One Last Try at Synthesis

Congratulations to Amanda Pustilnik for her insightful analysis elucidating why it is so hard to reconcile libertarian ideals with clinical reality.  And also for her very useful suggestions toward achieving the much needed, but elusive, synthesis.

I understand and share the libertarian fear that we can easily slide down a very slippery slope once we restrict the freedom of psychiatric patients. Experience teaches that countries, including our own, sometimes find it convenient to solve perceived societal problems by an improper misuse of psychiatry. And there is no bright line definition of mental disorder to provide a firewall against all the possible abuses. I have recently reviewed dozens of cases where rapists have been incorrectly redefined as mental patients in order to justify a preventive detention that would otherwise be deemed unconstitutional. In the 1980s, I witnessed the psychiatric mislabeling of political dissidents on visits to the Soviet Union, and recently I heard anecdotal reports of inappropriate commitments in China to quell economic dissent.

We can all agree that it is crucial to prevent these misuses of psychiatry in the service of inappropriate state coercion. The disagreement arises in the handling of the extreme psychiatric emergency—which creates an inherent conflict between the strictest libertarian ideal of absolute free choice and the practical need for a commonsense exercise of clinical responsibility.

Schaler and Sullum solve the dilemma by simply wishing it away. If schizophrenia is a myth, then the proper management of schizophrenics presents no theoretical problem—we should always respect their rights to free choice just as completely as we would respect the free choice of everyone else. This is an appealing and reasonable position—except in dire psychiatric emergencies when it devolves into allowing the patient the complete freedom to kill himself, the complete freedom to harm others, the complete freedom to die of exposure, and (all too often recently) the complete freedom to wind up in prison.

Schaler and Sullum ignore these real-world unintended consequences of their conceptual purity. They persevere in repeating an irrelevant straw man argument—if schizophrenia does not meet a stringent definition of disease, it must then be considered a myth and can therefore be ignored in clinical and legal decisionmaking.

But many medical conditions fail their disease test and certainly are not myths. Ask anyone with migraine if their symptoms are mythical. Schizophrenia is a very useful construct—no more, no less. It is a well described syndrome with a characteristic set of symptoms that can be diagnosed accurately; it runs in families and clearly has some genetic predisposition; it predicts course and some biological test results; and it responds reasonably well to specific treatments.

Schizophrenia is anything but a myth for the people who have its symptoms and for the people who care about them. The suffering of schizophrenia is real; the delusional convictions are experienced as real; the voices sound like real voices, the loss of judgment is real; and the risk of harm is real and cannot be blithely ignored. Only a closeted theorist, lacking clinical or personal experience, could think otherwise and suggest that it is okay to do nothing (beyond calling the cops) to help the patient avoid serious danger in an emergency situation.

What is schizophrenia, if it is not myth but also is not yet a discrete pathoanatomical entity? Schizophrenia is a construct in the same way that all of our understandings of the world are constructs. Our brains are ill-equipped ever to perceive reality straight on and without interpretation. This was Kant’s most powerful insight and it has been confirmed in thousands of experiments in cognitive psychology. We are constantly constructing perceptions and finding temporary meanings that are useful, but never completely accurate or the final word. One example: we subjectively experience matter as solid even though it objectively consists of tiny particle-like stuff surrounded by vast swaths of empty space. But this recently gained understanding of quarks and quantum mechanics doesn’t make the familiar construct of solid matter any less useful in negotiating everyday life. Constructs provide necessary heuristics even when they are not altogether definitive or completely accurate. Schizophrenia is no more than our current approximation of one type of mental disorder—but it is a very useful approximation in guiding clinical and legal decisions. The myth metaphor has outlived whatever usefulness it ever had.

Fifty years ago, Tom Szasz made an extremely valuable and courageous contribution to psychiatry when he so fiercely criticized  what was then the wildly excessive use of involuntary commitment. The situation has since changed dramatically, partly due to the success of his crusade. We no longer have tens of thousands of involuntary patients warehoused indefinitely under terrible conditions in massive psychiatric hospitals. Most psychiatric beds have been closed and it has become much harder now to get into, rather than out of, a hospital. Involuntary commitment is now relatively rare, usually brief, carefully monitored, and used only as a necessary last resort in extremely dangerous psychiatric emergencies.

Szasz’ followers seem stuck on fighting the last war. The noble Szaszian goals of freedom and dignity will always be relevant, but the rehashed rhetoric offered by Schaler and Sullum is now off target and has far exceeded its expiration date. They have not offered any solutions for today’s real crisis of coercion—the wholesale, inappropriate incarceration of psychiatric patients in prisons. And they offer no way to adapt libertarian principle to the dangers posed by psychiatric emergencies.

Pustilnik points the way toward a new synthesis: “The harder but more worthy endeavor is to figure out a set of libertarian responses that engage with the realities of the mentally ill.” She also lays out the means—providing improved community mental health services and decent housing to allow patients the freedom of living outside the coercive institutional environments provided by both prison and hospital. As she states: “There are many other potential approaches that are liberty-promoting (and quite possibly cost-saving)… Libertarian theory is not, or is not supposed to be, a cover for indifference to other human beings.” Because it provides patients with adequate community care, Europe is doing a much better job of protecting their liberty than we are.

Two hundred years ago, Pinel freed the mentally ill of their chains. Fifty years ago, Szasz helped free them from psychiatric incarceration. Now, we need someone to help get them out of jail. We owe hanks to Amanda Pustilnik for pointing us in the right direction.     

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.