When the Doctor becomes the Warden: On Mental Health

Dr Jess discusses the famous quote, and what happens when we question psychiatry

I noticed a post online a few months ago, which described me as the ‘modern day Thomas Szasz’. At first, I thought it was someone being a dick.

I have become accustomed to being called everything from a fraud to a scientologist for daring to question the evidence base of psychiatry. I had no idea it was going to be like this. I thought everything was open to debate and discussion. Lord knows, everyone debates and criticises everything that comes out of my mouth, so I was not aware that psychiatry was off limits.

For those of you who don’t know who Professor Thomas Szasz was, he was a psychiatrist and interestingly, and like many of the key thinkers around this, he was also a prominent critic of psychiatry. He very famously argued that the role of the doctor in psychiatry often shifts from healer to warden. He believed that psychiatric practice, particularly in cases involving forced treatment or institutionalisation, places doctors in a position of power over individuals, treating them less as ‘patients in need of care’ and more as individuals under control or confinement.

He writes about this in great detail in his book, The Myth of Mental Illness (1961).

I read several books by Szasz when I was trying to understand my own views about psychology, psychiatry and social control. As the years passed, it become increasingly clear to me that telling people that they had unproven mental illnesses inside their brains that no one could confirm or deny, that no one could test for, and no one could prove if they were ‘cured’ – sounded very much like social control. Anyone could be framed as mentally ill without proof – and where proof is not needed. Anyone could be told they would never recover, and anyone could be told that they were ‘relapsing’ if they didn’t conform. Anyone could be put on medications they didn’t want or understand, if a psychiatrist said they needed to.

I recalled reading a quote from Szasz at some point during my PhD, in which he said that there was a reason the only ‘health issue’ that requires law, incarceration and forced treatment is ‘mental illness’. I pondered on that for some years.

He argued often that mental health law was just an extension of criminal law, a way of locking people up and getting rid of them. Considering I teach the history of psychiatry and social control, and therefore know that being a ‘lunatic’ used to be considered a crime (hence why we called people ‘criminally insane’ and locked them up for the rest of their lives, even lobotomising them or shocking them with electrical current to the brain), I can’t say I disagree with him.

However, as a psychologist and as an avid reader, I had seen all sorts of wild criticisms about Szasz that had instantly got my back up when I saw I was being described as a modern day Szasz.

After his death, his work was deliberately misinterpreted, and in some cases, just outright lied about. Interestingly, there was a paper published in 2021 by Spillane and Counter in ‘Ethical Human Psychology and Psychiatry’ called ‘Szasz under friendly fire’, which explored the way his colleagues in psychiatry sought to frame him as mentally ill, paranoid, schizophrenic, abusive, dangerous, misinformed, inexperienced, and unscientific due to his beliefs.

However, many of us who work in an anti-pathology, trauma-informed way (such as myself and many of my contacts, trainees, and colleagues), would agree with his famous argument:

‘Mental illness is a myth, whose function is to disguise and thus render more palatable the bitter pill of moral conflicts in human relations’ (Szasz, 1960)

For any of you who have followed me for long enough will know – I talk about this exact point regularly. I would probably explain it without the poetic language, as I lack that ability! I would term it as:

Mental illness is merely a social construct that reframes horrible, painful, traumatic, abusive, sad, angry, confusing, worrying, and frightening parts of human experience as a disorder of the mind so we can individualise it into the brain of the person, lock them up, medicate them as ‘patients’, and ignore the systemic harms, powers and controls that encourage, profit and cause human suffering.

That’s the way I tend to explain it to people – and it is extremely similar to Szasz, without me even knowing, I guess.

So, what did Szasz mean by the doctor becoming the warden?

Coercion in Psychiatry

Szasz was highly critical of what he saw as the coercive elements of psychiatric practice. He argued that when doctors have the authority (and it appears, total discretion) to diagnose mental illness and impose treatments (such as involuntary hospitalisation or forced medication and treatments such as ECT), they essentially act as wardens, controlling, harming, and confining individuals against their will. For Szasz, this was a violation of personal autonomy and freedom. He likened it to being tortured and imprisoned.

Institutional Power

In psychiatric services, doctors often hold significant authority over patients. They can decide whether someone should be admitted to a psychiatric ward, whether they can be released, and what treatments they should receive. They can decide that their dosage needs to go up, that they need to change to another medication, that they need to engage in therapy – or even that they need to undergo ECT without their consent. Szasz viewed this power as akin to that of a warden in a prison, as it involves decisions about confinement, surveillance, and control, rather than healing and voluntary care which would require full informed consent and free choice of the person.

Pathologising Human Behaviour

Szasz believed that psychiatry pathologises behaviours that society finds uncomfortable, scary, confusing, or problematic, labelling them as "mental illness" and justifying the control of individuals who exhibit these behaviours.

Ummmm, okay I’m beginning to see why I was likened to Szasz now. LMFAO.

In this sense, doctors become enforcers of social norms rather than facilitators of health. According to Szasz, psychiatry becomes a way to manage deviance rather than provide care, turning the doctor into a warden overseeing those who do not conform to societal expectations. This one is fascinating, especially as all behaviour is socially, culturally, historically and geographically situated and specific, meaning what is ‘normal’ and ‘acceptable’ in one country and culture may be very offensive, strange and worrying in another. This obviously brings us back to the inherent white supremacy in psychiatry and psychology, but I will save that for a whole article. Cos that shit needs airing.

Importantly then, Szasz believed that psychiatry led to the loss of patient autonomy, choice and informed consent – which if we were honest – isn’t much different today. Szasz also frequently highlighted the power imbalance between psychiatrists and patients, where doctors have the authority to label individuals they meet as "mentally ill" and then make life changing decisions that can lead to their confinement, often with little recourse for the patient. I am especially interested in this issue, as the recent report by the UN and WHO (October 2023) argued for reparations and recourse for everyone harmed, abused and forced into psychiatric treatments.

I think often about Szasz’s argument that the ‘doctor becomes the warden’. I know I see this frequently when women are raped, abused, report their trauma or distress to mental health services only to be reframed as delusional, psychotic and hysterical. I know of cases where women went to the police about being raped, were referred for psychological assessment, and were ‘assessed’ in less than 30 minutes by a stranger, who then wrote a report for the police saying that the rape never occurred, the woman is delusional, and no further action should be taken.

Who gave doctors this power? How can they possibly be able to write a professional report claiming that a woman they have met for 30 minutes was never raped? Were they present? Do they have a crystal ball? Are they psychic? How can they prove that the rape never happened? Is this not just their opinion, and nothing more?

And what about the doctors who can section someone under the mental health act - for days, weeks or months of their lives purely based on their own views of the person?

Am I the only one who can’t see the evidence and science in these decisions? We harp on about evidence based medicine – but there is no evidence required for a psychiatric diagnosis… just opinion…

So, am I a ‘modern day Szasz’?

I don’t know. Probably not. He seems a lot smarter than me!

I know he is seen as extreme, and so am I. I know his own discipline turned against him, and framed his ideas as dangerous and radical – which is exactly what has happened to me. I know his ideas are frequently twisted and taken out of context by people who have never read any of his books… which is… horribly familiar. I know that he was often accused of being secretly mentally ill, psychotic, delusional and disordered - which I also have been by many psychiatrists and psychologists who disagree with me.

I read a paper by one of his critics who had the gall to write about him after his death (having claimed to have been his friend and colleague whilst he was alive, no less) which stated, ‘It is better to see Szasz as an ideologue than a practicing psychiatrist’ – which I think is just so insulting. Whether people like his ideas and theories or not, the guy was a practicing psychiatrist, he was a doctor, he was medically trained, and he was writing from a multi-faceted perspective about philosophy, human ethics, psychology, psychiatry, medicine, behaviourism, politics, social control and social justice.

It just fascinates me how defensive and personal professionals become when their ideas are questioned. No. Not even their own ideas. Ideas they were taught in their degrees. Szasz committed the unforgiveable sin of questioning his training, his discipline, and his peers.

And yet here I was, thinking that was the point of academia! Silly me.

So, one final point on this for everyone still reading – Szasz is often derogated and mocked for being ‘anti-psychiatry’, as if admitting that he was a staunch critic of psychiatry made him a quack, a fraud, an idiot, or dangerous in some way. I hear it all the time. ‘Szasz was an anti-psychiatrist!’

So?

Is that illegal? Is that blasphemy? Do you belong to a religion? Is psychiatry above criticism? Is it a religion or a science? Or a cult?

Why can’t we question it? Why can’t we abandon it and move on? Why can’t we admit that it’s not actually answered any of our questions about human suffering?

I have noticed that hundreds of professionals who do not believe in mental disorders, and are calling for anti-pathology, trauma-informed and human-rights-based approaches to human suffering are too scared to admit that they are anti-psychiatry.

Me? I think we should be braver in nailing our colours to the mast.

I am anti-psychiatry and I am absolutely fine with that. It is a personal, professional, ethical and theoretical position to hold.

Others can be pro-psychiatry. I am not.

I cannot see any value in psychiatry as it stands. It strikes me as a sophisticated and widely accepted form of social control. As an area of study, as a scientific discipline, it has had over 100 years to prove biological causes of these so-called ‘mental illnesses’ and yet cannot find a single one. The APA have been very clear on this, and have given multiple statements at conferences and in reports to clarify that no biological causes of any mental disorders have ever been found.

We are supposed to blindly believe that there are mental illnesses in the brain, caused by unproven chemical imbalances and hidden genetics – and that is supposed to be the sensible, safe, ethical stance? The scientific stance?

But if we say that we think human suffering is common, trauma is everywhere, abuse is endemic, poverty is horrific, governments are corrupt, capitalism is killing us all slowly and huge corporations are profiting billions from our distress and sickness – and we think that humans need support, time, patience, understanding, validation, safety, resources and protection from harm – we are radical, unsafe, unethical and dangerous?

Hmmm.

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