Psychiatry: The Science of Lies

Other books by Thomas Szasz available from Syracuse University Press

Anti-Freud: Karl Kraus’s Criticism of Psychoanalysis and Psychiatry

Ceremonial Chemistry: The Ritual Persecution of Drugs, Addicts, and Pushers, revised edition

Cruel Compassion: Psychiatric Control of Society’s Unwanted

Fatal Freedom: The Ethics and Politics of Suicide

Ideology and Insanity: Essays on the Psychiatric Dehumanization of Man

Insanity: The Idea and Its Consequences

Law, Liberty, and Psychiatry: An Inquiry into the Social Uses of Mental Health Practices

The Manufacture of Madness: A Comparative Study of the Inquisition and the Mental Health Movement

The Meaning of Mind: Language, Morality, and Neuroscience

The Medicalization of Everyday Life: Selected Essays

Our Right to Drugs: The Case for a Free Market

Pain and Pleasure: A Study of Bodily Feelings

Pharmacracy: Medicine and Politics in America

Sex by Prescription: The Startling Truth about Today’s Sex Therapy

The Theology of Medicine: The Political-Philosophical Foundations of Medical Ethics

Copyright © 2008 by Thomas Szasz

Syracuse University Press

Syracuse, New York 13244-5290

All Rights Reserved

First Paperback Edition 2019

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ISBN: 978-0-8156-0792-2 (paperback)

ISBN: 978-0-8156-0910-0 (hardcover)

ISBN: 978-0-8156-5044-7 (e-book)

Library of Congress has cataloged the hardcover as follows:

Szasz, Thomas Stephen, 1920–

Psychiatry : the science of lies / Thomas Szasz. — 1st ed.

p. ; cm.

Includes bibliographical references and index.

ISBN-13: 978-0-8156-0910-0 (cloth : alk. paper)

ISBN-10: 0-8156-0910-8 (cloth : alk. paper) 1. Psychiatry—Philosophy. 2. Psychology, Pathological. 3. Mental health—Philosophy. 4. Malingering. I. Title.[DNLM: 1. Psychiatry—trends. 2. Attitude to Health. 3. Deception. 4. Malingering. WM 100 S996p 2008]

RC437.5S925 2008

616.89—dc22

2008017999

Manufactured in the United States of America

Truth is mighty and will prevail. There is nothing the matter with this, except that it ain’t so.

—Mark Twain (1835–1910), Notebook (1898)

Thomas Szasz is a professor emeritus of psychiatry at the State University of New York Upstate Medical University in Syracuse. The author of more than six hundred articles and thirty-two books, he is widely recognized as the leading critic of the coercive interventions employed by the psychiatric establishment.

Contents

Preface

Acknowledgments

Introduction: The Invention of Psychopathology

1. Malingering

2. Doctoring

3. Inculpating

4. Sheltering

5. Cheating

6. Lying

Epilogue: The Burden of Responsibility

Notes

Bibliography

Index

Preface

[In the science of politics,] it is inconceivable that telling the truth can ever become more profitable than telling lies.

—Antoine-Augustin Cournot (1801–1877), quoted in Syphilis, Puritanism, and Witch Hunts: Historical Explanation in the Light of Medicine and Psychoanalysis with a Forecast about AIDS, by S. Andreski

The widespread belief that the scientist’s job is to reveal the secrets of nature is erroneous. Nature has no secrets; only persons do.

Secrecy implies agency, absent in nature. Nature, observed Thomas Carlyle (1795–1881), admits no lie.¹ Nature neither lies nor tells the truth. It has no secrets: secrets is the name we give to our ignorance of its workings. Because nature is not an agent, many of its workings can be understood by observation, reasoning, experiment, measurement, calculation, and truth-telling, the basic methods of science. Deception and divination are powerless to advance our understanding of natural phenomena; indeed, they preempt and prevent such understanding.

The human sciences are not merely unlike the physical sciences; they are, in many ways, opposites. Whereas nature neither lies nor tells the truth, persons habitually do both. This is why deception is a useful tool for persons such as detectives whose job is to ferret out other people’s secrets; why deception is a useful tool also for so-called experts—such as psychiatrists, psychologists, and politicians—whose ostensible job is to explain and predict certain human behaviors, especially behaviors some people consider dangerous or undesirable; and why such experts habitually deceive others and themselves.

The integrity of the natural scientific enterprise depends on truth-seeking and truth-speaking by individuals engaged in activities we call scientific, and on the scientific community’s commitment to expose and reject erroneous explanations and false facts. In contrast, the stability of religions and the ersatz faiths of psychiatry and the so-called behavioral sciences depends on the loyalty of its practitioners to established doctrines and institutions and the rejection of truth-telling as injurious to the welfare of the group that rests on it. Revealingly, we call revelations of the secrets of nature discoveries but call revelations of the secrets of powerful persons and institutions exposés.

Psychiatry—a term I use here to include psychoanalysis, psychology, and all the so-called mental health professions—is one the most important institutions of modern societies. The institution rests squarely on the postulate-proposition that mental illness is an illness like any other illness. That proposition is a lie. This lie is what makes malingering—the faking of disease—the great secret of psychiatry: a popular understanding that faking illness is a form of deception (and often self-deception) would destroy psychiatry. In this book I try to advance such understanding, and the constructive destruction it entails, by expanding on my thesis, first propounded more than a half century ago: the idea of mental illness and the apparatus of modern psychiatry as a medical specialty rest on the successful medicalization of malingering—that is, on the popular perception of behaviors called mental illnesses as bona fide medical diseases.

Understanding modern psychiatry—the historical forces and the complex economic, legal, political, and social principles and practices that support it—requires understanding the epistemology and sociology of faking in general and counterfeiting disease and disability in particular. Where there are fake diseases, there are healthy persons who pretend to be ill and deluded or dishonest doctors who diagnose and treat them. In 1976, protesting the official definition of psychiatry as the diagnosis and treatment of mental diseases, I proposed this definition:

The subject matter of psychiatry is neither minds nor mental diseases, but lies . . . [which] begin with the names of the participants in the transaction—the designation of one party as patient even though he is not ill, and of the other party as therapist even though he is not treating any illness. The lies continue with the deceptions that comprise the subject matter proper of the discipline—the psychiatric diagnoses, prognoses, treatments, and follow-ups. And they end with the lies that, like shadows, follow ex–mental patients through the rest of their lives—the records of denigrations called depression, schizophrenia, or whatnot and of imprisonments called hospitalization. Accordingly, if we wished to give psychiatry an honest name, we ought to call it pseudology, or the art and science of lies and lying.²

A caricature? Yes. However, a good caricature portrays its subject more accurately than does a flattering portrait, nay self-deluded self-portrait.

Acknowledgments

I am greatly indebted to Anthony Stadlen for his invaluable assistance. I thank also Mira de Vries and Roger Yanow for their careful reading of the manuscript and excellent suggestions, and the staff of library of the Upstate Medical University of the State University of New York in Syracuse for their devoted and generous assistance. As always, my brother George has been a boundless source of information and a sober critic.

Introduction

The Invention of Psychopathology

Psychopathology: the pathology of the mind; the science of mental disease.

—Oxford English Dictionary

I have dedicated much of my professional life to a critique of the immorality inherent in the practices of the modern misbehavioral sciences (the term is Jacques Barzun’s), particularly psychiatry. I say inherent, because deception and coercion are intrinsic to the practices of the mental health professions. The core concept of psychiatry, mental illness qua medical disease, and the profession of psychiatry as a medical specialty based on it, rest on the medicalization of malingering.¹

The imitation of illness is memorably portrayed by Molière (1622–1673) in his famous comedy Le malade imaginaire (The Imaginary Invalid). As created by Molière, the imaginary invalid, then called a hypochondriac, is someone who wants to be sick and be treated by others, especially doctors, as if he were sick. Telling Argan, the self-defined patient, that he looks well is considered rude in his household. Molière’s invalid confuses religion and medicine—imparting to medicine a sanctity that echoed the mysteries of religion—a confusion then obviously pregnant with comedic possibilities.²

Since those days, we in the West have undergone an astonishing cultural-perceptual change of which we seem largely, perhaps wholly, unaware. Today, medical healing is regarded as a form of applied science, the very opposite of faith healing, which is dismissed as hocus-pocus. Mutatis mutandis, the medical profession defines imaginary illnesses as real illnesses, in effect abolishing the notion of pretended illness. Malingering has become a disease just as real as melanoma.

Counterfeit art is forgery. Counterfeit testimony is perjury. But counterfeit illness is illness, mental illness, an illness officially decreed an illness like any other. The consequences of this policy—economic, legal, medical, moral, philosophical, political, and social—are momentous: counterfeit disability, counterfeit disease, counterfeit doctoring, and the bureaucracies and industries administering, adjudicating, and providing for them make up a substantial part of the national economies of modern Western societies.

According to classic, pathological-scientific criteria, disease is a product manufactured by the body, in the same sense that urine is. Diagnosis, in contrast, is a product manufactured by persons, in the same sense that works of art are. Charcot and Freud discarded the somatic pathological criterion of disease, destroying the empirical-rational basis for distinguishing real medical disorders of the body (diseases) from fake psychiatric disorders of the mind (nondiseases). Modern psychiatry is a gigantic edifice built on the poisoned ruins of this destruction.

Except for a few objectively identifiable brain diseases, such as Alzheimer’s disease, there are neither biological or chemical tests nor biopsy or necropsy findings for verifying or falsifying DSM diagnoses. It is noteworthy that in 1952, when the American Psychiatric Association (APA) published the first edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM), it did not include hysteria in its roster of mental diseases, even though it was the most common psychiatric diagnosis-disease until that time. The term’s historical and semantic allusions to women and uteruses were too embarrassing. However, the APA did not declare hysteria to be a nondisease; instead, it renamed it conversion reaction and somatization disorder. Similarly, in 1973, when the APA removed homosexuality from its roster of mental illnesses, it first replaced it with ego-dystonic homosexuality; when that term, too, became an embarrassment, it too was abolished. However, psychiatric researchers lost no time discovering a host of new mental maladies, ranging from attention deficit hyperactivity disorder to caffeinism and pathological gambling.

Objective (biological, chemical, physical) tests for diseases are based on the assumption that diseases are somatic phenomena. Accordingly, the claim that mental illnesses are brain diseases is profoundly self-contradictory: a disease of the brain is a brain disease, not a mental disease.

Because there are no objective methods for detecting the presence or establishing the absence of mental diseases, and because psychiatric diagnoses are stigmatizing labels with the potential for causing far-reaching personal injury to the stigmatized person, the mental patient’s inability to prove his psychiatric innocence makes psychiatry one of the greatest dangers to liberty and responsibility in the modern world.

The legal system recognizes the elementary distinction between innocence and guilt. The psychiatric system does not: it proudly rejects the concept of personal responsibility. Crime is a well-defined act. Mental illness is an ill-defined mental state. Criminal prosecution is defined, and popularly understood, as adversarial. Psychiatric treatment, even when forcibly imposed by law, is defined and widely accepted as nonadversarial. Those differences, together with the notion of mental illness, are the two great lies and injustices that undergird the psychiatric enterprise.

It is possible to establish that a person accused of a crime is not guilty, that is, has not performed the illegal act attributed to him and is the victim of malicious prosecution serving, say, the personal-political ambitions of an unscrupulous district attorney; it is also possible to punish the person responsible for such malicious prosecution.³ In contrast, it is impossible to establish that a person diagnosed as mentally ill is not mentally ill and is the victim of malicious psychiatrization serving, say, the economic-ideological ambitions of the diagnostician; it is not possible to punish the person responsible for the injurious diagnosis that may be erroneous but, by definition, cannot be malicious.⁴

In the Anglo-American adversarial legal system, the accused is presumed innocent until proven otherwise, and the onus of proof of guilt is on the accuser. In the psychiatric-inquisitorial medical system, this relationship is reversed: the person diagnosed as mentally ill is presumed insane until proven otherwise, and the onus of disproof of insanity is on the (usually powerless) individual incriminated as insane. A priori, psychiatrists disqualify such claims of psychiatric innocence as evidence of the insane patient’s denial of his illness.⁵

I

One of the most basic mechanisms of deception is imitation, a ubiquitous phenomenon in both the human and the animal worlds. The English language is rich in synonyms for imitation: bogus, camouflage, chicanery, copy, counterfeit, deception, disguise, dishonesty, duplication, duplicity, fabrication, facsimile, fakery, falsification, forgery, fraud, humbug, identity theft, impersonation, imposture, invention, lie, malingering, mendacity, misrepresentation, perjury, pinchbeck, pirating, plagiarism, pretense, prevarication, sham, simulation, substitute.⁶ Some of the terms we use to describe imitation-as-deception are associated with certain activities and social contexts—for example, forgery with art, perjury with law, pinchbeck with jewelry, malingering with medicine. The common denominator among these expressions is the contrast between an original and its copy, the genuine and the imitation.

Incentives for counterfeiting are everywhere. Practically everything is counterfeited, explains a private investigator engaged in identifying commercial counterfeiters:

[He] has investigated counterfeit vodka and counterfeit golf balls. He has seen a package of counterfeit prunes. There is counterfeit toothpaste and counterfeit breakfast cereal, and there are counterfeit truck parts (air dryers filled with kitty litter), counterfeit airplane parts (two percent of the parts installed each year), and counterfeit pharmaceuticals (ten percent). . . . Counterfeiting is more profitable than narcotics, and your partners don’t kill you. You can import a counterfeit watch from China for a dollar-sixty and sell it on Canal Street for thirty dollars or on the Internet for a hundred and fifty. There ain’t no markup like that in narcotics, not ever. And in narcotics if you get caught you go to jail for the rest of your life. If you get caught counterfeiting, you go to jail for three months. Not even.⁷

In this book I consider the elements of the medical situation subject to counterfeiting, such as the impersonation of the sick role by a healthy person (malingering), the impersonation of the healthy role by a sick person (dissimulation), and the impersonation of the role of a physician by a nonphysician (quackery).

We