But how about the sufferer from melancholia who announces his intention of committing suicide? Although it is true that suicide does usually harm those nearest to the suicide, I doubt if Mill would have thought this kind of harm sufficient to come within the category he defines. Suicide is primarily a matter of the individual harming himself; and this, Mill considers, he should be left free to do. Yet every psychiatrist will have had many patients who have been actively suicidal and who may have made more than one attempt to kill themselves but who, on recovery from their disorder, have been extremely glad that they were restrained from doing so and grateful for any treatment which led to their recovery. Moreover, there are patients in a state of mania or hypomania who may undertake all kinds of ill-judged commitments, financial and otherwise, which result in harm to themselves and from which, upon recovery, they have been grateful for being restrained. Should one deny treatment to those suffering from these types of mental disorder on the grounds that it is an unwarrantable interference with their personal liberty to do so?
In Great Britain, it has been the practice to certify and confine against their will not only those who are obviously likely to harm others but also those who are likely to harm themselves, either by suicide or else by overreaching themselves while in that state of high excitement and overconfidence we designate as hypomania. I think it right that this should be so, and I can see no way in which psychiatrists can in conscience entirely avoid the distasteful role of acting as temporary jailers and exercising coercion over some patients, even though this may conflict with their function as therapists.
But I also think that psychiatrists have a special duty, in the open society, to see that this coercion is kept to an absolute minimum. So far as I can see, this involves two principles. First, no psychiatrist should be misled by his own therapeutic enthusiasm or by the well-meaning therapeutic hopes of others into promising treatment for social deviants which he cannot carry out. Thus, because he believes that a criminal or an alcoholic or a psychopath or a psychotic might be helped by a full-scale analysis of fifty minutes five days a week, he should not agree to his confinement in a mental institution where he will get, if he is lucky, a ten-minute interview once a week. It is not disputed that some patients in these categories can be helped by analysis; or indeed by psychotherapies less drastic, although it must be admitted that the patients who benefit most from such treatment are generally those who are too inhibited to be social deviants, rather than the reverse. But there is no point in depriving people of liberty if one has no treatment to offer them. As Norval Morris of the University of Chicago has put it: “The rehabilitative ideal is seen to impart unfettered discretion. Whereas the treaters seem convinced of the benevolence of their treatment methods, those being treated take a different view, and we, the observers share their doubts. The jailer in a white coat and with a doctorate remains a jailer—but with larger power over his fellows.”11 So much is this the case that Professor Morris advises that no criminal should plead not guilty upon grounds of insanity.
Second, no psychiatrist should cooperate in coercion unless he is convinced that the person concerned is a danger to others or to himself. If we exclude the mentally defective, the intoxicated, the physically ill, and the senile, who raise problems beyond the scope of this paper, this will in practice involve only those individuals who are murderous, suicidal, or obviously manic. A few paranoid individuals may remain murderous throughout life, but they are very few. Manic depressives, whether manic or depressed, almost invariably recover from any given attack of their disorder. Therefore, by far the majority of those who are forcibly confined will need to be so for only short periods.
Twenty-five years ago, when I was a newly fledged psychiatrist, I should have been in favor of casting the coercive net far wider. It seemed obvious, for instance, that the schizophrenic with delusions and hallucinations and other clear-cut manifestations of mental illness should be in a mental hospital where, if he could not be cured, he would at least be treated with tolerance and understanding. If he had not the insight to see this, then reluctantly, he should be certified insane. Now I realize that our criteria of mental illness are sadly inadequate; that many harmless people have “delusional systems” by which they live; and I am against depriving anybody of liberty, however “mad” he may appear, unless he is a danger to others or to himself.
In the open society, the psychiatrist has a second duty which is equally important. That is, he must do his best to insure that techniques of psychiatric investigation and treatment are not misused for other purposes by governments or other agencies such as the police or military. I have already drawn attention to the misuse of mental hospitals as places of confinement for those whom society or government finds inconvenient. There are many other possibilities of abuse. Prefrontal lobotomy is an obvious example. The misuse of drugs which alter mood or which release inhibitions so that information can be obtained is another. The techniques of conditioning used in “behavior therapy” could easily be used for the convenience of society, rather than to promote the well-being of the individual. So could the new electronic techniques of modifying brain function by the implantation of electrodes into the brain substance. Such dangers, thanks to the publicity given to them by books and newspapers, are beginning to be widely appreciated. However, there is still a pressing need for vigilance. I shall end this chapter by giving an example of the misuse of psychiatric research by government in which I was personally involved in protest.
The history goes back a long way. In 1960, the late Professor Kennedy, then professor of psychiatry at the University of Edinburgh, was rash enough to reveal that he had been employed, during the last war, at an interrogation center in Cairo, in giving advice as to how methods of psychological pressure could be brought to bear upon prisoners from whom information was wanted. This disclosure created a certain amount of unease; more, I think, among the general public than among the medical profession. What, they asked, was a doctor doing in this context? Surely a doctor’s job was to heal the sick, not to instruct governments in how to break down prisoners mentally in such a way that they would yield up information. I took this point of view myself, although I knew that not all my psychiatric colleagues shared it. At the time, there was considerable interest in “brainwashing” techniques, as practiced by the Russians and the Chinese. The Korean War, with its revelations as to how nearly a third of the Americans captured had been persuaded to “collaborate,” was still fresh in people’s minds. There was still a lingering feeling that the British army did not behave like that, although, of course, no one expected that they would invariably behave to prisoners with saintly forbearance. The best I could do at the time was to write an article, which was published in the New Statesman, entitled “Torture Without Violence.” In it, I deplored the fact that doctors should lend themselves to use by government in the way which Professor Kennedy had indicated, and suggested that this conduct was contrary to the Hippocratic oath, as indeed it was. He made no riposte to the article; perhaps because of ill health, since in fact he died within a few months of its publication. There were various repercussions to this article. One lawyer wrote from Cyprus to say that he had knowledge of British methods of interrogation, and that these included what he called “drug-induced hypnosis.” It emerged that there was a special training center for interrogators—it still exists—at Maresfield in Sussex: though what went on there proved difficult to find out. Eventually, we got so far as to persuade Mr. Francis Noel-Baker to ask a question in the House of Commons of the Prime Minister, then Mr. Harold Macmillan. He evaded the issue, saying that it was not in the public interest to reveal what methods of interrogation were taught to British interrogators since such information might be of use to potential enemies. He did, however, write, “I can give an unequivocal assurance that in the training of British interrogators the use of ‘brain washing,’ drugs or physical violence is expressly and emphatically forbidden.”
I gave up inquiry at this poi
nt. It seemed difficult to carry matters beyond the Prime Minister. From time to time, various rather disturbing allegations of brutal conduct on the part of the British forces emerged from Cyprus, Aden, and other trouble spots. Then came the revelations about Northern Ireland. We learned that men were being starved, deprived of sleep, made to assume uncomfortable postures standing spread-eagled against a wall for hours at a time; and, more sinisterly, that they were being hooded and exposed to continuous noise at the same time. These revelations shocked a great number of people, and, eventually, an inquiry was instituted under the chairmanship of the former ombudsman, Sir Edmund Compton. This resulted in a report12 which, though deploring the use of “brutality,” alleged that the methods of interrogation employed in Northern Ireland were not in fact brutal. The hooding, the posture on the wall, and the continuous noise were, so Compton alleged, designed primarily to stop internees communicating with each other. A secondary effect, the report went on, might be to render the men so treated more susceptible to interrogation: “It can also, in the case of some detainees, increase their sense of isolation and so be helpful to the interrogator thereafter.”
I think that any uninformed person reading the Compton Report would have concluded that, although what was done to internees was not pleasant, there was little evidence of severe physical pressure being employed. Some men had complained of being knocked about, or being forced to do unaccustomed physical exercises, or being forced to stand up against the wall again when they had collapsed from fatigue and the effects of being given only one slice of bread and some water every six hours or so. But the tenor of the report was that although more supervision of interrogators was desirable—and it must be remembered that the interrogations were carried out primarily by the Royal Ulster Constabulary and not by British armed forces personnel—not much harm was being done, and possibly some unpleasant procedures were temporarily necessary if the IRA was to be stopped from pursuing its policy of terrorism.
It is at this point, I think, that specialized psychiatric knowledge became relevant. Anyone who had read the literature on sensory deprivation and its effects must have concluded that a variant of sensory deprivation was being used as a method of breaking down internees. The hooding and the continuous noise were designed, not to isolate men from each other, as the Compton Report alleged, but as a deliberate method of producing mental confusion and disorientation. I was no expert in the field of sensory deprivation: but I knew that the effects were so disturbing that, even among healthy volunteers who were acting as experimental guinea pigs and being paid for it, a high proportion pressed the “panic button” long before the experimental period was up. In mild sensory deprivation conditions, male volunteers endured only an average of twenty-nine hours; and in more rigorous conditions, only one man in ten endured more than ten hours. If no limit in time has been set to the termination of the experiment, fears of insanity and confusion may come on within as little as two hours. I knew that many people lost all sense of time; that others became hallucinated; that the experience could, at any rate for some people, be compared with a bad “trip” as a result of taking LSD. I knew, moreover, that an interesting fact had emerged from the Princeton experiments.13 If the experimenters used Princeton students, a number became paranoid, thought the experimenter had abandoned them, and so on. But when the experimenters had run short of their own students, and had to seek volunteers from further afield, the proportion who became paranoid was much higher. If the very mild degree of distrust which one might feel at entrusting oneself to the care of university professors not of one’s own university became so quickly magnified under sensory deprivation, what, one wondered, would be the effect of sensory deprivation upon men who knew themselves to be in the hands of actual enemies?
At the time of publication of the Compton Report I was asked if I would write an article on its psychiatric aspects for the Sunday Times and did so on the following day. In the article, I tried to make it clear that physical brutality was not the only kind of brutality which mattered; that sensory deprivation techniques could be used to produce what was equivalent to a temporary episode of insanity; that no one could possibly know what the long-term aftereffects of such procedures would be upon the men to whom they had been applied; and that the home secretary had no business to say that these methods had no serious sequelae, as he had been rash enough to do in the House of Commons. I thought it important to do this because I surmised that the general public would have no idea that any method of psychological pressure without actual physical torture could be expected to have serious effects. Psychiatrists who spend most of their time only in interchanges with other psychiatrists take for granted a number of things which it is actually rash to assume that non-psychiatrists have any idea of.
After various further protests in the House of Commons and elsewhere, a group of three privy councillors, Lord Parker, Lord Gardiner, and Mr. Boyd-Carpenter, were appointed to investigate the whole question of interrogation further, and I found myself giving evidence before them. I repeated to these distinguished men what I had said in the Sunday Times article, further reinforced by a study of the literature on sensory deprivation. I discovered that some of this literature is still not available, as it comes under the heading of “classified” information. It seems that government departments are quick off the mark in spotting what psychological and physiological techniques might be of use to them in war. A great deal of this research had, of course, been undertaken at the request of governments interested in the effect of isolation, weightlessness, and the like upon potential astronauts. What the Parker Committee was primarily interested in was whether the techniques of sensory deprivation employed in Northern Ireland could, as it were, be used in moderation without much risk of serious aftereffects. They told me that it was undoubtedly true that much useful information had been obtained from internees by the use of these methods, and no doubt many lives had been saved as a result. I was, of course, unable to answer this question, since there was no literature available to me which could tell me whether sensory deprivation employed as an interrogation technique upon enemies had the dire effects which any psychiatrist must guess it would be likely to have. All I could say was that so-called “traumatic” neuroses had been known to result from traumas which were less severe; that producing psychotic symptoms in “normal” people by other methods, like the use of LSD, for instance, was fraught with risk; and that one could only tell what the effects would actually be after a long-term follow-up of the people concerned. In the event, the Parker Committee produced a report in which Lord Parker and Mr. Boyd-Carpenter thought that the methods employed in Ulster could continue to be used if subject to more stringent safeguards; while Lord Gardiner produced a minority report saying that these methods were wholly detestable, their results unpredictable, and that they were unworthy of British traditions in the treatment of prisoners. The Prime Minister, after the publication of the report, said in the House that these methods would henceforth be forbidden.
The moral of this story is not so much that it is possible for psychiatrists, on occasion, to participate effectively in protest, important though this is. It is to underline the fact that psychiatric techniques and research, designed originally to be helpful to disturbed individuals, can, in many instances, be extracted from their therapeutic setting and used for exactly the opposite purpose. It is the duty of the psychiatrist, in the open society, to be aware of this possibility, and to prevent it when he can. In my view, it is also his duty to refrain from giving professional advice or in any way participating in such abuse. “The condition upon which God hath given liberty to man is eternal vigilance; which condition if he break, servitude is at once the consequence of his crime and the punishment of his guilt.”14
NOTES
1. Karl Popper, The Open Society and Its Enemies, 2 vols. (London: Routledge and Kegan Paul, 1945).
2. Jennifer Newton, Preventing Mental Illness (London: Routledge and Kegan Paul, 1988), p. 15.
&nb
sp; 3. Jonas Robitscher, The Powers of Psychiatry (Boston: Houghton Mifflin, 1980), p. 131.
4. Melanie Klein, Contributions to Psycho-Analysis (London: Hogarth Press/Institute of Psycho-Analysis, 1950), pp. 276–77.
5. Nicholas N. Kittrie, The Right to Be Different (Baltimore: Johns Hopkins Press, 1971).
6. Ibid., p. 236.
7. Ibid., p. 276.
8. Zhores A. Medvedev and Roy A. Medvedev, A Question of Madness (London: Macmillan, 1971).
9. Thomas Szasz, The Myth of Mental Illness (New York: Harper and Row, 1961).
10. John Stuart Mill, On Liberty (Harmondsworth: Penguin, 1974).
11. Norval Morris, “Impediments to Penal Reform,” University of Chicago Law Review 33 (1966):627–37.
12. Report of the Enquiry into Allegations Against the Security Forces of Physical Brutality in Northern Ireland Arising Out of Events on the 9th August, 1971, Sir Edmund Compton, G.C.B., K.B.E., chairman (London: Her Majesty’s Stationery Office, November 1971).
13. Jack Vernon, Inside the Black Room (London: Souvenir Press, 1963).
14. John Philpot Curran, “Speech on the Right of Election of Lord Mayor of Dublin,” July 10, 1790.
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