Antipsychiatry and Its Critics: Szasz, Diagnostic Inflation and the Depressive Realism Debate

Last updated: October 22, 2026

Antipsychiatry is the name for a mid-twentieth-century critique which held that psychiatry stretched the medical model over problems that were really social, moral or existential. The Stanford Encyclopedia of Philosophy’s entry on mental disorder groups Thomas Szasz with R.D. Laing and Michel Foucault under that label and summarises the charge Szasz and Laing made: applying the medical model to mental health was “emblematic of the overreach of psychiatry”. Szasz made the point with a book title, The Myth of Mental Illness (1961), whose thesis Holly Case sums up in Aeon as the claim that “there is no such thing as ‘mental illness’.” The strong version drew sustained criticism; a whole volume, Szasz Under Fire (Open Court), collected the critics and printed Szasz’s answers.

A related idea from psychology, depressive realism, still circulates as the claim that depressed people see the world more accurately. That claim began with a 1979 paper by Alloy and Abramson titled “Judgment of contingency in depressed and nondepressed students: Sadder but wiser?”, and the first meta-analysis of the literature, by Moore and Fresco in 2012, found only “a small overall depressive realism effect” across 75 studies (Clinical Psychology Review).

The Psychiatrist Who Called Mental Illness a Myth

Antipsychiatry was a loose cluster of critics rather than a school, and its leading figures disagreed on central points, starting with the label itself.

Medicine identifies disease in the body; psychiatry, as Case paraphrases him, could demonstrate no physical basis for the conditions it diagnosed and treated. Putting them in the same category as bodily illness was, in a phrase Case quotes, “a misuse of language”, applied to what the SEP calls Szasz’s “problems in living”. His sharpest target was coercion. According to Case, he regarded psychiatry as a danger to civil liberties, and a talk he gave at Cornell at the age of 91 was titled “The Insanity Defence: The Case for Abolition.” In Law, Liberty, and Psychiatry (1963), as Case quotes him, he complained that the “ethical implications of deviant behaviour were obscured” once conduct was relabelled as sickness. Jacob Sullum, reviewing a book of Szasz’s critics in Reason, calls him the psychiatrist “famous for rejecting the insanity defense”, and lists involuntary commitment and the concept of mental illness itself alongside it.

R.D. Laing, the Glasgow-born psychiatrist (1927 to 1989) whose first book The Divided Self appeared in 1960, came at the problem differently. Britannica summarises his account of schizophrenia as a defensive reaction to “ontological insecurity” in which the self splits into separate components, and notes that he opposed standard treatments such as hospitalisation and electroshock. Ron Roberts, writing in The Psychologist in 2010, records that the word “anti-psychiatry” was “coined by Cooper”, meaning the psychiatrist David Cooper, then disclaimed by Laing and rejected by Szasz, who saw “considerable distance” between himself and Laing. Roberts adds that Laing’s writings “do not in principle condemn” forced treatment. Michel Foucault, the third name usually attached, wrote a history of confinement, with no clinical theory of his own; C.M. Black unpacks it in our post on Foucault’s Madness and Civilization.

Kendell’s Reply: Medicine Didn’t Wait for a Lesion

The objection that has aged best is that his definition of disease is too narrow for medicine as a whole, so it cannot single out psychiatry.

Robert Kendell, a former president of Britain’s Royal College of Psychiatrists, argued in Szasz Under Fire that it is “impossible to identify any characteristic feature” that reliably separates mental from physical illness, as Jacob Sullum reports in his Reason review of the book. Szasz’s answer, “This is true, but not enough”, leaves open, as Sullum notes, what would count as enough. Ronald Pies pointed to migraine, a physical condition diagnosed largely from what patients report. Awais Aftab, MD, pressed the point in Psychiatric Times in 2014: in a passage he quotes from Kendell, disease was invoked historically “to account for suffering, incapacity, and premature death”, and Aftab concludes that the concept “is not restricted to the presence of a physical lesion.” On that view, severe psychosis or depression that leaves someone unable to work or look after themselves counts as disease whatever a scan shows.

Szasz’s side landed blows too. In the same volume, according to Sullum, Richard Bentall argued that the search for dopamine abnormalities in schizophrenia “has so far drawn a blank”, and E. Fuller Torrey, a former admirer of Szasz turned critic, conceded that no single brain abnormality is diagnostic of schizophrenia. Philosophers of psychiatry have since tried to keep what each side got right. The SEP sets out Christopher Boorse’s naturalist account, on which disease interferes with normal biological function, against Jerome Wakefield’s “harmful dysfunction” analysis, on which a disorder needs both a failure of some internal function and harm to the person. Wakefield’s version concedes the critics’ point that value judgements enter the definition, while insisting that the judgement is made about something that has really gone wrong.

Eight Pseudopatients and a Vote in December 1973

Two episodes from the 1970s put psychiatric diagnosis on trial in public, and one of them has worn badly.

The first is Rosenhan’s experiment. As Alison Abbott summarises it in Nature, eight healthy people got themselves admitted to 12 psychiatric institutions in five US states between 1969 and 1972; seven were diagnosed with schizophrenia and one with manic depression. The results appeared in Science in 1973 as “On Being Sane in Insane Places” and had, in Abbott’s words, “far-reaching and much-needed effects” on psychiatric care. Then Susannah Cahalan went looking for the pseudopatients for her 2019 book The Great Pretender. According to Abbott, Cahalan traced only one participant, found many mismatches between the paper and Rosenhan’s archives, and asked herself whether he had invented the rest, while conceding she cannot be completely certain he cheated.

The second episode holds up better. In December 1973, the American Psychiatric Association’s Board of Trustees voted to remove homosexuality from the DSM, as the psychiatrist Jack Drescher documents in Behavioral Sciences. Drescher calls gay activism “the most significant catalyst” for the change. Robert Spitzer, who chaired the relevant subcommittee, concluded that most disorders involve distress or impaired functioning and that homosexuality as such met neither standard. A replacement category for people distressed by their orientation lived on as “Ego Dystonic Homosexuality” in DSM-III until DSM-III-R dropped it in 1987. The episode supports Szasz’s warning that diagnoses can encode moral disapproval, and the repair came from outside pressure plus a sharper definition of disorder, inside psychiatry.

Saving Normal: The Insider Who Warned About Diagnostic Inflation

Diagnostic inflation is the worry that each revision of the diagnostic manual widens the boundary of disorder until ordinary distress is treated as illness, and its critics in the 2010s included the psychiatrist who had edited the previous edition.

Allen Frances, the former editor of DSM-IV, warned, as Paul Kudlow reported in the Canadian Medical Association Journal in January 2013, that most of its changes rested on “limited data” and that “the new DSM is going to make it much easier” to receive a diagnosis. He pointed to the new disruptive mood dysregulation disorder, which the CMAJ article glosses as “essentially, temper tantrums”, and said DSM-III had “sacrificed validity in some instances for agreement.” In the same CMAJ article, Dr Roger McIntyre criticised the removal of the bereavement exclusion for major depression, which he said left people in mourning “at risk for being called mentally ill.” Frances expanded the argument into a book, Saving Normal: An Insider’s Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life (William Morrow, 2013).

The APA did not accept the charge. Its then president, Dilip Jeste, pointed to a decade of work by more than 1,500 experts, and the DSM-5 Task Force chair David Kupfer was quoted saying, “We have sought to be conservative in our approach” to revising the manual. Frances’s objections, as CMAJ reports them, are about people wrongly labelled, which presupposes that other people are rightly labelled, the very thing Szasz denied. Our post on the “define normal” meme looks at how the American and international manuals draw those lines, and how a changed definition made a diagnosis disappear.

Sadder but Wiser? What Became of Depressive Realism

Depressive realism is the hypothesis that mildly depressed people judge their control over events more accurately than non-depressed people, and four decades of research have left it weak and contested.

In the original 1979 study, as Dev and colleagues describe it in a 2022 replication, students pressed a button and estimated how much control they had over whether a light came on. The theory that grew from it holds, in Dev and colleagues’ summary, that depressed people are less prone to optimistic bias “and are thus more realistic”. Dev’s team notes that the original sample was subclinical undergraduates and the effect was reported only among women. Moore and Fresco’s 2012 meta-analysis pooled 75 studies with 7,305 participants and found a small overall effect (Cohen’s d of minus 0.07). Both groups showed a positive bias, larger in the non-depressed, and the effect was larger in studies with no objective standard of reality and in those using self-report questionnaires.

Dev, Moore (a different Moore), Johnson and Garrett then ran a pre-registered test in Collabra: Psychology with 246 online participants and 134 undergraduates, using the classic contingency task plus an overconfidence task. They found “no evidence that depressive symptoms relate to illusory control or to overconfidence”; in one sample, more depressive symptoms went with more overestimation of control, the opposite of the hypothesis. Their conclusion: “depressive realism is not replicable.” At its strongest, the effect concerned a light bulb in a lab. Reading it as proof that depression grants deeper insight stretches a narrow task into a large claim and turns a painful illness into a badge of lucidity.

Ataraxia Is Not a Diagnosis: What Philosophy Can Add

Philosophy is most useful to psychiatry in the conceptual work of saying what counts as a disorder; ancient ideals make poor evidence that diagnoses are arbitrary.

One tempting argument says the calm of the ancient sage would earn a diagnosis today. The ancient texts describe something else. Ataraxia, tranquillity, is the Epicurean goal according to the Internet Encyclopedia of Philosophy, and for Sextus Empiricus, in the SEP’s summary, “the skeptic’s end (telos) is tranquility in matters of belief”. The Stoic ideal was a different thing, apatheia, freedom from the passions, and the SEP entry on Stoicism notes that the sage’s “good feelings” (eupatheiai) belie “the caricature of the Sage as an unfeeling robot”. None of these ideals describes emotional numbness, which is what the comparison with modern diagnoses would need.

Nietzsche gave the old idea of the philosopher as physician a cultural scale. In the preface to the second edition of The Gay Science, he wrote that he was waiting for “a philosophical physician, in the exceptional sense of the word” (Thomas Common’s translation), one who would study the collective health of whole peoples and periods. The Greeks had a word for the ambivalence of treatment: pharmakon, the root of “pharmacy”, meant “a drug, a poison, philter, charm, spell, enchantment” according to Etymonline.

Our post on philosophy in psychotherapy shows where philosophical ideas made it into actual treatment, from the Stoic roots of CBT to Frankl’s logotherapy. Arguments about where the manual draws its lines are worth having, and none of them has to be settled before anyone who is struggling right now gets help. If that is you, a doctor or therapist is the place to start, and findahelpline.com lists free, confidential support services by country.

For a structural look at how distress gets managed at work rather than examined, read our post on Byung-Chul Han, the burnout society and corporate mindfulness.