Tag Archives: Thomas Szasz

12/13/16

The Vicious Spiral of Suicidality

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A study published in the November 2016 issue of JAMA Psychiatry suggested that patients were at an increased risk of suicide during the three months immediately following their discharge. They were fifteen times more likely to commit suicide than similarly matched patients who were treated for non-mental health issues. Individuals without any outpatient care in the months before their hospitalization were at an even higher risk. Individuals diagnosed with depressive disorders were at the highest risk, followed by those with bipolar disorder and then schizophrenia.

The lead author of the study, Mark Olfson, was interviewed on the JAMA network about the study. He said one of the limitations of the study was it didn’t have the level of detail to get at why depression and depressive disorders were the highest short-term risk of suicide. However, he speculated that since one of the symptoms (diagnostic criteria) for depression was related to suicide, and many individuals are hospitalized because of suicide attempts or suicide risk, this is “probably what conveys their short-term risk of suicide following hospitalization discharge.” He added that effective approaches to suicide risk reduction should involve strengthening a patient’s connectedness, reducing social isolation, and engaging them in outpatient care. In his review of the study for Mad in America, Justin Karter quoted the study authors as saying:

These patterns suggest that complex psychopathologic diagnoses with prominent depressive features, especially among adults who are not strongly tied into a system of care, may pose a particularly high risk. As with many studies of completed suicide, however, the low absolute risk for suicide limits the predictive power of models based on clinical variables. These constraints highlight the critical challenge of predicting suicide among recently discharged inpatients based on readily discernible clinical characteristics.

The association of suicide risk and hospitalization has been evident in previous studies. For example, a 2005 study reported in the Archives of General Psychiatry, found there were two sharp peaks of suicide risk around psychiatric hospitalization. There were during the first week after admission and in the first week after discharge. The length of hospitalization was also a factor, with individuals receiving less than the median length of stay having a significantly higher risk. The study also confirmed previous reports that prior admission to a psychiatric hospital is also associated with a higher risk of suicide.

This study, to our knowledge, is the first to explore how suicide risk differs by diagnosis across the phase of psychiatric hospitalization. We find that affective disorders increased the risk for suicide the strongest across all phases of time since hospitalization compared with other diagnostic groups. We also find that affective and schizophrenia spectrum disorders tend to have a more intensive effect on the risk of suicide, whereas substance abuse disorders have a more prolonged effect on the risk of suicide.

In an article for the website, Speaking of Suicide, Stacey Freedenthal cited the recommendation by David Rudd, a nationally known suicide expert, who recommended initially seeing an individual at least twice in the week after discharge. The elevated risk of suicide after hospitalization was not necessarily related to a premature discharge. Referencing David Rudd, she said:

Instead, suicidal intent is fluid, impossible to predict from one moment to the next, let alone day-to-day. Of course, whatever led to hospitalization in the first place, whether a suicide attempt, mental illness, or some other crisis, places a person at higher risk than normal for suicide.

However, there was a 2014 study reported in Social Psychiatry and Psychiatric Epidemiology that found psychiatric admission in the previous year was highly associated with completed suicide. “Furthermore, even individuals who have been in contact with psychiatric treatment but who have not been admitted are at highly increased risk of suicide.” The authors said the relationship was one of association, rather than causation. “People with increasing levels of psychiatric contact are also more severely at risk of dying from suicide.”

An editorial in the same issue by Large and Ryan said that compared to those who had no psychiatric treatment in the previous year, those who received medication were 5.8 times the risk of suicide; those with at most outpatient psychiatric treatment had 8.2 times the risk; patients with emergency department contact without an admission had 27.9 times the risk; and admitted patients had 44.3 times the risk of suicide. These ratios were after controlling for other risk factors.

The strongest risk factors for suicide after discharge were: prior suicide attempts and depressive symptoms. Additional risk factors include: hopelessness, worthlessness, guilt and a family history of suicide. Large and Ryan said they believed it was likely that a proportion of individuals who suicide during or after an admission to hospital do so because of factors inherent in the hospitalization. They argued that such suicides should be considered as “nonsocomial”—acquired in a hospital.

There was a significant positive correlation between a PTSD diagnosis and suicidality in a study by Panagioti, Gooding, and Tarrier. Comorbid major depression was a compounding risk factor. The association of suicidality and PTSD persisted across “studies using different measures of suicidality, current and lifetime PTSD, psychiatric and nonpsychiatric samples, and PTSD populations exposed to different traumas.”  Another study of national suicide rates in 25 European countries concluded that stigma towards persons with mental health problems could influence suicide rates within a country. The authors hypothesized that possible mechanisms could include stigma as a stressor, or social isolation as a result of stigma. Large and Ryan said:

There is now little doubt that suicide is associated with both stigma and trauma in the general community. It is therefore entirely plausible that the stigma and trauma inherent in (particularly involuntary) psychiatric treatment might, in already vulnerable individuals, contribute to some suicides.

So it seems there is a vicious spiral with suicidality. Together, depression and suicidality may lead to hospitalization, which itself is a risk factor for suicide. Hospitalization, particularly when it is involuntary, can lead to stigma and trauma, which exacerbates feelings of worthlessness and hopelessness—-themselves further risk factors in suicide.

How then do we help the chronically depressed and suicidal person? Perhaps the place to start is by not harming them any further. We need to recognize and minimize the potential for stigma and trauma from hospitalization. We need to address feelings of helplessness and worthlessness from very beginning of any contact with a depressed and suicidal person. In Cruel Compassion, as he reflected on how to avoid further harm with chronic mental patients, Thomas Szasz gave the following quote of C.S. Lewis that I think is helpful here.

Of all the tyrannies a tyranny sincerely exercised for the good of its victim may be the most oppressive. . . . To be “cured” against one’s will and cured of states which we may not regard as disease is to be put on a level with those who have not yet reached the age of reason or those who never will; to be classed with infants, imbeciles, and domestic animals. . . . For if crime and disease are to be regarded as the same thing, it follows that any state of mind which our masters choose to call “disease” can be treated as a crime and compulsorily cured. . . .Even if the treatment is painful, even if it is life-long, even if it is fatal, that will be only a regrettable accident; the intention was purely therapeutic.

Szasz went on to add:

To help the unwanted Other, we must therefore first relinquish the quest to classify, cure and control him. Having done so, we can try to help him the same way we would try to help any person we respect—asking what he wants and, if his request is acceptable, helping him to attain his goal or accept some compromise.

10/28/15

Positively NOT Psychiatry

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© lightwise | 123RF.com

Positive psychiatry is a growing phenomenon within the profession of psychiatry. And Dr. Dilip Jeste, a former APA President, seems to be the primary “evangelist” for the positive psychiatry movement. The theme for his year as APA President in 2012 was: “Pursuing Wellness Across the Lifespan.” He said positive psychiatry was the future of psychiatry.  In a Psychiatric News article for June of 2012, Jeste said: “I believe that, as the medical field begins to appreciate the value of positive psychosocial factors in the prevention and management of pathology, positive psychiatry will increasingly take a central stage within medicine and health care.”

David Rettew, a child psychiatrist, wrote of his invitation by Dr. Jeste, to speak at a symposium on Positive Psychiatry at the 2015 annual conference of the American Psychiatric Association (APA) held in Toronto. He was excited by the opportunity and sees positive psychiatry as an opportunity for his profession to become “physician experts in mental health,” as opposed to their current emphasis on mental illness. Dr. Rettew noted that for too long, psychiatry has had two primary interventions: psychotherapy and medications. “Expanding our efforts into domains of wellness gives us so many more avenues to help children and families thrive.”

Jeste is also one of the editors of Positive Psychiatry: A Clinical Handbook, which was just released in June of 2015. Dr. Rettew is one of the contributing authors to that work. Jeste, Barton Palmer (co-editor of Positive Psychiatry), Rettnew, and Samantha Boardman (contributor to Positive Psychiatry) coauthored an article in the June 2015 issue of the Journal of Clinical Psychiatry, “Positive Psychiatry: Its Time Has Come.” They noted how psychiatry has traditionally focused on the diagnosis and treatment of mental illnesses. However, trying to find what causes mental illness and developing “safe and effective treatments” has not been enough to fulfill “the enormous potential of psychiatry to promote human welfare.”

The time has come to integrate positive mental health into psychiatric practice, training, and research and to expand psychiatric expertise to encompass the full spectrum of mental functioning.

Instead of an emphasis on managing mental disorders, Jeste et al. said positive psychiatry is a science and clinical practice that seeks to promote well-being through “assessment and interventions aimed at enhancing behavioral and mental wellness.” As a branch of medicine, positive psychiatry is rooted in biology and seeks to decipher the biological underpinnings of positive psychosocial characteristics (PPCs). “And eventually promote health and well-being through psychosocial/behavioral and biological interventions.“

Positive psychiatry traces its immediate influence to the positive psychology movement that was pioneered by Milton Seligman in the later 1990s. In his presidential address to the American Psychological Association in 1998, he called for “a reoriented science that emphasizes the understanding and building of the most positive qualities of an individual.” These qualities include: optimism, courage, work ethic, future-mindedness, interpersonal skills, the capacity for pleasure and insight, and social responsibility. Similarly, Jeste et al. pointed to how a growing body of research shows that higher levels of PPCs, such as resilience, optimism, and social engagement are associated with objectively measured better health outcomes. You can watch a TED talk given by Seligman, “The New Era of Positive Psychology,” where he describes positive psychology.

Possible biomarkers for positive mental health were noted by Jeste et al. They were: allostatic load, telomere length, oxidative stress, neuroinflammation and immune function. The authors then ran through the “association” of several positive psychological characteristics (PPCs) with biological factors. Jeste et al. believed that by strengthening the development of positive traits through psychotherapeutic, behavioral, social and biological interventions, “positive psychiatry has the potential to improve health outcomes and reduce morbidity as well as mortality.”

Instead of being narrowly defined as a medical subspecialty restricted to the management of mental illnesses, psychiatry of the future will develop into a core component of the overall health care system. Psychiatrists will thereby more explicitly reclaim their role as physicians in addition to their roles as mental health professionals. Clearly, much more work is needed to make positive psychiatry a norm in psychiatric practice, but it is time to start that process.

I’m troubled by the rhetoric of the so-called “positive psychiatry” movement. On the one hand, it is encouraging to hear an eminent psychiatrist like Dr. Jeste call for attention and research into positive psychological traits. Psychiatry has concentrated on the prevention and management of pathology, while it largely ignored positive psychological traits like resilience, optimism and self-efficacy and how important they are in preventing and managing pathology. This next quote, taken from the Jeste et al. article, succinctly captures both what encourages me and sends chills up my spine: “The time has come to integrate positive mental health into psychiatric practice, training, and research and to expand psychiatric expertise to encompass the full spectrum of mental functioning.”

The time has come to consider positive mental health in psychiatry. However, the expansion of psychiatric “expertise” and the authority that will accompany such expertise in modern society is not a positive outcome for society. It has disturbing social and political dimensions that were foreseen and noted by psychiatrist Thomas Szasz over fifty years ago. In his 1977 work, The Theology of Medicine, he said:

In the scientific-technological concept of the state, therapy is only a means, not an end: the goal of the therapeutic state is universal health, or a least unfailing relief from suffering. The untroubled condition of man and society is a quintessential feature the medical-therapeutic perspective on politics: conflict among individuals, and especially the individual and the state, is invariably seen as a symptom of illness or psychopathology; and the primary function of the state is accordingly the removal of such conflict through appropriate therapy—imposed by force if necessary. (Thomas Szasz, The Theology of Medicine, p. 128)

If we value personal freedom and dignity, we should, in confronting the moral dilemmas of biology, genetics, and medicine, insist that the expert’s allegiance to the agents and values he serves be made explicit and that power inherent in his specialized knowledge and skill not be accepted as justification for his exercising specific controls over those lacking such knowledge and skill. (Thomas Szasz, The Theology of Medicine, p. 17)

It seems that within “positive psychiatry,” psychiatrists are seeking to not only maintain their hegemony over preventing and managing pathology, but expand it to “encompass the full spectrum of mental functioning.” There has been a growing concern with the failed promises of psychiatry, such as the identification of biological or genetic cause in the “mental illness.” Critiques of DSM diagnosis have come from within psychiatry from individuals such as Allen Frances and Thomas Insel. Frances was the chair for the DSM-IV. Insel is the Director of the National Institute of Mental Health (NIMH). In Saving Normal, Frances’s critique of the DSM-5 and the medicalization of everyday life, he said: “Unfortunately, the DSM approach has been far too influential—dominating the field in a way we never intended.” Insel announced before the publication of the DSM-5 that the NIMH would be “reorienting its research away from DSM categories” (see “Psychiatry Has No Clothes”).

It was encouraging to hear Dr. Rettew acknowledge how psychiatry has been having an identity crisis. He alluded to the dominance psychiatry had as “skilled therapists” when it was ruled by psychoanalytic thought. But there is another way to see the consequences of the “explosion of neuroscience” and the “promise of medications.” Just as the reliability and validity of psychiatric diagnosis was effectively questioned, and from within and outside psychiatry, and psychiatrists faced losing their social status and power, they reframed diagnosis along purely biological guidelines and aligned themselves with the pharmaceutical industry.

As Rettew said: “Recent research has revealed that many of the risks of medications may have been under appreciated while the benefits somewhat overblown.”  He noted how neuroscience research has been impressive, but lacking immediate clinical applications. Despite the promise that these results may eventually help improve early identification and facilitate effective treatment with a variety of disorders, “in reality there remains a large number of dots to connect before that actually happens.”

Positive psychiatry seems to be about maintaining hegemony in the face of another serious challenge to its authority. It is not humbly admitting the limitations of a purely biochemical explanation for human behavior, it’s just “kicking the can” of research further down the road. The reductionism of the medical model is still at the heart of how positive psychiatry views psychopathology. Biology is still the “root” of positive psychiatry. Jeste et al. said:

As a branch of medicine, positive psychiatry is rooted in biology and seeks to decipher biological underpinnings of PPCs [positive psychosocial characteristics] and eventually promote health and well-being through psychosocial/behavioral and biological interventions.

Jeffery Liebeman, the president of the APA immediately after Dr. Jeste, has published a book, Shrinks, that purports to tell the story of how psychiatry overcame its dubious past. Lieberman seems more willing to acknowledge the still dominant medical model in psychiatric diagnosis and treatment.  With regard to the field of psychiatry, he said: “Ever since the very earliest psychiatrists began conceiving of disturbed behaviors as illnesses (and even long before), they held out hope that direct manipulation of a patient’s brain might one day prove therapeutic” (Shrinks: The Untold Story of Psychiatry, p. 160).  With regard to diagnosis, he said: “The DSM-III turned psychiatry away from the task of curing social ills and refocused it on the medical treatment of severe mental illnesses.” (Shrinks, p. 147)

Research into the impact of positive psychological characteristics on mental functioning and psychopathology is certainly a good thing, but it is positively NOT psychiatry that should have a controlling, leading role in that research. Its seemingly positive and hopeful view of the future is based upon seeing humanity as biological machines. While I don’t think this would lead to the dystopian future, like that portrayed in the Terminator movies, the rise of the biological machine would be just as apocalyptic.  For an alternative way of doing psychiatry, see “Psychiatry Is Not Neurology.”

09/23/15

Psychiatry Is Not Neurology

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© Lightsource |stockfresh.com

Psychiatry is not neurology; it is not a medicine of the brain. Although mental health problems undoubtedly have a biological dimension, in their very nature they reach beyond the brain to involve social, cultural and psychological dimensions. These cannot always be grasped through the epistemology of biomedicine. The mental life of humans is discursive in nature.

Wow. I want to get in contact with a psychiatrist in the Pittsburgh area who believes and practices their profession consistent with this position. The article from which I took the opening quote, “Psychiatry beyond the current paradigm,” is reminiscent of Thomas Szasz, who presented his argument that mental illness was a myth in his seminal book, The Myth of Mental Illness. His original article of the same title, “The Myth of Mental Illness,” is available on the website, Classics in the History of Psychology.

Szasz said that the notion of mental illness assumed that there was some neurological defect, “perhaps a very subtle one,” behind all disorders of thinking and behavior. “The crux of the matter is that a disease of the brain, analogous to a disease of the skin or bone, is a neurological defect, and not a problem in living.” Pat Bracken et al., who wrote “Psychiatry beyond the current paradigm” for The British Journal of Psychiatry, were more nuanced. They acknowledged the undoubted biological dimension in mental health problems, but also admitted the reality of other dimensions beyond the grasp of “the epistemology of biomedicine.” They believe the biomedical dimension should be a secondary—not the primary—consideration in psychiatry.

A “biomedical idiom” has guided psychiatry’s understanding of mental health problems. Problems with feelings, thoughts, and behaviors were thought to be capable of exploration and understanding just like our livers and lungs. The scientific tools and methods used to investigate problems with biological life would help unlock the secrets of mental life. In recent decades, even models of cognitive psychology have been developed to work within this “technological paradigm.” Its main assumptions made are:

  • The problem to be addressed is that of a faulty mechanism in the individual.
  • The mechanism or process can be modeled in causal terms; it can be described in a universal way that works regardless of the context.
  • Technological interventions are instrumental.

In the technological paradigm, mental health problems can be mapped and categorized with the same causal logic used in the rest of medicine, and our interventions can be understood as a series of discrete treatments targeted at specific syndromes or symptoms. Relationships, meanings, values, cultural beliefs and practices are not ignored but become secondary in importance. This order of priorities is reflected in our understanding of the training needs of future psychiatrists, what gets published in journals, what topics are selected for analysis at conferences, [and] the types of research that are promoted.

Bracken et al. said the overall evidence did not support the idea that mental health problems were best understood through this technical paradigm. While medical knowledge was relevant, “the problems we grapple with cry out for a more nuanced form of medical understanding and practice.” Psychiatrists need to develop an approach to mental health problems that is genuinely sensitive to the interplay of forces (biological, psychological, social and cultural) that underlie them.

Pat Bracken said in a lecture he gave at the University of Copenhagen in 2012, that: “The realm of mental health is one area of human life that cannot be grasped in a purely technical way.” He argued that psychiatry is very much a product of the cultural shift brought on by the Enlightenment. Without the Enlightenment, Bracken believes we would not have the discipline of psychiatry as it exists today. The attention to unreason, came as a byproduct of the Enlightenment emphasis on rationality or reason. It also gave rise to the isolation and confinement of the “mentally ill.”

As a result, they became the subject matter for the new discipline to study, theorize and treat. There could now be a “science” of madness and distress, with its own experts and authorities. The new medical specialty sought to frame all its problems within a modernist, scientific and technical idiom. This grew to become the technological paradigm of psychiatry. Now it’s the dominant paradigm of psychiatry and mental health. “It underscores not just the medical model in psychiatry, but many of the alternatives being argued for at present.”

This technological approach is the foundation of the medical model of psychiatric “disease,” some of the psychological approaches to mental health, and positivist forms of social science. The only questions asked by this approach are: does it work; is it efficient; and is it cost effective. The technological paradigm shapes the classification systems of mental health problems (the DSM-5 and the ICD-10), the research into mental health problems, and the delivery system of clinical care. This is particularly true in the concept of “evidence-based medicine,” which has become the standard for many aspects of clinical care. Looking for a specific technical “fix” for a condition pushes the less technical issues to the periphery. They are still acknowledged, but are seen as secondary issues or causes.

In an article published in the journal World Psychiatry, Bracken detailed how psychiatry is currently going through a crisis of confidence. He argued the need for a hermeneutical shift in psychiatry. And if it is to be truly “evidence-based,” psychiatry needs to radically rethink its guiding epistemology, namely that of the technological paradigm. “We need a radical rethinking of our guiding epistemology: a move from reductionism to hermeneutics.” He rejected the heralded Research Domain Criteria (RDoC) project (see “Psychiatry Has No Clothes;” or “Psychiatry’s Mythical Phoenix;” or “The Quest for the Holy Grail of Psychiatry”) as a “quintessentially technological view of the future” that conceptualizes mental illnesses as brain disorders. He believes such an approach is simply inadequate.

Good psychiatry, he contends, involves a “primary focus on meanings, values and relationships,” both in terms of how patients are helped and where their problems come from. When the word “mental” is put in front of the word “illness,” it demarks “a territory of human suffering that has issues of meaning at its core. This simply demands an interpretive [hermeneutical] response.”

I do not believe that we will ever be able to explain the meaningful world of human thought, emotion and behaviour reductively, using the “tools of clinical neuroscience”.  This world is simply not located inside the brain. Neuroscience offers us powerful insights, but it will never be able to GROUND a psychiatry that is focused on interpretation and meaning. Indeed, it is clear that there is a major hermeneutic dimension to neuroscience itself. A mature psychiatry will embrace neuroscience but it will also accept that “the neurobiological project in psychiatry finds its limit in the simple and often repeated fact: mental disorders are problems of persons, not of brains. Mental disorders are not problems of brains in labs, but of human beings in time, space, culture, and history.”

Pat Bracken has an intriguing background. Not only is he a clinical psychiatrist, he also has a Ph.D. in philosophy. His thoughts can be found in various places online. Here is a link for “Bracken” on Mad in America. He helped found the UK division of the International Critical Psychiatry Network (ICPN). He’s co-written Postpsychiatry: A New Direction for Mental Health. Currently he is the Clinical Director of the Mental Health Service in West Cork, Ireland. Sadly he lives too far away to consult on cases in the Pittsburgh area.

08/27/14

In Pharmakon We Trust

Christina and her husband, Sonny, separated in July of 2013. During a visit on December 18th,—his daughter’s birthday—Sonny strangled his 14 year-old son and then hung himself.  Sonny and Gunnar’s bodies were found in his apartment by Sonny’s girlfriend.  On December 19th Christina kept a previously scheduled appointment with a psychiatrist who she had been seeing for a couple of weeks.

BEFORE her appointment at the University Health Center, Christina’s doctor had placed the University of Vermont police on standby to take her into custody if she refused to admit herself to the psych unit in Fletcher Allen, the UV affiliated medical center. She did decline, so she was detained. A UVM police report showed that there was a delay of several hours before the officers could transport Christina to Fletcher Allen because the mental health staff didn’t have the proper paperwork to legally transport her! Five weeks later, Christina was finally released.

Justina Pelletier suffers with a rare disorder—mitochondrial disease. In February of 2013, at the recommendation of her doctor, she was taken to Boston Children’s Hospital by her mother.  Justina’s gastroenterologist had recently moved there from Tufts. The team at Children’s disputed the mitochondrial disease diagnosis and concluded Justina suffered from somatoform disorder—a psychiatric disorder in which symptoms are real, but have no underlying cause. Some reports indicated this re-diagnosis was first made within a matter of hours or minutes of Justina’s arrival at Children’s and was done without consultation with her treating physicians.

When her parents tried to have her discharged from Boston Children’s, the hospital contacted DCF, who took custody of Justina and accused her parents of medical child abuse. Justina remained a ward of the state until June 18, 2014. Most of that time she spent on a locked psychiatric ward. While in state custody, Justina only saw her family once per week for a supervised hour of visitation and spoke with them once a week on the phone.

In his essay, “Strategies of Psychiatric Coercion,” Jeffrey Schaler commented that treatment providers forcibly “treat” people they consider to be a danger to themselves or others in the name of compassion and care. In effect, psychiatrists and mental health professionals empowered by the state to commit someone involuntarily to a psychiatric hospital argue that the person is a child. Although not literally a child, he is a metaphoric child. “He does not, in their opinion, exercise responsibility for himself because he cannot do so.”

The coercion is supposedly done to protect him from himself. He “needs” to be deprived of his constitutional rights in the name of treating his “mental” illness. And the more a person objects to being coerced into treatment, “the more likely he is to be diagnosed with serious mental illness.”

Los Angeles recently decided to expand a pilot program from 20 to 300 slots that will allow a family member, treatment provider or law enforcement officer to pursue court-ordered outpatient treatment for individuals with serious mental illness. “Those who don’t comply can be taken into custody on a 72-hour psychiatric hold. Patients can’t be forced to take medication under law, but there are other mechanisms for court-ordered medication.”

In his 1963 book, Law, Liberty and Psychiatry, Thomas Szasz predicted the birth of what he called the therapeutic state: “Although we may not know it, we have, in our day, witnessed the birth of the Therapeutic State. This is perhaps the major implication of psychiatry as an institution of social control.” He even went further and coined a new term for this union of psychiatry and the state: pharmacracy.

Inasmuch as we have words to describe medicine as a healing art,  but have none to describe it as a method of social control or political rule, we must first give it a name. I propose that we call it pharmacracy, from the Greek roots pharmakon, for ‘medicine’ or ‘drug,’ and kratein, for ‘to rule’ or ‘to control.’ … As theocracy is rule by God or priests, and democracy is rule by the people or the majority, so pharmacracy is rule by medicine or physicians.

I don’t think we are a therapeutic state … yet. We aren’t a pharmacracy … yet. But I do think we need to be aware of the warnings given by Thomas Szasz. If you need more information before you decide whether the United States is in danger of becoming a therapeutic state, spend some time on the following websites:

PsychRights

Mad in America

ToxicPsychiatry

By the way, a UN report thinks that forced psychiatric treatment is torture:

Deprivation of liberty on grounds of mental illness is unjustified. Under the European Convention on Human Rights, mental disorder must be of a certain severity in order to justify detention. I believe that the severity of the mental illness cannot justify detention nor can it be justified by a motivation to protect the safety of the person or of others. Furthermore, deprivation of liberty that is based on the grounds of a disability and that inflicts severe pain or suffering falls under the scope of the Convention against Torture.