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Which Changes does Szasz Advocate?

Szasz is, first of all, a critic who analyzes all sorts of existing situations inside and outside of psychiatry. He attempts to apply certain premises and ideologies to them, and judges and condemns them in that light. He demands accountability, and has taken it upon himself to serve as a kind of professional conscience of psychiatry. It seems to me that this is his strength, and that he is much less someone who leads down new paths or proposes concrete changes. Yet the changes and improvements that he advocates are not only implied in the sense that they can be deduced from his social criticism. Szasz has made them explicit in two ways: by outlining the principles of a new theory, and by proposing concrete changes.

Outlines of a new theory can be found in the second part of The Myth of Mental Illness and in The Ethics of Psychoanalysis. In Part II of The Myth of Mental Illness he develops the rudiments of a theory for personal behavior, in which he attempts to combine psychoanalytic insights, game theory, and the rule-following model of human behavior. Although this theory seems to be promising, he is satisfied with laying only the foundation. He illustrates it with only one example, the hysterical conversion phenomenon. Later he repeatedly refers to this theory, but does not develop it any further. The same can be said for the autonomic psychotherapy that is discussed in The Ethics of Psychoanalysis. They are theoretical underpinnings and several sketches of, in my opinion, a promising theory regarding psychotherapy, of which further development in practice is missing.

In Law, Liberty, and Psychiatry and in “Whither Psychiatry” he proposes concrete changes and reforms in the mental health service.

His recommendations for change in Law, Liberty, and Psychiatry can be found in Chapter 19 of that book. They are preceded by three premises. The first is that freedom as a core value should be a priority above health as a core value. The second is that as diagnosing mental illness has such horrible consequences, the same principle should apply as in criminal law: a person is innocent unless proven guilty. Accordingly, a person should be considered mentally healthy unless he is proven mentally ill. This is a reversal of the principle that is normally followed in somatic medicine, namely, suspecting that someone is ill until he is proven healthy. The third premise is that changing the way in which society deals with social problems must necessarily occur slowly and gradually.

The long-term goals he sets are:
  1. Involuntary commitment to psychiatric institutions should be abolished. In particular it should be abolished regarding people who are threatening suicide and regarding people who are considered mentally ill by others, but themselves refuse hospitalization and treatment.
  2. Hospitalized psychiatric patients should remain in possession of all their rights as persons and citizens. Psychiatric hospitals are to be converted to institutions where contractual treatment is possible for those who want it. These institutions have no role in protecting society, nor in protecting hospitalized people against themselves. Both the custodial and the medical aspects of these institutions should be abolished, so that they will begin to resemble some schools, hotels, or vacation camps.
  3. Mental illness can no longer be used to exculpate criminals. Not only should it be abolished regarding criminal responsibility, but it should never be used to deny suspects a trial. The rule that people can be tried only if they understand the charge against them and can assist in their own defense should be maintained, but in the literal meaning. Psychiatrists may testify as expert witnesses but should confine themselves to facts and observations. Psychiatric considerations as such are irrelevant, as well as psychiatric views on criminal responsibility. This way, actually, there will hardly be anything left for psychiatrists to do in the courthouse. Postponement of trial would take place only in those extreme cases that even a lay person can see that the person in question is not capable of standing trial.
As short-term goals, he sets:
  1. It should be publicly acknowledged that psychiatrists and their involuntary patients are adversaries. Committed patients should develop a feeling for freedom and even for sedition.
  2. Patients’ rights should be protected by a regulating agency.
  3. Mental Hospitals should no longer be used to warehouse all people in society for whom a different solution cannot be thought of. There should be humane and reasonable alternatives that, temporarily, offer asylum to people who are socially troubled and have no other place to go.
  4. Hospitalized patients should retain their rights as much as possible.
  5. Involuntary commitment as a means of solving all sorts of problems should be discouraged.
  6. People should be informed about the dangers of psychiatric hospitalization and about the differences between medical and psychiatric services. People should be informed about the risks and pitfalls, instead of being encouraged to seek help as much as possible.
In “Whither Psychiatry” (which was later included in Ideology and Insanity) Szasz stresses the need for clarifying the social role of psychiatrists. It should be clear when psychiatrists are benefiting patients and when they are benefiting society. He suggests splitting psychiatrists into two groups, as is the case with attorneys, namely, there are attorneys who represent clients and there are attorneys who represent the state. The difference with the current situation is not that psychiatrists will fulfill these roles, because they already do. The difference is that they will have to choose which of these roles they will consistently play, rather than playing both roles at the same time or alternating between them.

D(efense) psychiatrists practice privately, have contractual relations with patients who seek their help, and exercise only contractual psychiatry. P(rosecution) psychiatrists practice institutional psychiatry but without the pretense of benevolence. Their role and goal is clear to all. This proposal consists of the classification of experts rather than the classification of illnesses. Szasz himself, however, seems to think such a proposal not realistic, as suggested by his remark that the role of P-psychiatrists “is often considered defamatory of psychiatrists and of the psychiatric profession.” (Ideology and Insanity, p. 232)

Furthermore, in this article he proposes a further demarcation between neurology and other somatic specialties on the one hand, and psychiatry on the other. Finally, he anticipates that the current trend in the direction of collectivist and scientistic psychiatry will continue in the near future, but in the long-run the pendulum may swing between individualism and collectivism, and between protecting citizens against the state, and protecting the state against citizens.
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