Calling Mental Illness “Myth” Leads to State Coercion

State psychiatry is a mouse in the manger of an elephant, a barnacle on a Leviathan. The coercive giant that straddles our country and that feeds its maw with people who have serious mental illnesses is not state psychiatry. It is our vast prison system, which coercively confines hundreds of thousands of nonviolent, severely mentally ill people who have wound up there for want of adequate treatment.

Some numbers tell the story:

Five times more people with severe mental illnesses are confined in penal institutions than are treated (or confined) in all psychiatric facilities combined in any given year. In a typical year, according to the Department of Justice, over 300,000 people with severe mental illnesses are incarcerated in state and federal jails and prisons. Yet for the same period, only about 40,000–60,000 people with such conditions reside in public psychiatric hospitals. This current total psychiatric hospital population is also only about ten percent of what it was at its height over a half-century ago, in or around 1957.

These numbers drive to two conclusions. First, what Professor Schaler calls “coercive psychiatry” is objectively a very small problem, although it was ten times greater in the past. Far from forcing people into treatment, psychiatrists every day face hard choices about who to force out of treatment: People who need and want help must be discharged due to lack of hospital space. People with major mental illnesses like psychosis and schizophrenia seek help at hospitals but are routinely turned away because the few available beds must be reserved for the handful who are truly dangerous. Getting out of psychiatric hospitals is occasionally hard for some people. Getting into them is hard for everyone.

It’s so hard to get treatment in a psychiatric hospital because nearly all of the funds that used to support them have been diverted into state prison systems. Which leads to the second conclusion from the incarceration numbers: Coercion of the mentally ill without psychiatry is an enormous problem.

The United States uses its prison system as a warehouse for adults and children with severe mental illnesses. This might be acceptable if it reflected the greater average criminality of this group. But it does not. As a group, people with these conditions are no more likely than typical people to break the law or to commit a violent crime. Their overrepresentation in the criminal system results from a host of factors including poor ability to communicate with police and attorneys, low socioeconomic status, confusion, and inability to follow directions—which leads to unintentional violations of parole or conditions of release, which leads to reincarceration. The list of such quotidian-but-important factors unrelated to increased culpability or public safety goes on and on. One of these factors is not, however, the role of psychiatrists, who become involved in a trivial, near-zero percentage of criminal cases.

Whether or not one views this mass incarceration as morally troubling, it is undeniably hugely costly. State prisons alone spend nearly $5 billion annually just to incarcerate non-violent mentally ill inmates. Many studies show that providing medical treatment and supportive housing to the same group of people would increase their subjective quality of life and reduce public spending. So why don’t we do this?

Put simply: Housing and treatment sound like benefits while prison sounds like (and is) punishment. And the punishment of people with mental illnesses seems to fit more easily with a certain version of the idea of personal responsibility. This version of personal responsibility suggests that if somebody doesn’t act right, you don’t give him a golden ticket—you give him a whack on the backside. Regardless of what that whack (or repeated whacking) costs to taxpayers and regardless of whether the approach changes behavior or produces any benefits.

This rational actor model of punishment and behavior change might make some sense if we were talking about rational actors and the importance of respecting their free choices. But despite the bizzaro edge cases that Professor Schaler describes of people choosing to mutilate themselves in gruesome ways, people with severe mental illnesses often are not expressing anything that looks like free choice because it doesn’t look like choice at all: Nobody has the power to choose to be confused, disoriented, or hallucinating.

This leads to the question of the reality of mental illnesses. Professor Schaler claims that as a matter of pure logic there can be no such thing as mental disease because the mind is a metaphor, not a bodily thing, and a metaphor cannot have a physical disease. Mind, he allows, may have reality as a social fact or construct but this is not real reality, the kind of reality you can put stitches in or cut with a scalpel.

This is a misdirection. “Mind” is not a metaphor. It is an abstraction that functionally describes some part of what our brains do. Abstractions and metaphors are not the same thing.

We use many abstractions to refer to our experience of the functions of diverse systems within our brains and bodies, like “memory” and “hunger.” When I describe my ability to visualize my mother’s face as “memory,” that’s an abstraction (or a functional description) about specific neurological processes. It corresponds to a hard core of physical reality. If I describe my imperfect memory as a capricious butterfly, that’s a metaphor. There is no butterfly. There is no correspondence between my imperfect memory and any butterfly “out there” in the world. But there is a correspondence between what I refer to as my “memory” and an “in there” that exists in my brain.

Doctors, scientists, and laypeople are comfortable speaking of “memory disorders” and “developmental disabilities” (formerly referred to as retardation). We accept that “cognitive impairments” often result from traumatic brain injury. Memory disorder, developmental disability, and cognitive impairment are abstract terms that functionally describe a range of underlying neurological injuries or diseases.

While philosophers continue to debate whether mind is entirely reducible to brain states or merely totally enabled by brain states, there is no doubt that the mind arises from the brain and that when the brain suffers injury or disease, those changes change the mind. As they change memory. As they change intellectual abilities. Imagine suggesting that people with memory disorders or developmental disorders suffer from no real medical condition and ought just to act differently because memory and intellect are metaphors. The universal response would be to find such a suggestion cruel and outlandish. Yet this suggestion remains acceptable in relation to mental illnesses.

The vast institution of coercive mental health treatment designed to transform socially unacceptable behavior into an illness and then forcibly treat that illness is itself a myth – or, more accurately, a ghost: the ghost of a long and sordid history in which mere social deviance was punished in the asylum. Yet severe mental illnesses properly defined are not myths, nor are they personal choices or eccentricities. They are genetically and developmentally influenced biological diseases. And the tragic problem is not government-coerced treatment, which almost never happens: It is the lack of treatment for people with severe mental illnesses that sends them into a spiral of homelessness, crime, substance abuse, and ultimately lives served out in prison or early death.

Also from This Issue

Lead Essay

  • Strategies of Psychiatric Coercion by Jeffrey A. Schaler

    Professor Schaler notes that mental illness differs in several important ways from physical illness, and these ways make a mockery of conventional diagnosis. Nonetheless mental illness plays an important role in our legal system; it permits psychiatrists to exercise a significant degree of coercion. Schaler challenges this arrangement and argues that those whom we may classify as mentally ill are still deserving of their liberties, including the liberty to refuse treatment. Schaler also questions whether “insanity” is an appropriate legal fiction at all.

Response Essays

  • A Clinical Reality Check by Allen Frances

    Professor Frances agrees that mental disorders are not diseases properly speaking, but he maintains that they are nonetheless useful analytic constructs. As to coercive psychiatric treatment, he argues it can indeed be a horrific abuse. Still, in some especially desperate cases it will be necessary to save lives and to prevent even greater harms. He recommends several practices designed to minimize the frequency and risks of coercive treatments.

  • Psychiatrists Create Their Own Reality by Jacob Sullum

    Jacob Sullum asks the mental health establishment for consistency: If mental disorders are not diseases, what justifies involuntary treatment? Evidence of criminal conduct is a matter for law enforcement, not mental health. And how is it that we punish sexual predators (on the theory that they are responsible) — then treat them afterward (on the theory that they aren’t)? Psychiatric diagnoses are ultimately arbitrary, Sullum argues, and they lead to the arbitrary exercise of power.

The Conversation