Over-medicalization of crime?

Kelly McAleer, Psy.D., concisely discusses the strengths and drawbacks of mental health courts in two recent blogs. This "solution" has gotten a lot of attention in the last couple years.

There are many arguments pro and con, mostly about what helps defendants in mental health courts, and what the price tag or savings is in tax dollars. But I see very little, if any, discussion of a more basic jurisprudential problem, namely the medicalization of crime. This involves fundamental social risks and costs, as much as outcomes for individual "mentally ill" defendants.

When we believe a defendant should be treated for mental illness rather than punished, we assume one or both of two propositions: 1. punishing people doesn't benefit society as much as treatment; 2. mental illness caused the defendant's misbehavior or otherwise made him or her not culpable.

I'm not interested in the first of these propositions now, except as it may be monitored by the second.

In some circumstances, we don't and shouldn't blame people for their behavior. If a man is forced at gunpoint to drive while drunk and there's no accident, a DUI citation would be gratuitous. If a recently returned prisoner of war has a terrifying nightmare and unknowingly slaps her husband in the middle of the night, she probably needn't be prosecuted for domestic violence.

The trick has always been where we draw the line. I just think we've gone far, far beyond what makes any social, ethical/moral sense. Culpability itself can never be a scientific medical question.

Criminal defense attorneys say the "not guilty by reason of insanity" defense is now a tougher sell to most juries than it has ever been. Everyday people don't believe psychiatric expert testimony, and psychiatrists are always available to contradict each other anyway, as long as they're paid by whichever side. Public cynicism is thus very deeply ingrained. Mental health courts may really be an elitist scheme to bypass traditional "unenlightened" popular justice.

Compassion, tolerance and leniency toward bad behavior can quickly become an unaffordable luxury if times get hard and violent. Forensic psychiatrists, and all medical professionals, had better hope that mental health treatment regimes work extremely well (which they certainly do not!) with increasing acceptance and fanfare over mental health courts.

The more crime is medicalized, the more the medical profession will own it and be blamed for it's continuation or increase.

Unfortunately, if this goes badly it may also strike directly against public confidence in the rule of law, or even in rationality as an appropriate quality of public policy.

The Witchfinder General and the Sad Clown

D. J. Jaffe's Wall Street Journal oped of March 26, together with an April 9 response by Michael J. Reznicek, M.D. demonstrate the near total confusion of psychiatry and the law. I believe the single biggest social advance of the twenty first century could come with a precisely opposite trend, separation of psychiatry and the law.

Jaffe writes of a "young man obviously in need of mandatory lifetime violence-preventing medications", and Reznicek claims "incarceration and medication often work well together" to enhance public safety. Both presume with these statements that traditional criminal justice -meaning punishment reliably administered upon conviction for crimes clearly defined - is impractical or useless.

Jaffe's concept of "violence-preventing medications" is not merely idealistic, as characterized by Reznicek. It's Orwellian psycho-totalism, anti-scientific and ultimately incoherent. The National Alliance on Mental Illness (an organization to which Jaffe's Treatment Advocacy Center happens to be closely related) has always insisted that mental illness itself does not make anyone more prone to violence. That's supposed to be a cruel falsehood, born of superstition and conducive of discriminatory stigma.

More than a few people believe the exact drugs Jaffe is pushing actually cause increased violence. It seems to me that recent black box warnings required by the FDA directly imply this.

The best violence-preventing medication would probably be cyanide: 100% effective, the patient is never violent again after a single dose! Psychotropic meds only "reduce violence" by giving a human being sufficient neurological disability to prevent self-determined action. Dehumanization is the real medical plan. "Therapy" is utter fraud.

Reznicek's combination of "incarceration and medication" is much closer to reality than Jaffe's delusion, but it's not socially palatable. People are supposed to be either punished or treated depending upon whether they are bad or mad. The pretense that we can separate bad from mad is the justification for "forensic psychiatry" and the insanity defense. Anyone who spends more than a couple hours in a state nuthouse knows perfectly well this is a very bald pretense. It keeps lots of public union members employed as security therapy aides and encourages the citizenry to believe they are liberal and enlightened, but it doesn't improve conditions anywhere or make anyone safer.

The violent criminals who are released from Elgin Mental Health Center under the standard plan - i.e., as brainwashed mental health consumers-for-life forced to believe they have a chemical imbalance in their brains they must treat with psych drugs - are pissed off, ticking time bombs. Sooner or later they stop taking the meds because they just can't stand them. Then they look around for their best chance at payback.

This is where we get Columbines and Fort Hoods from. Guys like Jaffe and Resnicek use those tragedies to hook us again with their bogus solutions. NAMI Massachussets has recently been trumpeting the stats of military suicide as an indication of a need for more treatment. But any increase in suicide is coincident with more psychiatry in the armed services! It's all a rolling disaster of misconceived causes and effects, slow motion mass hysteria on a level not seen since the great witch hunts and the plagues of the middle ages.

Michael J. Reznicek, M.D. is a sad clown with a bad job, who probably knows better. I work with a lot of guys like that.

D.J. Jaffe on the other hand, may be our modern Matthew Hopkins. Let's just hope that ultimately, his career will look as short as that of the notorious Withchfinder General.

Jesse James - Bill Zwecker

Chicago Sun-Times columnist Bill Swecker says he is "not qualified to address" the issue of whether sex addiction falls into the same category as alcoholism or drug addiction.

Nonsense! Who does he think is qualified?

Does Zwecker see all kinds of predictable, high rates of success in "treating" any of these addictions? Where are the presumed experts, who are qualified to say what an addiction is with such accuracy and authority that we will all agree on whether Jesse James should be blamed or rehabilitated for cheating on Sandra Bullock?

What qualifications exclusively entitle somebody to address ubiquitous, mundane human failure?

With what pretended experts are we so enthralled, that we reflexively bow without even knowing their names,  that we abdicate universal human experience to honor them, and arbitrarily enrich them with ceded social territory?

BILL! You ARE qualified, man. So am I.

Anybody is allowed to speculate about categories and the foibles of their neighbors. Take back human experience, suffering and struggle from the psychototalist usurpers! They don't know what they're doing, and "rehab" gets screwed up all the time.

If you want to make, or help, somebody else behave better, you sure have to confront them and persuade them yourself, face to face!

If you don't feel like doing that, fine. But spare the world these delusions of experts and systems. There probably aren't any.

And just shut up about Jesse James. Get him the hell out of the newspaper!

Beware, Prodromal Anosognosia!

Victoria Costello, a science writer, author, and Emmy Award winning documentary maker, complains in her blog for Psychology Today about what she sees as a recent "trend (back) towards the denial of mental illness, especially the debilitating disease of depression." She takes the opposite view to those who suggest that there are too many kids on psychiatric drugs, advocating "early intervention with high risk children as soon as symptoms appear". Ms. Costello is explicit in her presumption that mental illnesses like depression are brain diseases predisposed by genetics.

But the medical and scientific fact is that there is no proven biological basis for any mental disorder. Not one single objective medical test for any mental disorder, including schizophrenia, depression, bipolar, ADHD... has been recommended for inclusion in DSM-V. Prior to discussing the various hypotheses which Ms. Costello refers to with so much hope and fervor in her blog, and prior to discussing various other hypotheses which she neglects to mention, no up-to-date textbook on psychiatry ever fails to disclaim, e.g., "The biological basis of schizophrenia remains unknown."

This is not someone's opinion, it's the actual state of medical/biological science. What is opinion is that maybe someday soon the causes of mental illnesses will be discovered to be brain or other somatic disease. But so far, no. Thus depression, no matter how much it has hurt Ms. Costello's family for three generations, is only a metaphorical disease. It is not a literal disease.

When someone "denies mental illness" in the sense that Ms. Costello says is so dangerous, they are most often just saying they don't want a particular treatment that somebody else is trying to force on them. Sometimes, they are saying that people generally should have the right to be truthfully informed about, and to refuse, for any reason or for no reason, treatments that others want to force on them. Imagine that!

I'm going to propose a new mental disorder: Prodromal Anosognosia. This is when people merely show tendencies toward possibly denying mental illness in the future. For example, anyone reading this blog more than once probably has sympathy for the idea that orthodox biological psychiatry can be legitimately criticized. This could be dangerous.

Anyone who tends toward denying mental illness should perhaps be treated to ensure that they don't develop any full-blown disbelief (anosognosia), and wind up really denying mental illness.

As a matter of fact, if you even suspect, right now, that Prodromal Anosognosia is a satirical invention, or that it could become a totalitarian political device, you're actually showing signs of the disease!

Melinda Beck, Health & Anger

In today's Wall Street Journal Melinda Beck speculates about "When Anger Is an Illness". She degrades her value as a health issues reporter with this pop-psychiatric nonsense.

There's a simple reason why "...professionals can't agree whether a pattern of angry outbursts signals a mental illness or simply a behavior issue" ...THERE'S NO DIFFERENCE!

There are people who have actual organic problems, such as brain tumors, which may cause or be accompanied by anger of some intensity. But of course, nobody with a brain tumor would be diagnosed as "mentally ill" for it, nor would a psychiatrist be the specialist to treat it.

There is no medical test in existence for depression, anxiety, bipolar disorder, obsessive-compulsive disorder, or intermittent explosive disorder. None are even proposed for these, or for the new temper dysregulation disorder, or for any other mental disorder, in DSM-V. The only tools for diagnosis of mental disorder are direct and indirect observation of behavior and evaluation of self-reports by patients.

Whether anger of any type or intensity is "mental illness" is ultimately a subjective, if not arbitrary, evaluation. One professional can say anger is an illness in a particular case, or that it is always an illness; another equally qualified professional can say with equal evidential basis that the same anger is just bad behavior, or that anger itself is never an illness. Nobody can prove, scientifically, which expert is "right" because there isn't any right or wrong about it. It's not even a matter of opinion, really. It's pure semantics. People can speculate and agree or disagree or abstain on this according to whim.

Even worse, it will always be so, because "mental illness" itself has no objective definition based in any physical/biological reality. It's a metaphor, merely reflecting our indomitable hope and desire that we might someday be able to fix people up, rather than just fight or punish them.

Melinda Beck has sufficient training and education to know this. Her article is misleading, definitely not educational or a public service. It's no better than average entertainment.

NAMI offensive re Pentagon shooter

Patrick Bedell's family released a statement containing the following two (sequential) sentences:

We may never know why he made this terrible decision. One thing is clear though: his actions were caused by an illness and not a defective character.

What can this possibly mean? If Patrick Bedell made a decision of any sort, the decision must somehow reflect his character. If he had made a good decision, e.g., to not shoot anyone, even though he wanted to or demons told him to, wouldn't that have reflected good character? On the other hand, if his actions really were caused by an illness, then why bother to say that he made a terrible decision?

The Bedells' statement is obviously incoherent from grief. I hate to invade their privacy during a desperately tragic time by even mentioning the family's name in this blog. And I do not think a single decision, no matter how consequential, ever defines all aspects of anyone's character.

But NAMI's press release ... trumpeting the incoherent statement by an aggrieved family, is a grossly offensive and disrespectful act. It is gratuitous, spiritually pornographic, political opportunism. This is like a TV news reporter approaching a mother whose children have just been brutally murdered, as the small bodies are carried out of the house to an ambulance, and asking, "How do you feel?"

Logically, if we try to say a person decided to do something, and simultaneously maintain he was caused to do it by an illness, then one "fact" or the other doesn't mean very much.

NAMI would have it that mental illness means everything. They try to obscure the implication that such things as decision, individual responsibility, human dignity, honor and ethics thus mean nothing.

I'm a lawyer, so to me intent, responsibility and decision are vitally important. Without such concepts there would be no call or purpose for law to begin with. We could just turn ouselves and society over to omnipotent, benign experts in social engineering.

I do not obscure the necessary implication of my view: mental illness means nothing.

People and families feel joy and sadness and have character, because they are alive and responsible, and act according to their decisions. Life decides. It is not caused by illnesses and chemical reactions between transmitters and receptors in brains.

APA & Harvard vs. Shorter

Alan F. Schatzber, M.D., President of the American Psychiatric Association, and Henry J. Friedman, M.D. of Harvard Medical School offer an odd assortment of points, ostensibly to oppose Edward Shorter's views on why psychiatry is in trouble. (The Wall Street Journal, March 6-7, 2010.)

Schatzenberg wants readers to believe that the new diseases created by DSM-V are all perfectly circumscribed as problems of emotional regulation. They are not normal-range human emotions and reactions just being called disorders, because "minimum levels of pathology" are so clearly defined. Pathology...? This guy would love to sell you some swampland in Florida and a couple of Brooklyn Bridges, too.

"Emotional regulation" sounds biological, or at least technical. It's not. It's an arbitrary evaluation about whether somebody is justified to feel the way they feel. There's no objective test of whether emotional regulatory machinery in any human being -- whatever that is in any context -- is functioning properly, or has functioned properly, or will function properly. It's absolutely no more scientific than a couple guys sitting around saying, "Well, he seems pretty crazy to me, what do you think?" -- "Oh, I don't know, maybe the boss is just nagging him this week, give him a break."

I've seen how subjective the criteria are for mental disorders when nuthouse psychiatrists ask courts to order involuntary medication (forced drugging). If the patient is truly violent or unable to even feed or dress himself, then no "mental illness" excuse is necessary to pre-empt his rights because "self defense" and "emergency life -saving" are more to the point. But almost anyone can defeat an involuntary medication petition, especially if he or she is defended by a competent, zealous attorney who doesn't believe a priori that all psych patients, just by definition, need their medication.

Often, if forced to really litigate involuntary treatment, state psychiatrists will change the patient's diagnosis instead. Delusional, bipolar or schizo-affective disorders, even schizophrenia, can just as well be called substance induced psychosis, for which non-medical treatment is perfectly logical. I've had several cases over the years which went exactly this way. The point is they can call it whatever they want. Treatment comes first, diagnosis is mere justification after the fact.

Dr. Schatzberg actually verifies this when he points out the impetus for inclusion of "prodromal schizophrenic disorder" in DSM-V: people who don't meet the criteria for schizophrenia need to be treated.

Harvard's Dr. Friedman seems like an old-timer, not as slick as the APA President. He's a bit unfocused with his arguments, mostly just appalled over the brutality of Edward Shorter's attacks on such good, honest organizations as Big Pharma, who would never consider inventing diseases just for a larger market and profits....

All in all, I think these two guys fail more miserably in their attempts to refute Shorter, than the heads of NAMI and CHADD did when they went up against George Will the other day. Which is amazing, considering Shorter is ultimately an apologist for psychiatry.

The bad guys all fighting each other and all losing. This is good.