It has been previously asserted that there exist essentially two types of psychiatrists: authoritarian and libertarian, and that the differences in their approaches are attributable to differences in their personalities and their conceptualization of mental illness (see Szasz, 1965). The patient who consults each type of psychiatrist will, as a rule, have a radically different experience in terms of treatment, which is outlined below. I submit that the distinguishing characteristic that divides the authoritarian psychiatrist from his libertarian colleague is a need for power and control. This equates to the personality characteristic of authoritarianism.

Let us first define and describe the libertarian psychiatrist and then contrast him to his authoritarian partner. (The use of the word "libertarian" here does not refer to a political affiliation but rather to a philosophy which values the freedom of the individual from external constraint and coercion.) The libertarian psychiatrist deals with his patients on a voluntary basis, usually in the private practice setting, although he may see patients in the hospital who have consented to his care. This point is an important one, as the entirety of the libertarian psychiatrist's approach to his work is based on the principles of contract and consent. The libertarian psychiatrist engages in an effort, volitionally undertaken by his patient, to free the patient from his internal restraints and conflicts. This psychiatrist may use medication sparingly, and he always does so judiciously. He often has less of an interest in diagnosing his patient than he does in understanding him. If the libertarian psychiatrist practices psychotherapy, it is usually in a non-directive form, such as psychoanalysis or dynamic psychotherapy.

Mark L. Ruffalo, LCSW
Weston State Hospital, formerly the Trans-Allegheny Lunatic Asylum, in Weston, West Virginia. An example of the large, imposing state hospitals of 19th and 20th century psychiatry.
Source: Mark L. Ruffalo, LCSW

The libertarian psychiatrist is in sharp contrast to his authoritarian counterpart. Whereas the libertarian psychiatrist was born of Freud's consulting room, the authoritarian psychiatrist was born of the massive, custodial state hospitals of yesteryear. The authoritarian psychiatrist deals, sometimes exclusively, with involuntary patients, and his aim is not so much to cure them as it is to control them. I do not make this last point lightly, as great minds such as Goffman and Foucault have demonstrated the social control aims of institutional psychiatry. The authoritarian psychiatrist places great value in the categorization and classification of human beings in the form of psychiatric diagnosis, and he usually has an affinity for the use of medication and other means of altering the physiology of the brain. This psychiatrist may turn to medication immediately, seeing his patient not only as sick but as an object for him to "fix" and control. Psychotherapy is infrequently practiced by the authoritarian psychiatrist, and if it is, it is usually a directive modality which consists of little more than telling the patient to change his behavior.

What is the basis, intrapsychically, for this difference between authoritarian and libertarian psychiatry? I argue that the two types of psychiatrists each enter the field for vastly different reasons and this comes to shape how they view and treat the patients they see. The authoritarian psychiatrist, for reasons likely relating to his own development, is high in need for control, power, obedience, and submission. The libertarian psychiatrist, in contrast, has no such needs. The libertarian psychiatrist sees his patients as autonomous, individual human beings. Although the libertarian psychiatrist may not agree, personally or morally, with his patient's conduct, he is not going to engage in coercion to change the patient, insisting that it is the patient's own responsibility to change himself. The authoritarian psychiatrist, on the other hand, sees his patients through a collectivistic lens and as a result, sees himself as bearing a great responsibility to forcefully change others, even if his patients themselves do not wish to be changed.

Identifying and understanding the differences between authoritarian and libertarian psychiatry is not only useful for those entering the field as they engage in necessary self-examination, it is also helpful for patients seeking psychiatric help, as many have had poor experiences with psychiatry in the past. As noted elsewhere, the defining feature of mental disorder is a sensation of loss of control--over one's feelings, thoughts, or behavior. What patients are seeking in the form of treatment is freedom and autonomy, though few, of course, express it in these terms. Whereas the authoritarian psychiatrist emphasizes, and seems to thrive on, the deprivation of the patient's freedom, the libertarian psychiatrist has as his goal the support and maintenance of the patient's autonomy and self-determination.

It becomes evident, then, that the differences between the libertarian and authoritarian psychiatrist are likely rooted in their own personality structures, and that these differences come to define how each psychiatrist relates to his patient--the libertarian in a contractual and cooperative manner, and the authoritarian in a paternalistic and coercive one.

Author's note: The male pronoun is used as default in the English tradition as this author believes there are better ways to improve the condition of women than the now-fashionable flaunting of linguistic deformations.

References

Szasz, T. S. (1965). The ethics of psychoanalysis: The theory and method of autonomous psychotherapy. New York: Basic Books.

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