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European Association of Psychoanalysis |
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European Association of Psychoanalysis |
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Coercion as Cure: a critical History of Psychiatry
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
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 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 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.
Thomas Szasz
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