Table Of ContentMen in White Coats
Men in
White Coats
Treatment Under
Coercion
George Szmukler
Emeritus Professor of Psychiatry and Society
Institute of Psychiatry, Psychology and Neuroscience
King’s College London, UK
1
1
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Acknowledgements
The ideas in this book have had a long gestation, during which they have
been influenced by far too many people for to all be named here. Indeed,
there have been many whose names I don’t even know. In the course of my
involvement in numerous lectures, seminars, workshops, and discussions
during conference coffee- breaks, many people, from a range of disciplines,
by sharing their thoughts with me and through their criticisms have helped
me enormously to develop my ideas. I am furthermore extremely grate-
ful to the large number of patients (or ‘service users’ as they are known
in the United Kingdom) for their interest in my proposals and for their
forthright views on coercion. Here I must mention especially Diana Rose
at the Institute of Psychiatry, and the many service user collaborators in
the Mental Health Research Network, who, not being my patients and
through our relationship as colleagues, were able to speak openly about
their experiences. This could be extremely discomforting for me (and even
more so for them) but I appreciate their frankness. I must also mention
Mark Lockyer for his powerful dramatization of the experiences of being
coerced and bringing home to a wider audience their gravity, their pain,
and sometimes (I hope often) their value.
Frank Holloway and Paul Appelbaum were most helpful in the earlier
phases of my work and forced me to think through some basic questions.
Paul continues to be helpfully probing in his questioning whenever we
meet. I am enormously indebted to John Dawson for insisting that my
ideas make sense from a practical legal point of view and for our joint work
on the ‘Fusion Law’ proposal. We were then joined by Rowena Daw who
also demanded the rigor necessary for drafting key sections of a Fusion
Law. She also brought a huge experience in disability and discrimination
policy and law.
Genevra Richardson has been a huge influence ever since she became a
colleague at King’s College London. We first made contact when she was
the chair of the Expert Committee set up in 1998 to advise the govern-
ment on reform of mental health law in England and Wales. ‘Capacity’ has
been an endless subject of discussion for us ever since. She has been very
important to me.
vi ACKNowLEdGEmENtS
Numerous psychiatrist colleagues have engaged in stimulating discus-
sion and debate with me concerning a ‘Fusion Law’. I am grateful to them
for this. My closest colleagues, particularly in work on the concept of
‘decision- making capacity’, have been Gareth Owen, Matthew Hotopf, and
Tony David. They have pushed me hard to justify a capacity- based mental
health law, and perhaps by now they are more or less convinced. Graham
Thornicroft, Claire Henderson, Kim Sutherby, and Simone Farrelly have
been valued colleagues, especially in relation to work on ‘advance state-
ments’ in mental health care. Tony Holland has always been a valuable
source of advice.
I have benefited enormously from many discussions with Jonathan
Glover, Wayne Martin, Tania Gergel, Natalie Banner, Jill Craigie, and
Derek Bolton. These philosophers have, I hope, sharpened my ability to
deal with some of the complex concepts I have struggled with in formulat-
ing my ideas. Similarly, when it comes to the law, in addition to Genevra,
Peter Bartlett, Jill Peay, Alex Ruck Keene, and Lucy Series have been
important guides and critics. Peter Jackson has given me valuable insights
into the perspective of a judge.
Michael Bach, Oliver Lewis, and Felicity Callard have helped me to
understand the finer points of the United Nations Convention on the
Rights of Persons with Disabilities as well as its significance in non-
Western countries. Few people have had a deeper involvement in the study
of abuses of psychiatry than Robert van Voren; his accounts have left an
indelible impression on me.
Nikolas Rose and Diana Rose have been my ever- present guides to the
sociology of psychiatry, particularly in illuminating for me the less obvious
ways in which power can be exercised.
I am especially grateful for the support and comments from a number
of friends, in the role of ‘intelligent lay- persons’, who have read various
versions of the manuscript: Jo Wodak, Faye Crossman, Zellman Warhaft,
Bob Weiss, Denise Asen, Eia Asen, and Jennie McDonnell. Tania Gergel,
Jonathan Glover, and Gareth Owen have also been kind enough to look at
the manuscript.
Peter Stevenson at Oxford University Press has been most supportive of
the book.
I must express my gratitude to two people, who while not involved in
work directly relevant to this book, have nevertheless had a lasting influ-
ence on my approach to psychiatry and to research. Sid Bloch was impor-
tant in stimulating my interest, going back to my medical student days, in
the potential of psychiatry as a tool of social control; Gerald Russell was
an important mentor, always insisting on an unsparing meticulousness in
ACKNowLEdGEmENtS vii
psychiatric research as well as aiming for absolute clarity in writing. Even
today, often when I write, I imagine him sitting at my elbow, critically scru-
tinizing every sentence.
Finally, I thank my wife, Linnet, for graciously putting up with my end-
less preoccupation with, and ramblings about, ‘coercion’. At times I’m sure
she must have feared I was afflicted with an ‘idée fixe’.
Contents
Introduction xv
Involuntary treatment xvi
Justifying compulsion xvii
Questioning the orthodoxy xix
Discrimination xxi
A solution xxii
Treatment pressures and ‘coercion’ xxiv
A few explanations xxv
The title of this book xxv
How the book is structured xxvi
Part I The problem
1 A practice with a very long history 3
Reasons for detention: ‘plus ça change’ 5
The routine, accepted criteria: ‘mental disorder’ and
‘risk of harm’ 8
Do two centuries of no change mean no change is required? 8
A better explanation for the lack of change 11
The ‘shadow of coercion’ 13
References 14
2 Some troubling observations about involuntary
treatment 17
Disturbing statistics on variation by place and time 17
An unfortunate history of abuse, misuse, or mistreatment 20
Psychiatry as an instrument to control threats to
the social order 20
Mistreatment due to misplaced therapeutic confidence 25
Race, ethnicity, minority status, and involuntary treatment 28
References 30
