In my previous column (November 1999), I showed that mental illness is not a disease because it does not meet the scientific criterion of disease. In this column I will show that the primary purpose of psychiatry is not medical-therapeutic because its historical mandate and primary purpose is not to remedy a patient’s diseases but to soothe society’s conscience about its attitude toward unwanted persons.
In large part because of Freud’s influence, people now view psychiatry as a medical specialty devoted to helping persons suffering from mental illnesses. This is an error. Before psychiatry was called “psychiatry,” it was called “mad-doctoring” and its aim was to protect society from dangerous and troublesome madmen and madwomen. Today, psychiatrists perform two mutually antagonistic functions: they help society (involuntary psychiatry) and they help patients (voluntary psychiatry). However, these functions are typically confused and intermingled, with the result that helping society even if doing so harms the patient is also defined as a “treatment.” The situation was much clearer a hundred years ago.
Sex was a hot subject in fin-de-siècle Europe and perhaps nowhere else more so than in Vienna. Contrary to popular knowledge, the most famous expert on sex in those days was not Sigmund Freud, but Richard von Krafft-Ebing (1840-1902), whose enduring fame rests on his book Psychopathia Sexualis, first published in 1886. This work went through numerous editions in German and became an international best seller. Especially in retrospect, it is obvious why this book became so vastly popular: It was the first modern pornographic tract successfully merchandised as medical science, a feat accomplished largely by larding the text with Latin words. Given that in those days most educated people had a working knowledge of Latin, this must have made the book all the more titillating. There is indirect evidence for this assumption: In the Preface to the Twelfth Edition of Psychopathia Sexualis, Krafft-Ebing explained: “The number of technical terms has been increased, and the Latin language is more frequently made use of than in the former editions.” The medical mask succeeded in transforming the voyeurism to which Krafft-Ebing was pandering from sexual perversion into scientific compassion.
The technique worked like a charm. The public continued to devour this nonpictorial precursor to Playboy. This was not surprising. For the first time in history, Psychopathia Sexualis offered people a catalogue of the countless ways—other than the missionary position in heterosexual intercourse in which human beings could extract sexual pleasure from their bodies. Prior to the publication of Psychopathia Sexualis, abnormal sexual acts were, literally, “unspeakable abominations,” shoved under the carpet of human consciousness as bestial, unnatural, and sinful, and of course criminal as well. This meant that the law, and hence society, could not turn its back on what were then in a telling conflation of sin and sickness called “perversions.”
I can here provide the reader only with a small sample of the wares offered in this 617-page tome. Masturbation was, of course, high on Krafft-Ebing’s list of perversions, as it was also on Freud’s. He declared: “Nothing is so prone to contaminate under certain circumstances, even to exhaust the source of all noble and ideal sentiments, which arise of themselves from normally developing sexual instinct, as the practice of masturbation in early years.” Homosexuality also came in for its share of attention.
And so it went, offering the reader a manual on how to perform perversions, acts that, for the most part, have since been “discovered’‘ to be basic human rights.
The Method in Mad-Doctoring
Shakespeare said there is “method in madness.” He meant that madness say, such as Lady Macbeth’s had meaning and purpose, attributes we cannot attach to a disease, such as gout. There was method in mad-doctoring as well, and Krafft-Ebing told us what it is. “The object of this treatise [Psychopathia Sexualis],” he wrote in the Preface to the First Edition, “is merely to record the various psychopathological manifestations of sexual life in man and to reduce them to their lawful conditions.” Krafft-Ebing did not record “psychopathological manifestations”; he named certain forbidden behaviors “psychopathological manifestations.”
Why did he do so? He told us: “The medical barrister only then finds out how sad the lack of our knowledge is in the domain of sexuality when he is called upon to express an opinion as to the responsibility of the accused whose life, liberty, and honor are at stake” (emphasis added). Krafft-Ebing identified his role as that of medical barrister. He did not pretend to make a bona fide diagnosis, much less claim to treat a patient.
But if an act is defined as a crime, and if a person commits that act, is caught, and is brought to trial for it, what is or ought to be the role of a physician in the adjudication of that person’s guilt or innocence? Obviously, the answer hinges on whether the act is perceived and defined as caused, partly or wholly, by a disease from which the defendant suffers. If the act is viewed as having nothing to do with disease—and there are few acts still so viewed today, but bank robbery will do as an example then, clearly, doctors have no rational role in the trial. On the other hand, if the act is viewed as being a direct manifestation or “product” of a disease—the “meaningless” violence of a “diagnosed schizophrenic” is an example then, as we now see it, doctors have a decisive role to play in the trial. One of the main architects of this modern ostensibly scientific, but actually pseudoscientific perception was Krafft-Ebing. He declared: “It is the sad privilege of medicine, and especially of psychiatry, to ever witness the weaknesses of human nature and reverse side of life. The physician finds, perhaps, a (satisfaction) solace in the fact that he may at times refer those manifestations which offend against our ethical or aesthetical principles to a diseased condition of the mind or the body. He can save the honor of humanity in the forum of morality, and the honor of the individual before the judge and his fellow-men. It is from the search of truth that the exalted duties and rights of medical science emanate” (emphasis added).
Res ipsa loquitur. The thing speaks for itself. Krafft-Ebing candidly acknowledged that the basic aim of institutional psychiatry is moral and legal, not medical or therapeutic. I claim no originality for this opinion, only the courage to express it in America at the dawn of the 21st century. Karl Kraus (1874- 1936), the famed Viennese satirist, said it all: “The donkeys [psychiatrists] are led in, see through the accused, and say yeah just as the prosecutor wants them to. However, inasmuch as psychiatrists call their task… ‘disposition of difficult cases,’ they do not consider themselves stupid asses. Thus, they invite comparison with a more intelligent species of domestic animal: Our loyal psychiatrists are rather like good dogs—they protect house and yard.”