Review: Coercion as Cure

[Thomas Szasz. Coercion as Cure: A Critical History of Psychiatry. New Brunswick, NJ: Transaction Publishers, 2007.]

Thomas Szasz is a right-libertarian who has been writing against psychiatry since the 1950s. Despite his libertarian (that is, classical liberal, not anarchist) bent, his writings have been held in high regard by many left-leaning anti-psychiatry activists, including many of those in the milieu in which the interviewee for my current chapter was active. Szasz has written many books, and this is the second of three that I will be reading and reviewing on this site. (Here is the first.)

Szasz "regard[s] psychiatry as the theory and practices of coercion, rationalized as the diagnosis of mental illness and justified as medical treatment aimed at protecting the patient from himself [sic] and society from the patient" [xi]. This book systematically examines each major sort of psychiatric intervention in a historical way. Rather than being concerned with evaluating the evidence about what each intervention does or does not do as a treatment, in this book Szasz focuses on the ways in which each has been integrated into (and themselves become) practices of coercion. I have mixed feelings about this choice. On the one hand, the coercive nature of so much psychiatric practice tends to be ignored or erased in more mainstream discussions, so foregrounding that aspect is useful. At the same time, I think it could have been even more powerful to look at efficacy/impacts at the same time, in a way firmly grounded in Szasz's perspective on coercion. Though my vision for how this could be best done would, I think, require a more thoroughly critical analysis of knowledge production than Szasz offers.

He makes a very sharp distinction between psychiatry in which the patient is a voluntary participant, and psychiatry in which participation is coerced. In fact, he argues that they should have different names, because "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'" [xii]. This book focuses exclusively on the involuntary version.

The psychiatric interventions covered in the book include psychiatric incarceration, physical interventions designed to cause "shock or commotion," the so-called "moral treatment" of the 19th century, sleep therapy, insulin and electric shock therapy, lobotomy, and psychoactive drugs. Each chapter contains useful information usually omitted in uncritical accounts of psychiatry's history. He quotes extensively from the words of psychiatrists themselves to document massive, sustained atrocity committed in the name of psychiatry.

As I noted in my earlier review of a work by this author, there are a lot of challenging ideas that deserve to be taken up and other sorts of interesting material, but some of the underlying assumptions and the political framework that Szasz works with are quite troubling. As well, there were things about the writing in this book that I didn't particularly like.

I'll start with the writing. Though it was certainly not difficult to follow and it clearly articulated the author's ideas, the book was a bit disjointed, occasionally repetitive, and often had a tone that, though it is not quite the right word for this context, I can only describe as sectarian. The disjointedness was created in part by the decision to organize the book by intervention. I can see the value in that decision, but it also meant that there was a lot of jumping back and forth in time and less scope for smoothly integrated themes or arguments that could emerge in linear ways. I think the disjointedness was also created by the author's tendency towards a kind of anecdotal approach to writing. I should clarify I don't mean "anecdotal" in the ways that positivists use that word to smear certain approaches to history and social research -- I tend to like those approaches. My issue with it here is more about a tendency towards asides, unclear jumps, and interruption of flow. The repetition was also a result of organizing the book according to intervention, though it was also a product of the author's need to make the same handful of points over and over again. And the sectarianism -- like I said, that's not exactly the right word for the context, but there were plenty of spaces in the book where the tone felt similar to certain kinds of posture-prone radical left writing that I tend to avoid.

Overall, though, it was reasonably easy to tolerate these aesthetic concerns. My political and analytical objections are more serious, I think. They are much the same as in the previous review, though the emphasis differs with this volume.

Because of his grounding in classical liberalism and libertarianism, he is very critical of the state, which I have sympathy for, but has a theory of the state that is quite limited and narrow, and almost no analysis of oppressive and exploitative social relations beyond the state. While I think it is important to pay attention to the dangers of state involvement in health and medicine, his analysis that a completely unfettered capitalist market is the ideal way for people to obtain goods and services related to health and medicine and that any way of organizing, regulating, funding, or delivering such services other than this is a path to tyranny, strikes me as a typical liberal sort of willful blindness. It is grounded in the mistaken idea that the capitalist market is actually free in more than a very limited sense for the majority of people, and in a limited understanding of how ruling and domination actually happen.

I think I agree with Szasz that it is important to name and oppose coercive practices that come under the banner of psychiatry, and that naming coercion is one of the primary political factors when understanding how we respond to the diverse phenomena categorized as "mental illness." However he draws a sharp, simple boundary between "coerced" and "voluntary" that just does not reflect a lot of the crucial insights by many writers over the last fifty or sixty years into how power actually works. Using a more sophisticated and less binary understanding of how coercion happens would lead to a quite different, and to me much more interesting, analysis. I think this issue again goes back to his grounding in classical liberalism, because his use of this sharp binary tends to replicate the separation between the sorts of power-over that liberalism sees and opposes and the sorts of power-over that it refuses to see and thereby tacitly endorses.

However, it is also related to his attachment to the classical liberal understanding of the human subject. He references three possible frames for understanding human behaviour in this book, which really boil down to two approaches. One is the moral frame -- all human actions should be evaluated at the level of individual choices, which is understood to be made by autonomous entities and can then be labelled "good" or "evil." Another is the (liberal-democratic) legal frame, which he says should correspond to the moral frame and its assumptions that all human actions are products of human agency in formally equivalent ways for which individuals can and should be held responsible in formally equivalent ways. However, he deplores the fact that the legal system has incorporated far too much of the final frame, the psychiatric frame, which he argues sees human activities in ways that erase human agency, whether by permitting psychiatric incarceration of people who have not done anything wrong or by excusing evil actions through the "insanity defense." In other words, in his view, in understanding human behaviour you can see agency or you can see some other sort of determination that erases agency (he talks most about psychiatric but would also include social determinations in this category) and that is it. He seems to be saying that by employing the latter you are either engaged in willful deception or a foolish mistake on the path to creating realities that really do deprive people of their liberty.

I would argue, though, that this sort of sharp dichotomy is useless, that you can't understand human behaviour, and you can't evaluate it in ways that are ethically and politically meaningful, unless you abandon this sort of dualistic thinking and recognize that agency at the level of the individual -- which we must, I agree, never overlook or erase -- exists as part of a dynamic, integrated interplay of factors below the level of the individual that we do not choose as well as social factors. Under such an approach, agency is still important, but not a liberal fantasy of atomized, abstracted, and unrealistically autonomous agency. Values and responsibility are still part of the evaluation, but not in ways that detach agents from the ways in which their social circumstances and subjectivities are socially produced. Of course, one of Szasz's main concerns is with legal practices around mental illness, and I'm not sure how this more integrated approach to evaluating human activities can be reconciled with liberal-democratic legal systems; perhaps it cannot.

My final concern goes to the very heart of Szasz's analysis of "mental illness." As with a number of key issues in his writing, it's not that I agree more with the dominant ways of understanding things than with his analysis. I disagree with both. He bases much of his assertion that mental illness does not exist on the fact that conventional psychiatry reduces the mind to the brain and assumes a physical basis for mental illness that in most instances it cannot demonstrate, and that this allows psychiatry to take on a medical stance along with authority grounded in physical and biological sciences. At the same time, whenever something is irrevocably demonstrated to be a brain disease rather than a psychiatric disorder (such as the symptoms of late-stage syphillis were in the late 19th or early 20th century) then they cease to be the province of psychiatry and become neurological -- that is, genuinely medical. He argues that "mind" is an abstraction that is obviously connected to "brain" but that is cannot be reduced to it.

I think there is useful stuff in there, but I would turn it all a bit sideways. I agree that the epistemological basis is inherently different for the province of action currently claimed by psychiatry and that claimed by the rest of medicine. The former starts from complex human behaviours and experiences, which we can learn about and come to understand in particular ways; the latter from changes in the body that can be subjected to a much different, physically-based kind of research. I'm not sure the difference is necessarily as sharp and as clearly "bad vs. good" as Szasz sometimes portrays it, because I think practices that result from the latter kind of knowledge production can and should be subjected to similar sorts of critical analysis as the former. That is, just because formal, liberal-recognized power-over and coercion do not exist in conventional doctor-patient relationships does not mean that the kinds of knowledge informing the practices of doctors and the imbalanced power between doctor and patient do not have a lot of oppressive consequences in our experiences of healthcare. Nonetheless, these two forms of creating knowledge about human beings are meaningfully different.

He argues, I think, that complex human experiences and behaviours, though obviously not unconnected to the body, are distinct from the physical brain and it is meaningless or even oppressive to seek the origins of the former in the latter. I would frame it a bit differently. We are integrated entities. I don't think it makes sense to posit "mind" as separate from "brain", as Szasz seems to do. Nor do I think it makes sense to reduce "mind" to "brain," as conventional psychiatry often does. I think, rather, that human experiences and behaviours are integrated with and emerge from our brains and from our bodies more generally in complex and chaotic ways. Szasz, it seems to me, has a kind of 19th century understanding of science, how it produces knowledge, and what it has to say about causality. Given this, no wonder he objects to the rooting of "mind" in "brain." Most contemporary scientists share this understanding, though not all. However, I would argue that growing understanding through the 20th century of complex and chaotic systems provides room for a much different understanding of causality. If you take this into account, saying that the mind is not separate from the brain does not leave crude biological determinism as your only alternative but it does not depend on perpetuating the myth of the mind/body split either. And it reorients the basis for Szasz's critiques of psychiatry to attack something that he, albeit in a different and more limited way, shares with most psychiatrists: an unbelievable hubris about what scientific research and human intervention are capable of.

I would argue, in my own inexpert way, that seeking to reduce complex human behaviours to fairly blunt measurements of changes in brain chemistry is pretty ridiculous because we do not, and perhaps cannot, map out an easy, obvious, reliable, linear correlation between what we can measure in brains and complex human behaviours. It's not that there isn't a connection, but the kind of connection assumed by most psychiatry, particularly biological psychiatry, is not plausible. One of the ways in which biological psychiatry has used this simplistic misunderstanding of the connection between complex human behaviours and biology is to dismiss the value of actually engaging with people who are in mental anguish as subjects. But one of the points that seems obvious to me, though that I have not yet seen anyone else make it in my recent readings about psychiatry and anti-psychiatry, is that not only is complex human behaviour grounded (in non-clockworky ways that are far beyond our understanding) in biological processes, but that human experiences and complex human behaviours must shape those biological processes too. So seeing some rough correlation in some people between a particular kind of mental anguish (X) and particular patterns in the limited attributes of physical brain-states that we can measure (Y) does not necessarily mean in any simple sense that Y has caused X and therefore the only logical response is to infuse a chemical related to Y into the system to correct X. Surely by addressing X at the level of complex human experience -- some sort of working-stuff-out support -- will also in some instances change Y. Or maybe it won't and the person will feel better anyway.

In saying this, I'm not dismissing people who find psychiatric interventions like medication to be useful or that such interventions, when not imposed, are necessarily bad, though I think our actual understanding of what these things are doing to our brains is much, much more limited than psychiatric professionals, and especially popularized understandings of psychiatry in the lay media, usually admit. The thing is that we have to recognize the bluntness of the instrument, and the fact that so often underlying the health-based rhetoric, the intended goal of the instrument is not actually helping people deal with their own anguish but controlling behaviours that other people wish to be changed.

In presenting this model, I agree that much of the time importing the disease-model for experiences of mental anguish is destructive and we need new vocabulary, new concepts, new approaches. At the same time, Szasz's tendency to completely privatize experiences of mental anguish isn't helpful either. Often these experiences have been socially produced. I don't feel he presents evidence that they are never biologically produced, either. And for all that the disease metaphor brings lots of bad stuff with it and inappropriately implies links to a kind of knowledge production that just isn't applicable, whatever new way we come up with for thinking and talking about mental anguish has to allow for the fact that people do experience things going on inside of them that are unpleasant, that they do not want, and that they wish outside assistance to get rid of, even if we don't call it "mental illness."

I think, for all he raises useful questions about the role of the state, his arguments against social responses to mental anguish are specious. The question, of course, is what kinds of responses, and socially organized in what ways. Certainly I agree with him that the kinds of responses that are based in control rather than empowerment and support are things we should oppose. I don't agree with him, though, that there is no reason to modulate our understandings of human agency based on an individual's experiences of extreme mental anguish, though I have no easy, reliable, "objective" way to do that, and I am skeptical of current approaches. But we need to have ways to deal with the fact that you didn't choose to feel this way, feeling this way is not necessarily some easy moral consequence of past choices, and you can't just choose to feel differently. There is a social obligation to create real, empowering alternatives you can seek to deal with feeling this way, reacting this way, experiencing life in this way, that will not stigmatize, will not pull you into horrible coercive processes, will not end up amplifying your anguish.

As to the question of whether and when and what kind of coercive interventions might be legitimate in general, I don't have a ready-made answer. I agree that most of the time coercion is not legitimate, and it is valuable to deconstruct the medical pretext for current coercive interventions that are not really about health at all but about control and exertions of power of one sort or another. Coercive interventions -- and I'm not just talking about those currently justified by calling them "psychiatry" -- should be based on the safety of others rather than disingenuous claims about helping the person being coerced, at the very least. But what is justified and when, and how to really develop an understanding of and meaningful opposition to the sorts of coercion that liberals usually refuse to see as coercive, is a whole different topic.


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