Coercion as Cure

A Critical History of Psychiatry

Frank Villafana, Thomas Szasz

• Publisher: Routledge
• Year: 2017
• Print ISBN: 9781412810500
• eBook ISBN: 9781351527767
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

Understanding the history of psychiatry requires an accurate view of its function and purpose. In this provocative new study, Szasz challenges conventional beliefs about psychiatry. He asserts that, in fact, psychiatrists are not concerned with the diagnosis and treatment of bona fide illnesses. Psychiatric tradition, social expectation, and the law make it clear that coercion is the profession's determining characteristic.

Psychiatrists may "diagnose" or "treat" people without their consent or even against their clearly expressed wishes, and these involuntary psychiatric interventions are as different as are sexual relations between consenting adults and the sexual violence we call "rape." But the point is not merely the difference between coerced and consensual psychiatry, 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 coercive character of psychiatry was more apparent in the past than it is now. Then, insanity was synonymous with unfitness for liberty. Toward the end of the nineteenth century, a new type of psychiatric relationship developed, when people experiencing so-called "nervous symptoms," sought help. This led to a distinction between two kinds of mental diseases: neuroses and psychoses. Persons who complained about 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. Coercion as Cure is the most important book by Szasz since his landmark The Myth of Mental Illness.

1
Mental Hospitalization: Therapeutic Imprisonment

Every confinement of the person is an “imprisonment,” whether it be in a common prison, or in a private house, or in the stocks, or even by forcibly detaining one in the public streets.

—Black’s Law Dictionary¹

1

Although psychiatric illness is a fiction, psychiatric coercion is not. In this chapter, I examine how this practice came into being and offer some remarks about its present status.

Incarcerating people is what psychiatrists do. This is why mental illness is rightly considered a stigmatizing term and stigmatized condition, and psychiatry rightly considered a stigmatizing and stigmatized profession. Tennessee Williams was well aware of this when he wrote, “Confinement [in a mental hospital] has always been the greatest dread of my life.”²

Consensual relations—religious, psychiatric, sexual—pose no special moral or political problems. Coercive relations do. We recognize this with respect to religious and sexual coercion, but not with respect to psychiatric coercion. American law prohibits involuntary religious practices and protects voluntary religious worship. In contrast, American law forcibly compels persons to submit to psychiatric practices and does not protect voluntary psychiatric relations. This development is emblematic of the transformation of traditional theological societies into modern therapeutic states.

For millennia, religious affiliations, beliefs, and practices were forcibly imposed on people and they, in turn, generally accepted this arrangement as the natural order of things. In many parts of the world, this is still the case. Children still “inherit” the religious status of their parents. It requires deliberate effort on the part of an adult to reject the religious affiliation ascribed to him by birth, and his effort is more likely to fail than succeed.

In the modern world, psychiatric identities (“diagnoses”) and psychiatric interventions (“treatments”) are routinely imposed on millions of persons, and they, in turn, often accept this arrangement without protest. It requires great effort on the part of a “diagnosed mental patient” to reject the psychiatric affiliation ascribed to him, and his effort is more likely to fail than succeed.

Despite these seemingly self-evident caveats, psychiatrists and writers on the history of psychiatry refuse to distinguish between voluntary and involuntary psychiatry, as if doing so were a kind of heresy. In fact, it is heresy: a violation of the taboo against rejecting the analogy between bodily illness and mental illness. By definition, there are no mental illnesses the presence of which can be detected by objective methods such as those used in the detection of microbial diseases. If there were such methods, the conditions would not be called or considered mental illnesses and could not be treated against the patient’s will.³

A person infected with a microbial disease responsive to appropriate antibiotic treatment can be cured of his illness regardless of whether he voluntarily submits to treatment or is forcibly injected with the therapeutic agent. If we accept that mental illness is that kind of disease and if we also accept that mental patients, like infants, have no insight into their needs, then the forcible treatment of mental patients becomes just as beneficial and permissible as is the forcible treatment of sick infants.⁴ Virtually all psychiatric historiography reflects blind adherence to this pediatric model of mental health care. The professionally correct approach to psychiatry does not merely fail to distinguish between voluntary and involuntary interventions, it refuses to acknowledge the difference between them.⁵

This refusal pervades the writings of the experts on modern psychiatric ethics. Paul R. McHugh, long-time professor and chairman of the Department of Psychiatry at the Johns Hopkins University Medical School, simply denies that psychiatrists deprive their hospitalized patients of liberty. He cites my book, Schizophrenia: The Sacred Symbol of Psychiatry, in which I write, “In other words, the identity of an individual with schizophrenia depends on the existence of the social system of [institutional] psychiatry,” and he continues: “The only reply to such commentary is to know the patients for what they are—in schizophrenia, people disabled by delusions, hallucinations, and disruptions of thinking capacities—and to reject an approach that would ... deny them their frequent need for hospital care.”⁶ McHugh, a prominent figure in American medical and psychiatric ethics, speaks of knowing mental patients for what they are, not for who they are, and describes the desire of relatives and psychiatrists to imprison them as the denominated patients’ “need” for hospital care.

Sidney Bloch, professor of psychiatry at the University of Melbourne, Australia, and another prominent psychiatric ethicist, writes: “Ethical concerns about the psychiatrist’s role and function have dogged the profession for at least three centuries. Moral harms have emerged from the misuse of asylum as a ‘custodial warehouse,’ misunderstanding of the transference relationship, the gruesome effects of physical treatments such as leucotomy [lobotomy] and insulin coma.”⁷ Lobotomy causes physical harms, not just moral harms. Note Bloch’s silence about the neurological damage caused by ECT and psychotropic drugs, and his bracketing of involuntary psychiatric interventions with voluntary psychiatric relationships. He lists, as if they were the same kinds of harms, the physical and civil liberties injuries inflicted on mental patients by incarceration, coerced lobotomy and insulin shock on the one hand, and the harm the patient suffers as a result of “misunderstanding of the transference relationship,” on the other hand. This is to equate rape with marital misunderstanding, violent crime with inevitable contingency.

2

In his classic, The Mentally Ill in America: A History of Their Care and Treatment from Colonial Times, journalist and psychiatric historian Albert Deutsch (1905-1961) declares, “It is safe to assume that mental disease has always existed among mankind.”⁸ Gregory Zilboorg, author of the standard History of Medical Psychology, begins the story of psychiatry with remarks about tuberculosis in the Stone Age, as if mental illnesses were similar to infectious diseases. Yet, even he acknowledges that “until the very end of the eighteenth century there were no real hospitals for the mentally sick.... Bedlam and Bicêtre were no more hospitals than a trench on a battlefield is a retreat and shelter of safety.”⁹ Franz Alexander and Sheldon Selesnick subtitle their History of Psychiatry: An Evaluation of Psychiatric Thought and Practice from Prehistoric Times to the Present, glibly pretending that there was, in ancient times, such a thing as “psychiatric thought and practice.”¹⁰ The truth is that the idea of mental illness and the incarceration of the mentally ill are recent historical phenomena. Nevertheless, psychiatrists maintain, and historians of psychiatry assume, that mental illnesses have existed at all times and in all cultures, but that people called them by different names, for example madness or possession. This is a facile and self-serving view, which, for reasons I have set forth in detail elsewhere, I reject.¹¹ Suffice it to say that people exhibiting odd and offensive behaviors have, of course, always existed. But the idea that such behaviors are the symptoms of medical, that is, “mental,” illnesses is a modern idea, inseparably connected with the practice of incarcerating or otherwise coercing the persons exhibiting them. The only analogous medical practice is the segregation of individuals with contagious diseases, intended to protect the healthy members of society, not cure the patients.¹²

Historian Edward Shorter begins his History of Psychiatry by correctly stating, “Before the end of the eighteenth century, there was no such thing as psychiatry.”¹³ Mutatis mutandis, there was also no such thing as mental illness. This view Shorter emphatically rejects. Instead, he proclaims his belief in the existence of psychiatric illness as a disease entity outside of culture and history: “Having a partly biological and genetic basis, psychiatric illness is as old as the human condition.... It follows then that human society has always known psychiatric illness, and has always had ways of coping with it.”¹⁴ Shorter doesn’t say what psychiatric illness is, or which part is “biological and genetic,” and how he knows that.

David J. Rothman, professor of social medicine at Columbia University College of Physicians and Surgeons, is one of the rare historians of psychiatry sensitive to the role of coercion in so-called psychiatric hospital treatment. He notes that in the asylums one of the problems was “violence between patients, with staffs either too small or too uninterested to interfere,”¹⁵ and cogently criticizes Clifford Beers’s famous psychiatric autobiography, A Mind That Found Itself (1908).¹⁶ Although Beers (1876-1943) felt abused during the three years he spent incarcerated in a mental hospital, he became a zealous mental health crusader and a founder of the American mental hygiene movement. Comparing mental illness to typhoid fever, Beers declared: “Most insane persons are better off in an institution than out of one.... I have criticized with considerable, yet merited, severity, our State Hospitals for the Insane. Nevertheless, these two hundred and odd hospitals, erected at a cost to the Nation of over one hundred millions of dollars, constitute the nucleus of what will, in time—if rightly managed—become the most perfect hospital system in the world.”¹⁷

Skeptically, Rothman juxtaposes Beers’s enthusiasm with the candid remark of an anonymous state mental hospital superintendent in 1920: “Is it not a confession of weakness to commit an act of grand larceny by assuming a name which we have not earned and thus take a short cut to popular favor? There is nothing to gain by masquerading in borrowed plumage.”¹⁸ Citing a Massachusetts asylum superintendent’s boast about the hospital’s “various industries and kinds of employment...[in] the daily routine work of the hospital, the farm, kitchen, laundry, stable, engineer’s department, domestic work of all kind, etc., in all of which patients take an active part,” Rothman disdainfully comments: “It remains very doubtful that inmate labor was more a mode of therapy than of institutional peonage, more a matter of treatment than of exploitation.... In hospital economy employment established a blessed circle: work is good for the patient and the patient is good for work.”¹⁹ Rothman flirts with the idea that the whole business of defining psychiatric coercion as medical treatment may be a hoax, but stops short of reaching that conclusion:

[T]o confuse menial labor with therapy indicates just how crude the state of treatment was.... It may well be, with all the advantages that hindsight allows, that reformers made a fateful mistake in helping to justify a custodial role for the state hospitals.... As the performance of the state hospitals over these decades makes amply clear, institutional survival, not patient welfare, was the ultimate consideration.”²⁰

Having said this, I must add that Rothman’s psychiatric historiography displays many of the same flaws as do those that I have surveyed, plus one: he overemphasizes the similarities among the juvenile justice system, the criminal justice system, and the mental health system. To be sure, there are some similarities. However, no one believes that children who fall into the net of the juvenile justice system or adults into the net of the criminal justice system suffer, ipso facto, from brain diseases and need psychiatric treatment for their brain-mind disorder, whereas this is what psychiatrists now preach, and most people now believe, about persons who fall into the net of the mental health system. The so-called medical model of mental illness—there is no other model of it, nor can there be—requires either regarding the mental health system as fundamentally different from the criminal justice system or rejecting mental illness as a misleading metaphor. Rothman does neither. Instead, he protects himself from being branded as an “antipsychiatrist” by assuming the stance of a psychiatric apologist: “However disappointing the outcome of Progressive [sic] efforts, the analysis here is far more favorable to the prospects of constructive change within the systems of criminal justice and mental health care than might be at fi rst imagined.”²¹ Rothman does not say what a system of psychiatric coercions reformed by the “constructive changes” to which he alludes would look like. In the Foreword to the revised edition of Rothman’s Conscience and Convenience, Thomas G. Blomberg, professor of criminology at Florida State University, writes: “In communicating the story of these progressive reforms, Rothman reveals an unbroken pattern of good intentions leading to bad consequences.”²²

3

Samuel Johnson’s remark, “Hell is paved with good intentions,” has become a cliché. Nevertheless, we accept every new psychiatric brutality called “reform” as if we had never been warned. But we have been warned, time and again, as for example by Daniel Webster: “Good intentions will always be pleaded for every assumption of authority. It is hardly too strong to say that the Constitution was made to guard the people against the dangers of good intentions.”²³ With his customary acuity, Gilbert K. Chesterton (1874-1936) observed: “The business of Progressives is to go on making mistakes. The business of Conservatives is to prevent mistakes from being corrected.”²⁴

The terms “reform” and “progressive” prejudge the phenomena to be explained and preempt debate. “Progressive reform,” a pleonasm, accomplishes this even more effectively. Not surprisingly, persons who propose new social policies invariably call them “reforms” and “progressive.” The truth is that liberals and conservatives, Democrats and Republicans, have outdone one another in their vigor in waging the war on mental illness. This has not prevented some experts on mental health policy from casting conservatives as psychiatric slave holders, and liberals as psychiatric abolitionists. In Back to the Asylum (1992), John Q. La Fond and Mary L. Durham—one a law professor, the other a medical sociologist—write:

There has recently been a clear pendulum swing in how society perceives and treats the mentally ill. From about 1960 to about 1980—a period we will call the Liberal Era—law and mental health policy strongly emphasized fairness to mentally ill offenders...and permitted most other mentally ill individuals to live in the community, largely free of government interference. From about 1980 on—a period we will call the Neoconservative Era—there has been a noticeable reversal in these policies. ...there was growing pressure to return the mentally ill to the “asylum” of prisons and mental hospitals, a trend that continues to this day.... The Liberal Era toleration of personal differences and protection of individual rights gave way in the 1980s.… Tolerance for those who were different or dangerous evaporated almost overnight.²⁵

This is a wholly imaginary story. For two centuries—ever since Pinel’s iconic striking off the chains of lunatics—persons incarcerated by psychiatrists have been the beneficiaries of one well-intentioned reform after another, each leaving them worse off than bef...

Table of contents

• Cover Page
• Half Title
• Title Page
• Copyright
• Dedication
• Contents
• Preface
• Introduction: Force and Freedom
• 1. Mental Hospitalization: Therapeutic Imprisonment
• 2. Shock and Commotion: Terror Therapy
• 3. Moral Treatment: Renaming Coercion
• 4. Dauerschlaf: Requiescant in Pace
• 5. Iatrogenic Epilepsy: And Other Electrical Therapeutic Miracles
• 6. Lobotomy: Cerebral Spaying
• 7. Psychopharmacology I: Psychiatric Drugs
• 8. Psychopharmacology II: Psychedelic Drugs
• Conclusion: Psychiatry—A House United
• Notes
• Bibliography
• Acknowledgments
• Index