Editors’ Note: Rael Jean Isaac is co-author (with Virginia Armat) of Madness in the Streets: How Psychiatry and the Law Abandoned the Mentally Ill, Free Press, 1990. We are pleased to publish her letter here.
For decades Cato has remained attached to the ideas of Thomas Szasz, most recently recycled in the essay by Szasz acolyte Jeffrey Schaler in Cato Unbound. The notion that there is no such thing as mental illness is not a “big picture” or a profound idea but a foolish one, and Cato discredits itself by clinging to it. It is deeply ironic that it should be left to D.J. Jaffe, whose politically liberal beliefs are diametrically opposed to those of Cato (and to my own), to explain to Cato what a libertarian approach to mental illness should be, given libertarian principles and the realities of mental illness. Indeed Jacob Sullum concedes as much: were these diseases, Sullum agrees, Jaffe’s suggestions would make sense for libertarians.
On what do Szasz and followers like Schaler and Sullum base their claim that mental illness does not exist? It’s on rhetorical sleight of hand. To quote Szasz (and Schaler echoes him to such an extent that it makes sense to go to the source): “Mental illnesses do not exist; indeed they cannot exist, because the mind is not a bodily part or bodily organ.” As one of his critics has aptly observed, Szasz seems to think words can create and destroy, a belief in “word magic” that one usually loses at the age of two. For of course what is diseased in “mental illness” is the brain, which is as susceptible to malfunction as any other bodily organ.
Schaler, echoing Szasz, tries to dispose of mental illness as brain diseases by arguing that they do not appear in pathology textbooks. Ronald Pies has torn apart this argument in his letter to Cato Unbound, so there is no need to repeat what he says here. In his letter, D.J. Jaffe reports on the advances in brain imagery that have shown differences in the brain between mentally ill and normal individuals, such as enlarged ventricles and decreased functioning of the prefrontal area.
The notion that mental illness does not exist, which Szasz first advanced in the 1950s, would normally have remained a fringe curiosity. The reason it didn’t–and this should give Cato pause—is that the idea was taken up by the counter-culture and political radicals of the 1960s. The mentally ill became a group to be “liberated” along with blacks, Hispanics and Third World peoples. The mentally ill were an especially attractive cause because they were imprisoned, not in the invisible institutional complexes of law and custom, but in the concrete brick and mortar of the asylum. While many have noted the radical egalitarianism of the adversary culture, what escaped notice is the way that denial of mental illness dissolved the most fundamental distinction of all: that between sanity and madness. For the most radical claim of the left was that all realities were equal. Indeed some countercultural intellectuals went so far as to invert the consensual order. The mad were sane, the sane mad. After all the mad rejected the unacceptable, irrational reality of a rotten social system, while those called sane conformed to the sick values of the culture.
The upshot was that a literally mad idea—the bizarre conceit that the ancient, ongoing and universal scourge of mental illness did not in fact exist—became the foundation of public policy. Legislators and lawyers emptied state mental hospitals. As readers of Amanda Pustilnik’s contribution already know, their role has been taken over by jails and prisons. Involuntary commitment became contingent on imminent dangerousness and even then treatment was uncertain because the law instituted a right to refuse treatment, which could be exercised even after commitment.
These developments have wreaked untold havoc on the lives of the mentally ill, who have been left, in psychiatrist Darrold Treffert’s famous phrase, to die with their rights on. It has devastated families who have been forced to watch those they love deteriorate and are helpless to obtain treatment for them. Szasz recognized what the impact on families would be and, with typical hard-heartedness, shrugged it off. Families, says Szasz, have three options: they can beg the individual to change his behavior, sever the relationship, or enlist psychiatric help to obtain involuntary commitment. This last, says Szasz, “ensures the maintenance of family relationships, loyalties, and responsibilities as positive moral values.”
Szasz’s first option is (to use his favorite word) a myth. A mentally ill person cannot alter his behavior on command for he is a prisoner of his aberrant mental processes. The third option has largely been taken away. That leaves the second option and in many cases the family does indeed eventually withdraw, even flee from their mentally ill relative, whom they may physically fear. It is often these people, untreated and without family anchor, who engage in the random violence that makes headlines. More frequently, families reluctantly pursue what has become a fourth option, becoming a mini-institution. Only this staff is without shifts, without backup, without the ability to enforce daily routines or medication compliance.
Szasz asks: “Which should we prefer, the integrity of the family or the autonomy of the individual?” (Italics in original) For Szasz the choice is easy. He declares “Autonomy is my religion.” This emphasis on human autonomy is doubtless the source of the appeal of his ideas for Cato. But however ideologically inconvenient, the fact is that the mentally ill do not possess autonomy as Szasz himself defines it: “[Autonomy is] freedom to develop one’s self—to increase one’s knowledge, improve one’s skills, and achieve responsibility for one’s conduct. And it is freedom to lead one’s own life, to choose among alternative courses of action so long as no injury to others results.” But the mentally ill possess none of these freedoms as long as they are confined in the terrible prison of psychosis. The irony is that it is medications that can restore the individual’s autonomy, his ability to make choices in any meaningful sense.
What will it take for Cato to wake up from its own delusions regarding mental illness? In mental illness rational arguments are helpless to change distorted thinking. Let’s hope that does not prove to be the case with Cato, whose positions on so many issues are a model of intelligence and clarity.
 Thomas Szasz, The Therapeutic State, Buffalo: Prometheus Books, 1984, p. 15.
 Richard E. Vatz and Lee S. Weinberg, eds., Thomas Szasz: Primary Values and Major Contentions, Buffalo: Prometheus Books, 1983, p. 199.
 Rael Jean Isaac and Virginia Armat, Madness in the Streets: How Psychiatry and the Law Abandoned the Mentally Ill New York, The Free Press, 1980, pp. 25-26.
 Thomas Szasz, Law, Liberty and Psychiatry, New York: Macmillan, 1963, pp. 153-4.
 Ibid., p. 154.