Finding a Place for the Mentally Ill

Amanda Pustilnik surely is right that too large a share of the U.S. population is behind bars, including half a million drug offenders, people whose probation or parole is revoked because of drug use, and various nonviolent criminals subject to draconian mandatory minimum sentences. Whether some of those people should be locked up in mental hospitals rather than prisons is another matter.

One of the main questions raised by Pustilnik and Allen Frances is what to do with people whose disturbing behavior falls short of a crime. Frances complains that “armchair idealists… suggest no realistic alternative” to coercive psychiatric treatment. I am pretty sure that refraining from using force against someone who has committed no crime does not count as a realistic alternative as far as Frances is concerned, but to me it seems morally mandatory.

I see the logic of making exceptions for people whose ability to make decisions for themselves has been compromised by a brain injury or neurological illness. But when the condition allegedly impairing someone’s will or clouding his judgment is a “construct” that in practice amounts to nothing more than a catalog of his troubling actions and statements, the potential for abuse is clear. If “there is no objective biological or psychological test” for mental disorders, as Frances concedes, using these labels to strip people of their liberty (or relieve them of responsibility) is hard to reconcile with the rule of law.

Frances suggests, for instance, that “mass murderers whose killings are based on fringe, extremist political beliefs are usually better handled as murderers in the legal system than as mental patients in the psychiatric—even if their beliefs seem offensive and bizarre.” But as I suggested in my opening essay, such classifications seem utterly arbitrary, making legal outcomes hinge on psychiatric whim.

As far as common ground goes, I believe that Thomas Szasz himself would partly agree with Frances’ remarks about deinstitutionalization:

What started as the humanistically motivated civil rights crusade of deinstitutionalization quickly degenerated into a callous exercise in cost cutting and neglect. The money saved on hospitals rarely followed the patients into the community where it could have provided support for decent, independent living.

Similarly, Szasz had this to say in a 2000 interview with Reason:

This whole deinstitutionalization process was just as involuntary as the institutionalization process. First the patients were placed in the institutions against their will. Then they were kept there for a long time, and generally they became desocialized. They had no way of making a living, and their families didn’t want them; they had no particular place to live. Instead of being allowed to stay in the hospital, which the majority of them probably considered their home, they were forcibly evicted and placed in other institutions run by the state but which are no longer called hospitals.

Under the policy preferred by Szasz, all treatment would have been voluntary:

[Patients] would have been free to leave, and they would have been free to stay. They could have simply got room and board. That option was never given to anyone. I wouldn’t give that to anyone except those who have already been victimized. They should be given every chance to get out insofar as they want to get out.

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.

  • Calling Mental Illness “Myth” Leads to State Coercion by Amanda Pustilnik

    Amanda Pustilnik argues that the most profound violations of liberty in this area don’t come from coercive psychiatry, but from the warehousing of the mentally ill in our criminal justice system. Such people aren’t more likely to commit crimes, but they fare badly in the criminal justice system, where unusual behavior leads to convictions, longer sentences, parole violations, and reincarceration.

The Conversation