David Johnson
Society needs its scapegoats?the ‘bad’ have to be cast out and stripped of rights to reinforce the ‘goodness’ of the majority. For centuries witches were the persecuted outcasts, many people would maintain that the mentally ill fulfil this need today?and the rest of society is satisfied that this should be so.
Professor Szasz chooses provocative titles for his books. Author of The Myth of Mental Illness, he now presents us with The Manufacture of Madness*. I say ‘provocative’ because there is an immediate appeal to the reader’s righteous indignation. You are invited to seek out the villain of the piece. Who is responsible for perpetrating this myth? Who manufactures the madness ? - grist to the mill here for those who seek to attack everything.
Looking at the title and its subtitle, A comparative study of the Inquisition and the mental health movement’, before even opening the book, one might expect an extreme argument and this is what is presented. This makes it important to establish some basic facts and puts the author’s argument in his own simplest terms. Thomas Szasz, as the frontispiece tells us, is ‘a practising psychiatrist and Professor of Psychiatry at the State University of New York in Syracuse’. So we have an attack on ‘institutional psychiatry’ from within psychiatry. Furthermore - and it is absolutely crucial to emphasise this - his attack is on ‘institutional psychiatry’ as practised in the United States.
In the preface the author says ‘I shall compare the belief in witchcraft and the persecution of witches with the belief in mental illness and the persecution of mental patients’. Part one of the book is devoted to this comparison.
The Manufacture of Madness by Thomas S. Szasz, published by Routledge & Kegan Paul, ?3.50 5^ llfm As the witch was made a scapegoat and was persecuted so, argues Szasz, is the mental patient.
Who is responsible? He is in no doubt - ‘Although individuals occasionally assume the role of mental patients voluntarily, I shall presume that the mental patient is cast into his role involuntarily and that the organisation responsible for his situation is institutional psychiatry’. He indicts institutional psychiatry still further by claiming that ‘harming persons categorised as insane is its essential function’.
When confronted with such dogmatic statements, and other like ‘the principal problem in psychiatry has always been and still is violence’, the British reader must be forced to pause and conclude that the writer is part of a very different experience of psychiatry.
Most of us are aware that violence in America represents an enormous social problem far removed from anything we experience in this country. It is perhaps legitimate then to ask if violence and the fear of violence plays a much greater part in American psychiatry.
Szasz tells us that, in the States, something like 10% of psychiatric admissions to mental hospitals are on a voluntary basis and suggests that this is a generous estimate. He tells us that in 1961 in St. Elizabeth Hospital, Washington D.C., only 3.5% of admissions were voluntary. My own check with the records department of the Royal Edinburgh Hospital revealed that in the years 1966-71 over 90% of admissions were on a voluntary basis. Given that this is a teaching hospital there is, nonetheless, some confirmation that psychiatric practice in the two countries is very different - something which must be kept in mind while reading Szasz’s book.
To return to the comparative study of the Inquisition and the mental health movement - the author’s historical account of the persecution of witches is impressive and many of his claims that the abuses of American institutional psychiatry bear comparison must be accepted as fair. The appendix, bibliography and reference list bears out how well he has done his research and it is difficult to argue with the facts. Unfortunately, Szasz clearly does not accept that it is the abuses of a system with which he is concerned; his attack is on institutional psychiatry in its entirety. Nor does the matter rest there. Psychiatric practice in general comes under fire - the author sees it as becoming synonymous with institutional psychiatry.
In developing his theme, he takes sideways swipes at psychiatric training in America, seen as ‘as ritualised indoctrination into the theory and practice of psychiatric violence’, and at Community Mental Health Centres which are seen as extending ‘the This 16th century woodcut shows three witches being burnt at the stake, victims of ignorance and fear. Szasz argues that the mental patient today is in a similar position?that of the scapegoat. traditional police power of the psychiatrist’. Individuals too come under fire - among them a number of eminent American psychiatrists. With this breadth of criticism his original argument loses much force.
Basic human need In the second part of the book Szasz deals with modern methods of ‘manufacturing’ madness and develops his theory that institutional psychiatry ‘fulfils a basic human need - to validate itself as good (normal) by invalidating the other as evil (mentally ill)’.
The section opens with another verbal assault, this time on the ‘paternalism’ and ‘love of power’ of Benjamin Rush, regarded by some as the ‘father of American psychiatry’. He is seen as a veritable pioneer in the manufacture of madness, particularly in the manufacture of the myth of mastubatory madness. This historical chapter is masterly and brooks no argument. Other eminent doctors are also attacked for lending their support to that particular myth.
Some may feel that psychiatry has advanced since then but Szasz does not. ‘I maintain that the situation in psychiatry today is virtually the same as it was when mastubatory madness was the reigning dogma’, and he sets out to justify this in a later chapter entitled ‘The model psychiatric scapegoat - the homosexual’. However, while there is much truth in the scapegoat notion, it is impossible to agree with the assertion that psychiatry has made no advance. The closing chapters of the book are the most persuasive and the most constructive. The scapegoat theme is developed since the author sees it as a problem for society as a whole. He moves from his rather belligerent attack on institutions and individuals to discuss society’s apparent need for a scapegoat, be he Jew, Negro or mental patient. Society is composed of individuals and the author is here talking about the mechanism of ‘projection’, or as he puts it, ‘what is considered good must be included in the body the person, the community; and what is considered bad must be excluded from them’. Thus we create our black sheep.
Szasz speaks of our ‘existential cannibalism’, and asks if we can create meaning in our lives without demeaning others. He sees this as the most important moral question for man. He writes, ‘the cannibal incorporates his victim to give himself virtue - so we expel ours to give ourselves innocence’. The sincerity behind the author’s passionate criticism of any situation which, makes ‘the Other’ anything less than human is beyond doubt.
Equality and non-coercion
To return to the psychiatric framework; Szasz makes it abundantly clear that for him institutional psychiatry is incapable of fostering relationships between therapist and patient based on equality and non-coercion, but he believes private psychiatry can achieve this.
In recent months I have talked with a number of trainee American psychiatrists. They have been equally sincere in criticising private psychiatry in America on the grounds that many private psychiatrists there are making a very great deal of money while many people with psychiatric problems are unable to receive the attention they need because of lack of money. They judged that situation to be immoral.
But that is another point of view and I am left thinking that Szasz leaves little room in his philosophy for other points of view.
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