Dr. Frances is former Chair and Professor Emeritus of Psychiatry at Duke University. He was the Chair of the DSM-IV Task Force. Mr. Ruffalo is Affiliate Assistant Professor of Psychiatry and Adjunct Instructor of Social Work at the University of South Florida. He is a psychoanalyst in private practice.
From our beginnings, psychiatry has functioned at the intersection of medicine and the broader society—serving not only to treat psychiatric disorders but also to help prevent patients from harming themselves or others. When the father of modern psychiatry, Philippe Pinel (1745-1826), freed his patients from chains (at the Salpêtrière asylum in Paris) 220 years ago, he established a centuries-long precedent of attempting to appropriately balance the civil rights of the mentally ill with the occasional and carefully considered need for involuntary treatment. This requires finding a delicate balance in best serving the sometimes-conflicting values of patient welfare, protecting civil liberties, and public safety.
More than any other medical specialty, we sometimes feel compelled, and empowered, to treat patients against their will. With this comes two great responsibilities—to protect free choice and civil rights to the fullest degree possible, but also to restrict them on the very rare occasions when this is clearly necessary to protect the patient and/or society.
A system breaks down
The state-operated inpatient “asylums” in the US, originally intended as a respite for psychiatric patients, soon degenerated into overcrowded and degrading warehouses. Patients were deprived of liberty without due process, subjected to harmful neglect, and often locked up for years—sometimes for life—without any real treatment or normalizing interpersonal interaction. Rather than foster recovery, the social exclusion of hospitals often made patients much sicker.
As recently as the 1960s, there were more than 600,000 Americans involuntarily committed to psychiatric facilities that really functioned more like prisons than hospitals. False commitment was common. Hazardous and unproven treatments like lobotomy and insulin shock were sometimes imposed on unwilling patients for unclear indications.1,2
FIVE NODAL POINTS contributed to the massive deinstitutionalization of psychiatric patients that occurred in the 1960s and 1970s.
1 In 1946, Mary Jane Ward3 published The Snake Pit.3 This bestselling novel, that was made into an Academy Award winning film, exposed the dire plight of the mentally ill.
2 In 1961, psychiatrist Thomas Szasz4 published his classic book The Myth of Mental Illness. He described the destructive threats to civil liberties and a decent life posed by state “hospitals.”
3 Also in 1961, sociologist Erving Goffman5 described how the neglect and humiliation of asylums-turned-prisons made patients much more symptomatic and dysfunctional than they would be in real-life situations.
4 The availability of antipsychotic drugs in the 1950s and 1960s made feasible the closing of many state hospital beds and treatment in the more normal and socially inclusive community outpatient clinics.
5 And finally, Jack Kennedy, the newly elected president, had a strong personal commitment to help people with mentally illness based on his sisters’ disastrous experience with lobotomy.
1. Shorter E. A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. Hoboken, NJ: Wiley; 1998.
2. Lieberman JA. Shrinks: The Untold Story of Psychiatry. Boston, MA: Little, Brown; 2015.
3. Ward MJ. The Snake Pit. New York: Random House; 1946.
4. Szasz TS. Law, Liberty, and Psychiatry: An Inquiry Into the Social Uses of Mental Health Practices. New York: Macmillan; 1963.
5. Goffman E. Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. New York: Anchor; 1961.