The last post that I wrote regarding the very serious problem of psychosis has engendered more meaningful responses and critiques than anything I’ve ever written. Many of those responses were heartfelt appreciations for the article coming from people with loved ones who suffer from psychosis or from social workers who care for the mentally ill. Many of the critiques (not all) were good faith pushback on some of the finer points. Other critiques were more broad and more indicative of a difference in worldview, which was less useful but still very much illustrative of the intractable misapprehensions on this issue which continue to cause great harm for our society.
This current post is a response to some of those critiques. It is based on comment exchanges that I had with people on the original post as well as in-person conversations that I’ve had with various people since I wrote it. I gave a talk/presentation based on the original article to a group of friends, acquaintances, and strangers, and I received several useful questions afterwards as well as a handful of personal stories from people regarding psychosis that I think are important to share here.
Funnily, this response has become longer than even the original article was. Though it is longer, I will not be recapitulating all of the points that I made in the original article. If you haven’t read it yet, please do. This response, despite its length, may seem incomplete if you don’t know the background.
So, first.
On this topic, I proceed from some basic convictions:
1). Our healthcare system is broken.
2). Our mental healthcare system is very broken.
3). Involuntary commitment and involuntary treatment for the mentally ill can wreck people’s lives — but it also saves people’s lives all the time.
4). We cannot accept the current status quo of well-intentioned neglect for the mentally ill. Their lives and our lives are at stake.
I give that preamble because many of the misapprehensions that I saw from people seemed to suggest that I was unaware of the bureaucratic, byzantine, expensive, inhumane, and often broken state that our healthcare system is in, especially in regards to mental healthcare. I am not unaware of this. But as I will explain multiple times throughout this piece, the fact of something being broken, even when that brokenness causes great immediate harm, doesn’t necessarily mean that we should dismantle it — oftentimes we can fix it.
I also give that preamble to further emphasize that the reforms I am advocating for come from a place of wanting humane treatment for people who are quite possibly the least receiving of humane treatment currently. Of course, many of the problems that we have today with the severely mentally ill not being able to get the treatment they need came from people who thought they were acting humanely — when they made it more difficult to involuntarily commit someone, when they shut down asylums and state hospitals and released the patients onto the streets, when they crafted a narrative that told the mentally ill and their loved ones that mental illness wasn’t an illness of the mind, but an illness of society, and so forth. Sometimes, profoundly evil consequences have stemmed from people who were emphatic about their good intentions. Part of the subtitle of Jonathan Rosen’s book, The Best Minds, where he tears into the generations-long anti-psychiatry movement, is “the Tragedy of Good Intentions.”
I make this good intention defense at the start not to insulate these ideas from critique but just to say: let’s not be too cruel to each other here in this conversation. Please let us not try to ascribe malevolent motives to each other (one commenter accused me of being on the payroll of Palantir). This conversation is about the very real ruination, violence, and loss of life that mental illness causes every day, including to people who I personally know and care about. This conversation shouldn’t be an excuse to insult people over the internet or to lob unhelpful snark at each other.
Now, a story.
I have a friend who suffers from bipolar disorder. A few years ago they had a psychotic manic episode. Though they were in the throes of psychosis, they were still aware enough to understand that they needed help. They took themselves to the hospital. The hospital, being quite uninterested in anyone who isn’t actively hemorrhaging, while also having their hands tied by the “danger to one’s self or others” metric for determining whether to send someone to a psychiatric facility, promptly told my friend to get lost. My friend — immediately — stepped out into the hospital parking lot and tried to steal a car because the car was white so they thought the car was a glowing angel beckoning them to step inside it. The car owner beat the shit out of my friend, called the police, and my friend was thrown in jail for the night. They were soon after released back out onto the street and, thanks to their lawyer, not charged with a felony. They eventually got the medication they needed and they have been relatively stable since then. My friend’s story is a remarkably efficient demonstration of how broken our system is. My friend knew they were psychotic, had enough wherewithal to take themself to the hospital, the hospital didn’t want to deal with them and did not have a ready mechanism by which to give them care, they were kicked out on the street and immediately committed a crime, and it was only after they were released from jail that they received the care that they should have gotten when they first stepped into the hospital.
My friend should not be in prison for grand theft auto. And thankfully they aren’t, because in their case the system worked (relatively speaking) and they weren’t charged with a felony and punished but instead were given the help and treatment that they needed to become stable. If they were treated the same as a car thief, they would have been needlessly punished for an action that was not entirely in their control. They would be suffering manic/depressive episodes in prison alongside violent criminals.
There were some commenters who tried to defend punishing psychotic people for crimes committed while they were psychotic. There were some who found my defense of psychotic murderers distasteful. I knew when I wrote the following paragraph that it was potentially going to be the biggest pill to swallow: “In horrible situations such as these, the psychotic murderer, afflicted as they are with a debilitating illness, is the only person left who can be given the care that they deserve. They are the only person left who can be given the care that they deserve. I am truly sorry to say that. It hurts, it is bad, it is sad, it is difficult, it is unresolvably tragic, it feels wrong — but it is true. When we take away our ability to forcibly treat people suffering from an illness that does not want to be treated, we are then necessarily put into the regrettable position of mitigating the harm that is strewn in the psychotic person’s path, and that means we must care for their well-being despite the protestations for punitive measures on the part of the victim’s loved ones. That is the world that we have crafted for ourselves. It is wrong but it is real.”
I am very glad that I articulated and stood my ground on that position however, because it was that position that received the most searching and heartfelt responses from people who told me their stories about their loved ones who suffer from psychosis. If we care about the mentally ill, we must care about the most severe cases, and those are the cases that are the most difficult to care about. As I wrote, psychosis is extremis — extremis literally meaning the farthest reaches. And it is the farthest reaches, the extremes, that are the most illuminating. It is the extremes where our idealism, our ideologies, our stabilizing notions of truth and justice are broken. And they should be broken, so that we can make something better.
What I tried to make clear in the article is that psychotic-induced violence is in a category of its own. I find it quite dehumanizing to equate psychotic violence with the violence that people commit every day of their own cognitive volition. A jealous husband murdering his wife’s lover or a drunk guy instigating a knife fight or a cop shooting an unarmed suspect is in no way comparable to someone who kills people because their psychosis told them that killing people would stop the impending alien invasion. Equating the two is exactly how prosecutors and judges cruelly punish and imprison those who are in desperate need of mental healthcare. The actions that people commit while they are psychotic, though sometimes criminal and even violent and murderous, are actions which they are indeed responsible for, but their actions are not actions that fall within the same category as actions committed by sane people. It seems to me that some people are advocating for sane people and insane people to be treated exactly the same, to be lumped together within the same general prison population. That is just an incorrect way to view the problem and it absolutely does not help people with mental illness nor the people who surround them.
One person tried to say that we should punish psychotic violence because not all psychotic people become violent, and most psychotic violence is committed by men, so why should we treat these violent men any differently than we would other violent men? Well, yes, all men, whether they are psychotic or not, commit more violence than women. That’s just a given. And I understand that not all people who experience psychosis will commit violence. I never said otherwise. But the article was primarily about the violence and the immiseration that psychosis can cause, the woefully inadequate systems for getting people the help that they need to overcome their psychosis, and what the consequences are from those inadequate systems. From most of the cases of psychotic violence that I have read about, the psychotic person was operating under delusions that the people around them were not people at all, but androids, aliens, demons, possessive spirits, etc. Do all people who suffer psychosis have those same kind of potentially dangerous delusions? No. But I don’t see how that fact and the fact of gender differences in psychotic violence have anything to do with whether or not a person suffering from psychosis would benefit from involuntary treatment.
It is important to note that people suffering from schizophrenia do indeed commit violent acts at a disproportionate rate. They are about .5% of the population but commit about 6%-8% of all murders, depending on what data you look at. The psychosis that they suffer from is very much responsible for that violence. When you find yourself divorced from reality and believing that the people around you are literal demons, you are more likely to act violently against those literal demons. It is not dehumanizing for me to point this out. It is in fact essential to understanding that these people need humane treatment, not punishment, not abject neglect as they live out a horrifying, embattled existence on the street. It drives me mad when otherwise well-meaning people fail to see how their rhetoric contributes to a system that seeks to punish those who suffer from psychosis instead of actually helping them get better and lead productive lives.
Here’s a big thing that I think many people are missing in this conversation. When I say that severe mental illness such as psychosis can cause violence, which it can and does all the time, many people automatically assume that I am painting the mentally ill as broadly and inherently violent and therefore unworthy of basic human respect, care, dignity, and regard. This is wrong. Yes, not all people who are psychotic become violent. But some of them do become violent, and that violence was very much caused by their illness, it was a violence that would not have occurred but for the illness, and that illness necessitates proper understanding and treatment, not punishment. I made this explicit in the article when I said that those who commit murder while psychotic are themselves victims and therefore in need of mental healthcare, not punishment. And yet people still tried to tell me that I was demonizing the mentally ill. I think this misunderstanding reveals much about the people who have it. I believe in the apparently difficult to understand and radical notion that someone who commits an act of violence is not necessarily a bad person (there are very few people in this world who can properly be called “bad” people in some inherent sense). I believe in this notion even when the person who committed the violent act was sane and in full possession of their mental faculties, by the way. But I especially believe in that notion when the violent act was committed by someone who was mentally unwell. If you believe that someone’s act of violence deprives them of the right to empathy, understanding, care, and rehabilitation, then what makes you any different from tough-on-crime rightwing ideologues? What is your worldview?
Those who consider themselves to be on the left must get this through their heads. If you try to erase the worst effects of mental illness by saying that mental illness doesn’t cause violence, or that mental illness is just a social construct, or that mental illness can be cured through the abolition of capitalism, you are propagating a mindset that says the worst effects of mental illness, namely violence and death, can only be ascribed to the will of the individual suffering from mental illness, not to their illness itself, and therefore only the individual must pay the price, not society. That mindset sounds distinctly un-leftist to me. And here I must remind you that we are all living with the painful consequences of the callous ideology of pro-incarceration that was relentlessly bandied about throughout the 1980’s and ‘90s by the mainstream media, mainstream culture, and conservative and liberal politicians alike, including Joe Biden, who spoke on the floor of the senate saying that he didn’t give a shit about why someone committed an act of violence, he didn’t care if they came from disadvantaged backgrounds, these “super predators” should all be locked up no questions asked, and President Clinton obliged by signing the inhumane 1994 Crime Bill into law. This bipartisan punitive thinking is heinous, it is wrong, and we must dismantle it — including for the mentally ill. It is a basic tenet of the leftwing to be concerned with the underlying reasons that cause someone to be violent, not just the violence itself. And it is a standard leftwing position, as well as a simple humane position, to want violent people to be rehabilitated and hopefully returned to the status of a contributing member of society.
One commenter questioned my defense of eventually releasing those who committed murder while psychotic if they have been deemed to be sufficiently treated for their affliction. How could we ensure that they remain on their meds and nonviolent? That question applies to all psychotics who are deemed fit to enter society. What happens if they stop taking their meds? The simple answer is that they will fall into psychosis again, and that’s not good.
Ideally, people who have been committed and demonstrate progress with their mental health will move in stages from more to less security and more to less supervision, from in-patient to out-patient care facilities. If they show that they have the capacity to take consistent responsibility and care for themselves, even if they committed terrible crimes in the past, they may be properly judged to go free. If they do end up released, it would be good to have a kind of parole system, where former patients need to consistently check in with a social worker and demonstrate progress. If the person is receiving any kind of public welfare such as food stamps or housing assistance, that welfare could be contingent upon them continuing to take their medication. Ideally, the patient would be released into an existing support network of friends and family and social services. But given the nature of their illness, friends and family are unfortunately often in short supply and stretched thin as it is. Even with these safeguards, it is necessary for us to always have the involuntary treatment mechanism in place that can be applied at the sign of intractable psychosis, not at the unreasonable barrier of “imminent danger.” Without this safeguard, violence is much more likely.
It is also important to note that many violently psychotic people who do end up committed remain there for the rest of their lives, never judged fit to return to society. There are some psychotic breaks that people never emerge from unfortunately. We should have humane psychiatric institutions that can appropriately judge someone’s mental fitness and take care of them both long-term and short-term, as well as robust social services that can keep the mentally ill on track if they do ever end up being released.
Another issue that has cropped up in people’s responses, which I attempted to head off very early in the original text but which nevertheless presents a stumbling block for some people, is the argument that we should not further empower the state with methods of coercion such as involuntary commitment when the state is clearly not our friend. To which I say, are you a back-to-nature style anarchist? If not, then you clearly make some allowances for state control over certain systems in order to have a functioning system of government. Once you make those allowances, you open yourself up to having to argue for or against specific kinds of social controls imposed by the state. You must acknowledge that the state, regardless of its current character — monarchist, fascist, socialist, democratic, etc. — has a proper role to play in society, and that this role must be filled in the here and now, not in some theoretical future. For example, I don’t think the state should be allowed to spy on our personal communications — for any reason, ever. Other people think spying is okay so long as the state thinks you’re a terrorist. I don’t think the state should regulate speech — period. Others think the state should regulate “hate speech”, and so on. I have weighed the pros and cons of these issues and decided that maximal freedom in regards to our speech and our private behavior is the best option. Regarding mental healthcare, if you want to make the argument that the state is currently proto- or quasi-fascist and therefore cannot be trusted with the power to involuntarily commit people to psychiatric care, that’s fine. But you still need to offer a proximal solution to the problem of treatment-resistant violent psychosis, not just gesture towards a pie-in-the-sky dream of a socialist utopia where everyone is either mentally well all the time or magically receptive to treatment.
My own proximal solution to this problem is to robustly fund mental healthcare, create more in-patient treatment centers that can more readily perform patient intakes without having to deal with the existing hurdles of health insurance and “danger to one’s self or others” metrics, and empower care providers to involuntarily commit those who chronically refuse treatment despite their clearly degrading mental and physical health. Those are some broadly sketched proposals that seem within reach even under our current system of corporate dictatorship. Universal healthcare, stricter gun control laws, less cops with guns, and affordable public housing would also be nice. With those reforms, the mentally unwell could be treated without having to go into forever debt, they could be more easily prevented from obtaining a firearm, they would be less likely to be killed in police encounters, and they could have a guaranteed place to stay, respectively. Those are some ideas, some potential solutions to the problem, in broad strokes. We can deliberate on those points.
In contrast, there are strains of anti-psychiatry that seem downright Libertarian (the American version of libertarianism, not the classic version) — they want, what? To shut down psychiatric care facilities? Abolish life-saving anti-psychotic medications? Let the mentally ill remain sick and dying on our streets? Give psychotics homes that will do nothing to take away their delusions? Are those really the proffered solutions? Or, you can try to just handwave all of these problems away by saying that mental illness is a social construct, or that mental illness doesn’t actually cause violence, or that involuntary treatment is inherently evil and never justified but somehow imprisonment for psychotic violence is humane. Such positions are fantastical, unserious, and have caused an awful lot of very real, lasting, material harm to our fellow humans. The simple and banal fact that state powers can be abused does not by itself mean that we refrain from investing the state with certain powers. Do I want political dissidents to be locked up for life by an authoritarian state that has conveniently defined those dissidents as mentally unwell? Of course not. But I also don’t want people living and dying on the street because they are suffering from chronic delusions. And I can assure you, there are millions of people — right now — who are living and dying on the street because of their mental illness. There absolutely is not millions of people in the U.S. locked up in asylums against their will for being anti-capitalist. This doesn’t seem so difficult. It is quite achievable for us as a society to create and maintain a system of government-funded healthcare that can consistently and compassionately make distinctions between a schizophrenic and a socialist.
This ongoing and incorrigible anti-psychiatry blather is quite convenient for anti-government capitalists. Our neoliberal society is quite happy to defund and shutter mental healthcare facilities. I sometimes get the sense that this is precisely what those on the anti-psychiatry left want to happen. It is not extreme of me to advocate for involuntary (and humane) commitment of psychotics who refuse mental health treatment. It is extreme, rather, to be faced with someone who is detached from reality, suffering from delusions, violently screaming to themselves and menacing passersby, shitting on the sidewalk in broad daylight, constantly exposed to life-threatening heat and cold, and then say something like “They wouldn’t be crazy if they had housing.” That’s not how psychosis works. Four walls and a bathroom and a kitchen do not fix someone whose brain is making them hear angels whispering to them telling them that if they jump off a building they’ll be levitated on their wings.
One commenter claimed that I was ignoring the ongoing abuses of psychiatry, namely that it has inherent racial and gender biases in determining who is sane and who is insane. They claimed I was ignoring the dark history of how queer people, non-white people, and women have been and still are diagnosed with psychiatric disorders at higher rates than white people. Even though I did acknowledge this history in the article, they claimed I was “handwaving” it away in favor of my naive view of the current state of psychiatry. They then offered some articles and studies for me to read which they claimed showed gender and racial biases in psychiatry. Welp, turns out I’m not sure if they even read those articles.
So, two of those articles this person shared do not make the conclusions that they were trying to make. The articles describe racial differences in mental health outcomes, they do not describe racial differences in diagnoses of psychosis. And like, yeah, of course there are racial differences in mental health outcomes just like there are racial differences for all health outcomes. If you’re not white and financially stable, you generally have worse health outcomes in our capitalist society. That’s pretty banal. One of the articles seems to suggest that incidents of psychosis occur disproportionately in non-white populations and the authors speculate that the stresses associated with systemic racism may be causing increased rates of psychosis. The authors do not claim that racism is causing psychiatrists to diagnose non-white people as psychotic more than they would white people. And yeah, I wouldn’t be surprised that the stresses of suffering from racism would cause people to become psychotic from time to time. But that’s not what this commenter was arguing. That study’s authors also say over and over again that the data they reviewed for their umbrella study was of very poor quality.
The other article, from Psychiatry Online, is very poorly written and has almost nothing to say about psychotic disorders, so it hardly seems relevant to the discussion.
Two of the other articles that this person cited do show gender and racial differences in psychiatric appraisals, but one study merely showed a difference in “associations” when people were asked to associate pictures of people of different races with specific words like “schizophrenic.” That may be evidence of implicit bias but.....that’s not how actual psychiatric diagnoses are made. A diagnosis of a psychotic disorder requires actually talking with a patient and closely examining their personal history, not just looking at a picture of their face and associating it with a word. The other article shows differences in diagnoses of borderline personality disorder between transgender and cisgender people, suggesting that there may indeed be a bias, but the authors leave open the possibility that BPD symptoms may be more common in transgender populations. The sample size could also use some expansion.
Critically, none of the authors in those articles recommended dismantling our ability to care for people with psychotic disorders. They mostly recommended refining research techniques, training people on implicit bias, and further funding psychiatric studies and care facilities. I agree!
I am aware of the very dark history of psychiatric quackery and lasting harm against queer people, women, and non-white people. Heard. The history is there. I am not handwaving away that history here. I am asking people instead to take into account our current actual material conditions. Millions of people are not locked up in asylums against their will for being gay or for being political dissidents. Millions of people are instead living and dying on our streets because they are suffering from untreated psychotic disorders.
I don’t need to be told that the power of the state can be used to pathologize and marginalize dissidents and other such malcontents. Heard. Agreed. So what? Even in a socialist society, psychosis will always remain with us, which means that people will need psychiatric care, and sometimes (sometimes!) that care will have to be given without the consent of a psychotic brain in order to save the life of that individual and potentially the lives of those in their orbit. Literally any form of coercive power can be used for profoundly harmful and evil ends. That does not mean that we do not endeavor to create systems of power that actually benefit society. If that were the case, we should still be living in caves. I do not need lectures from leftists about how to be a good leftist on this issue. The prevailing anti-psychiatry leftist attitude on issues of mental illness today is sadly incorrect and in desperate need of adjustment. The evidence is on the streets every single day.
Regarding these leftist positions, some commenters recommended that I engage with the work of Michel Foucault, specifically his books Madness and Civilization and Discipline and Punish, which emphasize the different ways in which “madness” has been socially defined throughout the centuries, often in ways that chiefly benefit those with power, and how psychiatry is used primarily as a way to control people, not treat them. That’s the gist of the gist. I confess that I haven’t read Foucault, though I have watched his debate with Chomsky. And, I’m sorry, but I likely won’t read Foucault, at least not any time soon. I admire Joe Hill. I don’t admire Michel Foucault. That’s what flavor of leftist I am. Of course it is important to seriously engage with ideas that challenge your own, if for no other reason but to strengthen your own ideas (which the commenter expressed). But, frankly, I seriously cannot be bothered to read these academic, Western, post-modernist, obscurantist, quasi-Marxist, (sometimes C.I.A.-backed), critical theory, amoral philosophers like Foucault when Eduardo Galeano and Ghassan Kanafani and Vijay Prashad and Franz Fanon and C.L.R. James and José Carlos Mariátegui and Alexandra Kollontai and Mahdi Amel and Rosa Luxemburg and Emma Goldman and Susan Sontag and James Baldwin and Michael Parenti and Fred Hampton and Howard Zinn are just sitting right there. Life is too short to spend it on bad theory. When my reading list backlog of literally hundreds of books gets diminished, I will consider picking up the critical theory postmodernists. But for the time being, that ain’t happening. Give me the Foucault CliffsNotes.
Regardless of my anti-postmodernist bias, I don’t think it is much of an overstatement to say that the anti-psychiatry movement as represented by members of the academic New Left (such as Michel Foucault and Felix Guattari) as well as members of the counter-culture movement of the 1960s and ‘70s (such as Allen Ginsberg [I do adore Ginsberg’s Howl, though] and Ken Kesey) is substantially responsible for the many mentally ill people living and dying on our streets today. I think I addressed this point in the original article, and Jonathan Rosen does a very well-researched job of it in his book The Best Minds, one of the best books I’ve ever read. Rosen writes:
At some point it became impossible to ignore the way a metaphorical version of mental illness had been institutionalized in academic life at the same moment that people who suffered from actual psychotic disorders were being released from hospitals and forgotten, as if the university and the asylum had organized a sort of exchange program. … The real scandal at [Felix] Guattari’s experimental clinic — where he devised his theory that schizophrenia was a disease of capitalist culture and also an instrument of liberation that could bring it down — was the news that the clinic used antipsychotic medication and electroconvulsive therapy to complement its radically open and inclusive policies. For the metaphorical schizophrenia to do its theoretical job, the organic illness needed to remain quiet.
This all has deathly consequences, and our systems of law have been profoundly influenced by this kind of anti-psychiatry thinking. Rosen tells the story of a psychotic homeless woman who was discharged from psychiatric care after the ACLU sued the state on her behalf:
...a woman with schizophrenia named Joyce Brown had been hospitalized against her will as part of a new program to prevent people from dying on the streets. Though she slept on a sidewalk grate, ran into traffic, covered herself with her own excrement, screamed racial epithets at Black men (though she was Black herself), and tore up dollar bills, set them on fire, and urinated on them, a judge ordered her released, agreeing with her lawyers at the New York branch of the ACLU that her behavior was the result of homelessness, rather than its cause, and writing in his opinion that although burning money “may not satisfy a society increasingly oriented to profit-making and bottom-line pragmatism,” Joyce’s behavior was nevertheless “consistent with the independence and pride she vehemently insists on asserting.” Her four sisters, on the other hand, who had struggled to care for Joyce in their homes until psychosis, drug abuse, and violent behavior had made it impossible, came to a different conclusion. If the judge believed that a Black woman shrieking obscenities and lifting her skirt to show passerby her naked buttocks was living a life of “independence and pride,” he must be a racist who thought such degradation was “good enough for her, not for him or his kind.” Because if that were his sister on the street, they had no doubt, he “would not stand for it.”
Some commenters emphasized the odious revocation of autonomy and dignity that comes with forced treatment. That’s not not true. I have watched the incredibly disturbing forced feeding of political prisoners. I would not wish such forced treatment on anyone. But I would also not wish the death of someone because of their mental illness. One commenter was brave enough to share their personal experience with a treatment-resistant eating disorder and their forced feeding. They wrote:
I can speak for my own self, within the context of an eating disorder that caused me to be civilly committed many times. I am grateful to have been committed. I would not be alive had I not been involuntarily force fed and treated with medications. Though I of course experienced involuntary care as traumatic, I would rather have some trauma to work through in therapy than be dead. At the worst of my eating disorder, I had a death drive that was unable to be altered through kind words or voluntary care. I needed to be forced to stop. I needed someone to step in and say “we will not let you die.”
I am in a strong recovery. I am in college. I am thriving. I would be none of those things without involuntary commitment. It is needed and it is necessary, and I am lucky that those around me gave enough of a shit about my life and my future to do the difficult thing.
This person also shared with me the rather non-ideal situation of them being housed alongside violent offenders in the psych ward. That’s pretty scary, though they were nevertheless able to learn from that experience and hold compassion for their fellow patients. It would be preferable for those who need intensive mental health treatment but have not displayed any violent tendencies or ideation towards others to be cared for separately from those who are continuing to display violent behavior, at least as much as possible. Obviously many of our society’s facilities are currently woefully unequipped to accomplish this task.
For those who care to read about that person’s full experience, which I highly recommend, this is a link to the essay they wrote about it.
The loss of agency that comes with such treatment in no way refutes the reality that sometimes the severely mentally ill need to be treated involuntarily in order to make them well and also sometimes protect the people around them. Prioritizing an idealized version of autonomy over actually caring for people has deadly results. Rosen references the story of Elyn Saks, a schizophrenic woman who wrote about her experience overcoming her affliction and later graduating from Yale:
Elyn [Saks] was lucky her parents could afford daily psychoanalysis, and lucky they had been able to pay for private hospitals like the Yale Psychiatric Institute, where she’d spent several months after her law school breakdown. Just how lucky she was she realized on her first day at Yale Psychiatric Institute, talking to Eric, a young graduate of an Ivy League school. Like her, he’d also spent time in Yale-New Haven Hospital, the vast teaching hospital whose psych unit she’d found “inhumane and inhospitable.” All she’d wanted from any hospital was to be released, but Eric had a different regret. “I wish they’d made me stay,” he told her, “and then maybe moved me here, like they did with you. I fooled them into thinking I was OK. And I went home. And then I killed my father.” Elyn thought she must have misheard. “I’m sorry,” she said. “You did what?” The young man nodded. “I strangled him.”
The severely mentally ill already have little freedom, they have little agency, they have little dignity. Psychotics often hallucinate that they are being surveilled and followed and menaced. Getting the treatment that they need, even involuntarily, alleviates those unfortunate consequences of their illness — not necessarily cures, but alleviates. Just because treatment for psychosis is often debilitating, undignified, and extraordinarily difficult, that doesn’t mean that it’s not necessary for those who really need it. You know what else is debilitating, undignified, and extraordinarily difficult? Living your entire existence on the street, murdering your parents because the voices in your head told you to, draining your bank account because you spent years on the run from secret government agents who you thought had implanted a tracking chip in your brain.
I find this other story from Rosen’s book useful here, as it concerns a schizophrenic woman named Rebecca Smith who froze to death while living on the street:
New York City’s director of protective services for adults told the Times that a court order to hospitalize Rebecca Smith, which arrived hours after she had frozen to death, had taken ten days to obtain because Ms. Smith liked sleeping in a box, and it was necessary to show the court that every effort had been made [to help her]. “We’re concerned about people’s civil rights,” he said. Meanwhile, the libertarian psychiatrist Thomas Szasz wrote in the Times that it would have been a terrible infringement of Rebecca Smith’s rights to hospitalize her against her will because she was suffering only from what he called “problems in living.” Her failure to take care of herself was “pathetic,” he wrote, but became “tragic” when society blamed such troubles on a “nonexistent disease.” It was hard to believe that someone who seemed so indifferent to the plight of people with severe mental illness had helped shape laws governing the treatment of the most vulnerable members of society. … He did not simply deny the existence of Rebecca Smith’s illness, or the legitimacy of the state stepping in to help her if her family could not, but insisted on turning the most impaired subset of people suffering from untreated psychotic disorders into a test case of individual liberty. Denying the exceptional nature of Rebecca Smith’s illness, he made her autonomy essential to his own, even if she dies on the sidewalk to preserve it.
If I was in the tragic position of suffering from treatment-resistant psychosis, I would hope that there are people in my life who have the drive and capacity to get me the treatment that I need and that there is actually a mechanism by which they can do so. Unfortunately, for most people, there often is not. A huge thing that makes all of this so hard and which I did not really touch on in the original article is the overall disaster of our for-profit healthcare system in the United States. When people can’t even get access to routine preventative care without going into debt or draining their paychecks every month with payments to insurance companies, then of course people who need specialized mental healthcare the most are going to struggle mightily to even find the care that they need, let alone be able to pay for it.
There is also a cruelty in simply telling a severely mentally ill person that they need to get help. That is necessary, but woefully insufficient. “You need to get help.” Okay, how do they get help? How do they pay for it? Who will help them get that help? Who will help them navigate the byzantine healthcare system in their already debilitated state? Who will keep tabs on them throughout their treatment? Unfortunately, the severely mentally ill alienate their friends and loved ones with their illness, the people who could be best situated to help them through that process, thus isolating them further and further. As Elyn Saks put it: “They’re struggling with thoughts of wanting to hurt themselves or others, and at the same time, they desperately need the help of those they’re threatening to harm.” When there’s no other option for help, we need to have the option of forced treatment.
There were some commenters, prone to exaggeration, who equated forced treatment with fascism. This reminded me of this 1946 quote from George Orwell: “The word Fascism has now no meaning except in so far as it signifies ‘something not desirable.’” I am in fact advocating for involuntary commitment and treatment in order to save the lives of those who would otherwise die on the street and those who would be harmed by psychotic violence, yes. Nearly all of the horrible violent cases that I mentioned in the article could have been avoided if there was a robust mechanism to get people the mental healthcare that they need, free of charge and easy to access, that does not rely on the difficult to clear metric of “danger to one’s self or others” nor, in more severe cases, on the consent of a psychotic mind. That’s not fascist, it is humane, and to use the word fascism rhetorically like this cheapens the whole concept. Fascism is not just whatever you dislike. What is happening right now is that millions of mentally ill people are being left to die on the streets, kill themselves, or kill others (most often their family and friends). To say that that situation is bad and that it needs fixing through profound reforms to our healthcare system is not fascist, it is perfectly in line with the leftist priority of taking care of the whole community by sharing the costs of that care equally instead of foisting the costs of mental illness onto the individual and their immediate circles alone.
There was another commenter who took issue with me even mentioning that there are some people in our society who unfortunately think it is a good idea to summarily execute people who suffer from psychosis. I spent some time in the article explaining why exactly this is very wrong-headed thinking, but this person called me a eugenicist for even daring to speak the counterargument, which is quite an overly dramatic and bizarre comment to make and only really makes sense when you understand that people calling people eugenicist online has become quite common and is little more than a performative buzzword for leftists to wield, which is sad but predictable given the deformations and perversions to language and thought that social media engenders. I would nevertheless appreciate it if people would not be so glib about this issue and not willfully mischaracterize what I write in this way. I made it clear that the kind of callous thinking that the commenter took issue with is totally wrongheaded, both morally and practically, and that it should not be countenanced. I also made it clear why it is worth bringing up and critiquing those arguments in the first place — because those viewpoints are unfortunately very common amongst ignorant and callous people and therefore they should be fought against, not buried and ignored as if they don’t exist. I do not appreciate people casually throwing around accusations of fascism and eugenicism. To do so is to cheapen those words in an effort to terminate serious inquiry into these issues. I don’t think I can make it much more plain than I did in the article: seeking to eradicate psychosis through violent liquidation is a monstrous position to hold. I hope that is abundantly clear.
Some commenters questioned my ability and even my right to speak on these issues whatsoever. Which, if I’m being generous, represents an understandable desire for people to know what they’re talking about, but given the acerbic ways in which this criticism was expressed to me, it actually represents a deeply undemocratic, anti-egalitarian, and elitist view amongst certain circles. I find that making appeals to “credentials,” as if a credentialed, professionalized class ought to be treated with any inherent respect by virtue of their status, is a very silly position to hold. The social critic Thomas Frank has made a good number of books, articles, and talks that handily tear down the notion that only those who are “credentialed” should have any right to participate in public discussions of great importance (The People, No and Listen, Liberal are particularly good by Frank, though I also recommend Trust Us, We’re Experts by John Stauber and Sheldon Rampton and Voltaire’s Bastards by John Ralston Saul). I assure you, there are a great many people who can speak far more adroitly and competently on issues than the supposed “experts” on those same issues. And when the rabble is kept out of the room where decisions are made, the men in that room conveniently come up with solutions that only benefit them, not the rest of us. So, force your way into the room. That’s democracy.
Finally, for what it’s worth, I recently gave a talk based on the original article to a mixed crowd of adults who were effectively a random grouping. Afterwards, I had a handful of people come up to me individually and thank me for what I said. They noted the rarity of the standpoint. They noted its importance. They noted that it is humane to emphasize prioritizing the care of those suffering from psychosis even when that psychosis caused the person to commit heinous acts. Most of these people had friends or family members who suffer from chronic psychosis. They noted to me how much they felt that most people misunderstood the true nature of their loved one’s sickness and they thanked me for being willing to say that sometimes someone needs to be forced to accept the treatment that will vastly improve their life and the lives of those around them. One woman with a schizophrenic brother told me her frustration with people who tell her that she should just call the cops when her brother is being erratic, as if the cops were actually equipped to solve anything. Another woman told me about her psychotic friend and noted that even with repeated attempts to try to get them help, they have consistently refused treatment, a cause of great suffering to both them and their friend. Some of these people had tears in their eyes when they spoke to me. Their stories drove home to me that none of this is theoretical — it is embodied, it is material, it has lasting and devastating consequences. It hurts every day. I feel a very real sense of responsibility for people who choose to share their stories with me. Literally the very least that I can do for them is listen to them and try to write clearly about what I think our society can and should do to improve the care for mental illnesses that will always be with us.
All of this makes me very sad, most especially for the people who I know and care about that have been lost to psychosis. I think we can craft a better world that mitigates some, not all, of that sadness and suffering.
Thank you for being considerate about all of this.
Once again, you have hit all of the points so eloquently. Thank you for being kind enough to link my essay. Thank you for continuing to write so powerfully about this topic.
*tenet, not tenant