Commentary: Coercion as Cure: A Critical History of Psychiatry by Thomas Szasz

From the Canadian Journal of Humanities and Social Sciences
2010, Vol. 1, No. 1, 95-99

Thomas Szasz has been a psychiatrist for about as long as I, born in 1952, have lived. This year we saw the 50th anniversary edition of the book that marked his full-scale assault on coercive psychiatry—The Myth of Mental Illness. Szasz' productivity is astounding—even in the last four years, he has added dozens of articles and a handful of major books to his incredible body of work (see www.szasz.com). This essay is a commentary on Coercion as Cure: A Critical History of Psychiatry.

Szasz chooses a quote from one of his own intellectual inspirations, Lord Acton, for the epigraph of the book's preface:

All modern history, as learnt and taught and accepted, is purely conventional. For sufficient reasons, all persons in authority combined, by a happy union of deceit and concealment, to promote falsehood.
—Lord Acton

Szasz provides his view of psychiatry in the first page of the preface, and it is a clear window to his teachings:

I regard 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. (p. xi, italics his)

This man does not mince words: "Despite seemingly radical changes in psychiatric principles and practices during the past half century, I contend that the truth about this mala fide medical specialty remains so terrible that it invites disbelief " (p. 13). It is necessary to read Szasz to get a thorough explanation of the above two quotes.

Coercion as Cure is a pure history book, and as the subtitle indicates, it is critical. Many, perhaps most, of Szasz' other books also emphasize history in varying degrees. His classic 1970 volume, The Manufacture of Madness: A Comparative Study of the Inquisition and the Mental Health Movement, is particularly significant. In it he lays out the shift from religious persecution to psychiatric oppression as primary tool of social control, a reflection of the general cultural shift in worldview from religion to science. Szasz is a master of aphorism and analogy, and this one sums it up:

The Inquisition is to Heresy as Psychiatry is to Mental Illness.

Szasz published a related book three decades later, Liberation by Oppression: A Comparative Study of Slavery and Psychiatry (2002). A similar analogy might be, "Slaveowners are to slaves as psychiatrists are to mental patients." Chattel slavery was the norm from the founding of this country in the seventeenth century until it was abolished after the Civil War. Only then did the tension between liberty and slavery decrease.

As Szasz explains in Coercion as Cure, as soon as mad doctors started coercing and restraining people, there has been tension as some citizens argue for liberty and against paternalistic coercion. Regrettably the claims to virtue have held sway. Thomas Szasz is a libertarian, and emphasizes the virtues of liberty and tolerance. He notes that our country's founding fathers argued and fought for freedom of religion and against governmental intrusion into the private lives of citizens, and warned against the constant tendency of government to slide towards tyranny. The movement toward freedom of thought, belief, expression and affiliation has continued, from freedom of religion to other liberation movement for groups including people of color and women. It is folly to coerce, better to be tolerant—unless one is judged as "mentally ill," in which case a false or dissident belief becomes a delusion and a vision a hallucination, denoting "mental illness" and justifying complete abrogation of the principles on which this country was found. This was a blind spot for the founding fathers and continues to this day. Szasz marshals the evidence and lays out the history and current practice of psychiatric oppression as the most grievous remaining violation of freedom, liberty and tolerance. He devotes a couple of pages to one of our country's founding fathers who holds particular significance to psychiatry, so much so that the man is in fact honored as founding father of American psychiatry, his face emblazoned on the official seal of the American Psychiatric Association. Here is what Dr. Rush had to say in Medical Inquiries and Observations Upon the Diseases of the Mind, originally published a year before his death in 1813:

TERROR acts powerfully upon the body, through the medium of the mind, and should be employed in the cure of madness. ... FEAR, accompanied with PAIN, and a sense of SHAME, has sometimes cured this disease. [emphasis in original]

The title of Coercion as Cure simply and directly sums the situation up; the use of force is justified as necessary psychiatric treatment.

To see clearly through the linguistic obfuscation that is psychiatric rhetoric, one must understand the twisted ethics, and Szasz is the best I know in making it clear. He takes to task prominent experts on psychiatric ethics, such as Paul McHugh and Sidney Bloch, who minimize or simply deny the liberty violations and extent of harm done in the name of psychiatric coercion. Szasz shows how in the past psychiatrists resolved the problem that, given their task, they could not abolish the use of restraint by simply declaring that restraint is a remedy; hence coercion as cure—they always at least intended to do good! This was the situation when Szasz began work as a psychiatrist in the 1950s. He quotes from Sidney Bloch's Psychiatric Ethics to demonstrate the "mind-numbing jargon" of today's rhetoric:

Is there an optimal ethical framework for psychiatry? We propose a particular complimentarity of principlism (sic)—with its pragmatic focus on respect for autonomy, beneficence, non-maleficence and justice—and care ethics, a variant of virtue theory, which highlights character traits pertinent to caring for vulnerable psychiatric patients." (Bloch & Green, 2006; quoted in Szasz, p. 224)

Szasz comments that heart and cancer doctors also "care for vulnerable patients," but that only in psychiatry is care a code word for coercion. He says that, "Our society insists that the psychiatrists who deprives a person of liberty in the name of mental health serves the best interests of the imprisoned person, that psychiatric incarceration is preventive and curative medicine." (p. 225) It is medical malfeasance for the psychiatrist to refuse to coerce, and it is a symptom of mental illness for the citizen to deny and resist the "help."

In addition to a laying out the general issues that mark the lifework of Thomas Szasz, Coercion as Cure covers tremendous ground as a treasure trove of specific history. This is the kind of history that while troubling is very fascinating because it is so real and relevant. Szasz lays out the history on institutions and includes significant chapters revealing little known history on 'moral treatment," psychiatric epileptic colonies and lobotomy. Two meaty chapters address the ubiquitous arena of psychopharmacology. A chapter called "Shock and Commotion: Terror Therapy" covers the mechanical treatments, including but not limited to insulin coma and electroshock, also known as electroconvulsive therapy or ECT. As an active electroshock abolitionist (www.endofshock.com), I have learned a lot about that particular brain-damaging procedure. I knew for example that Ernest Hemingway had killed himself after a second series of electroshock at the Mayo Clinic. Here is the story as cited in Leonard Roy Frank's Electroshock Quotationary:

What these shock doctors don't know is about writers and such things as remorse and contrition and what they do to them. They should make all psychiatrists take a course in creative writing so they'd know about writers.... Well, what is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure but we lost the patient. It's a bum turn, Hotch, terrible.

ERNEST HEMINGWAY (U.S. electroshock patient and writer), remarks to the author who was visiting him at the Mayo Clinic in Rochester, Minnesota where Hemingway was being electroshocked in 1961, quoted in A. E. Hotchner, Papa Hemingway, ch. 14, 1967. During one of his stays at the Mayo Clinic, Hemingway had posted on the door of his room a notice, the first sentence of which read, "FORMER WRITER ENGAGED IN PREPARATION OF SCHEDULED FULL-SCALE NEWS CONFERENCE" (quoted in Frederick Busch, "Fear Was His Beat," New York Times Book Review, 25 July 1999). A few days after being released from the Mayo Clinic following a second electroshock series in 1961, Hemingway killed himself with a shotgun blast to the head at the age of 61. Several years later, Howard P. Rome, his Mayo Clinic psychiatrist, was elected president of the American Psychiatric Association. (http://www.endofshock.com/102C_ECT.PDF)

I learned another twist to the tale from Coercion as Cure. In a chapter called "Dauershlaf: Requiescant in Pace," Szasz lays out the history of the so-called "rest cure", little known to most of us. It seems a prominent nineteenth century Philadelphia physician, Silas Weir Mitchell, was famous for his "rest therapy," and as a celebrity doctor, treated a host of prominent American women, including Jane Addams, Rebecca Harding Davis, Charlotte Perkins Gilman, and Edith Wharton. As we have learned to expect from Szasz, he translates the rhetorical claims to virtue and reveals the underlying dynamic—in this case, "that "the real therapeutic agent is male medical authority, reinforced by the family and society. Mitchell knew what he was doing, and many of the patients knew it as well. He was teaching self-assertive, 'rebellious' women a lesson, and many of his patients never forgave him for it." ((p. 107) Regarding Hemingway, it seems that one of Mitchell's famous male patients was Clarence Hemingway, Ernest's father and a physician himself, who ended up committing suicide by shooting himself !

There are countless similar gems throughout this book, but I am emphasizing the perspective Thomas Szasz has labored a lifetime to share and which is beautifully conveyed in Coercion as Cure. His concluding commentary includes a quote from the Roman playwright Terence (Terentius, c. 190- 160 B.C.): "Homo sum: humani nil a me alienum puto," I am human: nothing human is alien to me."

Szasz goes on to state the opposite principle on which psychiatry rests, demonstrating once again his masterful prowess as a wordsmith: "I am human: nothing alien is human to me." Everything about psychiatric labeling and treatment functions to pathologize and suppress difference as "abnormality." Even people who at least know a little about the work of Thomas Szasz do not realize that he really is a freedom fighter and an intense activist against oppression and for tolerance of diversity and freedom of mind and action, a philosopher of liberty (Breeding, 2010, m.i.p.). Liberty supports responsibility, coercion creates non-agency and destroys morality.

Back to the very beginning of Coercion as Cure—Szasz chose to quote Friedrich Nietzsche as his frontis page:

This is the great, the uncanny problem which I have been pursuing the longest: the psychology of the "improvers" of mankind. A small and bottom modest, fact—that of the so-called pia fraus [holy lie]—offered me the first approach to this problem: the pia fraus, the heirloom of all philosophers and priests who "improved" mankind. Neither Mann nor Plato nor Confucius nor the Jewish and Christian teachers have ever doubted their right to lie. (1895)

Neitzsche said this was the longest of his pursuits; he died young. Szasz turned 90 this year 2010, which also marked publication of the 50th anniversary edition of The Myth of Mental Illness. He wins the prizes for endurance and longevity in pursuit of understanding and exposing the pia fraus of the psychiatric improvers.

A final joy I obtained from this book was one answer to my wondering how it is that a man endures so long in a relentless and largely unsuccessful—in the sense of stopping or even slowing down the coercion and the damage wrought by psychiatry. And make no mistake, Thomas Szasz has not been deterred—even in the last four years, he has added dozens of articles and a handful of major books to his incredible body of work (see www.szasz.com). He ends the preface to Coercion as Cure with an answer:

I believe, with Whitman, that

Liberty is poorly served by men whose good intent is quelled from one failure or two failures or any number of failures, or from the casual indifference or ingratitude of the people, or from their sharp show of the tushes of power, or the bringing to bear soldiers and cannon or any penal statutes. Liberty relies upon itself, invites no one, promises nothing, sits in calmness and light, is positive and composed, and knows no discouragement….How beautiful is candor!… Henceforth let no man of us lie. (Walt Whitman, 1855, Preface to Leaves of Grass)

One of my favorite history books is called, Lies My Teacher Told Me: Everything Your High School History Textbook Got Wrong. Loewen took a year and did a critical review of a dozen high school history texts, and exposed a lot of the false and/or significant missing data. The book is a powerful revelation of Lord Acton's point about history. My personal favorite historian is the recently deceased Howard Zinn; his People's History of the United States is a classic rejoinder to mainstream history. I heard Zinn speak in Austin a few years ago and he shared the statement that, "If you don't know history it is as if you were born yesterday!" He was speaking during this current period of United States aggression in Iraq, so he used President George W. Bush as an example, saying that if you did not know history you might think that presidents tell the truth about reasons for going to war and tend to believe Bush. Or if you recognized a lie, say about weapons of mass destruction, you would likely think that it is just that bad Mr. Bush who lies. But Zinn knows history, so he went on to give examples of how over the centuries, virtually every United States president, Democrat or Republican, has lied to the people in order to motivate public sentiment to support one war or another. For clear perspective and understanding it is important to know some history, and in terms of the history of psychiatry, Coercion as Cure is a great gift.

© 2010 by the CJHSS