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An Interview with Thomas Szasz, MD

An Interview with Thomas Szasz, MD by Randall C. Wyatt

The foremost psychiatric critic of our times, Thomas Szasz, engages in an in-depth dialogue of his life's work including freedom and liberty, the myth of mental illness, drug laws, the fragile state of psychotherapy, and his passion for humanistic values and social justice.
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Sections in this Interview:
  • The Myth of Mental Illness 101
  • Slavery, Witchcraft, and Psychiatry
  • The Right to Use Drugs
  • The Therapeutic State and the Medica Model
  • Liberty and the Practice of Psychotherapy
  • Psychotherapy, Szasz Style
  • Critics and Heroes
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The Myth of Mental Illness 101
Randall C. Wyatt: I am going to ask you a wide variety of questions, given the diversity of your interests, and I want to make sure to also focus on your work as a psychotherapist. A little background first. You've been well-known for the phrase, "the myth of mental illness." In less than 1000 words, what does it mean?
Thomas Szasz: The phrase "the myth of mental illness" means that mental illness qua illness does not exist. The scientific concept of illness refers to a bodily lesion, that is, to a material — structural or functional — abnormality of the body, as a machine. This is the classic, Victorian, pathological definition of disease and it is still the definition of disease used by pathologists and physicians as scientific healers.

The brain is an organ — like the bones, liver, kidney, and so on — and of course can be diseased. That's the domain of neurology. Since a mind is not a bodily organ, it cannot be diseased, except in a metaphorical sense — in the sense in which we also say that a joke is sick or the economy is sick. Those are metaphorical ways of saying that some behavior or condition is bad, disapproved, causing unhappiness, etc.
In other words, talking about "sick minds" is analogous to talking about "sick jokes" or "sick economies."
In other words, talking about "sick minds" is analogous to talking about "sick jokes" or "sick economies." In the case of mental illness, we are dealing with a metaphorical way of expressing the view that the speaker thinks there is something wrong about the behavior of the person to whom he attributes the "illness."

In short, just as there were no witches, only women disapproved and called "witches," so there are no mental diseases, only behaviors of which psychiatrists disapprove and call them "mental illnesses." Let's say a person has a fear of going out into the open. Psychiatrists call that "agoraphobia" and claim it is an illness. Or if a person has odd ideas or perceptions, psychiatrists say he has "delusions" or "hallucinations." Or he uses illegal drugs or commits mass murder. These are all instances of behaviors, not diseases. Nearly everything I say about psychiatry follows from that.
RW: Let's say that modern science, with all the advances in genetics and biochemistry, finds out that there are some behavioral correlates of biological deficits or imbalances, or genetic defects. Let's say people who have hallucinations or are delusional have some biological deficits. What does that make of your ideas?
TS: Such a development would validate my views, not invalidate them, as my critics think. Obviously, I don't deny the existence of brain diseases; on the contrary, my point is that if mental illnesses are brain diseases, we ought to call them brain diseases and treat them as brain diseases — and not call them mental illnesses and treat them as such. In the 19th century, madhouses were full of people who were "crazy"; more than half of them, as it turned out, had brain diseases — mainly neurosyphilis, or brain injuries, intoxications, or infections. Once that was understood, neurosyphilis ceased to be a mental illness and became a brain disease. The same thing happened with epilepsy.
RW: It's interesting, because a lot of students of mine, and colleagues, who have read your work or heard of your ideas, think that when condition previously thought to be mental is to be a brain disease, as noted, your ideas become moot.
TS: That's because they are not familiar with the history of psychiatry, don't really understand what a metaphor is, and don't want to see how and why psychiatric diagnoses are attached to people. Ted Kaczynski, the so-called Unabomber, was diagnosed as schizophrenic by government psychiatrists. If people want to believe that a "genetic defect" causes a person to commit such a series of brilliantly conceived crimes — but that when a person composes a great symphony, that's due to his talent and free will — so be it.

Objective, medical diagnostic tests measure chemical and physical changes in tissues; they do not evaluate or judge ideas or behaviors. Before there were sophisticated diagnostic tests, physicians had a hard time distinguishing between real epilepsy — that is to say, neurological seizures — and what we call "hysterical seizures," which is simply faking epilepsy, pretending to have a seizure. When epilepsy became understood as due to an increased excitability of some area of the brain, then it ceased to be psychopathology or mental illness, and became neuropathology or brain disease. It then becomes a part of neurology. Epilepsy still exists. Neurosyphilis, though very rare, still exists, and is not treated by psychiatrists; it is treated by specialists in infectious diseases, because it's an infection of the brain.

The discovery that all mental diseases are brain diseases would mean the disappearance of psychiatry into neurology. But that would mean that a condition would be a "mental disease" only if it could be demonstrated, by objective tests, that a person has got it, or has not got it. You can prove — objectively, not by making a "clinical diagnosis" — that X has neurosyphilis or does not have it; but you cannot prove, objectively, that X has or does not have schizophrenia or "clinical depression" or post traumatic stress disorder. Like most nouns and verbs, the word "disease" will always be used both literally and metaphorically. As long as psychiatrists are unwilling to fix the literal meaning of mental illness to an objective standard, there will remain no way of distinguishing between literal and metaphorical "mental diseases."
RW: Psychiatrists, of course, don't want to be pushed out of the picture. They want to hold on to schizophrenia as long as they can, and now depression and gambling, and drug abuse, and so on, are proposed as biological or genetically determined. Everything is thought to have a genetic marker, perhaps even normality. What do you make of this?
TS: I hardly know what to say about this silliness. Unless a person understands the history of psychiatry and something about semantics, it's very difficult to deal with this. Diagnoses are NOT diseases. Period.
Psychiatrists have had some very famous diseases for which they have never apologized, the two most obvious ones being masturbation and homosexuality.
Psychiatrists have had some very famous diseases for which they have never apologized, the two most obvious ones being masturbation and homosexuality. People with these so-called "diseases" were tortured by psychiatrists — for hundreds of years. Children were tortured by antimasturbation treatments. Homosexuals were incarcerated and tortured by psychiatrists. Now all that is conveniently forgotten, while psychiatrists — prostitutes of the dominant ethic — invent new diseases, like the ones you mentioned. The war on drugs is the current psychiatric-judicial pogrom. And so is the war on children called "hyperactive," poisoned in schools with the illegal street drug called "speed," which, when called "Ritalin," is a miracle cure for them.

Let me mention another, closely related characteristic of psychiatry, as distinct from the rest of medicine. Only in psychiatry are there "patients" who don't want to be patients. This is crucial because my critique of psychiatry is two-pronged. One of my criticisms is conceptual: that is, that mental illness is not a real illness. The other one is political: that is, that mental illness is a piece of justificatory rhetoric, legitimizing civil commitment and the insanity defense.
Dermatologists, ophthalmologists, gynecologists, don't have any patients who don't want to be their patients. But the psychiatrists' patients are paradigmatically involuntarily.
Dermatologists, ophthalmologists, gynecologists, don't have any patients who don't want to be their patients. But the psychiatrists' patients are paradigmatically involuntarily.

Originally, all mental patients were involuntary, state hospital patients. That concept, that phenomenon, still forms the nucleus of psychiatry. And that is what is basically wrong with psychiatry. In my view, involuntary hospitalization and the insanity defense ought to be abolished, exactly as slavery was abolished, or the disfranchisement of women was abolished, or the persecution of homosexuals was abolished. Only then could we begin to examine so-called "mental illnesses" as forms of behavior, like other behaviors.
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Slavery, Witchcraft, and Psychiatry
RW: In terms of involuntary hospitalization and coercive psychiatry, which you've critiqued in your works.
TS: Excuse me, all psychiatry is coercive, actually or potentially — because once a person walks into a psychiatrist's office, under certain conditions, that psychiatrist has the legal right and the legal duty to commit that person. The psychiatrist has the duty to prevent suicide and murder. The priest hearing confession has no such duty. The lawyer and the judge have no such duties. No other person in society has the kind of power the psychiatrist has. And that is the power of which psychiatrists must be deprived, just as white men had to be deprived of the power to enslave black men. Priests used to have involuntary clients. Now we call that forcible religious conversion and religious persecution; it used to be called "practicing the true faith" or "loving God." Now we have forcible psychiatric conversion and psychiatric persecution — and we call that "mental health" and "therapy." It would be funny if it were not so serious.
RW: The symbolic nature of psychiatry and the sociology of psychiatry are coercive. Yet, every act isn't literally coercive. Somebody comes to a doctor and says, "I can't sleep. I'm depressed. Can you give me something to help me go to sleep, help wake me up?" That's a free exchange.
TS: That's correct. There are voluntary psychiatric exchanges, at least in principle. As I like to say, I wholeheartedly approve of psychiatric acts between consenting adults. But such acts are pseudo-medical in nature, because the problem at hand is not medical, and also because the transaction often rests on taking advantage of the criminalization of the free market in drugs. Why do you have to go to a doctor to get a sleeping pill or a tranquilizer? A hundred years ago you didn't have to do that, you could go to a drug store, or to Sears Roebuck, and buy all the drugs you wanted — opium, heroin, chloral hydrate. In certain ways, the psychiatric profession lives off the fact that only physicians can prescribe drugs, and the government has made most drugs that people want prescription drugs.
RW: On a side note, isn't it interesting, and troubling, that most people who go to jail for drug abuse, or drug selling, are black and minority, and those that have the license to prescribe are often non-minority, and they get to be heroes in society for essentially selling what is sometimes the same merchandise, albeit legally, of course?
TS: Indeed. I discuss that new form of black enslavement in detail in my book, "Our Right to Drugs." Because of the kinds of laws we have, physicians prescribe mood-altering drugs, which patients often want and demand; it's a medicalized version of drug distribution. Physicians did the same thing with liquor during Prohibition, which was quite lucrative.
RW: And now psychiatry and pharmacology can be a lucrative business.
Psychiatry is a lucrative business only insofar as it partakes of these two medical-psychiatric privileges or monopolies — prescribing drugs, which only licensed physicians can do; and creating their own patients, that is, transforming people into patients against their will, which only psychiatrists can do.
Psychiatry is a lucrative business only insofar as it partakes of these two medical-psychiatric privileges or monopolies — prescribing drugs, which only licensed physicians can do; and creating their own patients, that is, transforming people into patients against their will, which only psychiatrists can do.
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The Right to Use Drugs
RW: So what is your view on psychiatric medication for people suffering from "schizophrenia" or "problems in living" as you call it, or "interpersonal difficulties," or "intra-psychic difficulties." Whatever you call it, people suffer or are troubled internally or interpersonally. What is your view on the use of either legal or illegal drugs to help people cope with these things?
TS: I am smiling because I know you know my views! However, I wouldn't phrase the question this way. In my opinion, using drugs is a fundamental human right, similar to using books or prayer. Hence, it comes down to the question of what does a person want and how can he get what he wants? If a person wants a book, he can go to a store and get it or get it on the Internet. He ought to be able to get a drug the same way. If he doesn't know what to take, then he could go to a doctor or a pharmacist and ask them. And then he should be able to go and buy it.
RW: That brings up the issue of drug and prescription laws, which you have written about extensively.
TS: Indeed. Prescription drug laws are a footnote to drug prohibition. Prescription laws should be repealed. All drug laws should be repealed. Then, people could decide for themselves what helps them best to relieve their existential ails, assuming they want to do it with a drug: opium or marijuana or cigarettes or Haldol or Valium. After all, the only arbiter of what ails a person "mentally" and what makes him feel or function better, as he defines better, is the patient. We don't have any laboratory tests for neuroses and psychoses.

As for insomnia, typically that's a complaint, an indirect communication, to obtain sleeping pills. A person can't go to a physician and tell him: Please write me a prescription for a barbiturate. If he did that, he would be diagnosed and denounced as an addict. So he must say: "I can't sleep." How could the doctor know if that's true?
RW: You ask him how many hours he sleeps, he says two hours a night.
TS: How would the doctor know if that's true? The term "insomnia" can function as a strategic lie that the patient has to utter to get the prescription he wants.
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The Therapeutic State and the Medica Model
RW: You seem to have a different view of the medical model of medicine, than the medical model of psychiatry.
TS: Yes, very much so. We don't speak of the medical model of medicine in medicine or the medical model of pneumonia. There is no other model. We don't speak of the electrical model of why a light bulb emits light. Language is very important. If a person says: "I am against the medical model of mental illness," that implies that mental illness exists and that there is some other model of it. But there is no mental illness. There is no need for any model of it.

The important issue is not the "medical model," a badly abused term; the issue is the "pediatric model," the "irresponsibility model" — treating people labeled as mentally ill as if they were little children and as if the psychiatrist was their parent. The pillars of psychiatry are medically rationalized and judicially legitimized coercions and excuses.
RW: If you were to use mental illness as a metaphor, or pseudonym... disease meaning "dis-ease," people are personally distressed, the psychosocial model of mental illness. If you substitute "emotional troubles".
TS: No. That won't do. Almost anything can be the cause of emotional trouble — being black or being poor or being rich, for that matter. Innumerable human conditions can create human distress. Which ones are we going to medicalize, and which ones are we not? We used to medicalize, psychiatrize, blacks running away from slavery, masturbation, homosexuality, contraception. Now we don't. Instead we medicalize what used to be called melancholia, and sloth, and self-murder, and racism, and sexism.
RW: To shift gears.
TS: Let's not yet. Because I want to add that
it is this tendency to call more and more human problems "diseases" and then try to remedy them, or "attack" them, as if they were diseases is what I call "the therapeutic state."
it is this tendency to call more and more human problems "diseases" and then try to remedy them, or "attack" them, as if they were diseases is what I call "the therapeutic state."
RW: Certainly everything used to be viewed religiously, and now so much is seen as medical. The transformation is almost pure.
TS: Exactly! And it's perfectly obvious. It requires the systematic educational and political dumbing down of people not to see it. Three hundred years ago, every human predicament was seen as a religious problem — sickness, poverty, suicide, war. Now they are all seen as medical problems — as psychiatric problems, as caused by genes and curable with "therapy." In the past, the criminal law was imbued with theology; now, it's imbued with psychiatry.
RW: President Bill Clinton is a prime example of how we use different models to describe the same problem. His wife said his problems were due to "emotional problems" in his childhood. His brother said he was a sex addict, because he was a drug addict, himself. And Bill Clinton said it was a sin issue — the religious model. He went to a minister.
TS: That's a good point. But note that Clinton didn't go to a real minister. He went to a politician — Jesse Jackson. His job was to make Clinton look good again. And he did it. Clinton hand-picked him as he did the others, much as a medieval emperor might have hand picked a bishop to make him look good.
RW: Can I shift gears now?
TS: Sure.
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Liberty and the Practice of Psychotherapy
RW: You're known as a libertarian.
TS: Yes, I am a libertarian.
RW: It's a philosophical view, an economic and political view. What does that mean in terms of practicing psychotherapy?
TS: I'll start at the end, so to speak. If you use language carefully and are serious about libertarianism and psychiatry, then the term "libertarian psychiatrist" is, quite simply, an oxymoron. Libertarianism means that individual liberty is a more important value than mental health, however defined. Liberty is certainly more important than having psychiatrists lock you up to protect you from yourself. Psychiatry stands or falls with coercion, with civil commitment. Non-coercive psychiatry is also an oxymoron. This is one of the main reasons why I never considered myself a psychiatrist — because I always rejected psychiatric coercions.

Now, in term of political philosophy, libertarianism is what, in the 19th century, was called liberalism. Nowadays it's sometimes also called "classical liberalism." It's a political ideology that views the state as an apparatus with a monopoly on the legitimate use of force and hence a danger to individual liberty. Contrariwise, the modern "Liberal" view regards the state as a protector, a benevolent parent who provides security for its citizens as quasi-children. To me, being a libertarian means regarding people as adults, responsible for their behavior; expecting them to support themselves, instead of being supported by the government; expecting them to pay for what they want, instead of getting it from doctors or the state because they need it; it's the old Jeffersonian idea that he who governs least, governs best. The law should protect people in their rights to life, liberty, and property — from other people who want to deprive them of these goods. The law should not protect people from themselves.

This means that, as far as possible, medical care ought to be distributed, economically speaking, as a personal service in the free market. There is much wisdom in the adage, "People pay for what they value, and value what they pay for." It's dangerous to depart too far from this principle.
RW: Why does money necessarily have to come into it? If people have less money, they can't afford as much as others who have more money. A poor person can benefit from therapy.
TS: Of course. The issue you raise confuses the quest for egalitarianism with the concepts of health or psychotherapy and also with the quest for health. Why should psychotherapy be dispensed in a more egalitarian manner than anything else? Also, people often value things other than health more highly than they value health — such as adventure, danger, excitement, smoking.

Let me elaborate on this. Economists and epidemiologist have shown, beyond a shadow of a doubt, that the two variables that correlate most closely with good health are the right to property and individual liberty — the free market. The people who enjoy the best health today are people in the Western capitalist countries and in Japan; and those in the poorest health are the people who enjoyed the blessings of 80 years of paternalistic statist, Communism. In the Soviet Union, where people's political liberty and economic well being were systematically undermined by the state — where they enjoyed "equal misery for all" — life expectancy dropped from more than 70 years to about 55 years. During the same period, in advanced countries, it increased steadily and is now almost 80. And medical care has little to do with it, since Russia had access to medical science and technology. It's primarily a matter of life style — of what used to be called good habits versus bad habits. And of good public health, in the sense of having a safe physical environment.
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Psychotherapy, Szasz Style
RW: You wrote, "The Ethics of Psychoanalysis" in 1965. That was your diving into psychotherapy, psychoanalysis. What do you have to say about what is useful in psychotherapy? What theories do you hold to or do you find valuable? When you're in a free relationship of psychotherapy — simply put, one person helping another with their personal issues — what have you found to be helpful, and what theories have you used in your own work?
TS: You are asking two questions: what did I find useful or interesting and what theories did I use. The kind of therapy one does, if one does it well, in my opinion, is selected and depends primarily on the therapist.
Different people have different temperaments about how to relate to other people. Because the therapeutic relationship is an intimate, human relationship with another human being, the kind of psychotherapy that makes sense to therapists reflects the kind of person they are.
Different people have different temperaments about how to relate to other people. Because the therapeutic relationship is an intimate, human relationship with another human being, the kind of psychotherapy that makes sense to therapists reflects the kind of person they are. In this respect, psychotherapy could not be more different from physical therapies in medicine. The proper treatment of diabetes does not depend, and ought not to depend, on the doctor's personality. It's a matter of medical science. On the other hand, the proper treatment of a person in distress seeking help is a matter of values and personal styles — on the parts of both therapist and patient.

The proper analogies to psychotherapy are not medical treatment but marriage or raising children. How should a man relate to his wife, and vice versa? How do you raise your child? Different people relate differently to their wives or husbands or children. As long as their life style works for them, that's all there is to it. So, first I say that I believe that any kind of so-called "therapy" — any kind of human helping situation that makes sense to both participants and that can be entered and exited and conducted wholly consensually, voluntary, and that is devoid of force and fraud — any and all of that is, by definition, helpful. If it were not helpful, the client wouldn't come and pay for it. The fact that a client returns and pays for what he gets from a therapist is, prima facie evidence for me, that he finds it helpful.

I would compare it, once again, to religion, to going to church. Personally, I'm not religious. But I respect religions and people who find solace in their faith. Millions of persons the world over continue to go to church. They wouldn't be going to church if they didn't find it helpful, assuming they're not just going for purely social reasons, in which case they still find it useful, though not for strictly theological reasons.
RW: What was your initial interest in becoming a psychiatrist?
TS: I was never interested in becoming a psychiatrist and never considered myself a psychiatrist. Psychiatry was a category I had to operate in, given the society in which we live. I was interested in psychotherapy, in what seemed to me the core of the Freudian premise - and promise, which, unfortunately, never materialized as a professional code. Freud and Jung and Adler had a very good idea — that is, that two people, a professional and a client — get together, in a confidential relationship, and the one tries to help the other live his life better. Each of these pioneers emphasized a different aspect of how best to go about this business. There are three aspects to life: the past, the present, and the future.
Freud dwelled on the past, Jung dwelled on the future, and Adler (and Rank) dwelled on the present. All of these make sense. But all this has to be tailored to whether or not it makes sense to the patient.
Freud dwelled on the past, Jung dwelled on the future, and Adler (and Rank) dwelled on the present. All of these make sense. But all this has to be tailored to whether or not it makes sense to the patient.
RW: How does this play out in term of the therapeutic relationship?
TS: The relationship has to be wholly cooperative. The two people may meet only a few times, or they meet many times over many years. The therapist is the patient's agent. This doesn't mean that he must agree with everything the patient believes or wants; far from it. But it means that the therapist is prohibited — by his own moral code — from doing anything against the patient's interest, as the patient defines his interest. That is part of my idea of the contract with the patient. That's why I titled my book, "The Ethics of Psychoanalysis." Therapy is a matter of ethics, not technique.

It was crucial that my patients selected themselves. They came when they wanted; they came to see me, because they wanted to see me, not someone else. And there wasn't any of this business about being "ready" to end therapy. Just as the patient decided when or whether to begin therapy, so he decided when or whether to end therapy. There isn't any of this business that the therapist has to change the patient, or make him better, or control his behavior, or protect him from himself, and so forth. It is up to the patient to change himself. The therapist's job is to help him change in the direction in which the patient wants to change, provided that's acceptable to the therapist. If it's not acceptable, then it is therapist's job to discuss that with the patient and end the relationship.
RW: What are the expectations of the patient then?
TS: The patient doesn't have to do anything except pay. This sounds like a selfish joke. It is not. It is important. It's up to the patient what he or she takes away from the situation. The situation is similar to what happens in school, especially at the university level. If you go to school and have to pay for it, the idea is that you should learn something. But there is no coercion. At the end of it, if you don't learn something, that's your business. It's your loss.
RW: You mentioned that change isn't a prerequisite, yet most people want some change.
TS: It's not that simple. People want to change and they also don't want to change. The behavior that the patient wants to change must, in some way — this is very Freudian — be also functional for the patient, or else he would already have changed it, without formal therapy. People can and do change themselves.
RW: Adaptive?
TS: Adaptive. Exactly. So-called mental symptoms are rather unlike medical symptoms. A cough, say, if you have pneumonia, is adaptive: it rids the body of mucus and infectious material and tissue debris as sputum. But it's adaptive in this or other similar pathological situation only. It's not adaptive to you as a human being. But a phobia, anxiety, depression, etc. maybe adaptive as some kind of a life strategy, economic or interpersonal strategy.
RW: Your goal for psychotherapy, that is, the fully-functioning human, is to increase their autonomy. You did have that as a goal.
TS: That was my underlying goal, which I communicated [to my clients] as the ethical principle. My premise is that responsibility is, morally speaking, anterior to liberty. So if a person wants to gain more freedom — in relation to his fears, his wife, his work, etc. — he must first assume more responsibility (than he has been) toward them; then he will gain more liberty in relation to them.
The goal is to assume more responsibility and therefore gain more liberty and more control over one's own life.
The goal is to assume more responsibility and therefore gain more liberty and more control over one's own life. The issues or questions for the patient become to what extent is he willing to recognize his evasions of responsibility, often expressed as "symptoms."
RW: That's a dialogue.
TS: Yes, that is likely to be a focus of the therapeutic dialogue. Actually, some people say they want to do this or that — say stop smoking or be a better parent — but they don't really want to do it, don't want to forego the pleasures of smoking or experience the burdens of caring for a dependent. A person comes to see a therapist and says that he wants to kill himself. Obviously, that's not all he wants. He also wants psychotherapy. In short, people are often ambivalent about basic choices. Ambivalence is not a pathological symptom; it a normal, appropriate mental state of many people, in many situations.
RW: Come back home to therapy, again, you're not practicing any more?
TS: No, but I did for 45 years.
RW: What was the most difficult and what was the most satisfying for you in working with people one-to-one?
TS: I found practicing therapy very satisfying and not at all arduous. I left Chicago for Syracuse mainly to escape having to fully support myself from doing therapy, which can create financial temptations to make the client dependent on therapy. Of course, everyone who does therapy is likely to say it, but I think a lot of people benefited from having a "conversation" with me.
RW: With all your work in politics and philosophy, your work on psychotherapy is overlooked. That you were in the trenches, helping people, conversing with them.
TS: And many of the people I saw would have been diagnosed as very sick by other people. Some of them would have been diagnosed as psychotic and put on psychiatric drugs.
RW: You never prescribed?
TS: No. Never when practicing psychiatry — psychotherapy —
I never prescribed a drug. I never gave insulin shock or electric shock. I never committed anyone. I never testified in court that a criminal was not responsible for his crimes. I never saw, as a patient, anyone who did not want to see me.
I never prescribed a drug. I never gave insulin shock or electric shock. I never committed anyone. I never testified in court that a criminal was not responsible for his crimes. I never saw, as a patient, anyone who did not want to see me. I went into psychiatry with my eyes wide open. I never viewed psychiatry or psychotherapy as a part of medicine. Perhaps I should add, though it should be obvious, that I had no objections to the patient taking drugs or doing anything else he wanted. As far as I was concerned, things outside the consulting room were not my business — in the sense that if the patient wanted to take drugs, he had to go to a doctor and get them, just as if he wanted a divorce, he had to go to a lawyer.
RW: With the laws today, it's very hard for a therapist or a psychiatrist to practice psychotherapy. You can shy away from involuntary hospitalization, or other state mandates, or insurance demands, but when push comes to shove, you are pressured to break confidences or end up in trouble.
TS: That's putting it mildly. For all practical purposes, it's impossible. It is the hallmark of totalitarianism that there can be no personal secrets from the state. That's why I call our present political system a "therapeutic state." Such a state is your friend, your benefactor, your doctor. Why should you want to hide anything from it? Keep in mind that it was impossible to do psychotherapy in Soviet Russia, too, or in Nazi Germany. Suppose someone came to you in Nazi Germany and said, "I'm harboring Jews in my cellar." If you did not report that, you ran the risk of being put in a concentration camp and gassed. Today, if you don't report that the patient is suicidal, or homicidal, or a child abuser, among other mandates, you are asking for trouble. So confidential psychotherapy is kaput, finished. Therapists and patients kid themselves that it isn't.

What can you do? Nothing. We have managed to make the free practice of psychotherapy de facto illegal! The psychotherapist has been transformed into a reporting agent, an agent of the state whose job is to betray his patient. Child abuse, drug abuse, violence, suicide — the therapist must stop, must prevent, all these things. The therapist must be a policeman pretending to be therapist. Increasingly, people complain about one or another of these "problems of confidentiality," but they don't see the larger picture. They don't see that this has to do with the alliance of psychiatry and psychotherapy with the state, replicating the alliance of church and state and all its implications.
RW: Even more so, when people go to a therapist who's working under managed care, they have to have enough problems to get in the door to see the therapist and talk, or get drugs, but not too many problems. If they have too many problems they're seen as "chronic" and they can't get help. Do you think a therapist working under managed care is able to freely practice psychotherapy? Is the client free to work in psychotherapy?
TS: Psychotherapy under managed care is a bad joke. It's like religion under managed care, or education under managed care. Even medical care gets complicated and contaminated if the direct relationship between doctor and patient is disrupted by the input of third parties, if the patient doesn't, in some form, pay for what he gets, and if he can't get what he wants with the money he pays.

Modern psychotherapy is based on psychoanalysis, and the psychoanalytic relationship was based on the relationship between priest and penitent in the confessional. The crux of the confessional is self-accusation on the part of the penitent, and the secure promise, by the priest, that the confession he hears will and can have no consequences for the self-accuser in this world (but only in the next). A priest hearing confession and working as a spy for the state would be a moral obscenity. Not in the darkest days of totalitarianism did such a thing occur.

The same thing is true for psychotherapy based on confidentiality and on the premise that the patient "accuses" himself in the hope that, by so doing and with the help of the therapist, he might be able to change himself.
What is truly ugly about psychotherapy today is that many patients labor under the false belief that what they say to the therapist is confidential
What is truly ugly about psychotherapy today is that many patients labor under the false belief that what they say to the therapist is confidential, and that therapists do not tell patients, up front, that if they utter certain thought and words, the therapist will report them to the appropriate authorities, they may be deprived of liberty, of their job, of their good names, and so forth.

Now, it should be clear that to place psychotherapy under the control of an insurance company or the state — that's just heaping nonsense upon nonsense. We can still call it psychotherapy, and we can treat it as if doing psychotherapy, "curing souls," were in principle no different from doing orthopedic surgery, setting a fractured bone. But, psychotherapy is like going to church. You go there voluntarily for a certain kind of service from a certain person. And it's spiritual. It's not physical.
RW: We only have a couple of minutes left. I want to ask you one or two more questions. It was a pleasure to talk about your therapy, because you get very little chance to talk about that work given the vitriol surrounding many of your views.
TS: Thank you.
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Critics and Heroes
RW: You've had a lot of critics in your career.
TS: You can say that again!
RW: Maybe an enormous amount! In your book, Insanity, you point out all the critics.
TS: Not all of them!
RW: You couldn't mention all of them?
TS: No. Just a few (laughter).
RW: How do you deal with this? You're one of the most criticized psychiatrists in history, perhaps. I don't know anybody else who's as criticized as you are.
TS: I was very fortunate. I had very good parents, a very good brother, a very good education as a child in Budapest. I have very fine children, good friends, good health, good habits, a fair amount of intelligence. Really, I have always felt blessed. It also helped at lot that I felt there were many people who agreed with me — that what I'm simply saying is simply 2 + 2 = 4 — but that many people are afraid to say this when it is personally and politically improvident to do so. I haven't made any scientific discoveries. I'm simply saying that if you are white and don't like blacks, or vice versa, that's not a disease, it's a prejudice.
If you're in a building that you can't get out of, that's not a hospital, it's a prison.
If you're in a building that you can't get out of, that's not a hospital, it's a prison. I don't care how many people call racism an illness or involuntary mental hospitalization a treatment.
RW: Did the criticism ever get you down?
TS: Of course it did, especially when people actually wanted to injure me — personally, professionally, legally. No need to get into that. I tried to protect myself and escaped, luckily enough. I found boundless support in literature, in the great writers. Ibsen said, among other things, that "the compact majority is always wrong."
RW: My last question. In addition to being criticized a great deal, you are also somewhat of a hero to a lot of people, in what you've fought for, liberty, individual rights, and increased freedoms with responsibility. Who are the your heroes, since childhood and now?
TS: Where should I start, there are many? Shakespeare, Goethe, Adam Smith, Jefferson, Madison, John Stuart Mill, Mark Twain, Mencken. Tolstoy, Dostoyevski, Chekhov. Orwell, C.S. Lewis. Ludwig von Mises, F.A. Hayek. Camus and Sartre, though personally and politically, he is rather despicable. He was a Communist sympathizer. He was willing to overlook the Gulag. But he was very insightful into the human condition. His autobiography is superb. His book on anti-Semitism is important.
RW: Camus challenged him.
TS: Yes, Camus broke with him, mainly about politics. Camus was a much better person, a much more admirable human being. He was also a terrific writer.
RW: We could go on about how each of them influenced you, I am sure of it, another day perhaps. I want to thank you for being with us today. I am sure our readers will appreciate your candor.
TS: Thank you.

Copyright © 2001 Psychotherapy.net. All rights reserved. Published December 2000
CE Course
Thomas SzaszThomas S. Szasz received his M.D. degree from the University of Cincinnati. He is currently professor of psychiatry emeritus at SUNY Health Science Center in Syracuse, New York, where he has taught since 1956. Dr. Szasz is the author of over 600 articles, book chapters, book reviews, and newspaper columns. His classic The Myth of Mental Illness (1961) made him a figure of international fame and controversy. Many of his works--such as Law, Liberty, and Psychiatry, The Ethics of Psychoanalysis, Ceremonial Chemistry, and Our Right to Drugs are regarded as among the most influential in the 20th century by leaders in medicine, law, and the social sciences.
Randall C. Wyatt is a practicing psychologist in Oakland and Dublin, California. He specializes in working with post-traumatic stress, cross-cultural therapeutic relationships and couples therapy and has extensive teaching experience.
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CE credits: 1.5
Learning objectives: • Explore the relationship between liberty and psychotherapy.
• Gain knowledge of Szasz's approach to psychotherapy.
• Gain awareness of a critique of the contemporary psychiatric approach to understanding and treating mental illness. 
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