Mental Illness: From Shame to Pride
Szasz, Thomas, Ideas on Liberty
The Therapeutic State
In the nineteenth century people were ashamed and embarrassed by their mentally ill relatives. This was especially true for parents who had a mentally ill child and for adult children who had a parent incarcerated in an insane asylum. Today, such persons take pride in having a mentally ill "loved one," make a career of speaking and writing about his "illness," and fight for his "right to treatment."
The attitude of journalists, writers, and social commentators toward psychiatry underwent an analogous transformation. In the nineteenth century they were critical of psychiatrists who locked up innocent people in insane asylums and excused criminals as mentally ill. Now they view and admire them as scientifically enlightened, caring doctors.
How and why did this change come about? One impetus for this transformation-which psychiatrists call the "remedicalization of psychiatry"-was the publication, in 1961, of my book The Myth of Mental Illness and Erving Goffman's book Asylums. Another was the fleeting interest of a few lawyers, stimulated by these books, in freeing mental patients from their psychiatric life sentences. (Sadly, these "civil rights" zealots were more interested in promoting themselves than in protecting liberty and responsibility, and showed no interest in opposing the insanity defense.)
These assaults on psychiatry as a medical specialty and on involuntary mental hospitalization as a species of preventive detention made psychiatrists close ranks and launch a well-organized and highly effective counteroffensive. The psychiatric defense of mental illness as brain disease and of psychiatric deprivation of liberty as medical treatment comprised several mutually reinforcing measures. One was the creation of a group of chemicals dubbed "antipsychotics," a term intended to resonate with the term "antibiotics." These chemical straitjackets were successfully sold to the public and the press-though not to involuntary patients-- as "miracle drugs."
The psychiatrists' second line of defense was equally inspired. State mental hospitals had acquired a bad name. Keeping persons "hospitalized" for years and decades did not conform to the image of how real doctors use hospitals. With wages rising sharply after the 1950s, the cost of such prolonged hospitalization was also becoming burdensome to the states. The solution was to "discharge" the hundreds of thousands of chronic mental patients, attribute their forcible expulsion to the therapeutic effectiveness of "psychiatric miracle drugs," and call the eviction "deinstitutionalization." The enterprise was a fraud from beginning to end. But it looked like the "right thing to do," just as formerly the chronic hospitalization of mental patients looked that way.
Still another important element of remedicalization consisted of sanitizing the psychiatric vocabulary. The classic diagnoses of hysteria, neurosis, and homosexuality were declared to be nondiseases and were quickly forgotten. So-called "severe" mental diseases were authoritatively declared to be "brain diseases," a claim supported by the invention of a new neurochemistry (in fact, a neuromythology) and the popularization of the view that such illnesses are due to "chemical imbalances in the brain."
Significant as these developments were, perhaps the single most important impetus for the change I am describing was the formation of a new social organization and political lobby, the National Alliance for the Mentally Ill, or NAMI.
The NAMI website describes the organization as follows: "NAMI is dedicated to the eradication of mental illnesses and to the improvement of the quality of life of all whose lives are affected by these diseases. …