Contractual Psychiatry

To be sure, all history is selective. My point is only that the standard histories of psychiatry—mixing as they do Institutional Psychiatry, psychoanalysis, and other social interventions considered psychiatric —blur the differences between procedures that help society (and often harm the patient), and those that help the patient (and sometimes harm society) and having blurred these differences, they emphasize the therapeutic value, to the so-called patient, of virtually all psychiatric methods. In contrast, my bias, which I have made explicit, has been to separate Institutional Psychiatry (which rests on coercion and whose function is to protect society) from Contractual Psychiatry (which rests on cooperation and whose function is to protect the individual client). I have therefore confined myself here to selecting materials relevant to the history of Institutional Psychiatry. 

By Institutional Psychiatry I refer generally to psychiatric interventions imposed on persons by others. Such interventions are characterized by the complete loss of control by the client or patient over his participation in his relationship with the expert. The paradigm service of InstituUonal Psychiatry is involuntary mental hospitalization. For further discussion, see pp. xxii-xxvii. t By Contractual Psychiatry I refer generally to psychiatric interventions assumed by persons prompted by their own personal difficulties or suffering. Such interventions are characterized by the retention of complete control by the client or "patient" over his participation in his relationship with the expert. The paradigm service of Contractual Psychiatry is autonomous psychotherapy. For further discussion, see pp. xxii-xxlii. 

The most important economic characteristic of Contractual Psychiatry is that the contractual psychiatrist is a private entrepreneur, paid for his services by his client its most important social characteristic is the avoidance of force and fraud (and the existence of legal penalties for their use). The relationship between contractual psychiatrist and patient is based on contract, freely entered into by both, and, in general, freely terminable by both (except where the therapist relinquishes some of his options in this regard). The contract consists of an exchange of psychiatric services for money. In short, whereas the institutional psychiatrist imposes himself on his patients, who do not pay him, do not want to be his patients, and are not free to reject his help — the contractual psychiatrist offers himself to his patients, who must pay him, must want to be his patients, and are free to reject his help. 

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