Diagnosis Isn’t the Problem. Coercion Is.

Editors’ note: Raymond Raad, M.D., is a psychiatrist in training and has previously published with the Cato Institute. We are pleased to publish his letter below.

I have followed with great interest the discussion thus far on Cato Unbound. However, it seems to me that the central question of whether the coercive practices of psychiatry are defensible has inappropriately been linked to whether psychiatric diagnoses are valid at all. Although Professor Schaler and Mr. Sullum assume that the former follows from the latter, and the other discussants follow suit, I fail to see the necessary connection.

We have come a long way from the 1960s and 70s, when a psychiatric diagnosis by itself justified involuntary hospitalization. This is partly due to writers such as Thomas Szasz and partly due to a realization among many psychiatrists, judges, and others that diagnosis and inability to make one’s own decisions are different issues. Today, the vast majority of individuals who meet criteria for a disorder in the DSM would not meet criteria for involuntary hospitalization, and no one to my knowledge argues that they should. Further, if reliable histologic markers of, say, schizophrenia and bipolar disorders were found next year, it’s not clear that more (or any) coercive measures would be justified or follow as a result. Nor would it likely help determine which patients with schizophrenia should be involuntarily hospitalized and which should not.

A good example is multiple sclerosis, which can be diagnosed reliably with an MRI (in addition to a medical interview and exam). Yet it’s not clear how that helps us decide what to do when a patient with multiple sclerosis has impaired cognition or has a suicide plan. Jacob Sullum says that court-appointed guardians for multiple sclerosis are justified when that disease has “so impaired someone’s mental faculties that he is no longer capable of managing his own affairs.” Yet the MRI and the diagnosis do not make the decision as to whether the patient can manage his own affairs. That decision is made by assessing whether the patient understands the nature and effect of his actions, on the basis of an interview and discussion – a technique and standard that was developed independently of the diagnosis of multiple sclerosis and can be equally applied to those with or without psychiatric diagnoses.

Conversely, the lack of a reliable diagnostic blood test for schizophrenia does not invalidate the question of what is to be done about those people who are brought to psychiatric emergency rooms and who are too cognitively impaired to make even basic decisions or are imminently dangerous to themselves or others. The determination of imminent dangerousness is most often made on the basis of recent behavior, not on the basis of a diagnosis (although the diagnosis may aid in the decision at times). For example, individuals may be brought to hospitals after being caught making suicide plans, or suicide attempts, or after violent episodes in their homes. If their medical tests are normal, and if we do not regard psychiatric diagnoses to be valid, the question still remains as to what to do with them. Perhaps the answer is to hospitalize them, or to send them all to jail, or to send them back home and wait until they either commit suicide or harm others before acting. Either way, this is a question that has to be addressed because these situations do exist, and hospitals face them every day.

The justifiability of psychiatric coercion is a difficult scientific-legal question that involves a number of considerations, including the extent of peoples’ rights, the mechanisms of the brain and mind, the principle that past behavior predicts future behavior (to an extent), and others. Libertarians have an important role to play in defending the individual rights of psychiatric patients. However it does not help to reduce the issue to a question of the validity of psychiatric diagnoses, because that both trivializes the problem and harms patients.

Invalidating psychiatric diagnoses invalidates not only involuntary treatment, but consensual psychiatry as well, which both Professor Schaler and Jacob Sullum seem to support. Without concepts like schizophrenia, bipolar disorders, depression, etc, psychiatrists cannot classify patients, perform research to determine what treatments work, and treat patients accordingly. This would be a shame, since the vast majority of psychiatric treatment today is voluntary.

Also from this issue

Lead Essay

  • Professor Schaler notes that mental illness differs in several important ways from physical illness, and these ways make a mockery of conventional diagnosis. Nonetheless mental illness plays an important role in our legal system; it permits psychiatrists to exercise a significant degree of coercion. Schaler challenges this arrangement and argues that those whom we may classify as mentally ill are still deserving of their liberties, including the liberty to refuse treatment. Schaler also questions whether “insanity” is an appropriate legal fiction at all.

Response Essays

  • Professor Frances agrees that mental disorders are not diseases properly speaking, but he maintains that they are nonetheless useful analytic constructs. As to coercive psychiatric treatment, he argues it can indeed be a horrific abuse. Still, in some especially desperate cases it will be necessary to save lives and to prevent even greater harms. He recommends several practices designed to minimize the frequency and risks of coercive treatments.

  • Jacob Sullum asks the mental health establishment for consistency: If mental disorders are not diseases, what justifies involuntary treatment? Evidence of criminal conduct is a matter for law enforcement, not mental health. And how is it that we punish sexual predators (on the theory that they are responsible) — then treat them afterward (on the theory that they aren’t)? Psychiatric diagnoses are ultimately arbitrary, Sullum argues, and they lead to the arbitrary exercise of power.

  • Amanda Pustilnik argues that the most profound violations of liberty in this area don’t come from coercive psychiatry, but from the warehousing of the mentally ill in our criminal justice system. Such people aren’t more likely to commit crimes, but they fare badly in the criminal justice system, where unusual behavior leads to convictions, longer sentences, parole violations, and reincarceration.