bmj.com Rapid Responses for Szasz, 327 (7429) 1449-1451

Rapid Responses to:

WARD ROUND:
Thomas Szasz
The psychiatric protection order for the "battered mental patient"
BMJ 2003; 327: 1449-1451 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

The "Battered Mental Paitient"- a different perspective: Jayne Sercombe (19 December 2003)

Tired Cliches: Dr Daniel M Beales (20 December 2003)

Where is the humanity?: David M Bowker (21 December 2003)

In the U.S., Psychiatrists Do Not "Commit" the Mentally Ill: Ronald Pies MD (21 December 2003)

Enough of anti-psychiatric rhetorics: Sudip Sikdar (22 December 2003)

A Mad World Doesn't Need Headshrinkers: Dr Lynne Wrennall (22 December 2003)

Psychiatric Protection Orders Would Protect Human Rights: Darby J. Penney (22 December 2003)

No competing interest?: Nestor J. Presas (22 December 2003)

Great article: LostBoyinNC (Eric Rucker) (23 December 2003)

Dr Thomas Szasz is a Member of the Church of Scientology: Dr P V F Cosgrove (23 December 2003)

There are no scientologists at the BMJ: Richard Smith (23 December 2003)

Rights imply responsibilities: Angela F Harte (24 December 2003)

Should endocrinologists assume responsibility for psychotic patients?: Richard G Fiddian-Green (24 December 2003)

psychiatry should be formally merged into Neurology: Eric Rucker (24 December 2003)

Dr Szaz's BMJ article cannot have been peer reviewed: Dr P V F Cosgrove (27 December 2003)

Re: Dr Thomas Szasz is a Member of the Church of Scientology: Nelson Borelli, MD (28 December 2003)

Re: Great article: Nelson Borelli, MD (28 December 2003)

Dr. Szasz's Insightful Analysis of Freedom of Choice: Thomas K. Zander (28 December 2003)

Szasz � the same old tune!: Richard L O'Reilly, John E. Gray (28 December 2003)

Your own worst enemy: Gurli Bagnall (28 December 2003)

Protecting the Vulnerable from Zealots: Richard J Winkel (28 December 2003)

re: Enough of anti-psychiatric rhetorics: Annie E Scotney (28 December 2003)

Re: Dr Szaz's BMJ article cannot have been peer reviewed: Nicolas S. Martin (29 December 2003)

You need to compartmentalize your emotions on this one: Eric Rucker (29 December 2003)

"Battered mental patients": Christmas article: M E Jan Wise (29 December 2003)

Civil rights and Mental Illness: Christopher J O'Loughlin (29 December 2003)

re: your own worst enemy: Angela Kennedy (29 December 2003)

Re: The "Battered Mental Paitient"- a different perspective: Melanie Seaman (30 December 2003)

Will neuropsychiatric disorders become the exclusive domain of radiologists, physicists or even mathematicians?: Richard G Fiddian-Green (30 December 2003)

Re: Will neuropsychiatric disorders become the exclusive domain of radiologists, physicists or even mathematicians?: Eric Rucker (31 December 2003)

Re: Will neuropsychiatric disorders become the exclusive domain of radiologists, physicists or even mathematicians?: Eric Rucker (31 December 2003)

Your own worst enemy: E.Ann Robertson (31 December 2003)

Re: Your own worst enemy: Eric Rucker (1 January 2004)

In reply to E. Ann Robertson.: Gurli Bagnall (1 January 2004)

Reform Psychiatry or Abolish Psychiatry!: Dr P V F Cosgrove (2 January 2004)

Re: In reply to E. Ann Robertson.: Eric Rucker (2 January 2004)

Re: Reform Psychiatry or Abolish Psychiatry!: Eric Rucker (3 January 2004)

Crazy talk: John Hopkins (3 January 2004)

Re: Crazy talk: Richard G Fiddian-Green (3 January 2004)

Re: Crazy talk: Nelson Borelli, MD (4 January 2004)

Flat World, Round World: Dan Beales (4 January 2004)

Can I take this back a step?: Kim Gregory (5 January 2004)

"Global Emergency": David W. Oaks (6 January 2004)

(Non)coercive pscyhotherapy and "care": Jacqueline R Roig (7 January 2004)

psychology is a pseudoscience: Ted Huntington (7 January 2004)

The "value neutral science": William K Smith (7 January 2004)

Survivor of Post Partum Psychosis: Jenny Hatch (7 January 2004)

Labeling Dissidents: David W. Oaks (7 January 2004)

Voluntarily Coercion? Coerced "Choice"? A Contradiction? NO! Not Now!: Roger D. Carlson, Ph.D., McMinnville, Oregon 97128 (7 January 2004)

Family of Lobotomy Victims Speak: Christine L. Johnson (7 January 2004)

Mad? Or afraid?: Patricia Robinett (7 January 2004)

Involuntary treatment gives profession a bad reputation: Ron J Unger (7 January 2004)

"No" is absolutely essential to ethical relationship: John C. Napier (7 January 2004)

Compelling Emotions But Not Practical: Edward D. Campbell (7 January 2004)

Stop coerced psychiatry: Fred A. Tenzer (7 January 2004)

Response to Dr.Szasz's Ideas on "Psychiatric Wills": John C. Hammell (7 January 2004)

Anti-abuse not Anti-psychiatry: David N. Gonzalez (7 January 2004)

Bothersome issues: Kim C. Maynard (7 January 2004)

Re: Flat World, Round World: Eric Rucker (7 January 2004)

recognize the future: Gregory D. Bowyer (7 January 2004)

Alternatives to hospitalization: Jay Fickling (7 January 2004)

Crazy talk: Advocating coercion?: Jacqueline R Roig, PsyD (7 January 2004)

protection orders are not enough: Nathaniel .S. Lehrman (7 January 2004)

Don't forget the learning disabled: Alan Challoner (7 January 2004)

Worldwide need for this open discussion: Mary S. Pearce (7 January 2004)

advanced psychiatry: joerg b. dao (7 January 2004)

Re: Family of Lobotomy Victims Speak: Eric Rucker (7 January 2004)

Enough is enough: Joni M Gallo (7 January 2004)

WHEN DO WE DRAFT THE DOCUMENT?: Carol Hebald (7 January 2004)

Well Done Tom: John Malone (7 January 2004)

The need to bypass the chain of command: Eric Rucker (8 January 2004)

Congratulations to the BMJ Chief Editor: Volker Kubillus (8 January 2004)

Re: Re: Family of Lobotomy Victims Speak: Christine L. Johnson (8 January 2004)

Coercion: Roderick J Harvey (8 January 2004)

Well Done BMJ Editors: Joseph .C. Obi (8 January 2004)

"Forced" psychiatric treatment: Irene Mazis (8 January 2004)

Psychiatry is always dodging the issues.: Cal Grandy (9 January 2004)

good article!: Roelof A. Bijkerk (9 January 2004)

Gratitude for Szazs's Article: John O. E. Laue (9 January 2004)

Re: In the U.S., Psychiatrists Do Not "Commit" the Mentally Ill: Roelof A. Bijkerk (9 January 2004)

Stunning correspondance and the medicalization of childhood: Sami Timimi (9 January 2004)

Re: "Forced" psychiatric treatment: David Gonzalez (9 January 2004)

Re: "Forced" psychiatric treatment: Eric Rucker (9 January 2004)

Re: Re: Re: Family of Lobotomy Victims Speak: Eric Rucker (10 January 2004)

Addressing various comments: Kim Gregory (10 January 2004)

Prophilaxis for psych drug harm: Daniel Q Burdick (10 January 2004)

First improve the mental health system: Phil Thompson (10 January 2004)

People who want change must deal directly with the high command: Eric Rucker (10 January 2004)

We need to understand evolution of the mind and "normal" human irrationality: Mario Heilmann (11 January 2004)

Re: Tired Cliches: Roelof A. Bijkerk (11 January 2004)

Re: Enough of anti-psychiatric rhetorics: Roelof A. Bijkerk (11 January 2004)

Re: Where is the humanity?: Roelof A. Bijkerk (11 January 2004)

Re: The "Battered Mental Paitient"- a different perspective: Roelof A. Bijkerk (11 January 2004)

,It will be more interesting to know the opinon of Prof.Szasz on other issues,Insane people can be executed&lethal injection of prisoners in US.: AK Al-Sheikhli (11 January 2004)

Re: Szasz � the same old tune!: Roelof A. Bijkerk (11 January 2004)

Re: psychiatry should be formally merged into Neurology: Roelof A Bijkerk (11 January 2004)

Re: Rights imply responsibilities: Roelof A. Bijkerk (11 January 2004)

Re: Civil rights and Mental Illness: Roelof A. Bijkerk (11 January 2004)

Re: Re: "Forced" psychiatric treatment: Irene Mazis (12 January 2004)

Denial of the hard cold truth condemns millions to a lifetime of misery: Eric Rucker (12 January 2004)

Thomas Szasz, the Critical Psychiatry Network and the psychiatric protection order: D B Double (12 January 2004)

Psychopharmacology versus actual biochemical medicine.: Daniel Q Burdick (13 January 2004)

Who then would treat patients as responsible moral agents??: Thomas M. Fraser (13 January 2004)

Re: Denial of the hard cold truth condemns millions to a lifetime of misery: Roelof A. Bijkerk (13 January 2004)

Re: Re: Re: "Forced" psychiatric treatment: David Gonzalez (13 January 2004)

Re: Can I take this back a step?: Glynis Meloy (13 January 2004)

Strong Support for Patients' Rights: Ann Fonfa (13 January 2004)

Re: Denial of the hard cold truth condemns millions to a lifetime of misery: Thomas M Fraser (13 January 2004)

Psychiatric wards misdiagnose epilepsy and force treatment on psychiatric ward while withholding appropriate epilepsy treatment: Vonne N. Worth (13 January 2004)

Re: Psychopharmacology versus actual biochemical medicine.: Eric Rucker (14 January 2004)

Re: Re: Denial of the hard cold truth condemns millions to a lifetime of misery: David Gonzalez (14 January 2004)

Re: Re: Denial of the hard cold truth condemns millions to a lifetime of misery: Eric Rucker (14 January 2004)

Are psychiatrists suffering from NERDS?: Sami Timimi (14 January 2004)

Best practice from various perspectives: Mary S. Pearce (15 January 2004)

Re: Re: Re: Denial of the hard cold truth condemns millions to a lifetime of misery: Eric Rucker (15 January 2004)

Time to abolish forceful restraint and detention?: Richard G Fiddian-Green (15 January 2004)

Re: Tired Cliches: David Gonzalez (15 January 2004)

Dr Szasz Is Right on Target: Harold Mandel (15 January 2004)

Re: Re: Re: Denial of the hard cold truth condemns millions to a lifetime of misery: Thomas M. Fraser (16 January 2004)

The bottom line is...: Eric Rucker (16 January 2004)

"Battered patient Syndrome": Harold A. Maio (16 January 2004)

Re: "Battered patient Syndrome": Thomas M Fraser (16 January 2004)

Re: Re: Re: Re: Denial of the hard cold truth condemns millions to a lifetime of misery: Roelof A. Bijkerk (18 January 2004)

Re: Re: Re: Denial of the hard cold truth condemns millions to a lifetime of misery: Roelof A. Bijkerk (18 January 2004)

Re: Re: Re: Re: Denial of the hard cold truth condemns millions to a lifetime of misery: Richard J Winkel (18 January 2004)

Re: Re: "Battered patient Syndrome": David Gonzalez (18 January 2004)

An interesting discussion.: Lloyd W Achtymichuk (18 January 2004)

Re: Re: "Battered patient Syndrome": Eric Rucker (18 January 2004)

"Battered mental patient as institutional problem: J�zsef Gerevich (18 January 2004)

Re: Re: Re: "Battered patient Syndrome": Thomas M. Fraser (18 January 2004)

Re: "Battered mental patient as institutional problem: Eric Rucker (18 January 2004)

Re: Re: Re: Re: "Battered patient Syndrome": David Gonzalez (20 January 2004)

Psychiatry is a pseudoscience and an Inquisition: C�sar Tort (20 January 2004)

Re: Re: Re: Re: "Battered patient Syndrome": Eric Rucker (20 January 2004)

Re: Psychiatry is a pseudoscience and an Inquisition: Eric Rucker (21 January 2004)

Re: Psychiatry is a pseudoscience and an Inquisition: Cesar Tort (21 January 2004)

Therapeutic Jurisprudence: Thomas M. Fraser (22 January 2004)

Re: Therapeutic Jurisprudence: Kathleen (Katie) M. Hill (23 January 2004)

Re: Therapeutic Jurisprudence: Kathleen (Katie) M. Hill (24 January 2004)

Context is important: Martin Briscoe (24 January 2004)

"In Strong Society": Roelof A Bijkerk (24 January 2004)

Doesn't the depth of needed improvement demand our minds be open?: james m nordlund, 901 s.w. Tyler, apt. 111, Topeka, KS 66612 (25 January 2004)

Re: Context is important: Roelof A. Bijkerk (25 January 2004)

Long Overdue Idea: Thomas J. Scheff, Santa Barbara, Ca. 93106 (27 January 2004)

Re: Doesn't the depth of needed improvement demand our minds be open?: Kathleen (Katie) M. Hill (28 January 2004)

Re: Long Overdue Idea: Kathleen (Katie) M. Hill (28 January 2004)

Re: Long Overdue Idea: Thomas M. Fraser (30 January 2004)

Re: Re: Psychiatry is a pseudoscience and an Inquisition: Kathleen (Katie) M. Hill (30 January 2004)

Mental Health or Is It Mental Death !: Dennis F. Nester (1 February 2004)

Re: Mental Health or Is It Mental Death !: Roelof A. Bijkerk (5 February 2004)

If it's any different is it worse here or there?: Roelof A. Bijkerk (5 February 2004)

Psychiatry is a Criminal Fraud: George Wynns (6 February 2004)

Re: Re: Re: Re: Psychiatry is a Criminal Fraud: Kathleen (Katie) M. Hill (8 February 2004)

Re: Psychiatry is a Criminal Fraud: Kathleen (Katie) M. Hill (9 February 2004)

Re: Re: Doesn't the depth of needed improvement demand our minds be open?: james m nordlund (9 February 2004)

Re: Re: Re: Doesn't the depth of needed improvement demand our minds be open?: Kathleen (Katie) M. Hill (10 February 2004)

Re: Re: Psychiatry is a Criminal Fraud: Roelof A. Bijkerk (10 February 2004)

Re: Re: Re: Psychiatry is a Criminal Fraud: Kathleen (Katie) M. Hill (11 February 2004)

Abuse in Therapy: Kathleen (Katie) M. Hill (11 February 2004)

Re: The "Battered Mental Paitient"- a different perspective: Kathleen (Katie) M. Hill (11 February 2004)

Retraumatizing the Victim: Kathleen (Katie) M. Hill (12 February 2004)

Re: Re: The "Battered Mental Paitient"- a different perspective: Roelof A. Bijkerk (13 February 2004)

Re: Re: Re: The "Battered Mental Paitient"- a different perspective: Kathleen (Katie) M. Hill (15 February 2004)

Re: Psychiatry is a Criminal Fraud: Kathleen (Katie) M. Hill (15 February 2004)

Re: Re: Re: Re: The "Battered Mental Paitient"- a different perspective: Roelof A. Bijkerk (16 February 2004)

suicide is not always preventable!: Stephen F Hayes (16 February 2004)

Re: suicide is not always preventable!: Roelof A. Bijkerk (17 February 2004)

one step further: Roelof A. Bijkerk (17 February 2004)

Re: Abuse in Therapy: Roelof A. Bijkerk (18 February 2004)

Creating Health vs Destroying Disease: Kathleen (Katie) M. Hill (19 February 2004)

Re: Re: suicide is not always preventable!: Stephen F Hayes (20 February 2004)

"Mercy Killing of the Psyche" (Freeman): Kathleen (Katie) M. Hill (20 February 2004)

RE: The Tools Have Changed But The Weaponry Remains The Same: Kathleen (Katie) M. Hill (22 February 2004)

Re: Re: Re: suicide is not always preventable!: Roelof A. Bijkerk (22 February 2004)

Re: Re: Re: suicide is not always preventable!: Roelof A. Bijkerk (22 February 2004)

Re: Re: Re: suicide is not always preventable!: Kathleen (Katie) M. Hill (23 February 2004)

Re: "Forced" psychiatric treatment: Roelof A. Bijkerk (23 February 2004)

Psychiatry: regression to pharmaceutical catastrophe since 1927?: Richard G Fiddian-Green (23 February 2004)

Re: Psychiatry: regression to pharmaceutical catastrophe since 1927?: Roelof A. Bijkerk (24 February 2004)

Re: Re: Re: suicide is not always preventable!: Roelof A. Bijkerk (24 February 2004)

Re: Re: Re: Re: suicide is not always preventable!: Stephen F Hayes (24 February 2004)

Re: Re: Re: Re: suicide is not always preventable!: Stephen F Hayes (24 February 2004)

Re: Re: Re: Re: Re: suicide is not always preventable!: Roelof A. Bijkerk (25 February 2004)

Re: Re: Psychiatry: regression to pharmaceutical catastrophe since 1927?: Roelof A. Bijkerk (25 February 2004)

Re: Reform Psychiatry or Abolish Psychiatry!: Roelof A. Bijkerk (25 February 2004)

Re: Re: Reform Psychiatry or Abolish Psychiatry!: Roelof A. Bijkerk (26 February 2004)

Re: Re: Re: Reform Psychiatry or Abolish Psychiatry!: Kathleen (Katie) M. Hill (28 February 2004)

Re: Re: Re: Re: Reform Psychiatry or Abolish Psychiatry!: Roelof A Bijkerk (29 February 2004)

Ecological vs Corporatist Cultural Logic: Kathleen (Katie) M. Hill (6 March 2004)

Bleed and Purge all Kensington!: Peter Morrell (3 April 2004)

Re: "Battered mental patient as institutional problem: Harold A Maio (20 October 2004)

The Pros and Cons of Psychiatric Living Wills (From Someone Who's Been Through It All): Lori E. Wiest (7 November 2004)

The "Battered Mental Paitient"- a different perspective 19 December 2003

Jayne Sercombe,
SpR Learning Disability Psychiatry
Bristol
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Re: The "Battered Mental Paitient"- a different perspective

As someone who has been troubled with major mental illness episodically for some years and who has seen psychiatry from both ends of the couch, I would like to make a few points.
I have an unfortunate, real and at times life threatening illness, which I have been successfully treated for by kind, compassionate psychiatrists and other mental health staff.
Though I would clearly never welcome detention under the Mental Health Act for myself were it unavoidable, I am aware that there may be times for myself when this could be potentially lifesaving. It would concern me to think that when my thoughts become so changed as to put me at risk there would be no safeguard for me to allow for help.
Were it not for the interventions of psychiatrists, alongside my GP, in the past I wonder whether I would be here to write this now.
It is well enough to philosophise about these things, injustices have surely been done in the name of psychiatry, however what is important for me and my family is that I am alive and well. I am certain that this is so for the majority of patients that we see.
Competing interests: Mental Health Service user and Psychiatrist

Tired Cliches 20 December 2003

Dr Daniel M Beales,
Specialist Registrar in Forensic Psychotherapy
Mersey Care NHS Trust, North Administration, Ashworth Hospital, Maghull, Merseyside, L31 1BD
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Re: Tired Cliches

Sir
As someone who has experienced mental illness that did not require compulsory treatment, and a relative of someone with a mental illness that did, as well as a psychiatrist and trainee psychotherapist, it is sad to see Szasz being given yet another platform from which to present his clich�d and increasingly out of date views unchallenged. Szasz�s denial that �mental illnesses are real diseases and that psychiatrists are regular doctors� illustrates the degree to which his argument has grown in sophistication since his �Myth of Mental Illness� in 1961. In other words, it hasn�t. Consent and compulsion are difficult issues in psychiatry: is it evident that Szasz�s article considers their complexity fully?
What an excellent Christmas present from the BMJ, the most widely read medical journal amongst British doctors. Perhaps one New Year�s resolution for you to consider would be to question your own indulgence of the further stigmatisation of psychiatry, which you perpetuate by allowing Szasz to go on suggesting that psychiatrists do not work to the same ethical considerations as all doctors should.
Competing interests: None declared

Where is the humanity? 21 December 2003

David M Bowker,
Retired
Retired: Home address Stockport SK7
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Re: Where is the humanity?

If one wished to study the psychopathology of the overvalued idea then one is naturally drawn to the writings of Szasz, but where is the humanity in his views? Popularly (but medical practitioners should know better) early treatments in psychiatry are derided, but cold baths and spinning among other similar techniques were arguably, although crude, relatively benign and thoughtful attempts to disrupt intrusive thoughts which were perceived as frightening, dangerous or senseless in cases of severe mental disorder. One could probably rate them as more rational than blood letting and cupping!
I am certain that if I had authored a similar piece to that submitted by Szasz, it would not have been published - the editor could not have missed a generalised, rambling, unsubstantiated content which also failed to address the practical consequences and management of the proposals described.
D M Bowker.
Competing interests: Retired consultant psychatrist

In the U.S., Psychiatrists Do Not "Commit" the Mentally Ill 21 December 2003

Ronald Pies MD,
Clinical Prof. of Psychiatry
Tufts University 02111
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Re: In the U.S., Psychiatrists Do Not "Commit" the Mentally Ill

� The notion that psychiatrists (and only psychiatrists) �commit� patients against their will represents a distortion of the relationship between psychiatry and the law in the U.S. It also ignores the role of other professionals, paraprofessionals, and even �ordinary citizens� in the commitment process. As Dr. Robert Simon points out in his book, Psychiatry and Law for Clinicians, ��mental health professionals must understand that it is not they who make commitment decisions about patients. Commitment is a judicial decision that is made by the court or by a mental health commission. The clinician files a petition or medical certification that initiates the process of involuntary hospitalization.� (Simon, 1998, p. 127, italics mine). This is not a trivial or semantic distinction. True: most states provide for brief, emergency hospitalizations (e.g., 48-72 hours) before a judicial hearing is held, at which time it is a judge�not a psychiatrist�who determines whether sufficient grounds exist for continuing the hospitalization. But the initial petition for involuntary civil commitment, in many states, may be initiated by ��police officers, next of kin, psychiatrists, other physicians, psychologists, social workers, or even �interested parties�� (Simon, 1998, p. 128). Of course, one might argue that in so far as these other parties �behave� like psychiatrists, the whole motley crew constitute agents of �state-sponsored social control�� (Szasz manifesto, op. cit.). This argument turns the concept of �agency� on its head. In fact, when a court authorizes a commitment, it is acting as the agent of the doctor, the social worker, or, in many cases, the parent of the sick individual. This is as it should be in a democracy, where the �state� (state and national government) exists to carry out the will of the people. To be sure, there are countries in which�at various times in their history�psychiatrists and other physicians truly have acted as agents of the state. This was clearly the case in Nazi Germany, the old Soviet Union, and arguably, in present-day China. I would submit that such �political� uses of psychiatry are very rare in the United States, and certainly not part of every day clinical practice. (I am aware that a few very high-profile cases, such as the confinement of Ezra Pound in the 1940s, may be exceptions to this general conclusion). The persistent failure of some critics of psychiatry to distinguish the system of civil commitment in this country from involuntary confinement in totalitarian countries greatly undermines the credibility of their moral claims.
Another myth: Non-psychiatrist medical specialists�those who deal with �real� diseases�do not involuntarily hospitalize patients. In part, this is a corollary of the previous myth. In reality, other medical specialists in the U.S. do hospitalize patients involuntarily, and the diseases these patients have, or are reasonably believed to have, are not necessarily those traditionally considered �mental illnesses�. It is only contingently true that psychiatrists are much more often involved in involuntary commitment procedures. In New York State, where the consent of any two physicians can initiate the commitment process, non-psychiatric physicians often do so, particularly in counties with few psychiatrists (M. Dewan MD, personal communication, April 2001). Emergency detention of dehydrated, demented patients with admission to the general medical ward�not the psychiatric unit�has been carried out in some states (Schneidermayer et al, 1982). In rare cases, neurologists may initiate the commitment process for demented patients with severe behavioral disturbance (J. Cummings MD, personal communication, April 2001).
Consider the following vignette:
An 84-year-old man with no previous �psychiatric� history falls and hits his head. He feels alright at first, but over the ensuing week, he notices some difficulty walking and urinating. He sees a neurologist who performs a CT scan of the brain, and determines that the man is developing normal pressure hydrocephalus, which often develops after a head trauma. The neurologist urges the man to undergo surgical treatment, and cautions him that his condition will probably worsen without the installation of a �shunt�. The man refuses and goes home. Three weeks later, he becomes confused, irritable, and verbally threatening to his wife and next-door neighbor. In the middle of January, the man runs outside in the snow, wearing only his pajamas. He absolutely refuses to see the neurologist or any other doctor. The man�s wife phones the neurologist and begs for help. The neurologist says that the patient�s behavior is �likely due� to the untreated hydrocephalus, though he �can�t be certain.� He recommends an emergency hospital admission, against the patient�s will.
Now: what is the Szaszian position with respect to the neurologist�s recommendation? If it is one of assent, then we must acknowledge that under certain circumstances, we do deprive some individuals of their liberty on the basis of �disapproved behaviors�, even when there are no criminal offenses involved, and even when we can�t be certain the behaviors are due to brain disease. Indeed, in Israel, involuntary hospitalization of senile and arteriosclerotic dementia patients is permitted under the 1991 Israeli Mental Health Act (Heinik & Kimhi, 1995). If the Szaszian position is to disagree with the neurologist, even when the patient�s behavior is likely due to clearly documented brain dysfunction, then the Szaszian quarrel is not with psychiatry or psychiatric diagnosis per se, but with the police power of the state and the doctrine of parens patriae (which asserts that the state may act on behalf of those citizens who are unable to take care of themselves; Simon, 1998, p. 121). [Reference citations available upon request]
Competing interests: None declared

Enough of anti-psychiatric rhetorics 22 December 2003

Sudip Sikdar,
Consultant Psychogeriatrician
Mersey Care NHS Trust, Waterloo day Hospital, Liverpool, L22 3 XR
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Re: Enough of anti-psychiatric rhetorics

Dear Editor,
I was truely amazed that even today Prof Szasz's articles still find their way into esteemed journals like BMJ.His views about psychiatrists and mental illness only adds to the terrible stigma that mentally ill patients already face in society.
The fundamental point that he misses is that no competent mentally ill patient can be sectioned. The sad truth about many serious mental illnesses is that it deems a person incapable of understanding the nature and impact of his/her illness and hence on occasion makes them a danger to themselves or to the society at large, which in turn occasionally necessiates a sectioning. A capacitated mentally ill person still has the rights to refuse treatment.
This particular issue will take a centre stage in British Law via the Mental Incapacity Bill which is going through the parliament as I write. Psychiatric patients further have access to independent advocacy services to uphold their rights.
I hope my colleagues all over the world join me in this column to give a robust rebuttal to Thomas Szasz.
Competing interests: None declared

A Mad World Doesn't Need Headshrinkers 22 December 2003

Dr Lynne Wrennall,
Honorary Fellow
University of Liverpool, L69 3BX
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Re: A Mad World Doesn't Need Headshrinkers

When a person chooses his or her own actions in life and takes responsibility for those choices, they present us with the single most impressive sight on earth. The truly powerful and provocative act of personal choice is what energises life, gives life it�s meaning and is ultimately what makes life worthwhile. When people who are autonomous partner, it is better and not worse, in health and not sickness and they are richer, not poorer for it. And when a people is formed on the interests of each of them they fight with the kind of strength that wins a battle of Stalingrad or stops a war in Vietnam.
To steal choices from people is one of the most pitiable actions a being can undertake. There is no more humiliated posture than a pretentious professionalism bloated by theft of choice. Relationships based on asymmetrical symbiosis are parasitical relationships and deserve no place or quarter. We should have none of them. However degraded the human condition may appear, it got that way by some people denying other people, the right to be themselves. The truth of who we are, is in the choices we make, even if is our choice to give up choice to the people around us, to the person who calls himself a professional.
If Sercombe and Beales (Rapid Responses to Szasz) want to wear coats with very long sleeves, tied around their waists, or take drugs with very psychotropic actions, taking their minds to zero on the Richter scale, I support their right, so long as it comes with informed consent, to do so. I trust them to understand in their own precious moments, the larger rationale for the choices they make. I support the right of Sercombe and Beales to make their own advance directives, mandating whatever compulsions they choose, but I insist that with their claiming of their rights is a mutual obligation to support the rights of others to make different choices. I would expect those who present themselves as experts on people to have the maturity to accept the diversity that dignifies and glorifies what it is to be human.
Further, I applaud the call for orders to restrain abuse. Inducement to psychiatrists to move beyond pill pushing and brain frying to understanding that people are more than their physiology and matter more than the value judgments inflicted upon them, are required. Szatz understands this.
Szazs knows things. He knows, along with Jean Paul Satre that people live by their choices and that if they choose to give up responsibility for the choices that they make, they live under a kind of Nazism. Szazs knows, along with Friedrich Neitsche that greatness follows to those who take their choices all the way down the line, to wherever they may lead. And Szazs knows along with Dosteovsky that it is better to be honestly wrong than dishonestly right. Szazs knows things. He has done more than all the flunkies and other followers of orders could ever do to inspire his contemporaries to reject the roles of patient and punisher. Szazs has inspired sufferers of mental anguish to be more than patients. He has inspired psychiatrists not to shrink heads, but to expand minds, nay, to expand lives.
It is Szazs� responsibility as a psychiatrist to make a people wiser He lives with the conundrum that to so, they must be able to hear him. Sercombe and Beales have that responsibility and that priviledge also. If they can lift humanity for one moment as Szazs has done, they will deserve their positions in society, they will deserve the rewards conferred upon the professions and they will deserve to be called healers of the human soul.
Competing interests: I am committed to Human Rghts and and this influences the research I undertake.

Psychiatric Protection Orders Would Protect Human Rights 22 December 2003

Darby J. Penney,
private consultant
Cambridge, NY 12816 USA
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Re: Psychiatric Protection Orders Would Protect Human Rights

Dr. Szasz�s proposal for the creation of �psychiatric protection orders� is a logical, reasonable, even ingenious response to the serious human rights issues that are inherent in forced psychiatric intervention.
In response to Dr. Szasz�s article, Dr. Daniel Beales calls Dr. Szasz�s views �increasingly out of date.� Over the last four years, I oversaw a project that collected oral histories from over 200 current and former psychiatric inpatients. Most of these people told stories of being traumatized by forced psychiatric treatment - I doubt that they would find the idea of psychiatric protection orders �out of date.� New York State, among others, frequently seeks court orders to deliver multiple electroshock treatments to objecting patients. These patients would benefit from psychiatric protection orders.
A colleague and I are presently curating an exhibit at the New York State Museum entitled �Lost Cases, Recovered Lives: Suitcases from a State Hospital Attic.� Based on the contents of their abandoned suitcases and their case files, we have attempted to reconstruct the life stories of a dozen deceased individuals both before and after their institutionalization. All of these people spent decades in a state mental hospital; as a direct result of forced treatment, their lives were essentially taken from them.
If Dr Beales and Jayne Sercombe, who also wrote a negative response to Dr. Szasz�s article, believe they have mental illnesses and wish to voluntarily seek help from psychiatrists, that is obviously their right. If they even wish to pre-authorize involuntary treatment for themselves, that is also their right. But people who don�t share that view and have found forced psychiatric treatment harmful should have the right to make their own choices, too. A �psychiatric protection order� should be legally available to people who want this protection.
Competing interests: None declared

No competing interest? 22 December 2003

Nestor J. Presas,
former P&A Specialist
Beverly Hills, CA
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Re: No competing interest?

I loved that most psychiatrists declared �no competing interest� while submitting a response to Dr Thomas Szasz article. Apparently they also have the same perceptive omission while interpreting their last paycheck.
The same omission they have when they characterize primitive torturous treatments as �benign.� While conveniently forgetting that such treatments took place in the context of an institution; a closed, insular, prison-like structure where people had been cut off from the rest of society.
The same omission they have when characterizing the legal protections afforded to the �mentally ill� while failing to mention that such protections only came into life as a societal response to the abuses and human rights violations of institutionalized psychiatry, or how corporate psychiatry fought and fights against each step of their implementation. By the way, anyone who has ever attended a commitment hearing knows that 98% of testimony is prosecutorial and offered by a state paid psychiatrist.
As long as psychiatry is part medicine, part law enforcement, its power must be curved by public scrutiny. Specially; since the �provision of mental health care by the government,� has introduced the element of �the state sovereign immunity� to further limit the relief available to a person victimized or, abused, by the system.
The maintenance of a free society demands an active response to assure the balance of power. The proposal by Doctor Thomas Szasz seems as a logical progression in this continuum.
Competing interests: None declared

Great article 23 December 2003

LostBoyinNC (Eric Rucker),
Disabled due to psychiatric abuse
Scotland Neck, North Carolina, USA
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Re: Great article

While I dont agree with Szasz on most issues, I found this article interesting. And its an idea that I would like to hear more about. While I totally disagree with Szasz on the idea that severe mental illness is not biologically based (brain based), I still find this particular idea a good one.
Due to the inherent subjectivity and lack of scientific rigor in psychiatry, many psychiatric abuses do indeed occur. Oftentimes from misdiagnosis or from overzealous "headcase" psychiatrists who like to label their patients with personality disorders and try to pharmacologically treat these personality disorders. Or try to use drugs strictly for behavioral control. From my experiences, which are extensive, "bad vibes" occur between psychiatrist and patient for these three primary reasons:
1) the patient is grossly misdiagnosed and placed on the wrong class of psychiatric medication altogether, which creates a further deterioration in the patient's health. Oftentimes the psychiatrist will refuse to acknowledge they made a misdiagnosis, despite the patient's complaints that they are feeling worse, not better. And will insist a patient continue to take medications despite the complaints of the patient that they are "feeling worse, not better." Usually, the patient has to switch psychiatrists and get a second opinion before their diagnosis/medication is changed to something more realistic and appropriate.
2) when the psychiatrist is a big believer in "personality disorders" and tries to pharmacologically treat these so called personality disorders. Pharmaceutical treatment of personality disorders should be severely curtailed in psychiatry. Psychiatrists who try to focus on a patients negative personality characteristics, rather than focusing on the core underlying Axis One disorder(s) (major psychiatric problems) oftentimes create extremely bad feelings between themselves and their patients.
3) When the psychiatrist tries to use drugs for behavioral control, rather than to treat an actual Axis One disorder. An example of this would be when a psychiatrist uses low dose neuroloeptics to treat agitation or irritability in a mood disordered patient or tries to use neuroleptics to calm down an upset patient who just needs to vent and decompress.
I believe it is time for individuals who have mental illness to take matters into their own hands. Sometimes, this may mean cutting themselves off from the so called "profession" set up to help them...psychiatry. Oftentimes psychiatry takes already unwell individuals...and makes them profoundly worse. While I realize this is hard for some to believe....particularly psychiatrists...its a true statement and many psychiatric patients would agree with me.
Until severe mental illness is formally recognized for what it truly is and formally removed from the psychiatric category and recategorized as Neurological illness...and we begin to see some real high tech improvements in diagnosis and treatment, there will continue to be friction between psychiatrist and patient. As long as psychiatry remains low tech and subjective, in an era when the rest of medicine is high tech and objective in diagnosis, there will continue to be friction between psychiatrist and patient. Until that day occurs, when psychiatry is able to bring itself up to par technologically and science-wise, an idea like Szasz presents here isnt a bad idea.
Additionally, one of the problems in psychiatry is that many psychiatrists have "control" issues. That is, some psychiatrists seem to have an internal need to control some of their patients...some psychiatrists are megalomaniacs.
Sometimes, a person can just be broken totally. Sometimes, a severely mentally ill individual who is already very unwell can be "finished off" by an emotional, violent involuntary or even voluntary hospitalisation. Due to the condescending nature of psychiatric hospitals and dissmissive attitudes of many psychiatrists towards their patients, psychiatric hospitals are more like minimum security prisons than real "hospitals."
I for one would like to see more work on this particular idea Szasz presents here. I believe there are many psychiarists who deserve criminal prosecution for some of the things they have done to some patients. Making it a criminal offense for involuntary committing individuals who want nothing to do with the mental health profession isnt a bad idea.
Competing interests: I hate psychiatry

Dr Thomas Szasz is a Member of the Church of Scientology 23 December 2003

Dr P V F Cosgrove,
Consultant All-Age Psychiatrist
The Bristol Priority Clinic. Bath BA2 5JJ
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Re: Dr Thomas Szasz is a Member of the Church of Scientology

Dr Szasz has completed his article with "Competing Interests: None Declared". Well now, Dr Szasz and the Church of Scientology founded the Citizens Commission on Human Rights in 1969.
Dr Szasz is famous for being the Grand Old Man of Anti-Psychiatry, and he is writing true to form in this BMJ article, which he has called "The Psychiatric Protection Order for the battered mental patient". He proposes a new legal safeguard against psychiatry, which would make it a criminal offence to impose involuntary psychiatric interventions on people protected by the order.
On the website of the Citizens Commission on Human Rights (www.cchr.org)under "What is CCHR?" is a photograph of none other than Dr Szasz himself. And looking dapper and far from emeritus in age.
The answer to "What is CCHR?" is: "CCHR was formed to combat psychiatry's oppression".
It continues: "CCHR members see it as their duty to expose and help abolish any and all physically damaging practices in the field of mental healing".
CCHR claims on its website: "CCHR has documented many thousands of individual cases that demonstrate that psychiatric drugs and other brutal psychiatric practices actually create insanity and cause violence".
And then, consistent with Szasz's 'psychiatric protection order' proposed on the pages of the BMJ, is the following on the CCHR's website: "In fact, a major cause of the drug problem worldwide is the psychiatrist who, for decades, has used his influence as a medical doctor to push extremely dangerous and addictive mind-altering drugs on persons of all ages".
What Szasz would not have dared to mention in his BMJ article, especially since he has declared no competing interests, is that the Church of Scientology is on trial in Florida for the manslaughter of a 36 year old woman, who died of dehydration whilst acutely psychotic over a seventeen day period. They are also charged with unlawfully practising medicine.
In an article in the New York Times, Douglas Frantz reported that this woman, Lisa McPherson, a member of the Church of Scientology, had had a minor traffic accident in the autumn of 1995. She, then, stripped off her clothes and began to mumble.
She was taken to a local hospital where a doctor wanted to provide psychiatric treatment for her. However, several members of the Church of Scientology went to the hospital and removed her, and took her to a Scientology owned hotel. The article in the New York Times (14 November 1998) stated that "The Church of Scientology prohibits psychiatric treatment for its members".
According to the affidavit of the state's medical examiner, Lisa McPherson had been hyperactive, delusional and hallucinating over the 17 days following the accident. During this time, she had tried to harm herself and others.
She was restrained repeatedly and prevented from leaving the room. Perhaps, Dr Szasz, we need a Scientologist Protection Order as well!
She urinated and defaecated on herself repeatedly; she rarely slept; she had conversations with people who were not there; she claimed to be people she was not; she sang and she danced around the room as if giving a performance; she crawled around the floor; she stood on the toilet; she got into the shower fully clothed; she drank her own urine on more than one occasion.
The Scientologists gave her magnesium chloride injections to get her to sleep; they gave her numerous doses of vitamins, herbal sleep remedies and, also, believe it or not, prescription drugs.
On the evening of her death, a Scientologist, working as an Accident & Emergency doctor at a hospital forty-five minutes away, was phoned by the Scientologists. They were advised to take her to the NEAREST hospital but, instead, they took her to this particular Scientologist doctor, who was three-quarters of an hour distant from them.
She was dead on arrival.
The pathologist stated that she had been deprived of water for 5-10 days, and that she had died from a blood clot brought on by dehydration.
All these allegations contained in this newspaper article are being tested in a Florida court at the moment, and a verdict is expected in January 2004.
How, then, did this anti-psychiatry article by Dr Szasz get into the BMJ, when psychiatry is a bone fide part of the medical profession?
How did this virulently anti-psychiatry article get past the Editors' desk, when many psychiatrists are members of the BMA?
The explanation I favour is that there are Scientologists employed in the production of the BMJ.
Sir John Foster QC, MP was commissioned in 1969 by Richard Crossman, Secretary of State for Social Services, to produce a report for the UK Parliament. The Enquiry into the Practice and Effects of Scientology was published in 1971.
Foster says that he was told by Scientologists that there were Scientologists actively involved in the BMA (Section 67). Since that was more than thirty years ago now, I would expect there are more members of this cult employed at the BMA and undertaking work at the BMJ.
There is now evidence indicating and suggesting that there are Scientologists working in the Fitness to Practise Directorate of the General Medical Council of the UK. So be careful all you British psychiatrists especially if Szasz's proposed 'Psychiatric Protection Order' comes into being.
Foster reported to the UK Parliament in December 1971 that, at that time, Scientology organisations had $75 million worth of law suits so far filed against psychiatric organisations and others over the world in the international conspiracy against Scientology. They had been filed for psychiatric efforts to destroy the Church of Scientology, and also for libel, slander and conspiracy (Section 184).
Competing interests: Specialist in clinical psychopharmacology of children, adolescents and adults

There are no scientologists at the BMJ 23 December 2003

Richard Smith,
Editor
BMJ
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Re: There are no scientologists at the BMJ

I can assure Dr Cosgrove that there are no scientologists at the BMJ, and I must confess that his rapid response seems to me to be full of chopped logic.
His argument seems to be:
1.Thomas Szasz had some link with the scientologists�albeit in 1969. ( I don�t know what Dr Cosgrove was doing in 1969, but many people have over 30 years had some strange links. I, for example, copresented some television programmes with Esther Rantzen, but she and I do not share a philosophy.)
2.Scientologists are anti-psychiatry.
3.Some scientologists have done some terrible things.
4.Therefore Szasz�s article is worthless, and the only reason the article can have got into the BMJ is because some of the staff must be scientologists. (Interestingly some of our younger editors have never heard of scientologists.)
The argument is very unconvincing. We published the article because it is well written and raises important ideas. We debated whether we had heard it all before and decided we hadn�t. The idea of a legally enforceable psychiatric protection order is new and interesting. Plus, although some older readers will be familiar with the writings of Szasz, many younger readers will not.
We bother not a hoot that the article criticises some psychiatric practices. Most of what is published in the BMJ criticises some part of medicine. That�s how a discipline advances, and I�m confident that psychiatrists can respond critically to Szasz�s ideas. Indeed, Dr Cosgrove�s response would be more convincing if it were to tackle Szasz�s arguments head on.
Richard Smith, editor, BMJ
Competing interests: I'm the editor of the BMJ and accountable for all it contains.

Rights imply responsibilities 24 December 2003

Angela F Harte,
Consultant Psychiatrist
Maroondah Hospital, East Ringwood, Australia 3135
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Re: Rights imply responsibilities

It is easy to speak of the right of the person to refuse treatment, however all rights are meaningless and their exercise may be damaging if the corresponding responsibilities are not identified and respected.
The right to drive a car relies on the responsibility to learn to drive, to remain alert and unimpaired by substances. The right to make one's own decisions depends on the responsibility that these decisions will not significantly harm one's self or others.
Where a person has accepted the right and responsiblity of driving, and then drives incompetently, whether due to anger, drinking, excessive fatigue or other cause, and causes harm, they are held to be legally responsible. It follows that the hypothetical person who has made a competent advance directive refusing coercive treatment will be legally responsible for all the consequences of their actions when unwell.
Although this contravenes principles of natural justice and reason, this is the reductio ad absurdum of Szasz' arguments. I find this a pity as I have enjoyed many of Szasz' pithy comments in the past.
Competing interests: Psychiatrist

Should endocrinologists assume responsibility for psychotic patients? 24 December 2003

Richard G Fiddian-Green,
None
None
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Re: Should endocrinologists assume responsibility for psychotic patients?

"Anyone who sees a psychiatrist needs his head read": Sam Goldwyn.
My interest in this subject extends beyond my academic interests in the neuropsychiatric effects of an intracerebral energy deficit(1), the body-mind split (2), and metaphysics (3).
The worst decision I made in my life was to agree to see a psychiatrist some ten years ago to reassure someone close to me that some of the observations I had made were not a figment of my imagination. What I discovered very quickly was that psychiatrists are like Brear Rabbit tar babies, once seen by one one is for ever stuck to them. After my initial encounters in which I was admitted and forcefully medicated against my will I refused to have anything to do with the psychiatrists other than to ask when I was to be released from my incarceration. The worst of my cummulative exposure has been the repeated efforts to modify my behaviour with a combination of carrots and the most noxious of sticks and intrusive monitoring of my behavioural responses.
I met some surprisingly normal and worldly psychiatrists, some that were undoubtedly very good at what they called "phenomenology" (ostentatious way of saying taking a good history), some that were the sterotype and on occasion scruffy weirdos, and none that appeared to have any knowledge of intermediary metabolism. I met a number of people who were not medically qualified but had some degree of understanding of psychology. All were incredibly naive relative to those with medical qualifications and appeared to follow printed protocols in their efforts to modify behaviour.
The patients were surprisingly normal. I met a number who had simply pretended to be psychotic with the intention of getting free board and lodging. Some called me the "doctor's spy". I cannot remember ever having met one that was overtly psychotic, although all were medicated. I did, however, see a few who were subnormal and were in the wrong institution. A lot of patients were drug abusers and those who had to be tied to their beds were usually suffering from withdrawal symptoms. The side effects of the medications were ubiquitous, so ubiquitous that those pretending to be psychotic became skilled in faking the motor side-effects.
I was forcefully administered Haldol in full doses under court order. The effects were not apparent for awhile. The most restricting were the interference with my facial musculature, and my ability to speak fluently and to shave. The latter was of the greatest interest for I lost almost all knowledge of what too do when I shaved, from the descriptions I have since read almost as though I had a split-brain. The net effect it took me infintely longer than usual. It was in short a completely dehumanising effect. What is more it took almost six months for the effects to wear off after I was able to discontinue them and refuse to see a psychiatist ever again.
The most destructive aspect of my "battering" has been the destruction of my relationships with those who were once close to me. I, for example, have never been told what was supposedly wrong with me but I believe my family have. If they have they have never disclosed the details to me and that in itself has destroyed our relationship and my credibility in their eyes. On one occasion when I agreed to meet with the psyciatists and my family I was told, "there are two hypotheses, the one is that you are ill and the other is that you ar not". That this psychiatrist was an effeminate sterotype did not help matters. I have never seen him or any other psychiatrist again.
As all legal rights to managing my own affairs were taken from me in court, again for reasons unknown to me, it would not surprise me if the US psychiatrists were holding this right with the intention of forcing m to return to them for follow-up or possibly to make sure that my family remained rsponsible for my financial affairs such as they might exist.
During my first forceful incarceration I agreed to speak to residents and even students as I was supportive of th