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Psychiatry and the control of dangerousness: a comment
  1. G M Sayers
  1. Consultant Physician and Honorary Clinical Senior Lecturer (Imperial College School of Medicine), Department of Geriatric and General Medicine, Northwick Park Hospital, Watford Road, Harrow HA1 3UJ, UK; gwen.sayers{at}

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    The paper by Szasz is about mental illness and its meaning, and like Procrustes, who altered hapless travellers to fit his bed, Szasz changes the meanings of words and concepts to suit his themes.1 Refuting the existence of “mental illness”, he suggests that the term functions in an apotropaic sense. He submits that in this sense it is used to avert danger, protect society, and hence (superstitiously) justify preventive detention of “dangerous” people.

    But his arguments misrepresent the precise meaning of the term “apotropaic”, which is an adjective, defined in Webster’s, Chambers and the New Shorter Oxford dictionaries as averting or turning aside evil. It is possible that amulets and incantations ward off evil, in the same way as garlic repels vampires, but evil and danger are different concepts. Yet Szasz talks of using phrases like ‘“dangerousness to self and others’ as apotropaics to ward off dangers we fear”, and the word “evil” does not appear in his paper.

    I will argue that “dangerousness to self and others” and “psychiatric treatment” have a prosaic rather than an apotropaic function.

    The word “danger” is familiar rather than arcane, and includes many risks. A predatory paedophile is usually both dangerous and evil, but many dangerous people are not evil. For example, a child who plays with a box of matches is dangerous, as is a demented person who drives a car, or a schizophrenic who, acting on delusional beliefs, arms herself with a knife and roams the streets believing she is an avenging angel.

    Suppose we accept that mental illness is not a disease but rather, as Szasz himself suggests, “not something a person has, but something he does or is”.2 After all, it does not matter whether mental illness is a disease like diabetes or merely a particular state of mind. What matters, is that the mind, however it is conceived, initiates thoughts that may prompt behaviour.

    This behaviour can be judged in moral terms as good or bad, in human terms as harmless or dangerous, in psychiatric terms as normal or abnormal, and in legal terms as lawful or criminal. If judged criminally culpable, the law ensures that both actus reus (bad deed) and mens rea (evil mind) are present, otherwise the person cannot be held responsible for their action, sometimes through reason of insanity.3

    The fact that the substance of psychiatry is subject to reconstruction does not mean it has no substance. It is an evolving discipline that deals with the mind. The mind cannot be measured in the way depth is plumbed. It can only be assessed by way of its manifestations, which are thought content and behaviour. Psychiatry addresses abnormal thinking and acting.

    Szasz rightly points out that the notion of normality is linked to social relativism, but he implies this is reason for psychiatrists and psychiatry to be discredited. A more credible approach would relate psychiatry to prevailing social values. Thus homosexuality, previously classed as a mental disorder, is now considered normal. This is because societal beliefs and attitudes change with time. “Witches” no longer being burnt at the stake, but instead practising their craft undisturbed in Glastonbury, does not discredit the legal system, it simply demonstrates that over time the law is subject to revision.

    When it comes to real rather than mystical “danger”, there are two types to consider in conjunction with this paper. People described as having “dangerous severe personality disorders”, who do understand the nature of their actions, do appreciate reality, and are both legally and morally accountable for their actions, may cause harm. And psychotic individuals, who cannot be held legally or morally responsible for their actions because they are divorced from reality, may be dangerous to themselves and others.

    Some psychotic individuals manifest irrational homicidal behaviour and kill their victims, sometimes strangers to the patient. Some display irrational suicidal behaviour. Recently, a schizophrenic man entered the lion enclosure at London Zoo. Assuming he had the mistaken belief that he was Daniel would not make his behaviour rational, if only because he was not Daniel and got eaten, which was not what he intended.

    Szasz cites the NAMI web site, and ironically likens the manipulative tactics of patient advocates trying to help relatives of emotionally disturbed patients, to the Ku Klux Klan representing the interests of black Americans. The validity of this statement depends on how interests are to be defined. Most relatives care about the harm that could be caused by a disturbed individual to himself or others, and threatened violence needs to be communicated rapidly and unambiguously to the police.

    Szasz interprets this protective action as the relatives’ attempt to “divorce” themselves from the disturbed, or disturbing, family member. If this were so, the parent described would allow her son to jump off the roof, thus facilitating the ultimate “divorce”. Szasz, however, believes such relatives use psychiatrists to incarcerate their family members and call it “care” and “treatment”. The psychiatrists manage this, in his view, by using the magic mantra: mentally ill and dangerous to himself and others.

    Szasz then introduces what could be a justifiable debate on whether it is medically, legally, and morally permissible to involuntarily detain, under psychiatric auspices, patients with dangerous severe personality disorders before they commit a crime. These people manifest “bad” behaviour and some of their actions are thought to be evil. They are therefore of more interest to lawyers than psychiatrists. They also interest politicians who have to satisfy societal needs for safety.

    It is this debate which approximates the dangerousness of “danger”,4 and if the English Mental Health Act is changed in order to prevent potential crime, by permitting the detention of people with a violent propensity who do not require psychiatric treatment, it would do much to support what Szasz maintains about social control. However, he uses the Draft Mental Health Bill,5 as a springboard from which to leap into the murkier waters of whether suicidal patients should ever be involuntarily detained and treated.

    If Szasz is correct, and suicidal patients should be allowed, unhampered, to kill themselves as a manifestation of their autonomy, we need to ask whether physicians should treat them for their overdoses when they fail, or simply place them in comfortable surroundings to die. If Szasz’s arguments are plausible, it follows logically that doctors should not intervene with antidotes. Yet how are they to know which one of these patients reasonably intends suicide, which is too disturbed to sustain rational intentions, and which intends simply to attract sympathy or attention?

    Finally, let us consider double agents, “Caesar” and “God”. Szasz believes that psychiatrists play two incompatible roles. One is to “help voluntary patients cope with their problems in living”, and the other is to “help relatives and society rid themselves of certain unwanted persons, under medical auspices”. It interests me that he refers only to the former group as “patients”. It is the “unwanted persons”, however, who may be the most disturbed and most in need of help. They may lack the autonomy to ask for help as, unlike the former group, they often have no insight into their problems. Because they do not perceive their mental state as abnormal, they are likely to refuse treatment.

    Are these “unwanted persons” then deemed the responsibility of the state (“Caesar”)? If they are neither detained nor treated because psychiatrists (“God”) ought not submit psychotic individuals to coercive intervention, and they then kill, should they be punished by execution or life imprisonment even though the law considers them to be criminally insane? Jesus also said: “Father, forgive them: for they know not what they do”.6