[A National Medical Audiovisual Center Production]

[Jules Masserman:] I'm Jules Masserman, Professor of Psychiatry at Northwestern University 

and President at the International Society for Social Psychiatry.

I do not believe that total abolition of hospitalization for serious behavior disorders, 

which is a term preferable to mental diseases, is at present either advisable or practical. 

And I'll try to clarify that position on psychiatric as well as legal and social grounds later in this discussion.

[Thomas Szasz:] I am Thomas Szasz, Professor of Psychiatry at the State University of New York in Syracuse. 

My position is that involuntary mental hospitalization should be abolished.

[Harold Visotsky:] I'm Harold Visotsky. 

I'm Professor and Chairman of the Department of Psychiatry at Northwestern Medical School, 

and as a former Director of the Illinois Department of Mental Health I'm interested in a broad discussion of this issue, 

and I will serve as the moderator for this discussion.

[concepts and controversies in modern medicine] 

[Involuntary Hospitalization of the Psychiatric Patient: Should It Be Abolished?]

[Host:] Welcome to the exploration of concepts and controversies in modern medicine. 

One of a series of programs dedicated to examining the uncertain, 

candidly recognizing that much of today's teaching is necessarily based upon opinions and that the opinions of eminent physicians 

in a given field vary widely.

The National Medical Audiovisual Center believes that openly airing such opposing views 

is a basic responsibility of medical communications. 

Dr. Harold Visotsky, Chairman, Department of Psychiatry at Northwestern Medical School, will act as moderator of this presentation.

[Harold Visotsky:] We will be discussing the issue of whether any conditions justify involuntary commitment 

if a person is diagnosed as being mentally ill. 

There is a point of view which holds that involuntary commitment is never justified, 

that only voluntary commitment is ever justified in a democratic society.

This point of view is supported on the basis of both libertarian views and the strong criticism of 

the quality as well as the intensity of mental health care and treatment in our mental institution. 

When this is applied to harmless and eccentric- acting individuals or peculiar-acting individuals in our society, 

we can see that this position can be strongly supported.

However when we see individuals who are clearly violent in their intent and in their propensity, 

and we see suicidal persons and patients in catatonic immobility, 

what does society have to do in order to safeguard their health and the health of society? 

And so involuntary commitment may be justifiable, under what conditions, 

and in this discussion we would like to cover all of these areas.

The second point involves the consideration of confining individuals against their will 

because of undesirable activities and the role that predictability are, ability to predict their acting out has in involuntary commitment.

I should like to start this discussion with the presentation of the view of Dr. Szasz.

[Thomas Szasz:] Well, I think I can best present my reasoning, which urges abolition of all involuntary 

mental hospitalization and treatment by first citing a quite typical example of it from the popular press for the kind of circumstance 

which is considered to be justified and then enumerating my reasoning.

So I will quote very briefly from last week's Time magazine, which relates to the story of a 62-year-old prominent attorney

whose name need not be mentioned,

a graduate of the Harvard Law School, an official of the United Church of Christ, who boarded an airplane 

from Boston to Washington and with a broad grin asked the stewardess, 

"How long does it take to Cuba?" He was hauled off the plane and then he was not sufficiently contrite. 

I quote, one of the police officers told him, "You be careful of what you say or we'll send you to a state insane asylum for a 30-day examination." 

End of quote.

Now I consider this a typical example of the way psychiatry, institutional psychiatry, is used not in a useful way.

If this man had not been as prominent as he was, he may very well have ended up in a psychiatric hospital. 

Now the theoretical underpinnings of my position...

first, I contend that psychiatry--and I distinguish sharply between psychiatry and neurology--neurology deals with disease of the brain. 

I contend that what we now call psychiatry deals not with any kind of disease, but with human conflict 

or what I have sometimes called problems in living.

It deals, as Dr. Visotsky already alluded to for example, with people who behave deviantly or violently. 

Now that's, what we call violent behavior actually is conflict. 

Somebody does not like, the violence.

Secondly, it is my opinion that confronted with an individual, 

and I don't think we should call such an individual "a patient" too readily, because the word "patient" 

implies that the person is sick and perhaps needs medical treatment. 

In my opinion he is not a patient, he's a person, an individual who feels troubled.

Thirdly, then, we come to the issue that commitment, as presently practiced 

and as historically justified, has been supported by a very ambiguous and confusing dual justification, 

namely, that it helps the individual, for example if he is suicidal, by preserving his life, 

I'll come back to this, and it also helps society by protecting society from unpleasant or harmful so-called mental patients. 

Now I contend that these two functions have nothing in common and must be separated. 

Helping an individual must, in my opinion, in a free society, always be free and contractual. 

Whereas protecting society is very eminently a legitimate function of society, 

but must in my opinion be exercised under the rubric of the law and due process, 

and never under the rubric of medicine or science or mental health.

In short then, taking a category of so-called mental patients, those about whom or with respect to whom 

involuntary interventions are perhaps most easily justified, namely the so-called violent patients, the Oswalds as it were, 

my view is that indeed violence is real, 

and a great many people in modern society who misbehave are nowadays called mentally ill.

What my view is, is that although their violence is real, this is not an illness, 

that in fact what we witness is the violence and uncivilized behavior of the mental patient being met by the violence, 

by the counter-violence in similarly uncivilized behavior of psychiatry, so that involuntary mental hospitalization 

is in effect a kind of counter-violence against sometimes violent so-called mental patients. 

In sum, my view is that if individuals do not injure or threaten to injure others, help, medical psychiatric help should be offered to them. 

But under no circumstances will it be justifiable to coerce them, to accept so-called help. 

If they threaten or injure others or society, then they fall clearly in the class of those individuals 

for whom the criminal law and the sanctions are designed, 

and they should be restrained under the auspices of the criminal law and not of psychiatry.

[Harold Visotsky:] I think Dr. Masserman may want to discuss his aspects of this issue a little bit more broadly 

and perhaps to initiate the discussion of Dr. Szasz's position, 

and I think we ought to get to it as soon as possible.

[Jules Masserman:] Thank you, Harold. 

Tom, let's make my discussion completely impersonal so that there's nothing other than scientific issues between us. 

We're old friends. 

We were trained together at the University of Chicago, I think at the beginning of the Pleistocene age as I remember it...

and both at the university and at the Institute for Psychoanalysis, 

both sort of mavericks then, and I've followed your career with mixed feelings. 

Mostly I must confess, a good deal of admiration for your courage and your honesty 

and putting your own position on the line for your beliefs. 

I think a little bit of amusement because you take yourself so very seriously as a Jeremiah, 

sort of lecturing the sinning Israelites when most of us agree with you, actually, on very important issues.

I must also say that I've had a good deal of trepidation and some sorrow, because some of your extreme statements,

I think impair your position, and in a sense make it more difficult to help those with serious behavior disorders 

or, uh, mental diseases and, you know, in fact impair some of our images more than necessary. 

Now I don't want to play antics with semantics...let's clarify what we mean by mental diseases 

in the first place because you use the term. 

I use behavior disorders.

Now in modern philosophy and modern science we don't deal with things, we deal with processes, with interactions, with dynamics. 

So when you talk about the mind, it isn't a thing, it's a process. 

If you change it from a noun to a verb, what does it mean? 

When we put our mind to something we perceive, we see, we hear, we feel. 

You can say these are neurological processes and therefore are subject to the term of disease when they go awry, perfectly true. 

But when we remind ourselves of something we lose our memory. 

We place it in a context of previous experience.

Now that experience can be highly distorted, don't you see? 

And it gets into the social sphere, 

the sphere of individual relationships with other people, 

and then finally when we mind our manners, or mind the laws, or mind society, or mind culture, this is certainly a social process. 

And so when we talk about the mind we're talking not only about physical but also about social relationships.

Now let me be a little bit more radical than you are. 

I agree that there's hardly a, something we call a mental disease in the back wards of any hospital, 

that somewhere in this world, in some other culture, would be considered not only normal but commendable. 

A person in an epileptic fugue who sees visions might be a holy man somewhere. 

A person who is a paranoiac is perfectly normal in a [?] society where everybody is suspicious of everybody else. 

Somebody who we call exhibitionistic who would be considered perfectly normal in a nudist colony 

and if he tried to wear anything is would be considered obsessive-compulsive or what, now that's perfectly true.

Then it's a relative thing, but then what do we mean by disease? 

Disease means that somebody is uneasy about something, which means that behavior is unpredictable. 

Now this can be either individual or social. 

And this clarifies the whole concept because an individual can be uneasy about organic disease, 

but he can also be exceedingly uneasy about his social relationships, he can be uneasy about his philosophy. 

So we have existential anxiety, and they can be uneasy enough so they appeal for help and want it, 

and sometimes can be so uneasy they're confused and anxious and depressed 

and sometimes suicidal and don't know where to seek help and must be given it. 

Now the society can be uneasy about these individuals also.

Society is uneasy about the same three categories: physical, social, and philosophic. 

So society is uneasy about pollution, and about the spread of diseases, this is physical. 

But society is also uneasy about individuals that transgress 

its cultural norms and this extends beyond crime. 

Society is also uneasy about philosophy, so we go to the moon to settle our cosmology 

and we invent new religious systems to settle what we believe is values in life. 

All of these can get so deviant that an individual must interact with society in certain ways so that both are protected. 

Now let me give you examples.

Would you call epilepsy a disease? 

It's certainly a physical disease, isn't it? 

It's deviations in electroencephalogram. 

It's treated by drugs. 

You can find lesions in the brain in some cases, and so on. 

But that's also a social disease. Would you want to drive with an epileptic bus driver? 

Would you like to have an epileptic pilot fly a plane? 

Now who's going to judge that? A lawyer? Or a judge? 

We've got to have a psychiatrist say that this individual must be regulated because a psychiatrist has

special information both on the physical and on the social planes as to what the interaction can be.

What would you judge about the general paretic, for example? 

Can a lawyer diagnose that? 

Is it simply a question of some neurologist saying "disease of the brain"? 

We must also judge as to what his behavior can be social-wise.

I wish we had psychiatrists at the time, shall we say, of Frederick the Great, who was a paretic. 

We could have saved an awful lot of trouble. Or Genghis Khan who may have been a paretic. 

But if psychiatrists had judged that these people should have been put under regulation, 

despite the laws that they themselves passed, a great deal of human sorrow would have been saved.

And so while I agree with you, we must not use our position as determiner of men's lives and liberty and so on, 

we still have special information and special training that do indicate when individuals 

need to be protected from themselves and society needs to be protected from them for mutual benefit. 

And this sometimes does take medical and psychiatric as well as legal process.

[Harold Visotsky:] You know I can't help hearing as I listen to both of you, a certain theme that comes through. 

You, Jules, feel that if psychiatrists were around when Genghis Khan was around, 

or Frederick the Great, that they could have stopped the activity. 

That was a political power decision, 

and I'm not quite sure that psychiatrists are as powerful as you would want them to be or as Tom fears that they are, 

and I think maybe this is the concept that we have to discuss.

There is one issue that I'd like to take up with you Tom, 

and that has to do with one of the statements that you said that if individuals threaten or injure others, 

they fall into the class of criminal law and should be handled by the criminal system. 

You know, I also in agreement with most of the concepts of how to deal humanely with individuals 

who are deviant or have problems or may be ill, by both their definition and ours.

But when we say that when individuals threaten or injure someone on the basis of illness or what might be deviant behavior, 

and then to put them into the criminal justice system which is an impure and imperfect system even for others, 

it seems like we're doubling the stigma. 

They have a clearly deviant pattern which whether we diagnose it as mental illness or society diagnoses as being crazy or queer, 

you then superimpose another kind of jurisdictional system, that of the criminal law. 

And what do we do? 

Do we, if they are guilty do we send them to jails, which are imperfect facilities? 

You've equated jails with state hospitals, so it doesn't matter.

You're saying what society is saying: "Let's get 'em out of here. Let's extrude them." 

And whether we use a medical system to extrude them or a legal system, we'll get 'em out. What are you saying?

[Thomas Szasz:] Well, of course it does matter. 

We hardly have the time to do justice to this subject but the gist of my writings 

has been directed in the last two years toward explicating precisely the differences that ensue 

whether is someone is dealt with as a potential mental patient or as a potential criminal.

First of all, if someone is dealt with under the criminal law, this doesn't mean putting him in prison. 

It may mean imposing a money fine on him or possibly imposing a suspended sentence on him.

[Harold Visotsky:] Or putting him in a hospital.

[Thomas Szasz:] Now my contention is that a hospital ought not to be used in lieu of a jail. 

But I would like, just like to make one comment, one further comment on what you said Harold, 

because of course you are right in a historical sense. 

Historically, psychiatry in many of the renamings of social problems as mental illnesses,  

has come into being in an effort to humanize,to liberalize harsh, uncivilized, penologic practices. 

But you can't, I believe you can't correct one deficiency by erecting an illusory and sometimes equally harsh if not worse, 

system in place of it.

In other words, the whole tendency to say yes, jails are bad, 

therefore we should lock up people in mental hospitals, is all wrong. 

Because then mental hospitals, A, mental hospitals will become just as bad. 

B, what is lost in the process is the entire body built up over the last 700 years in English 

and American law of determining whether in fact someone is a criminal or not, 

or whether he has been falsely accused or whether there are mitigating circumstances...

[Jules Masserman:] But Tom, you just raised two issues that I think are very apropos. 

In the first place, historically, psychiatrists such as Pinel, Escro, William Tuke, 

[?] in this country and so on, have liberated people. 

They took chains off. 

They didn't put them on. 

And modern hospitals do their best to get patients out as soon as possible. 

I don't know whether you've visited some of the modern hospitals recently. 

I work with them all the time. 

There are places that are rather attractive and hygienic and interested in getting people out, 

curing people, which means caring for them, it's exactly the same root, as soon as possible.

So I wonder why you would equate hospitals with jails.

[Thomas Szasz:] Well, may I respond to this directly? 

As you both know, it's uh, if I may be allowed to explicate to this audience, my view is that Pinel did not liberate mental patients. 

That all this kind of description in psychiatric history is pontification. 

Pinel liberated mental patients like Jefferson liberated the negro. 

He ran a more elegant plantation. 

My essential thesis is that liberty, human liberty, is [?]

If you cannot leave a building, it's a jail. 

If you can't leave a farm, if you are recaptured and put back to work, it doesn't matter whether you have, if you eat 2,000 calories or 800, 

whether you have a decent house, if you can have your wife around you...it's a plantation and you're a slave. 

And I am not talking about the improvement of mental health.

I'm not talking about doing away with abuses. 

I am talking and analogizing involuntary hospitalization to involuntary servitude and analogizing treatments to contractual labor. 

You either have contractual labor or you have slavery. 

You either have voluntary treatment, or your hospitalization is involuntary.

How much nicer it is is not [?]

[Harold Visotsky:] As a matter of fact I'm not satisfied with the hospitals in Illinois. 

I am concerned, if I were following your train of thought Tom, 

that what do you do with the patient who is suicidal and who's made suicidal gestures? 

Now I've had discussions with students of law and they say a man's body is his own. 

You know they follow Mill's moral concept. 

It may be that in a Pollyannaish way John Donne's "No man is an island" is also a kind of moral concept.

What do you do with a man who is clearly suicidal? 

Do you put him in jail? He's breaking the law if he commits suicide, if he makes an attempt.

[Thomas Szasz:] Well, Harold, first of all you realize, I hope you realize, and I want to make this again very clear, 

we have slipped into a purely moral discourse. 

Now whether or not suicide is or is not a permissible act or what kind of an act it is, 

has nothing to do as far as I can see with medicine or a psychiatry...

[Harold Visotsky:] Let's see it as a conflict. 

You deal with that as a conflict. A man has a conflict with his environment and he wishes to leave it by killing himself.

[Thomas Szasz:] One second. 

The whole concept of a man being suicidal is psychiatric euphemism. 

If a man wants to kill himself, how do you know it? 

Does he tell you? 

In what context does he tell you?

Secondly, my contention is and presumably this differs in a very radical way from the standard psychiatric view, is a purely moral, 

up to a person, like religion. 

One person is Catholic, another one is Jewish. 

My view is that suicide is an unqualified human right. 

This is not to say that making a suicidal gesture by standing on the twentieth floor of a building in Manhattan is a human right. 

That's disturbing the peace.

[Jules Masserman:] Well in that case Tom, you would also say that alcoholism is a unqualified human right, 

that a person can deprive his wife and his children of a proper parenthood, 

that all sorts of things that really affect society rather deeply are human rights.

Now an alcoholic...let's admit right away, the law is just about as crazy as some of the old psychiatric notions were. 

For example in California, if you're just found with a little marijuana on you, you get five years in jail. 

LSD hasn't gotten around to it yet. 

And psychiatrists are put in a position really that are impossible. 

For example, you can't hang a man or electrocute him legally unless he's found sane.

A psychiatrist can be called in by a lawyer, say, or by the governor, say, "Will you please certify this man as sane so we can electrocute him?" 

The psychiatrist becomes the executioner. 

There are all sorts of absolutely, if you will, insane things about it. 

But on the other hand, suicide affects not only the individual, it affects many other people. 

The person's family, his children, his associates, his friends.

This is a social problem and cannot be left up to the judgment of the individual. 

Well, let's take another instance. 

Let's take general paresis.

Or you can say this syphilis of the brain, this is a disease, this belongs to neurologists and internists, not psychiatrists. 

But suppose the general paretic is still infectious and he thinks he's a Napoleon 

and he can go around and infect as many women as possible and he is a real social danger. 

He doesn't think he needs to be hospitalized and as a matter of fact, he can hire a lawyer to defend him.

Would you let such an individual, just because he has the advantage of the Constitution, free in society to infect women, 

to invoke this delusional system on other people, when as a matter of fact he'd be much better off in the long run, 

so would society, if he were treated under temporary involuntary commitment. 

I would want my daughter to be treated so.

[Harold Visotsky:] You can see that we haven't discussed this as broadly as we would have wanted to. 

Rather we have opened the discussion which must go on not only here, and we will go on for the rest of the day I'm sure, 

but must go in with the members of the audience to look into themselves as to what role they want to play in this.

Do they want to follow a role in which the psychiatrists deals with those individuals who see themselves 

as being in conflict and having difficulties with society and come voluntarily to them? 

Or do they feel that as some of us may feel that some individuals will not come to us,  

and through not coming to us may injure themselves or others or be in some sort of difficulty with the world around them.

This is a very important issue and can't be debated. 

I think it requires great understanding and broad discussion amongst all of us.

[Host:] We thank Dr. Jules Masserman, Dr. Thomas Szasz, 

and Dr. Harold Visotsky for their interesting analysis of a critical problem in patient care. 

In subsequent programs we shall continue to record equally significant concepts and controversies in modern medicine.

The opinions expressed on this program do not necessarily constitute endorsement by the Department of Health, Education, and Welfare, 

the Public Health Service or its constituents.

[Jules H. Masserman, M.D. Professor of Neurology and Psychiatry Co-Chairman of Psychiatry Northwestern University] 

[Thomas S. Szasz, M.D. Professor of Psychiatry, State University of New York, Upstate Medical Center Syracuse, New York] 

[Harold M. Vistosky, M.D., Professor and Chairman, Department of Psychiatry 

Northwestern University Medical School, Chicago, Illinois] 

[concepts and controversies in modern medicine] 

[The End V-1478  T-1478]