A Dialogue between Vatsal Thakkar and Jeffrey Schaler

[I am very grateful to Professor Vatsal Thakkar for kind permission to reproduce our recent dialogue. Please do not reproduce without a link to this post on The Szasz Blog. Thank you.– JAS}

----- Original Message -----
From: Thakkar, Vatsal
To: jschale@american.edu
Sent: Thursday, August 04, 2005 6:07 PM
Subject: feedback on your article

Dr. Schaler,

I just read your piece in The Conservative Voice. I don't think that most people would argue that abuses in psychiatry do occur, especially around commitment and forcible restraint and med administration. I am against this. I have talked other doctors, even superiors, OUT of committing patients. But to say that there is NO place for these interventions is foolhardy, since there has existed a severely mentally ill population since the beginning of recorded history. If we can't find a medical etiology in a patient who presents with symptoms of psychosis, unruly behavior, and no ability to care for themselves, what do you suggest we do with them?

I agree with Dr. Szasz on issues like the one above and certain aspects of his views of illegal drugs. However, Tom Cruise basically takes an all or nothing approach and claims all of psychiatry is a sham. Then a fine Ph.D. like yourself appears to defend him in your article. Then the reader of your article will view this debate as more akin to one about politics or religion rather than medicine or science. Then they will refuse to get help for symptoms for themselves or loved ones and that will be a tragedy.

Vatsal Thakkar, M.D.
Assistant Professor, Psychiatry
Vanderbilt University School of Medicine
vatsal.thakkar@vanderbilt.edu

-----Original Message-----
From: Jeffrey A. Schaler [mailto:jschale@american.edu]
Sent: Thu 8/4/2005 6:18 PM
To: Thakkar, Vatsal
Subject: Re: feedback on your article

Dear Dr. Thakkar,

Thanks very much for your letter, which I appreciate. You write: "But to say that there is NO place for these interventions is foolhardy, since there has existed a severely mentally ill population since the beginning of recorded history. If we can't find a medical etiology in a patient who presents with symptoms of psychosis, unruly behavior, and no ability to care for themselves, what do you suggest we do with them?"

I believe your reasoning is unsound. The fact that there has existed a population of people you and others label "severely mentally ill . . . since the beginning of recorded history" is irrelevant to the issue at hand, namely, whether psychiatrists as extensions and agents of the state should have the power to deprive innocent persons of liberty without due process of law. This is not a medical or scientific issue. It is a constitutional issue. * Institutional psychiatrists have absolutely no right to deprive innocent persons of liberty because you think they will harm themselves or others. Study the difference between the rule of law and the rule of man.

We cannot predict who will commit a crime with an accuracy beyond that expected by chance. Two things are necessary for criminal guilt: mens rea and actus reus. If there is no actus reus, there is no crime. On what basis do you think you have the right to deprive a person of liberty? Because you think he or she will commit a crime? The US Constitution does not say at the end, "PS: For mentally healthy people only."

Real doctors do not treat people against their will. If a person does not want to be treated by you, he or she has every right to refuse "treatment." What you are advocating has nothing to do with science or medicine. It has everything to do with social control. Even if you could find a lesion in the brain of a person who presents with symptoms of psychosis, that still does not justify depriving that person of liberty or "treating" him against his will.

You ask, "what do you suggest we do with them?" My reply: Nothing. You leave them alone. If they want help, you and others who want to help such a person may help them. If they break the law, they go through the criminal justice system. Otherwise, you leave them alone. A person has the right to refuse treatment for kidney failure, for lung cancer, etc. You are not being an ethical physician when you treat someone against his or her will. You are being a jailer. Trying to justify or legitimize depriving a person of liberty in the name of medicine and science is no excuse. You know that has nothing to do with science and medicine. You say it has something to do with science and medicine because you know what you're advocating is wrong. It goes against your sworn oath as a physician.

You continue, writing "I agree with Dr. Szasz on issues like the one above and certain aspects of his views of illegal drugs. However, Tom Cruise basically takes an all or nothing approach and claims all of psychiatry is a sham. Then a fine Ph.D. like yourself appears to defend him in your article. Then the reader of your article will view this debate as more akin to one about politics or religion rather than medicine or science. Then they will refuse to get help for symptoms for themselves or loved ones and that will be a tragedy."

Tom Cruise has every right to say what he wants to say. Would you deprive him of his freedom of speech? Many physicians think that psychiatry is a sham, and you know it. Many psychiatrists think it is a sham. The numbers of people doing their residencies in psychiatry is going down for good reason: Medical students know that psychiatry is a sham. Psychiatry has little to do with science and medicine. Why do you think the suicide rates are so high among psychiatrists? A bad investment.

You write "the reader of your article will view this debate as more akin to one about politics or religion rather than medicine or science." You know very well that the debate has precious little to do with medicine. Psychiatrists diagnose on the basis of symptoms, not signs. They treat people against their will, not by consent. They confuse theories with facts: There is no known lesion that causes "schizophrenia." Giving people drugs that change the way they feel and behave doesn't treat a neurochemical imbalance, and you know it.

When you, a psychiatrist, write that depriving people of liberty is science and medicine YOU are mistaking politics and religion for science and medicine. You are not telling the truth. Depriving people of liberty when they've committed no crime has little to do with science and medicine. Again, you know that very well. If people refuse to get help, that is their choice. You would do well to respect their wishes. If people want to see a psychiatrist, by all means they should be free to do so, just as they should be free to see a homeopath, an astrologer, or a chiropractor.

I suspect that if involuntary commitment and the insanity defense were abolished, psychiatry as a profession would collapse. People know psychiatry is fraud, that's why they don't like psychiatrists. Psychiatrists know that psychiatry is fraud, that's why so many of them commit suicide. How many cardiologists do you hear saying that heart disease is a real disease, based in science, over and over again? How many cardiologists deprive people of liberty in the name of "science and medicine"?

I've spoken and corresponded with a good number of psychiatrists such as yourself over the years and I know it is difficult to admit that you've made a tremendous mistake with your medical career by specializing in psychiatry. Not only is it based in junk science, it has very little to do with medicine. You have a choice: practice psychiatry on a purely consensual basis, or go back and specialize in some other area of medicine, a branch of medicine that does no harm to people in the name of treating them. That is, every other branch of medicine besides psychiatry.

Reconsider your position, Dr. Thakkar. You've no right to interfere in the lives of others who want nothing to do with you. It takes courage for you to see that in yourself. Look inside. Be brave.

Tom Cruise upset so many people such as yourself because what he said was right. Here, a layman, a movie star, knows more about science and medicine than psychiatrists. Pathetic.

Professor Jeffrey A. Schaler
Department of Justice, Law and Society
School of Public Affairs
American University
Washington, D.C.
jeffschaler@attglobal.net

----- Original Message -----
From: Thakkar, Vatsal
To: Jeffrey A. Schaler
Sent: Friday, August 05, 2005 12:40 AM
Subject: RE: feedback on your article

Wow! Quite a fiesty retort.

I don't know where to start. First of all, I know the difference between the law and medicine. But a group of lawmakers has entitled licensed physicians (not just psychiatrists) and licensed psychologists the power to temporarily deprive someone of their liberty based on what is defined by a "mental defect" in my state. Now I agree that this is vague and subject to interpretation. After 3 days in Tennessee, an involuntarily committed individual goes before a judge, then ever 15 days thereafter. I also serve on the board of the TN-ACLU and take personal liberty very seriously. I never attempt to force my beliefs on others, even when I think their decision is foolish. I am probably more on the liberal (conservative?) side of the equation compared to many/most other psychiatrists. All doctors push their treatments usually because they have seen it work so many times. In fact, society would punish me through malpractice suits and even revocation of licensure if I do NOT commit those like the example above.

Vanderbilt operates a psychiatric hospital where 90+% of the inpatients are voluntary. However, I worked at a state psychiatric hospital for five years where 90+% of the inpatients are involuntary. There is a special courtroom built within that hospital for fair review of cases, along with free counsel. Now a typical admission to this hospital will be a homeless schizophrenic who is crossing the interstate naked or something like that. Someone who seems possessed by demons. Someone who pays more attention to the voices in his head than to me doing the interviewing. Is it more ethical to let me release him because he refuses treatment and let him fade away into death by starvation or getting hit by a car? Or should I at least attempt to treat him so that his psychosis lessens and he can make more of an informed judgment about treatment? This case plays out thousands of times a year at this hospital. The patient is medicated, condition is improved, he can carry on a conversation and feed & bathe himself, knows to seek a shelter, but then upon discharge, quits taking his meds and then within 3 months is back at the admissions desk brought in by police. You state that they should go to jail. Even jailors bring patients in when they are defecating on themselves or trying to hang themselves.

Your accusation that more psychiatrists commit suicide because they see their profession as a scam is truly peurile. More physicians commit suicide than the general public. Psychiatry shares the spotlight with dentistry, anesthesiology, emergency medicine. Could it be that medical students who suffer psychiatric disorders go into psychiatry to help others with similar disorders and their original predisposition to these conditions increases their risk of suicide?

Just because something cannot be seen, touched, or heard, does not mean it does not exist. Yes, much of psychiatry is based on indirect evidence. But it is evidence nonetheless. Absence of tangible proof is NOT absence of existence. Bacterial infections in the middle ages were thought to be all manner of things, such as evidence of sinful behavior. We know better now.

Most of psychiatry, in contrast to what you allude, is based on voluntary and legal grounds. Eliminating involuntary treatments would do nothing but add to human misery and more numbers for jails and prisons. I practice mostly outpatient service and do not deprive anyone of their liberties.

If you think that NO mental illness manifests with physical symptoms, consider: PSEUDOCYESIS. It is nothing but physical, measurable symptoms without cause. A brain-body connection which has yet to be understood. It exists.

Tom Cruise has the right to say whatever he wishes.
You have the right to say whatever you wish.
As does Szasz, who I've read.
As do I.

I truly believe that in my lifetime science will prove you wrong and me right in this debate.

VGT

PS "Tom Cruise upset so many people such as yourself because what he said was right. Here, a layman, a movie star, knows more about science and medicine than psychiatrists. Pathetic."

I have to laugh...

From: Jeffrey A. Schaler [mailto:jschale@american.edu]
Sent: Saturday, August 06, 2005 3:44 PM
To: Thakkar, Vatsal
Subject: Re: feedback on your article

Vatsal Thakkar:

You write: "But a group of lawmakers has entitled licensed physicians (not just psychiatrists) and licensed psychologists the power to temporarily deprive someone of their liberty based on what is defined by a 'mental defect' in my state."

I believe Hitler "entitled licensed . . . .psychiatrists . . . to temporarily deprive [Jews and others] of their liberty based on what [was] defined by a 'mental defect' in [that] state." Think about what you've written.

You write: "Now I agree that this is vague and subject to interpretation." There is nothing vague about it. There is nothing to be interpreted if you are not free to go home!

You write: "I also serve on the board of the TN-ACLU and take personal liberty very seriously." Obviously you don't take it very seriously. A person is either free or imprisoned. A person is either entitled to due process or is not. You support depriving a person of liberty without due process. Stop creating excuses based in "compassion." Plenty of people are imprisoned, killed, harmed in the name of "compassion."

You write: "I am probably more on the liberal (conservative?) side of the equation compared to many/most other psychiatrists." Ah, so you're the least racist of the bunch, right? You belong to the Nazi party, but you're not as much a Nazi as the others, right? Look at what you're saying.

You write: "All doctors push their treatments usually because they have seen it work so many times." A person has the right to refuse treatment. You cannot treat someone without his consent. Psychiatry is the exception. Psychiatrists are not like real doctors in this respect (as well as in many other respects). It is either a contractual relationship or one based on coercion.

You write: "In fact, society would punish me through malpractice suits and even revocation of licensure if I do NOT commit those like the example above." I think Eichmann said something very similar, remember? Take responsibility for the harm you to do people in the name of treating them. Look how you avoid!

You write: "However, I worked at a state psychiatric hospital for five years where 90+% of the inpatients are involuntary." Ordinarily, one calls that a prison. In a hospital, a person can enter and leave voluntarily. You participated in assaulting and imprisoning people you diagnosed as "patients", deprived them of their civil rights, and call it "treatment." You know what that means . . .

You write: "Is it more ethical to let me release him because he refuses treatment and let him fade away into death by starvation or getting hit by a car?" Ethical? You have no right to imprison him. You have violated his civil rights by imprisoning him. You've committed a crime. When the Nazis gassed people were they "unethical" or criminals, murderers? Look how you try to ease your guilt by using the word "ethical."

You write: "You state that they should go to jail." Only if a person commits a crime. You jail and imprison people when they've committed no crime. They have no due process. You are participating in a criminal activity. Just because it's sanctioned by the state doesn't mean that it's not a criminal activity. The Nazi doctors were sanctioned by the state. Still, they were criminals.

You write: "Someone who seems possessed by demons." Is this person Muslim? He knows what Allah wants? Is he Christian? He knows what Jesus wants? Is he Jewish? He knows what God wants?

You write: "Your accusation that more psychiatrists commit suicde because they see their profession as a scam is truly peurile." Ask them. What do real doctors think of psychiatrists? What do real doctors think of the prisons you run in the name of "medicine?" How do psychiatrists feel about themselves in relation to real doctors? Ask around. Study it. See for yourself.

You write: "Just because something cannot be seen, touched, or heard does not mean it does not exist?" Does this mean you acknowledge that mental illness cannot be seen, touched, or heard? Is this why pathologists include something that cannot be seen, touched, or heard in standard textbooks on pathology?

You write: "We know better now." Can you tell the difference between a sinful behavior and a sick behavior? Do you consider yourself to be God? If so, you know what that means . . .

You write: "Yes, much of psychiatry is based on indirect evidence." Much of psychiatry is based on power and coercion. Take away the power of psychiatrists to coerce and you'd be out of business!

You write: "Absence of tangible proof is NOT absence of existence." There are many people you diagnose as schizophrenic who would agree with you. When you say that, you call it practicing psychiatry. When they say it, you call it being psychotic.

You write: "Bacterial infections in the middle ages were thought to be all manner of things, such as evidence of sinful behavior. We know better now." You are claiming that the state of psychiatry today is akin to that of knowledge of bacterial infections in the middle ages? On that we agree. I suggest you reread Thomas Szasz's The Manufacture of Madness. Psychiatrists burn people at the stake of ECT to cleanse their souls, aka, mental illness.

You write: "Eliminating involuntary treatments would do nothing but add to human misery and more numbers for jails and prisons." I see. That is why people don't want to see psychiatrists, right? That is why people comply with their medication regimens, right? People are miserable being treated against their will. They are suspicious of psychiatrists who deprive them of their freedom, who force them to take drugs they don't want to take. What you are saying is straight out of Orwell. Involuntary means they don't want it. How can involuntary, doing something to people they don't want, make them happy? Doing something to people they don't want makes YOU happy, not them. If they were happy with what you did "for" them, they'd come and see you voluntarily!

"If you think that 'NO; mental illness manifests with physical symptoms, consider: PSEUDOCYESIS. It is nothing but physical, measurable symptoms without cause. A brain-body connection which has yet to be understood. It exists." And the difference between that and lying, pretending, is . . . ? Pretending to be pregnant is not a mental illness. Neither is pretending to be a doctor. It's just pretending, lying, deception. Some people throw their whole life into it. Consider psychiatrists who believe in, diagnose, and treat "mental illness"? Not so unusual. And sanctioned by the state! Isn't that folie à deux if one has ever seen it?!

You write: "I truly believe that in my lifetime science will prove you wrong and me right in this debate." Science cannot prove involuntary commitment "right." What you are searching for is a brain lesion. If a new brain lesion is discovered, then that will be a new brain disease, subject to the same nosological criteria for disease classification as any other. It will not "prove you right" about mental illness. The mind can be sick in a metaphorical sense only. If you're so interested in searching for a brain disease, devote your life to neuroscience, instead of being a jailer masquerading as a doctor. You're a neuroscientist wannabe. Be a neuroscientist if you want to be. Commit yourself to that work. Stop looking for a lesion to ease your guilt as a psychiatrist. The lesion won't resolve your guilt. People still have the right to refuse treatment!

You write: "I have to laugh . . . " But you weren't laughing when Tom Cruise said what he said. You got upset. So did the American Psychiatric Association. Now THAT'S funny!

Jeff Schaler

Professor Jeffrey A. Schaler

----- Original Message -----
From: Thakkar, Vatsal
To: Jeffrey A. Schaler
Sent: Wednesday, August 10, 2005 11:54 AM
Subject: RE: feedback on your article

Pseudocyesis is NOT just “faking” a pregnancy:

TABLE 1. SIGNS AND SYMPTOMS OF PSEUDOCYESIS
Signs or Symptoms Percentage of Patients
Abdominal enlargement 63
Menstrual irregularities 56
Sensation of fetal movements 48
Gastrointestinal symptoms 41
Breast changes or secretions 40
Labor pains 28
Uterine enlargement 9
Cervical softening 6
From small.[sup.]5

There is no consistent or convincing neuroendocrine pathology that has been found to explain this. Yet. But then the same could be said of major depression. And bipolar disorder. And schizophrenia.

VT

From: Jeffrey A. Schaler [mailto:jschale@american.edu]
Sent: Wednesday, August 10, 2005 11:02 AM
To: Thakkar, Vatsal
Subject: Re: feedback on your article

Well, it's either real pregnancy or it's fake pregnancy, isn't it? What else could it be?? Look at the physical changes that occur when people starve themselves, e.g., "anorexia." Or make themselves obese? This is nothing unusual. People delude themselves in all sorts of ways, for all sorts of reasons. Please, tell me, if this is not fake pregnancy, and I certainly don't think you consider it to be real pregnancy, what "it" is? And what kind of conversation might you have with such a person, assuming the person came to see you voluntarily? What might you talk about in light of these symptoms?

Jeff Schaler
jeffschaler@attglobal.net

----- Original Message -----
From: Thakkar, Vatsal
To: Jeffrey A. Schaler
Sent: Wednesday, August 10, 2005 3:17 PM
Subject: RE: feedback on your article

I’m only trying to illustrate a mind-body experience which is inexplicable in its etiology, and cannot be simply “faked” (cessation of menses, lactation). Now if this same person is psychotic (delusional) to the point of wanting to give herself an abortion, she may need involuntary hospitalization!

VT

Vatsal Thakkar writes:
I’m only trying to illustrate a mind-body experience which is inexplicable in its etiology, and cannot be simply “faked” (cessation of menses, lactation). Now if this same person is psychotic (delusional) to the point of wanting to give herself an abortion, she may need involuntary hospitalization!

VT

Schaler: No, you are avoiding the issue again. You have not been addressing the points I make. Involuntary hospitalization is not treatment. It is imprisonment, the deprivation of a person's liberty. Giving herself an abortion, whether she is pregnant or not, is still behavior. You and I may find it upsetting that someone wants to cut out parts of her body, but a person has a right to do it. After all, how do you think plastic surgeons make their living doing cosmetic surgery? The doctor who treats himself has a fool for a patient. It is still behavior. A person believes in God. That is a delusion. Would you deprive that person of liberty for believing in God? People who believe in God have long harmed others and themselves in the name of their delusion. You are not illustrating "a mind-body experience." Either the person is pregnant or she is not. If she is not pregnant, her "pregnancy" is fake. If she has a disease that causes hormonal problems, signs and symptoms, then she has a disease. Still, she has a right to refuse treatment. Wanting to be pregnant is not a disease. Pretending to be pregnant is not a disease. Not wanting to be pregnant or a mother is not a disease. Why is it that undergraduate students understand this, and yet you do not? I suspect you are pretending not to understand. I suspect you're beginning to realize that what you've been believing in is a house of cards, something that falls down easily when certain fundmental premises, i.e., only the body can be diseased, are exposed as false.

I would like to post our dialogue on the Szasz Blog. May I have your permission to do so?

Jeff Schaler

From: Thakkar, Vatsal
To: Jeffrey A. Schaler
Sent: Saturday, August 27, 2005 11:31 PM
Subject: RE: feedback on your article

Dr. Schaler,

I don’t know if I got back to you on this—you may post the discussion if you post it in its entirety.

Also, I am teaching medical students next week—may I use your emails?

VGT

Do not condemn the judgement of another because it differs from your own. You may both be wrong.
--Dandemis

From: Jeffrey A. Schaler
To: Thakkar, Vatsal
Sent: Sunday, August 28, 2005 8:11 AM
Subject: Re: feedback on your article

Yes. Thanks very much. We're both busy. I appreciate the dialogue.
Kind regards,

Jeff Schaler

*Strictly speaking it is a moral and political issue. The Supreme Court has repeatedly upheld the constitutionality of involuntary mental hospitalization. I believe the Supreme Court has ruled in error. The constitutionality of involuntary mental hospitalization is like the constitutionality of slavery.