Needed: Voluntarist Psychiatry
A libertarian critique strikes at the very foundation of psychiatry, for nearly all of that institution grows upon assumptions hostile to personal freedom and personal sovereignty. By personal freedom, I mean individual people's right and potential for maximum freedom of action within their chosen environment—freedom limited only by restraint upon acts which unequivocally aggress against the freedom of others. By personal sovereignty, I mean something more subjective and personal—individuals' right and capacity to seek the fullest experience of their own passionate, intellectual and spiritual life, and to hold themselves totally responsible for the judgments and decisions which they make.
Personal sovereignty to me is an absolute. Individuals can and ought to decide for themselves what they will think and feel, and they can and ought to hold themselves responsible for each and every judgment that they make. While there will always be some limits on personal freedom—albeit very circumscribed ones in a libertarian society—there must never be any limits on personal sovereignty. A person's internal life must be entirely his own possession. Personal sovereignty is thus the subjective, psychological counterpart of personal freedom in libertarian politics.
Psychiatry is generally hostile to both personal freedom and personal sovereignty, but it is most menacing in the area of personal sovereignty. Psychiatrists specifically assign to themselves the realm of the mind—other people's minds—and much of what they do is based upon the assumption that they can and should judge the content of what goes on in these other minds. Because of this, whatever freedom ideology psychiatry pretends to espouse, its history and practice have been characterized by the most antilibertarian principles and practices.
In this critique of psychiatry, I cannot hope to raise, let alone solve, the myriad of problems inherent in such drastic criticism of an existing institution. My intention is merely to present a perspective on psychiatry that has received all too little attention.
Institutional psychiatry began more than three centuries ago in 17th century France at the start of industrialization and urbanization, when new means were sought to control large, uprooted masses of people milling about and languishing in the growing cities of Europe. Up to then, psychiatry as a medical specialty had been almost unheard of, and mental hospitals, very few in number, were private institutions, usually run by religious orders, and typically serving the needs of the rich to lock up their more difficult or disturbed relatives. With the urbanization of Europe, however, more efficient and expeditious methods were called upon to incarcerate and "rehabilitate" the large numbers of sick, indigent, disabled and abandoned from the lower classes. Thus psychiatry from the start reflected an antilibertarian or totalitarian alliance between government civil authority and the industrialization process. As Michele Foucault describes it in Madness and Civilization:
From the very start, one thing is clear: The Hopital General is not a medical establishment. It is rather a sort of semijudicial structure, an administrative entity which, along with the already constituted powers, and outside of the courts, decides, judges, and executes.…A quasi-absolute sovereignty, jurisdiction without appeal, a writ of execution against which nothing can prevail—the Hopital General is a strange power that the King establishes between the police and the courts, at the limits of the law: a third order of repression. The insane whom Pinel would find at Bicentre and at La Salpetriere belonged to this world.
In America, as elsewhere, there were only a handful of large mental hospitals before the industrial revolution. Prior to 1830, only a few existed, but by 1860, there was at least one major facility in every state, all in response to urbanization. These enormous lockups have remained with us today, and as the latest statistics from the National Institute of Mental Health confirm, poverty, unemployment and lack of education are still the main variables which describe the inmate populations.
The police state orientation of these modern institutions is no better expressed than by J. Sandor Bockoven, himself a state hospital superintendent in Moral Treatment in American Psychiatry:
The Mental hospital's relationship with its patients is entirely predicated on the thesis that the patient cannot be trusted and must therefore be kept under complete control. Indeed the very essence of the function of the mental hospital is that of controlling and protecting. The attendant controls the patients and protects them from each other. The nurse controls the attendant and protects the patient against his harshness or laxity. The physician controls the nurse and protects her against supposedly unprincipled attendants, while the superintendent controls his physicians and protects them against the critical public. The energies of the hospital staff are expended in maintaining personnel at a high pitch of alertness to all signs of impending violence of patients. The prevailing psychological climate is one resembling military vigilance against attack. High value is placed on unquestioning obedience to authority, and traditional hospital customs and procedures are revered for their ostensibly time-proven worth in averting disaster. Proposed changes are viewed as threats to the security of all concerned. The entire hospital society has a vested interest in the status quo and looks to the superintendent as the greatest single stabilizing force assuring its preservation.
From the beginning in the 17th century, the backbone of this institutional psychiatry has been involuntary treatment, a process whereby one or two psychiatrists, with or without a judicial rubber stamp, assume total power over the fate of the individual by declaring him "insane" or "mentally ill." This method of imprisonment, made without the due process typical of criminal proceedings, leaves the individual at the mercy of his "physician" who can often determine both the length of stay and the "treatment," which may include anything from solitary confinement to lobotomy.
Thus for 300 plus years, institutional psychiatry has been and continues to be a totalitarian institution, one of the worst in the Western world.
Institutional psychiatry has maintained this totalitarian thrust wherever it has insinuated itself into the society. In the courts, psychiatry engenders its totalitarianism by declaring individuals unfit for trial by reason of incompetence, thereby frequently dooming them to life-long incarceration for alleged crimes which, with conviction, might have earned them meager sentences. In the prison system itself, psychiatry justifies the most cruel and unusual punishments under the guise of treatment—everything from behavior modification by means of fear-inducing drugs to psychosurgery. In the government, schools and military, psychiatrists are used to control, isolate or dismiss troublesome individuals who might otherwise escape these fates through appeal to due process.
Biological psychiatry has been the henchman of repressive institutional psychiatry from its inception. Throughout the first centuries of psychiatry, masses of patients were beaten into submission by bleeding, dunking, whipping, cold water baths, poisoning, and starvation, all in the name of biological therapy. Even so sanguine a critic of psychiatry as Emil Kraeplin must describe in One Hundred Years of Psychiatry a history of atrocities unparalleled by anything save the Inquisition. The father of American psychiatry, Benjamin Rush, still revered in psychiatric histories, regularly bled his patients after that custom had been long abandoned in medicine. He described threatening them with weapons, pouring cold water down their armpits and spinning them around in a mechanical chair—all to subdue their anguished resistance against the hospital. Even slavery in America fell short of such generalized barbarity, if only because a relatively healthy slave was required for the performance of work.
In the 1930's, haphazard attacks on the body gave way to more effective assaults on the integrity of the brain. International war against the mental patient began with the technology of electroshock, insulin coma therapy and lobotomy. Electroshock, borrowed from the slaughter houses of Italy where it knocked out livestock, was used with equal efficiency in subduing mental patients by obliterating the mental capacities with electrically induced grand mal seizures. Insulin coma produced the same result; a dulling, obtunding and confusing of the person by subjecting their brains to a lowered blood sugar with resultant coma and convulsions. For those who survived sufficiently to express still more anguish and resistance, lobotomy made the pacification more permanent. Each of these therapies works primarily by its assault on personal sovereignty, robbing the person of his mental capacities and subjecting him more easily to the control of others. Thus the illusion of increased personal freedom is created at the expense of personal sovereignty, without which the apparent freedom becomes an empty hoax.
This assault continued with growing ferocity until the 1950's with the advent of the tranquilizers, which produce chemical lobotomy, combined with a chemical paralysis, limiting both sovereignty and freedom in a most gross fashion. Recently reports are accumulating to the effect that these drugs can cause brain damage, making permanent many of these mental and physical symptoms and reducing some patients to chronic cripples with fog in their minds and stiffness in their nervous system.
Biologic psychiatry further justified institutional, repressive psychiatry by declaring many forms of human misery and unhappiness to be caused by genetic defect and biologic inferiority. Thus far totally unproven, and hardly likely to find any substantiation in the future, these theories nonetheless carry the weight of truth in many circles. This despite the obvious absurdity of reducing personal and political problems to mechanical explanation. Altogether, the biological conception is rooted in determinism, that most dangerous enemy of libertarianism.
Now we are again witnessing a rejuvenation of genetic and biologic theories of so-called mental illness, along with their implementation in the extreme through eugenic sterilization, and severe biologic assaults, such as psychosurgery. It is important to remember that these approaches, supported by the world's leading authorities and medical journals, led eventually to the extermination of Germany's mental patients early in World War II as a prelude and first phase of the extermination of the Jews for equally "hygienic" reasons. This hygienic approach follows a natural progression, starting with the conviction that personal sovereignty and personal freedom are myths or expendable luxuries, and ending with the actual disregard for human life.
Behavioral psychiatry too is again growing in vogue, though like the others, its history is much older than one might suspect. It is rooted in academic psychology, and from the beginning has been part and parcel of psychological theories which assault personal freedom and individual self-determination. From the start, these theories have been used by psychiatrists to declare human beings objects devoid of free will and personal responsibility and hence fit subjects for control. In Russia, Pavlov carried these theories to the extreme and became the psychologic henchman for Russian materialism, determinism and totalitarianism. In the United States, we now find Skinner arguing against every aspect of "freedom and dignity" on the same behaviorist basis, and indeed, praising the Russian use of Pavlovian control in the 1950's. In every instance, we find behaviorism expressing an antilibertarian view of humans as objects devoid of personal sovereignty and personal freedom.
Behaviorism is rapidly becoming the most dangerous psychological expression and implementation of totalitarianism. It is now replacing Freudianism as the language for justifying control in psychiatry. This is perfectly illustrated by the evolution of Karl Menninger who in the 1930's wrote Man Against Himself invoking concepts like the "unconscious" to justify his control over the patient's life. By declaring the patient driven by "unconscious" drives, he made the patient a fit subject for Menninger's own controls. Now in his more up-to-date book, The Crime of Punishment, he relies almost entirely on a Skinnerian concept of life to justify doing away with due process in the courts while replacing it with "scientific" judgments by psychiatrists. Jose Delgado, a noted psychosurgeon, is still another behaviorist, using these principles to call for a "psychocivilized" state run by methods of psychiatric control.
Meanwhile, psychoanalytic psychiatry has played but a small part in psychiatric history, at first offering the hope of a nonauthoritarian alternative, but eventually succumbing nearly in its entirety to totalitarian institutional psychiatry. Although this fact is expurgated from the education of young psychiatrists, Freud was not a psychiatrist. From the beginning, when he gave up his research in neuropathology, he was ostracized from the psychiatric-medical community. He set up his own autonomous Psychoanalytic Institutes to maintain his separation from the communities of academic medicine and psychology, and toward his last years, in his Autobiography and The Question of Lay Analysis, he argued that a medical degree should not be a requirement for the psychoanalyst. He suspected that medicine's interest in psychoanalysis was largely rapacious.
Freud's fears have proven entirely realistic. Today the Psychoanalytic Institutes require training in psychiatry as a prerequisite, and it is almost impossible to become a psychoanalyst without first becoming a psychiatrist. Almost all psychoanalysts are therefore first trained in the assault on personal freedom and personal sovereignty through institutional psychiatry. They continue these institutional ties even after going into private psychoanalytic practice, and so trained and so affiliated with a totalitarian system, they can hardly practice their trade in another manner. Thus few psychoanalysts have supported the fight against psychiatric oppression.
Freud himself was confused on moral issues in general and libertarian ethics in particular. At times he seemed to put the individual's freedom above all else, as in his fight against those authoritarian deviations from psychoanalysis which encouraged "transference cures" based on the authority of the therapist and the dependence of the patient. But at other times, he couched his work in a pseudo-scientific language which robbed it of any moral and political essence. By doing this, he became a behaviorist who in part at least reduced the individual to the status of an object lacking in free will, self-determination and moral and political responsibility. Nowadays it is typical to find psychoanalytic psychiatrists justifying all sorts of authoritarian interventions on the grounds that they can read the patient's unconscious wishes or have the answers to his psychoanalytic conflicts. (In the January 1974 REASON, Thomas Szasz described how this attitude has corrupted the ACLU itself, turning it into a promoter of the therapeutic state.)
There is a growing awareness in America that psychiatry poses a totalitarian threat. On the other hand, a voluntaristic psychiatry must be no different in its basic conception than a libertarian educational system, religion or social club. In a libertarian psychiatry, we simply maintain our original hierarchy of values—with personal freedom at the top. A voluntaristic psychiatry is merely the determination not to compromise freedom in the name of mental health. The psychiatrist must obviously refuse to cooperate with any involuntary treatment, even if the refusal to use force seems in some way contrary to the patient's immediate best interest. Libertarianism does not flow from the principle of paternalism or even from the principle of a pragmatic concern for individual welfare. It grows from a respect for freedom as the working principle of society.
In my own view, a truly voluntaristic psychiatry must also concern itself solely with techniques which enhance personal sovereignty—or the inherent capacity and desire for personal freedom. A libertarian psychiatrist may decide never to use drugs, electroshock or psychosurgery, if he believes as I do, that they can only work by blunting personal sovereignty. Similarly, he will scrutinize his verbal techniques to rid them of any vestiges of authoritarianism and paternalism.
On the other hand, a libertarian therapist would not interfere with a patient's right to seek elsewhere any therapy which he freely chooses for himself, even drugs, electroshock, or psychosurgery, however personally offensive or wrong-headed they may appear to the therapist. Thus the Center for the Study of Psychiatry, which I helped found, no longer seeks to outlaw psychosurgery but instead encourages malpractice suits when patients have been operated on involuntarily or without fully informed consent.
(Occasionally individuals ask if I don't infringe on the patient's liberty when I refuse to give him drugs or electroshock. Most certainly not. Instead, it would be an infringement on my liberty if I were compelled to offer services which I consider unethical and unsound. It would also be unethical for me to offer techniques which I ultimately believe to be harmful.)
From what I am saying, it should be apparent that I do not envision a single, stereotyped form of voluntaristic therapy, but rather a set of principles from which a variety of therapies can be derived. Some may choose the psychoanalytic model of human problems as improved upon by Thomas Szasz. Others might want a more spiritually oriented therapy. Some might prefer to work individually, others in groups. Libertarian therapies are those consistent with libertarian principle, nothing more and nothing less, and within that category in a free society one would undoubtedly discover a flourishing variety of approaches. Such is human nature that in a free society there will be much opportunity for honest disagreements and for a variety of services.
The degree to which "psychiatric humanitarianism" has permeated western thinking is reflected in my experience that some otherwise consistent libertarians nonetheless drop their love for freedom in favor of paternalism when dealing with psychiatric issues. Thus an otherwise thorough libertarian will challenge me with the question, "But what if the individual does not have personal sovereignty?" This is the equivalent of the political-economic question, "What if the person can't compete or can't make it in a free society?" By putting his politics in one pocket and his psychiatry in the other, the half-hearted libertarian in effect says freedom is good—for some people. Once this compromise is made, the entire system of freedom collapses. This is nowhere better illustrated than in psychiatry where the humanitarian "concern for others" leads to incarceration of uncounted millions of mental patients in the western world each year.
Put another way, personal sovereignty loses all meaning unless it is assumed to exist in every one. As soon as one person is allowed to judge another person's sovereignty, that other person automatically loses his sovereignty. That is a fixed principle. Sovereignty, like freedom, is not granted to people, but exists as an inherent attribute of people. It is a natural right, a given, a first premise. When the psychiatrist takes it on himself to decide who is personally sovereign or "mentally healthy" he usurps both personal sovereignty and personal freedom by making it subject to his whims and his will.
This does not mean that we fail to accept the reality of differences among individuals. Any sophisticated person knows that individuals will vary enormously in their capacity or their willingness to make the most of their inherent personal sovereignty and personal freedom. But once an attempt is made to compensate for this by involuntary treatment we have destroyed the very foundations of freedom. We have a therapeutic state rather than a libertarian society.
Libertarianism can be justified from a practical viewpoint as well as from first principles, and the same holds for a libertarian, voluntaristic psychiatry. In brief, one can look at the consequences of involuntary psychiatry, and see in them all the consequences of totalitarianism—manipulation of the person as an object, oppression, inhumanity, and ultimately, a tendency for the totalitarian to seek ever more power for himself, moving us toward a therapeutic state. Compromise with libertarianism simply doesn't work. It merely leads to more compromise, and ultimately, to the loss of ever more freedom.
What then do we do about individuals whom we now commit to state mental hospitals? This question is little different from "What do we do with welfare recipients?" or "What do we do with the poor?"—for in fact most mental patients are poor people. What we must do, of course, is encourage a free society in which each person will have the opportunity to make the most of his life. Committing people to large state hospital lock-ups for their own good is the very essence of the problem, not the solution. It is paternalistic statism; it is this totalitarian solution that has caused the problem in the first place, by robbing the economic and political system of its vitality.
What about the violent patient then? First, it must be acknowledged, as Bruce Ennis has so well shown in Prisoners of Psychiatry, that the mental patient population as a whole is dependent and passive, not violent, and that violence is less common among mental patients than among the general population. Second, we must see that dealing with violence by psychiatric commitment is the ultimate in totalitarianism. A person who is alleged to be violent should be given the protections inherent in the criminal law, and not be subject to the vagaries of personal law as laid down by psychiatrists under commitment proceedings. Ultimately, the convicted criminal should be sent to jail, not to a mental hospital.
If this seems cruel, consider that most prisoners would prefer jail to a mental hospital. This is in part because prison terms are generally shorter than hospital commitments when crimes of violence are involved, for the parole board must work within a prescribed sentence while the psychiatrist is left with total responsibility for the person's future. The psychiatrist is likely to keep the person for fear he will do something wrong again, while the parole board knows the sentence must sometime end. If we feel prisons are terrible places, as they are, then we must reform them. Do not instead use involuntary commitment to mental hospitals as an alternative still more threatening to personal freedom.
But what about the dangerous person who has committed no crime and hence is not subject to criminal prosecution? In a society which values freedom, freedom must not be compromised by a need for security. Mental hospitalization of the potential criminal is "preventive detention" at its worst. It has no place in a constitutional republic such as ours, let alone in a libertarian society.
At the present time, it is extremely difficult to pursue the practice of voluntaristic therapy. The laws of the states and malpractice case law require the physician to incarcerate or otherwise control his client at moments when the client is dangerous to himself or to others, or sometimes is merely "mentally ill" by ordinary psychiatric standards. Libertarian therapists can and do defy these legal responsibilities in our private practices. But it is impossible to run an institution, such as a voluntary hospital or a voluntary retreat, in defiance of these requirements. Therefore, there is no truly voluntary psychiatry on an institutional level in America today.
Until all involuntary treatment is ended, the practitioner of private office therapy will always hold a potential legal gun to their patient's head, and practitioners of institutional therapy will be forced to coerce some of their patients. The first goal of libertarian psychiatry must therefore be the abolition of all involuntary treatment. Once this aim is achieved, truly libertarian alternatives will begin to flourish in competition with each other.
Dr. Peter Breggin is a psychiatrist in private practice in Washington, DC and is the founder of the Center for the Study of Psychiatry, whose purpose is to identify, research and oppose psychiatric interventions where they threaten personal and political freedom. Dr. Breggin is also a novelist, having published The Crazy from the Sane (Lyle Stuart, 1971) and The Good War (Stein and Day, 1972; Popular Library, 1974).