Mental Disorders Are Not a Myth

Professor Schaler has misread and misstated my views.

1) Most emphatically, I have not agreed with Professor Schaler that mental disorders are a myth. Quite the contrary, my strongly held view (stated several times and in very plain language) is that mental disorders are very useful constructs, not well established diseases—but certainly not myths.

2) Professor Schaler claims that I “avoid any mention of the nefarious ways psychiatrists coerce innocent persons in the name of practicing medicine.” Again, please reread my first response where I provide specific examples of the risks of coercion drawn from the United States, China, Russia, and Australia. And in more than a dozen papers and postings, I have relentlessly exposed the abuse of involuntary commitment in Sexually Violent Predator hearings. I am anything but blind to the risks, but unlike Professor Schaler, I understand the occasional necessity.

3) Professor Schaler attributes statements to me that I simply didn’t make—that all patients lack insight, that this is equivalent to unconsciousness, that patients are children.

4) I have written often that psychiatrists cannot accurately predict precisely who is going to harm self or others and precisely when such violence will occur. The prediction issue came up recently in regard to discussions about the relative roles of psychiatry and gun control in reducing the harms done by mass murderers. Psychiatrists can’t mind read or pull needles out of haystacks—we can do no more than identify a group of people at high general risk, the overwhelming majority of whom require no hospitalization at all. Clearly, involuntary commitment should be invoked very rarely and as a last resort—only under the most extreme circumstances when it would be irresponsible to ignore risks that are urgent, obvious, immediate, and terrifying and only when it is impossible (at least for a time) to forge a voluntary therapeutic relationship. There should always be careful clinical quality control and by law there is always a judicial monitoring process.

5) Just as psychosis is no “myth,” the laws governing involuntary commitment are not a “legal fiction.” They are in place throughout the world for the simple reason that involuntary commitment is sometimes a necessary practical response to a difficult problem that has no other solution. Nothing in Professor Schaler’s ivory tower ideology changes this clinical or legal reality.

Jeffrey Schaler’s response is not really a response; it is just a repetition. He misstates my views and offers no practical solutions to the problems I raise and none to the even bigger problems raised in Amanda’s brilliant discussion of the inappropriate warehousing of mental patients in the prison system.

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.