"In the animal kingdom, the rule is, eat or be eaten; in the human kingdom, define or be defined."
THOMAS S. SZASZ, "Language," The Second Sin, 1973—ABSTRACT
Since its inception, critical observers have expressed concern about psychiatry's treatment of people who are labeled as mentally ill. Some modern day observers express an even deeper concern, pointing out that coercive psychiatry destroys the hard earned balance in United States law between the interests of social responsibility and group cohesion on the one hand, and individual freedom and liberty on the other. More clearly and consistently than anyone, Thomas Szasz has delineated in great detail the fundamental problems that go with a fusion of psychiatry and the law, most notably that our country's courts routinely and systematically violate the civil rights and liberty interests of those designated as mentally ill. This essay tells a story of the case of Sohrab Hassan, faced with a state of Texas effort to involuntarily commit him to 90 days of psychiatric incarceration and forced psychiatric drugging. The author uses the case to reveal the fundamental problems that Dr. Szasz' life work describes. The essay also reveals an inspiring, partially successful defense of Hassan's liberty interests in the face of psychiatric coercion.
The Case of Sohrab Hassan
Sohrab Hassan is a 31-year-old Somalian-born American. He immigrated to the United States at age 21, obtained his degree in electrical engineering from the University of Windsor in Canada. In 2000, he took a job in the computer electronics industry with Motorola in Austin, Texas, where he worked the next 4 years. During that time, in an effort to be of service as a more integral part of the Austin community, he became first a volunteer, then a professional youth soccer coach. He took a team to the state championship.
Up to age 30, Sohrab Hassan had no occasion to experience direct contact with psychiatry or with law enforcement. In September 2004, however, Sohrab was having difficulty. He was experiencing stress and dissatisfaction with learning and advancement opportunities at Motorola. He was reeling from recent deaths of 2 family members. He was having trouble sleeping, and a night of drinking beer and wine, from which he usually abstains, made matters worse. His brothers became concerned and convinced Sohrab to admit himself to the state psychiatric hospital. They then connected him with a private psychiatrist, Dr. Patel, whereupon Sohrab was transferred to a private hospital where he stayed for a week under Dr. Patel's care. Though it seems clear to me that the above quatrain of difficulties are more than sufficient to elicit and explain a temporary breakdown, the doctor attributed Sohrab's problems to the emergence of a serious "mental illness."
Psychiatry Belief System #1: Biologically Based Mental Illness
The primary belief system of psychiatry today virtually guarantees this attribution. Simply put, the belief is that problems in living are due to biologically or genetically based mental illness, requiring psychiatric drugs to keep under control. Healing and cure is impossible and irrelevant. Dr. Patel diagnosed Sohrab as having a psychotic disorder and started him on a drug regimen of the neuroleptic Risperdal, the "mood stabilizer" Depakote, and a sedative-hypnotic called Ambien. Later his diagnosis was changed to Bipolar Disorder with psychotic features.
Sohrab Hassan was a patient of Dr. Patel's from September 2004 to July of 2005, during which time he was on medical leave from Motorola, awaiting his doctor's release to return to work. This was granted at the end of July, and Sohrab returned to work August 1st. At noon that day, he was summoned to Human Resources and informed that he was no longer needed at Motorola.
Sohrab's prescriptions had run out in May and he assumed—a false assumption it appears—that was the doctor's intention. In any event, he was happy to stop taking the drugs, as he never liked the way they made him feel. Dr. Patel never discussed drug discontinuation, possible or actual, with Mr. Hassan.
On October 5, 2005, Sohrab was visited three times by local law enforcement authorities. Two times, at the request of his brothers, city police confronted him. Both times, they let him be after ascertaining that he was rational and peaceable. The third time, Sohrab was at his apartment. Two cars pulled up, and the sheriff's mental health deputies came to the door. Working at the request of his brothers in alliance with Dr. Patel, the deputies presented Sohrab with an order of protective custody. Sohrab asked to see it, and started asking questions. He ended up with a gun pointed at him, quickly submitted to detainment, and was taken directly to the same private psychiatric hospital where he had stayed for a week a year ago. Shortly after arrival, a Dr. Michael evaluated Sohrab, and verbally assured him of his release, then disappeared. Dr. Patel showed up later, and despite Sohrab's consistent rejection, remained his doctor.
On Tuesday, October 11, I got a call from Laura Donnelly, who had been hired to represent Mr. Hassan. The usual situation is that a court appointed attorney handles the "patient's" (read defendant) case. The court appointed attorneys tend to handle a number of these cases, and tend to think in terms of "best interests" of the patient, rather than the usual attitude of an adversarial lawyer in our legal system of paid champions. This is just one piece of the fact that mental health courts really are, for the very most part, kangaroo courts. Once an individual is caught up in the process of involuntary commitment, the odds are intensely stacked against him. Laura Donnelly, however, is far from your typical half-hearted mental health court defense attorney. She is an experienced lawyer who specializes in civil and criminal litigation. The fact that she had never handled a psychiatric case was a disadvantage in some ways re knowing exactly how it works; on the other hand, she had adopted none of the hopelessness or paternalism that tends to go with this process. She was very clear about being an advocate for Mr. Hassan, and not confused by the rhetoric that these hearings were about how best to help this "mentally ill" man. She was focused on issues of liberty, civil rights, and self-determination.
Though this is a true story, at least from the perspective of this writer, the names in this essay have been changed for reasons of confidentiality. This should be obvious regarding the patient/victim of these proceedings, but in this case it is very true for the lawyer. Not only is she an unusual mental health court defense lawyer because of her lack of conditioned confusion leading most of the participants to think that involuntary commitment is not really incarceration or imprisonment, but she also just had her own brush with psychiatry. Faced with an intensely stressful custody fight with the father of her child, she was feeling understandably depressed. Her sister encouraged her to visit the local mental health center, where she honestly answered the social worker's question about whether she ever felt like life was just not worth it; subsequently everything kicked into gear, and next thing she knew her sister had transported her to a private psychiatric hospital to get a little extra care. It just so happened that her attending physician was none other that Dr. Patel. Though he strongly suggested that she commit herself to the hospital, her stay was short, as she quickly saw the hospital as a detainment facility and was badly put off by the scene of a crew of nurses protected by thick glass walls, patients having to pound on the glass and make a scene to get attention. She mobilized her abundant energy and intelligence, and was soon out of there. During her stay, she met Sohrab Hassan, who actually offered her solace and consideration. They connected, and he hired her to be his lawyer. Also unusual was the fact that this man actually had a little money from his Motorola severance package to spend on defending his rights. Ms. Donnelly found me through an Internet search that yielded my website. Ms Donnelly needed an expert witness. I called Mr. Hassan, met with him that night, and agreed to testify the next morning on his behalf.
The First Hearing
The October 12 mental health court hearing for a 90 day "temporary" commitment, euphemistically called involuntary commitment and treatment, accurately called incarceration and control, was scheduled for 8:30am, but Mr. Hassan's case was third on the docket. I was not surprised upon arrival at the court, on the grounds of Austin State Hospital, to discover that Sohrab faced two petitions—the 90 day commitment and a separate petition for involuntary drug treatment. Described above as psychiatric belief #1, "mental illness" and drug "treatment" are inseparably wed in the world of psychiatry. While we waited, we observed the proceedings of the first case of the morning. I mention only five points here. 1) The defendant, a young baker by trade, spoke only Spanish; everyone testifying against him from the hospital spoke only English (a translator was appointed for the hearing. 2) The prosecution elicited comments on the importance of psychiatric drugs and how he had benefited from them in the past. This defendant's own testimony said the opposite, which was interpreted as evidence of his "mental illness". 3) When the psychiatrist was asked about alternatives to drug treatment, she said there was only one, but he probably would not consent to electroshock. 4) He lost on both counts. 5) The judge counseled him at length on the reality of mental illness, that it was nothing to be ashamed of, and that he really needed these "medications." Afterward, he asked a social worker to have someone from the man's religion visit and try to explain to him that it was not against his religion, (Jehovah's Witness) to take the drugs.
Mr. Hassan's commitment hearing finally commenced at 11:30. The prosecution attempted, apparently with some success at least in the eyes of the judge, to portray Sohrab as a mentally ill man, in denial about his illness. She brought up 4 or 5 allegations of questionable public behavior in the realm of lewd or indecent sexual exposure. He does have two misdemeanor criminal charges pending—a trespass charge and a DWI. Ms. Donnelly challenged the information, distinguishing allegations from convictions. Along this line, there was a very telling interaction when Donnelly expressed disapproval of Sohrab's already existing weeklong commitment. The judge countered that he was not committed yet, and so it was decided that detainment would be a better word applying to the original Order of Protective Custody (OPC). Donnelly dismissed this with the one word, semantics. She could not have known, given that this was her first experience with psychiatry and the law, that the life work of Thomas Szasz, has made exceedingly clear that the entire charade is based on semantic distortion of the truth.
A brief tutorial on semantics by Dr. Szasz might include the following:
"Although linguistic clarification is valuable for individuals who want to think clearly, it is not useful for people whose social institutions rest on the unexamined, literal use of language. Accordingly, I have long maintained that psychiatric metaphors have the same role in our therapeutic Society that religious metaphors have in Theological Societies." (Szasz, 1993)
"Why do we talk about the rights of mental patients? Who threatens or abridges them? The answer is painfully obvious: relatives, physicians, psychiatrists, judges, legislators — all those responsible for the complex web of images, justifications, and policies that result in institutional psychiatry and its involuntary "patients." Commitment, involuntary mental hospitalization, is, of course, the paradigm of psychiatric power. In my opinion, it is also a paradigm of the perversion of power: for if the "patient" is not a criminal, then he or she has a right to liberty; and if the patient is a criminal, then he or she ought to be restrained and punished by the criminal law, like anyone else....
Involuntary mental hospitalization and the insanity defense should be seen for what they are: symmetrical symbols of psychiatric power. In the one case, the psychiatrist "accuses" the innocent; in the other, he "excuses" the guilty. Civil commitment and the insanity defense both create and confirm the impression of psychiatric expertise, where none exists. Civil commitment and the insanity defense also foster the impression that they provide a socially beneficial solution for troubling problems of human existence, when, actually both aggravate these problems." (Szasz, 1982)
For further tutorial, and a wealth of cutting edge information on psychiatry and the law, I recommend the website, www.psychrights.org, on Jim Gottstein's work with the law project for psychiatric rights.
An observer commented to me after Mr. Hassan's trial that in today's political climate, a series of questions about ethical handling of detainees might have been appropriate.
Sohrab asserted that he had experienced negative effects from the drugs—confusion, memory impairment, and impulsivity—that he had experienced and behaved during his last year in "treatment" in ways incongruous with the previous 30 years of his life. (He had already privately informed me that it was only after watching the recent movie, "Ray," about legendary singer Ray Charles, in which Charles was shown going through intense withdrawal from a heroin addiction, that he realized that he himself was having what he experienced as similar withdrawal reactions from the psychiatric drugs he had been taking. Sohrab referred to having what he called "seizures.")
Ms. Donnelly challenged Dr. Patel on his recommendations. We were all astounded when the doctor made a categorical statement that there were no withdrawal effects from any of the drugs he had prescribed for Sohrab—Risperdal, Depakote and Ambien. He testified that he had closely monitored blood levels, and Donnelly had none of Mr. Hassan's medical records.
Dr. Patel did allow that electroshock would be a good alternative treatment.
Psychiatry Belief System # 2: The Value of the Insanity Defense (Psychiatry Protects Mentally Ill People From the Harsh Criminal Justice System)
During my own testimony, which focused on Sohrab's mental status, an opinion about his experiences, and a discussion of alternative "treatments," the prosecutor worked hard to paint me as a radical outlier, eschewing belief in all mental illness and drug treatment. I managed to not answer some of her questions and to over answer others, and to largely keep the focus on this case. At one point, she asked me point blank whether I would rather see Mr. Hassan "butt-raped" in prison than receive the psychiatric treatment he needed for his mental illness. This theme runs very deep in the mental health courts. A major claim to virtue is that the state taking beneficent psychiatric care of these sick mentally ill people is so much kinder and gentler than harsh judicial trial and sentencing. After decades of experience with the mental health system, and work on cases like that of Rodney Yoder who served about 12 years in what he calls an Illinois psychoprison on grounds of being a very dangerous psychotic man…and after years of intensely confronting the overwhelming damage caused by what Jewish lawyer and director of the Alaskan Law Project for Psychiatric Rights, calls the pharmacaust… I am in complete alignment with the clearest thinker of them all on this issue—psychiatrist and prolific author, Thomas Szasz—that psychiatry and the law need to be kept very far apart. As Szasz (1993) asserts, "liberty and responsibility are indivisible."
The claims to virtue of the therapeutic state ring worse than hollow when one sees the reality of psychiatric infringement on human rights and the damage caused by ubiquitous use of drugs and electroshock on people who psychiatry continues to fail to demonstrate have any real disease. This last is a fact, tragically overwhelmed by the opinions and vested interests of the state and private psychopharmaceutical industry, of which the Texas mental health courts stand as an exemplary enforcer.
We lost the case. Ms. Donnelly's jaw dropped when she heard the verdict. Naïve to psychiatry, based on her considerable experience with both civil and criminal litigation, she thought we had won. She was astounded at the judge's decision that Sohrab was mentally ill and dangerous to himself and others, by "clear and convincing evidence." Due to time, the petition for forced drugging was postponed.
The Hearing on Forced Drugging
The forced drug petition was postponed until Friday. Ms. Donnelly requested a continuance to prepare and obtain medical records. The judge denied her request due to the purported urgency on "medication." When Dr. Patel, however, reported a schedule concern, the hearing was postponed until noon Monday, October 17th.
Dr. Patel was the first witness, and Donnelly immediately challenged his credibility. The judge told her to move into voir dire mode, which is when it is argued whether the witness may be qualified as an expert for the court. Donnelly had unearthed a current finding by the state medical board against Dr. Patel, the charge being the practice of polypharmacy without proper substantiating documentation. The prosecutor and Dr. Patel were taken aback. The judge did qualify Dr. Patel to testify as he still has his license and is appealing the finding, but a serious point had been made. Donnelly drew out the doctor's opinion about the difference between allegation and conviction, and pointedly asked him if he believed in the principle of innocent until proven guilty. Given the heavy weight of allegations against Mr. Hassan to prove his mental illness, this was a major point—Donnelly aptly drew the comparison.
At the prosecutor's behest, he reiterated his opinion that Sohrab was mentally ill and badly needed medication for his illness. The "incidents" were mentioned, as was the family's opinion. Along this line, Donnelly asked Dr. Patel whether he considered the possibility of acrimony or conflict among the brothers, and he said no. She asked whether he ever inquired about such a possibility in commitment cases like this, and he again said he did not, that he trusted the family members who were there voluntarily. This seems a very naïve or convenient position—or both. While Dr. Patel implicitly trusted the brothers, Sohrab most certainly did not.
Patel also told the court that over the weekend Sohrab had thought that Dr.Patel was his brother, an apparent hallucination. Ms. Donnelly asked a very long series of questions of the doctor, including very specific questions about each of the drugs he had previously prescribed for Sohrab. Dr. Patel opined his certainty that none had withdrawal effects, and denied certain other specific drug effects. I am certain I even saw the judge raise her eyebrows and look askance at the doctor as he testified that there were no addictive concerns with Ambien, and that it did not include troubling effects on thought and behavior. Donnelly's last question actually made the judge drop her jaw and utter an audible gasp: "Is it true that you are known in the community as Dr. Commitment?" The objection was sustained.
Mr. Hassan did a fine job testifying on his own behalf: his version of the alleged hallucination was that Patel showed up in his room early in the morning and startled him out of sleep. As an observer, the behavior of the prosecutor during Sohrab's testimony seemed to clearly belie the notion that these mental health hearings are really different form a criminal trial. She repeatedly cut him off if he started to over answer her question, or bring in a different perspective; apparently, he was her opponent and she wanted him convicted.
The defendant's next witness, a very experienced, but retired pharmacist, began her testimony with an attempt to read briefly form the Physician's Desk Reference (PDR) on Ambien. The prosecutor objected that this needed to be admitted into the record. Neither the pharmacist nor the lawyer had a PDR on hand, so this information was not allowed. The prosecutor decided to challenge the witness in voir dire, and the judge subsequently did not allow her to testify.
I was the last witness, and the effort to disqualify me was fairly intense as both the judge and the prosecutor asked me many questions. Although my degree is in School Psychology, the fact that I have over 20 years as a licensed psychologist doing counseling and clinical work got me qualified by the judge. This time I did an even better job of refusing to answer questions on the prosecutor's terms. She would setup yes or no on questions such as "Do you believe in mental illness?" or "Would you ever think medication was a good idea if Mr. Hassan was seriously mentally ill?" While I do have a direct answer, in this context, either yes or no is damning. The one supports her case, the other paints me as a fringe radical in the eyes of the court—to effectively answer the question in this context requires laying out a discussion of what these terms mean. On the one hand, I would bring the focus back to Mr. Hassan, and on the other, I would have to expand on the concept of mental illness, and the issue of safety and efficacy of various kinds of help. I appreciate that the judge did at least give me a little leeway in confronting the prosecutor and explaining myself. Perhaps I gave the judge an open doorway to justify the final decision that was apparently so noxious for her to make.
The judge ruled that Sohrab Hassan was competent to refuse medication and disallowed the petition. She did go on an extended lecture to the defendant, which had the feel of a rant, about her certainty that even though she had to concede he had the legal right to refuse medication, that this was a bad decision. She particularly emphasized that it would look so much better for his criminal cases if he were to show the judge and prosecutor that he was taking medication for his mental illness. This judge could use a Szasz tutorial herself, perhaps starting with this quotation:
"We should not forget the value inherent in the right to be tried — in public and by one's own peers, and also the values inherent in the right to go to jail — instead of being subjected to unwanted psychiatric "treatments." In a jail, a person is "let alone"; in a mental hospital he may not be. A prisoner will be released after he completes his sentence, and possibly before. A mental patient may be required to undergo a change in his "inner personality" — a change that may be induced by measures far more intrusive than anything permitted in a jail — before the psychiatric authorities let him go. And they may never let him go. Commitment, unlike a sentence, is for an indefinite period.
How different the world might be today if only a handful of people had been sent for psychiatric "treatments," instead of being tried and sent to jail! Gandhi, Nehru, Sukarno, Castro, Hitler — and of course many others, for example the "freedom riders" in the South — have been sentenced to terms in prison. Surely, the social status quo could have been better preserved by finding each of these men mentally ill and subjecting them to enough electric shock treatments to quell their aspirations.
If this is not the kind of tyranny against which the Constitution was intended to protect us, what is?" (Szasz, 1963)
Unlike the Spanish speaking man in the first hearing on October 12, Sohrab Hassan was fluent in English. His first language, and his first culture, however, is African. As with the first man, the prosecution painted Sohrab as seriously mentally ill; Sohrab thought differently, and had different explanations for the behaviors construed as evidence of his mental illness. Both men were sentenced to 90 days of psychiatric incarceration. The Hispanic man was forcibly drugged; Sohrab was allowed to refuse. One big difference was that Sohrab had resources, and in an unusual way, found competent experts as allies, and mobilized a vigorous defense. However hopeless we allies might have felt given the nature of a kangaroo court where judges are true believers in the value of biological psychiatry and the paternalistic coercion of a therapeutic state, we did not give up or yield to an assumption of loss. We did our best to act on behalf of the best interests of Sohrab Hassan. In the first hearing, no matter how effective Donnelly perceived us to be, we lost. In the forced drug hearing, we achieved a rare win.
That same evening, I called the hospital to speak to Sohrab. My intention was to check in and to counsel him briefly on the very real possibility of retaliation—added pressure in hopes of convincing him to change his mind or to cause him to lose his cool and justify emergency drugging. I wanted to support him and encourage him to stay strong. The hospital informed me that he had been discharged. I had erroneously thought they would keep him at least for awhile, as it seemed to me that immediate release looks bad in light of the vigorous argument that he was so mentally ill that he needed to be locked up for 90 days.
I can only think of three reasons to release him.
First, though not the focus of this paper, it is appropriate to acknowledge that in order to understand most decisions in our society, especially those that are institutionalized as is the case with psychiatry, one must follow the old journalistic axiom, "follow the money." Psychiatrist David Viscott noted in his 1972 autobiographical book, "Finding that the patient has insurance seemed like the most common indication for giving electroshock." (p. 352) When I visited Mr. Hassan before the hearings, he told me he had been having trouble finding out whether it was the insurance or some other source (he suspected a wealthy brother) that was paying for his incarceration. He had been intent on canceling his insurance. Sohrab Hassan, though undergoing a trial on state psychiatric coercion, was receiving services at a private psychiatric hospital, so the availability of funds lurks as a likely determining factor in the hospital's precipitous decision to release him.
The next two reasons go right to the heart of coercive psychiatry. One, Mr. Hassan has proven an effective, litigious fighter, and the hospital and doctor have reason to be concerned about further legal action. As Tom Szasz aptly observed in a speech last year, "Doctors use pathologists to prove disease; psychiatrists use lawyers." To see clearly the fundamental violation of civil rights inherent in the fusion of psychiatry and the law, consider simply that a fundamental tenet of United States law is the principle that a citizen is "innocent until proven guilty." The case of Sohrab Hassan is one instance of an ongoing universal perversion of this sacred right; in our country's mental health courts, the citizen, now defined as a mentally ill patient, is "guilty until proven innocent." That is a tough charge, given a setup in which the very effort to prove such "innocence" is considered the psychiatric symptom of denial of the alleged illness. The final reason to release Mr. Hassan: psychiatry is bereft of genuine care alternatives.
- Szasz, T.S. (1993) A Lexicon of Lunacy: Metaphoric Malady, Moral Responsibility, and Psychiatry New Jersey: Transaction Publishers, p 1.
- Szasz, T.S. (1982) "On the Legitimacy of Psychiatric Power," Metamedicine, vol. 3.
- Szasz, T.S. (1993) A Lexicon of Lunacy: Metaphoric Malady, Moral Responsibility, and Psychiatry, New Jersey:
- Transaction Publishers, p 155.
- Szasz, T.S. (1963) Law, Liberty, and Psychiatry: An Inquiry into the Social Uses of Mental Health Practices, New York: Anchor Books, p 13.
- Viscott, D.S. (1972) The Making of a Psychiatrist, 26, 1972, p. 352.