Monday, November 24, 2014

Arguments in support

(The following is adapted from recent filings in Cook County, Illinois Circuit Court, Criminal Division, and the Supreme Court of Illinois. Most citations and all footnotes are omitted for brevity.)

1.  The Illinois Mental Health and Developmental Disabilities Code [405 ILCS 5/1-100 et seq.] mandates that the Illinois Department of Human Services and Elgin Mental Health Center formulate an individual services plan, or treatment plan for the Defendant, which must be reasonably calculated to result in sufficient improvement to enable his release, or to arrest his decline, and which takes into consideration his own preferences regarding treatment.

The legally prescribed purpose of the treatment plan does not admit any intention to punish the Defendant for the crime he was charged with, nor does it direct DHS and Elgin to chemically disable him from all possible commissions of bad or dangerous future behavior.  Rather, the most optimistic conception of the purpose of the treatment plan is to enable the Defendant to become a more social and trustworthy person who can live peaceably and as productively as possible in the community.

Toward this purpose the statute recognizes positive value in the Defendant’s own free and willing collaboration with his treatment; and it contemplates the probable negative effects from adversarial coercion or forced treatment.  If a mentally ill person, having been violent in the past due to his mental illness, cannot attain un-coerced insight into his own condition approximating the understanding and diagnoses of those mental health professionals who are treating him, he is not likely to be considered safe for release into the community.  But the treating clinicians are not exact scientists of the mind or behavior.  Their information about their patient comes mostly from their patient. Mutual trust and open, honest agreement are thus great facilitators of positive change; strict orders, poorly understood evaluations, and resentful compliances are not.  The Illinois Mental Health and Developmental Disabilities Code, as a whole, embraces these realities of mental health and mental illness.  Treatment planning cannot avoid them.

2.  Section 2-107 of the Code [405 ILCS 5/2-107] establishes the Defendant’s right to refuse psychotropic medication, for any reason or for no reason; this section also establishes the duty of DHS and Elgin to not make the Defendant take drugs once he has refused, whether or not it may be a current and generally accepted or recommended treatment for his mental illness, unless an immanent threat of serious harm exists and no less restrictive alternative is available.

Whether an individual does or does not take any drug must remain primarily a matter for that individual’s own competent choice under almost all circumstances, and must not become the separate decision of (supposedly) benevolent experts who work for the state.  The only exception must remain situations wherein some serious and immanent harm is truly threatened.  The history of mental treatment in particular is rife with abuse and irrational whim, often recognized only in retrospect.

At the dawn of the discipline of psychiatry, one of its founders (Benjamin Rush, a signer of the Declaration of Independence) believed that terror should be employed to cure mental illness frequently caused by masturbation.  If this seems strange, superstitious or far removed from our modern scientific culture, we should recognize that the bulk of physicians of his time were convinced by Rush’s theories, and his image still adorns the seal of the American Psychiatric Association to this day.

In the 1850’s American psychiatrists generally agreed that African American slaves ran away from their white masters because of a mental illness called drapetomania.  But over 100 years later, in the 1960’s, multiple studies by the National Institute of Mental Health still concluded that blacks had a 65% higher rate of schizophrenia than whites; and a 1974 advertisement for the antipsychotic medication Haldol in a leading professional journal showed an African American man with a clenched Black Power fist, whose symptoms of social belligerence obviously required chemical management.

In 1990, Time magazine declared Prozac a “breakthrough” drug for depression.  Less that a quarter century later, the fraudulent nature of the story told by Ely Lilly and psychiatry is well known, and pharmaceutical companies have backed away from research into new psychotropic medications as they pay billions in fines.   The Director of the National Institute of Mental Health has recently taken the public position that even the latest (“atypical”) antipsychotic drugs cause more long-term harm than good, and the disorders that they supposedly treat are invalid medical concepts anyway.

The Illinois Supreme Court stated a crystal clear precedent, alluding to such history and defining a public policy prerogative with regard to refusal or coercion of psychiatric treatment, in In re C.E. 161 Ill. 2d 200, at 214-215 (1994):

     "Two fundamental concerns have guided our conclusion that the prerogative to refuse unwanted psychotropic medication is a protected right of the mental health recipient. The first of these concerns arises from the substantially invasive nature of psychotropic substances and their significant side effects… Our second concern is the recognition that psychotropic substances may be misused by medical personnel, and subverted to the objectives of patient control rather than patient treatment."  (Internal citations omitted.)

The Unified Code of Corrections [730 ILCS 5/1-1-1 et seq.] does not modify the Defendant’s essential right to refuse psychotropic medication or the duty of DHS and Elgin to not make him take it. Section 5-2-4 [730 ILCS 5/5-2-4] merely specifies certain security procedures and safeguards required before defendants found not guilty by reason of insanity and in need of inpatient treatment may be released back into the community. A “requirement to be medicated” is not specified.

3.  This case presents no relevant issue of fact, and it does not concern the proprieties or standards of practice in psychiatry or any other professional field of medicine; the only issue is one of law alone, regarding the legally prescribed nature of a treatment plan for the Defendant, which DHS and Elgin have a ministerial duty to formulate under the Mental Health Code and the Unified Code of Corrections.

The Elgin treatment team recommends, and would apparently prefer for reasons of their own, that the Defendant take antipsychotic medication. However, they cannot convince him that this would be in his best interest. He refuses to follow their recommendation, and he gives every indication that he will continue to do so indefinitely.

Having taken no psychotropic medication for many years, Defendant yet has not been involved in any serious incidents to indicate that he might threaten harm to himself or anyone else during that entire time.  In fact he is consistently reported to be getting along well with everyone. Thus, DHS and Elgin have had no reason to consider asking a court for any involuntary medication order, and they have not done so.

While unable or unwilling to ask for a court order for involuntary medication, DHS and Elgin have yet stated or implied in the Defendant’s treatment plan that he must willingly take psychotropic medication as a necessary criterion for eligibility for conditional release.  This is equivalent to telling him he will never be released if he doesn’t take medication, because DHS and Elgin know very well that he never will take medication.  Thus, they are simply refusing to formulate a treatment plan reasonably calculated to enable his release, though that is precisely what the law requires of them.

There might be any number of behavioral criteria, to theoretically qualify the Defendant for conditional release.  Indeed, taking medication is itself only a behavioral criterion.  No one knows what the Defendant thinks, whether he secretly believes things that are delusional, whether he harbors grudges or whether he honestly understands his mental illness correctly.  They can only carefully observe how he behaves and what he tells them.  Nobody knows with certainty how (or whether) any drug works against a specific mental illness or whether it will make future violent acts by a specific person less likely, except through observing how the behavior of the person taking the drug changes or fails to change.  When someone refuses to take recommended medication, clinicians in the position of DHS and Elgin have a right to demand whatever behavioral demonstrations or proofs will convince them that releasing the person will be safe. Indeed, it is their job to do exactly that.  But making a person take drugs is a substitute or short cut for careful observation of behavior, at best. More importantly in this case, it is an illegal substitute. At worst, trying to make this Defendant take psychotropic medication at this time is pure coercion, totally at odds with the purpose of a plan for individual mental health services, as envisioned in the law. This is not reasonable calculation of possible future release for the Defendant, but only a continuing strategy to force him to take drugs.

We may suppose arguendo that without taking antipsychotic medication this Defendant can never prove by his behavior, to a reasonable degree of medical and psychiatric certainty, that he is qualified for conditional release.  But the behavioral criteria themselves can and must be formulated, because he will not take the medication, and the law still requires a reasonable plan.  If only drugs will really do the final trick, that will be born out by the obvious failure of an honest non-drug treatment plan.  (And perhaps that, alone, might convince the Defendant to willingly try taking psychotropic drugs.)  In any event, a “treatment plan” that merely acknowledges a permanent impasse is not the ministerial act that the law requires of DHS and Elgin.

4.  A court order is appropriate because DHS and Elgin are refusing to perform an official act required of them; this Court need not prescribe the manner in which they exercise such discretion as they properly have, in ordering them to perform the statutorily mandated ministerial act.

The Illinois Mental Health and Developmental Disabilities Code, 405 ILCS 5/, especially Sections 3-209, 2-102(a), 1-101.2(a), and 2-107, in combination with Section 5-2-4 of the Unified Code of Corrections, cannot be logically understood except to require DHS and Elgin to perform the ministerial act of the formulation and periodic review of a treatment plan for the Defendant, which considers his preference not to take psychotropic drugs, and which is also reasonably calculated to enable his release.

The law does not require any specific behavioral criteria for the Defendant’s release , nor does it detail procedures for evaluation of his progress, nor does it mention any time frame or goal .  DHS and Elgin retain discretion and all professional psychiatric or medical judgment in these matters.  Their refusal to formulate an appropriate treatment plan for this patient, or their refusal to consider his preference regarding treatment, or their refusal to reasonably calculate a way forward toward release for the Defendant (three alternative interpretations of what exactly is happening here) … are not matters over which they have any proper discretion.  As public officials they have a prescribed duty that they are paid by the taxpayers to fulfill, and this Honorable Court must compel them to do so.

5.  Conclusion.

DHS and Elgin are required by law to perform a purely ministerial act: to formulate and periodically review a written treatment plan for the Defendant that is reasonably calculated to result in sufficient improvement in his mental health to enable his release.  The required treatment plan must provide for Defendant’s care and services in the least restrictive environment, and must consider his own views concerning treatment.  Because the Defendant has long and often voiced his objections to taking psychotropic medication, as it is his right to do, and in the absence of any threat by the Defendant of immanent harm to anyone, the treatment plan may not include a necessary requirement that he take drugs.

There is no relevant issue of fact in this case.  The only issues are of law.  DHS and Elgin are arbitrarily refusing to perform a purely ministerial act legally required of them, and an order from this Court compelling them to perform that act is therefore appropriate and necessary.

Saturday, November 22, 2014

A brain disease

The website of Treatment Advocacy Center currently features a short article by Joseph Bowers. I just ordered Mr. Bowers' book, just published about a year ago, which I will read for the purpose of discovering all possible, honest qualification or amendment of the opinion I am about to write here...

The article asserts that serious mental illness is brain disease, without offering any reference to specific supporting evidence, and without acknowledging any dispute, but apparently just presuming that readers simply must agree, perhaps because of the moral authority of the writer (Mr. Bowers), or perhaps because of the background information in the writer's book or in the literature of mental health/illness/psychiatry, or perhaps for some other reason which I am not able to identify at all.

Mr. Bowers begins:

   "When I hear or read about the opinions of people opposed to psychiatry, antipsychotic medication or assisted outpatient treatment, I often think that we are talking about different things and different people.

    "Sometimes I think that those opposed don’t even acknowledge the existence of people like me. I suffer from a serious brain disease that has been diagnosed as schizophrenia."

He claims to believe that his own life condition, his personal existence and experience, necessarily contradict any possible disagreement with psychiatry, antipsychotic medication or assisted outpatient treatment (AKA, forced drugging). People who have such disagreements could not possibly be aware of him. If such people were aware or could consciously consider him, they surely would not disagree.

He's talking about me, because I (mostly, but not categorically) do disagree with psychiatry, antipsychotic medication and assisted outpatient treatment.

This is an entirely natural human view (or lack of view) in a sense, exemplified by expressions like, "If I were you..." and "Walk a mile in my shoes...". But here it's childish, almost as if T.A.C. is robotically repeating the old third-grader chant, "I-know-you-are-but-what-am-I?" to any offered reasoning by nominal opponents. I don't think Mr. Bowers even wrote those opening two paragraphs in good faith. If he authored a whole book, he's probably smart enough to know better. (But I'll wait to read the book before I confirm that, I suppose.)

I certainly do acknowledge the existence of people like Mr. Bowers, especially if by "like" he means "also diagnosed with schizophrenia". I work with a number of them, as well as their doctors, or keepers, and the institutions which society has specially designated to deal with such people whether they like it or not. I spend several days per week working with diagnosed psychotics, and I've been doing it for twelve years. But I don't think of my clients as people with serious brain diseases: I think of them as psychiatric slaves. 

Mr. Bowers wrote those two opening paragraphs to sound reasonable, that's all. But it's too over-obvious. I think it reveals him to be a propagandist and a liar. Come to think of it, "Joseph Bowers" is such a common name, it's a bit "John Smith"-ish. Maybe this is not a real person, and that's why the writer "protesteth too much" that his existence is unacknowledged -- he's disguising it himself! (But again, I should at least read the book....)

Anyway, the writer, whatever his real name may be, continues:

    "When I talk about treatment, I am speaking about people with serious mental illness (a psychiatric brain disease). I put schizophrenia, severe bipolar disorder, schizoaffective disorder and severe clinical depression into this group. Those of us in this group experience psychotic episodes that include hallucinations and delusions, severe emotional swings and sometimes a strong desire to end all of our suffering once and for all.

    "I often suspect that when speaking about mental illness, some people are actually referring to those with much more moderate, less life-threatening symptoms. These people may have a “psychiatric disability” rather than a brain disease.

    "They might benefit from counseling, behavioral therapy or maybe even light doses of medication. But their diseases are not nearly as debilitating or life threatening as those with serious mental illness."

The apparent attempt here is to designate a group identity, and then to appear to carefully qualify who is part of the group and who isn't. As a speaker for the group, Mr. Bowers establishes a moral status that is more difficult to argue with. The implication is, the only way anyone can legitimately disagree with psychiatry, antipsychotic medication or assisted outpatient treatment, is if they disagree with it for those outside Mr. Bowers' self-defined group.

One problem is that the qualifications for membership in the group are very hazy. Schizophrenia is definitional only in the sense that any epithet is. If you're ever "diagnosed" you cannot definitively disprove it with all the science and all the money on earth. "Severe" bipolar or clinical depression (as opposed to "moderate" or "moderately serious" let's say) is completely relative as far as I know. And the category of "schizoaffective disorder" just confuses everybody, including experienced clinicians. 

There is mounting cynicism about these "diagnoses" throughout the professional world of mental health. Even the U.S. National Institute of Mental Health has disavowed their medical validity. Almost no one flatly asserts anymore, that these are, properly in a medical science sense, "diseases".

Again, if Joseph Bower is competent enough to write a whole book that anyone buys (and I just did buy it), I can't help thinking he's aware of these things. There's something wrong with this short article on T.A.C.'s website. There's no way it's as innocent as it appears.

Possibly the most telling paragraphs follow:

    "There is growing evidence that diseases like mine are largely physical in nature and cause. They are not caused by poor parenting, stress or extremely traumatic life events. They cannot be overcome by will power and are not related to a person’s character or intelligence, but instead require a combination of pharmacological and social support.

    "It stands to reason that treatments appropriate for people like me with serious brain diseases are not as appropriate for those less serious mental illnesses."

First of all, no one argues that serious brain diseases are caused by poor parenting, or that they can be overcome by will power. These are straw men. The argument has to do with the fact that there is not sufficient evidence, and it is not growing, that schizophrenia, bipolar, schizoaffective disorder and depression "are largely physical in nature and cause."

But whether or not people should be held accountable for their behavior will never be a matter of evidence. That will forever be a social decision, a question of ethics and policy. What "treatment" is appropriate for what person's mental problem under what circumstances can never be properly adjudicated as a matter of medicine.

Mr. Bowers is stating a religious creed in this article, not a rational argument. And as far as I am concerned, T.A.C. is for all practical purposes a religious cult. They have to convince people to believe in schizophrenia as a biological brain disease, because they think that peculiar faith will save the mental health world. They have to lie about "evidence" and invent straw man arguments. I happen to believe more or less the opposite, that mental illness is best understood as the individual's chosen behavior. (But I sincerely hope I am more relaxed about my faith than T.A.C. is about theirs!)

The final paragraph in the Bowers article is ironic:

    "I think that much of the raging controversy surrounding treatment issues involving mental illness could be lessened if we could just agree on who and what we are talking about."

If he admits there's a raging controversy, how can he blithely presume with parentheses that we'll all acknowledge serious mental illness as "a psychiatric brain disease"? 

And "who and what we are talking about" is not ever going to be the definitional boundary of Mr. Bowers' group, no matter how cleverly T.A.C. changes the subject.

The issue is psychiatric slavery, Mr. Bowers. There are growing numbers of abolitionists out there, and Billy the Torch is coming to burn T.A.C.'s city.

Thursday, November 20, 2014

Baby killers and tears

A woman named Luanne killed her baby several years ago. She was found not guilty by reason of insanity and remanded to the custody of the Illinois Department of Human Services at Elgin Mental Health Center for "treatment". In fairly short order Luanne was "diagnosed" with bipolar disorder and told to take all the latest psychiatric drugs....

The only problem was, Luanne had begun to wonder whether those same drugs had been the cause of her insanity to begin with, whether her baby was in fact dead because she had suffered from an iatrogenic psychosis. After all, SSRI's have that black box warning now, that says their use may be associated with homicidal ideation and other darkly dangerous, crazy behavior. That sounded a little too coincidental to Luanne, so she started doing some research.

The research took awhile, because at Elgin they get pretty restrictive with library privileges. They can't easily afford to let "patients" access information that might be inconvenient to the institutional machinery of coercion. (It's a bit like some classic totalitarianism, perhaps the Soviet Union, where psychiatry was so avidly practiced.)

Eventually however, Luanne decided to wean herself off psychotropic medication. She tried to get her doctor to help, but he refused, so she did it herself, successfully. By the time she told the "treatment" team that she wasn't taking meds and would refuse to take them in the future, she had retained me as legal counsel to protect her rights.

It's not difficult to make sure a client isn't forced to continue taking psych drugs, that's a cut-and-dried strategy for me. On the other hand, getting them released (especially when they were charged with murder) is a much tougher row to hoe. That takes serious work by the client.

I usually try to explain it this way...

      "You killed somebody. The judge decided that you can be fixed instead of just punished, so you're not in prison, you're in this so-called hospital. The judge more or less trusts these clinicians, your treatment team and the administration here at Elgin, to know how you can best be fixed, and whether or not you have been fixed, and when it might be safe to let you return to society.

      "Now society really hates finding bodies that are not supposed to be dead but are, especially bodies of children. So the judge sort of stuck his neck out by not sending you to prison forever. He will need strong reassurance that it's right to let you out of Elgin Mental Health Center any time soon. He'll probably need all relevant opinions on that matter to be unanimous. Your psychiatrist is in a similar position, assuming he's well intended. Nobody wants to be wrong about whether another dead body might turn up because of you.

      "So you have to convince a fair number of people that you are mentally healthy, that you'll never hurt anyone, and that you totally understand what happened and why, with regard to the crime you were charged with. I expect this will be a rather long and difficult task, although I think you can do it and I'll try to help. It is entirely a task in communication, agreement and empathy."

This is what I told Luanne, a year or so ago. She's been working on it but, as anyone would perhaps be tempted to do, she occasionally wishes there were some kind of more convenient shortcut. I have worried that her theory about iatrogenic psychosis would distract her from what she really needs to accomplish.

Today I was trying to explain this for the umpteenth time. Luanne alternately tried to explain to me what it had been like to believe (insanely) that she needed to kill her baby, that somehow it was the right thing to do. She had gotten into this before in a handful of conversations. But for some reason, today she got into it much more deeply. I found myself listening to specific, grisly details: whether it's better to cut a baby's trachea or carotid artery, which hurts more or takes longer to result in unconsciousness, what a surprise the amount of blood was, what Luanne was thinking, how she counted to herself as she drew the knife across her poor baby's neck, how sad she was, how she suddenly wondered too late if it was a mistake....

I shut up and just steeled myself to listen. It took five or ten minutes. Luanne was in tears, sobbing. Then it occurred to me, I'm this woman's lawyer, not her therapist or confessor. (Maybe it was a selfish protest: Why do I have to subject myself to this horror?)

I said, "Can I ask you something, Luanne? In the year and a half that you've been here at Elgin, have you ever been able to tell anyone what you've just told me, in the last ten minutes?"

I was honestly heartbroken and surprised by her immediate response: "No! Because they don't let me, they don't want to listen, they just call me a murderer and insist that I take more drugs like the ones that caused this to happen in the first place."

On the way home, I cried in the car. How can it be so difficult to help a person? What are these people doing, what am I paying for with my taxes? I didn't even ask Luanne to talk about her crime, but she sure wanted to! How can it be possible, that no one at Elgin ever managed to get her through this, in a year and a half? Why do they choose to fight against her? Why can't anybody listen to her?

The only answer I can think of is, this is psychiatry. They declare mental diseases and enforce prescriptions. They just don't know anything about, or deal with, people.

Thursday, November 6, 2014

Help, Harm and Delusion

One suggestion I've always offered to people who wish to understand what state psychiatric institutions are really like is that the patients and the doctors have much more in common than any lay person would ever expect. It's an old joke of course, but in truth, they're almost indistinguishable from each other. I realize this seems unlikely as a serious proposition, and I can't completely explain it, but it is my own subjective experience.

The other day one of my clients, a man who attempted to kill his family some years ago (I'll call him Pedro) gave me new insight about this.  

It was election day, a holiday for all clinical and administrative personnel at Elgin Mental Health Center. Pedro mused that it was a very different atmosphere when the the only staff around were the security guys. He liked it, it was a simpler community, somehow more straightforward. He commented, "When the clinical and administrative staff are gone, you don't feel so much like you're being continuously watched and evaluated. It's subtle, but quite a relief!"

Our conversation eventually came around to a fascinating parallel: When Pedro attempted to kill his family, he recalls really believing that he was trying to help them avoid a terrible spiritual fate. He was deluded, perhaps consciously self-deluded. The result of his action clearly was violent harm.

When psychiatrists and other mental health clinicians coerce and drug their patients and keep them locked up, they believe they are trying to help them. They are deluded of course, perhaps self-deluded. The result of their actions is violent dehumanization and long-term social harm.

What do you know, maybe that's why these two nominally opposing classes, forensic psychiatrists and forensic mental patients, seem so much alike! They're both immersed in delusion obfuscating the difference between help and harm.

When a psychiatrist at Elgin tells a patient he must take anti-psychotic drugs because of his mental illness, and the judge will never release him if he's not medicated, that appears to me to simply be a lie, or (charitably) a mistake caused by incompetence.

Anti-psychotic drugs turn guys into diabetics and zombies, dramatically reducing their life expectancy, etc., for no long-term benefit. This is the conclusion of scientific medicine, it's acknowledged from the very top of the mental health food chain, i.e., by NIMH. The judge who decides on anyone's release from Elgin Mental Health Center defers to the "clinical experts" and doesn't care or much notice what diagnosis or treatment they consider appropriate, so then those experts can be blamed for any bad result, like recidivism or future violence.

When Pedro concludes that the thing he must do from loving concern is kill his family, because otherwise they will all surely be taken by the Devil, that likewise appears to me to simply be a lie, or (charitably) a mistake caused by incompetence.

Attacking human beings with a knife causes violent harm, the blood is visible. There is probably no evidence in the whole history of philosophy and theology that murdering a body will save the soul inhabiting it. The moral codes of every civilization without exception have prohibited this crime. No judge who decides on anyone's release from Elgin Mental Health Center ignores the common-sense implications of an act of violence, or entirely escapes suspicion of complicity, when they say a guilty criminal may be "treated" instead of punished.

The psych and the crazy guy are brothers in delusion. The judges are our own elected enablers. And all our jokes about it are dark indeed, because help and harm cannot be the same no matter what the people in state nuthouses say.