Bryan Caplan  

What Does a Szaszian Therapist Do?

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I've occasionally said that if unicorns don't exist, we can't have a real argument about what unicorns are like.  But if that's right, how is Szaszian therapy possible?  How can you practice psychotherapy if you don't believe in the existence of mental illness?  An interview in Psychology Today has Szasz's wise response.  He begins with this caveat:

My view is that there is no mental illness and hence also no "therapy/psychotherapy." Therapy, then, is a particular kind of human relationship (arrangement, contract), aimed at helping people cope with their "problems in living." This makes it necessary to reframe some of the questions you pose.

Here's part of Szasz's response to the interview's first question: "How would you respond to a new client who asks: What should I talk about?'":
It was my practice to never meet with a prospective patient without first speaking to him on the telephone. I used this opportunity to ascertain the sort of help the client was seeking and to inform him of the sort of assistance I was, and was not, offering. If these matters are properly clarified, the question, "What should I talk about?" does not arise, just as it does not arise in, say, the office of a divorce lawyer meeting a client seeking a divorce. Nevertheless, a new client may feel embarrassed, fearful, or tongue-tied for other reasons and ask, "What should I talk about?" In such case I said, "How can I be of help to you" or "What made you decide to come and see me (today)," or something similar.
This may seem underwhelming, but my one dinner with Szasz was a highlight of my intellectual life.  Conversation that good doesn't even have to be called "therapy" to be worth hundreds of dollars an hour.


HT: Dan Klein


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COMMENTS (18 to date)
bil. writes:

Now that is a dinner conversation I would have love to have overheard. If feasible, I would enjoy seeing a blog post about it.

Lee Kelly writes:
I've occasionally said that if unicorns don't exist, we can't have a real argument about what unicorns are like.
But presumably we can have a pretend argument, right?

*rolls eyes*

Lee writes:

I may have mentioned this before in a comment, but to EconLog readers who are curious about skeptical interpretations of mental illness I recommend you check out Neil Pickering's excellent "Metaphor of Mental Illness," an approachable, well-written, not-too-long philosophical exploration of the different schools of thought. His conclusions are a little weaker than Szasz's. For another book that's respected in it's field of philosophy and a little less radical than either Szasz or Pickering, but still smartly skeptical, check out Dominic Murphy's "Psychiatry in the Scientific Image." But it's a little drier. Here's a review:

http://ndpr.nd.edu/review.cfm?id=11223

For a little (of what I think is) silliness, I'll also point readers to this neat article in the Stanford Encyclopedia of Philosophy on fictionalism in philosophy of math. Here's a snippet that I called to mind when Bryan mentioned unicorns:

Fictionalism... is the view that (a) our mathematical sentences and theories do purport to be about abstract mathematical objects, as platonism suggests, but (b) there are no such things as abstract objects, and so (c) our mathematical theories are not true. Thus, the idea is that sentences like '3 is prime' are false, or untrue, for the same reason that, say, 'The tooth fairy is generous' is false or untrue—because just as there is no such person as the tooth fairy, so too there is no such thing as the number 3.

http://plato.stanford.edu/entries/fictionalism-mathematics/


Mike Rulle writes:

Even if what I am about to say is true, it is possible I would find Szasz helpful in one's "arrangement" with him, as well as personally pleasant.

I do not know what he defines as "mental illness", so I cannot opine on his view that it does not exist. But, my impression is he is just changing the label "therapy" to "contract" or "arrangement". It seems to me if someone comes to him, pays money, discusses problems of an emotional and/or some other nature, and then hopes to leave these sessions better off (or not) that "behavior pattern" is indistinguishable from what we call "therapy". Maybe the impact of not calling the individual's issue an "illness", is palliative in itself. But that could be seen as part of the "therapy". It seems like we are playing with semantics.

Dr. T writes:

Szasz is a fraud. He says there are no mental illnesses, yet he treats the mentally ill with talk therapy. He sees people with blatant mental illnesses such as psychosis, schizophrenia, bipolar disorder, and severe clinical depression, but he claims they are just different-acting and should be accepted as they are. But, what if they want to be better, functional people! They have real illnesses that need real treatments by real psychiatrists.

Szasz is intelligent and asks challenging questions of the psychiatry profession (which definitely needs challenging). But, he goes beyond skepticism to disease denial, and he appears to seek publicity more than he seeks real change. I think the net effect of Szasz on medicine is negative.

Lee writes:

Dr. T, I find Szasz's firebrand approach off-putting, too. But I think you are too quick to dismiss the radical claims against the reality of at least some mental illnesses. In particular, the word "function" in a biological context is tricky, and "better" seems almost purely aesthetic.

KP writes:

To clarify, Szasz believes mental illness is a myth (hence the title of his famous book: the myth of mental illness). His argument, therefore, is that mental illnesses are no more real than spiritual illnesses.

Those who believe in mental illness are quick to assert the legitimacy of these "diseases" by mouthing the platitude that "everyone knows" that mental illness exists, so therefore it must exist.
Yeah, and a thousand years ago "everyone knew" that witches and heretics existed and needed to be "saved," whether or not they wanted saving.

I don't find Szasz's "firebrand approach" off-putting at all. The proper response to a popular craze is unremitting skepticism.

Russell Hanneken writes:

Dr. T wrote:

Szasz is a fraud. He says there are no mental illnesses, yet he treats the mentally ill with talk therapy.

You see him as having "treated" people with "illnesses." He sees himself as having helped people with problems. Perhaps you are correct, and he is mistaken about the nature of what he was doing. That doesn't mean he's a "fraud."

He sees people with blatant mental illnesses such as psychosis, schizophrenia, bipolar disorder, and severe clinical depression, but he claims they are just different-acting and should be accepted as they are.

Where does he say people should be accepted as they are?

Snark writes:

Dr. Szasz: [One of] the most rewarding parts of being a therapist [is] engaging in a serious, in-depth, private, confidential relationship with an intelligent fellow being.

Prof. Caplan: ... but my one dinner with Szasz was a highlight of my intellectual life. Conversation that good doesn't even have to be called "therapy" to be worth hundreds of dollars an hour.

Was this a casual dinner date or professional appointment?

George writes:

Bryan,

Go over to the neurobiology department. Tell them you want to deplete the serotonin in your brain. They can tell you what to do to get rid of the tryptophan in your system, which will cause your serotonin to crash about an hour later.

When the hellish, hopeless, despairing feeling hits you (possibly along with phantom muscle aches), you can just keep telling yourself it isn't real — you just have a vastly increased preference for performing the speech act "I wish I were dead."

It will be especially helpful to you to emphasize that this is just a "problem in living," not a disease (no lesion, after all — unless you have a razor blade handy and have managed to hang on to some small shred of motivation), and you should work on accepting yourself as you now are.

Jacob Oost writes:

Never heard of Szasz or this concept of there being no mental illnesses (apart from Scientologists), but if I *don't* have obsessive-compulsive disorder then what is wrong with me, and what is it that fluoxetine fixes?

More to the point, tell Szasz to come where I work, with mentally retarded adults. Psychosis, schizophrenia, etc., abounds.

Vasile writes:

Go over to the neurobiology department. Tell them you want to deplete the serotonin in your brain.

I hate when people do this. You point to a way of changing chemistry of the brain (body) and call it a mental illness?

Shall I elaborate on this?

Urstoff writes:

There's a functional ideal of how hearts work, about how livers work, how kidneys work, how eyes work, and on ad infinitum. Why can't we have a functional ideal about how the brain (and thus the mind) works?

przemek writes:

In the economic psychology literature (Benabou, Tirole and no doubt some others), personalities are modelled not as preferences but as equilibria (of an intertemporal game between one's "short-term" and "long-term" selves). As such, all personalities are by definition rational, but that doesn't mean they can't be judged normatively, considered undesirable or pathological. Equilibria can be so judged--for example, an equilibrium can be Pareto-dominated by some other one. Similarly, one can have meta-preferences over personality types. Suppose my current (equilibrium) personality exhibits schizophrenia. Then, even though in a very real sense I want to be a schizophrenic, it doesn't follow that I want to want to be one. I might have a meta preference to have a different personality; whereas what Szasz is saying implies that it is not possible for someone to be genuinely unhappy about the way they are.

rickyp writes:

Check out the youtube channel psychetruth. They are of the opinion that many mental illness labels are misued by the health care system. Dr. John Breeding is the main speaker about this.

George writes:

rickyp:

It would be incredibly surprising if no mental illness labels were misused by the health-care system: (a) many doctors bill one thing as another so insurance will cover it; (b) back in the 1950s, pretty much every mental illness in America was labelled "schizophrenia". Just because doctors are bad at labelling or lie about labels doesn't mean Szasz is right and there's no mental illness.

Vasile:

Yes, you'll need to elaborate if I'm to see what you're driving at.

Vasile writes:

George:

Most probably do not know very well what Dr. Szasz objects to.

Well, Szasz strongly objects to defining mental illness on evidence of behaviour/mood only. Only then you have an illness (Szasz) when you have a body organ which is not functioning properly.

Szasz, maybe wrong on this, but your example of changing behavour/mood using chemicals it is rather a confirmation than a refutation of Szasz thesis.

Eapen Thampy writes:

My comment requires a little background. Mental health policy played a focal role in a high school debate topic several years ago while I was competing, so I've done a great deal of research on the topic and am quite familiar with Szasz.

I'll roughly agree with the premise of the thread: that part of how we address mental illness is very much linked to its representation as a explanation for many of the simple problems of living and that there are a lot of people who use drugs and therapy as crutches. I agree that Americans tend to overmedicate, and this problem is especially bad amongst youth populations.

But to reject the prospect of mental illness truly existing is intellectually specious, and a careful examination of Dr. Szasz's record reveals a dangerous fanaticism. His theorizing about medicine and mental illness and his well publicized criticisms of the industries related to mental illness have been funded by Scientology and its subsidiaries for decades. This rather bizarre connection makes more sense in context: L Ron Hubbard's foray into the mental health profession, Dianetics, was lambasted by professionals and since then Scientology has used everything from threats to intimidation to lawsuits to wage war, so to speak, on the mental health profession.

This is fairly well documented. A google search should be fairly fruitful; I don't have access to the work I did for this debate topic.

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