It's Terrible to Force Treatment On the Mentally Ill. But It's Worse Not to.
David Berreby is the author of "Us and Them: The Science of Identity." He has written about human behavior and other science topics for The New Yorker, The New York Times Magazine, Slate, Smithsonian, The New Republic, Nature, Discover, Vogue and many other publications. He has been a Visiting Scholar at the University of Paris, a Science Writing Fellow at the Marine Biological Laboratory, a resident at Yaddo, and in 2006 was awarded the Erving Goffman Award for Outstanding Scholarship for the first edition of "Us and Them." David can be found on Twitter at @davidberreby and reached by email at david [at] davidberreby [dot] com.
My mother had always been a suspicious and secretive person, but it wasn't until I was 14 that she really went nuts—with many of the same symptoms described in Rachel Aviv's piece in this week's New Yorker (available in full only to subscribers, unfortunately, but the summary is good and there's also this fine podcast available). My mother lived the kind of life Aviv describes so well: Early promise and achievement, check. Then a period of frustration and obscurity, check. Then the symptoms: Conviction of a vast conspiracy centered on the self, check. Mysterious lover who in reality was a passing acquaintance with no knowledge and no interest, check. Friendlessness and a tendency to drive away help, check. And, above all, the subject of Aviv's article: An absolute conviction that there was no need for psychiatrists, talk therapy, drugs or any other kind of treatment, because there's nothing wrong with me!
I have been through the wormhole of someone else's full-blown paranoia several times in my life (just lucky, I guess) and I was glad to see journalism touch on this central fact. Part of the reason crazy people are crazy is that they believe they're fine. In my mother's case, the helicopter overhead was there to spy on her, my teacher's idle chat about my day was part of a plot to spy on her and the phone rang because people were checking to see where she was—but as she'd always say, redfaced and roaring at the insulting thought, she was not crazy.
How often have I heard, from well-meaning people or from healthcare-system bullies, that there was plenty of help available, and it was just a matter of getting this or that paranoid to a psychiatrist. As if mental illness was like a having a bad cough or a bum knee. In fact, as Aviv reports, nearly half of people diagnosed with psychotic illnesses insist that they aren't mentally ill (and that number, of course, doesn't include people like my mother or her sister, who were never diagnosed at all).
Moreover, as I have learned from bitter experience, delusional people are very fond of their delusions. A paranoid person is a prince-in-exile, misunderstood and abused, but always the star: The fulcrum of a vast conspiracy, the target of top-flight surveillance tech, the object of some famous person's hidden love. Who'd want to trade that in for being a sorry, addled nobody in line for a paper cup full of meds? When a college acquaintance of mind ended up wearing a mental-hospital tag that read "10WA" (for 10th floor, Ward A) he told us visitors he was in the CIA's supersecret "Project IOWA." Many time in her life, my mother had to choose between friendship and delusion, work and delusion, me and delusion—and she always chose the self she loved best, the self at the center of the world's attention, her beloved delusional self. And a culture of absolute individual rights supported her.
Time was, family or friends or government could force such a person to get treatment, but since the 1970s concern for people's privacy and autonomy has eroded that power. Aviv's subject, Linda Bishop, was released from her final hospitalization with no place to live and without the knowledge of her family. Why? In order to qualify for housing assistance, she would have had to sign a form acknowledging that she had a disorder, and she refused. She also refused to let the hospital inform her daughter and sister, and, according to today's rules on patient privacy, her will had to prevail.
This is a pretty sorry state of affairs—as the psychiatrist Edwin Fuller Torrey points out in the piece, it is bizarre to speak of the freedom of people who are trapped in wholesale delusions. Torrey's organization, the Treatment Advocacy Center, lobbies for laws that would tip the balance away from protecting the right of the mentally ill to deny their afflictions. Many patients, ex-patients and their advocates oppose that move for many of the reasons that prompted the move away from forced treatment in the first place: Why should someone be forced to agree with a doctor's diagnosis? And how could we prevent this power being abused to force the merely strange and unpopular to conform?
What struck me in Aviv's skillful rendition of these debates was its individualistic orientation. Fuller Torrey argues that patients' suffering is greater when they're free to deny their condition. The psychoanalyst and law professor Elyn Saks,herself a schizophrenic, replies that the alleviation of suffering is no reason to violate an individual's rights—and that the suffering of forced treatment may be worse. Where, I wondered, are the rest of us? As framed in the piece, the subject of this debate is the mentally-ill person as social atom, floating in a social vacuum, with no need to consider the suffering or the rights of anyone else.
Missing from this conversation, as it often is in discussions of disability rights, is the effects of the mentally ill person on everyone around him—those who love him, do business with him, try to help him, fear him. In fact, mentally ill people cost the rest of us a lot. They cost us love, anxiety, fear, time and money.
Why doesn't that count? Surely the notion that anyone, sane or insane, has a limitless claim on the rest of us is morally questionable and practically ridiculous. Elyn Saks has written that society "should not be in the business of choosing selves" for individuals. Why not? Society does this to children for 20 years—it's called being raise and educated, a process in which the self that is entirely self-centered and wildly emotional is replaced by whatever the local child-raisers consider a polite young person. Society continues to choose selves for us, by means of convention and law, throughout our lives.
I hate paperwork, like to hold on to money, and enjoy lounging around naked in the sun. But society strongly pushes me to choose a self that files tax forms, pays what they say I owe, and declines to stroll naked to the park. By one light, this is an imposition on my absolute right to choose among possible selves. By another, it's simply the necessary business of connecting people to one another, and to community. When we suggest that mentally ill people should be exempt from such claims on them, we aren't claiming their rights are equal to those of typical people. Instead, we're saying their rights are superior. Whether the misery of treatment is worse than the misery of delusion for the individual could be debated. But when delusions aren't addressed, the misery of the rest of us is never in doubt.
My mother died at 60. Her funeral was as friendless and strange as her life, with only me, her only child, and her sister in attendance. Her death saddened me, but I have never, in the decades since, ever wished that she was still alive. All in all, a sad, painful, broken life. But her right to immiserate other people was intact, inviolate, protected to the end.
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