A documentary film review that compels one to wonder if Szasz’s alleged suicide should be seen as a courageous adherence to the principles by which he lived or a symptom of a pathological avoidance of helplessness. Dr Szasz might reply that either way, it was his choice.
The Last Interview of Thomas Szasz
Directed by Philip Singer, PhD • Documentary • 2013 • 50 minutes
A Traditional Healing Productions Film • Witness Films (www.witnessfilms.com)
The Last Interview of Thomas Szasz would make an excellent discussion piece for a psychiatry residency ethics seminar, because it pushes the viewer to think more deeply about the issues and principles that underlie capacity and informed consent. It would also serve well in any introduction to a psychotherapy course, since it draws out distinctly and compellingly the question, “What is the nature of the therapeutic conversation?”
Thomas Szasz, a psychiatrist and psychoanalyst, reportedly ended his own life last year, at the age of 92, after a spinal compression fracture.1 His suicide might be a topic of debate, however, because some obituaries report that Dr Szasz “died of a fall.”2
Director Philip Singer, PhD, a medical anthropologist whose focus has been the cross-cultural study of healing practices, interviewed Szasz 2 years before his death. The interview focuses on the central argument in the 1961 book The Myth of Mental Illness: Foundations of a Theory of Personal Conduct, for which Szasz is best known. It forms the core of Szasz’s career-long sermon, a radical-which is to say, epistemological-attack on the construct of mental illness. Namely, he argues that illness belongs to bodies and not to minds; the brain can be sick, but the mind cannot.3
An important and elusive corollary of this observation is that mental illnesses must be defined syndromically in terms of mental and behavioral symptoms. The lack of change in the basic diagnostic system of DSM-5, which follows DSM-IV in this approach, speaks to this logic. What is easy to lose sight of is that where symptoms of an illness typically represent problems for the ill, those of mental illnesses, while certainly presenting problems for their sufferers, may more often also represent problems for somebody else; after all, many of the patients we see have been brought to us by loved ones who are distressed by the patient’s behavior or by the police for disturbing the peace.
This epistemological argument is ultimately motivated, however, by Szasz’s unbending libertarian ethics; the point of saying minds cannot be sick is revealed in this interview to be a principled guarding against the intrusions of society on personal liberty and liberty of thought. Permitting such an intrusion might also allow for society to slip into totalitarianism. This might be paraphrased as “Don’t call your distress at someone else’s behavior their sickness; if a person wants help with a problem, it is their own responsibility to seek it. If they are bothering you, that is your problem.” Although Szasz indicates that some societal controls are acceptable, he resents the presentation of such controls as medical matters, a tactic that quietly removes them from the realm of social debate.
Although principled, in this context, it is also a deeply emotional defense. That hidden emotionality makes the discussion difficult, but it also highlights its importance. In fact, such an argument highlights the importance of a questioning approach to the concepts that make up “mental illness,” and this emotionality should perhaps also be understood as a necessary “flaw” in the discussion. The questions themselves are essentially emotional ones. Insofar as we are social animals, the complex functions of a mind are necessarily to a great extent socially constructed, even as they necessarily have biological underpinnings (a physical event in the organism underlies the non-physical event of a thought). The controversial elimination of the bereavement exclusion from the major depressive episode criteria in DSM-5 is a prime example.
Dr Szasz places equal demands on patient and doctor-of doctors, to act only in accord with the patient’s immediate (free) will, and of the patients, to act in accord with their best interests or (freely) suffer the consequences of their poor choices or bad luck.
Singer, attempting to find a situation Szasz might regard as a moral gray zone in his critique of common psychiatric practice, is driven to call him “Jesuit” in his adherence to his conclusions. Here, something emotional has come into play; how do we recognize the imbalances in a doctor-patient relationship and how do we feel about them? Szasz’s avoidance here is telling.
Indeed, the perplexing power of Szasz’s epistemological problem with “mental illness” is obscured at times by its complex, often tenuous, connection to the libertarianism that motivates it. This is not to say that his libertarianism is not powerfully thought-provoking in its own right and must give any psychiatrist pause when pursuing involuntary commitment or treatment over objection. Even if one is ultimately to disagree with Szasz (as, in practice at least, almost all psychiatrists do), such pause is an invaluable burden.
Beyond these matters, which are readily available in Szasz’s writings, Singer’s film allows us to meet Szasz near the end of his life. I cannot help but feel that the hard edges of his arguments serve as guards against survivor guilt that could otherwise cripple a man of evidently deep, tender, and curious humanity. (Szasz emigrated to the US in 1938 to study medicine, wittingly escaping the storm of fascism already overtaking central Europe.)
Throughout the interview, we find Szasz demands that the discussion be on his terms. “I never saw anyone before talking to them myself,” he explains. “My secretary didn’t make any appointments.” To explore this, Singer plays a prospective patient: “Help me to want to live again,” to which Szasz replies, “That’s not the kind of thing I can do. I would not make an appointment.” A pause ensues and, slightly frustrated, Singer tries again: “Okay. I’ve heard, Dr Szasz, that you’re a very good psychiatrist and I just don’t feel I can live this way anymore; can you help me?” Szasz responds, “Perhaps. Okay. We can have a conversation; come and see me.” The transcript reads perhaps as harsh, but in Szasz’s voice there is something ameliorating. When he says, “Come and see me,” he does not sound clinical. Rather, one hears a genuine and fully willed invitation.
What is the difference between Singer’s first, rebuffed, approach and his second, accepted one, besides the compliment to Szasz? In the first, Singer lacks agency. He positions himself as seeking rescue. In the second, he seems similarly distressed but he takes ownership of his choice to seek Szasz’s help. Szasz demands ownership of his own choices; he decides whether he will see someone, but he demands that ownership of choice of others as well. “The goal,” he says, “is to assume more responsibility and therefore more liberty and more control over one’s own life.”
Szasz’s fierce independence and his symmetric insistence on the responsibility of others for their own fate read to me as a defense against the emotional burden of having escaped the Holocaust. Indeed, that fierce independence seems to be one that he held to the death. Singer asks, “If you were dependent on someone else, caretakers . . . would you think . . . of killing yourself?” Szasz pauses and smiles before replying, “Off the record.”
Should Szasz’s alleged suicide, then, be seen as a courageous adherence to the principles by which he lived or a symptom of a pathological avoidance of helplessness? Dr Szasz might reply that either way, it was his choice.
Dr Yaseen is Attending Psychiatrist at the Family Center for Bipolar Disorder, an affiliate of Beth Israel Medical Center in New York City. He reports no conflicts of interest concerning the subject matter of this article.
1. Schaler J. Kaddish for Thomas Szasz. The Thomas S. Szasz, MD Cybercenter for Liberty and Responsibility. http://www.szasz.com/szaszdeath.htm. Accessed October 17, 2013.
2. Carey B. Dr. Thomas Szasz, Psychiatrist Who Led Movement Against His Field, Dies at 92. New York Times. September 11, 2012. www.nytimes.com/2012/09/12/health/dr-thomas-szasz-psychiatrist-who-led-movement-against-his-field-dies-at-92.html. Accessed October 17, 2013.
3. Szasz TS. The myth of mental illness. Am Psychol. 1960;15:113-118.