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Reviewed by:
  • Coercion as Cure: A Critical History of Psychiatry
  • Jonathan Sadowsky
Thomas Szasz . Coercion as Cure: A Critical History of Psychiatry. New Brunswick, N.J.: Transaction Publishers, 2007. x + 278 pp. $34.95 (ISBN-10: 0-7658-0379-8, 978-0-7658-0379-5).

All good history is critical history. When historical scholarship ceases to be critical, it lapses into antiquarianism or hagiography. The history of psychiatry has had no shortage of good, critical history. Diverse authors have provided valuable accounts of psychiatric history that have called attention to psychiatry's abuses, its excesses, its tendencies toward disease mongering, and its role in enforcing invidious social conventions (to name just a few of the criticisms). And because these criticisms have validity, there have always been some who marshal psychiatry's failures and abuses toward an argument that the profession is, by its nature, essentially malevolent. No one, however, has argued this as continuously and influentially as Thomas Szasz.

Nothing in this book will surprise readers of any of Szasz's other books. He argues that psychiatry is a social evil that should be abolished, and the argument rests on two premises. The first premise is that what are called mental illnesses are not illnesses at all, but simply behavior that is inconvenient for others; on these grounds, psychiatry is not properly a branch of medicine. The second is that psychiatry's treatments are coercive and a violation of the liberty of those called patients.

One might think that a book seeking to exclude an entire class of illness from the very category of illness would contain a systematic discussion of exactly what an illness is. Coercion as Cure asserts repeatedly that so-called mental illnesses are not really such, in an outraged tone that treats the assertion as self-evident, but it contains no such systematic discussion. Szasz frequently refers to conditions psychiatrists would call psychosis as personal idiosyncrasies that are inconvenient for those around them. Whether or not they are properly called "illnesses," and whether or not one believes involuntary treatments are morally justified, this simplifies and trivializes a serious problem. Calling people who, for example, are considering taking their own lives because of morbid delusions "eccentric" is dramatically unpersuasive. Szasz does say that mental illnesses lack physical bases and objective criteria for diagnosis. I consider these claims over-stated, but even if they are not, the question remains, why should these be the criteria for considering something an illness?

Szasz proposes a restrictive definition of psychiatry. He has no argument, he says, against voluntary treatments, and he advocates removing psychoanalysis from the domain of psychiatry, since psychoanalysis traffics in noncoercive contractual relationships. This is semantic legerdemain. One could write a "critical" history of the labor unionization movement that condemns the movement for being an exclusively oppressive force, because it forces people to join unions against their will. Evidence that people wanted to join unions would not be a problem, if one then defined "unionization" as only those unionization practices that are involuntary. [End Page 797]

It would not be fair to say that Szasz omits evidence that runs counter to his thesis. Rather, he includes it, but ignores its significance. Take, for example, the chapter in this volume that deals with electroconvulsive therapy (ECT). The title of the chapter, "Iatrogenic Epilepsy," is itself an argument; ECT operates by inducing seizures, which is a symptom of a real disease, epilepsy, and Szasz expects us to be outraged by this. Szasz puts great stock in precedents from other (he would say "real") areas of medicine, but here he ignores that it is common practice in medicine to perform procedures—surgery, and chemotherapy for cancer, for example—that cause unhealthful effects in healthy people. Szasz notes, correctly, that the original clinical rationale for ECT was a supposed inverse relationship between schizophrenia and epilepsy, a rationale that is dubious now. He details the story of the first ECT treatment in Italy, which was performed involuntarily and continued even after the patient vigorously protested. Szasz then cites the considerable evidence from subsequent ECT patients of the benefits they have gotten from the treatment. But having cited such patients, Szasz does not consider...

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