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Psychiatrists Create Their Own Reality

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 By Jacob Sullum
Response Essays
August 10, 2012

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J
effrey Schaler notes that both Ted Kaczynski, a.k.a. the Unabomber, and Anders
Breivik, who killed 77 people in Norway last year, resisted efforts to reclassify their
politically motivated crimes as symptoms of schizophrenia. I suspect that Wade
Michael Page, the gunman who was killed by police in the middle of an attack that left six
people dead at a Sikh temple near Milwaukee on Sunday, likewise would have rejected such
an explanation. Indeed, speculation about his motives so far has focused not on mental
illness but on his white supremacist ideology. Page killed Sikhs, people tend to assume,
because he was “fueled by hate,” as one headline put it, not because he was driven by
psychotic delusions.

By contrast, consider the 1980 trial of Darlin June Cromer, which Thomas Szasz describes in
Szasz Under Fire: The Psychiatric Abolitionist Faces His Critics, a 2005 collection of essays
edited by Schaler. Cromer was a 34-year-old white woman charged with kidnapping and
murdering Reginald Williams, a 5-year-old black boy. There was no question that Cromer,
who attracted suspicion because she had a history of talking about “killing n‑‑‑‑‑s” and
trying to lure black children into her car, had abducted Reginald from an Oakland,
California, supermarket, strangled him, and buried his body near her home. She had told

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 police as much when they questioned her. Neither was her motive in doubt. She explained
that “it is the duty of every white woman to kill a n‑‑‑‑‑ child,” telling a jail psychologist she
hoped to ignite a race war. But as the San Francisco Chronicle reported, Cromer’s attorney
argued that “his client killed because she is consumed by schizophrenic paranoia—not hate
for blacks.” Or as the lawyer put it, “This case does not involve racism; it involves insanity.”
To help undermine this claim, the prosecution sought help from Szasz, who testified that
“schizophrenic paranoia” was a label, not an explanation.

That point is only reinforced by Allen Frances’ concession that “mental disorders most
certainly are not diseases.” If they are not diseases, what are they, why do medical doctors
treat them, and how do we know when someone has one? The mystery deepens when we
consider Frances’ comments in a 2010 interview with Gary Greenberg in Wired that quoted
him as saying: “There is no definition of a mental disorder. It’s bullshit. I mean, you just
can’t define it.” While it is startling to see the lead editor of psychiatry’s bible say such
things, it is even more surprising that he does not acknowledge the implications. If mental
disorders are not brain diseases like Parkinson’s or Alzheimer’s, if they cannot be
objectively verified or even satisfactorily defined, how can they justify forcibly detaining
people and compelling them to take neuroleptic drugs?

Frances says psychiatrists should use coercion only as “a last resort when nothing else will
do.” His example is a man who waves a gun and threatens to kill his daughter, a case that
seems to cry out for intervention by police rather than psychiatrists. But because the man
“meets the criteria for the construct ‘schizophrenia’” (an undefinable nondisease, by
Frances’ own account) and claims to be hearing murderous commands (which would

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 certainly qualify as “a socially unacceptable self-reported imagining,” to use Schaler’s
phrase), he is locked in a mental hospital instead of a jail.

The “sexually violent predators” that Frances mentions, by contrast, are first punished as
criminals, serving time in prison, and then “treated” as patients, kept indefinitely in mental
institutions after they complete their sentences. This dual identity stems from two
incompatible ideas that have both been embraced by our legal system: The sexually violent
predator is convicted and imprisoned based on the premise that he could have restrained
himself but failed to do so; then he is committed to a mental hospital based on the premise
that he suffers from irresistible urges and therefore poses an intolerable threat to
public safety.

Talk about a legal fiction! This incoherent theory is a transparent attempt to conceal what is
really going on: the retroactive enhancement of duly imposed sentences by politicians who
decided certain criminals were getting off too lightly. That policy is so plainly contrary to
due process and the rule of law that it had to be dressed up in quasi-medical,
pseudoscientific justifications. Yet Frances’ main objection to what he describes as a
constitutionally dubious form of “preventive detention” is that some “ignorant and/or
unscrupulous psychologists” too readily diagnose sex criminals as mentally ill.

Similarly, Frances regrets that some psychiatrists suppress political dissent by treating it as
a mental illness, and in the Wired interview he complained that labels such as “bipolar
disorder” and “attention deficit hyperactivity disorder” are applied too promiscuously. The
implication is that if only these concepts were used more carefully and conscientiously, all
would be well. But I have to agree with Schaler: The problem lies in the concepts, not in

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 their application. As Schaler says, “These are terms used by members of the mental health
profession to do and not do certain things to certain people.” If the terms do not describe a
relevant reality, they are no more than an empty excuse for exercising power.

The Diagnostic and Statistical Manual of Mental Disorders, which is currently evolving from
the fourth edition overseen by Frances into a fifth edition scheduled to be published next
year, dramatically improved the reliability of psychiatric diagnoses (i.e., inter-practitioner
consistency) by gathering together descriptions of behavior, giving them names, and listing
criteria for assigning the codes that mental health professionals need to get paid by
insurers. But the DSM did nothing to improve the validity of psychiatric diagnoses: the
confidence that such labels indicate an underlying phenomenon with a common etiology,
let alone one rooted in a measurable biological defect. Mental disorders, as Szasz has been
pointing out for half a century, are whatever psychiatrists say they are. They are born by
decree of the American Psychiatric Association, and they die in the same way. Hence
homosexuality used to be a mental disorder but no longer is, while Asperger syndrome is
for now but won’t be next year.

Frances says psychiatrists are calling balls and strikes as they see them, which is an apt
metaphor in the sense that balls and strikes are meaningful only within the arbitrary rules
of baseball. Psychiatrists change their rules at will, and those rules cannot be right or
wrong, since psychiatrists create their own reality.

ALSO FROM THIS ISSUE

Lead Essay

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 Strategies of Psychiatric Coercion by Jeffrey A. Schaler

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

A Clinical Reality Check by Allen Frances

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.

Psychiatrists Create Their Own Reality by Jacob Sullum

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.

Calling Mental Illness “Myth” Leads to State Coercion by Amanda Pustilnik

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

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 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.

The Conversation

In Search of a Middle Ground by Allen Frances

Reply to Allen Frances by Jeffrey A. Schaler

A Way Forward? Or, Libertarianism Is Not Equal to Indifference by Amanda Pustilnik

Mental Disorders Are Not a Myth by Allen Frances

Finding a Place for the Mentally Ill by Jacob Sullum

Reply to Amanda Pustilnik by Jeffrey A. Schaler

One Last Try at Synthesis by Allen Frances

The Legal and Moral Problems of Involuntary Commitment by Jacob Sullum

Access to Voluntary Treatment by Amanda Pustilnik

A Summation, but Not a Middle Ground by Jeffrey A. Schaler

Letters: A Libertarian’s Proposal to Reform Involuntary Commitment by The Editors

Letters: The Pathology and Reality of Schizophrenia by The Editors

Diagnosis Isn’t the Problem. Coercion Is. by The Editors

Recycling Thomas Szasz by The Editors

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