Curing the Therapeutic State.

Thomas Szasz on the medicalization of American life

Simply having one of Thomas Szasz's books on your shelf can lead to an argument. Explaining his most familiar contention--that there is, strictly speaking, no such thing as "mental illness"--almost invariably does. And the very mention of his name has been known to provoke a heated response from certain people. I once asked a psychiatrist I knew if he was familiar with Szasz's work. "Oh, he's crazy!" he exclaimed, inadvertently illustrating Szasz's point that such labels are often used to stigmatize people who offend or disturb us.

I don't think this psychiatrist was ready to have Szasz committed; he was expressing an intellectual rather than a clinical judgment. But Szasz's critique of psychiatry suggests that such distinctions are ultimately arbitrary. A psychiatrist could, if he were so inclined, diagnose as mentally ill someone with whose worldview he disagreed--which is essentially what it means to say that a person is "suffering from delusions." If the psychiatrist could make a case that the "patient" might harm himself or others (a prediction that many psychiatrists privately concede they are ill-equipped to make), he could have him confined and forcibly "treated."

In Szasz's view, this should not be possible. For decades, what he calls his "passion against coercion" has driven him to denounce involuntary mental hospitalization, while his insistence on individual responsibility has made him a dedicated opponent of the insanity defense. If someone commits a crime, Szasz says, he should be punished, not "treated." But if he has not violated anyone's rights, he should be left alone, no matter how bizarre his behavior.

As unpopular as such ideas are now, they were even more heretical when Szasz started to express them in the late 1950s. Born in Budapest in 1920, he immigrated to the United States in 1938 and attended the University of Cincinnati, where he majored in physics as an undergraduate and earned an M.D. in 1944. After a residency in psychiatry, he underwent psychoanalytic training at the Chicago Institute for Psychoanalysis, where he remained as a staff member for five years. In 1956 he took a position as a professor of psychiatry at the State University of New York in Syracuse, where he is now a professor emeritus. Shortly thereafter, he began to publish articles that questioned the basic premises of his profession, work that would lead to his classic The Myth of Mental Illness in 1961.

"I became interested in writing this book approximately ten years ago," he wrote in the preface, "when I became increasingly impressed by the vague, capricious, and generally unsatisfactory character of the widely used concept of mental illness and its corollaries, diagnosis, prognosis, and treatment. It seemed to me that although the notion of mental illness made good historical sense--stemming as it does from the historical identity of medicine and psychiatry--it made no rational sense." Szasz's bold attack on a concept that most people took for granted (and still do), bolstered by the efforts of civil libertarians and other social critics, encouraged skepticism about the justification for coercive psychiatry. That uneasiness led to legal reforms in the 1960s and '70s that made it harder to lock up people deemed to be crazy.

"Mental illness is a myth whose function is to disguise and thus render more palatable the bitter pill of moral conflicts in human relations," Szasz wrote in "The Myth of Mental Illness," a paper that appeared in American Psychologist the year before his book of the same name was published. "In asserting that there is no such thing as mental illness, I do not deny that people have problems coping with life and each other." Likewise, Szasz has never denied that organic conditions--say, Alzheimer's disease or untreated syphilis--can have an impact on thought and behavior. But he insists on evidence of an underlying physical defect, and he emphasizes that behavior itself is never a disease. "Classifying thoughts, feelings, and behaviors as diseases is a logical and semantic error, like classifying the whale as a fish," he writes on his Web site (www.szasz.com).

This error has serious consequences, Szasz argues: "The classification of (mis)behavior as illness provides an ideological justification for state-sponsored social control." As he put it in his 1990 book The Untamed Tongue, "What people nowadays call mental illness, especially in a legal context, is not a fact, but a strategy; not a condition, but a policy; in short it is not a disease that the alleged patient has, but a decision which those who call him mentally ill make about how to act toward him, whether he likes it or not."

The collaboration between government and psychiatry results in what Szasz calls the "therapeutic state," a system in which disapproved thoughts, emotions, and actions are repressed ("cured") through pseudomedical interventions. Thus illegal drug use, smoking, overeating, gambling, shoplifting, sexual promiscuity, pederasty, rambunctiousness, shyness, anxiety, unhappiness, racial bigotry, unconventional religious beliefs, and suicide are all considered diseases or symptoms of diseases--things that happen to people against their will. Szasz believes this sort of thinking undermines individual responsibility and invites coercive paternalism. A prime example is drug prohibition, an area where his work--especially his penetrating 1974 polemic Ceremonial Chemistry: The Ritual Persecution of Drugs, Addicts, and Pushers--has had an important influence.

As Szasz marks his 80th birthday this year, the misuse of the medical model and the literalization of the disease metaphor are rampant. But skeptical voices, often those of Szasz admirers, can be heard on issues such as criminal responsibility, the nature of addiction, and the reality of the mental disorder du jour. Szasz himself continues to drive home the dangers of surrendering our autonomy to physicians acting as agents of the state. Last year he published Fatal Freedom: The Ethics and Politics of Suicide (Praeger), in which he warns that "relying on physicians to prevent suicide, prescribe suicide, and provide suicide...is an evasion fatal to freedom." When I interviewed him by telephone in February, he was completing a book on the evolution of the therapeutic state. After that, he said, he'd like to write "a history of psychiatric misdeeds, from its beginning to the present."

Szasz, a REASON contributing editor whose work has also appeared in publications ranging from The Lancetto Playboy, has produced some 700 articles and two dozen books, including Law, Liberty, and Psychiatry (1963), The Ethics of Psychoanalysis (1965), The Manufacture of Madness (1970), The Myth of Psychotherapy (1976), The Therapeutic State (1984), and Our Right to Drugs (1992). Asked if he was working on a new book, he said, "What else can I do?" Asked if he had plans for another one after that, he said, "Always."

Reason: You've said that true brain diseases are the province of neurologists, not psychiatrists. I gather that what people call mental illness, which you understand as problems in living, would be something for psychotherapists to handle. Do psychiatrists have any legitimate role as physicians who specialize in psychological problems?

Thomas Szasz: That entirely depends on what sort of arrangement society allows and the economic system permits. There is no reason why physicians should be prevented from talking to people.

Reason: Do you see any benefit from having an M.D. in doing that sort of work?

Szasz: Yes, but not as a requirement. There are two aspects of life without which it's very difficult to [manage], and those are medicine and law. Knowing how the body works is beneficial for anyone. That could help you as a therapist because there are all kinds of personal complaints, and people who come to you may very well also be sick. [A knowledge of medicine] helps you in the same sense that it helps if you are familiar with law, because people are entangled in all kinds of legal problems too.

Reason: How would you describe your approach to therapy?

Szasz: I see psychoanalysis as a contractual conversation about a person's problems and how to resolve them. I tried to avoid the idea, which seemed to be particularly pernicious, that the therapist knows more about the patient than the patient himself. That seems to me so offensive. How can you know more about a person after seeing him a few hours, a few days, or even a few months, than he knows about himself? He has known himself a lot longer!

To me the whole idea of calling it "therapy" is crippling. So there was a kind of understanding between the other person and me that we were having a conversation about what he could do with his life. That obviously involves adopting different tenets of sorts--different ways of relating to his wife, his children, his job. The premise was that the only person who could change the person was the person himself. My role was as a catalyst. You are making suggestions and exploring alternatives--helping the person change himself. The idea that the person remains entirely in charge of himself is a fundamental premise.

Reason: You were trained as a psychoanalyst. How have your views on Freud's theories changed over the years?

Szasz: Freud had a very good idea which was very quickly abused. Bertrand Russell said that Christianity is a wonderful idea--it's too bad it's never been tried. That is my view of psychoanalysis. Freud had a wonderful idea, namely, that he was going to have a completely private, confidential, one-to-one conversation with another human being about his or her life. There's no coercion. It's entirely contractual. The patient pays. But as soon as he developed this, he sacrificed it by betraying confidentiality, by creating training analysis, by creating child analysis, and so on. It immediately became a thing where the premise was that the therapist knows more about the patient than the patient himself. There was a kind of manipulation, exploitation involved.

My feeling all along was that there was something wrong with the authoritarian, top-down stance. At the same time, I was very much impressed that this was a radical departure from "psychiatry," which was based entirely on an involuntary relationship. Traditionally, there is no such thing as a voluntary psychiatric patient. That's an oxymoron. If you are crazy, then you are locked up in a state hospital. So Freud's great departure was that, within medicine, you could go and talk about your problems and not be considered crazy, not be locked up.

Reason: In the 1960s people like R.D. Laing and Michel Foucault agreed with you that psychiatry was a form of social control, a way of stigmatizing and punishing unwanted behavior in the guise of therapy. Both of them identified themselves as men of the left, whereas you allied yourself with classical liberalism. What would you say are the basic differences between their views on psychiatry and yours, and how are those related to political ideology?

Szasz: Although we agreed on the criticism of traditional psychiatry, they somehow never made it clear that bodily diseases--pneumonia, cancer, and so on--are real, but mental diseases are metaphoric diseases, in the sense of a "sick" joke. They are problems, but they are not medical problems in that they do not involve somatic, organic etiologies and are not amenable to a somatic, organic resolution. They are essentially conflicts within oneself and conflicts between oneself and other people. So that would be the first distinction.

Secondly, Laing in particular was completely inattentive to the legal aspects, so he never really distinguished between involuntary and voluntary psychiatry. Here my classical liberal convictions are crucial, in that I firmly believe that there should be no interference in voluntary relationships between psychiatrists and patients. If the patient wants a drug, fine. If the patient wants electric shock, fine. If the patient wants a lobotomy, fine. Now that doesn't mean that I like it, any more than I would if the patient wants to have an abortion just because it's inconvenient to have a baby. I don't think that's a good idea either. But I don't think the law should interfere with it.

By contrast, with involuntary psychiatry, under no circumstances do I consider it permissible. Neither Laing nor Foucault made this clear. They offered a kind of a blanket condemnation of psychiatry which smacked of a socialist, left-wing indictment of capitalism. [In their view,] the whole thing is no good. Of course, in some ways the whole thing is no good, in that it's misconceptualized, but so is religion if you don't believe in religion. Yet you don't want to forbid it or interfere with it.

Reason: Since The Myth of Mental Illness appeared, it seems that more and more areas of life have been medicalized. But at the same time it seems that people are more willing to question the authority of psychiatrists and of physicians in general. On balance, do you think psychiatrists and physicians have more or less power than they used to?

Szasz: I think they have much, much more power, but it has become increasingly covert and subtle. If you focus on psychiatrists per se, then perhaps they have a little less power, but the power has been diffused among "mental health professionals": school psychologists, grief counselors, drug treatment specialists, and so on. It pervades society. Sixty years ago, when I went to medical school, this kind of activity was limited entirely to psychiatrists.

So traditional psychiatrists may have less power. They certainly don't have the feudal slave estates of the old state hospitals, where the patients were washing their cars. That's gone. On the other hand, there is a Tocquevillean kind of oppression--a softer kind of totalitarianism.

Reason: In some respects people do seem to be more skeptical than they used to be of psychiatry's attempts to medicalize behavior. Psychiatrists themselves often acknowledge that the Diagnostic and Statistical Manual of Mental Disorders is increasingly arbitrary and unscientific. It also seems that the use of the term disorder, as opposed to disease or illness, is designed to fudge the question of whether these conditions have a biological basis. Meanwhile, journalists are increasingly alert to controversies over what constitutes a bona fide disorder, as in the case of "multiple personality disorder," which has fallen into disrepute. Is this skepticism just temporary?

Szasz: Without seeming excessively pessimistic, my view is that this whole development subtly reinforces the basic error and the basic authority of psychiatry. People are saying that, of course, multiple personality disorder and social phobia are excesses, but schizophrenia, depression, and so on are real diseases and therefore justify involuntary hospitalization, outpatient commitment, wholesale drugging of children, of people in nursing homes, and so on.

I have always challenged the "psychoses." Why don't you have a right to say you are Jesus? And why isn't the proper response to that "congratulations"?

Reason: Since you criticized involuntary hospitalization in the '60s, legal reforms have changed the standards for locking people up. To what extent have those changes been in line with what you wanted to see?

Szasz: They have been diametrically opposite. This whole deinstitutionalization process was just as involuntary as the institutionalization process. First the patients were placed in the institutions against their will. Then they were kept there for a long time, and generally they became desocialized. They had no way of making a living, and their families didn't want them; they had no particular place to live. Instead of being allowed to stay in the hospital, which the majority of them probably considered their home, they were forcibly evicted and placed in other institutions run by the state but which are no longer called hospitals. So this is a huge deception. The number of people who are now maintained by the state as mental patients is probably no smaller than it used to be.

Reason: Where are they now?

Szasz: They're in so-called transitional living quarters, in group homes, in nursing homes, in prisons, on the street, maintained on Social Security. In the old days, you didn't get money for being schizophrenic. Now you get a lot of money for it. They are now maintained like pets rather than being locked up in a zoo.

Reason: The deinstitutionalization of mental patients has been criticized for putting helpless people, sometimes dangerous people, on the streets. How would you have handled it differently?

Szasz: There are two things that I would have done very differently, and they really have to do with my passion against coercion, especially unnecessary coercion and especially coercion outside of a due-process legal system. The first thing I would have done is to stop all further involuntary psychiatric interventions. This is unthinkable stuff, because this means stopping the fundamental social function of psychiatry, which is partly to relieve society, families, physicians of unwanted people and partly to "prevent suicide." "Dangerousness to self": This to me is the keystone in the Roman arch. Until it is knocked out, it's impossible to destroy the edifice. People should not be protected from themselves by involuntary psychiatric interventions. Psychiatrists should play no more of a role in this than priests do.

Reason: And after involuntary psychiatry was ended people would have been free to leave mental hospitals, but they would not have been forced to leave?

Szasz: They would have been free to leave, and they would have been free to stay. They could have simply got room and board. That option was never given to anyone. I wouldn't give that to anyone except those who have already been victimized. They should be given every chance to get out insofar as they want to get out.

By the way, this brings us back to the old, pre-war system, when there were as many as 15,000 patients in a single state hospital. Nothing was easier than escaping from these places; they were not surrounded by barbed wire. In fact, escape--"elopement"--was the standard way of being discharged from the hospital. The hospital didn't go after you. But the fact that most people didn't leave indicated that they had no place to go, and that in fact this place was not all that bad for them, especially before there was any treatment.

Reason: When a crime is committed by a homeless person who has been diagnosed as a schizophrenic, critics of deinstitutionalization say it's too hard nowadays to commit people to mental hospitals. They say the standard of dangerousness to yourself or others is too demanding. Are they right?

Szasz: No, they are not right. But this brings us back to what else I would have done: Not only would I have stopped on day one all further involuntary mental hospitalization-commitment--I also would have stopped on that same day the insanity defense. The psychiatrist simply would not be allowed in the court to give expert testimony, any more than a priest is allowed to give testimony about heaven or hell.

So I would have stopped both of these [commitment and the insanity defense], as a result of which, I think, 99 percent of the people who now commit crimes would be and should be in jail and punished, probably by long prison sentences. Because in every one of these cases we learn that the person who has committed the crime--let's say this fellow who pushed the woman under a subway train in New York--has a long record not only of mental hospitalization but of violence.

Typically, what people call severe mental illness begins with some sort of violence in the family: A 17- or 18- or 19-year-old boy attacks his mother with a kitchen knife. Well, he should go to jail for five years, right away. This is a potentially fatal attack on a person. But these things are usually swept under the rug via diagnosis. And then people wonder five years later what happened.

Reason: What about people who haven't actually committed violence but are simply behaving in a bizarre and perhaps threatening way? Last year I was walking with my wife and daughter in Manhattan, and we saw this guy in camouflage pants who was running down the street, holding a piece of concrete pipe over his head, pumping it up and down, and cursing at nobody in particular. What, if anything, can you do about someone like that?

Szasz: This is a political question: In a relatively open society, what kind

of communication can people give off, both verbally and nonverbally? How many earrings can you have in your nose, on your ears, in your belly button? I think this is a question of social control; it has nothing to do with medicine, nothing to do with psychiatry except as social control. And I have no particular answer to this other than my own preferences. I don't like this any more than you do, and this is how people segregate themselves. I avoid places where people are like this. In a free society, I think that's how it would be. If a city allows enough of this, maybe people would avoid it and it would go into economic decline.

Reason: Alternatively, a disruptive person could be arrested for menacing people or for something like disturbing the peace?

Szasz: Or for disorderly conduct. Any of those things. The law is a disciplining agent. Just like with illegal parking. There are lots of things which are a relatively small nuisance for which people get disciplined.

Reason: Since you first called for abolishing the insanity defense, lawyers have become increasingly creative at devising excuses to absolve their clients of responsibility. Yet to judge by the kind of criticism and ridicule you hear from commentators, comedians, and people on the street, skepticism about such excuses also is increasing. Are people finally listening to your warnings?

Szasz: That's not for me to say, but my feeling is that the inconsistency does not impede the spread of this practice, as illustrated by the cases of John Hinckley and Ted Kaczynski. People were skeptical, but [the insanity defense] is so convenient that I know of no serious pundit--no George Will or William Safire--who denounces it as a general practice, on principle. They may say that in this particular case it's wrong to use it, but in general they think it's a fine thing.

The Kaczynski case was a wonderful example, where he was begging not to be called insane, and that was interpreted as being crazy! He refused to recognize his problem. Now he is petitioning to be retried, so he can be executed. But that's buried in the back pages. And of course that will be interpreted as further evidence that he's crazy--he wants to be killed.

Reason: The psychiatrist E. Fuller Torrey has written that "studies using techniques such as magnetic resonance imaging and positron emission tomography scans have proved that schizophrenia and manic depressive illness are physical disorders of the brain in exactly the same way as Parkinson's disease or multiple sclerosis." Is that true? If not, what do these studies actually show?

Szasz: Most educated people, if they think about it, know how real disease is diagnosed. Take anemia. If a person comes in and says he is tired, he has no energy, and he looks very pale, the physician may think he is anemic. But the diagnosis is not made until there is a finding in the laboratory that he has a diminished blood count, a diminished hemoglobin level. Conversely, a laboratory technician can blindly make a diagnosis of anemia simply on the basis of vials of blood submitted to him or her--without having any idea of whose blood it is. As soon as that can be done with schizophrenia, it will be a brain disease, exactly as neurosyphiis was recognized as a brain disease.

Reason: In other words, you would need to be able to look at the scan and say, "This is a schizophrenic."

Szasz: Or this is not a schizophrenic....My skepticism is infinitely high, because I actually lived through a time when a man got the Nobel Prize for discovering that excessively activated electrical circuits in the frontal lobe cause schizophrenia. The cure for that was lobotomy. Or consider electric shock treatment: The rationale was that epileptics don't get schizophrenia, which was complete nonsense. There has been a long series of claims like these.

And the idea of schizophrenia as a brain disease negates the justification for involuntary treatment. The diseases that Torrey mentions--Parkinson's, multiple sclerosis--can under no circumstances be legally treated without the consent of the patient. This is really just propaganda for coercion. It does not stand the least scrutiny. But you see, they don't have to be right; they have power.

Reason: Is it possible that some of the people who are now diagnosed as schizophrenics do in fact have some kind of neurological defect?

Szasz: Absolutely.

Reason: If that could be demonstrated, would it change your view of mental illness?

Szasz: No, because they would then simply have a disease with which they would have to live, just like Stephen Hawking has to live with amyotrophic lateral sclerosis. In other words, having a disease does not define everything that you do.

Reason: But people with certain kinds of brain diseases--Alzheimer's, for example--might reach a point where they're no longer able to take care of themselves, and they could legally be declared incompetent. Should that same sort of procedure be possible with some of the people now diagnosed as schizophrenics, if they do in fact have a brain disease?

Szasz: In principle, that should be possible, but the judgment of whether you can or cannot take care of yourself ought to be a common-sense, empirical one, not an esoteric, psychiatric one. Also, the old Roman principle of cui bono should be the guiding light. Charges of incompetence used to be brought by greedy children against their rich, elderly parents--especially if the father, say, wanted to marry a young woman. The charge is also brought after someone dies, to contest the person's last will. So here the issue of competence is really tied to the motives of the person who is raising the question.

Reason: You may have seen the TV commercials in which drug companies urge people suffering from "social anxiety disorder" or "generalized anxiety disorder" to ask their doctor for a certain brand of pill. These ads reinforce the idea that anxiety and other kinds of psychological problems are medical issues, and they highlight the physician's role as pharmacological gatekeeper. But they could also be seen as empowering individuals by encouraging them to be assertive with their doctors. On balance, do you see this kind of message as a positive or a negative development?

Szasz: This phenomenon illustrates what I call the creeping therapeutic state. I see it as insidious, especially given the cooperation between the government and the media. This is allowed on television. But advertising Scotch, a legal drink, is not allowed. This subtly undermines the rule of law, the principle that if something is legal, then it's legal, and if it's illegal, then it's illegal. A prescription drug is illegal; pharmacists cannot sell it to you unless you have a prescription. These are illegal drugs, but nobody calls them illegal drugs. So I see this as pernicious, as an example of what F.A. Hayek and Ludwig von Mises talked about--that the opposite of freedom is not brutal tyranny but capriciousness.

Reason: Suppose someone feels depressed, and he finds that when he takes Prozac he feels better. Or suppose he's anxious, and he finds that he calms down when he takes a Xanax. He can get these pills from his doctor. Is he doing anything wrong by taking these drugs?

Szasz: I don't think he's doing anything wrong, except I think he should be able to buy these drugs in the free market so he can compare them to opium, marijuana, or other drugs. There is no competition now between the prescription drugs and the traditional drugs which people took when they felt bad. After all, people have medicated themselves since time immemorial. I suspect that opium in small doses is safer over a long period of time than these complicated organic compounds.

Reason: In recent years, we're told, this country has been hit by an epidemic of "attention deficit hyperactivity disorder." What are the roots of this epidemic?

Szasz: I would first say that the epidemic doesn't exist. No one explains where this disease came from, why it didn't exist 50 years ago. No one is able to diagnose it with objective tests. It's diagnosed by a teacher complaining or a parent complaining. People are referring to the fact that they don't like misbehaving children, mainly boys, in the schools. The diagnosis helps tranquilize the parent, tranquilize the school system. It offers them the sense that they are doing something about the problem, that they are dealing with it in a rational, scientific way. It's a kind of pharmacological magic.

Reason: What do you think the consequences of prescribing Ritalin for all of these kids will be?

Szasz: We may not know all of the medical consequences for another 20 or 30 years. In social terms, it gives the impression to people that behavioral problems are medical and should be handled with drugs; it imposes a certain stigma on the child, possibly on the family. It medicalizes educational and childrearing problems, and it may cause biological problems in the person taking the drug. I don't know if the average person on Main Street realizes that if a 30-year-old man has a pocketful of Ritalin, he can go to jail for years. This is called "speed." And this is what they give as a treatment to schoolchildren when there's absolutely no laboratory or medical evidence that they are sick.

Reason: Recently we've heard Tipper Gore and other people say that health insurers should be forced to cover mental health treatment on the same terms as medical treatment. What do you think the consequences of such "parity" will be?

Szasz: We are talking about a situation where the government is mandating that an ostensibly private insurance company provide coverage for a disease which doesn't exist. There is so much to say about it, I don't know where to begin. The people who clamor for this--mainly politicians and psychiatrists--want parity for mental illness, but they don't want parity for the mental patient, because ordinary patients can reject treatment.

They don't mean therapy; they mean getting a foot in the door for involuntarily treating people and having these huge bowls of money going into psychiatry and psychiatric drugs. Again, cui bono: Who profits from this? It finally came out that Eli Lilly is a big donor to the National Alliance for the Mentally Ill, and they have millions of dollars to propagandize their views. The critics don't have any money to propagandize their views. This is a completely one-sided, government-sponsored movement.

Reason: Alan Leshner, the director of the National Institute on Drug Abuse, says "Drug addiction is a brain disease." Is there any scientific basis for that claim?

Szasz: As far as I know, there is not one iota of evidence for this. When people take drugs and get "hooked," this is simply another way of saying it becomes a habit, which makes the drug more difficult to abandon than if you haven't got the habit. But it's no different from speaking English or Hungarian. Any habit is difficult to change. And of course you can also become chemically habituated to drugs, so that you have withdrawal symptoms when you stop. Of course, taking a drug can make you sick, but a therapeutic drug can also make you sick. It's a question of dosage, what you take, and why you take it.

Reason: In the area of drug policy, you've criticized the idea of shifting from a criminal justice approach to a "medical" or "public health" model, which you say would only reinforce the therapeutic state. But if a drug offender who might otherwise go to jail can instead undergo "treatment"--which is now the case in Arizona, for example--isn't he better off, even if the treatment is bogus?

Szasz: He may be better off in the sense in which a Jew in 15th-century Spain may have been better off converting to Christianity than being tortured. But I reject the dilemma. One of these so-called treatment options maybe less punitive for the subject. But the side effect is that it reinforces the legitimacy of this kind of medical autocracy.

Reason: Another reform pushed by advocates of a "public health" approach is needle exchange programs. What do you think of them?

Szasz: I am unqualifiedly opposed to this kind of piecemeal reform. I keep falling back on the slavery analogy. You cannot prettify the plantation. You either have slaves as a legal arrangement or you don't. Either you have access to empty syringes just like you have access to guns, or you don't have access.

Reason: A simple way of addressing that issue would be to make the needles available without prescription and to stop penalizing people for possessing them. That's not exactly a fundamental reform in terms of drug policy, but is that the kind of reform you could support?

Szasz: I think that would be fundamental, because the message it would send is that this is a problem only because the government has made it a problem. The American people don't realize that a very large proportion of the AIDS cases in America are government-manufactured, in the sense that the government has prohibited needles. People talk about iatrogenic--doctor-caused--diseases. People never talk about government-caused diseases. There is no Latin word for that.

Reason: Another so-called harm reduction reform is to make methadone more readily available to current opiate users or to make heroin available by prescription. Do either of those suggestions make any sense to you?

Szasz: They make a great deal of sense, in the sense that they strengthen the establishment which is causing the problem. I am bitterly opposed to all of these autocratic medicalizations. All of these glorify the punitive state and the punitive doctor and debase the citizen for exercising his free choice. It's as simple as that.

Reason: You take a similar view when it comes to medical marijuana, that it reinforces the therapeutic state, since the doctor gets to say whether you can have it or not. But from the point of view of somebody who is sick and who finds that marijuana relieves his pain, his nausea, or his muscle spasms, a measure like California's Proposition 215 means that he's less likely to be arrested and prosecuted. Isn't that an improvement?

Szasz: I see this as analogous to leaving Soviet Russia. You could appeal to Stalin and say, "My father is living in America, and he is 80 years old. Won't you let me out?" And then Stalin might say, "OK. I'll let you out, because that really would be a good thing for you, because of your father." The patient is getting a special exception from a general rule, which I find totally unacceptable.

Reason: The general rule or the exception?

Szasz: I find the general rule unacceptable, and the exception is simply doing one particular favor to one particular person or group of persons.

Reason: But the people to whom the exception applies are better off. Is equal enforcement of a bad law better than making exceptions?

Szasz: This is one of those classic problems where if you leave the bad law in place long enough, then maybe it will be repealed, whereas making exceptions prolongs its life expectancy. I am not opposed to being nice to particular groups of people as a humanitarian gesture, obviously. If somebody who is undergoing anti-cancer treatment has nausea and benefits from marijuana, it would be a nice thing for this person to have it. How can I be opposed to that? But that's like smuggling Jews out of Nazi Germany with the help of a Gestapo agent. Wouldn't it be better not to persecute them in the first place?

Reason: The question of whether people may use marijuana to treat various kinds of symptoms seems to be a small part of the drug policy debate. Yet the medical marijuana movement has drawn a very strong response from the federal government. Why do you think people like the drug czar, Barry McCaffrey, get so upset about attempts to legalize the medicinal use of marijuana? Does that reaction suggest that maybe the medical marijuana activists are on to something, that they've found an effective way of undermining prohibition?

Szasz: Probably the reason why the drug warriors are so upset is that they think this will have a kind of a domino effect, that we have to fight the enemy here; otherwise he is going to move somewhere else. I personally think that they are wrong. The drug warriors are the victims of their own ideology. They really believe their own propaganda. I don't think medical marijuana would particularly weaken them, any more than it weakens them that people can smoke cigarettes and relieve their anxiety that way. I think prohibition would be strengthened by making these exceptions. The rationale would be, "See, we leave these relatively harmless ones alone. But by golly, we have to really strike hard at the drug lords if we can find them."

Reason: People who support physician-assisted suicide claim that giving terminally ill patients a legal way to obtain lethal drugs will enhance their autonomy. You disagree.

Szasz: This is the same question as medical marijuana: Anything that people want is being made contingent on getting it from a doctor.

Reason: In Fatal Freedom, you say the debate over physician-assisted suicide ignores the roles of drug prohibition and psychiatric coercion. Why are those factors important?

Szasz: They are fundamental. First of all, if there were no drug laws, then they wouldn't need doctors to give suicidal people drugs to commit suicide with; after all, they don't give patients guns or ropes. Second, people seem oblivious to the fact that doctors-psychiatrists--are given the job both of preventing suicide and of providing suicide. To me these are symptoms of the galloping therapeutic state, where increasingly we are giving away our existential choices and responsibilities to doctors--and therefore to the state, because they're really not talking about doctors as healers; they're talking about doctors as agents of the state.

Reason: You say that the very term physician-assisted suicide is misleading. How so?

Szasz: "Physician-assisted suicide" can be one of two things. The physician can give the patient a drug--let's say a barbiturate--and then the patient takes the drug and dies. But that's simply suicide, a person killing himself. If you buy a rope in a store, you don't talk about "merchant-assisted suicide." On the other hand, what can also happen is that the physician helps a person to die--in effect, speeds his death or kills him. This is how many old people have died in the past and continue to die. They are going to live another few days or weeks; they are in heart failure and can't breathe. The physician gives them a little extra morphine, and they stop breathing. This is how Sigmund Freud died. But this is not suicide. As I emphasize in my book, it's rather significant that the physician-assisted suicide legislation in Oregon specifies that dying in this way is not suicide.

Reason: Looking back at your career, what do you see as your major contributions?

Szasz: It's really two very simple propositions: that there is no mental illness, and that if you are incarcerated in a mental hospital, you are in prison. You are not treated or cured.

Now as far as the greatest impact, there's no question that "the myth of mental illness" and the idea of the therapeutic state are terms and concepts that are widely copied, and often used in ways quite different than I have used them. There's a third idea that hasn't caught on quite as much, though I've seen it used in English publications: "pharmacracy," which I used in Ceremonial Chemistry. It refers to the substitution of medical controls for legal and religious controls. We are pharmacratizing everything, including the control of unruly children. Attention deficit disorder is a perfect example of pharmacratic control of a social problem: how to educate children.

Reason: You seem generally pessimistic. Can you cite any encouraging developments?

Szasz: I should correct that. Intellectually, I am very pessimistic, but temperamentally I am an optimistic person. I am pessimistic because I see the trend as a progressive evasion of personal responsibility.

Reason: But have you seen any encouraging developments since you first started talking about these issues?

Szasz: Yes. The encouraging development is essentially the uprising of the slaves, the increasing protestation by ex-mental patients, many of whom call themselves victims. Through all kinds of groups, they have a voice now which they didn't have before. We should hear from the slaves. Psychiatry has always been described from the point of view of the psychiatrist; now the oppressed, the victim, the patient also has a voice. This I think is a very positive development.

More generally, I see the American political system as infinitely elastic and hopeful. And of course there's the Internet, which is a huge opening of information, giving people access to what the establishment doesn't want them to hear, not only politically but especially medically. I was quite intrigued to learn fairly recently that my Web site was blocked by filtering software at a library in Indiana. Why it was blocked, God only knows. But I was struck by the fact that someone was com plaining about it.