Thomas Szasz takes on his critics: is mental illness an insane idea?Szasz Under Fire: The Psychiatric Abolitionist Faces His Critics, edited by Jeffrey A. Schaler, Chicago: Open Court, 450 pages, $36.95 paper
IN 1980 THOMAS Szasz testified for the prosecution in the trial of Darlin June Cromer, a 34-year-old white woman charged with kidnapping and murdering Reginald Williams, a 5-year-old black boy. There was no question that Cromer, who attracted suspicion because she had a history of talking about "killing niggers" and trying to lure black children into her car, had abducted abducted Distal angulation of an extremity away from the midline of the body in a transverse plane and away from a sagittal plane passing through the proximal aspect of the foot or part, or away from some other specified reference point Reginald from an Oakland, California, supermarket, strangled stran·gle
v. stran·gled, stran·gling, stran·gles
a. To kill by squeezing the throat so as to choke or suffocate; throttle.
b. him, and buried his body near her home. She had told police as much when they questioned her. Neither was her motive in doubt. She explained that "it is the duty of every white woman to kill a nigger child," telling a jail psychologist she hoped to ignite a race war.
But as the San Francisco Chronicle The San Francisco Chronicle was founded in 1865 as The Daily Dramatic Chronicle by teenage brothers Charles de Young and Michael H. de Young. The paper grew along with San Francisco to become the largest circulation newspaper on the West Coast of the reported, Cromer's attorney argued that "his client killed because she is consumed by schizophrenic paranoia--not hate for blacks." Or as the lawyer put it, "This case does not involve racism; it involves insanity." To help undermine this claim, the prosecutor enlisted the assistance of Szasz, the iconoclastic i·con·o·clast
1. One who attacks and seeks to overthrow traditional or popular ideas or institutions.
2. One who destroys sacred religious images. psychiatrist famous for rejecting the insanity defense A defense asserted by an accused in a criminal prosecution to avoid liability for the commission of a crime because, at the time of the crime, the person did not appreciate the nature or quality or wrongfulness of the acts.
The insanity defense is used by criminal defendants. , involuntary commitment, and the very concept of mental illness. At the trial, Szasz explained the difference between a medical diagnosis and a psychiatric diagnosis: "Medical diagnoses deal with objective and demonstrable lesions of the body, broken bones, diseased livers, kidneys, and so on. Psychiatric diagnoses deal with behaviors that human beings display, and they have to be interpreted in moral, cultural, and legal terms and, therefore, different interpreters will arrive at different judgments." He pointed out that "homosexuality was recognized as a mental disease until a few years ago" and that smoking, previously considered a habit, had recently been classified as a mental disorder mental disorder
Any illness with a psychological origin, manifested either in symptoms of emotional distress or in abnormal behaviour. Most mental disorders can be broadly classified as either psychoses or neuroses (see neurosis; psychosis). Psychoses (e.g. .
Asked "what [Cromer] was suffering from, if anything," on the day of the murder, Szasz offered the following opinion based on her records: "She was suffering from the consequences of having lived a life very badly, very stupidly, very evilly.... From the time of her teens, for reasons which I don't know Don't know (DK, DKed)
"Don't know the trade." A Street expression used whenever one party lacks knowledge of a trade or receives conflicting instructions from the other party. ... whatever she [has] done, she has done very badly. She was a bad student.... She was a bad wife. She was a bad mother. She was a bad employee insofar in·so·far
To such an extent.
Adv. 1. insofar - to the degree or extent that; "insofar as it can be ascertained, the horse lung is comparable to that of man"; "so far as it is reasonably practical he should practice as she was employable. Then she started to engage [in taking] illegal drugs, then she escalated to illegal assault, and finally she committed this murder.... Life is a task. You either cope with it or it gets you.... If you do not know how to build, you can always destroy."
Szasz did not really try to explain why Cromer killed Reginald. Indeed, the main strength of his testimony was his acknowledgment of how difficult it is to get inside the head of a criminal--or anyone else. Cromer was the way she was and did the things she did "for reasons I don't know." By contrast, the defense experts confidently asserted that her crime was caused by a mental illness.
In Szasz UnderFire, a new collection of exchanges with his critics, Szasz, a reason contributing editor and an emeritus professor of psychiatry at the SUNY SUNY - State University of New York Upstate Medical University in Syracuse, explains why, unlike the defense experts, he did not conduct a "psychiatric examination" of Cromer. "I regard the practice as the epitome of junk science and refuse to participate in it," he writes. Not only is there "no objective test for mental illness," but psychiatrists are supposed to determine a defendant's state of mind at the time of the crime by talking to him many months later, a pretense Szasz considers "prima facie [Latin, On the first appearance.] A fact presumed to be true unless it is disproved.
In common parlance the term prima facie is used to describe the apparent nature of something upon initial observation. absurd." This was one of the main points he made in his testimony, which was condemned by psychiatrists outraged that he had dared to question the premises of their profession. The jurors, who convicted Cromer, apparently agreed with Szasz about the reliability of psychiatric testimony.
As illustrated by the case of Andrea Yates, whose 2002 conviction for drowning her children was recently overturned because of false testimony that may have undermined her insanity defense, the questions raised at Cromer's trial are as relevant today as they were a quarter century ago. Do some people have mental impairments, either temporary or permanent, that prevent them from controlling their behavior ? If so, how can such people be identified, and how should they be treated ?
Although insanity pleas are offered in only about I percent of criminal cases and are usually unsuccessful, they have played a role in a number of sensational trials, including those of would-be presidential assassin John Hinckley and D.C. sniper Lee Boyd Malvo Lee Boyd Malvo (alias John Lee Malvo or Malik Malvo) (born February 18, 1985), is a Jamaican born American convicted mass murderer. He, along with John Allen Muhammad, was arrested on October 24, 2002 in connection with the Beltway sniper attacks. . Furthermore, issues of mental impairment are important not just in cases where defendants offer insanity pleas but in every context where there is potential for psychiatric coercion, including legally mandated addiction treatment and civil commitment of people deemed a threat to themselves or others. Each year in the United States more than 1 million people are committed to mental hospitals; some two-thirds of these commitments are officially voluntary, but that status can change once a "patient" tries to get out. Since mental illness is a widely accepted rationale for both relieving people of responsibility and depriving them of liberty--the twin dangers to which Szasz has been alerting us for more than four decades--the psychiatric is unavoidably political.
Szasz Under Fire, edited by the Szaszian psychologist Jeffrey Schaler, appropriately focuses on this theme. Szasz's debating partners include psychiatrists, psychologists, bioethicists, and legal scholars, most of whom seem to have reservations about psychiatry's tendency to treat every facet of human behavior--happiness and sadness, energy and lethargy, neatness and sloppiness, shyness and boldness, inattentiveness in·at·ten·tive
Exhibiting a lack of attention; not attentive.
inat·ten and obsessiveness, thievery Thievery
See also Gangsterism, Highwaymen, Outlawry.
Alfarache, Guzmán de
picaresque, peripatetic thief; lived by unscrupulous wits. [Span. Lit. and honesty, promiscuity and celibacy, thinness and fatness--as a symptom of mental illness. At the same time, they ostensibly part company with Szasz when it comes to "severe" mental illnesses, which are usually said to include schizophrenia, bipolar (manic-depressive) disorder, and major depression. I say "ostensibly" because the contributors to Szasz Under Fire generally seem to believe that schizophrenia and a few other disorders that psychiatrists diagnose are in fact brain diseases, which would mean they are not "mental illnesses," any more than a brain tumor Brain Tumor Definition
A brain tumor is an abnormal growth of tissue in the brain. Unlike other tumors, brain tumors spread by local extension and rarely metastasize (spread) outside the brain. or Huntington's disease Huntington's disease, hereditary, acute disturbance of the central nervous system usually beginning in middle age and characterized by involuntary muscular movements and progressive intellectual deterioration; formerly called Huntington's chorea. is.
"I struggle with ambivalence about [Szasz]," confesses E. James Lieberman, a professor of psychiatry at the George Washington University George Washington University, at Washington, D.C.; coeducational; chartered 1821 as Columbian College (one of the first nonsectarian colleges), opened 1822, became a university in 1873, renamed 1904. School of Medicine. "He's on the right track, but he goes too far and too straight." This book mainly deals with the ways in which Szasz's critics think he "goes too far," and in doing so it illuminates vital questions about the nexus between psychiatry and the law.
Discussions of Szasz's ideas tend to begin with his insistence that mental illness is, strictly speaking, a contradiction in terms Noun 1. contradiction in terms - (logic) a statement that is necessarily false; "the statement `he is brave and he is not brave' is a contradiction"
logic - the branch of philosophy that analyzes inference , a literalized metaphor that confuses more than it clarifies. Not surprisingly, much of Szasz Under Fire continues the conceptual and semantic battles provoked by Szasz's 1961 classic The Myth of Mental illness. His critics offer various alternatives to the Szaszian perspective, which insists upon an objectively measurable bodily defect as the sine qua non [Latin, Without which not.] A description of a requisite or condition that is indispensable.
In the law of torts, a causal connection exists between a particular act and an injury when the injury would not have arisen but of a true disease. Among other things, they argue that some so-called mental illnesses are genuine brain diseases, although their precise etiologies have not been figured out yet; that if mental illness is a myth, so is physical illness, because both categories have fuzzy boundaries and are to a large extent culturally determined; that viewing mental illness as a myth is a fiction that is necessary to maintain the integrity of psychotherapy as a moral enterprise; and that the distinction between mental and physical disease is misleading, since (as the American Psychiatric Association The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential world-wide. Its some 148,000 members are mainly American but some are international. puts it) "there is much that is 'physical' in mental disorders and much 'mental' in 'physical' disorders."
This book is the first in an Open Court series featuring debates between important thinkers and their critics, and Szasz should be commended for responding directly and at length to people who disagree with him, given how easy it is for a writer of his stature to retreat to an echo chamber populated by loyal followers. He sticks to his guns and scores many points, but his responses are not always completely satisfying. That's a shame, because many readers will look to this book for an introduction to his ideas and may be put off by the questions he neglects or only partially answers.
Consider Szasz's response to the late Robert E. Kendell, former president of the U.K.'s Royal College of Psychiatrists The Royal College of Psychiatrists is the main professional organisation of psychiatrists in the United Kingdom and the Republic of Ireland, responsible for representing and certifying psychiatrists, psychiatric training and providing high quality public information about mental . Kendell writes that "it is impossible to identify any characteristic feature of either the symptomatology symptomatology /symp·to·ma·tol·o·gy/ (simp?to-mah-tol´ah-je)
1. the branch of medicine dealing with symptoms.
2. the combined symptoms of a disease.
n. or the etiology of so-called mental illnesses which consistently distinguishes them from physical illnesses." This assertion seems to go to the heart of Szasz's insistence that mental illnesses are not real diseases. But rather than refute it, he replies, "This is true, but not enough." Enough for what isn't exactly clear. Szasz then cites three distinctions between physical and mental illness that are generally valid but do not hold in every case: I) "Typically, physical illnesses are identified by observing the patient's body," while "typically, mental illnesses are identified by observing the patient's verbal pronouncements." 2) There are "objective, physical-chemical markers" to ascertain whether someone has a particular brain disease but "no such markers" to ascertain whether he has a particular mental illness. 3) "The typical medical patient" is treated only with his informed consent, while "the typical mental patient" is treated without his consent.
Although that last claim does not apply to the millions of Americans who voluntarily seek antidepressants Antidepressants
Medications prescribed to relieve major depression. Classes of antidepressants include selective serotonin reuptake inhibitors (fluoxetine/Prozac, sertraline/Zoloft), tricyclics (amitriptyline/ Elavil), MAOIs (phenelzine/Nardil), and heterocyclics or psychotherapy as a way of improving their lives, it arguably describes hospitalized mental patients, keeping in mind the blurry line between voluntary and involuntary commitment. The combination of subjective diagnosis and involuntary treatment poses obvious dangers. As Szasz says, "There is no way that someone can disprove disprove,
v to refute or to prove false by affirmative evidence to the contrary. the 'diagnosis' that he 'suffers' from schizophrenia." Still, the hallmarks of true disease that Szasz mentions do not always apply. In his contribution to Szasz UnderFire, Ronald Pies, a professor of psychiatry at the Tufts University School of Medicine The Tufts University School of Medicine is one of the eight schools that comprise Tufts University. Located on the university's health sciences campus in the Chinatown district of Boston, Massachusetts, the medical school has clinical affiliations with thousands of doctors and , cites migraine headaches as an example of a physical condition that is diagnosed based entirely on "the patient's verbal pronouncements" (complaints of pain, nausea, light flashes, etc.). Then again, migraine sufferers are not treated against their will.
Amid all this terminological disputation, it is important, though not always easy, to keep in mind the real-world consequences of these ideas. Defenders of psychiatry can be remarkably blithe blithe
adj. blith·er, blith·est
1. Carefree and lighthearted.
2. Lacking or showing a lack of due concern; casual: spoke with blithe ignorance of the true situation. about those consequences. The American University sociologist Rita Simon, co-author of a book on the insanity defense, uses barely two pages of Szasz Under Fire to defend the practice, which she does simply by asserting that "a few individuals," because of "a mental disability or disease," lack "the minimal capacity for rational and voluntary choices on which the law's expectation of responsibility is predicated." She leaves unexamined the question of how the legal system should determine whether it is confronting such an individual. At the end of her very brief essay, she offers more cause for doubt by approvingly quoting legal scholar Alan Stone's statement that the insanity defense "purports to draw a line between those who are morally responsible and those who are not, those who are blameworthy blame·wor·thy
adj. blame·wor·thi·er, blame·wor·thi·est
Deserving blame; reprehensible.
blame and those who are not, those who have free will and those who do not." As Szasz notes in his reply, purport usually suggests a pretense of some sort.
In any event, how should a court decide whether someone like Darlin June Cromer is a paranoid schizophrenic or merely a racist murderer? And if it decides she is a schizophrenic, is that diagnosis enough to show that she should not be held responsible for strangling a 5-year-old-boy? In theory, the jury in her case could have decided that she was a schizophrenic but still responsible for her actions, since the legal definition of insanity--which generally requires that the defendant either did not know what he was doing, did not know it was wrong, or could not stop himself--is not the same as the criteria for a psychiatric diagnosis. Cromer's repeated attempts to kidnap black children, her explanation of her motive, and the fact that she tried to hide the body all suggest she knew what she was doing, which presumably pre·sum·a·ble
That can be presumed or taken for granted; reasonable as a supposition: presumable causes of the disaster. helps explain why the jury found her guilty. But the defense argued that her appalling actions and statements all were symptoms of her disease--indeed, that they were so appalling they had to be. "If she isn't crazy," one of the expert witnesses asked, "who is?"
Similarly, Lieberman complains in his essay that, when it comes to individual responsibility, Szasz "makes no exception for a woman who drowns her five children" This reference to Andrea Yates implies that the nature of her act proves she was not responsible for it--a standard that would give a pass precisely to those guilty of the most horrendous crimes.
Still, surely there are people who commit what would ordinarily be considered crimes when they are mentally incapacitated mentally incapacitated Forensic psychology adjective Referring to a person rendered temporarily incapable of appraising or controlling his/her conduct due to the influence of a narcotic, anesthetic or other substance administered to that person without the : a sleepwalker who assaults a stranger while acting out a dream, say, or a Huntington's patient who throws a dish at his caretaker. Szasz's reply to Simon would have been stronger if he had explained how such cases should be handled. And if some people diagnosed as schizophrenics do in fact suffer from an incapacitating in·ca·pac·i·tate
tr.v. in·ca·pac·i·tat·ed, in·ca·pac·i·tat·ing, in·ca·pac·i·tates
1. To deprive of strength or ability; disable.
2. To make legally ineligible; disqualify. brain disease--a possibility Szasz concedes--presumably they too should be held less culpable Blameworthy; involving the commission of a fault or the breach of a duty imposed by law.
Culpability generally implies that an act performed is wrong but does not involve any evil intent by the wrongdoer. than people in full possession of their faculties.
But as Szasz notes, if psychiatrists were interested merely in identifying and treating the brain diseases underlying certain forms of insanity, their field ultimately would be swallowed by neurology. Their agenda is far more ambitious than that, as illustrated by their attachment to the calculatedly ambiguous term mental disorder, which the American Psychiatric Association continues to use even while complaining that it "unfortunately implies a distinction between 'mental' disorders and 'physical' disorders that is a reductionistic anachronism a·nach·ro·nism
1. The representation of someone as existing or something as happening in other than chronological, proper, or historical order.
2. of mind/body dualism dualism, any philosophical system that seeks to explain all phenomena in terms of two distinct and irreducible principles. It is opposed to monism and pluralism. In Plato's philosophy there is an ultimate dualism of being and becoming, of ideas and matter. ." Given the sweep of the APA's Diagnostic and Statistical Manual of Mental Disorders Diagnostic and Statistical Manual of Mental Disorders /Di·ag·nos·tic and Sta·tis·ti·cal Man·u·al of Men·tal Dis·or·ders/ (DSM) a categorical system of classification of mental disorders, published by the American Psychiatric Association, that delineates objective (DSM 1. DSM - Data Structure Manager.
An object-oriented language by J.E. Rumbaugh and M.E. Loomis of GE, similar to C++. It is used in implementation of CAD/CAE software. DSM is written in DSM and C and produces C as output. ), which takes in misbehavior ranging from rudeness to murder, it's fair to read this caveat to mean that anything bad people think, feel, say, or do can be interpreted as a symptom of a disease. In practice, psychiatrists often distinguish between "severe" disorders thought to have a physiological basis and the myriad sins, foibles, bad habits, and eccentricities cataloged by the DSM. But their training, terminology, diagnostic framework, and billing practices imply that all these are medical problems appropriately handled by physicians. As Kendell notes, "the inexorable expansion of the concept of mental illness" despite a "fragile empirical basis" leaves psychiatrists "vulnerable to accusations of unjustified medicalization medicalization Social medicine A term for the erroneous tendency by society–often perpetuated by health professionals–to view effects of socioeconomic disadvantage as purely medical issues of deviant behavior and the vicissitudes vicissitudes
changes in circumstance or fortune [Latin vicis change]
vicissitudes npl → vicisitudes fpl; peripecias fpl of daily life."
The DSM's broad scope is consistent with a perspective that sees brain defects at the root of all misbehavior and psychological problems. According to this view, the contents of the mind are determined by the structure of the brain; that structure, in turn, is shaped by genetics and experience. When something goes seriously wrong with either or both, the result is a disorder that is just as rooted in biology as a so-called physical disease. In this light, it makes perfect sense for Harvard psychiatrist Alvin Pouissant to argue that "extreme racism" should be considered a mental illness. So far the APA (All Points Addressable) Refers to an array (bitmapped screen, matrix, etc.) in which all bits or cells can be individually manipulated.
APA - Application Portability Architecture has rejected this suggestion, which would render racist murderers like Darlin June Cromer insane by definition and open the door to psychiatric treatment of unconventional opinions, a la Soviet Russia and Communist China. On the brighter side, the equation of broadly defined mental disorders with physical illness has the potential to let everyone--not just the Darlin June Cromers of the world--off the hook (although the legal system might continue to punish for the sake of deterrence, as opposed to justice). If we consistently apply the assumption that bad behavior is caused by defective brains, the question is not whether a particular murderer has a brain disease but whether there can be such a thing as a murderer who doesn't.
The breadth of the territory claimed by psychiatry would not be nearly as troubling if it were not so often settled by force. In addition to peering backward in time to determine a defendant's state of mind when he committed his crime, psychiatrists are expected to predict the future, assessing whether a given individual is likely to harm himself or others. Based on that judgment, innocent people can be forcibly "treated" and deprived of their liberty indefinitely. As with the insanity defense, defenders of psychiatry tend to minimize both the frequency of civil commitment and the importance of the psychiatrist's role in it.
Lieberman, for instance, casually remarks that "one rarely hears of someone being committed involuntarily to a mental hospital." Szasz rightly calls this an "astounding a·stound
tr.v. a·stound·ed, a·stound·ing, a·stounds
To astonish and bewilder. See Synonyms at surprise.
[From Middle English astoned, past participle of astonen, assertion," citing an estimate from the 1996 book Mental Health and Law that "each year in the United States well over one million persons are civilly committed to hospitals for psychiatric treatment." The book adds that "it is difficult to completely separate discussions of voluntary and involuntary commitment because voluntary status can be converted efficiently to involuntary status, once the patient has requested release."
Given their defense of involuntary treatment as not only justified but morally mandatory, psychiatrists seem weirdly reluctant to acknowledge their role in it. Pies approvingly cites a passage from Robert Simon's Psychiatry and Law for Clinicians that says "mental health professionals must understand that it is not they who make commitment decisions about patients. Commitment is a judicial decision that is made by the court or by a mental health commission. The clinician files a petition or medical certification that initiates the process of involuntary hospitalization involuntary hospitalization Forensic psychiatry A civil commitment in which a person is formally confined to a mental health institution, due to mental illness, incompetence, alcoholism, drug addiction, or other, as he/she is deemed dangerous to him/herself or ." A prosecutor might with equal plausibility deny that he is the one who puts a defendant away for life; after all, it's the jury that convicts and the judge who imposes the sentence. True enough as far as it goes, but the prosecutor plays a crucial role. The same is true of the psychiatrist who "initiates the process of involuntary hospitalization"--even more so, since people who are committed do not receive the same protections as criminal defendants. "How do judge and mental patient meet?" Szasz asks. "The psychiatrist introduces them to one another. How does the judge know whom to commit? The psychiatrist tells him."
To get a sense of why psychiatrists might want to disclaim responsibility for civil commitment, consider the case of Rodney Yoder, an Illinois man whose cause Szasz has championed. Yoder, who completed a prison sentence for assaulting his ex-wife in 1991, has been locked in a mental hospital ever since, based on a series of dubious and contradictory diagnoses. To judge by a 2002 report in Time and other press accounts, Yoder's "illness" boils down to an abrasive personality that rubbed the wrong people the wrong way. Ostensibly, he is kept behind bars because he represents an intolerable threat to the public, even though a psychiatrist who examined him in prison said he wasn't a danger and did not meet the standard for involuntary hospitalization. In a 2001 letter about Yoder to then-Illinois Gov. George Ryan, the psychiatrist Loren Mosher said "the state is practicing preventive detention The confinement in a secure facility of a person who has not been found guilty of a crime.
Preventive detention is a special form of imprisonment. Most persons held in preventive detention are criminal defendants, but state and federal laws also authorize the preventive in the guise of mental-health 'treatment.'"
As Szasz notes, in 1997 the U.S. Supreme Court endorsed such detention for sex offenders who have completed their sentences but who, because of a "mental abnormality" or "personality disorder personality disorder
Mental disorder that is marked by deeply ingrained and lasting patterns of inflexible, maladaptive, or antisocial behaviour to the degree that an individual's social or occupational functioning is impaired. ," are deemed likely to commit new crimes. These offenders, who are confined indefinitely in mental hospitals after serving their time, are considered sane enough to be convicted and punished but not sane enough to be released. Given the plethora of mental abnormalities and personality disorders Personality Disorders Definition
Personality disorders are a group of mental disturbances defined by the fourth edition, text revision (2000) of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) identified by psychiatrists, this practice could be extended to many other criminals--for example, those suffering from antisocial personality disorder antisocial personality disorder
A personality disorder characterized by chronic antisocial behavior and violation of the law and the rights of others. , "a pervasive pattern of disregard for and violation of the rights of others." The Bureau of Justice statistics Noun 1. Bureau of Justice Statistics - the agency in the Department of Justice that is the primary source of criminal justice statistics for federal and local policy makers
BJS estimates that 16 percent of prison and jail inmates are mentally ill, and that includes only those who "reported either a mental condition or an overnight stay in a mental hospital."
Civil commitment does not require dangerousness to others; dangerousness to oneself will do. A diagnosis of schizophrenia, which is said to afflict af·flict
tr.v. af·flict·ed, af·flict·ing, af·flicts
To inflict grievous physical or mental suffering on.
[Middle English afflighten, from afflight, about 1 percent of the population, is much more likely to result in hospitalization (or, as Szasz would say, imprisonment Imprisonment
See also Isolation.
former federal maximum security penitentiary, near San Francisco; “escapeproof.” [Am. Hist.: Flexner, 218]
German prison ship in World War II. [Br. Hist. ) than is a diagnosis of, say, major depression: Data from the Substance Abuse and Mental Health Services Administration The Substance Abuse and Mental Health Services Administration (SAMHSA), an operating division of the Health and Human Services Department (HHS), was established in 1992 by the Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act (Pub. L. No. 102-321). indicate that in 1997 schizophrenia accounted for more than a quarter of in-patient psychiatric admissions of people with "serious functional impairment," compared to 38 percent for affective disorders and 12 percent for substance-related disorders--both of which, according to the DSM, are far more common than schizophrenia in the general population. Still, the rationale for most of these admissions presumably is the patient's own welfare, as opposed to public safety. And since psychiatric diagnoses, unlike the typical medical diagnosis, generally imply that the "patient" either does not properly understand his own interests or is not capable of acting on them, the threat of involuntary treatment always hangs in the background.
Although Szasz emphasizes the contrast with medicine proper, which usually is predicated on the patient's consent, there are exceptions based on competence: Children, the severely retarded, and patients in the advanced stages of Alzheimer's do not make their own medical decisions. In North Dakota, the children of former federal judge Bruce Van Sickle Bruce Van Sickle, (February 13, 1917 - April 21, 2007), was an American federal judge who served from 1971 to 2002. In 1982, he was appointed to preside over a civil rights case in the federal court for the Western District of Arkansas in which it was claimed that the state court , who has Alzheimer's, are engaged in a legal battle over whether he should remain in a nursing home. One of his sons says Van Sickle wants to go home, while his other three children say he is too far gone to know what he wants. Elsewhere Szasz has acknowledged the need for a legal process to determine competence in such cases. Some discussion of that issue would have been appropriate in response to Pies' hypothetical question A mixture of assumed or established facts and circumstances, developed in the form of a coherent and specific situation, which is presented to an expert witness at a trial to elicit his or her opinion. regarding an elderly man who begins to behave strangely after falling and hitting his head. If involuntary treatment can be justified in such a case, can't it also be justified for a schizophrenic? Szasz's failure to address that question leaves him open to the charge of dodging an important issue. I think he would have to say that the two cases should be handled in a similar way--provided the schizophrenic's brain injury can be demonstrated as readily as the old man's.
But as Richard Bentall, a psychologist at the University of Manchester The University of Manchester is a university located in Manchester, England. With over 40,000 students studying 500 academic programmes, more than 10,000 staff and an annual income of nearly £600 million it is the largest single-site University in the United Kingdom and receives , shows in his contribution to this volume, the science regarding the etiology of schizophrenia is not nearly as clear as psychiatrists often imply. Bentall points to several weaknesses in the leading theory, which holds that schizophrenia is caused by an excess of the neurotransmitter dopamine dopamine (dōp`əmēn), one of the intermediate substances in the biosynthesis of epinephrine and norepinephrine. See catecholamine.
One of the catecholamines, widely distributed in the central nervous system. . He notes that antipsychotic drugs Antipsychotic Drugs Definition
Antipsychotic drugs are a class of medicines used to treat psychosis and other mental and emotional conditions.
Purpose that block dopamine receptors within hours do not affect behavior for weeks; that some drugs considered effective in treating schizophrenia do not zero in on dopamine receptors; and that antipsychotic drugs do not work for all schizophrenics but may work for people with different diagnoses. Perhaps most important, "an expensive and sustained search for dopamine abnormalities in schizophrenia patients has so far drawn a blank." Kendell likewise concedes that "in schizophrenia a structural abnormality can only be demonstrated in populations, not in all or even most individuals." By comparison, while the etiology of Alzheimer's disease Alzheimer's disease (ăls`hī'mərz, ôls–), degenerative disease of nerve cells in the cerebral cortex that leads to atrophy of the brain and senile dementia. remains murky and its initial diagnosis depends partly on behavior (along with brain scans and cognitive tests), the diagnosis can be confirmed in autopsies by the presence of brain plaques and tangles. The postmortem postmortem /post·mor·tem/ (post-mort´im) performed or occurring after death.
Relating to or occurring during the period after death.
See autopsy. evidence, which confirms the initial diagnosis about 85 percent of the time, gives physicians confidence that they are looking at a discrete condition with a common physiological cause.
To a large extent, then, the issue of involuntary treatment comes down to a question of where the burden of proof should lie and how heavy it should be. Even those who are skeptical of psychiatric pretensions cannot easily dismiss Pies' invocation of "the young man, rocking back and forth in a pool of his own urine, responding to voices from 'a CIA CIA: see Central Intelligence Agency.
(1) (Confidentiality Integrity Authentication) The three important concerns with regards to information security. Encryption is used to provide confidentiality (privacy, secrecy). computer' that are instructing him to kill himself." If such a person is indeed suffering from an incapacitating brain disease, it should be possible to allow his family to make treatment decisions on his behalf. At the same time, anyone who cares about liberty has to hesitate before imposing treatment on someone who insists he does not want it.
The psychiatrist E. Fuller Torrey Edwin Fuller Torrey, M.D. (b.September 6, 1937, Utica, New York), is an American psychiatrist and schizophrenia researcher. He is Associate Director for Laboratory Research at the Stanley Medical Research Institute (SMRI). , once a Szasz admirer, is now one of his most vocal critics, having concluded that "schizophrenia is a disease of the brain in the same sense that Parkinson's disease Parkinson's disease or Parkinsonism, degenerative brain disorder first described by the English surgeon James Parkinson in 1817. When there is no known cause, the disease usually appears after age 40 and is referred to as Parkinson's disease. and multiple sclerosis are diseases of the brain. "Yet Torrey, a prominent advocate of involuntary psychiatric treatment, concedes "there is no single abnormality in brain structure or function that is pathognomonic pathognomonic /pa·thog·no·mon·ic/ (path?ug-no-mon´ik) specifically distinctive or characteristic of a disease or pathologic condition; denoting a sign or symptom on which a diagnosis can be made. for schizophrenia" and therefore "we do not yet have a specific diagnostic test."
That limitation should give Torrey pause in light of the concerns he expressed in his 1974 book The Death of Psychiatry, quoted in Szasz Under Fire. He argued that "it is better that we err on the side of labeling too few, rather than too many, as brain diseased. In other words Adv. 1. in other words - otherwise stated; "in other words, we are broke"
put differently , a person should be presumed not to have a brain disease until proven otherwise on the basis of probability. This is exactly the opposite of what we do now as we blithely label everyone who behaves a little oddly 'schizophrenic.' Human dignity rather demands that people be assumed to be in control of their behavior and not brain diseased unless there is strong evidence to the contrary."
While the identification of schizophrenics may be less casual today than it was three decades ago, psychiatric labels have multiplied since then, and a significant part of the population is still forcibly treated, whether in mental hospitals, through outpatient commitment, or in drug treatment programs fed by the criminal justice system. In other words, there is still a need to guard against invasions of liberty justified in the name of mental health. The approach Torrey suggested seems about right to me, although much hinges on what counts as "strong evidence" of brain disease. Szasz continues to make a powerful case that a psychiatric diagnosis is not enough.
Senior Editor Jacob Sullum (jsullum@reason. com), the author of Saying Yes: In Defense of Drug Use (Tarcher/Penguin), received the 2004 Thomas S. Szasz Award for Outstanding Contributions to the Cause of Civil Liberties.