Psychiatric Power

January 1, 1997

The state of North Carolina has relatively liberal policies regarding petitions for involuntary commitment. If such documents bear words like "dangerous" or "mentally ill," even in the most nebulous sense imaginable, the police will surely locate the relevant individuals and dutifully bring them to the emergency department. This generosity of interpretation produces some sticky situations for the lucky ED resident of the day.

The state of North Carolina has relatively liberal policies regarding petitions for involuntary commitment. If such documents bear words like "dangerous" or "mentally ill," even in the most nebulous sense imaginable, the police will surely locate the relevant individuals and dutifully bring them to the emergency department. This generosity of interpretation produces some sticky situations for the lucky ED resident of the day.

I recall a case in which a middle-aged man was petitioned by his wife, who had written, in effect, that he was "drinking himself to death" and urgently needed substance abuse treatment. The "patient" (for he had just become such) was pleasantly inebriated and had taken his mandatory ride in good humor. He wasn't particularly interested in hospitalization and had no known medical problems or history of complicated alcohol withdrawal. When I called his wife, I encountered a well-intentioned, long-suffering soul who, far from trying to manipulate the system, honestly considered her move to represent her husband's best chance for treatment. He was neither depressed nor psychotic, and she did not deem him immediately dangerous to himself or others. After explaining to both of them the relative purposes of involuntary commitment and outpatient substance abuse counseling, I sent him on his way.

More disturbing than this case were the many petitioned adolescents I saw during the month of September, when the new school year elicited a predictable spate of crises. Some were true emergencies, but a fair number of cases entailed such activities as skipping school, smoking an occasional joint, and defying authority figures. In other words, the kids were doing things that, in other times or places, would have resulted in such measures as suspension from school or withholding of privileges at home. Many panicked parents have learned, however, that an involuntary hospital stay produces a more immediate and marked impression. In some instances I felt genuinely sorry for adolescents whose parents seemed inadequate and vengeful. In the chaos of the emergency department it is difficult at times to ascertain where therapy ends and discipline begins. Treatment is, after all, a word with many connotations.

Much overdue attention has rightly been lavished upon the subtle imbalances of power in psychiatrist-patient relationships and their perils of emotional and sexual exploitation. But if my fairly standard medical school and training experiences are at all representative, then what is often overlooked—and what is worse, taken for granted—is the much more brutal fact of involuntary commitment. Just as oncologists often become numb to death, so do psychiatrists tend to grow insensitive to the everyday exercise of what is, after all, an incredible degree of social power.

Medical students are typically amazed to learn that by filling out a simple form, any psychiatrist, even one just out of medical school, can effectively force a patient to be detained against his or her will until a court hearing occurs, which can take up to a month, at least where I work. Residents' familiarity with commitment often breeds a certain contempt, and the procedure soon becomes routine on a busy inpatient service. In fact, we time-pressed residents even tend to become a bit cross when we are called to court to testify, as if we had received an unwelcome rebuff to our authority.

Psychiatrists sometimes seem a bit insecure in the medical world. Our frenzied attempts to establish diagnostic criteria and gather neurobiological data give us away. We are trained to demonstrate that we have as much diagnostic and therapeutic power as our medical and surgical colleagues. I propose that we do not learn enough about the history and sociology of psychiatry, that is, how it comes about that ours is the only specialty whose patients are frequently brought to us and kept against their will. We are eager to prove that we have enough power, but are we prepared to counter charges that we have too much?

Some incisive critics of psychiatry have written extensively in the past 30 years; I will briefly allude only to the most prominent, and naturally, I cannot do justice to their arguments here. Thomas Szasz, M.D., himself a psychiatrist, has written about the theme of psychiatry as a means of social control masquerading as medicine. In The Myth of Mental Illness and other books, he contended that society "deals with" certain kinds of undesirables by locking them away or medicating them. Similarly, Michel Foucault, the polemical French philosopher, argued in Madness and Civilization that the rise of psychiatry and asylum coincided with the Age of Reason and society's pressing need to sequester its members who would not comply with Reason. In a more poetical vein, R.D. Laing speculated in

The state of North Carolina has relatively liberal policies regarding petitions for involuntary commitment. If such documents bear words like "dangerous" or "mentally ill," even in the most nebulous sense imaginable, the police will surely locate the relevant individuals and dutifully bring them to the emergency department. This generosity of interpretation produces some sticky situations for the lucky ED resident of the day.

I recall a case in which a middle-aged man was petitioned by his wife, who had written, in effect, that he was "drinking himself to death" and urgently needed substance abuse treatment. The "patient" (for he had just become such) was pleasantly inebriated and had taken his mandatory ride in good humor. He wasn't particularly interested in hospitalization and had no known medical problems or history of complicated alcohol withdrawal. When I called his wife, I encountered a well-intentioned, long-suffering soul who, far from trying to manipulate the system, honestly considered her move to represent her husband's best chance for treatment. He was neither depressed nor psychotic, and she did not deem him immediately dangerous to himself or others. After explaining to both of them the relative purposes of involuntary commitment and outpatient substance abuse counseling, I sent him on his way.

More disturbing than this case were the many petitioned adolescents I saw during the month of September, when the new school year elicited a predictable spate of crises. Some were true emergencies, but a fair number of cases entailed such activities as skipping school, smoking an occasional joint, and defying authority figures. In other words, the kids were doing things that, in other times or places, would have resulted in such measures as suspension from school or withholding of privileges at home. Many panicked parents have learned, however, that an involuntary hospital stay produces a more immediate and marked impression. In some instances I felt genuinely sorry for adolescents whose parents seemed inadequate and vengeful. In the chaos of the emergency department it is difficult at times to ascertain where therapy ends and discipline begins. Treatment is, after all, a word with many connotations.

Much overdue attention has rightly been lavished upon the subtle imbalances of power in psychiatrist-patient relationships and their perils of emotional and sexual exploitation. But if my fairly standard medical school and training experiences are at all representative, then what is often overlooked—and what is worse, taken for granted—is the much more brutal fact of involuntary commitment. Just as oncologists often become numb to death, so do psychiatrists tend to grow insensitive to the everyday exercise of what is, after all, an incredible degree of social power.

Medical students are typically amazed to learn that by filling out a simple form, any psychiatrist, even one just out of medical school, can effectively force a patient to be detained against his or her will until a court hearing occurs, which can take up to a month, at least where I work. Residents' familiarity with commitment often breeds a certain contempt, and the procedure soon becomes routine on a busy inpatient service. In fact, we time-pressed residents even tend to become a bit cross when we are called to court to testify, as if we had received an unwelcome rebuff to our authority.

Psychiatrists sometimes seem a bit insecure in the medical world. Our frenzied attempts to establish diagnostic criteria and gather neurobiological data give us away. We are trained to demonstrate that we have as much diagnostic and therapeutic power as our medical and surgical colleagues. I propose that we do not learn enough about the history and sociology of psychiatry, that is, how it comes about that ours is the only specialty whose patients are frequently brought to us and kept against their will. We are eager to prove that we have enough power, but are we prepared to counter charges that we have too much?

Some incisive critics of psychiatry have written extensively in the past 30 years; I will briefly allude only to the most prominent, and naturally, I cannot do justice to their arguments here. Thomas Szasz, M.D., himself a psychiatrist, has written about the theme of psychiatry as a means of social control masquerading as medicine. In The Myth of Mental Illness and other books, he contended that society "deals with" certain kinds of undesirables by locking them away or medicating them. Similarly, Michel Foucault, the polemical French philosopher, argued in Madness and Civilization that the rise of psychiatry and asylum coincided with the Age of Reason and society's pressing need to sequester its members who would not comply with Reason. In a more poetical vein, R.D. Laing speculated in The Divided Self that the psychotic, or "mad," experience of the world is not inevitably diseased, but may be an authentic variant.

These claims have prompted rebuttals by many who feel that they represent an extremely romanticized view of mental illness, and in general, I agree with this assessment. What bothers me most, however, is that these formidable critiques of psychiatry are ignored almost without exception in mainstream psychiatric journals, textbooks and residency programs. Cross-cultural psychiatry is gaining in prominence, receiving a nod even in the DSM-IV, but this is only a beginning in a meaningful inquiry into the social dimensions of the field. Had I not done some reading on my own, I never would have suspected that anyone, anywhere, had ever accused psychiatry of having not too little power, but too much. Nor would I have any idea that psychiatry has a history (even before Freud)!

Ubiquitous these days is the concern that psychiatry, in its zeal to gain biological legitimacy, is becoming "mindless" and losing sight of "the whole patient," that holy grail of our endeavor. I submit that we should also be better trained to keep in view "the whole profession," and the nature and history of the philosophical and social assumptions that support it. I am not advocating negativism about psychiatry's ultimately noble enterprise. However, we should maintain a healthy respect for the very potent privilege, granted us by society, of pronouncing certain modes of experience and behavior to be "disease." Every good psychiatrist acknowledges Socrates' famous admonition, "Know thyself," but this encompasses more than countertransference and the therapy hour.

The Divided Self

that the psychotic, or "mad," experience of the world is not inevitably diseased, but may be an authentic variant.

These claims have prompted rebuttals by many who feel that they represent an extremely romanticized view of mental illness, and in general, I agree with this assessment. What bothers me most, however, is that these formidable critiques of psychiatry are ignored almost without exception in mainstream psychiatric journals, textbooks and residency programs. Cross-cultural psychiatry is gaining in prominence, receiving a nod even in the DSM-IV, but this is only a beginning in a meaningful inquiry into the social dimensions of the field. Had I not done some reading on my own, I never would have suspected that anyone, anywhere, had ever accused psychiatry of having not too little power, but too much. Nor would I have any idea that psychiatry has a history (even before Freud)!

Ubiquitous these days is the concern that psychiatry, in its zeal to gain biological legitimacy, is becoming "mindless" and losing sight of "the whole patient," that holy grail of our endeavor. I submit that we should also be better trained to keep in view "the whole profession," and the nature and history of the philosophical and social assumptions that support it. I am not advocating negativism about psychiatry's ultimately noble enterprise. However, we should maintain a healthy respect for the very potent privilege, granted us by society, of pronouncing certain modes of experience and behavior to be "disease." Every good psychiatrist acknowledges Socrates' famous admonition, "Know thyself," but this encompasses more than countertransference and the therapy hour.