Book Review
General Psychiatry 
Szasz Under Fire: The Psychiatric Abolitionist Faces His Critics Jeffrey A Schaler, editor. Chicago (Ill): Open Court La Salle; 2004. 450 p. US $36.95.
Reviewer
rating*: Good
Review by: Gilbert Pinard, MD
Montreal, Quebec
This book is edited by Jeffrey Schaler, a psychologist and associate professor of justice, law, and society at American University. The format is as follows: a “critic” states his or her position vis à vis Szasz and then he replies. Few authors of the 12 chapters are psychiatrists or psychotherapists– psychoanalysts, with the exception of RE Kendell and Ronald Pies. Most contributors have doctorates in philosophy or law, which colours the content and sets the tone. Several contributors seem to subscribe partly to some of Szasz’ views, although they are less extreme in their propositions.
The first chapter is an autobiographical sketch by Thomas Szasz, and herein we find the crux: “mental illness is a myth, and therefore it is foolish to look for the causes or cures of the imaginary ailments we call ‘mental diseases.’”
Kendell builds on this, summarizing Szasz’ claims that a condition is a disease only if a morphological abnormality is demonstrated (following the Virchow criteria). It follows, then, that there is no medical, moral, or legal justification for involuntary psychiatric hospitalization or treatment. Szasz restates his belief that psychiatry and coercion are like “conjoined twins” and cannot be separated.
KWM Fulford, a professor of philosophy and mental health, believes Szasz is skeptical rather than antipsychiatry, and by explaining what he calls value-based medicine, he hopes to show that Szasz does not lead to the demise of psychiatry but, rather, to its strengthening. Szasz disagrees with much of Fulford's paper, and he states that value-based medicine and its twin, evidence-based medicine, are “merely obfuscatory, self-approbating slogans.” This pattern runs through practically every chapter. One critic at times agrees with part of Szasz’ beliefs or thesis and yet, in a devastating counterattack, is severely criticized for his “misinterpretations.”
Another author, Scott Percival, thinks Szasz is unnecessarily open to criticism because he lacks a strong epistemology and proposes that his perspective could be found in the work of Karl Popper. Interestingly, Szasz, by way of answer, invites us to read his exchange of letters with Popper.
Szasz also defends his position on suicide, clearly stating that he is opposed to “suicide prevention” because it refers to “the practice of using the coercive apparatus of the state to deprive people of their liberty.” He is also opposed to “physician assisted suicide because it augments the physician’s power.”
At times, there is an attempt to incorporate neuroscience and theories that rest on neurotransmitters to demonstrate that psychiatric disorders, particularly schizophrenia, indeed have a genetic and neuropathological base. This could enable one to attribute the symptoms to biology. Szasz replies trenchantly that it is not because biological research has not yet conclusively shown schizophrenia to be a disease that he believes it to be a myth but “that no one can find such a disease.” For example he states “I do not regard hallucinations and delusions as symptoms . . . but as disowned self-conversations and delusions as stubborn errors or lies. Both are created by patients and can be stopped by them.”
Another author, Ralph Slovenko, also points out how much Szasz believes that “the therapeutic state is a threat to individual freedom” and even that “by treating offenders as responsible human beings [not psychiatric patients, my own words] we offer them the only chance to remain human.” Szasz is convinced that the insanity defense is morally wrong. In another reply, he accuses his critic, Rita Simon, of being slanderous in her short paper making the case that the insanity defense is necessary to differentiate between illness and evil. I use this point to illustrate the tone with which Szasz writes his replies. Other chapters address the “pharmacracy” surrounding psychiatry as well as the diagnostic system and its inadequacies, but I cannot do justice to all the dense philosophical and legal content of this rich work.
The purpose of the book is obvious from the title and the publishing house—Szasz Under Fire: The Psychiatric Abolitionist Faces His Critics (published by Open Court): it is to spark debate between Szasz and erudite critics of Szasz's points of view. To some degree, the book does this spectacularly. Nonetheless, I would have liked the inclusion of comments from some of psychiatry's better thinkers. Some apparently refused to comment.
The authors are obviously competent in their domains and make most chapters sharply analytic, yet very readable and clear. Szasz is unfailingly critical and biting.
This is an attractive book destined for people who would like to go deeper into this debated area, although it may be that most psychiatrists think this debate a thing of the past, a remnant of the 1960s. The price is reasonable.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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