A criterion for recovery

When a criminal defendant is found not guilty by reason of insanity, he or she is involuntarily committed until no longer mentally ill and dangerous. Such recovery is very difficult to prove, especially to the clear and convincing standard usually required. "Not mentally ill" is almost impossible by definition, because mental illness is officially known to be incurable, and no objective test exists to rule it out. Of course there's "remission", but that only means the mental illness may come back at any time with little or no warning.

Thus once an "NGRI" verdict is in, an insanity acquittee is virtually forced to profess faith in psychiatric treatment and slave away in the temples of forensic mental health orthodoxy, until sufficient favor is curried from the masters and high priests, who alone and arbitrarily, can affirm or deny the necessary recovery before the judge.

If the NGRI verdict disposes of a violent criminal charge, the acquittee effectively faces a choice between long incarceration or permanent status as a consumer of mental health services. I.e., you're either locked up for life, or drugged for life (and your drugged life may be shorter). There is virtually no way to mitigate that choice, no matter how you feel, how you think, or how you behave.

There should be clear, objective criteria for recovery from mental illness. These should not be made up separately by treatment teams for each patient. They should be universally accepted signs that any person is no longer mentally ill. Acquiring a formal education could surely be such a sign. Learning (or teaching someone else) a second language could be one, too. Regularly performing any function (e.g., janitorial or secretarial) essential to the operation of the forensic clinical community might qualify. It seems like if psychiatrists can create diseases by voting on complex lists of symptoms and contingencies (as in the DSM), then formulating general criteria for recovery from mental illness wouldn't be impossible. The only thing preventing that exercise is the completely irrational presumption itself, that nobody is ever cured of mental illness.

One possible criterion occurred to me today. Maybe it's just because I'm a lawyer, but....

When a forensic psychiatric patient files a lawsuit against the state, that behavior is generously despised by the powers that be. Elgin Mental Health Center and the Illinois Department of Human Services suffer when they are sued. They have to get the Attorney General to appear at least once in their defense; sometimes they even have to go through civil discovery. If the complaint is not frivolous on its face, if it's not completely delusional, it might cost significant money, and the money will have to come out of somebody's already-dicey budget. Somebody will be blamed for the nuisance, and it will probably be somebody in addition to the patient-plaintiff.

Now almost anybody can file a lawsuit. That's the way our system is designed. But filing lawsuits that lose is tediously unrewarding. Most people won't do it repeatedly, and forensic mental patients especially dislike being pathologised as "litigious". There's always an Assistant State's Attorney just waiting to trumpet such a credible symptom of illness, in arguments against court ordered privileges or release.

So what if (this does happen) a patient files a lawsuit against the state that succeeds, or what if he or she files lawsuits on multiple occasions that are not quickly and cheaply defeated? That should be a particularly reliable criterion for "not mentally ill" or "no longer mentally ill".

To win a civil lawsuit, or even to keep one going for very long, a person has to be able to predict multiple sides of often complex arguments. He or she has to have some appreciation for the social basis of law, and patiently follow socially evolved procedures and court rituals. Only litigators (whether they are regular lawyers or jailhouse lawyers) who think effectively, control emotions and behave well have any real chance in court. If they are mental patients they have to be even better, because they are overwhelmingly stigmatized from the word go.

Thus, if an NGRI patient is known for causing trouble with lawsuits, it should be strongly suspected that he or she is no longer mentally ill.

The APA is corrupt

Dr. Paul Appelbaum, M.D., a psychiatrist from Columbia University and a past President of the APA, was one panelist in the symposium I attended today in San Diego, entitled "The Battle Over Involuntary Psychiatric Care". This was Dr. Appelbaum's seventh presentation during the week of APAAM 2017. Clearly, he is an APA star.

Dr. Appelbaum did not "battle" at all, however. He gave a fairly boring synopsis of the history of involuntary psychiatry, the main point of which was that it was only beginning in very recent times when voluntary hospitalization even became a concept. Historically, everything was involuntary. He believes now that society will not relinquish its dangerousness-only-based justification for forced treatment, despite the fact that there may be better justifications. In particular, he considers that the possibility of successful treatment should be a basis.

In other words, whether or not a person is truly dangerous to themselves or others, it might make sense to force them into "treatment" that will work and actually help them live better. It seems illogical (to Dr. Appelbaum) that a person can meet legal criteria for involuntary hospitalization and yet be allowed to refuse "treatment". These issues should suggest a new look at the laws, which were more or less all created in the 1970's. The doctor's opinions were communicated in a very calm, conservative way that could be interpreted as banal arrogance. No need for any "battle" in any event.

What Dr. Appelbaum fails or refuses to consider is that his own concept of "treatment" (that would be drugs, drugs, drugs, and nothing but drugs) is something that many people do not want and go to enormous trouble to escape from. It is damaging. It causes disability, dehumanization and loss of life. 

This reality is something that Dr. Appelbaum seems to completely deny, or to be completely ignorant of. In fact when one member of the audience brought up the recently less controversial position that long term "maintenance" on antipsychotic drugs is bad for recovery from psychosis, he threw out a citation of the new article by Jeffrey Lieberman saying neuroleptics aren't bad for people at all! That article, of course, was meticulously criticized and decisively refuted by Robert Whitaker in a MadInAmerica  blog. (What a surprise, Dr. Appelbaum didn't mention Whitaker's criticism.)

Drs. Appelbaum, Lieberman and their ilk are exactly what Whitaker refers to as "a case study of institutional corruption". If they are American psychiatry, then American psychiatry has little or no future. 

I asked Dr. Annette Hanson, M.D., about the future of psychiatry. Dr. Hanson is one of the authors of the book, Committed: The Battle Over Involuntary Psychiatric Care, from which the symposium's name was derived. She graciously signed my copy of her book, and got her co-author Dinah Miller, M.D. to do the same.

My question was, "Given a presumed, hypothetical continuation or acceleration of two trends, how do you see the future of psychiatry and the law? The two trends have been repeatedly suggested and evidenced during the week of the APA conference. They are: 1) the substantial loss of faith in a pure medical/brain-pathology model of psychosis; and 2) the loss of public will to force people into treatment for mental illness."

Dr. Hanson liked my question, and we had a short conversation. She practices in the field of correctional (i.e., prison) psychiatry. Her experience has much in common with my own. People have to be "treated" by alert human beings who understand them and care, and take time to predict what they think and what they will do as people. It may take years, patience, much trial and error, many steps back for many steps forward, much negotiation, etc., before a violent criminal said to be "mentally ill" becomes well and civil. This is a teaching project far more than any procedure for medical cure. In short, the psychiatrist must talk the "patient" into changing his attitudes and his behavior.

Obviously this is a far cry from the Appelbaum-Lieberman vision of psychiatric power based on medical technology and access to legal force. Those guys are on their way out.

I also told Dr. Hanson to let her co-author know I am a member of the group she claims she had to "ambush" to get a statement for her book. (See pages 34-36 of Committed.) More conversation, please!

APA Annual Meeting 2017 (San Diego)

Interesting thoughts provoked by a session on outpatient commitment, or "Assisted Outpatient Treatment" yesterday...

When a court requires an individual to be "treated" although he/she truly and competently wishes not to be, are we trying to help that person, or are we controlling risks and adverse influences in the community? Certainly either purpose is legitimate. The two combined may even describe civilization itself rather fully.

But helping people and controlling them are distinct, separate activities. In psychiatry, especially involuntary psychiatry, they are hopelessly confused. And that may even describe the whole problem rather fully.

The session I attended featured seven speakers: Dinah Miller, M.D., from Maryland; Ryan Bell, M.D., J.D. and Kimberly Butler, LCSW-C, from New York; Erin Klekot, M.D., from Ohio; Mustafa Mufti, M.D., from Delaware; Adam Nelson, M.D., from California; Marvin Schwartz, M.D., from North Carolina.

Dr. Miller, the moderator, was the biggest reason that I actually came to this conference. She and co-author Annette Hanson, M.D. recently published a fascinating book, Committed: The Battle Over Involuntary Psychiatric Care (Baltimore: Johnson Hopkins University Press, 2016). They are also running a symposium today based on that book, at APAAM 2017.

Amost all my life, I've been an advocate for the total abolition of psychiatry. Many people interpret that to mean I am opposed to helping people with "mental illness" or opposed to medical treatment or science generally. None of that has ever been true.

My friend Tom Szasz said that psychiatry as we know it would wither away if it only lost its facility to acquire and retain "patients" using the police power of the state. I have long believed this is a compelling argument and a highly reliable prediction. In fact, it has primarily informed my career as a lawyer and my advocacy as an abolitionist.

Now an even more fundamental framework is occurring to me. Is "treatment" help, or control? If so-called "mental health professionals" could be required to honestly confront that distinction with their "patients" many things could improve.

When you have four security guards hold a woman down, struggling and screaming, for a nurse to force a needle into her body and inject a drug that will alter her mind against her will, there is simply no chance that your "patient" will experience it as help. You should not be allowed to call it help, or even to think that you are helping. Your lie will degrade you, and if your "patient" gets any wind of it she will hate you and forever dream of revenge.

On the other hand, precisely the same violence recognized openly and officially as control, while regrettable, may be an inevitable compromise in an imperfect society subject to disagreements and fears. That can be forgiven. It also may not require creation of elaborate bureaucratic machinery to protect falsehoods in the institutions where I practice law. 

Dr. Miller said yesterday that she doubts forced treatment can or should be justified as a public health measure. I absolutely argue the opposite: it must and can only be justified as a public health measure! The public has a right, and will always assert the right, to protect itself. If subduing a violent person (or even a merely obnoxious person) with antipsychotic medication were workable as public protection or community improvement, we would probably be confident in involuntary psychiatry as morally justified control.

But if you are a doctor and you honestly want to help a person in front of you, it will be necessary to find the insight and patience to treat that person only with his or her informed consent.

Dr. Bell, who had more direct experience with outpatient commitment (in New York) than anyone else on the panel, responded to a question I asked, about whether patients might occasionally change the minds of clinicians, even about such fundamental issues as what is wrong with them and what is needed. He told a story of a man he treated for some years. The end point was, yes, a human being's autonomy must be respected or help simply does not occur. 

This seems obvious and fundamental. There should be a rule or a law. 

Constitutional Amendment 28

   Section 1. [Abolition of Forced Mental Treatment]

   Neither involuntary mental hospitalization, nor coerced mental treatment of any competent person whose refusal of help is clearly expressed for any reason or for no reason, shall be permitted within the United States or any place subject to their jurisdiction; nor shall the presumption of any person's mental competence require medical or scientific proof; nor shall benevolent medicine be considered to justify criminal justice or lawful security measures.

   Section 2. [Power to Enforce this Article]

   Congress shall have power to enforce this article by appropriate legislation.

Rescinding psychiatric "diagnoses"

Dr. Lucy Johnstone, British clinical psychologist and author, recently suggested that a psychiatrist who was praised for his recent, honest about-face regarding his entire life's work on "schizophrenia" could be respected even more if only he would rescind the invalid diagnoses he has saddled so many people with over the decades. This is a great idea just waiting for practical implementation.

My first thought is a standardized form, which could be used immediately by anyone, but gradually accepted and made more and more "official" under whatever organizational and legal rules or policies can be successfully lobbied in support.  For example:

RESCINDED DIAGNOSIS

Name of individual:__________________________________________________

Address of individual:________________________________________________

Date of birth:_____________________________ Gender:__________________________________

Name of mental health professional:__________________________________________

Affiliation:_______________________________ License:__________________________________

STATEMENT:

The individual identified above was given a diagnosis of: ____________________________________________________________ on or about___________(date), by (check one): ___Me ___ a mental health professional whom I have identified as: ___________________________________(name), of ___________________________________(institution and/or address).

I hereby declare this diagnosis to be invalid from this date forward, because of the following (check all that apply):

___ the original diagnosis was based only upon symptoms of which this individual no longer complains, or observations which are not apparent or susceptible to any objective validation in present time;

___ the original diagnosis is no longer considered to be any valid disorder by mental health professionals;

___ the original diagnosis is an unscientific and arbitrary characterization which serves no medical or psychological purpose to help the individual or protect society;

___ other (please summarize):

Therefore, pursuant to _______________________________(specify at least one specific rule, statute, case precedent, ethics code or regulation), enacted on _____ (date) by _________________________ (name of authority), I hereby caution all persons, that any future or continuing reference to, or use of, the above invalid diagnosis, if such reference or use could create any disadvantage to the individual identified in this document, may subject you to civil and/or criminal liability for defamation, discrimination or fraud.

(Signed)

(Witnessed/Notarized)

Michael A. Cohen, dumb hack

A recent article in the Boston Globe is just beyond amazing, for its combined arrogance and naïveté.

Dylan Roof, the murderer of nine black parishioners at the Emanuel AME Church in Charleston, SC, is about to be sentenced to death. The journalist is obviously writing from an anti-death-penalty perspective, which is fine with me, I'm neither pro- nor anti-death penalty, in any general way...

But the real point author Michael A. Cohen wants to make is apparently more about mental illness and crime: "(T)here is perhaps no better example of the inherent flaws in the death penalty -- and the problematic way that the criminal justice system deals with mental illness -- than this case." Dylan Roof supposedly has "a broken brain", for which phrase Cohen cites celebrity TV psychologist Dr. Xavier Amador.

Dr. Amador (at least as Cohen quotes him) quite confidently diagnoses Dylan Roof with schizophrenia. Never mind that Amador has never examined Roof. Never mind that Roof apparently experiences no hallucinations, and he demonstrates no disorganized speech and no grossly disorganized or catatonic behavior. The only "delusions" that can be ascribed to Roof are his racist beliefs. Amador says that Roof shows flat affect and is unable to express emotions. But how does he know that, just from the media about the trial?

Even referring to the diagnostic criteria for schizophrenia in DSM-5 as if it were valid and reliable (which is a real stretch or fantasy), we should notice that Dr. Amador's "diagnosis" of Dylan Roof is pure speculation. But Amador is a TV psych. He makes his living largely by entertaining people, maybe not so much by effectively treating them.

Why would a journalist of Mr. Cohen's stature get so serious about repeating the glib psychobabble and speculation? Cohen seems to believe that Amador is saying something substantial, something that can be analyzed for significant implications about society and justice, etc. But it's pretty obvious to anyone who can read, it's all nonsense.

Something about motive here seems inexplicable....

Well... people hate to look at death, don't they? They fear death, they fear insanity, and they fear evil. Whenever they can, they pretend that these things don't exist, or at least that they're far away. Mental illness, schizophrenia and Dr. Xavier Amador are merely social fashion, to help with the pretense.

And I'm sorry, but Michael A. Cohen is a dumb hack when he writes an article like this.

Judges and lawyers appreciate the nature of "mental illness" better than psychiatrists: at least they occasionally admit they have no idea what causes people to be evil or how to cure them.

All of those "great strides (that) have been made in understanding these illnesses within the public health community" enabled no prediction and no protection against Dylan Roof's bullets, and they offer no solution and no reassurance, whatsoever, for the future.

Those "great strides" are trips and stumbles in the dark, by idiots preyed upon by charlatans. There is no scientific knowledge here, only pretense and fear.

Moral Reconation Therapy verses Mental Illness

Over several years, Moral Reconation Therapy ("MRT") has become a big business at Elgin Mental Health Center. Some people (clinicians or patients - the difference is minimal) like it, and some don't. But veteran administrators in Illinois' "forensic mental health system" must be aware that it presents a rather interesting, perhaps a rather dangerous, intellectual problem.

MRT situates the problem of criminal recidivism in dysfunctional behavioral choices and deficient moral reasoning. Psychiatry situates the problem of an NGRI acquittee's dangerousness in mental illness, a disease like any other, in the brain.

The MRT therapist at Elgin is basically telling patients that their problem is they lie, cheat, steal, betray, victimize and blame other people; and the fact that they are where they are (locked up in that fake "hospital") is their own fault entirely. 

At the same time, the psychiatrist is basically telling patients that it's only the mental illness that limits their ability to make behavioral choices or to reason morally; it's not their fault at all, they just need to take drugs to adjust their brains.

I have several clients who have failed or opted out of MRT because they cannot honestly reconcile the demand for acceptance of sole blame with the demand for acceptance of psychiatric doctrine on mental illness. They figure one idea or the other must be bullshit. But it sure is unacceptable to mention this discrepancy! 

The psychiatrists sure will tell the judges that any patient who questions the "illness needing medicine" view lacks insight and therefore remains dangerous. The MRT therapists sure will tell judges that any patient who blames their brain disease is being manipulative and therefore remains dangerous. The bottom line is, you have to lie, in the right way at the right time, or you can't ever get out.

This is the essential, overriding lesson of forensic mental health: You must become a really competent liar, to others, to society, and to yourself.

It's a terribly expensive lesson, in blood, treasure and human dignity.