Thomas Szasz has been the scourge of psychiatry for
decades. His criticisms are now well-known: that psychiatry is an unscientific
profession which enforces social conformity for the aggrandizement of the psychicatric
professionals and the political/social structure that privileges them.
Motivated by libertarian politics, Szasz insists that psychiatry must not lend
itself to the state as a tool of coercion or punishment; he opposes psychiatric
evaluations of criminal defendants and the involuntary detention of psychiatric
patients for either the protection of society or their own good. In Psychiatric
Slavery (originally published in 1977, reissued with a new Preface in
1998), Szasz revisits the issue of involuntary detention, through the lens of the
obligation to provide psychiatric treatment to patients who are so confined

Szasz centers his discussion around the groundbreaking
case O’Connor v. Donaldson. A psychiatric patient, held involuntarily in
a state institution with no psychiatric treatment provided, filed a lawsuit
claiming he had a right to such treatment.  Szasz, characteristically, regards
this move as a step backward for patients’ rights: requiring the state
to treat patients while it detains them involuntarily necessarily
ratifies the state’s right to detain them involuntarily. Szasz repeatedly
insists, and not metaphorically, that involuntary psychiatric detention is a
form of "slavery," and the Court’s ruling, which did not seriously
question whether the state has the right to hold such persons at all,
perpetuated this slavery under the guise of improving conditions for the
slaves. His preferred solution is a divorce of psychiatry from the coercive
power of the state:

To correct the abuses of the
psychiatrist’s arbitrary power to confine and release mental hospital patients,
the legislatures and the courts have only two alternatives. Either they must
limit the psychiatrist’s powers to confine and release by assuming more of
these powers themselves. . . . Or they must abolish psychiatric imprisonment,
psychiatric prisons, and the whole system of involuntary psychiatry.

Kenneth Donaldson was involuntarily detained in a Florida
state psychiatric institution for almost 15 years; he was provided no
treatment. He repeatedly demanded his freedom but was always denied. Donaldson
initiated a class action suit on behalf of all patients similarly situated; he
was (suspiciously) then discharged from the hospital, voiding his lawsuit. His
legal advisors sued the hospital director, O’Connor, for damages, hoping to put
other hospitals on notice that they could be held liable for holding patients
without treatment. State courts found both that involuntary patients had a
right to treatment and that Donaldson deserved damages because of O’Connor’s "wanton,
malicious, and oppressive" behavior. The Supreme Court vacated the award
against O’Connor on legalistic grounds. The Court also sidestepped the issue of
a right to treatment, but held the state could detain Donaldson only if he was
dangerous, and had violated his rights because he clearly was not. Though the
high Court had not stipulated a constitutional right to treatment for
involuntarily-held patients, the decision was hailed as a victory.

Szasz is almost uniformly caustic in his reaction. He
argues that each party to the case acted to some degree stubbornly and in bad
faith. (Donaldson was not treated because as a Christian Scientist he staunchly
refused all treatment, he was held so long because he refused to participate in
the official discharge evaluation process, the hospital clearly did not regard
Donaldson as dangerous but refused to discharge him, both the Supreme Court and
Donaldson’s activist attorneys ignored the central issue of the justification
of any involuntary detention, the Court attempted a Solomonic balancing
of a process that is morally bankrupt in every respect, and so on.) Szasz is
contemptuous of this disingenuous game-playing, and feels the lawyers
manipulated Donaldson and scapegoated O’Connor for their own purposes.

The Supreme Court refused to address the putative
right to treatment, deciding the case only on grounds of wrongful detention and
explicitly stating that the Court of Appeals finding of a right to treatment
was not to be regarded as precedent. Szasz, however, agrees with Warren Burger’s
argument that the Court should have gone further to deny any such right
entirely, on the grounds that a right not to be confined without due process
is not the same as a right to be treated if confined, and the
Constitution guarantees only the former.

It should be noted that Szasz himself is somewhat
disingenuous in characterizing the case. The Court’s ruling holds, in a passage
Szasz ignores: "A finding of ‘mental illness’ alone cannot justify a State’s
locking a person up against his will . . . . There is still no constitutional
basis for confining such persons involuntarily if they are dangerous to no one
and can live safely in freedom." Thus it seems the Court was
sensitive to the issue of involuntary confinement, although unwilling to go as
far as Szasz. The Court’s review of the facts also includes a number of factors
Szasz left out, especially O’Connor’s active connivance at keeping Donaldson
incarcerated (even going to the point of deceiving Donaldson’s parents and
imposing idiosyncratic rules of O’Connor’s own devising).

It seems fair to say Szasz has shaped his presentation
of Donaldson to illustrate his criticisms of involuntary detention. A
more even-handed reading of the case makes it clear why O’Connor was originally
held liable, and the language of the Court itself constitutes a strong brief
for patients’ liberty while still affirming the traditional precept that the
state is justified in detaining mental patients whom it judges are dangerous.
In addition, the fact that the Court did not find a positive right to
treatment for detained patients would seem to obviate Szasz’s concern that such
a ruling deflects from the issue of the justification for involuntary detention
itself, an issue on which the Court did comment though not to Szasz’s
liking. In the end, Szasz indulges his obsessions by overstating his analysis
of Donaldson.

This critique of the Donaldson case was
relevant at the time Psychiatric Slavery was originally published, but
is overburdened with details now largely of historical interest. More
interesting today are the opening chapter, "Justifying the Unjustifiable,"
which makes Szasz’s case that involuntary detention is literally a form of
slavery, and the penultimate chapter, "A Right to Treatment or a Right to
Treat?," in which he argues that the movement for a right to treatment for
involuntary patients is actually designed to strengthen psychiatrists’ rights
to detain them, by ratifying that power as the logical prerequisite of their
right to be treated afterward. Either of these would stand alone as useful
overviews of Szasz’s positions on these topics; his arguments are
characteristically well-put in hard-hitting prose, and neither chapter depends
greatly on Donaldson. Perhaps the best single piece in the book is the
updated Preface to the 1998 edition, in which Szasz makes his case in strong
but reasonable terms, includes a very brief recount of Donaldson and his
views on its outcome, and succinctly puts his argument against involuntary
detention and his view of it as an abuse of state and professional power. The
Preface could stand as a summary article for those uninterested in digging
through the minutiae of his more detailed criticisms.

In the end, Psychiatric Slavery is a solid
brick in the edifice Szasz has been erecting throughout his career, but is now
rather dated. It makes his case against psychiatry as an extension of the
coercive power of the state, both complementing and supporting his similar
arguments against the social-conditioning role of psychiatry (The Myth of
Mental Illness; Law, Liberty, and Psychiatry), the use of psychiatry
in judicial mental-competency hearings (Psychiatric Justice), and
involuntary detention as a general practice (The Age of Madness).
However, the close focus on the details of one rather old legal case restricts
its general usefulness. Though Donaldson is still cited, the historical
review of its arguments and the facts of Kenneth Donaldson’s own life are of
limited interest today (professionals in forensic psychiatry or mental health
law may still find this book useful, however). Its main interest is Szasz’s
argument that attempts to better the conditions of involuntarily detained
patients — such as by guaranteeing them psychiatric treatment — are analogous
to attempting to provide better conditions for slavery, and just as morally
bankrupt; this argument occupies only a portion of the text, though. Selections
from the book could be used as stand-alone readings in a course on the ethics
of psychiatry. Finally, as an example of "classic Szasz," Psychiatric
Slavery certainly represents his distinctive views, but one of his
better-known books might serve that purpose and be of more interest to the
general reader.

© 2005 Kevin
T. Keith

Kevin T. Keith, M.A., City College, CUNY

Categories: Philosophical, Psychology