Psychiatry appears at first to be like any other medical specialty, but on closer examination it deviates significantly from the practice of “normal” medicine, such as orthopedics or urology. Normal physicians are trained in explaining the workings of the body and in what to do if a disease is identified. Psychologists are trained in the study of mental processes and behavior, whereas psychiatrists are trained in mental health and mental disease. Controversy arises over to whom “mental illness” belongs, whether to psychologists or psychiatrists. Economic interest plays no small part in turf wars of this sort: Psychology, psychiatry, and medicine are trade professions, and, like all businesses, the seller seeks to convince consumers to buy his product rather than that of his competitor.
Politically speaking, people supporting state-sanctioned psychiatric practices such as involuntary commitment to mental hospitals and the insanity defense tend to be on the left, favoring a therapeutic (paternalistic) state. Civil libertarians have been at times conspicuously silent regarding these practices, although some have argued that liberty is for mentally competent people only. Psychiatrist Thomas Szasz is the lone exception. As a staunch defender of classical liberalism and a critic of state entanglement with psychiatry, he has consistently held that mental illness is a metaphor and coercive psychiatric practices are inconsistent with libertarian principles and the rule of law. His seminal work, The Myth of Mental Illness (1961), changed the world of psychiatry forever. To this day, people still blame “deinstitutionalization” and “the problem of the homeless mentally ill” on Szasz’s writings (despite the fact that “deinstitutionalization” was implemented for economic reasons, not out of concern for the rights of those labeled “mentally ill”). To the extent that civil libertarians believe in mental illness and support involuntary commitment and the insanity defense, they appear to be guilty of an a priori contradiction when it comes to the liberty of self-ownership and coercive psychiatry: If they truly believed that a person owned his body, then surely they would oppose government efforts to coercively prevent suicide and to incarcerate in mental hospitals those who fail in their attempts to end their lives. The proper role of the state is to protect us from one another. The state has no place protecting a person from himself. Nowhere is this principle truer than with respect to a right to suicide.
Differences between psychiatry and normal medicine include how we define and treat a person labeled as a patient, how diseases are defined and diagnosed, and how psychiatry and the state interact, particularly in terms of whom the psychiatrist serves. Is a psychiatrist his patient’s agent and advocate? Or is a psychiatrist first an agent of the state, feigning patient advocacy, disregarding the sacred medical ethic of primum non nocere by placing the interests of society over those of the patient? In the normal practice of medicine, most people assume that the doctor acts with the patient’s welfare in mind. However, this assumption is not always clear in the case of psychiatry.
The psychiatric relationship can be contractual (i.e., one based on consent and mutual respect between doctor and patient [client]) or institutional (i.e., one based on coercion and paternalism). Contractual psychiatry is like any other medical practice in terms of the doctor–patient relationship. A person chooses to purchase a psychiatrist’s services, the choice is mutual, and the patient as consumer can terminate the relationship at any time. This notion is referred to as “psychiatry between consenting adults.” A person with cancer or severe osteoarthritis can choose not to have chemotherapy or radiation treatment for his cancer or choose not to have a knee replacement. People may try to persuade him to do otherwise, but ultimately his right of refusal must be accepted. In either case, choosing to reject medical advice will likely result in harm to oneself. Although a person may choose to purchase an institutional psychiatrist’s services, there may come a point when the patient cannot terminate the relationship. He is held in treatment against his will because the psychiatrist asserts that he poses a threat to himself or others.
Further, psychiatric and normal medicine differ in several aspects, among them the way diseases are defined, diagnosed, classified, and treated. In psychiatry, behavior is considered a disease. Psychiatric diseases are classified by how much a behavior or symptom deviates from the norm; the duration, intensity, and frequency of mental and emotional discomfort; and behavioral and social maladjustment. Psychiatric disorders are not found in standard textbooks on pathology and cannot be located in a cadaver at autopsy. To differentiate, behavior is something that a person does, whereas disease is something that a person has. Behaviors are the expression of a person’s values. Diseases are value-free; they refer to alteration and destruction of tissue.
Psychiatry is deeply involved with the law, particularly in the courtroom, where a psychiatrist’s expert testimony is often given tremendous latitude. This fact is most obviously true with respect to the insanity defense and involuntary commitment to a mental hospital. Psychiatric opinion regarding insanity bears heavily on how we understand justice, whereas psychiatric opinion regarding involuntary commitment bears heavily on our understanding of liberty. According to Szasz, the theocratic state (i.e., the union of church and state) has metamorphosed into the therapeutic state, the union of medicine and state. Institutional psychiatry functions as legal fiction in court, and the psychiatric examination of a defendant—with or without his consent—is used to circumvent basic constitutional protections regarding due process. Innocent persons are deprived of liberty and guilty persons of justice on the basis of psychiatric notions of mental illness and its legal corollary “insanity.” In addition, any otherwise legally binding contract can be declared invalid based on psychiatric examination and testimony, and a person can be declared incompetent to stand trial and detained in perpetuity although other legal criteria for competency to stand trial are met. Psychiatry’s dependence on its involvement with the law is so extensive that, were psychiatrists to be forbidden to testify in court, the profession would likely cease to exist.
Although in normal medicine a patient is free to refuse medical advice even to his own detriment, this freedom is not allowed when it comes to the opinion of an institutional psychiatrist. Moreover, the courts and others believe that psychiatrists can ascertain whether a person is likely to be a threat to others, although there is no hard scientific evidence to support the idea that we can predict, with an accuracy beyond that expected by chance, who is likely to be dangerous to others and who is not. Thus, a person who is normally regarded as innocent until proven guilty is deprived of liberty without due process of law, and the deprivation of liberty is applied in an arbitrary manner.
Although psychiatrists diagnose behavior as a disease, in normal clinical medicine, based on the sciences of pathology and nosology, diseases are marked by cellular abnormalities, lesions, and changes in physical tissue. These observational characteristics are the gold standard for disease definition as established by German pathologist Rudolf Virchow. In psychiatric medicine, a person is diagnosed with a putative disease based on a patient’s symptoms alone, not signs. In cases of brain disease, there are signs of brain disease, but in cases of mental disease, there are no bodily signs (i.e., no physiological markers). Contrary to a widespread impression, there is no way to tell who is and is not mentally ill by taking pictures of the brain or by drawing blood and assessing levels of neurotransmitters. Because psychiatrists diagnose mental illness on the basis of behavior, and behavior is the expression of a person’s values, the diagnosis of mental illness inevitably involves moral judgments. A person’s values, morality, and ethics have nothing to do with the nature of cancer, and so the diagnosis of cancer has nothing to do with the values of the person discovering or diagnosing cancer.
Ordinarily, treatment for real disease may proceed without a person’s consent only when one of three conditions is met. When a person is literally unconscious, he does not have the capacity to refuse treatment, so medical personnel err in the direction of saving a person’s life by administering medical treatment. Similarly, when a person is literally a child, treatment is coerced because a child does not have the mental capacity to comprehend the consequences of refusing treatment. Finally, treatment may be forced when someone has a contagious disease, but the person is then quarantined and treated to protect others, not to help the diseased person. Institutional psychiatrists modify these three conditions to justify treatment without consent in the following ways. A person who refuses treatment for a mental illness is said to be metaphorically unconscious when he is literally conscious. The symptoms of metaphorical unconsciousness are “lack of insight” into the nature and course of mental illness when a patient disagrees with a psychiatrist’s diagnosis. For example, one symptom of schizophrenia or depression is when the patient denies that he is schizophrenic or depressed. Thus, a person who is mentally ill is treated as if he is a child when he is literally an adult because the metaphorical child is allegedly incapable of being responsible for himself and is thus a danger to himself. Contagious is changed to danger to others.
The crucial factor for psychiatrists in determining mental illness is abnormal behavior. Behavior is considered abnormal when it deviates from the norm and is viewed as unacceptable. In addition, behavior is viewed as abnormal when there is a persistent experience of subjective discomfort beyond that established within a normal range. Everyone feels depressed at one time or another, but depression becomes clinical depression when the experience goes on “too long”—that is, beyond that considered normal. Finally, behavior is considered abnormal when a person has a difficult time adjusting to some major life change, in the sense that his adjustment again deviates significantly from the norm.
Contractual and institutional psychiatry have particular consequences for libertarians for policy in four areas: legal, clinical, public, and social. Depending on how mental illness is defined and explained, consequences for legal policy may vary based on the extent to which legal authorities hold a person responsible for his behavior. If he commits a crime, and the criminal behavior is attributed to mental illness, he may be exculpated or forced into a mental institution, with an indeterminate sentence. If he has committed no crime, but his mental illness is interpreted as posing a threat to himself or others, he may be deprived of his freedom and placed in a mental institution for the rest of his life. With respect to the clinical area, someone may or may not choose to receive treatment depending on whether contractual or institutional psychiatrists are involved. If the psychiatrist believes that the behavior of the person he is treating is not the result of a disease and if a psychological theory offers the most logical explanation for the client’s behavior, he may engage in conversation called psychotherapy. If the psychiatrist believes in a biological explanation for mental illness, the client may receive any number of drugs that change the way neurons communicate with one another, or he may receive electroconvulsive therapy, where electricity is passed through his brain for a few seconds, causing seizures and then short-term memory loss, which may assist in his not being able to remember what was bothering him.
Institutional psychiatry is most likely to flourish in the area of public policy. “Mental health screening” days, sponsored by the federal and state governments, held at public schools and through federally subsidized businesses and organizations help to gather up people for diagnosis and treatment. When psychiatrists and other “mental health professionals” participate in these state activities, we have institutional psychiatry functioning within the context of formal social control—that is, control by the state.
Psychiatry also plays an important role in shaping social policy, where the control is more self-imposed and where people are left to their own devices. It is in this area that contractual psychiatry is most at home. For example, currently drug prohibition is a function of formal social controls. However, if these laws were to be repealed, informal social controls, in the form of relational and self-controls, would replace state control of drugs. Institutional psychiatric sanctions will have been removed, and at that point contractual psychiatric relationships would replace them or die depending on demand.
True libertarians are not “antipsychiatry,” but seek to expand contractual relationships in psychiatry while ultimately eliminating the coercive elements that mark institutional psychiatry.
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———, ed. Szasz under Fire: The Psychiatric Abolitionist Faces His Critics. Chicago: Open Court, 2004.
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———. Law, Liberty, and Psychiatry: An Inquiry into the Social Uses of Mental Health Practices. New York: Macmillan, 1963.
———. The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. New York: Paul B. Hoeber, 1961.
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Originally published .