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Coercion as CureReview - Coercion as Cure
A Critical History of Psychiatry
by Thomas Szasz
Transaction, 2007
Review by Alice Gee, M.Sc.
Feb 12th 2008 (Volume 12, Issue 7)

In Coercion as Cure, Szasz covers an extensive history of the use of coercion throughout psychiatry, including the early use of various mechanical restraints (e.g. the tranquilising chair), moral treatment, the 'resting cure', insulin shock therapy, ECT, lobotomy, and finally the development of modern-day drug therapies.  He maintains throughout that each one of these breakthrough 'discoveries' in psychiatric medicine are simply a reworking of old ideas, all share in common the act of coercion, that is, the depriving of innocent persons of liberty.

According to Szasz, the 'great reformers' in psychiatry, such as William Tuke (1732-1822) in England, and Philippe Pinel (1745-1826) in France, were far from great liberators of the madman, but instead were involved in 'renaming coercion', that is transforming psychiatric torture into treatment, under the guise of humanitarianism.   Similarly, the more contemporary 'liberation' of patients from mental hospitals by virtue of drugs such as chlorpromazine in the 1950s amounted to no more than drugged coercion, with patients still under compulsory treatment orders in the community.  In light of this, Szasz's critique is radical rather than reformist; he is not trying to reform treatment from the point of 'psychiatric ethics' or 'best practice' but rejects it altogether, calling for an abolition of psychiatric coercion as a "crime against humanity" (p. 227).

Szasz's argument is twofold, firstly in his rejection of the existence of mental illness, and secondly in his belief in the wrongfulness of treating people without their consent, thereby depriving them of liberty (coercion).  The first part of the argument is an ontological point, one perhaps well known to those familiar with Szasz's arguments in the 'Myth of Mental Illness' (1960) and subsequent works.  To summarize, Szasz believes that if it were the case that physical evidence could demonstrate the existence of mental illnesses in the brain, we would call them brain diseases and not mental diseases.  The second part however is an ethical point; that psychiatric intervention is not justified because of its inherently coercive nature. The question, then, is how Szasz gets from the first part of the argument to the second, that is, from an ontological to an ethical position.

A standard solution to this problem would be to examine Szasz's metaphysics.  There are many parts of the text which could be taken to mean that Szasz is a dualist.  Take, for example, the following passage:

"Only after we abandon the pretense that mind is brain and that mental disease is a brain disease can we begin the honest study of human behaviour and the means people use to help themselves and others to cope with the demands of living." (p. 149)

However, later on in the book, when discussing the use of pre-frontal lobotomy, he states:

"Prima facie, lobotomy is the destruction of a human being qua person." (p. 159)

If Szasz is stating that by first appearances the person is identical to the brain, then where does he actually believe personal identity lies?  Is it really true that by resolving the mind-brain problem in contemporary philosophy of mind we will have solved the problem of psychiatric coercion?  The answer perhaps lies in the problematic nature of the concept of mental illness; if the mind can become ill (and, for Szasz, illness has to be biological illness), it is assumed this entails loss of volition, or existential liberty which is then used as a justification for loss of political liberty by means of coercion on the part of the psychiatrist (see pages 74-75).  The concept of mental illness, then, is inherently coercive; the patient is seen as unfit to make sound judgements about their own condition.  This is exemplified in the concept of 'anosognosia'; a form of brain disorder which prevents insight into one's illness.  (There is a particular response to this which is brought out in the Szasz/Kendell debate, as outlined by Fulford et al (2006), whereby it is suggested that the problem is with the definition of bodily illness, not mental illness, although I think this position is equally problematic - for an outline of the debate, see Fulford et al, 2006).

Szasz's view of the mind seems to be less that of a detached Cartesian ego and more as mind in the world, within the realm of meanings and morals, rather than medicine.  Coercion in practice results from a political event, not a metaphysical one, which is perhaps why it is difficult to analyse his position from a purely metaphysical point of view.  It is for this reason that his is described as being the 'moral' model of mental disorder; that mental disorders are 'problems of living' rather than mental illnesses.

There are a number of problems with this view.  Firstly, not all the symptoms described as 'mental illness' are moral -- a good deal of symptoms (e.g. hearing voices) can be morally neutral or benign.  Secondly, not all symptoms of mental illness are deviant behaviours, many of the symptoms in the DSM describe subjective appraisals of one's experiences and state of mind, rather than observable forms of behavior.

Szasz makes a great point of first distinguishing voluntary and involuntary (or coerced and consensual) psychiatry, and criticises the psychiatric profession for failing to distinguish between the two.  However, he later goes on to claim "as long as we live in a society with coercive mental health laws, there can be no such thing as voluntary psychiatric intervention." (p. 172).   From this, he concludes that "psychiatric peace and tolerance" will only be achieved once we reject the "misleading metaphor" of mental illness, and psychiatric coercion (p. 227).

It is puzzling from this what he would then consider this sort of voluntary, non-coercive psychiatry to be. It would have been interesting to have more discussion on, for example, the use of Advance Directives, as Szasz has discussed elsewhere  (Szasz, 1982; 2003, see also the the Mind [online] article, 2008).  At the moment, Advance Directives are only legally binding under UK Mental Health Law for non-compulsory treatment, not compulsory treatment, and perhaps if they were made universal for both (and for both mental and physical illness, see Dawson and Szmukler, 2006) then this would meet Szasz's criteria for non-coercive psychiatry.

In terms of the moral model, Szasz would have to conclude that all wrongdoing should be treated equally, and in the case of forensic psychiatry (although it must be said that Szasz holds that all psychiatrists act in a forensic capacity at some point):

"I maintain that neither mental illness nor psychiatric drugs cause suicide or murder.  Self-killing and the killing of others are voluntary acts for which the actor is responsible" (p. 180)

It is perhaps this uncompromising libertarian stance which leads him to conclude that "Mental Hospitals are Prisons" (p. 52).  It seems difficult to discern from this which way Szasz wants to argue.  Is Szasz objecting to the criminalization of the medical or the medicalization of the criminal?  Is it wrong that mental hospitals act as prisons, or that prisons act as mental hospitals?  It also depends on what view one takes of the function of prisons -- if the function of prisons is merely punitive then it is of course unjustified for mental hospitals to operate as prisons, if only because punishment does little to alleviate (and indeed may exacerbate) the symptoms of mental illness.  If, on the other hand, the function of prisons is rehabilitative, then it would be right to say that mental hospitals serve a similar function but through using a different method.

Szasz's description of the early similarities between treatments for witchcraft and madness may be quite familiar to readers, although his outline of the moral treatment movement is particularly informative, as is his extrapolation of the symbiotic development of the concepts of epilepsy and schizophrenia and the resultant development of ECT, as well as his criticisms of lobotomy and psychopharmacology.  It is interesting that he chooses to compare psychiatric drugs with psychedelic drugs in the final chapters, particularly in light of the current ideology over the psychiatric risks of cannabis 'abuse'. 

His last chapter is particularly revelatory and this perhaps gives us a glimpse of his position in relation to other anti-psychiatrists.  In particular, he makes pains to distance himself from R.D. Laing, whom he accuses of abusing the doctor-patient relationship (and resorting to physical reductionism) through his experiments with LSD.  He also makes the very good point that when considering the outcomes of any therapeutic intervention, ultimately what should be assessed is not primarily whether it works or not (amongst various other measures), but rather whether it is brought about consensually or coercively (p.226), a point which is potentially sidelined in the development of Evidence-Based-Practice. 

The only criticism of the book is that Szasz often conflates the distant past with the present, and I would have liked more discussion comparing archaic methods with modern psychiatric practice in the 21st Century, for example with the use of Advance Directives.  Other than that, it would be of great interest to those who follow Szasz's work and require a condensed summation of his work to date.

References:

Dawson, J. and Szmukler, G. (2006) Fusion of mental health and incapacity legislation, British Journal of Psychiatry, 188, pp. 504-509.

Fulford, K. W. M., Thornton, T. and Graham, G. (2006) Oxford Textbook of Philosophy and Psychiatry, Oxford University Press.

Mind (2008) Legal briefing: Advance directives [online]

Available from:

http://www.mind.org.uk/Information/Legal/Legalbriefing+advancedirectives.htm

[cited 01/29/2008]

Szasz, T. (1982) 'The psychiatric will. A new mechanism for protecting persons against "psychosis" and psychiatry', American Psychologist 37(7): 762-70.

Szasz, T. (2003) 'The psychiatric protection order for the "battered mental patient"', British Medical Journal, 327: 1449-1451.

 

 

© 2008 Alice Gee

Alice Gee, MSc Philosophy of Mental Disorder, King's College London, BA (Hons) Philosophy and Psychology, Durham, a.d.gee.83@gmail.com

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