COERCION AS CURE: A CRITICAL HISTORY OF PSYCHIATRY

By Thomas Szasz All modern history, as learnt and taught and accepted, is purely conventional. For sufficient reasons, all persons in authority combined, by a happy union of deceit and concealment, to promote falsehood.

          Lord Acton (1834 - 1902)

For more than a century, leading psychiatrists have maintained that psychiatry is hard to define because its scope is so broad. In 1886, Emil Kraepelin, considered the greatest psychiatrist of his age, declared: “Our science has not arrived at a consensus on even its most fundamental principles, let alone on appropriate ends or even on the means to those ends.”

  Contrary to such assertions, I maintain that it is easy to define psychiatry. The  Dr. Thomas Szasz     problem is that defining it truthfully — acknowledging its self-evident ends and the                                  means used to achieve them — is socially unacceptable and professionally suicidal. Psychiatric tradition, social expectation, and the law — both criminal and civil — identify coercion as the profession’s determining characteristic. Accordingly, I regard psychiatry as the theory and practice of coercion, rationalized as the diagnosis of mental illness and justified as medical treatment aimed at protecting the patient from himself and society from the patient. The history of psychiatry I present thus resembles, say, a critical history of missionary Christianity.

  The heathen savage does not suffer from lack of insight into the divinity of Jesus, does not lack theological help, and does not seek the services of missionaries. Just so, the psychotic does not suffer from lack of insight into being mentally ill, does not lack psychiatric treatment, and does not seek the services of psychiatrists. This is why the missionary tends to have contempt for the heathen, why the psychiatrist tends to have contempt for the psychotic, and why both conceal their true sentiments behind a facade of caring and compassion. Each meddler believes that he is in possession of the “truth,” each harbors a passionate desire to improve the Other, each feels a deep sense of entitlement to intrude into the life of the Other, and each bitterly resents those who dismiss his precious insights and benevolent interventions as worthless and harmful.

  Non-acknowledgment of the fact that coercion is a characteristic and potentially ever-present element of so-called psychiatric treatments is intrinsic to the standard dictionary definitions of psychiatry. The Unabridged Webster’s defines psychiatry as “A branch of medicine that deals with the science and practice of treating mental, emotional, and behavioral disorders.”

  Plainly, voluntary psychiatric relations differ from involuntary psychiatric interventions the same way as, say, sexual relations between consenting adults differ from the sexual assaults we call “rape.” Sometimes, to be sure, psychiatrists deal with voluntary patients. As I explain and illustrate throughout this volume, it is necessary, however, not merely to distinguish between coerced and consensual psychiatric relations, but to contrast them. The term “psychiatry” ought to be applied to one or the other, but not both. As long as psychiatrists and society refuse to recognize this, there can be no real psychiatric historiography.

  The writings of historians, physicians, journalists, and others addressing the history of psychiatry rest on three erroneous premises: that so-called mental diseases exist, that they are diseases of the brain, and that the incarceration of “dangerous” mental patients is medically rational and morally just. The problems so created are then compounded by failure — purposeful or inadvertent — to distinguish between two radically different kinds of psychiatric practices, consensual and coerced, voluntarily sought and forcibly imposed.

  In free societies, ordinary social relations between adults are consensual. Such relations — in business, medicine, religion, and psychiatry — pose no special legal or political problems. By contrast, coercive relations — one person authorized by the state to forcibly compel another person to do or abstain from actions of his choice — are inherently political in nature  and are always morally problematic.

  Mental disease is fictitious disease. Psychiatric diagnosis is disguised disdain.  Psychiatric treatment is coercion concealed as care, typically carried out in prisons called “hospitals.” Formerly, the social function of psychiatry was more apparent than it is now. The asylum inmate was incarcerated against his will. Insanity was synonymous with unfitness for liberty. Toward the end of the nineteenth century, a new type of psychiatric relationship entered the medical scene: persons experiencing so-called “nervous symptoms” began to seek medical help, typically from the family physician or a specialist in “nervous disorders.” This led psychiatrists to distinguish between two kinds of mental diseases, neuroses and psychoses: Persons who complained of their own behavior were classified as neurotic, whereas persons about whose behavior others complained were classified as psychotic. The legal, medical, psychiatric, and social denial of this simple distinction and its far-reaching implications undergirds the house of cards that is modern psychiatry.

  The American Psychiatric Association, founded in 1844, was first called the Association of Medical Superintendents of American Institutions for the Insane. In 1892, it was renamed the American Medico-Psychological Association, and in 1921, the American Psychiatric Association (APA). In its first official resolution, the Association declared: “Resolved, that it is the unanimous sense of this convention that the attempt to abandon entirely the use of all means of personal restraint is not sanctioned by the true interests of the insane.” The APA has never rejected its commitment to the twin claims that insanity is a medical illness and that coercion is care and cure. In 2005, Steven S. Sharfstein, president of the APA, reiterated his and his profession’s commitment to coercion. Lamenting “our [the psychiatrists’] reluctance to use caring, coercive approaches,” he declared: ” A person suffering from paranoid schizophrenia with a history of multiple rehospitalizations for dangerousness and a reluctance to abide by outpatient treatment, including medications, is a perfect example of someone who would benefit from these [forcibly imposed] approaches. We must balance individual rights and freedom with policies aimed at caring coercion.” Seven months later, Sharfstein conveniently forgot having recently bracketed caring and coercion into a single act, “caring coercion.” Defending “assisted treatment”–a euphemism for psychiatric coercion– he stated: “In assisted treatment, such as Kendra’s Law in New York, psychiatrists’ primary role is to foster patient improvement and help restore the patient to health.” 

Psychiatry and society face a paradox. The more progress scientific psychiatry is said to make, the more intolerable becomes the idea that mental illness is a myth and that the effort to treat it a will-o’-the-wisp. The more progress scientific medicine actually makes, the more undeniable it becomes that “chemical imbalances” and “hard wiring” are fashionable clichés, not evidence that problems in living are medical  diseases justifiably “treated” without patient consent. And the more often psychiatrists play the roles of juries, judges, and prison guards, the more uncomfortable they feel about being in fact pseudomedical coercers — society’s well-paid patsies. The whole conundrum is too horrible to face. Better to continue calling unwanted behaviors “diseases” and disturbing persons “sick,” and compel them to submit to psychiatric “care.” It is easy to see, then, why the right-thinking person considers it inconceivable that there might be no such thing as mental health or mental illness. Where would that leave the history of psychiatry portrayed as the drama of heroic physicians combating horrible diseases?

  Alexander Solzhenitsyn is right: “Violence can only be concealed by a lie, and the lie can only be maintained by violence. Any man who has once proclaimed violence as his method is inevitably forced to take the lie as his principle.”

  Scientific discourse is predicated on intellectual honesty. Psychiatric discourse rests on intellectual dishonesty. The psychiatrist’s basic social mandate is the coercive-paternalistic protection of the mental patient from himself and the public from the mental patient. Yet, in the professional literature as well as the popular media, this is the least noted feature of psychiatry as a medical specialty. Pointing it out is considered to be in bad taste. It would be difficult to exaggerate the extent to which historians of psychiatry as well as mental health professionals and journalists ignore, deny, and rationalize the involuntary, coerced, forcibly imposed nature of psychiatric treatments. This denial is rooted in language.  Psychiatrists, lawyers, journalists, and medical ethicists routinely call incarceration in a psychiatric prison “hospitalization,” and torture forcibly imposed on the inmate “treatment.” Resting their reasoning on the same faulty premises, psychiatric historians trace alleged advances in the diagnosis and treatment of mental illnesses to “progress in neuroscience.” In contrast, I focus on what psychiatrists have done to persons who have rejected their “help” and on how they have rationalized their “therapeutic” violations of the dignity and liberty of their ostensible beneficiaries.

  I regard consensual human relations, however misguided by either or both parties, as radically different, morally as well as politically, from human relations in which one party, empowered by the state, deprives another of liberty. The history of medicine, no less than the history of psychiatry, abounds in interventions by physicians that have harmed rather than helped their patients. Bloodletting is the most obvious example. Nevertheless, physicians have, at least until now, abstained from using state-sanctioned force to systematically impose injurious treatments on medically ill people. Misguided by fashion and lack of knowledge, sick people have often sought and willingly submitted to such interventions. In contrast, the history of psychiatry is, au fond, the story of the forcible imposition of injurious “medical” interventions on persons called “mental patients.”

  In short, where psychiatric historians see stories about terrible illnesses and heroic treatments, I see stories about people marching to the beats of different drummers or perhaps failing to march at all, and terrible injustices committed against them, rationalized by hollow “therapeutic” justifications. Faced with vexing personal problems, the “truth” people crave is a simple, fashionable falsehood. That is an important, albeit bitter, lesson the history of psychiatry teaches us.

  One of the melancholy truths of the story I have set out to tell is that, stripped of its pseudomedical ornamentation, it is not a particularly interesting tale. To make it interesting, I have tried to do what, according to Walt Whitman (1819-1892), the “greatest poet “does: He “drags the dead out of their coffins and stands them again on their feet … He says to the past, Rise and walk before me that I may realize you.” To this end, I have, where possible, cited the exact words psychiatrists have used to justify their stubborn insistence, over a period of nearly three centuries, that psychiatric coercion is medical care.

On Dr. Szasz And Coercive Psychiatry

Pseudoscience, Psychiatry, BAB's A List

By Leonard Roy Frank

Thank you, Ilana Mercer, for performing a valuable public service by publishing Thomas Szasz’s extraordinary essay, “Coercion as Cure”! For 50 years now Dr. Szasz has courageously challenged the ideology and practice of coercive psychiatry. In the revised edition (1974) of his landmark work “The Myth of Mental Illness” (1961), he stated some of the major principles underlying his critique. They are worth repeating here:

  -“Disease or illness can affect only the body; hence, there can be no mental illness.

  -‘Mental illness’ is a metaphor. Minds can be ‘sick’ only in the sense that jokes      Leonard Frank      are ‘sick’ or economics are ‘sick.’

  -Psychiatric diagnoses are stigmatizing labels, phrased to resemble medical diagnoses and applied to persons whose behavior annoys or offends others….

  -If there is no mental illness there can be no hospitalization, treatment, or cure for it….

  The introduction of psychiatric considerations into the administration of the criminal law—for example, the insanity plea and verdict, diagnoses of mental incompetence to stand trial, and so forth—corrupt the law and victimize the subject on whose behalf they are ostensibly employed….

  There is no medical, moral, or legal justification for involuntary psychiatric interventions. They are crimes against humanity.”

   That the psychiatric profession and society at large have mostly ignored Dr. Szasz’s critique helps explain the deplorable state of the current “mental health system.” More and more people are being labeled with psychiatric “diseases” as more and more diagnoses are being conjured up. Philippe Pinel (1745-1826), the “father of modern psychiatry,” had only four categories of what was then called “insanity,” but in 1952 the American Psychiatric Association described about 106 “mental illness” categories in its “Diagnostic and Statistical Manual,” and its 4th edition published in 1994 had 374 such categories.

   As was true on a smaller scale in Pinel’s time, psychiatric violence, coercion and deception are today standard operating procedures: e.g., “mental patients” who refuse psychiatry’s powerful drugs, called “medications,” are held down and forcibly injected. These drugs, especially in large doses, are frightening in their effect but the bottom line is that sooner or later they make the individual feel mentally, emotionally and physically wasted. Moreover, the longer the drugs are taken, the more likely they are to cause permanent brain damage and other, sometimes life-threatening and life-shortening, medical problems. And even when consented to, the consent is likely to be fraudulent because psychiatrists seldom supply accurate and full information about the risks involved in taking these drugs.

  In addition to the many millions of adults being subjected to this kind of abuse, psychiatrists and other physicians, in a practice almost unheard of a generation ago, are “prescribing” a variety of psychiatric drugs to an estimated 5-10 million children and adolescents. The drugs will cause many of these youngsters to become habitual psychiatric- and street-drug users and eventually “chronic mental patients.”

   There has also been a resurgence in the use of electroshock (electroconvulsive treatment, ECT). Since 1940 more than 6 million people in this country alone have undergone this brainwashing, brain-damaging, and memory-destroying procedure. Even today, more than 100,000 Americans are being electroshocked every year.

   Coercive psychiatry may be defined as the use of psychiatric methods by means of outright force and intimidation or in the absence of genuine informed consent to “treat” non-existent “diseases,” diseases for which there are no proven physical markers.

   There is no way to calculate the amount of suffering coercive psychiatry has caused and continues to cause those individuals directly affected. Nor is there any way to assess the degree to which coercive psychiatry has undermined and continues to undermine the values and moral standing of every society in which it operates.

   In “The Second Sin” (1973), Dr. Szasz anticipated the coming of “the Therapeutic State” in which “the principal requirement for the position of Big Brother may be an M.D. degree.” In such a state, the prevailing creed of “therapeutism” will justify “proclaiming undying love for those we hate, and inflicting merciless punishment on them in the name of treating them for diseases whose principal symptoms are their refusal to submit to our domination.”

   Two questions need to be asked: 1) How close are we to “the Therapeutic State” which would necessarily result in the loss of our freedom, and 2) What are we, the people, going to do to prevent its establishment?                

—Leonard Roy Frank, Editor, The Random House Webster’s Quotationary