In the nineteenth century people were ashamed and embarrassed by their mentally ill relatives. This was especially true for parents who had a mentally ill child and for adult children who had a parent incarcerated in an insane asylum. Today, such persons take pride in having a mentally ill "loved one," make a career of speaking and writing about his "illness," and fight for his "right to treatment."
The attitude of journalists, writers, and social commentators toward psychiatry underwent an analogous transformation. In the nineteenth century they were critical of psychiatrists who locked up innocent people in insane asylums and excused criminals as mentally ill. Now they view and admire them as scientifically enlightened, caring doctors.
How and why did this change come about? One impetus for this transformation-which psychiatrists call the "remedicalization of psychiatry"-was the publication, in 1961, of my book The Myth of Mental Illness and Erving Goffman’s book Asylums. Another was the fleeting interest of a few lawyers, stimulated by these books, in freeing mental patients from their psychiatric life sentences. (Sadly, these "civil rights" zealots were more interested in promoting themselves than in protecting liberty and responsibility, and showed no interest in opposing the insanity defense.)
These assaults on psychiatry as a medical specialty and on involuntary mental hospitalization as a species of preventive detention made psychiatrists close ranks and launch a well-organized and highly effective counteroffensive. The psychiatric defense of mental illness as brain disease and of psychiatric deprivation of liberty as medical treatment comprised several mutually reinforcing measures. One was the creation of a group of chemicals dubbed "antipsychotics," a term intended to resonate with the term "antibiotics." These chemical straitjackets were successfully sold to the public and the press-though not to involuntary patients-as "miracle drugs."
The psychiatrists’ second line of defense was equally inspired. State mental hospitals had acquired a bad name. Keeping persons "hospitalized" for years and decades did not conform to the image of how real doctors use hospitals. With wages rising sharply after the 1950s, the cost of such prolonged hospitalization was also becoming burdensome to the states. The solution was to "discharge" the hundreds of thousands of chronic mental patients, attribute their forcible expulsion to the therapeutic effectiveness of "psychiatric miracle drugs," and call the eviction "deinstitutionalization." The enterprise was a fraud from beginning to end. But it looked like the "right thing to do," just as formerly the chronic hospitalization of mental patients looked that way.
Still another important element of remedicalization consisted of sanitizing the psychiatric vocabulary. The classic diagnoses of hysteria, neurosis, and homosexuality were declared to be nondiseases and were quickly forgotten. So-called "severe" mental diseases were authoritatively declared to be "brain diseases," a claim supported by the invention of a new neurochemistry (in fact, a neuromythology) and the popularization of the view that such illnesses are due to "chemical imbalances in the brain."
Significant as these developments were, perhaps the single most important impetus for the change I am describing was the formation of a new social organization and political lobby, the National Alliance for the Mentally Ill, or NAMI.
The NAMI website describes the organization as follows: "NAMI is dedicated to the eradication of mental illnesses and to the improvement of the quality of life of all whose lives are affected by these diseases. . . . Founded in 1979, NAMI has more than 210,000 members who seek equitable services for people with severe mental illnesses, which are known to be physical brain disorders."
The NAMI rhetoric conceals that the organization is composed of, and controlled by, principally the relatives of so-called mentally ill persons and that its main purpose is to justify depriving such persons of liberty in the name of mental health. So convinced is NAMI of the nobility of its cause that its website once offered this scenario:
Sometime, during the course of your loved one’s illness, you may need the police. By preparing now, before you need help, you can make the day you need help go much more smoothly. . . . It is often difficult to get 911 to respond to your calls if you need someone to come & take your MI relation to a hospital emergency room (ER). They may not believe that you really need help. And if they do send the police, the police are often reluctant to take someone for involuntary commitment. That is because cops are concerned about liability. . . . When calling 911, the best way to get quick action is to say, "Violent EDP," or "Suicidal EDP." EDP stands for Emotionally Disturbed Person. This shows the operator that you know what you’re talking about. Describe the danger very specifically. "He’s a danger to himself" is not as good as "This morning my son said he was going to jump off the roof." . . . Also, give past history of violence. This is especially important if the person is not acting up. . . . When the police come, they need compelling evidence that the person is a danger to self or others before they can involuntarily take him or her to the ER for evaluation. . . . Realize that you & the cops are at cross purposes. You want them to take someone to the hospital. They don’t want to do it. . . . Say, "Officer, I understand your reluctance. Let me spell out for you the problems & the danger." . . . While AMI / FAMI is not suggesting you do this, the fact is that some families have learned to "turn over the furniture" before calling the police. Many police require individuals with neurobiological disorders to be imminently dangerous before treating the person against their will. If the police see furniture disturbed they will usually conclude that the person is imminently dangerous.
(This material is no longer posted at the national NAMI site. But it can be found linked from the Athens, Ohio, NAMI site at www.seorf.ohiou.edu/~xx091/911calls.html.)
Giving false information to the police is a felony. Except, it seems, when the falsehood serves the avowed aim of providing mental health treatment for a "loved one."
Am I tilting at windmills? How important is involuntary mental hospitalization in our age of deinstitutionalization, when mental illnesses are said to be brain diseases like Parkinsonism, and forced psychiatric confinement is considered an anachronism? The authoritative text, Mental Health and Law: Research, Policy, and Services, edited by Bruce D. Sales and Saleem A. Shah, published in 1996, states: "Each year in the United States well over one million persons are civilly committed to hospitals for psychiatric treatment."
Quod erat demonstrandum.
Thomas Szasz is professor of psychiatry emeritus at SUNY Upstate Medical University in Syracuse. His latest book is Liberation by Oppression: A Comparative Study of Slavery and Psychiatry (Transaction, 2002).