In Search of a Middle Ground

I agree with everything in Amanda Pustilnik’s brilliant and depressing analysis. During the past forty years, our mentally ill have gone from frying pan to fire. What started as the humanistically motivated civil rights crusade of deinstitionalization 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. Instead, we have created a vicious revolving door—discharging our mentally ill from hospitals that were often admittedly far less than ideal and admitting them to totally inappropriate, dreadfully Dickensian prison environments. This is a barbaric throwback to more primitive times and a shameful contrast to the more humane, enlightened, and cost-effective community treatment available in most of the rest of the developed world. And things have gotten worse as a result of the erosion of state revenues that followed the banking crisis—two billion dollars have been cut from what were already draconian mental health budgets.

Regarding the comments of Jeffrey Schaler and Jacob Sullum: The fundamental question is whether there is a possible middle ground where their lofty principles defending individual freedom can meet the difficult reality that a psychotic person is not really expressing anything resembling a ‘free choice’ when he follows a command hallucination to jump out the window. So far, it looks like the answer is probably no—this is unfortunate, but not surprising. The view from their academic perch is very different from the reality in the clinical trenches. I will try to clarify my views in the continuing hope that we can still find some points of contact.

Schizophrenia is an extremely useful clinical construct; not a disease, but also not a myth and certainly not some arbitrary invention of psychiatry. The construct “schizophrenia” should not be reified or given more weight than it can carry—but it also shouldn’t be given less credit than it deserves as a useful predictor of prognosis and treatment. The same appreciation of both the limits, but also the uses, of psychiatric diagnosis applies to the other mental disorders included in DSM.

If the definition of “disease” requires a well-understood etiology and pathology, then schizophrenia—along with many other conditions treated by physicians—would not be considered a disease.

Despite all the powerful tools at our disposal, science is still in the early stages of discovering the causes and mechanisms of most the things that doctors treat. And we are often in the dark about how treatments work and why they sometimes don’t. Medicine is still based much more on trial and error than deep understanding of cellular mechanics.

We know less about schizophrenia than about lupus or Parkinson’s or migraine, but we really don’t know much about the pathogenesis of any of these or many other psychiatric and medical conditions. This doesn’t mean we can’t accurately diagnose and effectively treat them. Until we learn more, clinical constructs in psychiatry and medicine count as wonderfully useful, if temporary, heuristics.

Almost certainly, schizophrenia will not turn out to have a unitary cause. Bleuler (who first coined the term one hundred years ago) intuited this and described the ‘group’ of the schizophrenias. But the term “group” doesn’t do full justice to the great heterogeneity likely to characterize the causality of psychiatric disorder. Brain functioning is ridiculously complex and things can go wrong in all sorts of different ways. As with breast cancer, there will likely be dozens, perhaps hundreds, of different pathways to the final common descriptive construct we call “schizophrenia.” This inherent heterogeneity is also probably true of neurodegenerative processes that get lumped under useful but also temporary rubrics like “Alzheimer’s Disease” or “Parkinson’s Disease.”

It will be the work of many decades to tease out the multiple causes of most medical conditions. The human brain is the most complicated thing in known universe—far more complicated than any other organ of the body. It will yield its many secrets only very slowly and in small bites. But the secrets are there to be found along the steady (if frustratingly slow) path of scientific discovery. This is not the stuff of “myth” or “there are no balls or strikes til I call them.”

Indeed, schizophrenia can be considered a “myth” only by those who haven’t had much clinical or life experience getting to know well the unfortunate people who bear its burdens. Though not a discrete “disease entity” (like, say, tertiary syphilis or pulmonary tuberculosis), schizophrenia certainly does produce profound and prolonged “dis-ease”—that is, distress and incapacity. The patterns of its presentation are clearly recognizable, can be reliably diagnosed, run in families, have brain imaging correlates, predict course, and respond to specific treatments. Schizophrenia is real enough and no “myth” or psychiatric invention for those who suffer from it and for their loved ones. Pustilnik’s discussion is also worth rereading for its concise and elegant explanation of the epistemology of mental illness.

Admittedly though, schizophrenia is an imperfect construct. There is no objective biological or psychological test. Its presentation and course are heterogeneous and its boundaries are fuzzy. Schizophrenia has often been (and still is) diagnosed far too loosely, and antipsychotics are often prescribed carelessly, without proper indications or concern for dangerous side effects. The diagnostic evaluation is fallible when done quickly or inexpertly. It relies on information gathered from the patient and other informants, family history, and the findings on the mental status exam—after also ruling out the many psychiatric, substance use, and medical conditions that can mimic schizophrenia. Definitive diagnosis may require following the patient and observing his course over a period of months or years. But the procedures used in diagnosing schizophrenia are not very different than a neurologist diagnosing “migraine headache” or an internist diagnosing lupus or many other medical conditions. Reliable and accurate diagnosis of schizophrenia and other psychiatric disorders is possible when care is taken.

And with all its limitations, the diagnosis of schizophrenia does convey a great deal of information that is vital to clinical decisionmaking. Mental disorders don’t have to be well defined “diseases” (in the pathoanatomical sense) to be useful. It is enough if their recognition guides treatment, predicts prognosis, and helps to reduce our patients’ suffering and incapacity. Most of medical diagnosis does no more.

Involuntary commitment is easy to attack on idealistic, theoretical grounds—but in practical, real life is sometimes absolutely essential. There are rare and extreme circumstances when someone with the diagnosis of schizophrenia has dangerous, commanding delusions and/or hallucinations—placing him at unacceptably high and immediate risk of hurting himself or others. Involuntary psychiatric hospitalization is an unpleasant, but necessary, last resort in explosive situations where voluntary cooperation to reduce risk cannot be achieved.

As Pustilnik’s data make clear, the suggestion to instead call in the cops is absurdly off the mark. Jail has been the worst possible outcome for the individual, the jail, and the society; attempted arrest would often provoke more violence; and imprisonment is not a feasible legal solution if no crime has yet been committed. Legal systems throughout the world have long made provision for involuntary psychiatric commitment for the simple and compelling reason that at times no other societal response is more suitable. When nothing else will do, psychiatrists have a clinical, legal, and moral responsibility to protect people with serious mental illness who would otherwise be at great risk.

Involuntary commitment should never be casual or careless, should be a last choice, will usually be very brief, should be carefully monitored to prevent abuse, and is often appreciated by the patient after the fact. Commitment is always a judicial decision under very restrictive “emergency” criteria—usually imminent dangerousness to self and/or others. It is a necessary last option that can’t be wished away by armchair idealists who can suggest no realistic alternative—because there really is none.

The role of schizophrenia in the criminal justice system is even more complicated and fraught with hopeless controversy and misunderstanding. The construct of schizophrenia was created for clinical, not forensic purposes, and adversarial psychiatric testimony often sheds more heat than light. My personal view is that in boundary cases the diagnosis should be used extremely narrowly and sparingly. For example, I believe that the recent run of 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.

So where does all this leave us? Is it possible to reconcile Szaszian extreme libertarianism with common sense psychiatry? Throughout my career, I have advocated for an anti-paternalistic psychiatry—for engaging the patient as a full partner in all decisionmaking whenever this is possible; avoiding over-diagnosis and over-treatment; normalizing; and accepting individual difference. I have not seen much value in psychiatric hospitalization except when the risks of outpatient care have become too great to assume. I have discharged many hundreds of patients from emergency rooms and hospitals when the risks were real but worth taking. And I have admired Tom Szasz personally, respected his principled stance, and found great value in his cautions against the real and potential abuses of psychiatric power.

But I think Szasz and his followers go too far. Insulated from clinical reality, they present an inflexible, impractical, and extremist position that creates its own set of serious dangers (committing violent acts or winding up in jail) for the very people he is trying to defend. Individual freedom of choice is one of our highest values and is to be preserved at almost all costs- except in rare and extreme situations when it clashes with the even more pressing value of preserving life in those who have lost the capacity to make free choices. I could be wrong (and it is not really a fair argument), but I am pretty sure Tom would have been less extreme and dogmatic if he had allowed himself to have clinical experience dealing with real life-and-death situations rather than playing with abstractions.

Laying out the differences between libertarian theory and practical clinical reality is probably useful even if sadly we can’t hope to resolve them. I am fully mindful that involuntary treatment is a slippery slope that can easily lead to grave abuse (witness the loose diagnostic practice in sexually violent predator cases in the United States). But I am also convinced there are dangerous clinical situations in which it would be irresponsible to let things freely follow what would be an obviously disastrous course. Doctors should first do no harm, but also cannot shirk unpleasant responsibility.

Also from this issue

Lead Essay

  • 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

  • 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.

  • 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.

  • 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.