Ruffalo on Szasz and civil commitment

In a recent Psychology Today article Mark Ruffalo, a psychiatrist in Tampa, alleges that Thomas Szasz who opposed involuntary psychiatric commitment and the idea of mental illnesses in fact supported involuntary commitment in a public interview:

Thus, I was surprised to come across a videotaped 1983 interview in which Szasz does just that. In his discussion with Jonathan Miller in an episode of Miller’s television series States of Mind, Szasz concedes that society should treat the gravely disturbed (“mad” or psychotic) person in the same way it treats the person who has been rendered unconscious by an accident, implying support for involuntary treatment in these cases. This is a rare admission for Szasz. To my knowledge, it may represent the only such statement he ever made publicly.

I have transcribed the exchange below, emphasizing the pertinent points. Readers can view the full video here.

Szasz’s remarks regarding society’s role in treating the gravely disturbed can be found around the 33-minute mark.

Miller: What do you do about those people who, in fact, are, for reasons which we needn’t discuss—either because of brain disorder or something else, some existential disorder—have become mad, and mad in a way which renders them incapable of asking for the help which, in fact, a profession might be able to give?

Szasz: What do we do about this? Well, we can have a conversation about this, obviously, and your question is, again, well-taken.… But again, let me first say, this is why psychiatry is so powerful—because it is so useful…. Now, whether it is as good a thing as we can possibly do or not is debatable. Obviously, many people think it’s the best we can do, and in many situations, it may be the best thing we can do…. To the extent to which people behave that way [mad], there is no great problem, and there is no great conflict between my views and those of traditional, ordinary, regular psychiatrists. Because these persons, then, should be treated more-or-less on the model of someone who has been hit by a taxi and is unconscious. The ordinary channels of medicine, science, compassion, and humanity should be mobilized and this person should be cared for and treated in whatever way makes sense to society, scientifically and humanly. There is no great problem.

I have watched the relevant part of the interview and made the transcript below:

Miller: There are nevertheless the problems of helping the apparently helpless, the agonised, the distressed and those who are not merely agonised and distressed themselves, but those who agonise and distress their relatives, who, for reasons of their madness, whether you call it illness or not, are not in a position to offer themselves as plaintiffs in the way that a patient suffering from a physical disease is able to do. What do you do on the basis of philanthropy one the basis of helping in terms of kindness about such people? While I agree with you wholeheartedly that there is always the threat of the tyranny of the involuntary commitment of simply taking away someone’s liberty merely because you have denominated them one way rather than the other, what do you do about those people who are – for reasons which we needn’t discuss either because of brain disorder or something else some existential disorder – have become mad and mad in a way which renders them incapable of asking for the help which in fact a profession might be able to give?

Szasz: What do we do about this? Well, we can have a conversation about this obviously and your question is again well taken and I would like to say all sorts of things about it and will. But again let me first say that this is precisely why psychiatry is so powerful because it is so useful. I love to paraphrase Voltaire to say that if there were no god we would have to invent him. I believe that if there were no psychiatry we would have to invent it because psychiatry in fact comes in and does something in these existentially, humanly very difficult situations. Now whether it is as good a thing as we could possibly do or not is debatable. Obviously many people think it is the best we can do and in some situations it may be the best thing we can do. Now in some ways we have to break down the kind of phenomenon which you described because first of all you emphasised the helpless, the inability of the patient to act as their own agent seeking help. Now if we really take that seriously you see that is not a very that does not characterise the whole panoply of the situation but that is certainly one part of the group you are talking about. To the extent to which people behave that way, there is no grave problem and there is no grave conflict between my views and those of traditional, ordinary psychiatrists because these persons then should be treated more or less on the model of somebody who has been hit by a taxi and is unconscious. The ordinary channels of medicine, science compassion and humanity should be mobilised in this person should be cared for and treated in whatever way makes sense to society scientifically and humanly, there’s no great problem.

Miller: No I see that.

Szasz: But Doctor Miller, you know very well that this is a minute problem because what happens very often is, and there are such people, is that although they are helpless in many ways, and don’t seek help, the one thing they seem to want to know, and want to do, is to get out of a mental hospital as soon as they are taken there, that’s why they are locked, so that the people can’t walk out. So although they don’t quite know what to do with themselves they do know they don’t want psychiatry. Now but this is not really a representative sample.

Szasz then goes on to discuss Lady Macbeth whose problems he regards as more typical of psychiatric patients. Szasz is not completely explicit in this interview, but his position as I read it is the following. Some people are helpless and don’t seek help. Szasz’s position is that facilities should be available for such people to get help that resembles the help offered by psychiatrists in some respects. But those facilities shouldn’t lock up the people in their care. This has the merit of being consistent with other material Szasz wrote, such as his detailed discussion of how to reform the mental health field in Chapter 19 of Law, Liberty and Psychiatry. Whether or not Szasz’s position is good he isn’t supporting involuntary treatment of mental patients.

Ruffalo is trying to smear Szasz as a hypocrite rather than actually discussing his position with full and accurate quotes interpreted in the light of the rest of Szasz’s work. This is a common problem in discussion of Szasz’s work. His views are very different from those of other psychiatrists. Psychiatrists and supporters of psychiatry aren’t interested in stating his position correctly and discussing it rationally: they prefer lies and hostility.