MISUNDERSTANDING THOMAS SZASZ: It's hard to think of a writer who expressed himself as clearly as the late Thomas Szasz did, or who argued his points with such precision. You might fault his logic or disagree with his premises, but it ought to be hard to misunderstand what exactly he was saying. And yet he was constantly misunderstood. How many times, for example, has someone suggested that Szasz's argument against the idea of mental illness has been refuted by research on the biological basis of schizophrenia? The implications of that research are routinely overstated, but set that aside: Even if the most breathless pop-science coverage of those investigations were accurate, they wouldn't affect Szasz's distinction between metaphorical mental diseases and actual physical lesions. They would simply move schizophrenia from the first category to the second one. Far from being unable to process such scientific developments, Szasz wrote thoughtfully about something similar that had happened in the past, when the treatment of epilepsy moved from the dominion of the psychiatrists to the dominion of the neurologists.
Meanwhile, there seems to be no limit to the medicalization of our lives. So while Szasz's critics tout those schizophrenia studies as evidence that their target is no longer relevant, I read stories like this CNN report and conclude that he's more relevant than ever:
A federal court judge on Tuesday ordered Massachusetts officials to provide sex-reassignment surgery for a transsexual prison inmate, after determining that it was the only adequate treatment for the inmate's mental illness.
The state's Department of Correction said Michelle Kosilek, previously known as Robert, who is serving a life sentence without parole for murdering his wife in 1990, has a gender identity disorder....
Chief Judge Mark L. Wolf ruled that sex reassignment surgery is the "only adequate treatment" for Kosilek, and "that there is no less intrusive means to correct the prolonged violation of Kosilek's Eighth Amendment right to adequate medical care."
In the old days, "gender identity disorder" or some similar label would have been a license to coerce Kosilek back into a male identity. Now it's a license to coerce taxpayers into subsidizing a sex-change operation. Szasz would have said it's absurd to think of the sexual roles people adopt in terms of a disorder.
The medicalization mindset has taken hold even among the people you'd expect to like it the least. While many transsexual activists object, on understandable grounds, to the idea that they're sick, reporters haven't had trouble finding others willing to say things like "It's great to see a judge recognize that transition-related health care is medically necessary health care." In 2012, there are social advantages as well as social disadvantages to acquiring a psychiatric label -- and not just when it comes to a headline-grabbing subject like sex-change surgery behind bars. The Diagnostic and Statistical Manual of Mental Disorders is filled with diagnoses designed to describe ordinary life problems, some of which might be solved or made more manageable by talking to a counsellor or by taking a mood-altering chemical. Once upon a time, a label from its pages would have been a stigma; now it's a way to get an insurance company to cover the costs of those talks or those drugs. (The flow of money from insurance companies has, in turn, become an incentive encouraging psychiatric coercion, a process Joe Sharkey described in his muckraking book Bedlam. Circle of life!)
It was bad enough when readers misunderstood Szasz's own ideas. It was worse when they misattributed other figures' ideas to his work. Forty years ago, when people heard that Szasz was a critic of psychiatry, they often assumed he must be a countercultural "antipsychiatrist" like R.D. Laing. In fact, while Szasz saw some of the antipsychiatrists as allies early on -- he recommended one of Laing's books in a footnote to The Manufacture of Madness -- he concluded quickly that they were no more opposed to coercion than the psychiatric establishment was. Eventually he grew so aggravated at being conflated with them that he wrote a book-long critique of their worldview. By then, with Laing forgotten, people were more likely to insinuate that Szasz was some sort of Scientologist. L. Ron Hubbard's weird church denounces psychiatry all the time, after all, and it was Szasz's ally in the political fight against electroshock and other involuntary treatments. But no, he wasn't a Scientologist, and no, they aren't the master manipulators behind every challenge to psychiatric authority.
I had my disagreements with Szasz, but I can't think of anyone who wrote with as much bracing clarity about the ways psychiatric ideology distorts our understanding of issues ranging from religion to the drug war. (Did I say "ranging from"? Szasz's best book -- Ceremonial Chemistry -- makes a strong case that the drug war and religion are closely linked.) He had the ability to look at claims that are presented as objective science and to see the cultural assumptions lurking behind the curtain. Just as important, he could see the ways our it served our social hierarchies to pretend those cultural contingencies weren't there.
I met Szasz just once, at a conference sponsored by Liberty magazine. I asked him about Gregory Bateson's theory of schizophrenia in Steps to an Ecology of Mind, which paralleled Szasz's writing in several significant ways but stopped short of Szasz's full critique of the idea of mental illness. "It seemed like he got halfway to your position," I told him. "No, he got all the way there," Szasz replied, "but he wasn't brave enough to say it." Whether or not it was fair to charge Bateson with cowardice, it's difficult to imagine anyone levying such an accusation at Szasz: Here was a man with the courage of his convictions. And here was a man with the literary skill to express those convictions clearly, no matter how hard some might find it to decipher his plainly stated arguments.
It's an interesting sleight-of-hand that allowed Ciano to get from praising small government to defending a new government mandate in just three sentences. But that's not why I'm quoting her. I'm bringing her up because it's useful to think about why Ciano's employer would have a role in her birth control purchases in the first place.
The answer comes in two parts. First, because the law requires a woman to get a prescription before she can buy the pill, and it requires her to get an invasive and frequently unnecessary medical exam before she can acquire that prescription. Eliminate those controls, and insurance coverage would be beside the point; the pill would be cheaply available over the counter. Second, because changes to the tax code in the 1940s and '50s have channeled us into a system where Americans overwhelmingly get their health insurance through their jobs. Eliminate those incentives, and far fewer people would be dependent on their employers for insurance at all, substantially reducing the relevance of the boss's opinions about birth control.
It goes without saying that Barack Obama has displayed no interest in rolling back the FDA's birth control rules. Nor has he moved away from the policies that push people into employer-based health coverage, or, more broadly, from a system where so many medical services are purchased via insurance in the first place. Indeed, his signature accomplishment is a law requiring people who don't have health insurance to buy it.
If you can't afford to buy it, you may qualify for financial assistance. That's the Democratic Party's promise: We won't end the policies that empower big institutions and raise the cost of living, but when they send you the bill we might help you pay. You saw the same idea at work when various speakers this week invoked student loans: The Democrats will lend you money for college, but they'll do nothing to end the legally enshrined credentialism that makes so many professions off-limits without a degree. And if those subsidies end up inflating the cost of tuition and health care even more...well, then the pols will just call for more subsidies.
When Democrats invoked "equality of opportunity" this week, that's what they were talking about: government action to help people run through mazes that the government helped erect. I don't expect the Dems to stop looking for ways to offer assistance, but dammit, it would be nice if some of them would take on the mazes instead of hatching plans that'll make them more complex.
Last week the Republicans touted themselves as the party of I-built-that entrepreneurship while presenting corporate welfare queens like Boeing as business heroes. This week the Democrats touted themselves as the party of working Americans while praising policies that shore up the insurance industry and the collegiate sorting machine (and while offering an argument for the auto bailout that amounted to a trickle-down defense of corporate welfare). For the next two months, those parties' standard-bearers will tout this election as a stark choice between deeply different alternatives. Where are those factcheckers when you need them?
(cross-posted at Hit & Run -- with pictures! click 'n' see!)