Imagine Insanity

In reading Ginny’s post below as well as the posts and comments of the sites she links to, I note a strong presumption among most that in the case of mental illness we should err on the side of under-treating rather than risk over-treating someone. Dr. Jonathan Kellerman makes this observation:

Talk to anyone who’s tried to commit a dangerously violent child or parent for even a few days: A stranger with a law degree will show up at the hearing and paint you as a fascist. So it’s far too much to expect anything resembling a decisive approach to those whose level of threat remains at the verbal level.

The presumption of minimal or no treatment doesn’t exist in the rest of medicine. We expect that if our wishes are not otherwise known medical professionals will do all in their power to treat us. Yet in the case of mental illness, we all seem to imagine that we would rather not be treated than to receive treatment we do not at the time think we need.

Why the difference? I think the major reason is quite simple: Most of us simply cannot image that we will even go truly insane.

We can easily imagine that we might suffer from accident or disease of the body and be rendered unconscious or incoherent, so we support a public policy creating a presumption of treatment but we cannot really imagine that we might develop a severe disease of the mind that would have the same effect.

In part, this is a reasonable assumption. Today, if a person makes it to 25 without developing a severe organic mental illness, chances are they never will. They might get some kind of dementia very late in life but otherwise not. For the age group that creates and implements public policy, the chances they will go crazy or even know a peer who does so is very,very low.

Neither do we give a lot of thought to the risk that one of our children will develop a serious organic mental illness. Perhaps the prospect is just too damned frightening. Few people today know someone who is institutionalized. Due to the stigma of mental illness, many do not inform even close family of the true extent of a loved one’s illness. Most of us will spend out lives without directly experiencing the reality of severe mental illness.

Few artistic works realistically portray mental illness. This leaves us with little but our imaginations to inform us about mental illness. I think we find it much easier to imagine ourselves being wrongly or maliciously diagnosed as mentally ill than we do to image that we might really need treatment but be so impaired that we do not realize it. When we sit down to make public policy, we unconsciously start from the presumption that a mental health misdiagnosis is more likely to be wrong than to be right, because we generalize from our own ego-experience. We imagine that we would prefer to remain untreated than risk being over-treated or mistreated.

Sadly, severe mental illness tends to strike first in the age range of 18-24 years of age. It strikes young adults who have just left their parents’ oversight but have not yet established their own mature support networks or resources. Unsupported, they can degenerate with frightening rapidity. Yet, our current legal system presupposes that they can make decisions of such difficulty as to challenge the mentally fit and more mature. We do this, I think, because we intuitively believe that we ourselves could make good decisions in the same circumstances.

Well, you could not and would not have. The person standing mumbling on the street corner is proof of that.

Related posts:
Howl & Reality
One of Those Things We Forget About the 50’s & 60’s

8 thoughts on “Imagine Insanity”

  1. Shannon,
    As usual, you think about a problem from an original and useful angle. I suspect, as usual, your point is good. And of course, the patients shouldn’t be in charge of the asylum. And, of course, people like Forman were wrong. I was truly irritated both by Hair & One Flew Over the Cuckoo’s Nest. Insights that see such systems as like those in Eastern Europe are not helpful. That way of looking at things (as Kellerman points to Szasz) had consequences.

    However, I also suspect we are more suspicious of these treatments than of most physical ones; this field has not always held itself to high standards and has often followed fads. I remember, for instance, when the root cause was sexual abuse by parents. Before that, the causes were thought to be cold mothers. In the fifties homosexuality was considered a mental illness; now, homophobia is. I respect some psychiatrists, but some appear charlatans.

    While I have been fortunate in this life not to have had an immediate relative who was seriously ill, I have known many and in families quite close. Part of the reason we don’t embrace treatments as quickly is that the medications that truly do help have not been around long – and used intelligently an even shorter time. What was described as “help” for those of us past a certain age or unfortunate enough to take a loved one to doctors who were not competent were high-dose shock treatments, operations & medications that “cured” by leaving a patient barely sentient. That may, indeed, have been preferable to becoming Cho, but is not attractive. As you observe, the rate of mental illness is lower; it takes us longer to see the medication working, while antibiotics were used by almost everyone several times in a childhood. While a calm may appear quickly with a sedative, only in time do we see the changes that antibiotics gave in a few hours, when temperatures fell from 104 to 98 degrees.

    Not surprisingly, this uncertainty makes insurance coverage erratic. I suspect my neighbor’s problem of twenty years ago was not unrepresentative: her son was diagnosed first as schizophrenic; the doctor recommended putting him into a new and expensive local treatment center; they kept him there until insurance stopped paying at which time they discovered he was manic/depressive.(Since his mother was depressive, this was a diagnosis a layman, who had no ties to any facility, might have made.) While most of us would be quite willing our insurance cover the kind of medications that allow my schizophrenic friend to function as a useful part of society, few of us want to pay for endless sessions for Woody Allen – analysis we tend to see as self-indulgent & not very effective.

  2. I think this is the site where I read about the “mental hospital reform” that took place in NYC in the 60’s. (You know, the one that gave us all the “homeless” people?) So I appreciate this post.

    I live in Austin currently. This place has to have the highest per capita population of beggars outside of CA and NYC. One night my friends and I… err… One very LATE night my friends and I got the idea to go out and interview the homeless in South Austin and around the downtown. We talked to quite a few and the ones that didn’t openly admit they were mentally ill didn’t need to. (One guy was calmly explaining to us how the REAL earth was caught in a different dimension and we were on a different fake earth – I forget the actual name of this new terra – and how it was, of course a conspiracy – although he never blamed it on the Jews)

    One guy was pretty put together, but he said that a month earlier he was banging on the door of a hospital begging to be committed so he didn’t kill himself. He said it happened alot and sometimes they helped him (fed him drugs and tied him up) and sometimes they didn’t. It seemed like most of the folks had family that could take them in, but were embarrassed and/or didn’t want to bother them with their severe illnesses (the family was often adult children.)

    Strangely enough, a surprising number had advanced degrees.

  3. Ginny,

    I don’t disagree with anything you say. I think the simplest solution to the problem is simply to see if individuals can function at the minimal level require to manage a household. If the person can pay their bills from whatever income they have, find their home and not burn it down, then I think we should define them as basically mentally competent regardless of how odd they act unless some other dramatic evidence comes to the fore. Note this functional definition would also place severe drug addicts under supervision as well.

    Prior to the 60’s, this was the de facto because it was illegal to be homeless. People who couldn’t at least find a corner in a flop-house ended up in either the hospital or jail. When the judges replaced the traditional concept with the idea that people had the “right” to crash wherever they wished whenever the wished. The last fail safe for the most vulnerable disappeared.

  4. ElGaboGringo,

    Way back in college, I worked security in West Campus and became very familiar with the “Dragworms” who prowled the UT campus area. It was quite an education for a small town person like me. A UT professor went undercover as dragworm for a year and wrote a very interesting book on the dragworms social structure. I can’t recall the title offhand.

    I would be very cautious about relying on self-reports from the homeless. The reports of the mentally ill cannot be trusted for obvious reasons. The drug addicts are even worse.The scramble for existence on the streets breed in them a very manipulative streak. Each one often has as many stories as they have people who interview them. Most of them tell their life stories in such a way as to minimize their own culpability for their current state. Independent confirmation usually shows that they end up on the street because they alienated all their friends and family in their single minded pursuit of drugs. Far more people claim to be vets than actually served, and so on.

  5. Got attacked by huge dog. Sued. Had to get therapy for stress disorder. Doctor chatted for two min utes thengave out drugs. Told me that a few years back, therapists did the talk thing but insurnce thought this not science so paid but for limited number of visits. N0w, with med degree, therapists can hand out drugs and this is real science and so insurance goes on much longer. Then he told me, after a number of visits for my meds, that I would have to stay in treatment for the rest of my life because I was older and would not recover sufficiently. I left and never went back.

  6. There was a very good article the other day at “The Corner” about the coldness of the “therapeutic” culture we’re living in. This situation, i.e., thousands of people turned out onto the streets to fend for themselves, however badly, because keeping them in a secure faciltity was “inhumane”, is a very good example.

    The myth of the homeless as being a group of ordinary people who have suffered some kind of financial or medical setback, and were suddenly unable to afford a place to live, has been peddled relentlessly by the media, but applies to only a very small fraction of those who live on the street. The great majority are mentally ill, addicted, or both.

    It is an odd commentary on our society that stray animals are taken into a shelter and cared for, but doing the same thing for these damaged humans is considered “cruel” and a violation of their rights.

  7. Can’t argue with that Shannon. I’ve always thought that at least 75% of homeless were mentally ill and/or druggies/alcoholics. I think the crux is what portion of those are mentally ill because they were druggies/alcoholics.

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