Wednesday, July 27, 2011

So Says Thomas Szasz

Voluntaryist Issue 22 contains an article called, “The Psychiatric Will,” that introduces fascinating theories and ideas about mental illness that I have never heard previously.

I had heard of Thomas Szasz before in passing, but did not really know much about him at all. Just reading the Wikipedia entry about his views gives me many new things to think about in regards to society’s views on mental illness as a “disease.”

Szasz does not believe in mental “disease,” and he says it is a myth and a metaphor which has (and I presume still does) caused a lot of damage in the past. As I understand it, he says the disease concept developed at least partly because of a desire to control the behavior of others that some found to be undesirable or uncomfortable.

Two historical examples that helped me understand what he means are “hysteria” as a mental problem for women who were not behaving in the way men wanted them to and homosexuality, again as a mental disease for not behaving in the way some in society wanted people to behave.

I’m not sure how I feel about mental “illness’ and “disease” but I do wonder how our continuing efforts to learn about the brain will affect Szasz’ theories.

Szasz has written many books and articles so you can access plenty of information if you want dig deeper into his views but let’s discuss the purpose of this particular article. In this piece Szasz is proposing an idea intended to address the conflict that results from involuntary hospitalization and treatment due to a diagnosis of mental disease.

He wants to respect both the “psychiatric protectionists,” individuals who believe mental illness exists and fear consequences and problems as a result of psychosis and the “psychiatric voluntarists,” who don’t necessarily agree with current psychiatric premises and practices and do not want to see forced hospitalization and compulsory treatment.

Here’s how Szasz describes the two opposing viewpoints:

Psychiatric protectionists
“Many people (and virtually all psychiatrists and other mental health experts) fear the danger of a "nervous breakdown or psychotic illness." These persons believe that mental illness exists, that it is like any other illness, " that it is amenable to modern psychiatric treatment, and that the effectiveness and legitimacy of such treatment are independent of the patient's consent to it. Accordingly, such persons seek protection from life-threatening mental illness and support the use of involuntary psychiatric interventions."

Psychiatric voluntarists:
“On the other hand, some people (including a few psychiatrists and other mental health experts) fear the literal danger of psychiatry more than the metaphoric danger of psychosis. Some of these persons also believe that mental illness does not exist and that psychiatric coercions are tortures rather than treatments. Accordingly, such persons seek protection from the powers of psychiatry and advocate the abolition of involuntary psychiatric interventions.”

Szasz’ solution to this conflict is the creation of a Psychiatric Will, similar to traditional wills and living wills. So to protect the desires of the individual who wishes to prepare for a possible future inability to state his or her desires concerning the possibility of psychiatric problems, the competent individual can state their wishes and desires in writing, which would avoid conflict and indecision of those left to deal with the situation.

Szasz believes individuals have the right to determine their possible future treatment of “mental disease,” just as they do for physical disease and should not be coerced into any treatment.

Of course we can see that individuals wouldn’t necessarily even consider such a possibility. I certainly didn’t before reading this article. So Szasz takes this one step further by saying that society should accept that any individual who does not specifically say he or she WANTS psychiatric coercion in the case of mental problems, would automatically be assumed to prefer liberty over psychiatric coercion.

I really like how Szasz worked to develop an idea that respects everyone, no matter where they stand on the issue of mental illness:

“The use of psychiatric wills might thus put an end to the dispute about involuntary psychiatric interventions. Earnestly applied, such a policy should satisfy the demands of both psychiatric protectionists and psychiatric voluntarists. Surely, the psychiatric protectionist could not, in good faith, object to being frustrated in their therapeutic efforts by persons competent to make binding decisions about their future —specifically, decisions to prohibit personally authorized psychiatric assistance. Nor could the psychiatric abolitionists object, in good faith, to being frustrated in their libertarian efforts by persons competent to make binding decisions about their future—specifically, to authorize, under certain circumstances, their own temporary (or not-so-temporary) psychiatric enslavement.”

As usual, the article itself goes into much more depth that I do here, so if you are interested, read the entire piece.

I think it just might blow your mind, but in a good way.


Paul Z said...

You wrote, "...I do wonder how our continuing efforts to learn about the brain will affect Szasz’ theories."

Szasz has addressed this. If an organic cause is discovered for something that is now called a "mental illness", then this futher establishes that it was not a "mental" illness, but a physical illness that we did not understand the cause of until the new information came to light.

Debbie H. said...

Well that makes sense Paul. So much so that I'm having a "duh" moment right now. Of course that would move things to an organic level. I wonder how that will play out. For example, aren't people now saying that addiction is a real organic disease in the brain? That it's not a fight of the "will" but that there is a real physical problem in the brain.

Paul Z said...

I have a psych degree and have in the past worked in both drug/alcohol rehab units and in psych units.

Yes, the "disease model" is applied to addiction (to both booze and other drugs) and there are genetic predispositions to addiction and demonstratable, observable changes to the central nervous system to addicts. On the one hand addiction is recognized and treated as a disease, on the other hand, it is treated as a crime. At one time homosexuality was also treated as a disease and as a crime.

If one is accused of being 'mentally ill' and someone, for example an ER doctor (who might be an intern who has no psychiatric experience) claims that you are either a danger to yourself or others (and refusing to take your medication can be cited as evidence that you are a danger to yourself), then you can be held on a 72 EDO (emergency detention order). This is Indiana that I'm talking about, but most other states have similar laws. So without any crime, without a defense lawyer, without a judge or jury you or anyone can be held against their will in a locked psych unit. If you try to argue with the staff and say you're not crazy and don't belong there they'll just take that as evidence that you're in denial and discount anything you say because you're 'crazy'. After 72 hours they hold a court hearing (the psych unit I worked in had a court room attached for these hearings) and normally the judge discounts what you have to say and believes the 'experts'.

Most people in psych units are troubled people, or obnoxious people, who are odd or disturbing in someway, who are locked up 'for their own good'. Most have committed no crimes or done any wrong, but they are people, like Dr. Szasz says, who exhibit behavior that we don't want to see.

There are also a minority of people in psych units who are criminals who are seeking to play the system by pretending to be 'crazy' (see 'One Flew Over the Cuckoo's Nest').

People have so absorbed this idea of mental illness that when someone commits some horrendous crime (for example the Arizona shootings of the Congresswoman and others) that people automatically say, he must be crazy, who else would have done such a thing?

Dr. Szasz wrote an article about just that:

Sgt. Jarhead said...

I think a psychiatric will is a great idea for all voluntaryists. The ideas we advocate are so foreign to most people, that we are sometimes labeled as kooks and crazies. On my road from neo-conservatism to voluntaryism, I had a few discussions with family members who were "concerned about my well being." Now that I have had more time to express my views, I am actually bringing them around to the philosophy. These ideas take time to discuss in full. A knee jerk reaction by a well meaning family member could cause a lot of problems for a voluntaryist who has a hard time expressing their worldview.

Having a will in place would be in our best interests.