Book Review

Coercion as Cure: A Critical History of Psychiatry

N Engl J Med 2008; 358:435-436January 24, 2008

Article

Coercion as Cure: A Critical History of Psychiatry
By Thomas Szasz. 278 pp. New Brunswick, NJ, Transaction, 2007. $34.95. ISBN: 978-0-7658-0379-5

Thomas Szasz, professor of psychiatry emeritus at the State University of New York Upstate Medical University in Syracuse, has written more than 30 books that have made his reputation as a gadfly of psychiatry. The first, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (first published in 1961), was the most influential. Szasz wrote it during the U.S. Civil Rights Movement, and in it he questioned whether schizophrenia is a valid medical diagnosis and proposed instead that schizophrenia is society's mislabeling of alternative lifestyles and beliefs as deviant. Civil rights movements have held up the treatment of persons with mental illness as examples of the repression against which they were rebelling. Philippe Pinel's seminal reform of the treatment of patients with mental illness began in the context of the French Revolution in 1792. Nearly all repressive regimes either have targeted persons with mental illness for extermination, as the Nazis did, or have used mental hospitals to incarcerate and torture political prisoners, as the Soviets did. Szasz's works are polemical, but they have failed to bring any insight into the fundamental medical and sociological issues that could be raised about the diagnosis and treatment of mental illnesses. Coercion as Cure, which focuses on involuntary mental health treatment, is no exception. The repetitive assertions that relate to the book's argument are interspersed with Szasz's attempts to belittle critics of his previous books.

The fundamental assumption of involuntary treatment is that some cases of dangerous behavior indicate abnormal physiology or psychology. To the extent that the behavior is imminently dangerous to others or to the patient, some form of protective restraint is required. In U.S. society, such restraint is regulated by the justice system instead of by the treating psychiatrists. Its length and intensity — which can range from incarceration in the penal system to periodic outpatient visits — is limited by the judge's decision. The psychiatrist's role in this process is to provide a medical opinion about whether the behavior reflects an illness that is likely to respond to treatment. A murderous impulse that is provoked by the delusions of schizophrenia is currently considered treatable, whereas a lifelong history of cruelty because of sociopathic personality disorder is not. Although psychotropic medications are effective treatments for mental illnesses such as schizophrenia, involuntary medication requires specific judicial consent.

In his earlier works, Szasz argued that psychiatric diagnosis was flawed, and in this book he proposes that the flaw is magnified by coercive treatment. Recent events such as the shootings at Virginia Tech suggest that psychiatrists need to be more active in recommending involuntary treatment for psychotic individuals whom they have assessed as mentally ill and dangerous. Most states have adopted legislation that allows such persons to be ordered to receive longer-term treatment in outpatient settings. Szasz does not grapple with the complexities that the Virginia Tech case raises and instead bombards readers with a litany of the abuses of previous generations of psychiatrists. The lesson of the book, if there is one, is not that involuntary treatment makes the field of psychiatry evil, as Szasz asserts, but rather that psychiatry is neither better nor worse than the society in which it is embedded and the character of the physicians who practice it.

Robert Freedman, M.D.
University of Colorado at Denver, Denver, CO 80262
robert.freedman@uchsc.edu