasz's rhetorical model sees anti-psychiatry as similar to normal psychiatry in its rhetorical structure in which "the struggle over definitions is much the same" (Szasz, 1976, p. 73), and most significantly in its use of "base rhetoric" in that "one cannot reason or argue with any of [the Laingian anti-psychiatrists]" (Szasz, 1976, p. 54). Like normal psychiatry, anti-psychiatry, although "occasionally say[ing] almost exactly what I say about schizophrenia" (Szasz, 1976, p. 72), uses often the same language as psychiatry (e.g., "madness") to glorify or vilify behavior, albeit in anti-psychiatry, the heroes and villains are inverted, in that anti-psychiatry finds the cause of "madness" in "the family and society instead of the patient and his disease" (Szasz, 1976, p. 66). Szasz also maintains that both psychiatry and anti-psychiatry have overriding political agendas, and therefore neither can be truly scientific.

Thus, while Szasz concedes some general similarities in his and anti-psychiatrists' "oppos[ing of] certain aspects of psychiatry" (Szasz, 1984, p. 4), Szasz's rhetorical paradigm is neither intellectually similar, nor even literally anti-psychiatric. The rhetorical paradigm implies the libertarian political grounding wherein the individual must be free to make behavioral decisions, and whose unimpeded decisions must be seen as freely made. In contrast, much of anti-psychiatry (like psychiatry itself) utilizes a rhetorically scenic approach, wherein the mad or mentally ill are victims -- and often portrayed as heroic because of their victimization --- of outside social forces. Thus, anti- psychiatrists, such as Laing and Foucault, use mental illness rhetorically to promote a political agenda -- usually leftist (Szasz, 1984, pp. 24-26). The rhetorical paradigm implies that "...just as, in psychiatry, the literalized metaphor of schizophrenia as illness leads to and justifies its management by means of doctors, hospitals and drugs, so in anti-psychiatry, the literalized metaphor of schizophrenia as journey leads to and justifies its management by means of guides, hostels and first aid" (Szasz, 1984, p. 26).

Finally, from Szasz's perspective anti-psychiatry's paternalistic rhetoric celebrates the mentally ill as morally superior, but often helpless, victims, and therefore, like psychiatry, effectively robs those seen as mentally ill of their autonomy, which includes the right to choose to engage in psychiatric therapy. Thus, Szasz rejects the term "anti-psychiatry" as applied to his views (1984, p. 24) despite agreeing that the medical model is invalid. He does not in fact oppose the practice of psychiatry, except as it is practiced on people involuntarily (Szasz, 1984, p. 25).

Szasz's rhetorical paradigm, in further contrast to both the medical model and critiques of anti-psychiatry, provides for a contractual relationship to replace the coercive model in saying that those who do wish to talk with psychiatrists should not be prevented from doing so any more than those who do not wish to talk with psychiatrists should be forced to do so. On this point, he differs from both supporters and opponents of traditional institutional psychiatry: "Supporters of the medical model...[act] like pediatricians, who must convince parents that their child is sick before they can treat the child - - and having convinced the parents, can treat the child regardless of whether or not the child wants to be treated .... Opponents of the medical model -- typically anti-psychiatrists -- [also] act like pediatricians, who, if they can convince parents that their child is not sick, can prevent the child from being treated, whether or not the child wants to be treated (1987, p. 91). Szasz's contractual psychiatrist is a "private entrepreneur" who, absent medical mystification, "offers himself to his patients, who must pay him, must want to be his patients, and are free to reject his help (Szasz, 1970b, p. xxiii). In Szasz's rhetorical paradigm, the client (not "patient") is seen as the agent responsible for defining what is a problem, and involuntary psychiatry -- but only involuntary psychiatry -- and third party subsidization are eliminated.

The Future of the Rhetorical Paradigm

Kuhn theorizes that the success of any paradigm conversion ultimately rests on persuasion (Kuhn, 1970b, p. 198-200), a concept which forms the cornerstone of the discipline of rhetoric (Cooper, 1960). But the persuasive process is often a lengthy one, and, in the current example, has engendered an acrimonious struggle in both the popular and academic press.

Despite claims by some that the debate over whether "mental illnesses" are diseases is over and that the medical paradigm has won (Adelson, 1991; Isaac and Armat, 1990), there is evidence of a slowly increasing skepticism regarding much of the "normal science" of psychiatry.

Of potential significance is ambivalence regarding the key concept of normal psychiatry: "mental illness" itself. The Diagnostic Manual of Psychiatry uses the terms "disorder" rather than "illness," although this is rarely, if ever, discussed in the popular press or public forum. The omission of the term mental "illness" is further evidence within the normal science of some doubt as to its validity, despite the claim that the use of the term "disorder" "by no means implies that mental disorders are unrelated to physical or biological factors or processes" (APA, 1987, p. xxv). The mental health professionals revising the diagnostic manual (the APA Task Force on DSM-IV) demonstrates further erosion of confidence in the concept of mental disorder, even while claiming that such conceptual problems do not put the enterprise outside of science and medicine: "The concept of mental disorder is like other concepts in medicine and science in failing to have a clear and consistent definition... The implicit definition of mental disorders and medical disorders -- 'that which clinicians treat' -- is tautological, but other more abstract concepts consistently fail to provide greater explanatory power" (Frances et al., 1990, p. 1442). This "tautological" bind may be increasingly seen by some even within psychiatry's normal science as constituting the above-mentioned Kuhnian concept of a "self- validating and circular system," which militates against the production of "major novelties, conceptual or phenomenal" critical to the evolution of problem solving.

Despite their own apparent doubts, mental health interests do not take external criticism of the existing paradigm without significant resistance. In Commentary, when Carol Iannone, the embattled former nominee to the advisory council of the National Endowment for the Humanities, reviewed William Styron's book describing his suffering from the "disease" of depression, she wondered how Styron overcame his depression by, as he claimed, sheer force of will if the depression were truly a disease. In response, one psychiatrist at Columbia University asked, "How is it possible that, in the year 1990, one can still come across a person of considerable education (and literary erudition) who somehow has not learned that depression (and, most especially, suicidal depression) is a psychiatric illness, not primarily a moral dilemma or a mortal sin" (Goldstein, 1991, p. 10).

Despite this resistance, there is an increasing tendency among mental health practitioners to adopt elements -- but only some elements -- of Szasz's paradigm. Psychiatrists often concede that Szasz has alerted them to the "abuses of psychiatry." Dr. Thomas Detre, head of the University of Pittsburgh's Western Psychiatric Institute and Clinic, wryly noted in the above-mentioned meeting of the Pennsylvania Mental Health Association in the 1970's that Szasz would be disappointed to learn that "he is not so heretical as he once was."

Stronger Szasz-like doubts about the current paradigm usually come from outside of psychiatry and curiously seem to ignore Szasz's contribution. A recent popular book condemns "the diseasing of America," but accepts, contrary to the Szaszian paradigm, the reality of addictions (Peele, 1989). Yet the author cites Szasz but twice. Philosopher Herbert Fingarette, in his work Heavy Drinking: The Myth of Alcoholism as a Disease (1988), argues a position clearly prefigured by Szasz's work and written about by him for decades, and yet does not even mention him. Doubts about "behavioral addictions" abound now in the popular press: a column in U. S. News and World Report deplores the "It's-Not-My-Fault Syndrome" (Leo, 1990); a Pulitzer Prize-winning feature writer derides "The Addiction Addiction" (Steinbach, 1991); and a magazine cover story questioning the sympathy accorded people with alleged self-destructive disorders was titled "Don't Blame Me" (Taylor, 1991). A recent example in the popular press questions psychiatrists' tendencies to label abnormality as "sick" (Goode, 1992). In none of these is Szasz even mentioned.

Even among some world renowned psychiatrists, there is new doubt about the medical nature of "mental illness." Just before his death, Karl Menninger wrote, "[Szasz's] new book, Insanity, makes some points that I agree with and have been trying to get across for years" (1989, p. 351). In a published letter to Szasz, Menninger spoke with derisive skepticism about psychiatric diagnosis, prognosis and treatment, and at one point used the term psychiatric "sickness" in quotation marks. He ended his letter with an implicit admission that much psychiatric "treatment" might not be the cause of patients' feeling better: "Long ago I noticed that some of our very sick patients surprised us by getting well even without much of our 'treatment'" (1989, p. 351).

A recent editorial in Lancet seems to support the notion that the medical model as transformed into biological psychiatry has not provided promised solutions either. The editorial states, "We seem to be no closer to finding the real, presumed biological, causes of the major psychiatric illnesses" (1991, p. 785).

In the rhetorical paradigm the unfulfilled promises of the discovery of neurobiological correlates specific to particular "mental illness" constitute an irresolvable crisis for psychiatry, and the promises serve only as rhetorical strategies to buy endless forbearance time. Szasz observes, "If psychiatrists had to pay interest on their promise of pathological lesions [to prove "mental illness" as a putative brain disease], as borrowers must to lenders, the interest alone would already have bankrupted them; instead, they keep reissuing the same notes, undaunted by their perfect record of never meeting their obligations" (1987, p. 51).

Szasz's postulation of a rhetorical paradigm holds out the prospect not of simply a new paradigm within psychiatry, but of a complete negation of psychiatry as a scientific enterprise. As Szasz has described it, "With the simple, but uncompromising idea that mental illness is a metaphor I hoped to inflict a fatal blow, philosophically speaking, on the conceptual foundations of psychiatry" (1991b, p. 118).

The new emphasis on biological psychiatry, representing research advancements in pharmacology with no revisions of basic assumptions -- the psychiatric paradigm has all along assumed a biochemical basis for behavior -- has provoked considerable resistance within the "normal science." In one typcial expression, a recent letter to the editor of Psychiatric News sees biological psychiatry as a "danger to psychiatry as a specialty simply because one need not be a psychiatrist to prescribe" pharmacological agents (Gadish, 1992). Some textbooks emphasize the new biological paradigm. Most standard texts do not. Moreover, most psychiatric texts do not even mention Szasz at all, including, for example, one published by the American Psychiatric Press (Talbott et. al., 1988) which includes chapters on "Psychiatry and the Law" and "Ethics and Psychiatry," topics on which Szasz is a recognized scholar. Kuhn sees textbooks as an index of the more conservative element of a science's normal research, and therefore also a lagging index to the fact and direction of revolutionary change (Kuhn, 1970b; Kuhn, 1977). As Szasz sees it, however, the substitution of a biological paradigm represents, in reality, a last ditch effort to retain the medical model paradigm, which was always methodologically inauthentic since it never proceeded with the apparatus of medical science. Szasz does not believe that the interim model will in the end bring about any change in the ability of psychiatry to solve "psychiatric" problems. For, as Szasz often points out, the discovery of brain disease in those labelled mentally ill constitutes an advancement in neurology, not psychiatry.

In the end, as Kuhn suggests, "The transfer of allegiance from paradigm to paradigm is a conversion experience that cannot be forced" (1970, p. 151) and successful arguments for a new paradigm typically are "based upon the competitors' comparative ability to solve problems" (p. 155). Szasz's rhetorical paradigm, in its total rejection of medicine and psychiatry in favor of politics and ethics as the proper discourses for addressing human problems, has not been and may not be successful in the short run in convincing either psychiatrists or the public of its "comparative ability to solve problems." For as difficult and protracted as Kuhn finds scientific paradigmatic revolutions to be, the total replacement of a scientific paradigm with a non-scientific political and moral paradigm will require a degree of change which is nearly unprecedented. Moreover, there appears to be no extra-scientific motive for such change, since not only does Kuhn's "different world" await those who adopt Szasz's method, but also a substantial drop in financial reward and an end to the critically prestigious medical identity. Whatever the merits of Szasz's paradigm, its emergence as the dominant paradigm, even if successful, will reflect Kuhn's slow revolution whose completion is at least decades away.




Nancy C. Andreason, The Broken Brain: The Biological Revolution in Psychiatry (New York: Harper & Row, 1984).

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (3rd edition, revised) (Washington, D. C.: American Psychiatric Association, 1987).

Robert Boyers (ed.), R.D. Laing & Anti-Psychiatry (New York: Harper and Row, 1971).

Kenneth Burke, A Grammar of Motives (Berkeley: University of California Press, 1969).

Peter Conrad and Joseph W. Schneider (Eds.), Deviance and Medicalization: From Badness to Sickness (St. Louis: C. V. Mosby Company, 1980).

Lane Cooper (ed), The Rhetoric of Aristotle (New York: Appleton Century Crofts Inc., 1960).

Herbert Fingarette, Heavy Drinking: The Myth of Alcoholism as a Disease (Berkeley: University of California Press, 1988).

Rael Jean Isaac and Virginia C. Armat, Madness In The Streets: How Psychiatry and the Law Abandoned the Mentally Ill (New York: The Free Press, 1990).

Harold I. Kaplan and Benjamin J. Sadock (eds.), Comprehensive Textbook of Psychiatry/V (Baltimore: Williams and Wilkins, 1989).

Charles Krauthammer, Cutting Edges: Making Sense of the 80's (New York: Random House, 1985).

Thomas Kuhn, Structure of Scientific Revolutions (2nd ed.) (Chicago: University of Chicago Press, 1970b).

Thomas S. Kuhn, The Essential Tension (Chicago: The University of Chicago Press, 1977).

Bruno Latour, Science in Action (Cambridge: Harvard University Press, 1987).

Stanton Peele, The Diseasing of America: Addiction Treatment Out of Control (Lexington: Lexington Books, 1989).

Thomas Szasz, The Age of Madness: The History of Involuntary Hospitalization (Garden City: Anchor Press/Doubleday, 1973).

Thomas Szasz, The Ethics Of Psychoanalysis: The Theory and Method of Autonomous Psychotherapy (New York: Basic Books, Inc., 1965).

Thomas Szasz, Ideology and Insanity: Essays on the Psychiatric Dehumanization of Man (New York: Doubleday Anchor, 1970a).

Thomas Szasz, Insanity: The Idea and Its Consequences (New York: John Wiley & Sons, Inc., 1987).

Thomas Szasz, The Manufacture of Madness (New York: Dell Publishing Co., Inc., 1970b).

Thomas Szasz, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (New York: Hoeber-Harper, 1961).

Thomas Szasz, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (revised edition) (New York: Harper & Row, 1974).

Thomas Szasz, The Myth of Psychotherapy: Mental Healing as Religion, Rhetoric, and Repression (Garden City, New York: Anchor Books, 1978).

Thomas Szasz, Schizophrenia: The Sacred Symbol of Psychiatry (New York: Basic Books, 1976).

Thomas Szasz, The Second Sin, (Garden City, New York: Doubleday Anchor, 1973).

Thomas Szasz, The Therapeutic State: Psychiatry in the Mirror of Current Events (Buffalo: Prometheus Books, 1984).

Thomas Szasz, The Untamed Tongue: A Dissenting Dictionary (La Salle, Illinois: Open Court, 1990).

John A. Talbott, Robert E. Hales, and Stuart C. Yudofsky (eds.) The American Psychiatric Press Textbook of Psychiatry (Washington, D.C.: American Psychiatric Press, 1988).

E. Fuller Torrey, The Death of Psychiatry (Radnor, PA., Chilton Book Co., 1974).

E. Fuller Torrey, Surviving Schizophrenia: A Family Manual (New York: Harper and Row, 1983).

Articles and Book Chapters

Joseph Adelson, "The Ideology of Homelessness," Commentary 92 (March, 1991).

Elissa Benedek, Presidential Address: Looking Ahead: New Psychiatry, Old Values, American Journal of Psychiatry, 148 (1991) 1123-1129.

Catherine Brown, "Hartmann Urges Colleagues to Practice Psychiatry from Strong Humane, Biopsychosocial Base," Psychiatric News, XXVII (June 5, 1992) 2.

Barry Brummett, "Some Implications of 'Process' or 'Intersubjectivity': Postmodern Rhetoric," Philosophy and Rhetoric, 9 (Winter, 1976), 21-51.

Bulletin of the Menninger Clinic 53 (July, 1989) 350-352.

Norman Dain, "American Psychiatry in the 18th Century," in George Kriefman, Robert D. Garner, D. Alfred Abse (eds.), American Psychiatry, Past Present and Future (Charlottesville: University Press of Virginia, 1985).

Editorial, "British Psychiatry at 50," Lancet 338 (1991), 785-786.

Allen J. Frances, Michael B. First, Thomas A. Widigers, Gloria M. Mick, Sarah M. Tilly, Wendy W. Davis, Harold A. Pincus, "An A To Z Guide To DSM-IV Conundrums," Journal of Abnormal Psychology, 100 (1991) 407-412.

Allen Frances, Harold Alan Pincus, Thomas A. Widiger, Wendy Wakefield Davis, and Michael B. First, "DSM-IV:" Work in Progress," The American Journal of Psychiatry, 147 (November, 1973), 154-161.

Erica E. Goode, "Sick, or Just Quirky: Psychiatrists are labeling more and more human behaviors abnormal," U.S. News and World Report, February 10, 1992, 49-50.

Jon E. Gudeman, "The Person With Chronic Mental Illness," in Armand M. Nicholi (ed.), The New Harvard Guide To Psychiatry (Cambridge: Harvard University Press, 1988)

Melanie Hirsch, "Home on the Hot Seat," The (Syracuse) Post-Standard, February 19, 1992 A1, A7.

Thomas S. Kuhn, "Logic of Discovery or Psychology of Research," in I. Lakatos and A. Musgrave (eds.), Criticism and the Growth of Knowledge (Cambridge: Cambridge University Press, 1970a).

Ronald Leifer, "Introduction: The Medical Model as the Ideology of the Therapeutic State," in David Cohen, (ed) Challenging the Therapeutic State: Critical Perspectives on Psychiatry and the Mental Health System in a special issue of The Journal of Mind and Behavior, 11 (Summer and Autumn, 1990) 247-258.

John Leo, "The It's-Not-My Fault Syndrome" U. S. News and World Report (June 18, 1990) 16.

Jerome K. Myers, Myrna M. Weissman, Gary L. Tischler, Charles E. Holzer, Philip J. Leaf, Helen Orvaschel, James C. Anthony, Jeffrey H. Boyd, Jack D. Burke, Morton Kramer, and Roger Stoltzman. "Six-month Prevalence of Psychiatric Disorders in Three Communities," Archives of General Psychiatry, 41 (1984) 959-967.

Richard Restak, "Psychiatry in America," The Wilson Quarterly, VII (1983) 94-122.

Lee N. Robins, John E. Helzer, Myrna M. Weissman, Helen Orvaschel, Ernest Gruenberg, Jack D. Burke, Jr., and Darrel A. Regier, "Lifetime Prevalence of Specific Psychiatric Disorders in Three Sites," Archives of General Psychiatry, 41 (October, 1984) 949-958.

C.G. Schoenfeld, "An Analysis of the Views of Thomas S. Szasz," Journal of Psychiatry and Law 4 (Summer, 1976) 245-263.

Alice Steinbach, "The Addiction Addiction," The Baltimore Sun (May 20, 1991).

Thomas Szasz, "Diagnoses are not Diseases," Lancet, 338 (1991a) 1574-1576.

Thomas Szasz, "Noncoercive Psychiatry: An Oxymoron; Reflections on Law, Liberty and Psychiatry," Journal of Humanistic Psychology, 31 (Spring 1991b) 117-125.

John Taylor, "Don't Blame Me," New York, June 3, 1991 26-34.

Richard E. Vatz, "The Myth of the Rhetorical Situation," Philosophy and Rhetoric, 6 (Summer, 1973) 154-161.

Richard E. Vatz and Lee S. Weinberg, "The Conceptual Bind in Defining the Volitional Component of Alcoholism: Consequences for Public Policy and Scientific Research," in David Cohen, (ed) Challenging the Therapeutic State: Critical Perspective on Psychiatry and the Mental Health System, in a special issue of The Journal of Mind and Behavior, 11 (Summer and Autumn, 1990) 531-544.


American Psychiatric Association, American Psychiatric Association Statement on the Insanity Plea, Washington, DC: American Psychiatric Association, 1982.


Carl C. Bell, Review, Thomas Szasz, Insanity: The Idea and Its Consequences, Journal of the American Medical Association (July 10, 1987) 269.

Jerome Frank, Review, Thomas Szasz, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct, Annals of Internal Medicine 55 (November, 1961) 877-888.

Carol Iannone, Review, William Styron, Darkness Visible: A Memoir of Madness, Commentary 91 (November, 1990) 54-57.

Eugen Kahn, Review, Thomas Szasz, The Myth of Mental Illness, American Journal of Psychiatry (1962), 494.

O. Hobart Mowrer, Review, Thomas Szasz, Myth of Mental Illness: Foundations of A Theory of Personal Conduct, Science, 134 (December 15, 1961), 1974-1975 .

Review, Thomas Szasz, The Myth of Mental Illness, The Psychiatric Quarterly 36 (1962), 591.

Jurgen Ruesch, Review, Thomas Szasz, The Myth of Mental Illness, Journal of the American Medical Association (January 13, 1992), 190.

Dava Sobel, Review, Thomas Szasz, Insanity: The Idea and Its Consequences, The New York Times Book Review (March 15, 1987) 22.


Mary D. Bublis, "Letter to the Editor," Psychiatric News XXVII (May 15, 1992) 16.

Daniel B. Gadish, "Letter to the Editor," Psychiatric News XVII (August 7, 1992) 23.

Robert Lloyd Goldstein, "Letter to the Editor," Commentary 92 (March, 1991), 10-11.

Richard E. Vatz and Lee S. Weinberg, "Letter to the Editor," Commentary 92 (September, 1991) 14-15.

Non-Print Media

Owen Shapiro and Lester Friedman, "Thomas Szasz and the Myth of Mental Illness," Syracuse University, (film, 1989).

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