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Friday, October 1, 2004

Psychiatric Services

The Rhetoric of Psychiatry Is Deceptive

The standard political-philosophical justification for the state is the need of the community for protection from criminals at home and enemies abroad. The community is now believed to be threatened by another group as well: the mentally disordered. Liberals and conservatives take for granted that coercing these persons is also the duty of the government.

Psychiatry is usually thought of as a healing art, a type of health-care service. Sometimes it is. However, mostly and most importantly, psychiatry is a type of social control, a legal-medical system of coercion unconstrained by the rule of law.

British psychiatrist John Crammer states the need for psychiatry thus: “The need to restrain the antisocial person leads governments to intervene both administratively and legally with these [mental] disorders.” This is not true. Governments do not “intervene with disorders.” They imprison persons whom psychiatrists identify as proper subjects for such disposition.

Crammer’s rhetoric is characteristic of the modern psychiatrist as loyal agent of the state. First, he denies the ubiquity of psychiatric coercion: “It has not been true for 50 years that patients in mental hospitals are mostly shut up against their will.” Then, he distances contemporary psychiatry from it by characterizing the practice as passé and tries to exonerate the psychiatrists from responsibility for depriving innocent persons of liberty: “Nor till recently did doctors have much to say about what went on in them [mental hospitals]; they were the servants of magistrates or county councillors.” Today, they are creatures and servants of the state more than ever.

There is no war without military action, no operation without surgical action, and no psychiatry without psychiatric action. The paradigmatic psychiatric actions are civil commitment and the insanity defense, each euphemism for depriving persons of liberty. Civil commitment—the paradigm of preventive detention—deprives the innocent individual of liberty directly, on the ground that he is “mentally ill and dangerous to himself or others.” The insanity defense—the paradigm of the diversion of the defendant from the criminal-justice system to the mental health system—deprives the person accused of lawbreaking of liberty indirectly, on the ground that he lacks “criminal responsibility.” Imputing mental unfitness to stand trial to the defendant is a variation on this tactic. Both interventions deprive the subject of the opportunity to assert his right to trial, prove his innocence, or receive a finite prison sentence instead of an indefinite sentence in a mental hospital.

Regarding the injustice intrinsic to preventive detention, British historian Lord Macaulay (Thomas Babington, 1800–1859) observed: “To punish a man because we infer from the nature of some doctrine which he holds, or from the conduct of other persons who hold the same doctrines with him, that he will commit a crime, is persecution, and is, in every case, foolish and wicked.”

Foreign Aid and Psychiatric Aid

There is a good deal of similarity between my critique of mental-health policy and Peter Bauer’s critique of foreign-aid policy. This is not surprising. Each rests on perceiving and defining the “problem” in terms of a “need” for which the needy are not responsible and which they cannot relieve unaided—and a “duty to relieve” it, which is the moral responsibility of the state and its specialized agents.

Much of what Bauer said about foreign aid holds true and applies even more powerfully to psychiatric aid: “To call official wealth transfers ‘aid’ promotes an unquestioning attitude. It disarms criticism, obscures realities, and prejudges results. Who can be against aid to the less fortunate? The term has enabled aid supporters to claim a monopoly of compassion and to dismiss critics as lacking in understanding and compassion.” He defined foreign aid as “an excellent method for transferring money from poor people in rich countries to rich people in poor countries.”

The rhetoric of psychiatric aid is perhaps even more deceptive. We don’t call getting a speeding ticket “receiving police services”; getting audited by the Internal Revenue Service “receiving tax services”; or being indicted for a crime “receiving legal services.” But we call being involuntarily diagnosed as mentally ill and incarcerated in a mental hospital “receiving mental-health services.” Paraphrasing Bauer, we could define psychiatric aid as an excellent method for transferring money from relatively poor taxpayers to relatively rich psychiatrists and other practitioners of psychiatric-psychological disablement.

Bauer scoffed at what he called “the axiomatic case for foreign aid,” that is, “the unanimous opinion of all foreign-aid experts that the total amount of development aid is grossly inadequate for even the minimum needs of the developing countries.” If we replace the phrase “the unanimous opinion of all foreign-aid experts” with “the unanimous opinion of all psychiatric experts,” “the total amount of development aid” with “total amount of public funds spent on psychiatric services,” and “the minimum needs of the developing countries” with “the minimum needs of the mentally ill,” we arrive at the axiomatic case for psychiatric aid. Not surprisingly, every respectable public organization, national and international, supports both foreign aid and psychiatric aid.

Foreign aid, Bauer pointed out, is not a form of assistance given by a donor to recipient; instead, it “is paid by governments to governments,” ostensibly to help the needy. The actual result is that the intermediary—typically, an African despot—uses some of the funds to line his own pockets and the rest to purchase the goods and services necessary to subjugate and terrorize his people.

The situation in the case of publicly funded psychiatric services is similar. The donors are the taxpayers. The recipients are psychiatric institutions and organizations, which use some of the funds to enrich their members and employees, and the rest to purchase the goods and services necessary to subjugate and frighten the denominated and would-be beneficiaries.

Bauer noted that foreign aid is ineffective as an instrument for raising general living standards and promoting long-term economic development in poor countries. The experience of more than 200 years has demonstrated the utter ineffectiveness of public psychiatry in reducing the incidence or severity of the conditions psychiatrists call “mental diseases.”

After decades of neglect, by the end of Bauer’s life, in 2002, his views gained the support of libertarian economists and some conservative politicians. Still, it is important to recognize that the forces he was up against are similar to the forces a critic of psychiatric services is up against, and that these forces continue to gain strength.

  • Dr. Thomas Szasz (1920-2012) was a Psychiatrist, academic, and champion of individual rights. He devoted much of his life to campaigning against many aspects of conventional psychiatry, in particular involuntary psychiatric treatment and commitment.