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Psychiatric Patients and the Biomedical Disease Concept

Although Szasz prefers to discuss people in their relationships with each other, he much more frequently discusses psychiatrists and what they do and pretend than their partners, and according to Szasz, victims, psychiatric patients. Nonetheless it is important to know what Szasz thinks of what other psychiatrists call psychiatric patients. The label psychiatric disorder dehumanizes and humiliates people according to Szasz. What would be thought of these people if the label were abolished?

Who are psychiatric patients when they are not called psychiatric patients? Szasz prefers to answer that they are normal people. There is no point in calling them sick. There is nothing special about them that would justify a separate classification. Szasz has never denied that the behaviors that lead to psychiatric labeling do exist. He only opposes their conceptualization as psychiatric disorders. As he as well observes features by which these people are distinguishable from others, his view of these people can be inferred.

In The Myth of Mental Illness Szasz asserts that people who were called hysterical by Charcot and Freud were before then considered impostors, malingerers, and frauds. In a 1961 article he calls this process “renaming,” which he condemns as a semantic maneuver. Such a maneuver is pointless because it is only a matter of time before the stigma returns. This article suggests that Szasz considers hysterical patients impostors and frauds.

In his discussions on responsibility and liberty the psychiatric patients are the ones absconding from their responsibilities and choosing the dependence of the patient role. In Ideology and Insanity he writes, “Psychiatry has accepted the job of warehousing society’s undesirables.” (p 82) Szasz does not state directly that he regards these people undesirable, only that they are considered undesirable, and that that is the reason they are labeled as psychiatric patients. In The Theology of Medicine he states, “The renaming and reclassifying as sick of a whole host of behaviors formerly considered sinful or criminal is the very foundation upon which modern psychiatry rests,” (p. 69) and in a 1969 article, “Commitment shields the non-hospitalized members of society from having to accommodate to the annoying or idiosyncratic demands of persons who have not violated any criminal statures. In Schizophrenia he asserts, “The facts are, that in the main, so-called mad-men … are not so much disturbed as they are disturbing; it is not so much that they themselves suffer (although they may), but that they make others suffer.” (p. 36)

More quotes can easily be added to the above. Taking them all together the following description emerges: Psychiatric patients are non-criminal deviants who misbehave, who are often troublesome, irritating, or peculiar, and dangerous in the sense that they threaten the fabric of society because their deviance may be a response to social wrongs. They are impostors, so unreliable, and exploiters because they fraudulently use the sick role. They do not know how to live properly. They sabotage their responsibilities. On the other hand they are people who should be held responsible for what they do and say like everyone else and whose judgment (for instance, regarding the desirability of psychiatric hospitalization) should be respected.

So the image of the psychiatric patient as it emerges from Szasz’s writings is quite negative and unpleasant. This image consistently recurs in his work. Szasz poses a moral criterion for judging behavior rather than a medical-psychiatric criterion which for him generates a very negative picture. At the same time this means that psychiatric patients can have little hope that the image of them, which is negative due to stigmatization as psychiatric patients, will improve when they are no longer considered psychiatric patients and their aberrant behavior is no longer conceptualized as disease – at least, in Szasz’s view. It may be true that “renaming” has in the long run not improved the image of psychiatric patients. In view of the above, they do not seem to be any worse off either, at least not as far as stigmas go.

There has been not a little research done about the image of psychiatric patients among “normal” people as well as among psychiatric patients themselves. This image is rather strongly negative. Aside from the features listed above psychiatric patients are not uncommonly associated with violence and danger. O’Mahony concluded that in Dublin psychiatric patients were viewed as unhappy, confused, withdrawn, and (by a minority of people) dangerous.

Another question examined is whether the stigma that seems to adhere to these patients results from psychiatric treatment or psychiatric hospitalization rather than from their disorders themselves. Bagheri et al noted that of 103 referrals by other physicians to psychiatrists, 68% of these patients were not informed of the referral by the physician, apparently because the physicians expected the patients to respond in a negative way. Unjustified, Bagheri et al posit, as two-thirds of the patients either were positive about the referral or accepting. Bockel, too, found that patients not uncommonly themselves suggest to their family doctors that they be referred to a psychiatrist. Bockel also lists several other research projects which reveal that, although patients generally tend to await their family doctors’ advice, 30 to 40% of them initiate the referral to a psychiatrist themselves.

Phillips investigated 300 white women. They were given five stories, four of which were about psychiatric patients, and the fifth about a “normal” person. The women’s judgment became more negative as the people in the stories were described to have a mental counselor, a physician, a psychiatrist, or visited a Mental Hospital. This suggests that the stigma was not so much formed on the basis of the disorder itself but rather on the basis of the type of assistance provided. Goudsmit, too, pointed this out regarding psychotherapy, and protested against it. Gove possibly offers an explanation for Phillips’s findings by suggesting that in the general public there is great reluctance to recognize psychiatric disorders in people. Apparently treatment is used as a tool that legitimizes recognition of psychiatric disorders. Gove further emphasizes that according to several investigations people as a rule are hospitalized as psychiatric patients only when their behavior has become unbearable, but that the stigma often later disappears again when the ex-psychiatric patient achieves a reasonable measure of adjustment.

In accordance with the above Schwartz concludes that the image family members of psychiatric patients have is based more on the current level of adjustment than on the fact of having been treated. Clausen, who researched psychiatric patients and their families, reaches a similar conclusion, namely, that ex-psychiatric patients’ feelings of being stigmatized are particularly engendered by self-doubt and (remaining) symptoms of the psychiatric disorder.

Finally I note Weinstein’s comprehensive study of a large number of research projects regarding patients’ attitudes about psychiatric hospitalization. He concludes that 78.9% of patients’ attitudes are positive. In general patients considered their hospitalization helpful. The facilities were experienced as good. They generally did not feel restricted. The main reasons for hospitalization had been care and protection, and escape from daily stresses and conflicts with other people. The patients were not disappointed. Most interesting is also Weinstein’s finding that neither social class nor level of education made any difference to this positive evaluation. “The evidence indicates that the defenders of mental hospitals have more accurately portrayed the patients’ point of view than the critics’.” I doubt that it is fair to draw this conclusion from the findings. The subjects of the research were people who had a psychiatric hospitalization in their past. They were dealing with the challenge of accepting what had happened after the fact and making the best of it, which may well have greatly influenced their judgment. Yet Weinstein’s survey does clearly suggest that ex-psychiatric patients have a positive image of psychiatric hospitalization. It permits me to reach the important conclusion that it is a good thing that most of the people who have had such an experience can deal with it this way.

In summary, Szasz’s viewpoint that psychiatrists are the ones who stigmatize their patients and that the Mental Hospitals are but prisons is remarkable. The image of psychiatric patients, held by themselves as well as by others, seems to be formed in a rather complicated way. It can be assumed that five factors in particular in varying degrees determine that image. Those factors are: becoming a psychiatric patient and the way in which it happens; being treated; the nature of the institution; the achieved level of (re)integration into society; and the presence of remaining symptoms of psychiatric disorder.

We can conclude from Szasz’s work that not calling psychiatric disorders diseases provides little prospect for improving psychiatric patients’ image. His position that psychiatric patients lose out at being treated, according to him, as inferior beings remains valid. He bases this on the fact that different laws have been legislated for them, that certain laws applying to everyone else no longer apply to them, that they can be detained even when (usually) not having committed any crime, that they are declared incompetent, and that they may lose their driver’s license, their right to vote, and other civil rights. This problem will be discussed in Chapter VII as well.
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