A CRITIQUE OF PSYCHIATRY AND AN
INVITATION TO DIALOGUE

by
Ron Leifer, M.D.
This article has been published in Ethical Human Science and Services, December
27, 2000

The medical
model is the dominant paradigm of psychiatry. Over the past forty years
it has become the target of a rising tide of criticism. What is the medical
model? Why is it the object of criticism? The medical model is not a scientific
concept or theory. It cannot be confirmed or falsified by facts. A model
is a conceptual-linguistic construction, a metaphor. The balsam wood model
airplane is a metaphor for a real airplane. It is not a real airplane. It
is a representation which highlights similarities and ignores differences.
A fire in the eyes may sparkle but it doesn’t burn. The medical model is
a metaphor which portrays psychiatry, psychiatrists, and psychiatric patients
in the language of medicine. Medicine does not need a medical model. It
is the standard on which psychiatry models itself, like the real airplane
is to the toy. The medical model projects the metaphors of illness on to
the patient and the metaphors of medicine on to the psychiatrist.

Psychiatry
is described as a medical specialty. Anyone who becomes the object of psychiatric
attention, voluntarily or involuntarily, is viewed through the medical model
and is subject to being labeled as mentally ill. The medical model, while
based on superficial similarities between psychiatry and medicine, disguises
and obscures crucial differences between them. The general and superficial
similarity between medicine and psychiatry is that both are concerned with
people who suffer and/or deviate from criteria of normality. The difference
is that medicine deals with conditions of the body which it classifies as
medical illness. Psychiatry deals with certain kinds of thinking, feeling,
and acting which it classifies as mental illness. Another crucial difference
is that all adult medical patients are voluntary. Their consent is required
before treatment can occur. Adult psychiatric patients, by contrast, can
be defined as mentally ill, involuntarily committed to a psychiatric institution,
and forced to submit to drugging and electroshock. The criticisms of psychiatry
are based on both the logical flaws of the medical model and the moral and
political implications of its social use.

The modern
critique was inaugurated in 1961 with the publication of The
Myth of Mental Illness by Thomas Szasz.
In this now classic work, Szasz offers
a conceptual and logical critique of the medical model broadly based in
philosophy, psychology, and political theory. The basic problem with the
medical model is that people take it literally rather than understanding
it as the metaphor it is. The medical model portrays the mind as an object.
It equates mind with brain and uses this assumption to justify defining
certain thoughts, feelings, and behavior as medical diseases. It is like
thinking that a model plane can actually board passengers and fly, or that
spring fever is a medical symptom. It is pure imagination. Szasz
criticizes the view of mind as object by reminding us of the well established
ontological, epistemological and linguistic differences between mind and
matter. Simply stated, mind is different than matter, or body, or brain,
for the obvious reason that the body is an object and the mind is not. The
body is known through the methods of physics and chemistry. The mind is
known through introspection, communication and interpretation. The language
used to describe the body is literal. The language used to describe the
mind is metaphorical. The thesis of The
Myth of Mental Illness is that mental illness is a metaphor. The medical
model of psychiatry is a metaphor which psychiatry, the media and, hence,
the general public take literally.

A second, parallel
critique of psychiatry focuses on the social uses, functions, and consequences
of the medical model. It maintains that the medical model of psychiatry
is an ideology which justifies covert social control. “Diagnosing”
persons as mentally ill who complain of or display certain forms of undesired
and undesirable thought, mood, and behavior renders them vulnerable to being
managed by a ubiquitous mental health system. Involuntary confinement and
forced drugging can be seen as means of social control. Indeed, the only
reason not to see them as such is to hide the fact. Incredibly, this obvious
fact is denied and ignored by most psychiatrists, the media and the general
public in spite of the fact that people labeled mentally ill may be deprived
of their freedom and coerced to take drugs without having been accused and
convicted of a crime. The clearly stated purpose of commitment and forced
treatment laws is to prevent suicide and harm to others. The medical model
of psychiatry serves as an ideology which camouflages this covert form of
social control as medical treatment.

Critics argue
that mental illness is an ideology used to protect the public against persons
who are judged to be dangerous or disturbing but who have not necessarily
violated any law. As a covert form of social control, psychiatry violates
the principle of rule of law which prohibits depriving a person of freedom
without an accusatory indictment and a trial by jury governed by rules of
evidence which gives a verdict of guilt for violating a specific law. This
critique of psychiatry is based on the ethical and political respect for
individual freedom under law which is the political foundations of this
republic. Medical-coercive psychiatry violates these fundamental values.
These issues invite debate in competent forums, yet they are ignored.

A third approach
involves the critical evaluation of psychiatric and psycho-pharmacological
research. This criticism has two prongs. First, it examines the methodology
and validity of the research and the factual findings. Second, it questions
the use of these facts in support of the medical model. Critics argue that
the research is deeply flawed and that the flaws are ignored for social,
political, and economic reasons. The premise of the medical model is that
“mental illnesses” are caused by “pathological” changes
in the chemistry, structure, or organization of the brain. Many eminent,
non-medical neuroscientists have pointed out that the brain is far more
complex than psychiatrists believe. Critics of the medical model maintain
that the scientific evidence at hand does not adequately support the claim
that neurochemical factors cause the behaviors which are labeled “mental
illness.” Nevertheless, due to a vigorous marketing program, the claim
is widely believed to be true. There is a strategic disingenuousness to
this critique of psychiatric research. It assumes that proper research could
demonstrate a causal connection between brain function and certain kinds
of thought, speech, and behavior. This is questionable and debatable since
the language of brain science and the language of mind and moral behavior
belong to different logical categories. One vital question which has not
been addressed is: if neurochemistry can cause undesirable thoughts, feelings
and actions can it also cause desirable ones? Another vital question which
has never been addressed is whether neurochemical changes are the cause
or effect of psychological factors. And for good reason. How can we know?
How do we decide? Every behavior has a simultaneous neurophysiology. Which
is cause and which is effect? Ironically, this is a rhetorical and political
question not a scientific one. Biological psychiatry, to no one’s surprise,
prefers a theory of biological causation. Humanistic psychiatry, to no one’
surprise, prefers to understand the person as a thinking, feeling, acting
agent. Considering the logical gap between mind and body and the difficulty
of establishing causal relations between them, it is not surprising that
this research is vulnerable to technical criticism.

The fourth
branch of criticism, the most heartfelt and vocal, consists of the cry of
those who have been abused, harmed, coerced and drugged by medical-coercive
psychiatry. Their voices are raised against medical coercive psychiatry,
against involuntary confinement, against forced drugging and electroshock,
against psychiatrists who only give drugs and don’t talk to their patients,
and against the inhumane milieu of psychiatric hospitals. Their pain, suffering,
and courage add heart to the critique of medical-coercive psychiatry.

In the Spring
of 1998, psychiatry was called to public account by the
Foucault Tribunal: Psychiatry on Trial which was organized in Berlin
by a group of psychiatric survivors and activists. Dr.
Szasz was invited to represent the prosecution but excused himself for
personal reasons and invited me to substitute for him. The paper he planned
to present, “The Case
Against Coercive Psychiatry,” was translated into German and distributed
at the conference. The jury consisted of psychiatric survivors and activists
led by forewoman, Kate Millett. As prosecutor, I presented ten indictments
against medical-coercive psychiatry, defined as that branch of psychiatry
which espouses the medical model, defines human, moral problems as medical,
serves as a covert agent of social control, and in that capacity confines
people against their will and forces upon them unwanted drugs and other
invasions. These indictments summarize the mounting criticisms of the medical
model and coercive psychiatry. The indictment, like all dialectical forms,
tends to elicit defenses which impede productive dialogue. The purpose of
this paper is to call for a dialogue on ten serious philosophical, ethical,
social and political problems raised by medical-coercive psychiatry. Our
purpose is to promote critical debate in the hope of relieving human suffering.
We ask for an open, constructive dialogue on these ten issues which deserve
reflection and public discussion.

1.
THE REPRESSION BY MEDICAL-COERCIVE PSYCHIATRY OF ITS CRITICS AND DISSENTERS:
WHO CONTROLS THE DISCOURSE?
Post World War II psychiatry was split into two camps. One was the public
mental hospital system. The other was psychoanalysis and psychotherapy.
The discovery in the fifties and sixties of drugs which alter mind and mood
changed the psychiatric climate. In its desire to appear scientific and,
hence, legitimately medical, psychiatry focused attention on drugs and the
brain. The mind-body pendulum, which has been swinging back and forth since
philosophy began, began to swing back towards the biological-medical paradigm
of human suffering. Whereas psychoanalysis heavily influenced culture and
popular thought in the fourth, fifth and sixth decades of this century,
the medical model and the discourse of the medical model dominates at the
turn of the century.

In 1961, when
Szasz published The
Myth of Mental Illness, the pendulum was at midpoint. The situation
at Syracuse dramatized the schism in psychiatry. The chairman of the department
of psychiatry was both a psychoanalyst and the director of the Syracuse
State Psychiatric Hospital. State psychiatry’s response to the psychoanalyst
Szasz’s critique of the medical model was to restrict and repress him. He
was forbidden to teach in the state hospital which was the flagship of the
department of psychiatry. Serious attempts were made to remove him from
his tenured appointment as professor of psychiatry.

His two main
defenders at that time, Ernest Becker and myself, both of us untenured,
were fired. Becker went on to posthumously win the Pulitzer Prize in 1974
for The Denial of Death. The chairman of the department at the time told
me in front of the dean of the medical school that the reason for my dismissal
was that he didn’t want my forthcoming book, In the Name of Mental Health,
to be published while I was a member of the department. The possible development
of a critical, humanistic school of psychiatry at Syracuse was aborted.
Szasz and other critics of psychiatry have been blackballed, repressed and
oppressed by medical-coercive psychiatry and its supporters. Szasz has been
a tenured professor of psychiatry at Syracuse for more than forty years.
Since the attack on him by establishment psychiatry he has taught minimally
and has no students or followers in that department as most academic professors
do. I know of no critics of the medical model has been any academic department
of psychiatry in this country. Psychiatric journals have routinely rejected
articles submitted by Szasz, Becker, and myself.
Psychiatry’s response to its critics has been “Todschweigen,”
death by silence. The time has come for dialogue.

The repression
of the critics of psychiatry may seem a minor historical note but it has
great potential significance. The issues here transcend the triumphs or
tragedies of any individual critic. They transcend psychiatry itself. They
involve nothing less than the future well being of our society. The question
raised by the repression of critics of the medical model is: “Do we
really have free debate on vital issues in this country, as the public assumes
we do?” If one critique can be repressed other critiques can also be
repressed. There is ample evidence to those who are willing to see that
intellectual repression is endemic, subtle, and unnoticed in this country.
If a critical discourse is repressed, the public will be unaware of it unless
and until critics speak out, at great personal risk, expose what is repressed
and raise public awareness.

The repression
of critics of the medical model silences the long western debate on vital
human issues which began in ancient Greece. Mindlessly reducing mind to
brain, as medical psychiatry does, ignores the long, tortuous, historical
debate on the relationship between mind and body. Accepting psychiatry as
a medical discipline like any other and ignoring it’s social functions is
tantamount to shutting off political debate on the vital question of the
balance between individual freedom and social order. Ignoring critiques
of the insanity defense blinds us to the meaning of personal responsibility.
These issues have broad, global significance and must be debated if humanity
is to intelligently influence its fate.

A question
raised by the repression of the critics of medical model is: “Who controls
the discourse?” Who determines which paradigms shall be used for understanding
human behavior? How we see the world shapes how we act in it. How we see
people shapes how we act towards them. If we see people as machines we will
fix them with physical interventions when we think they are broken. If we
see people as active agents we will treat them with respect, regard them
as responsible, and accept their choices. Classical sociologists recognized
that knowledge is a commodity. It has (social) value, either in support
of prevailing interests or against them. Paradigms arise in a social context,
in relation to the interests and resistance of competing powers. Each society
has its own fabric of discourses which establish and preserve its identity
and functions. The critique of a prevailing discourse can rent the fabric
of society and generate unsettling social change. The repression of critics
serves the stability of the prevailing order. At present, there are two
principle competing paradigms for understanding human behavior. the deterministic
paradigm, of which the medical model is the driving example, and the moral
paradigm. The deterministic paradigm explains human behavior in terms of
causes. The moral paradigm refers not to any particular morality but to
the person as moral agent who desires, intends, plans, acts and experiences
the consequences of those actions, for better or for worse. It explains
and judges human behavior in terms of desires, intentions, motives, purposes,
ideals, actions, values, ethics, context, contracts, and laws. There are
several versions of the causal deterministic paradigm: biological determinism
explains behavior as caused by body and brain; social determinism explains
behavior as caused by social conditions; and psychological determinism explains
it in terms of historical events and traumas. Each of these paradigms discounts
moral agency and hence, personal responsibility.

On the deterministic
model, behavior cannot be free. It is contradictory to say an act is both
caused and free. There is no freedom in causality and no cause of freedom.
They are antithetical terms. If an individual’s behavior is viewed as caused
and, hence, not freely chosen, that person cannot be held responsible for
his or her actions. If a person’s behavior is viewed as a choice, then that
person is responsible and accountable. The paradigm chosen to explain an
individual’s behavior thus defines that person socially. On the moral model,
a person is defined as responsible and entitled to freedom under law. On
the deterministic model, a person is defined as non-responsible and vulnerable
to being deprived of freedom without accusation or trial.

Each paradigm
has its own special discourse and discourse community. Academic, medical-coercive
psychiatry and public mental health facilities use the deterministic paradigm.
Private psychotherapists use the moral paradigm, whether they know it or
not and whether they like it or not. Often they use both, explaining the
patients suffering and symptoms as caused but assigning to the patient responsibility
for change. The state and the pharmaceutical industry and their champions
in the media favor the deterministic model. They control and dominate the
public discourse with the result that the medical model, the causal-deterministic
model of human behavior is the unquestioned dominant paradigm.

By repressing
its critics, psychiatry violates one of the basic principles of the scientific
method, namely free, critical inquiry and debate.
Psychiatry claims to be a science. Society regards the psychiatrist as an
expert in medical science. But the hallmark of the scientific method is
the “null hypothesis,” the systematic effort to falsify and criticize
methods, observations, and theories . In principle, any statement which
is not possible to falsify, or which is not subject to critical evaluation,
cannot be claimed as scientific. Psychiatry’s successful efforts to silence
its critics is contrary to the rules of science and refutes the psychiatric
claim to psychiatric validity.

By repressing
its critics, psychiatry has marked itself as intolerant and indifferent
to the great debates of intellectual history and resistive to the development
of new ways of understanding human behavior, including that behavior on
which they designate themselves to be the final authority. As Nietzsche
observed there are some truths that people don’t want to see. On the other
hand, it is the responsibility of the critical intellectual to open the
debate, to propose new ways of understanding ourselves and the world. New
ways of viewing human behavior might help us to understand vexing modern
problems such as our endemic domestic aggression and violence, a spreading
depression, and pervasive anxiety and stress. New paradigms for understanding
human behavior might provide a new insights into the problems of people
who seek professional help. It may even serve as the basis of a constructive
critique of society. But the development of new ways of thinking is obstructed
by those who control the discourse: psychiatry, the state, and the pharmaceutical
industry. The State-Science Alliance.

2. THE MEDICAL
MODEL AS IDEOLOGY.
An ideology is a set of ideas which emphasizes facts that promote certain
social interests and represses facts that oppose them. The medical model,
pretends to be scientific but functions as an ideology. It is an ideology
because it emphasizes the similarities between medical disease and mental
illness, namely, that both involve suffering and disability. And it represses
their differences, namely, that the suffering and disability of medical
illness is caused by demonstrable changes in the body, while the suffering
and disability of mental illness have no demonstrable cause in the body
and refer instead to speech, feelings, and social conduct. The skewing of
the discourse on human suffering towards the brain brands the medical model
of psychiatry as an ideology.

3. THE MEDICAL
MODEL IS AN IDEOLOGY WHICH JUSTIFIES COVERT SOCIAL CONTROL.
The social interest served by the medical model ideology is the public mandate
for a greater degree of social control than can be provided under rule of
law. By labeling certain behavior as medical illness, the medical model
serves, enables and justifies an extra-legal, covert form of social control.
Unlike persons who are diagnosed with physical illness, whose responsibility
as individuals is not usually questioned and who are not confined against
their will because of their illness, persons who are “diagnosed”
with serious mental illness may be defined as not responsible, be deprived
of freedom without indictment or trial, and be forced to take drugs and
other “treatments” against their will. Viewed through the medical
model, these violations of human rights appear and are justified as medical
treatment. Viewed through the moral paradigm they are seen as a covert means
of social control.The medical model developed as an ideology in a historical
and political context. It was “selected” by powerful social and
political forces for its utility as a paradigm to describe and control certain
forms of deviant behavior. The medical model developed in the context of
the European Enlightenment, the rise of science and the French and American
Revolutions. As the scientific view of the world replaced the religious
view, jurisdiction over suffering was transferred from religion to science,
and human behavior was explained in terms of cause and effect rather than
in terms of virtue and sin. The political revolutions signify a historical
transformation from rule of man to rule of law, from tyranny to democracy.
Under rule of man, persons who were judged as acting against the interests
of the state could be confined by a simple writ signed by the king or his
officer. These tyrannical “lettres de cachet” were eliminated
by political revolution. Under rule of law, a person cannot be deprived
of freedom except after having been convicted of violating a specific law
by a jury in a trial governed by rules of evidence. Rule of law is a limitation
on the power of the state in the name of individual liberty. A society could
not be called free that is governed by laws which are so vague and broad
as to regulate ordinary speech and behavior. The medical model developed
as an ideology to disguise and justify covert forms of social control. Without
invoking the medical model, could we call a society free where people can
be deprived of their freedom and forcibly drugged because they are homeless
and disturbing to the public? For hearing or speaking to their gods? For
going on spending sprees? For believing the government is after them or
that they are being monitored by electronic devices? For not being able
to face the difficulties of life? It happens in this country and we pretend
to the world to stand for the ideal of individual freedom. The problem is
that society demands a greater degree of social control than law allows.
The public wants to be protected from unconventional, threatening, and dangerous
behavior. There is, thus, a public mandate for a covert form of social control
which supplements rule of law. Medical-coercive psychiatry, in alliance
with the state, performs this function disguised as medical diagnosis and
treatment.

4. PSYCHIATRIC
ABUSE, COERCION, FORCE, AND FRAUD IN THE NAME OF MENTAL HEALTH.
Disguising social control as medical treatment is a deceit which conceals
an abuse. Civil rights advocates have focused primarily on the physical
abuse and inadequate treatment of involuntary patients in mental hospitals.
This is laudable. They have sometimes failed to understand, however, that
involuntary psychiatric confinement is an abuse in itself. The constitution
guarantees that a person shall not be deprived of life, liberty, or property
without due process. A lettre de cachet, which is what the physician’s certificate
of psychiatric commitment is, does not constitute due process. Nor does
a judge’s automatic ratification of the psychiatrist’s recommendation, which
is the rule. The legal justification for involuntary detention is the allegation
that a person has violated mental hygiene laws which are so vague and broad
that almost anyone who misbehaves is subject to arrest and transportation
by the police to a mental “hospital.” Only the rich, powerful,
and clever can avoid it. The majority of victims are powerless, poor, young,
old, or a member of a minority class. In contrast to genuine medical patients,
involuntary psychiatric patients may be deprived of all their civil rights.
They can be held indefinitely against their will on the word of a psychiatrist.
Habeus corpus hearings, where the psychiatric “patient” petitions
for freedom, are typically farcical rubber stamps of the psychiatrist’s
authority. Committed patient can be deprived of the right to drive, to vote,
to manage money, and to communicate with their friends, relatives, and doctors.
The psychiatric ward is a total institution under the absolute authority
of psychiatrists and their designated agents. Inmates can be forced to take
drugs against their will. They can be put in isolation. They can be forced
to undergo electroshock treatment and lobotomy against their will. They
are at the mercy of their “helpers.”

In a society
ruled by law how can deprivation of liberty without trial not be an abuse
of power? Is a society free where people may be forced to submit to drugging,
electroshock, or lobotomy? Many of my patients who have been involuntarily
confined in a mental hospital have found the experience extremely traumatic.
And while medical patients in the best hospitals might find the experience
unpleasant, the unpleasantness of mental hospitalization is its inhumanity.
Some former mental patients are grateful, but much in the guilt expiating
way that some convicts are grateful for their imprisonment.

To deny that
involuntary hospitalization is a form of covert social control seems absurd
and dishonest, approaching fraud. Most psychiatrists are aware, and will
admit in private, that involuntary hospitalization is a form of social control.
But they deny it in public, insisting it is necessary for the medical treatment
of mentally ill people. This in spite of the fact that the law in most jurisdictions
stipulates that, to be deprived of freedom without trial by psychiatric
confinement a person must be dangerous to him or herself, or others! Psychiatrists
refuse to address the question of why medically ill persons whose diseases
may be dangerous to themselves or others are not forced into confinement
and treatment of their medical condition? The denial of the fact that the
psychiatric “illness” is dangerousness and that the “treatment”
is social control serves neither justice, fairness, honesty, integrity nor
freedom under the rule of law. But society is afraid to debate this issue
for fear that the consensual fraud will be exposed and the public will be
deprived of an extra-legal means of maintaining domestic tranquility. Facing
our problems is disturbing. Not facing them is even more disturbing.

5. THE MEDICAL
MODEL IS THE BASIS OF PSYCHIATRIC IDENTITY.
Ideologies support and perpetuate social interests and, in turn, are supported
and perpetuated by those interests. The medical model serves society as
an ideology which justifies covert social control. It also serves the interests
of psychiatrists by supporting their identity as a physicians. The personal,
professional, and economic interests of psychiatrists are promoted by the
medical model. No medical model, no medical psychiatry. If mental illness
“exists” then they are true members of the medical fraternity.
If mental illnesses do not “exist,” if the term is a metaphor
which uses the language of medicine to judge and describe thoughts, feelings,
and behavior, then psychiatrists cannot not be viewed as “real doctors.”
The medical model supports the self-interest of psychiatrists and psychiatrists
promote the medical model. The critics of the medical model threaten the
identity of psychiatrists and, hence, are ignored, suppressed, and repressed.

6. COERCIVE-MEDICAL
PSYCHIATRY MAKES AND MARKETS FALSE CLAIMS.
Psychiatrists proclaim that so called “mental illnesses,” for
example, schizophrenia, depression and bipolar illness, have neurochemical
or genetic causes. In their journal articles and private conversations,
however, they admit that the evidence is “suggestive but not conclusive.”
It is suggestive to them because it is in their interests to see it that
way. To neutral observers, their claims are far from being scientifically
verified. Critics have raised questions about psychiatric methodology, claims,
and conclusions, but their voices are repressed, suppressed and ignored.
For example, psychiatrists claim that depression is “caused” by
low brain serotonin levels, the infamous “biochemical imbalance.”
The evidence for this claim is primarily based on the response to a certain
class of drugs called anti-depressants. Anti-depressants are stimulants.
Calling them anti-depressants is like calling a flashlight an “anti-darkness
tool.” Aside from the fact that the role of serotonin and other synaptic
transmitters is incompletely understood, and even granting the supposition
that serotonin levels are reduced in depression, the question remains: Is
this cause or effect? There is ample evidence that mental events can alter
brain events. Why has this issue not been debated?
The death or loss of a loved one usually involves feelings of depression,
called mourning. Is the depression due to low serotonin levels or the loss?
An exciting sports event may elevate the catecholamine levels of the crowd.
Is the excitement due to the elevated catecholamines or to the drama of
the game? An “anti-psychotic” drug may inhibit a musician’s ability
to play the piano as it may inhibit a “schizophrenics” unconventional
thought pattern. Does that necessarily mean that the playing or the thinking
was caused by neurochemicals?

As a psychiatrist
in private practice I get many calls from people who say they want treatment
for their “biochemical imbalance.” I ask them if they have had
a chemical test that demonstrated the imbalance. The answer is always no
because there is no test. I ask them whether they know which chemical is
imbalanced. They typically have no idea. I ask them how they know they have
a chemical imbalance. They tell me either their primary physician told them,
or that their aunt was told she has it, or they saw it on television. So
called “biochemical imbalances” are the only illnesses I know
of which are spread by word of mouth. The claim that depression is a disease
is propaganda promoted by psychiatry and the state and marketed by drug
companies: the State-Science Alliance.

7. COERCIVE-MEDICAL
PSYCHIATRY COLLUDES WITH DRUG COMPANIES AND THE INSURANCE INDUSTRY TO BOLSTER
THE MEDICAL MODEL.
The medical model serves the interests of the pharmaceutical industry by
proclaiming that mental illnesses are brain diseases which can be treated
with drugs the pharmaceutical industry makes, markets, and sells. The pharmaceutical
industry, in turn, subsidizes research, training, education and professional
journals which support the medical model. Psychiatric theories are drug
driven. Psychiatric therapies are drug driven. The pharmaceutical industry
grants millions of dollars to psychiatrists for research on psychiatric
drugs from which the industry profits. It’s advertising supports psychiatric
journals which publish the positive findings of this research. It contributes
money for the training of psychiatric residents and the continuing education
of psychiatrists at conferences and seminars which support the use of psychiatric
drugs. Pharmaceutical companies spend between eight to thirteen thousand
dollars per physician in this country on gifts, meals, speaking honoraria,
consulting fees, luxurious travel to conferences, and free samples of their
products. In most other circumstances, the default presumption would be
that money buys influence. But psychiatrists deny that money from the pharmaceutical
industry influences their thought and practices.

Managed care
companies also support the use of the medical model in psychiatric practice
and contribute to the medicalization of human problems. The mission of managed
care is to manage payment for psychiatric services. This means that every
patient seen by a psychiatrist who belongs to a managed care plan must have
a psychiatric diagnosis. This encourages viewing the patient’s life problems
as medical illnesses. Often, managed care companies will pressure the practitioner
to use psychiatric drugs which they believe save time and money. Psychotherapists
who avoid the medical model and who avoid psychiatric drugs in favor of
encouraging the patient to experience and learn from their life problems
are penalized by being excluded from insurance reimbursement.

The pharmaceutical
industry and the managed care industry are powerfully linked in support
of the medical model. The state, which supports the use of the medical model
because it justifies covert social control is also a partner in this meeting
of minds. The NIMH, which supports the medical model, is the research arm
of the state. The state maintains public psychiatric hospitals which hold
involuntary patients. The medicare and medicaid systems follow the official
DSM of psychiatric diagnoses. It is bad enough that psychiatry, the state,
and private industry are working together to patronize the medical model.
It is far worse for the future of our society that this complex relationship
has not been fully examined.

8. THE MEDICAL
MODEL CONTRIBUTES TO THE EROSION OF PERSONAL RESPONSIBILITY.
The medical model views certain human thinking, moods, and behavior as caused.
If an act is caused then it cannot also be chosen or intended. In law and
ethics, intention is the key to responsibility. If an act is intentional
the actor is responsible. In law, if an act is not chosen or intended, the
actor cannot be held responsible and is excused, except in cases of negligence
which is the failure to form proper intent. Does it not follow, then, that
the increasing tendency to view human behavior through the lenses of the
medical model as caused results in a erosion of the public sense of personal
responsibility?

If a person
who commits violence has a history of psychiatric treatment, the act is
often explained as a product of mental illness. If the act is claimed to
be the product of mental illness the perpetrator may not be held responsible
and can plead insanity in a criminal trial. This often results in excusing
the obviously guilty, as in the case of John Hinckley who was found not
guilty by reason of insanity for shooting President Reagan in front of millions
of witnesses on national television. Ironically, the medical model is used
not only to incarcerate the innocent but to excuse the guilty.

When someone
commits suicide, the most common explanation is that he or she suffered
from a clinical depression caused by a biochemical imbalance. Suicide is
thus, reduced from a moral problem to a medical problem. The list of caused
(and excused) thoughts, moods and behaviors is long and growing rapidly.
It now includes anxiety, depression, suicide, homicide, anger and aggression,
phobias, obsessions, compulsions, binge eating, anorexia, sexual deviance,
sexual abstinence, addictions, and various forms of withdrawal, intrusiveness,
garrulousness, shyness, excitement, sloth, insomnia, somnolence, hedonism,
anhedonia, egotism, self hatred, rebellion and conformity. The more we explain
the spectrum of thoughts, emotions and behavior with the medical model the
greater the erosion of the public sense of personal responsibility. Ironically,
the more the ethic of personal responsibility is eroded, the stronger the
state must be to control deviant behavior. The erosion of the sense of responsibility,
thus, leads inevitably to totalitarianism.
It this age of political absurdities, it is considered politically incorrect
to suggest that people are responsible for their thoughts, feelings, and
actions. Nevertheless, we are responsible for our states of mind and our
moods as much as for our actions. If one observes human behavior with a
degree of self reflection it will be perfectly obvious that it is always
possible to exert a greater degree of control over one’s thoughts, feelings
and actions if only one makes an effort and persists with patience. Contrary
to the implications of the medical model, our intentions, choices, and deeds
can make a difference. This leads to the heretical suggestion that we are
responsible for our anxiety, depression, and anger, as much as for our conduct.
Were this not so psychotherapy would not be possible, self-improvement would
not be possible, maturity and spiritual growth could never happen.

The medical
model is contrary to the concept of human agency. It does not permit of
choice and responsibility. If depression is a disease, as the medical model
asserts, it must viewed as caused in spite of the contradictory fact that
to heal it the person must take responsibility for his or her attitudes
and life choices. To suggest that depression may be better viewed as an
existential or a spiritual problem rather than as a biochemical imbalance,
exposes the critic to vicious attacks by medical psychiatrists and their
supporters, notably, NAMI. The fact that the antidote to hopelessness, the
main mark of depression, is hope, a spiritual quality, is ignored, much
to the detriment of those suffering from depression who are told they need
prozac rather than courage and hope.

The ideology
of the medical model also serves the social function of diverting our attention
away from serious social and political problems which society does not want
to confront. To regard anger, aggression, and violence as symptoms of brain
disease distracts us from a criticism of the social conditions and values
of our anomic, consumer society in which desires run rampant and violence
is recreational. By diagnosing children who disturb the classroom or do
not absorb its lessons as ADD, caused by a brain defect, we do not have
to examine the culture of schools which cannot capture the imagination or
attention of its students. In these ways and others, the medical model serves
the status quo of prevailing social interests. It is a form of social neurosis,
analogous to the neurotic symptoms of the individual, which avoid, repress,
and deny the awareness of conflict while constructing convenient, self serving
compromises. The repressed wish is for a greater degree of social control
than provided by rule of law. The super-ego, which represents the social
value of individual freedom under law, opposes. Clever ego finds the neurotic
solution. Social control disguised as psychiatric diagnosis, involuntary
hospitalization, and forced drugging.

9. MEDICAL
PSYCHIATRY CONTRIBUTES TO THE REPRESSION AND CONSTRICTION OF HUMAN CONSCIOUSNESS
Psychiatry is a house divided against itself. On the one side, represented
by the medical model and the state hospital, is the function of covert social
control of individual behavior and the repression of dissent. On the other
side, represented by the moral model and voluntary, humanistic psychotherapy
is the function of liberating the individual from self-imposed suffering
and raising consciousness. By repressing its critics, medical-coercive psychiatry
deceives the nation. Knowingly or unknowingly psychiatry practices social
control under the rubric of medical diagnosis and treatment. Some psychiatrists
know it but won’t admit it. Others refuse to even consider the idea. Santayana
is famously quoted for reminding us that those who forget the past are doomed
to repeat it. It may be equally pertinent that those who become fixated
on the past are doomed to miss the present. Historically, every new tyranny
has taken an unprecedented form that those fixated on tyrannies past failed
to recognize. From the historical lessons of Hitler, Stalin, Mao and the
like, we expect tyranny to emanate from the head of state. The new tyranny,
however, is more subtle, disguised, and diffused. It is disguised in the
garb of the psychiatric helper, and it is diffused through every community,
institution, organization, and industry in this country. Psychiatry contributes
to the confusion and constriction of public consciousness by disguising
its social functions. The American public represents its political self
to itself and to the rest of the world as the defender of individual freedom
under law. At the same time, it gives silent assent to the coercion, confinement,
and abuse of individuals in violation of rule of law.

Psychiatry
contributes to the repression and constriction of consciousness by interpreting
human behavior as caused by the brain thus blinding us to the world of mind
and meaning. If human thoughts, feelings, and behavior can be reduced to
brain and bodily functions then what happens to the person?What happens
to choice and purpose? To ambition and hope? To tragedy and comedy? To clarity
and love? To law and ethics? If our thoughts, feelings and actions are no
more than neurochemical eruptions, then we have lost our humanity. Our narratives
are meaningless. We have forsaken the possibility of knowing ourselves.
And we have lost the capacity to heal ourselves.

10. FOR
ALL THE ABOVE REASONS MEDICAL COERCIVE PSYCHIATRY CONTRIBUTES TO THE DECLINE
OF CIVILIZATION AND THE INCREASE OF HUMAN SUFFERING.
How shall we evaluate the contributions of medical-coercive psychiatry to
the development of civilization? To answer this question we must distinguish
between the persons and the acts, the people who work in the “mental
health field”who follow the medical model and the social functions
and practices of medical psychiatry.

We should not
fail to note and pay homage to those honest and decent practitioners who
follow the medical model, but eschew coercion, and display wisdom, warmth,
respect, and kindness to those who come to them for help. These personal
qualities are precious, vital contributions to the development of civilization.
Those who suffer mental, emotional, and spiritual pain the pain of life
often suffer from frustrated yearnings to be loved and respected. The maturity,
wisdom, warmth, respectfulness, and kindness of a helper can be therapeutic,
not in a medical sense, but in a spiritual sense it can work miracles.

We should not
hesitate to add, however, that working with the medical model is a handicap
in developing the virtues vital to healing and social progress. It depersonalizes
and dehumanizes both the therapist and the patient. In addition, we must
remember that therapists and other workers in mental health have egos too.
They can be selfish and self centered, defensive and aggressive, callous
and disrespectful. When the dehumanizing medical model is used by insensitive,
egotistical workers the result can be, and often is, the infliction of great
suffering at the hands of medical-coercive psychiatry on people who are
already suffering from the difficulties of life.

The practice
of coercion through involuntary hospitalization and forced drugging is a
serious issue which begs for debate. On the one hand, involuntary, coercive
psychiatry serves society by providing a supplemental form of social control
which, because it is covert or disguised, preserves our national pride by
giving us the appearance of being a nation of free individuals under law.
On the other hand, when the covert is exposed it can be seen to violate
the honored values on which this nation was founded. The question of the
contribution of medical coercive psychiatry to civilization is a question
of what balance between social order and individual freedom best serves
human happiness? What balance of honesty and illusion? From the events of
the past century, it is evident that totalitarian societies, which provide
a high degree of social order, as well as free market capitalism, which
provides a maximum of individual freedom, are both obsolete extremes. Nations,
like ours, which began as free market polities, and nations like the Soviet
Union, which experimented with state communism, both failed and moved towards
each other. As western nations have become more socialist and closed over
the past fifty years, communism has collapsed into a chaotic free market.
Governments everywhere now seek to balance the mandate for social order
with the mandate for individual freedom.

The fact that
coercive-medical psychiatry disguises social control as medical treatment
is a serious impediment to the public debate on the desirable balance between
social order and individual freedom. The handicap is aggravated by psychiatry’s
repression of its critics. If the question whether psychiatry functions
as a supplementary instrument of social control cannot be debated, then
how can the question of the optimal balance between social order and individual
freedom be intelligently debated? The conclusion cannot be escaped that
medical-coercive psychiatry’s repression of its critics does not serve the
advancement of civilization because it results in the obfuscation of debate
on serious ethical, social and political issues.

Whatever one’s
views on the desirable balance of social order and individual freedom may
be, the practice of psychiatric coercion and abuse cannot possibly contribute
to the development of a humane society. Depriving individuals of freedom
without trial by means of involuntary confinement in a psychiatric hospital
is an abuse. It violates the basic principle of individual freedom under
law. When people are involuntarily confined and their keepers are undereducated
and underpaid cruelty and abuse are bound to result. The voices of the oppressed
and abused are rising in numbers and volume in opposition to medical-coercive
psychiatry and the society which permits, even sanctions its practices.

If mental illness
is a social construct rather than a bodily illness, then questions naturally
arise about the use psychiatric drugs. What does it mean to prescribe a
drug for a metaphorical illness? When is it proper for an individual to
ingest mind altering substances? These questions bear on our national policy
on drugs. If psychiatric drugs are not given to treat a genuine medical
illness but to alter thought, mood and behavior, then what is the difference
between legal and illegal drug use? Surprisingly, there is no consensual
understanding of why people self administer psychoactive drugs. It is a
mystery to the experts who rely on the medical-deterministic model. Indeed,
it is a mystery to them because they rely on it. They cite early or current
deprivations, peer pressure, abnormal brain chemistry, genetic predisposition,
mental illness and the like as causes. Many believe that people take illegal
drugs to medicate themselves for their (presumed) mental illness. But what
does this explain? It is circular and illogical. It implies that if a person
self administers a drug, it must be to treat a mental illness. But the taking
of the drug is itself also an illness — addiction. On the other hand, psychiatrists
can legally force people to take mind and mood altering drugs for their
alleged mental illness in which case the drug taking is not considered an
addiction but a ‘treatment.” If the patient becomes addicted to the
prescribed medication, the addiction is called a side effect, rather than
an iatrogenic illness. The logic is baffling but unexamined and unchallenged.

To understand
the deed we must look to the motive. The logic may be baffling but the motive
is clear. Language is a tool, a socially useful tool. The language of the
medical deterministic model facilitates social control but impedes understanding.
The moral model impedes social control but facilitates understanding. The
medical deterministic model cannot explain why people use drugs because
the explanation of why calls for a motive, a purpose, and a context. From
the moral point of view, from the point of view of the person as agent,
the reason people take mind and mood altering drugs is simple, too simple
for scientists to accept. People take these drugs because, in some way,
they feel bad, are unhappy or dissatisfied and they want to feel good. And
the drug helps them to feel good enough to suffer the risks. All one need
do to confirm this as fact is to ask people. Our national failure to understand
why people use drugs, in spite of a decades of war against drug users, is
a symptom of the endemic repression of critical thought. We need only reframe
the language of the drug discourse to understand the rationale for using
mind altering drugs, legal and illegal. The majority of these drugs are
either uppers, downers, pleasure enhancers, or psychedelics. If you feel
down you take an upper; if you are anxious you take a downer; if you want
to sleep you take a downer; if you want to stay awake you take an upper;
if you want to feel sensuous you take pleasure enhancer like ecstacy or
cocaine; if you are bored or curious and adventuresome you take psychedelics.
The psychiatric rationale is similar, only the language differs: if the
person is depressed (down) give them anti-depressants (upper); if the person
is anxious or manic (up) give them an anxiolytic or a mood regulator (downers).
If they suffer from their thoughts (thought disorder) give them anti-psychotics
(thought suppressors.) Pleasure enhancers and psychedelics are regarded
as dangerous and are prohibited.

The primary
difference between the two groups of drugs is that psychiatric drugs are
manufactured by pharmaceutical companies, are legal, and are prescribed
by physicians, often against the patient’s will. Street drugs, are usually
natural substances, are illegal, and are consumed voluntarily. There are,
thus, two classes of psychotropic (mentally active) drug users. One portion
of the population is advised or forced to take psychiatric drugs which have
similar aims and effects as the street drugs taken voluntarily by another
portion of the population who are hunted, prosecuted and imprisoned for
it. The people who take drugs voluntarily are regarded by medical model
adherents as suffering from the disease of addiction while the people upon
whom the drugs are forced are described as getting well as the result of
their treatment. If we examine this situation more carefully, the conclusion
is inescapable that the defining issue is social control. Psychiatric drugs
are used to control people whose thoughts, feelings, or behaviors are judged
out of control. The voluntary use of street drugs for mood regulation and
personal pleasure is prohibited. Arguably, the social motive of drug prohibition
is to keep people from dropping out of the work force or engaging in unconventional,
heretical, treasonous or otherwise disturbing behavior. Thus, psychiatric
drugs and drug prohibition have the same social function, to keep people
in line.

One may reasonably
argue that the use of any psychoactive drug is contrary to the welfare of
civilization. On the other hand, every known culture has tolerated the use
of intoxicants and many have endorsed the use of psychedelic sacraments.
The medical model sheds no light on the question of why human beings from
ancient times to the present choose to modify their mental state with natural
substances. And it sheds no light on why increasing numbers of people who
have been prescribed psychiatric drugs are desperately trying to withdraw
from them. Something seems wrong here, and we aren’t clear on what it is
because debate is suppressed.

Does it contribute
to the advancement of civilization that increasing numbers of people are
acquiring psychiatric diagnoses as the result of innocently seeking guidance
for their troubles and pain? Managed care and insurance companies require
every person they reimburse for psychotherapy to be given a serious psychiatric
diagnosis. Psychiatric diagnoses are forced on anyone who seeks help from
a mental health professional paid for by a third party. And psychiatrists
are paid to supply it. A person’s diagnosis becomes part of the national
data base. People are excluded from public office, from jobs, from the military,
from the priesthood, from school, and even from their children based on
psychiatric diagnoses acquired as a consequence of contact with psychiatry.
This information is not privileged because the state, the employer, and
the insurance company require the individual to give consent for its release
as a condition of their approval. The unintended and unexpected result of
the dominance of the medical model is the medicalization of social control
and personnel management and the obfuscation of our understanding of human
behavior.

Is civilization
served by the deterministic view of human behavior and the designation of
suffering and deviance as illness? The causal-deterministic view is amoral.
The foundation of civilization is ethics, morality, and law. If behavior
is viewed as caused by the brain, then the citizen, who is motivated by
the desire for happiness to be virtuous and law abiding, disappears. Causes
may explain the behavior of creatures but not of citizens. Behavior which
is caused cannot also be intentional. If it is not intentional, it cannot
be ethical, virtuous or law abiding. “Cause” and “intention”
belong to different logical levels of discourse. If behavior is caused,
the individual cannot be held responsible. The language of science and the
medical model exclude the concept of personal responsibility. By discounting
personal responsibility for thoughts, feelings, and actions, medical model
psychiatry contributes to the erosion of the awareness of and the respect
for individual responsibility, which is a precondition for individual freedom
under law. Can anyone honestly say that this serves the advancement of civilization?

11. A CALL
FOR DEBATE ON THE TEN POINTS
It is fitting to conclude these points with a simple plea to open up the
intellectual milieu in this country. A blanket of fear and cynicism has
suffocated the open exchange of ideas. Many intellectuals feel it. Few talk
about it.
A critique of medical coercive psychiatry raises a host of moral, ethical,
social, economic and political issues. The repression of critics of the
medical model mutes the debate on these important issues. If the debate
were opened many points of view would be heard. No one fully appreciates
the scope of the problems raised. No one has the answers. We cannot even
imagine the scope or the possible answers until the debate is opened, the
issues are evaluated, and proposals are considered.

The repression
of critics of the medical model is the tip of the iceberg. Freud wisely
noted that if we leave one skeleton in the closet unexamined, then all the
skeletons will hide there. The shallowness of debate in our political campaigns
is a symptom of the constriction of public consciousness and discourse.
The danger exists that by crippling open discourse we may blindly lead ourselves
down the road to the invisible totalitarianism of the therapeutic state
where coercion is disguised as help, condemnation is couched in diagnosis,
social control poses as health management, responsibility evaporates into
helplessness, and moral consciousness is replaced by a mechanistic view
of a world ruled by the established plutocracy.

Debate is a
double edged sword. On the one hand, it can threaten the establishment,
which is why it is suppressed. Debate can expose flaws and injustices in
the social fabric which may awaken a call for changes unfavorable to prevailing
social interests. On the other hand, debate casts the light of awareness
on the dark shadows of hypocrisy, injustice, insensitivity and cruelty.
Debate on the ten points may stimulate the development of a society and
a psychiatry which is voluntary, humane, compassionate and also respectful
of scientific knowledge without reducing humans to biochemical machines.

Ron
Leifer, M.D.
215 North Cayuga Street
Ithaca, New York 14850
Tel. (607) 272-7334
e-mail ronleifer@aol.com

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