COMMENTARY

The Return of the Alienist

James L. Knoll IV, MD

Disclosures

May 10, 2013

In This Article

The Ebb and Flow of Antipsychiatry Sentiment

There has long been an antipsychiatry movement, analogous to the resistance to orthodox western medicine. Now, however, antipsychiatry proponents will need to come up with something of greater societal value than decrying "coercive psychiatry" if they sincerely wish to address the problems of inadequately treated mental illness.[6] Incidentally, my friend and colleague, the late Thomas Szasz, MD, is sometimes erroneously held out as a leader of the antipsychiatry movement, but this was simply not the case. Szasz was always a staunch libertarian, and as he said to me in the months before his passing, "I do not like the so-called antipsychiatry movement. They have misinterpreted my writings. I am not saying psychiatry is good or bad. I am only saying that ideas have consequences."[7]

The antipsychiatry sentiment circa 2013 should be of some interest. In recent times, we have seen a significant reduction in National Institute of Mental Health funding of psychiatric research,[8] as well as a prominent former editor of the New England Journal of Medicine make inaccurate and disparaging comments about psychiatry.[9] But suddenly, in the wake of highly publicized mass shootings and deceptive correlations of mental illness with gun violence, the national dialogue has changed.

A close look at this national dialogue reveals that it has included such statements as "We need to get these [insert offensive label for persons suffering mental illness] off the streets," and my personal favorite, "The mental health system failed [him/her/us]." It is the classic double-bind for psychiatry: Take away our societal and legal ability to truly help, yet still insist that we are responsible for not "detaining" persons who happen to be both mentally ill and dangerous. If that fails to confound, try the equally absurdist stance: Condemn our duty to hospitalize patients involuntarily, yet enact legal statutes making it our duty to perform that very function.[6]

Ever a proponent of education, I cling to the hope that this societal confusion is the result of laypersons, for want of details, not fully understanding the psychiatrist's predicament. They may be blissfully unaware that to commit someone involuntarily today requires a full due process hearing in court, with evidence that an individual is a danger to himself or others. What kind of evidence? The mere judgment of the psychiatrist is woefully insufficient. One must have recent behavioral evidence (eg, the person did something dangerous) or verbal evidence (eg, the person said something dangerous). All of this has to be proven to the court by "clear and convincing evidence."[10] If you are in a state such as Wisconsin, make that "beyond a reasonable doubt" -- the same burden of proof as required in criminal cases.[11]

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