Two quandaries hallmark psychiatry as an independent discipline, social institution, profession, and applied empirical science in practice. These quandaries are the subject of this book. They impart to psychiatry its structural ambiguity.

The first quandary regards the extent of the psychiatric realm that must be considered relevant. Psychiatric disorders manifest themselves in behavior and feeling. History has seen the pendulum swing from an extremely narrow view on the realm of psychiatric disorders to an extremely broad one. In the narrow view psychiatric disorders require the presence of biological determinants. It is assumed that their causes and processes will eventually be unmasked by the neurosciences. The broad view holds that although biological deviation is a factor in psychiatric disorders, all sorts of psychological, social, interactional, and cultural conditions and conflicts affect them as well, independently from the biological factors. A person’s development and experiences are also considered relevant. These two views alternate from time to time, but also exist alongside each other.

This quandary is echoed in daily practice in such practical questions as, “Does the massive flow of patients to institutions for voluntary psychiatric treatment reflect an upsurge in the number of psychiatric disorders in the population? Is it expedient to distinguish between people with psychiatric disorders and people with psychosocial problems?” etc. These are conceptual problems inherent to the view and conviction one has on the definition of psychiatric disorders.

The second quandary regards the social function of psychiatry. On the one hand psychiatry is a “normal” field of medicine dedicated to diagnosing and treating people with psychiatric disorders. On the other hand psychiatry as a social institution is vested with the task of assisting in the control of all sorts of disruptive influences in society. In this sense psychiatry can be described as a social institution that serves the social order in addition to the justice system. It is to protect society against the dangers evoked by the disturbing or dangerous behavior of people with psychiatric disorders. The application of coercion is unmedical. Medicine is hallmarked precisely by its being a service institution, that acts only at the patients’ request. In addition, in medicine the interests of the patient as defined by himself are paramount. Inasmuch psychiatry is to serve this social role, it is unmedical in both of these aspects.
For the sake of argument the contrast between the patient’s interests and that of society has been exaggerated here. To a certain extent such interests in reality run parallel in a macro model. This holds true on a micro level as well. When a psychiatric patient can be treated, he himself is benefited as well as his environment. Conversely, treatment which benefits the patient’s environment benefits himself. Nonetheless refusal of psychiatric treatment frequently occurs. This may be because the person does not want it, does not regard it necessary, or fears it. In the case of somatic illness the patient’s wishes are generally respected, but not in psychiatry. Therefore the problem of coercion, in commitment as well as in treatment, returns to center stage.

Together with these two quandaries, the following question can more generally be posed: how can society best deal with people who…

• cannot manage on their own and require assistance to prevent their social ruination?
• pose a nuisance to others, disrupt normal social processes, or are otherwise troublesome though do not commit crimes?

Foucault vividly described how this social problem urgently required a solution during the seventeenth century, and which categories of people were affected. The solution arrived at for the various groups was initially incarceration. Later other solutions were found for all sorts of subgroups, or the problem was accorded less weight. Only the category of psychiatric patients was left, until through deinstitutionalization this group too was “socialized”, only to partly return as homeless people, vagabonds, and asocial folk. Criticizing and rejecting the psychiatry as an institution that spreads its wing over this group raises the question whether we have or can imagine other social systems that could handle this job better.

In principle the quandaries are not insoluble. But making the choices necessary for such solutions appears to be impossible in practice due to a complicated network of ideological convictions, scientific and ethical considerations, and professional and social-political interests. Certain aspects of this problem can be clarified by empirical-scientific research. But as the choices are between concepts, and the goal is finding the best solution for social-political predicaments, which view is the right one cannot yet be empirically determined. What can be done is to weigh the different options, and clarify the advantages and disadvantages of the various choices.