Thomas Szasz: The Uncompromising Rebel and Critic of Psychiatry

Psychiatr. Pol. 2021; 55(4): 851–867 PL ISSN 0033-2674 (PRINT), ISSN 2391-5854 (ONLINE) www.psychiatriapolska.pl DOI: https://doi.org/10.12740/PP/125902 Thomas Szasz: The uncompromising rebel and critic of psychiatry Jan Domarad zk i Poznan University of Medical Sciences, Chair of Social Sciences and Humanities Summary April 2020 marks what would have been the hundredth birthday of Professor Thomas Stephen Szasz, who passed away in 2012. This year was also the 60th anniversary of the first publication of his iconoclastic thesis on the “myth of mental illness.” In the present paper, Szasz’s main views on mental illness and modern psychiatry are summarized. By showing the origins of Szasz’s ideas in particular, it describes the following topics: Szasz’s distinction between bodily disease and mental illness, his preoccupation with the progressive medicalization of everyday life, his description of psychiatry as an institution of social control, his critique of the therapeutic state, i.e., the alliance between psychiatry and the state, and his deliberations on liberty, personal freedom and responsibility. While addressing Szasz’s main critics, the paper attempts to show the influence of Szasz’s concept on today’s psychiatry and stresses that despite well-deserved criticism he expressed some of the epistemological and ethical problems of modern psychiatry better than anyone else, which makes his legacy still important for the mental health practitioners of today. Key words: mental illness, medicalization, critical psychiatry, Thomas Szasz Introduction Professor Thomas Stephen Szasz, who passed away in 2012, would have celebrated his hundredth birthday in April 2020. This year also marks the 60th anniversary of the publication of his iconoclastic thesis on the “myth of mental illness,” first announced in 1960 in American Psychologist [1], and further elaborated in a book published a year later [2]. Since that moment Szasz became, next to Roland David Laing, the best known social critic of modern psychiatry [3, 4] and for over 60 years criticized the basic assumptions and practices of psychiatry, clinical psychology and psychotherapy. In particular, he challenged their moral and scientific foundations, the increasing alliance between psychiatry and the state and the ubiquitous medicaliza- 852 Jan Domaradzki tion of “problems in living.” Nevertheless, while some consider Szasz as the most important moral philosopher of psychiatry [5], others neglect his ideas and emphasize the negative, detrimental and dangerous impact that his theory has had on psychiatry and psychoanalysis [6, 7]. Thus, this paper highlights Szasz’s main views on modern psychiatry and addresses some of his main critics. It also aims to outline his impact on modern psychiatry. Professor Thomas (Tomás) Stephen (István) Szasz was a Hungarian-American psychiatrist and scholar born in Budapest, Hungary, on 15 April 1920. He was the second son of a Jewish lawyer and agricultural businessman, Gyula Szasz, and his wife Livia Wellisch. He was a sickly child and nearly died of diphtheria at the age of seven, but he studied diligently at school. In 1938, on the eve of the Second World War, when Hitler invaded Austria, at the age of 18, Szasz and his family emigrated to Cincinnati, Ohio, in the United States. After being admitted to the University of Cincinnati, the young Szasz first graduated (with honors) in physics in 1941, and then he earned his medical degree at the College of Medicine of the University of Cincinnati in 1944. Two years later, after he completed his residency requirement at the Cincinnati General Hospital, Szasz moved to Chicago, where he trained in psychiatry at the University of Chicago, and psychoanalysis at the Chicago Institute for Psychoanalysis, gaining his diploma in 1950. For the next five years he was a member of its staff [8]. In 1951, Szasz received a diploma in psychiatry. During his residency at the University Chicago Clinic, Szasz deliberately refused a psychiatry training program that involved working with psychotic patients [8, 9]. In 1954, during the Korean War, Szasz, then aged 35, spent two years in US Naval Medical Center in Bethesda, Maryland [8]. It was particularly this experience, the only time he worked with involuntary patients, that led him to develop his ideas on mental health [9]. After his military service ended in 1956, Szasz settled at the Upstate Medical Center in Syracuse of the State University of New York, where he became professor and became head of the chair of psychiatry. He also worked at the Syracuse Psychiatric Hospital. After he publicly declared war on what he called “coercive psychiatry” and published his opus magnum The myth of mental illness: Foundations of a theory of personal conduct in 19611 [2], which made him a figure of international fame and controversy, he was threatened to be banned from teaching in the hospital, but eventually he managed to keep his position at the University until 1990, when he became professor Emeritus [12]. After expressing his ideas on psychiatry, in 1969 Szasz collaborated with the Church of Scientology in setting up the Citizens’ Commission on Human Rights, which opposed involuntary psychiatric treatments [13]. Nevertheless, he never became a member of the Church. In 1970, he cofounded, with George Alexander and Erving Goffman, the American Association for the Abolition of Involuntary Mental Hospi1 Mark Cresswell [10] and Jan Pols [11] rightly observe that the seeds of Szasz’s future rebellion against biopsychiatry can be traced back to his earlier works on pain, psychosomatic illness and scientific reductionism. Thomas Szasz: The uncompromising rebel and critic of psychiatry 853 talization, which provided legal help to psychiatric patients, and published a journal The Abolitionists [12]. After retirement he continued lecturing and publishing. In 1995 he retired from private practice. Thomas Szasz died aged 92 at his home in Manlius, New York, on September 8, 2012. In 1951 Szasz married Rosine Loshkajian, who committed suicide in 1971, following their divorce [14]. They had two daughters: Margot and Suzy. During his academic career Szasz published 35 books, translated into numerous languages, and hundreds of articles [12]. He was a popular teacher and his lectures were lively and well attended. Szasz was also a member of many professional organizations, including a Distinguished Life Fellow of the American Psychiatric Association, a life member of the American Psychoanalytic Association and a life fellow of the International Psychoanalytic Association. He received several honorary degrees and many awards, including the Humanist of the Year from the American Humanist Association (1973), the Jefferson Award for Outstanding Public Service Benefiting the Disadvantaged from the American Institute for Public Service (1974), Martin Buber Award (1974), the Free Press Association’s Mencken Award (1988), Humanist Laureate Award (1995), Great Lake Association of Clinical Medicine Patients’ Rights Advocate Award (1995), Rollo May Award from the American Psychological Association (1998), honorary doctor of science degree from Upstate Medical University (2001), and the George Washington Award from the American Hungarian Foundation (2003). Putting Szasz into perspective Although some consider Szasz as the most prominent critic of modern psychiatry, he began expressing his revolutionary ideas in the very particular social context of the 1960s and 1970s, a time of rapid and extensive social, political and cultural changes; when counterculture, hippie subculture and anti-Vietnam war protesters flourished, new art, music and fashion styles emerged questioning the basics of Western culture. Moreover, psychiatry itself was at a particularly vulnerable moment: Freudian theory began to lose its privileged status and psychiatry aimed to establish deeper bonds with medicine and become an empirically-based science. All these changes influenced the emergence of an intellectual movement of critical psychiatry, often called antipsychiatry, which radically challenged the theories and practices of the mainstream psychiatry [3, 4, 15–17]. While antipsychiatry was never a homogeneous movement – as its prominent thinkers, i.e., David Cooper, Roland David Laing, Joseph Berke, Leon Redler or Franco Basaglia, differed in their theories and approaches – they all shared some ideas: antipsychiatrists questioned the nature of mental illness and its place within the medical model, they also questioned psychiatry’s status as a medical specialty, defined it as an agent of social control, and stressed psychiatry’s tendency to harm people. Significantly, all these thinkers were psychiatrists themselves. For this reason, sociologist Nick Crossley [16] defines antipsychiatry as a “revolt from 854 Jan Domaradzki above” and argues that it should be distinguished from the critique “from without”, i.e., the Church of Scientology, and “from below” such as the formation of the Mental Patients’ Union in 1973. At the same time, as an intellectual enterprise, antipsychiatry was influenced by the labelling theory and its view of mental illness as a form of deviance that is controlled through social and political tools [18–20]. Another inspiration came from the works of the British anthropologist Gregory Bateson and the “Palo Alto” group, especially their contention that mental illness is an appropriate, or at least understandable, reaction to disturbing social interactions, and in particular “double-bind manoeuvre” as a schizophrenic factor [21]. The third source of inspiration was existentialism, which stresses the uniqueness of individual experience and the subjective nature of reality. Finally, the movement was also inspired by some sociologists, including Erving Goffman [22] or the French philosopher Michele Foucault [23] who developed their own critique of psychiatry and the mental health service as a system of control. All these theories and concepts influenced antipsychiatrists’ rejection of the medical model and status of “mental deviance” as a “mental illness” and shaped their belief that the concept of mental illness has a political genesis and is used for political purposes. Although Szasz, considered by many the grandfather of antipsychiatry, is often linked to the movement, he himself vigorously rejected the label and argued that Cooper, Laing and other prominent antipsychiatrists were merely calling for a reframing of mental illness, while he denied its existence altogether [24, 25]. He also argued that while antipsychiatrists did not reject compulsory psychiatry and the insanity defense, he deplored and rejected both these concepts. As for Szasz himself, while his liberal humanism was largely shaped by such thinkers as Thomas Jefferson, John Stuart Mill, Adam Smith, and Lord Acton [26: 11], his view on psychiatry was mainly influenced by both Sigmund Freud and his critics and by existential philosophy, in particular Søren Kierkegaard, Jean-Paul Sartre and Albert Camus [27]. Not surprisingly, drawing from their ideas, the core of Szasz’s work was liberty and responsibility. Nevertheless, Szasz’s preoccupation with freedom and liberty was also shaped by his lived experience. Firstly, during his early childhood, when he was six, he was forced to go to school and attend religion classes conducted by a rabbi, which he opposed [8, 28]. Secondly, there was his experience of Nazi Europe which forced his entire family to emigrate to the United States. Thirdly, there was the racism and anti-Semitism Szasz faced in the United States which sensitized his awareness to any type of oppression [8]. Finally, during his military service in a psychiatric hospital, Szasz was shocked and upset with the involuntary and coercive character of psychiatric practice and the dehumanized language of psychiatry and psychoanalysis [8, 29]. Together they shaped Szasz’s belief that freedom and personal liberty are more important than health, and that modern psychiatry, and medicine in general, resort to terms like “mental illness”, “mental health” and “mental health service” to curtail Thomas Szasz: The uncompromising rebel and critic of psychiatry 855 freedom. Thus, it is Szasz’s deep faith in human freedom that led John Breeding to consider him as “the philosopher of liberty” [26]. The myth of mental illness: Bodily disease versus mental illness Szasz’s entire critique of modern psychiatry rests on his idea that mental illnesses are a myth and do not exist, and that the modern, biomedical model of psychiatry is untenable [1, 2]. To prove his point, Szasz stressed the difference between somatic diseases and mental illnesses, and argued that while the former are real diseases, the latter are diseases only in the metaphorical sense. He argued that in the true sense diseases are biological phenomena, i.e., they are defined by a physical lesion which leads to a demonstrable alteration in the functioning of the body and refer to observable, pathological states or processes affecting a living organism (plant, animal or human). Thus, because diseases affect the body (cells, tissues or organs), the brain, liver or lungs can be diseased and their state can be measured, diagnosed and treated regardless of the physician’s or the patient’s religious, political or ethical beliefs and ideologies. They are a matter of observable facts, not of faith [1, 2, 30]. In contrast, according to Szasz, mental illness fails to meet the Virchowian standard of disease as an observable, confirmable, physical abnormality of the body. It results from the fact that the mind is not a physical object, but a function of the brain, and for that reason it cannot, at least in a strict medical meaning, be diseased. Thus, due to the lack of physical character of the mind, in the case of “mental illness” no direct pathoanatomic or pathophysiological lesions nor causative agents (viruses, bacteria, parasites or genetic mutations) can be identified. Consequently, there is no such thing as mental illness and psychiatry lacks any scientific bases for diagnosis or treatment. Thus, according to Szasz’s reasoning, mental illness is a myth, i.e., it exists only as a term and idea. Nevertheless, because ideas invented by humans become objectified, so does mental illness become real and function as a reified being. As Szasz declared: “When people believed in witchcraft, then witchcraft was real. When people believe in mental illness, then mental illness is real” [32:21]. From the Szaszian perspective, due to its metaphorical character, there are no objective criteria or tests for diagnosing mental illness, as there are for pneumonia or cancer. On the contrary, Szasz argued that psychiatric “diagnosis” is not a matter of objective facts but of subjective opinions about a person, and it does not reflect inherent “patient” characteristics. The only “test” for mental illness is a conversation with the “patient” and observation of his or her behavior. Consequently, searching for a medical basis of psychiatric diagnosis and medical remedy is unjustified and arbitrary, especially in the circumstances that while diseases can be diagnosed, even after a person dies, psychiatric diagnosis is “valid” only at the time of the examination, as the psychiatrist possesses neither the knowledge nor the ability to determine the mental condition of a person during that person’s past. 856 Jan Domaradzki Thus, according to Szasz, although the concept of mental illness is now institutionalized in Western societies, in reality it exists only as a metaphor, which is widely, although mistakenly (ab)used to describe three types of phenomena: (1) the psychic consequences of somatic diseases, in particular of the brain, like epilepsy, which used to be considered mental illnesses, but as a result of the development of neurology it was later re-categorized as a disease of the central nervous system; (2) deviances, i.e., socially undesirable, unaccepted or incomprehensible thoughts, feelings or behaviors that offend, disgust or outrage society, such as homosexuality, which was demedicalized in the 1970s; and (3) fundamental “problems in living” [2, 30–32]. Nevertheless, according to Szasz, while diseases of the central nervous system are in the domain of neurology, not psychiatry, classifying thoughts, feelings and behaviors as illnesses is a semantic and logical error similar to classifying the whale as a fish [2]. For this reason, he dismissed psychiatry as a specialty without a medical cause, committed it to the category of pseudoscience, and placed it in the company of alchemy and astrology [2]. At the same time, while Szasz questioned the very existence of mental illness, he did not deny that humans experience psychological and social disturbances. Nevertheless, he opposed labeling these disturbances as mental illnesses and argued that they should be reclassified as “social and ethical problems in living” [2]. Szasz opposed and rejected the view that reduces human behavior to biology, whether it refers to the brain’s “chemical imbalance” or “genetic predispositions”; he emphasized that human behavior can be described in terms of reasons, motivation, and not mechanistically understood causes. He claimed that while primitive man personified things, psychiatry thingifies persons and the concept of mental illness helps to mystify the fundamental aspects of human existence: that life is a constant struggle for meaning, a moral choice and the necessity to resolve interpersonal conflicts [32]. So, from the Szaszian point of view, psychiatry, like psychoanalysis, should focus on individuals’ personal relations with the world and the existential problems of everyday life, in particular the problems with the meaning of life and interpersonal relations. The manufacture of madness: Pathologization and psychiatrization of everyday life While denying the existence of mental illness, Szasz was also concerned over the progressive medicalization of everyday life and psychiatrization of culture [30]. Indeed, he stressed that modern psychiatry has broadened the criteria for defining disease so much that it encourages the constant proliferation of new psychiatric disorders or stretching the boundaries of those already established. Consequently, as the modern concept of disease encompasses malfunctioning of any kind, any undesirable or unaccepted thought, feeling or behavior has become a psychiatric “symptom” and falls under the domain of psychiatry [31]. Thus, according to Szasz, the concept of mental illness serves as a unique ideology [32] which enables the increasing penetration of Thomas Szasz: The uncompromising rebel and critic of psychiatry 857 psychiatric discourse into every domain of human life and the “manufacturing” of new “diseases”, i.e., “depression” (unhappiness), “social anxiety disorder” (shyness), “attention deficit hyperactivity disorder” (hyperactive and unruly behavior), “anxiety disorder” (anxiety), “post-traumatic stress disorder” (distress after a horrible event), “sex addiction” (sexual promiscuity), “kleptomania” (shoplifting), and “diseases of addiction” (gambling, overeating, alcohol or drug abuse) [31]. As a result, the psychiatric establishment medicalizes any unwanted behavior and human problems traditionally defined in religious, ethical and political terms, and hence transforms sins, deviations and crimes into medical problems [30, 31, 33]. Nevertheless, because the aforementioned “fictitious mental diseases” do not result from biological lesions but are deviations from “psychosocial and ethical norms” [30, 31, 34], Szasz argued that mental illnesses are not being discovered but invented [2, 30–32]. Because mental illness points neither to pathoanatomic or pathophysiological lesions nor to diseases-causative factors, but rather to human thoughts, feelings, behaviors, and problems, the psychopatological standards of mental illness are very flexible, unclear, value-driven and can be defined ad hoc. In Szasz’s opinion, they are not medical but moral, legal, social, and political matters [2, 30]. Consequently, they should be judged (morally or legally) and not medicalized and hospitalized. Coercion as cure: Psychiatry as an institution of social control Because Szasz reasoned that psychiatry is not dealing with real, literal diagnoses, diseases and treatments, but with the metaphorical uses of these terms, he stressed the fact that mental illness is not something a person “has” or “suffers from”, but something a person does or is [2]. Consequently, the term “mental illness” serves only as a label for unwanted or disapproved aspects of one’s personality or behavior. Nevertheless, because labelling a person is stigmatization and not diagnosing, the primary function of psychiatry is social control [35]. This should not come as a surprise, as one of Szasz’s key arguments was that in medicine, and in psychiatry in particular, there is an deep interplay between knowledge (diagnosis) and power [31, 32, 37]. In his writings, Szasz always emphasized that the concept of mental illness helps to increase the social role of psychiatrists, who seek to exercise power over individuals. And because the act of naming is an act of power [2, 32], the classification of thoughts, feelings and behaviors as “mental illnesses” provides an ideological justification for state-sponsored social control as “medical treatment” [28, 31, 32, 34–36]. Consequently, from the Szaszian perspective, mental illness is not a condition a patient has, but a strategy or a policy that those in power undertake over a person irrespectively of his or her will [30, 32]. To support his claim, Szasz underlined the fact that while within a physician’s examination personal, religious, ethical, and political values, opinions, biases, and stereotypes have no relation with diagnosis, in the case of psychiatry they are the 858 Jan Domaradzki core issues. Thus, in his view, the concept of mental illness becomes a tool of the domination, social control and social exclusion of minorities that can be deprived of their civil rights, placed involuntarily in mental institutions and treated against their will. To prove his point, Szasz often referred to the history of psychiatry when it was used as an oppressive tool against runaway black slaves who were once diagnosed with “drapetomania”, females labelled as suffering from “hysteria”, political dissidents imprisoned in Soviet mental institutions due to their alleged “sluggish” or “slowly progressive schizophrenia”, or homosexuals who were diagnosed as mentally disturbed until the 1970s. Nevertheless, Szasz argued, just like none of these “diseases” was discovered but fabricated, none was “cured” but demedicalized. For this reason, while he compared psychiatry to the Inquisition and stressed that it had inherited the task of quarantining society’s dangerous or rebellious elements [31], Szasz also observed that organized psychiatry serves as an agency of social control which enables the medicalization of society, including the legal [34, 36] and educational systems [32], alcohol [33] and drug abuse [38–40], suicide [41–43] and many other areas of personal and social life [31]. The therapeutic state: The alliance of psychiatry and the state Szasz’s assumption that mental illnesses are not legitimate disorders but medical metaphors used to stigmatize and control deviances and human life problems, and that psychiatry is founded on coercion which is in sharp contrast with the idea of compassion and counselling, fueled his relentless attack on what he called the therapeutic state, i.e., the “unhealthy” alliance of psychiatry and the state [44]. In particular, he criticized the fact that because the concept of illness takes responsibility from the individual for both the causes of disease and its treatment, health care has become dominated by the state, which usurps the right and the duty to protect the health of its members. This, in turn, provoked a radical transformation of society and the state: while the former transformed into a “nonjudgmental support group” unwilling to condemn any behavior, no matter how immoral, the punishing state transformed into the curing state or “pharmacracy.” Thus, the therapeutic state is a system in which all human problems, thoughts, feelings, and conducts are perceived as medical in nature and susceptible to medical remedies [44, 45]. Consequently, they have become medicalized and repressed through coercive psychiatric interventions, and psychiatrists, who have become agents of the state, gain unlimited power to interfere in all dimensions of personal life. As a result, Szasz argued, modern societies live under “psychiatric slavery” [46]. Nevertheless, as a true libertarian, Szasz believed that only the individual has custody of themselves and is responsible for protecting their health. For this reason, he postulated that in the name of personal liberty, psychiatry and the state should be separated, just as the Church and the state are. As the individual is a private person, not a public property which the state can forcibly medicalize, as long as he or she does Thomas Szasz: The uncompromising rebel and critic of psychiatry 859 not pose a danger to others, the state should refrain from protecting one’s health as any coercive intervention would be tyrannical [28, 35, 48,]. At the same time, while criticizing mental illness as an ideological justification for limitations of personal liberties, whether it is the use of drugs [39, 40] or taking one’s own life [43–45], he emphasized the fact that the flip side of the coin of the therapeutic state is the insanity defense [34, 37, 48]. From his early years Szasz criticized psychiatry for, what he called, its “war on criminal responsibility”, and pointed to the paradox that while modern psychiatry is attributing good behaviors to free will, it ascribes bad conducts to mental illness. Consequently, as it offers individuals an opportunity to avoid responsibility for their actions, criminals are said to be “temporally insane” and “incompetent to stand trial” and therefore considered not guilty by reason of “insanity” [34, 37, 48]. Simultaneously, from the Szaszian point of view, although mental illness constitutes an excuse for civil wrongs, it is the insanity defense that constitutes the prime example of the violation of personal liberty and rights by the therapeutic state. Therefore, while the defendant has a right to deny his crime and disagree with the prosecutor, and his negation of guilt is not interpreted as evidence of his guilt, the label of mentally ill deprives a person of that right, as not only he or she cannot disagree with the psychiatrist but his or her disagreement is interpreted as “denial”, and the individual labelled as mentally ill is perceived as lacking insight into their illness. Thus, for Szasz, while the concept of mental illness displaces morality and the rule of law [34], the civil commitment and insanity defense constitute the therapeutic state’s twin pillars of power [36, 44, 45, 47]. Nevertheless, he argued that because neither involuntary hospitalization nor the insanity defense are within the medical profession’s jurisdiction, criminals labeled as “insane” should be placed under the criminal justice system instead of mental institutions. Mental illness, liberty and personal responsibility Finally, because in Szasz’s view mental illness provides an amoral and impersonal thing (an “illness”) as an explanation for the problems of living, it serves as the “institutionalized denial” of the tragic nature of life. As he argued, once people felt or were depressed, then they have depression; formerly some depressed persons killed themselves, now it is depression that kills them [30]. Nevertheless, in Szasz’s view individuals are not passive objects or “patients”, whose behaviors are “caused” by their brains or “mental illness”. They are free, rational and responsible persons who act in accord with their values, beliefs and goals. Thus, holding a person not responsible for his or her act by reason of mental illness means that an individual is denied a status of a moral agent. Instead he or she is regarded as a passive victim of an “illness”. For this reason, Szasz insisted that the concept of “mental disease”, which assigns a person the sick role and deprives him or her of responsibility is, in fact, an ethical and political term used to identify, excuse, condemn or justify human aspirations, thoughts and 860 Jan Domaradzki behaviors [30, 43]. Nevertheless, mixing these two concepts enables the progressive medicalization of life. Moreover, it activates psychiatry’s twin pillars described above: involuntary commitment and the insanity defense, which, in Szasz’s view, are an assault on freedom and liberty. Consequently, Szasz advocated the removal of all drug prohibitions [38–40] and supported the right to suicide [41, 42]. As for the former, Szasz argued that the medicalization of alcohol or drug abuse mystifies the fact that human behavior is always a moral action and stressed that they should be defined as personally and morally motivated acts of free will. Szasz believed that humans always have a choice and it is inappropriate to call someone an “addict” just because he or she prefers drug or alcohol induced euphoria to a socially accepted lifestyle [38–40]. The fact that the drugs or alcohol cause physiological, psychological and social damage was not an issue for him. On the contrary, while he stressed that having the right to (ab)use drugs does not mean that doing so is a good thing, Szasz simply argued that the state should not have the right to forbid anyone to do anything, even if a person chooses to endanger their life [45]. Similarly, emphasizing that respect for personal autonomy requires letting individuals hurt themselves by taking any drug he or she wants, Szasz also claimed that society should defend every individual’s right to commit suicide. As he believed, including in the case of suicide, neither hurting oneself nor the threat of such harm should be understood as a symptom of mental illness but as an important aspect of human agency. Consequently, he claimed that individuals should be able to choose the moment and the method of their own death without interference from the therapeutic state [41–43]. Nevertheless, although Szasz considered suicide to be the most fundamental human right, he strongly opposed state-sanctioned, medically-assisted and pharmaceuticallyinduced killing – euthanasia. Interestingly, his main argument against it was not so much related to the immorality of killing a dying patient but to his preoccupation with the medicalization of assisted suicide by physicians who usurp the right to decide who is competent to ask for it and the power to terminate one’s life. Thus, Szasz claimed that just as killing oneself is a moral act of free will, taking someone else’s life does not require medical expertise. He claimed that euthanasia should not be considered a medical intervention and should not be delegated to physicians. Discussion and conclusions Without a doubt, Thomas Szasz was one of the most important luminaries of the movement of critical psychiatry. Nevertheless, although his role in the history of psychiatry cannot yet be fully determined, it is undeniable that Szasz’s long-lasting relationship with psychiatry and psychotherapy has been problematic. Admired by some, mocked, ignored and ostracized by others, Szasz was a unique ill bird that fouls its own nest, the uncompromising rebel and critic of psychiatry. One of the reasons Thomas Szasz: The uncompromising rebel and critic of psychiatry 861 for this was that his view on psychiatry was all-or-nothing, as rarely did he allow for any nuances. Consequently, although some stress his role as a leading critic of biopsychiatry and a key moral philosopher of psychiatry and psychotherapy [5, 26], Szasz was, and still is, the most debated and criticized psychiatrist in the history of the discipline [49, 50]. Not surprisingly, most critics stress the fact that Szasz’s notion of disease was too narrow. In particular, they accuse Szasz of splitting the mind from the body and argue that he overly emphasized the physical dimension of disease and ignored its complexity [51]. For example, both Robert E. Kendell [52] and K.W.M Fulford [53] argue that contrary to Szasz’s dualism, the mind and the body are strictly interrelated and neither of the two become ill in isolation. Thus, while for Kendell only people, not minds, brains or their bodies become ill, according to Fulford physical disease and mental illnesses are not categorically different but should be viewed as a continuum. Moreover, Kendell [52] argues that although in medicine there is no agreement regarding a universal definition of disease, Szasz’s focus on physical lesions was not applicable to such widely recognized diseases as migraine and torticollis which do not meet the Virchowian criterion of “cellular pathology.” While accusing him of dualism, many authors stress that Szasz’s reductionist and materialistic approach was contradictory to the advances of modern neuroscience [52]. Even authors who acknowledge some of Szasz’s ideas criticize him for denying the fact that medical knowledge and our understanding of disease are constantly evolving. For example, Elliot Valenstein [54] observes that at some period in the history of medicine the causes of every disease were unknown and lack of empirical evidence on the physical causes of disease does not have to necessarily undermine the legitimate status of the idiopathic condition. On the other hand, Edward Shorter [55] mocks Szasz for building his critique on the outdated concept of the mind, typical of the first half of the 20th century, his denial of “solid biological findings in psychiatry” and “evidence of brain pathology”. In the same vein Richard Bentall [56] criticizes Szasz for denying the “enormous advances in the neurosciences”, while E. Fuller Torrey [57, 58] accuses him of denying the increasing amount of evidence proving that schizophrenia is a brain disease [52]. Additionally, Tony Benning argues that Szasz’s view did not include non-Western conceptualizations of mental illness [7]. Critics also underlie the seductive and dangerous influence Szasz’s ideas have had on mental health policy. In particular, they argue that his opposition against involuntary treatment fueled his rejection of any other psychiatric reform. Consequently, as Szasz is often accused of blocking of the improvement of treatment of people with mental problems, he is said to have denied the needs of the most helpless members of society [6, 7, 59]. For example, Arthur R. Williams and Arthur L. Caplan [6] observe that deinstitutionalization, which, at least in some part, was inspired by Szasz’s ideas, has led not only to a rapid decrease in the number of mental patients in public psychiatric 862 Jan Domaradzki hospitals but it also influenced the rapid increase in the number of inmates in state prisons, many of whom suffer from mental disorders. At the same time, regardless of the criticism, some argue that Szasz was not an opponent but a sceptic about psychiatry [26]. Indeed, although he questioned the foundations of modern psychiatry, he did not debunk psychiatry or psychiatric interventions per se and believed that both play an important role in helping individuals with their problems. He simply emphasized that psychiatric treatments should not be based on coercion but on consensual contracts. Thus, while opposing involuntary treatment, Szasz insisted that people should have the right to choose any psychiatric interventions they believe will be beneficial to their problems, be it psychotropic drugs, electroshocks or hospitalization [38–40]. Moreover, as he was strongly influenced by Freud’s psychoanalysis, Szasz was committed to voluntary psychotherapy himself and worked as a private counsellor for many years. Because he believed that psychotherapy extends the person’s autonomy, which is the main requirement of a voluntary and personal contract between the therapist and his or her client, through his entire professional career Szasz practiced and promoted “autonomous psychotherapy” [60], i.e., a voluntary conversation between consenting and autonomous adults which he regarded as the only psychotherapy. Nevertheless, he also criticized modern forms of psychoanalysis and argued that far too often psychotherapists take the role and identity of the psychiatrist and ascribe themselves the leading and somehow coercive position [36, 47]. Meanwhile, from Szasz’s perspective, neither the psychoanalyst nor the psychiatrist can or should claim that they are the only experts who are able to help individuals with their problems, since also relatives and family members, friends, clergymen, physicians and other health care professionals can help. Nevertheless, it seems that in spite of his radicalism, Szasz’s greatest impact has been outside institutionalized psychiatry and his ideas influenced significantly neither psychiatric thought nor practice. Contrary to his beliefs, due to the advances in genetics, neuroimaging and psychopharmacology, psychiatry has evolved in a very biological direction. At the same time, it is undeniable that some of his ideas have led to profound changes within psychiatry and society. First and foremost, his implacable critique of the concept of mental illness focused public attention on the arbitrariness of psychiatric diagnoses. At this point it is worth noting that Szasz was among the first psychiatrists who challenged the concept of homosexuality as a form of “mental illness”, opposed its classification as a mental disorder and its compulsory “aversion therapy” [61]. Secondly, he helped to raise the awareness of the misuse of psychiatric diagnoses for social and political purposes, especially in totalitarian countries [62, 63]. Thirdly, his ideas played some role in the deinstitutionalization of mental patients which began in the 1960s [64, 65]. Fourthly, even though some of his ideas have been criticized or somehow reformulated, Szasz has found a new generation of admirers, many of whom are also psychiatrists, who actively oppose the increasing psychiatrization of human Thomas Szasz: The uncompromising rebel and critic of psychiatry 863 behaviors and involuntary treatment [66–68]. Moreover, Szasz has inspired many psychiatrists, including Peter Breggin [69], Joseph Glenmullen [70] or David Healy [71], who have questioned the biochemical explanation for psychiatric conditions, have critically elaborated his ideas on pharmacracy and have developed their own critique of “psychopharmaceutical complex” and dangerous behavioral abnormalities and brain dysfunctions resulting from psychiatric treatments and psychotic drugs in particular. Fifthly, although Szasz is best known for his critique of psychiatry and the medicalization of everyday life, there is yet another concept elaborated by Szasz that is worth mentioning. In a series of collaborative papers written with Marc Hollender, Szasz outlined three models of doctor–patient relationship: activity–passivity, guidance–cooperation and mutual participation, and argued that different disorders and clinical situations require different approaches [72, 73]. At the same time, it is intriguing that although Szasz and Hollender emphasized the need of complementarity between the patient’s and the doctor’s model, in contrast to Szasz’s crusade against the concept of mental illness, they acknowledged the importance of the disorder of function as well as physical lesions. All in all, although Szasz’s ideas are controversial and still debated in a lively way, it is undeniable that he was one of the leading intellectual voices in the history of modern psychiatry. Most importantly, he expressed some of the epistemological and ethical problems of modern psychiatry better than anyone else. Thus, because Szasz’s critique of psychiatry has influenced, at least somehow, the transformation of psychiatric practice, just as Szasz divided opinion during his lifetime, he will continue to do so even after he passed away. 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Address: Jan Domaradzki Chair of Social Sciences and Humanities Poznan University of Medical Sciences 60-806 Poznań, Rokietnicka Street 7 e-mail: jandomar@ump.edu.pl