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A symposium at the World Congress for Psychiatry in Athens in 1989 was dedicated to the desirability of treating psychotic homeless people with depot-neuroleptics. These are psychoactive drugs that can retard psychotic manifestations. They are injected, and remain effective for two to four weeks. After discussion about the pros and cons, one psychiatrist rose and related to have done much work with the homeless, including psychotic homeless. He asserted that what this group of people needs, in the very first place, are shelter, beds, and food. This contradiction in views is characteristic for psychiatry.

In 1984 Kimble elaborately described what he called the two cultures of psychology. This view seems to me applicable to psychiatry as well. He calls one of the cultures scientific, and the other humanistic. He names five dimensions in which these cultures differ. They are: determinism versus indeterminism; observation as the prime source of knowledge versus intuition; knowledge collection (in laboratories in particular) versus in the field or through case studies; nomothetic versus ideographic rules; and analytic versus synthetic thinking. Using questionnaires, he researched these dimensions in colleagues. According to Kimble, these two different orientations on reality have existed for millennia, and psychologists have also adopted them. The same can be said about psychiatrists. Perhaps these two orientations can explain in part why psychiatry’s history is alternately dominated by one or the other. Clearly, today the scientific, analytical, deterministic view dominates, as it did in Athens. The humanistic view is marginalized, and mainly espoused by psychiatrists practicing in the field. Scientific approaches have the upper hand.

It is tempting to juxtapose these two orientations to the two most important disease concepts of the moment: the biomedical and the biopsychosocial. In a period of domination by the biomedical concept, relatively little attention is paid to the humanitarian-social aspect, as is illustrated by psychiatrists’ relative disinterest in the circumstances of the treatment and the environment in which it has to occur. Contrarily, nowadays there is a great deal of preoccupation with the more technical-therapeutic side of the profession: disease as an ontological concept, rather than as a value concept. This generates exaggerated optimism, but sometimes also underestimation, about what is achievable. The exaggerated optimism these last decades is especially as to the possibilities and prospects of therapies involving biological intervention. Psychological influencing and the humanitarian aspects are underestimated.

Furthermore, most psychiatrists have practically a blind spot for the aspect of their work that relates to power. They surrendered paternalism for lack of choice under the new law. At the same time, these past years they raise their voices continuously more loudly in demand of the reinstatement of paternalism.

Perhaps concrete and immediate improvement could be achieved if the balance between empirical-scientific and humanistic aspects could be restored. In that case, more attention would be directed at:
  1. Reinstating the asylum function of psychiatry, by creating safe havens, where people who apparently cannot hold their own in society can be provided shelter and protection;
  2. Providing for the primary needs of the homeless, in the sense of places to sleep and eat which are sufficiently comfortable, also in quantity, with an opportunity for permanent shelter if so desired, without the threat of the often so feared treatment;
  3. Further development of possibilities for intervention and other forms of persuasion on a voluntary basis.
On the one hand, these “solutions” are too attractive, as Szasz tried to show in Cruel Compassion (1994). The worry is that there will be too much demand for such provisions, which will massively draw candidates. That would of course mean that the need for such provisions is quite great, probably greater than the need for today’s provisions which are preoccupied with treatment and therapy. At the same time, precisely because they refrain from the ideology of treatment and therapy, they are too modest to appeal to politicians.

Apparently, restriction and pretence tempt the state to choose solutions within the framework of psychiatry, with its inaccessibility, its stigmatization, and for many its unwelcome therapeutic ideologies. The restriction that a psychiatric disorder must be present prevents excessive demand for assisted living. The pretense that treatment truly cures makes funding more acceptable.

In my opinion, coercion as practiced by psychiatry has much more complex roots than psychiatrists’ thirst for power and status. Apparently, society – the state, the legal system, and the public at large -- has a need to remove from its midst the feelings of being threatened and the fear of the unknown that psychiatric patients can evoke. It seems that this need for protection cannot be satisfied by the legal system with its precise rules and legal guarantees because of the impossibility of determining the exact nature and size of the threat.

This, I believe, is the complex reason that a more informal system of social control developed alongside the system of justice. Perhaps this clarifies why every protest or criticism of this system is met with recoil, whether shouted in fire and brimstone by heretics like Szasz, or whether levelly evaluated, weighing the pros and cons, the way I have done in this book.
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