Thomas Szasz - The Manufacture of Madness

Already Szasz’ early works show a decided front position against the medical guild, where it extends its competence beyond the limits of objectifiable physical illness. The narrower subject from which he initially drives his attack is physical pain. A person who complains of pain is usually considered to be ill. At the same time, however, pain cannot be demonstrated as a medical finding in the strict sense, because it is difficult to offer anything other than conclusions if we do not want to rely on the communications of the sufferer himself. Usually we are content to infer the efficacy of a medical treatment from the fact that perceived pain is eliminated or alleviated by it.

In an early 1957 paper on Pain and Pleasure, Szasz dealt with cases in which no underlying physical disease could be identified for perceived pain and the pain did not respond to treatment. Such pain-stricken patients confront the physician with pain, or more precisely, with their complaints about pain that the physician cannot eliminate. In doing so, they make the doctor himself suffer from his own powerlessness. Often these are patients who are severely depressed and who have obviously accepted the role of the sufferer and sick person for themselves. Here the question is: Whose pain is the doctor supposed to help, whose pain is he supposed to relieve: The patient’s, who feels his suffering as part of his own identity? That of the relatives who groan under the patient’s constant complaints? Or his own, which may result from an inability to help effectively? — What is usually striking about such pain-ridden patients is that they have already had a “career” as sufferers. They may have once been a lawyer or an architect, a bus driver or a businessman, a model or a maid. Their career of suffering began when the professional role did not bring the desired success or could no longer be sustained.

Inspired by Sartre’s theory of the emotions (1939), Szasz opposes the custom of doctors to refer such patients to psychiatrists so that they can diagnose them as hysterical, hypochondriacal, schizophrenic, or depressive and “treat” them accordingly. This medical strategy seems illogical to him if the group of persons in question has actually chosen his ailment like the mathematician’s lifelong occupation with algebraic problems or like a politician who has written the tireless fight against “communists” or “fascists” on his banner. In the past, such persons who knew only one salient interest in life were called “monomaniacs.” To them belonged the figure of the obsessed political leader, that of the religious zealot and also that of the agitator, who does not look for solutions to problems, but who finds or even invents problems for which he already has ready-made solutions. — The extent to which the patient suffering from incurable pain chooses his role of suffering himself and elevates it to a passion is illuminated for Szasz by the contrary case. Even severe chronic physical illnesses do not have to lead to a career of suffering if the person concerned knows something better to do with his life than to suffer. Sigmund Freud, for example, lived devotedly to his work despite his oral cavity cancer; he was, however, hypochondriac in his younger years, when the success and significance of his life’s work were still uncertain.

The case of the “passionate sick person” is complicated by the fact that many physicians also see their profession as a vocation. Since their youth, they have passionately devoted themselves to the idea of being able to alleviate the pain of others, and with this goal in mind, they have learned and developed strategies for coping with pain either through reflected acceptance, understanding, and distraction, or how pain can be more directly and effectively combated through suggestion, medication, and finally surgery. If they now encounter patients for whose pain there are no organic findings, but who at the same time defy all the efforts of the doctor, they save themselves the admission of their helplessness, indeed their defeat in the battle against the enemy, by speaking of “psychogenic” pain and diagnosing the resistant patient with a “mental illness” for which the colleague from psychiatry is responsible. Szasz sees this as a deception of the patients by the doctors and an intellectually inadmissible expansion of the concept of illness. As little as there is a real victim in a murder acted out on stage, so little is there an illness for him in mentally induced pain. If a patient simulates pain, he only plays the role of a patient. A treating physician, in turn, who accepts the simulator as ill, plays the role of a psychotherapist or psychiatrist. The latter, for his part, insofar as he pretends to treat an illness, plays the role of an organ physician without actually having an organic event in front of him. A confusion of roles is the result:

It is as if detectives and theater critics on the one hand, gangsters and actors on the other, were mingling and exchanging their roles with each other. (Szasz 1968; transl. R. W.)

L’Homme douloureux, the man of pain, is, in Szasz’s interpretation, a conception of life that in the Christian Occident ranks equally with the homo politicus of the Athenian polis and the homo oeconomicus of the 18th and 19th centuries. Suffering, he strives to rise above those who are incapable of suffering. Suffering is a mode of existence that permeates the whole personality and is also borne by the whole person. The life of Jesus stands as a sign of how, through boundless suffering, humanity can be freed from its sin and the sufferer can be elevated. Also the Virgin Mary was and is seen as Mater Dolorosa, the Mother of Suffering. — On the other hand, liberalism, as the worldview of the bourgeoisie that arose in the struggle against the Church, shows a contrary relation to the world: civilizational progress is here synonymous with the reduction of the suffering present in the world. From the point of view of modern reformers, be they economically, politically, or psychotherapeutically oriented, those who suffer always appear as “victims” deprived of their genuine rights. The spectrum ranges from the members of underdeveloped nations to the mentally ill to criminals; the causes of the misfortunes always passively suffered range from tyrants to microbes to the abnormal chromosome sets of violent criminals.

The creative aspect of suffering remains completely alien to this view.
Szasz sees the zeal for improving the world associated with liberalism at work in the form of the various campaigns waged in the U.S. against enemies such as fear, disease, need, and poverty. In this conception of reality, the physician becomes a general who wages war against disease and pain, with a constantly modernized arsenal of drugs and surgical techniques at his disposal. In community psychiatry, this war perspective leads for Szasz to direct social coercion: modern social therapy appears in the tradition of all political-bureaucratic thinking as a hunt for victims and their rapists. The administered benefits often have a harsher and more hurtful effect on the “victims” than the previous neglect. The individual is increasingly denied the competence to judge his own living conditions. In all of this, the therapeutic goals of medical care understood in this way are only apparently as “good” as the reform enthusiasts naively assume. In fact, behind the relentless reform zeal lies the only thinly veiled desire for control. Control of the “patient estate” works smoothly in the medical field, where people are willing and ready to play the patient role so that doctors can play the diagnostician and therapist. In this regard, the relationship of authority between the two sides resembles the relationship that existed between priests and believers in the religious world of the Middle Ages.

Modern physicians, on the other hand, hate nothing more than patients who refuse to dutifully play the patient role. For Szasz, the prototype of such unwilling patients in the sixties is the “delinquent” youth. Student protest is seen by quite a few psychologists and psychiatrists as an expression of a fundamental character deformation from which young people suffer. For Szasz, however, it is not so much the unruly young people who suffer from this as school principals, university rectors and psychiatrists. From their point of view, the unwillingness of the boys to take on the role of the sick and thus hand themselves over to the doctors is a dangerous sign. The worried warnings foreshadow where they want to drag society at large: denying individuals the inalienable right to suffer and forcing them to undergo standardized treatments administered by the bureaucratic welfare state in the name of freedom and health.

Szasz raises the question of why doctors seem to so stubbornly refuse to accept suffering as an intrinsically meaningful life design. After all, they accept it when a man in love thinks his beloved is the most wonderful person in the world and marries her, although a closer look does not necessarily confirm the finding. Doctors and non-doctors call this “love” and usually see no reason to intervene. Similarly, when a young man thinks the president of his country is a great leader and willingly lets him send him to war, this is called “patriotism.” But when someone imagines that his body is sick and complains of pain, we refuse to accept that someone finds it attractive to think of himself as sick, even though the facts do not correspond to his wish — and take action. For Szasz, this is as nonsensical as if someone were to call the police after a “murder” performed on stage instead of applauding or making their displeasure known. Doctors who accept imaginary sick people as sick behave like a museum that accepts fake Rembrandts as real masterpieces and exhibits them in a separate room, while in another one the real Rembrandts are on display. At any rate, this logic is followed in the modern hospital system, in that there are departments for organ patients and departments for false organ patients. For doctors, such expansion of their sphere of competence is lucrative. The concept of “pathological” imagination gives work and bread to a whole army of specialists, the psychiatrists.