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The following essay is reproduced here by permission of Sheldon Richman, Editor, The Freeman. The Freeman is published by The Foundation for Economic Education, Irvington-on-Hudson, NY 10533.

Szasz, T., "Defining psychiatry," The Freeman, 57: 22-23 (July/August), 2007.

Defining Psychiatry

Thomas Szasz

In the United States today everyone considers himself an expert on psychiatry, especially in the aftermath of a mass murder by a "deranged madman." Yet, academically and legally qualified experts in the field keep telling us that they cannot even define psychiatry.

In 1886, Emil Kraepelin, the undisputed founder of modern psychiatry as a medical specialty and science, declared: "Our science has not arrived at a consensus on even its most fundamental principles, let alone on appropriate ends or even on the means to those ends." Eighty years later, the encyclopedic American Handbook of Psychiatry opened with this statement: "Perhaps no other field of human endeavor is so ... difficult to define as that of psychiatry." Andrew Lakoff, a professor of sociology at the University of California in San Diego, airily opines: "Two centuries after its invention, psychiatry's illnesses have neither known causes nor definitive treatments." This did not prevent him from writing a book about the diagnosis and treatment of a particular mental disease, "bipolar illness," in a particular country, Argentina.

Perhaps even more dramatic is the recent comment by Nancy Andreasen, professor of psychiatry at the University of Iowa and a former editor of the American Journal of Psychiatry, about American psychiatry's sacred symbol, schizophrenia.

Concerns about the American Psychiatric Associations "Diagnostic and Statistical Manual of Mental Disorders (DSM)," she writes, "led the author to write several editorials for the American Journal of Psychiatry about the current problems that have been created by DSM. ... Europeans can save American science by helping us figure out who really has schizophrenia or what schizophrenia really is." One wonders how Andreasen reconciles her uncertainty about "who really has schizophrenia" or "what schizophrenia really is" with the standard legal-psychiatric practice of using the diagnosis to deprive innocent persons of liberty and excuse guilty persons of crimes, and deprive them, too, of liberty, often for a much longer period than they would have been had been sentenced to prison.

Actually, it is easy to define psychiatry. The problem is that doing so -- acknowledging its self-evident ends and the means used to achieve them -- is socially unacceptable and professionally suicidal. The law, social expectation, and psychiatric tradition and practice point to coercion as the profession's paradigmatic characteristic. Accordingly, I define psychiatry as the theory and practice of coercion, rationalized as the diagnosis of mental illness and justified as medical treatment aimed at protecting the patient from himself and society from the patient. It is impolite and impolitic to take this truism and its consequences seriously.

Non-acknowledgment of the fact that coercion is a characteristic and potentially ever-present element of so-called psychiatric treatments is intrinsic to the standard dictionary definitions of psychiatry. According to the Unabridged Webster's, psychiatry is "A branch of medicine that deals with the science and practice of treating mental, emotional, and behavioral disorders."

Plainly, voluntary psychiatric relations differ from involuntary psychiatric interventions the same way as, say, sexual relations between consenting adults differ from the sexual assaults we call "rape." Sometimes, to be sure, psychiatrists deal with voluntary patients. As I have shown elsewhere, it is necessary therefore not merely to distinguish between coerced and consensual psychiatric relations, but to contrast them. The term "psychiatry" ought to be applied to one or the other, but not both. As long as psychiatrists and society refuse to recognize this, there can be no real psychiatric historiography nor any popular understanding of the varied practices called "psychiatric treatments."

Consider the parallels between coercive psychiatry and missionary Christianity. The heathen savage does not suffer from lack of insight into the divinity of Jesus, does not lack theological help, and does not seek the services of missionaries. Similarly, the psychotic does not suffer from lack of insight into being mentally ill, does not lack psychiatric treatment, and does not seek the services of psychiatrists. This is why the missionary tends to have contempt for the heathen, why the psychiatrist tends to have contempt for the psychotic, and why both conceal their true sentiments behind a facade of caring and compassion. Each meddler believes that he is in possession of the "truth," each harbors a passionate desire to improve the Other, each feels a deep sense of entitlement to intrude into the life of the Other, and each bitterly resents those who dismiss his precious insights and benevolent interventions as worthless and harmful.

The writings of historians, physicians, journalists, and others addressing the history of psychiatry rest on three erroneous premises: that so-called mental diseases exist, that they are diseases of the brain, and that the incarceration of "dangerous" mental patients is medically rational and morally just. The problems so created are then compounded by failure -- purposeful or inadvertent -- to distinguish between two radically different kinds of psychiatric practices, consensual and coerced, voluntarily sought and forcibly imposed.

In free societies, ordinary social relations between adults are consensual. Such relations -- in business, medicine, religion, and psychiatry -- pose no special legal or political problems. By contrast, coercive relations -- one person authorized by the state to forcibly compel another person to do or abstain from actions of his choice -- are inherently political in nature and are always morally problematic.

Mental disease is fictitious disease. Psychiatric diagnosis is disguised disdain. Psychiatric treatment is coercion concealed as care, typically carried out in prisons called "hospitals." Formerly, the social function of psychiatry was more apparent than it is now. The asylum inmate was incarcerated against his will. Insanity was synonymous with unfitness for liberty. Toward the end of the nineteenth century, a new type of psychiatric relationship entered the medical scene: persons experiencing so-called "nervous symptoms" began to seek medical help, typically from the family physician or a specialist in "nervous disorders." This led psychiatrists to distinguish between two kinds of mental diseases, neuroses and psychoses. Persons who complained of their own behavior were classified as neurotic, whereas persons about whose behavior others complained were classified as psychotic. The legal, medical, psychiatric, and social denial of this simple distinction and its far-reaching implications undergirds the house of cards that is modern psychiatry.

Fashionable Clichés

Psychiatry and society face a paradox. The more progress scientific psychiatry allegedly makes, the more intolerable becomes the idea that mental illness is a myth and that the effort to treat it a will-o'-the-wisp. The more progress scientific medicine actually makes, the more undeniable it becomes that "chemical imbalances" and "hard wiring" are fashionable clichés, not evidence that problems in living are medical diseases justifiably "treated" without patient consent. And the more often psychiatrists play the roles of juries, judges, and prison guards, the more uncomfortable they feel about being in fact pseudomedical coercers -- society's well-paid patsies. The whole conundrum is too horrible to face. Better to continue calling unwanted behaviors "diseases" and disturbing persons "sick," and compel them to submit to psychiatric "care."

It is easy to see, then, why the right-thinking person considers it inconceivable that there might be no such thing as mental health or mental illness. Where would that leave the history of psychiatry portrayed as the drama of heroic physicians combating horrible diseases? Where would it leave psychiatrists, the law, and the public that depend on the myriad social institutions that rest on the mendacious premises that the phenomena we call "mental illnesses" are illnesses, and that "mental illnesses are like other illnesses"?

Copyright 2007, by The Foundation for Economic Education

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