By John Weston Parry, J.D.
Whether it is climate-change, vaccinations, or mental health, progress is repeatedly stifled in this country by what Washington Post columnist Catherine Rampell describes as an “anti-intellectual, anti-science epidemic, one that prioritizes populist punch lines over smart policy….” This epidemic embraces beliefs over facts and confuses cultural values with knowledge. Unfortunately, irreparable damage may already have occurred to our planet and the environment.
In addition, there is a growing potential for the deaths of many people as a result of irrational beliefs about vaccinations, which have been falsely and misleadingly characterized as ineffective or dangerous based on rumors from gossip magnets, including media personalities and politicians. States—not the federal government—have the power to ensure community safety by requiring everyone to be vaccinated, except for those who have a medically-indicated exemption. Unfortunately, extreme pandering to the ill-informed beliefs of various political constituencies have rendered states and localities substantially impotent if faced with legitimate public health emergencies, such as the spread of measles or some other more lethal infectious disease.
This epidemic of ignorance is made much worse by what New York Times columnist Frank Bruni identifies as “all those God invocations” to determine social policy. “Faith and government shouldn’t be so cozy as they are in this country.” It certainly should not invade our judicial decisions as it has in Alabama where the state’s Chief Justice Roy Moore has said “`[R]ights… contained in the Bill of Rights, do not come from the Constitution, they come from God.’” From this skewed and imperious perspective, Moore sees gay marriage as “pervert[ing] God’s will” and has attempted to preempt federal courts on this issue. Similarly, for many years now religious views and related pro-life beliefs about the right to die have forced millions and millions of people in the United States to experience awful deaths that could have been avoided were those patients allowed to die on their own terms, with intelligent safeguards, like people in Canada soon will be able to do because of their enlightened national Supreme Court.
Whether beliefs are based on the Bible, the Internet or social media, they become most destructive in the United States when they inform or determine public policies and governmental actions. This is not to say that experts who pretend to embrace logic and scientific methods when issuing subjective opinions to benefit themselves, their employers, or their untested beliefs are any better. They may be even worse or more hypocritical. The point is that there should be rational and rigorous processes for determining public education curricula, public policies, and the enactment and implementation of our laws, which prevent subjective beliefs and opinions, no matter what the source, from dominating the discussion and manipulating outcomes at the expense of knowledge, logic, and empirical evidence.
The consequences of not acting intelligently have become increasingly apparent in a multitude of settings. Sporadic brilliance and insight, which seems to be declining in this country, is not nearly enough to overcome widespread ignorance. One of the most damaged settings is mental health. Beliefs informed by stereotypes, stigma, sanism, and unbridled fear have produced a broad array of dysfunctional and inhumane laws and policies governing the burgeoning population of people with mental disabilities. Instead of curtailing abuses against this population, we are expanding the policies that produce these indignities and cruelties to encompass others who are poor and devalued. Perceptions and beliefs about possible intrusions on community safety, comfort, and convenience have overwhelmed social justice. Decisions about what should happen to those who are devalued and viewed as possibly dangerous too often have been placed in the hands of people who spout ignorance, intolerance, and fear cloaked as popular public policies.
We consistently fail to provide housing, non-coercive treatment, and other social services that can substantially reduce the incidence of what we label as mental disorders, as well as the relatively small percentage of crimes that people with mental disabilities may commit. Instead, we put our resources into policies and programs to incarcerate, detain, monitor, and supervise anyone who fits—or we think might fit—inherently unreliable risk profiles of actual perpetrators of the types of events that we fear. In the process, a vast majority of those with serious mental health issues escape attention until it is too late, and those who would have been released if they did not have a diagnosed mental disorder are ensnared in a governmental and psychiatric belief system about dangerousness that is virtually impenetrable using empirical knowledge and logic. Moreover, we choose to deny minimally adequate mental health services to those who we place in government detention, almost guaranteeing that the inmates who need those services will be held longer than is justified by their legal circumstances.
Two recent compelling threads of knowledge provide valuable insights into what might be done to improve our mental health and detention systems, as well as the obstacles that need to be overcome to make any substantial progress. The Vera Institute on Justice issued a comprehensive report, which focuses on the increasing number of people who populate our jails. These locally-run criminal detention centers have become warehouses not only for people with so-called mental disorders, but also people with substance abuse problems and those who lack the financial resources to post bail—in other words the poor. Not surprisingly a high percentage of people with mental health issues in jail, including those with addictions, also are poor. Thus, they experience a double whammy.
Every day our jails confine about three-quarter of a million people. In this setting, what has been termed the criminalization of persons with mental disorders, including those with addictions and other substance abuse problems, has been expanded to ensnare any defendant who is poor. Jails, even more so than our intolerably inhumane prisons, are known for being dangerously overcrowded, unsanitary, and lacking in adequate treatment and other basic social services that are essential in preventing inmates with mental health or disability issues from deteriorating further. Inmates needing care and treatment and do not receive it—which is about 80% of those in need—tend to spend much more time in custody as a result.
Moreover, judges, due to political pressures, are far less likely than in the past to release defendants who commit misdemeanors and other minor crimes on their own recognizance. Thus, the ability to pay for bail mostly determines which of those defendants awaiting trial will be released or held in inhumane captivity. Often, because speedy trials are so rare and indeterminate delays so frequent, many of these defendants awaiting trial spend more time incarcerated before trial than their sentence requires after they have been convicted. Even worse, those who are found not guilty have been confined for no good reason other than that they were poor and/or needed mental health treatment, which they did not receive.
On the civil side, those who need mental health treatment and other basic services encounter obstacles that prevent them from receiving adequate, much less good, care. In particular, how psychiatrists diagnose and treat people with mental disorders has come under close scrutiny from both sides of the Atlantic. There is increasing—and arguably persuasive— evidence, writes T.M. Luhrmann in the New York Times, that how we treat and care for individuals with mental disorders in the United States is badly flawed. The psychiatric model appears to be broken and dysfunctional. Exclusive and/or unquestioning reliance on the Diagnostic Statistical Manual of Mental Disorders (DSM 5) for diagnoses and pharmaceutical drugs for treatment is counterproductive in concept, and too often inhumane and unnecessarily coercive in its implementation.
To begin with, according to researchers representing the British Psychological Association, the dividing line between mental disorders—including what we label as psychoses—and so-called “normal experience” is arbitrary, variable, and individualized. This is a version of the argument that Thomas Szasz made in the early 1960’s that psychiatry, which was using DSM I at the time, was inappropriately labeling various inabilities to function in society as illnesses, which need to be treated. In other words, much of what we view as being mental diseases are components of a person’s character that sometimes lead to behaviors that society labels as dysfunctional, anti-social, or unlawful. To a certain extent, psychiatry already recognizes this dynamic in the category of illnesses called personality disorders. What the British researchers have found is that a similar dynamic exists for schizophrenia and other psychoses.
Many—and arguably most—of these unwanted behaviors are traceable to character traits that have developed as a result of “trauma, abuse or deprivation….” Stated another way, “social experience plays a significant role in [determining] who becomes mentally ill, when they fall ill and how their illness unfolds.” Antipsychotic drugs “are sometimes helpful, but…`there is no evidence that [using them] corrects an underlying biological abnormality,’” much less improves social inequities that trigger many of the episodes that lead to coercive interventions, including imprisonment, compelled hospitalizations, and inappropriate and excessive medication.
At the same time, these powerful pharmaceutical drugs have serious negative side effects, which typically accumulate the longer one takes them and which the drug companies deliberately try to downplay. Thus, there is a broad range of circumstances where antipsychotic drugs are not useful, not wanted, dangerous, or counterproductive, which demonstrates that other care and treatment approaches, including decent housing, should be readily available. These other approaches embrace voluntary, non-coercive community-based services, including various “talk therapies.” They also should include preventive services that target the social risk factors of mental illness by providing more humane environments, especially for infants, children, young adults, and families.
In the United States, the National Institute of Mental Health has radically changed the ways in which it funds research into mental illness. This is because the prior approach to its research, which presumed that specific diagnoses, particularly as defined in the DSM, represented “biologically distinct diseases…didn’t pan out.” The identified genetic markers or “neural circuits were…common across diagnostic groups.” Thus, the idea that those who are diagnosed with conditions described in the DSM have diseases that necessarily need to be treated with specific drugs for that condition runs counter to the leading current research into mental illness both here, and for other reasons, in England.
Instead, mental illness should be viewed as “complex individual responses… in which a collection of risk factors increases your chance of … disease.” In other words, a public health approach is required. This research also calls into question the reliability and validity of all the expert opinions about legal notions of dangerousness that depend upon diagnoses from the DSM, which is the legal shortcut for admitting those diagnoses in the courtroom as reliable and valid with a minimum of judicial scrutiny.
Modern psychiatry with its heavy reliance on the DSM and antipsychotic medications may have arrived at a juncture that is similar to where Freudian-based psychoanalysis was a half a century ago. Apparently psychiatry has been rebuilt on an intricately and magnificently jeweled thrown, supplied in large part by the financial contributions of the pharmaceutical companies. Unfortunately, the legs of that thrown have been eaten away by empirical evidence. Hopefully, meaningful changes will come before there is a complete collapse. However, given over sixty years of experiences with deinstitutionalization and the criminalization of people with mental disabilities, whatever happens in response is likely to be at the expense of those most in need of treatment and other services, who also are the least likely to be heard and most likely to be abused.
There also is the strong possibility that nothing much will change. Psychiatry will continue to function as it has in the past, based more on myths and past practices than science. The psychiatric branch of medicine will continue to focus on: providing treatment for the well-to-do and well-insured; and serving as salespeople and shills for the pharmaceutical companies, jailers in detention and coercive-care settings, and fortune tellers in the legal system. Those most in need of non-coercive mental health assistance and services will continue to go without, while many gifted and compassionate psychiatrists and psychiatrically trained mental health professionals will continue to do work they do not particularly like or admire.