The case against psychiatric coercion.

• Author: Szasz, Thomas

"To commit violent and unjust acts, it is not enough for a government to have the will or even the power; the habits, ideas, and passions of the time must lend themselves to their committal."

--Alexis de Tocqueville (1981, 297)

Political history is largely the story of the holders of power committing violent and unjust acts against their people. Examples abound: Oriental despotism, the Inquisition, the Soviet Gulag, the Nazi death camps, and the American war on drugs come quickly to mind. Involuntary psychiatric interventions belong on this list.(1)

When Tocqueville referred to "unjust acts," he was speaking as a detached observer, viewing state-sanctioned violence as an outsider. From the insider's point of view, state-sanctioned violence is, by definition, just. The Constitution of the United States, for example, recognized involuntary servitude as a just and humane economic policy. Throughout the civilized world people now recognize involuntary psychiatry as a just and humane therapeutic policy. Making use of the fashionable rhetoric of rights, a prominent psychiatrist describes adding the "right to treatment" to the existing criteria for assessing civil commitment as a "policy more realistically and humanely balancing the right to be sick with the right to be rescued" (Treffert 1996).

The fact that the psychiatrist is authorized to use force to impose the role of mental patient on legally competent persons against their will is prima facie evidence that the psychiatrist possesses state-sanctioned power. In 1913, Karl Jaspers ([1913] 1963)(2) acknowledged the unique importance of this element of psychiatric practice. He wrote:

Admission to hospital often takes place against the will of the patient

and therefore the psychiatrist finds himself in a different relation to his

patient than other doctors. He tries to make this difference as

negligible as possible by deliberately emphasizing his purely medical

approach to the patient, but the latter in many cases is quite convinced

that he is well and resists these medical efforts. (839-40)

The systematic exercise of force requires legitimation. Formerly, Church and State, representing and implementing God's design for right living, performed this function. Today, Medicine and State perform it. W. H. Auden ([1962] 1968) put it thus:

What is peculiar and novel to our age is that the principal goal of

politics in every advanced society is not, strictly speaking, a political

one, that is today, it is not concerned with human beings as persons and

citizens, but with human bodies.... In all technologically advanced

countries today, whatever political label they give themselves, their

policies have, essentially, the same goal: to guarantee to every member

of society, as a psychophysical organism, the right to physical and

mental health. (87)

So long as the idea of mental illness imparts legitimacy to psychiatric coercion, the myriad uses of psychiatric compulsions and excuses cannot be reformed, much less abolished. Hence, for those opposed to psychiatric coercion, the principal adversary is its legitimacy.

The Varieties of Power

In social affairs, power is usually defined as the ability to compel obedience. Its sources are coercion from above and dependency from below. By coercion I mean the legal or physical ability to deprive another person of life, liberty, or property, or to threaten such "punishment." By dependency I mean the desire or need for others as protectors or providers.(3) "Nature," observed Samuel Johnson ([1709-84] 1981), "has given women so much power that the law has very wisely given them little" (172). The sexual control women wield (over men who desire them) is here cleverly contrasted with their legal subservience (a condition imposed on them by men).

Because the definition of power as the ability to compel obedience fails to distinguish between coercive and noncoercive means of securing obedience, it is imprecise and potentially misleading. For example, when Voltaire exclaimed, Ecrazes l'infame! he was using the word l'infame to refer to the power of the church to incarcerate, torture, and kill people, not to the influence of the priest to misinform or mislead the gullible. The distinction I draw here is not novel, yet needs to be stated and restated. As the American philosopher Alfred North Whitehead ([1933] 1961) put it, "[T]he intercourse between individuals and between social groups takes one of these two forms, force and persuasion. Commerce is the great example of intercourse by way of persuasion. War, slavery, and governmental compulsion exemplify the reign of force" (83).

I use the word force to denote the power to harm, or threaten to harm, another,(4) and the word influence to refer to obedience secured by money or other rewards or temptations. The potency of force, symbolized by the gun, rests on the ability to injure or kill the Other, whereas the potency of influence rests on the ability to gratify the Other's desires. By desire I mean the experience of an unsatisfied urge, for example, for food, drugs, or sex. The experience is painful; its satisfaction is pleasurable. Individuals who depend on another person for the satisfaction of their needs (or whose needs or desires can be aroused by another) experience the Other as having power over them. Such (though not such alone) is the power of parents over their children, of doctors over their patients, of Circe over Ulysses. In proportion as we master or surmount our desires, we liberate ourselves from this source of domination.

Dependence, Domination, and Psychiatry

The paradigmatic exercise of psychiatric coercion is the imposition of an ostensibly diagnostic or therapeutic intervention on subjects against their will, legitimized by the state as protection of subjects from madness and protection of the public from the mad. Hence, the paramount source of psychiatric domination is force. Its other source is dependency, that is, the need of the powerless for comfort and care by the powerful. Involuntary psychiatric interventions rest on coercion, voluntary psychiatric interventions on dependency. It is as absurd to confuse or equate these two types of psychiatric relations as it is to confuse or equate rape and mutually desired sexual relations. I oppose involuntary psychiatric interventions not because I believe that they are necessarily "bad" for patients but because I oppose using the coercive apparatus of the state to impose psychiatric relations on persons against their will. By the same token, I support voluntary psychiatric interventions, not because I believe that they are necessarily "good" for patients but because I oppose using the power of the state to interfere with contractual relations between consenting adults (Szasz 1982).(5)

When people suffer from disease, oppression, or want, they naturally seek the assistance of persons who have the knowledge, skill, or power to help them or on whom they project such attributes. In ancient times, priests, whom people believed to possess the ability to intercede with powerful gods, were the premier holders of power. For a long time, curing souls, healing bodies, and relieving social-economic difficulties were all regarded as priestly activities.(6) Only in the last few centuries have these roles become differentiated, as Religion, Medicine, and Politics, each institution being allotted its "proper" sphere of influence, struggled to enlarge their scope and power over the others.

The...