Psychotic Disorders Do Not Respect Autonomy, Independence, Agency, or Freedom
freddiedeboer.substack.com
All political debates are subject to the imposition of emotion and the distortion of bullying, but I know of none where that is more true than with the issue of involuntary commitment. I never think of myself as a contrarian or try to be divisive for divisiveness’s sake, but I have a lot of positions on which I’m out on a lonely hill. Somehow, though, no corner is lonelier than this one. As I’ve said before, most people continue to allow their perception of mental healthcare to be dictated by
It’s very strange for me to go into bipolar support groups (which I am as well) and hear them talk about how they were “forced against their will” into involuntary commitment.
My mom can be roaming the streets telling people god wants her to die and there’s no help. She’s run a car into a wall because god says so and there’s no help. She’s been homeless and starving while ranting and there’s no help.
It’s a simple question, one that they ask the person with the mental illness, not witnesses. “Do you plan on harming yourself or others?” And when they say “no,” they take them at their word—bloody head and wrecked car in the back.
Even once admitted, you are given the same questions again, if no, back on the streets you go.
And if you ARE admitted, it’s a measly 72 hours, then where shall they put you? Oh, back on the streets.
I don’t trust the tales of involuntary commitment trauma. They had to answer yes multiple times. If you say “yes I plan to hurt myself” and then talk about the helium tank in your closet, that’s what inPatient is for, and what is more traumatic: a hospital stay while awake or a three month coma and explaining to your friends and family why you made a makeshift helium mask?
Fucking enrages me when these people try and make it even HARDER for people like my mom to get help. This is exactly why schizophrenics and the like commit violence. Before the act of violence, their loved ones had likely been begging for help for months or years. The system won’t help until violence has been committed, and that help is jail.
Throughout my early twenties I was exposed to a lot of anti-psychiatry politics and mad studies analysis. The liberal arts anarcho-leftism that I had immersed myself in had me blindly convinced that the correct way to think about “madness” was as an oppressive social construct designed to punish difference and deviance from bourgeois social norms. The completely ignorant and righteous adoption of these positions is deeply embarrassing to me now. And my heart races with anger when I continue to encounter these positions in left organizing spaces, publications, etc. These people do nothing to advance the changes to systems of care and treatment that are desperately needed to bring true relief to those who are suffering most. If anything they hinder them (especially the mad activist lawyer types).
While doing my nursing degree I was placed to complete my final practicum on a hospital-based Assertive Community Treatment team (in my program we had little choice over where we completed our practicums). I came into it with the totally deluded and righteous belief that it would only deepen my prior convictions - I couldn’t have been more wrong. I wound up working on the ACT team for many years and encountered so many people whose struggles mirrored those that Freddie so eloquently describes in this piece. People who refused life saving treatments owing to their delusions, people who engaged in dangerous and harmful behaviour (like eating glass or batteries) who did not want to die or harm themselves but acted upon psychotic beliefs that led to self-injury and personal neglect. I also experienced first hand how difficult it can be to get someone a hospital bed in a psych ward even when they are agreeable to going. I spent hours waiting in EDs with my clients advocating *with them* for an admission.
We need to remain critical of mainstream psychiatry while also advocating easier access to more humane treatment. You can do both. You can say: there’s lots that’s fucked up about our psychiatric and mental health systems now; and people are suffering and they need all of the medical care and socio-economic support we can offer. Psych wards can be horrible places, but also life saving ones. They can and should be more humanely designed - but we need them. We also need more R&D into psychiatric medications and we need this R&D to be government led and funded because pharmaceutical companies won’t take the risks required to develop novel treatments and, yes, there are real problems with their data. The material interests of the pharmaceutical industry severely compromises the quality and trustworthiness of the information they make public about their drugs. The fact that studies with pharmaceutical industry funding are far more likely to report positive findings has been well documented. But this is not just true for psychiatric drugs- this is a problem for basically all drugs. And acknowledgement of this problem doesn’t mean that we should abandon the project of investigating any and all treatments (pharmaceutical, psychotherapeutic, material, social, etc) that could bring some relief to the profound suffering that people with severe and persistent mental illness face.
I can’t tell you how much I appreciate your persistent voice on this topic, Freddie. I can barely bring myself to engage with it publicly because of the profound intellectual dishonesty that often animates it.
As an aside - would you consider reviewing Rachel Aviv’s book “Strangers to Ourselves”?
Beautiful piece. My wife is a service provider (being a bit vague on purpose), and last week she encountered a clearly mentally ill man lying on the floor of his public housing unit, pissing and shitting himself, bed bugs crawling all over his body. The apartment smelled rancid. She could surmise that someone was bringing him bottled water and McDonalds every day, essentially the bare minimum he needed to not die. She took him to the hospital, and a few hours later he was discharged and brought back to his home. In one sense the man was free and his most basic needs were provided for. But I can't imagine saying this man was free in any true sense of the word.
"Jordan Neely didn’t deserve to die. I don’t know what a prison abolitionist like those in this Twitter thread does with Daniel Penny, but I’m happy to say he should go to prison. "
Good point.
Are prison abolitionists really prison abolitionists? Or do they really propose assigning guilt and innocence, depending on how many Wokemon points are allocated to perpetrator and victim, respectively?
"Howard clubbed Taylor to death with an aluminum baseball bat, but Howard is a Native American with one leg and Taylor listened to Rush Limbaugh for a while, but his maternal grandma had a drinking problem, but that's not enough so Howard gets off this time."
Somewhat related to your argument, there's been a lot of discussion of Dianne Feinstein for obvious reasons lately. Everyone has seemingly come around to admitting finally openly that yes, she has advanced dementia. But the discourse around who's "fault" it is that she's still serving is just...weird. It seems patently obvious to me that those with dementia cannot recognize their own shortcomings, cannot really know anything is wrong with them. Therefore, (separate from my own negative feelings towards her), the fault must lie on her family and staff, who should be stepping in and making the morally upright and proper decision when she cannot, even if that means making her sign a resignation letter under false pretenses.
But a lot of people are really holding onto this cognitive dissonance, arguing "well, okay, she does have dementia, but it's still her fault she chose to run for another term - her fault she hasn't resigned. None of that is on anyone else." And...I just can't compute. It's like they're so bought into the idea that every adult is a capable individual who can make autonomous choices and holds full moral responsibility for their own actions that they ignore the plain evidence in front of their faces.
As a person with Bi-polar disorder, and growing up with a social worker mom who ran day treatment centers for the seriously mentally ill, and someone who had a bi-polar dad, I agree. Involuntary confinement/treatment has to be part of the picture. My dad, suffering from a severe bi-polar episode, was confined in a California jail for over a year, doing lovely things like smearing feces on the walls in protest. We confine now all the time, we just wait for the crime first, and then give substandard care. Some people need long-term confinement in healthy institutions, followed by supportive housing/care as they recover and stabilize. This need will not go away. My dad was actually at his healthiest when he was released from jail into a correctional mental institution, where he put his organizing skills to use in the library. He seemed happy. Years later, he was very unhappily confined to a crappy CA private nursing home, with substandard mental health care, where he eventually died.
So yes, I agree with your arguments, even if your essay had me thinking of that cartoon that says, "I can't go to bed yet, someone is wrong on the internet."
A good friend of my brother-in-law actually did have a Kafka-esque time getting out of psychiatric treatment after voluntarily committing himself. Yes, I know, anecdotes aren't data. My point here is: he and his friends are not going to easily be swayed towards the "involuntary confinement is often necessary", because a visceral, ugly, and immediate story like that has a way of overshadowing other things. Including similarly visceral and ugly stories that happened to strangers who didn't get what they needed.
I wonder how many activists are spurred on by similar stories . The left* likes to believe trauma grants some kind of special wisdom and understanding the non-traumatized will never have, but it seems to me it has the opposite effect: if not properly treated, it is a blazing light that does not reveal, but obscures and blinds.
* EDIT: per Finster's point below, I should clarify I mean a particular activist, romanticist strain of it currently dominant in most nominally left-wing organizations and think tanks
I’ve been in the unfortunate situation of seeing first hand the ignorance and pure terror of mental illness unhinged. When I was 20 I was in a home with a friend of mine’s brother who was severely schizophrenic and suffering from delusions. It escalated so bad that at one point I watched him put a .22 caliber pistol in the mouth of an infant. Everyone protected him from being committed. He was “just having an episode” and his whole family seemed to be used to it. I tried to call the police and found myself at the hands of violence trying to protect the child who was under his roof. This was back in the early 2000s when the baker act still had power. Unfortunately I wish I could tell you this had a happy ending. It didn’t. Years later this man when to prison for killing a baby... his family said of course it was someone else’s fault. SMH...
"I don’t know what a prison abolitionist like those in this Twitter thread does with Daniel Penny, but I’m happy to say he should go to prison."
I am surprised that so few commenters have questioned this tangential statement of belief. I don't know anything about the incident that anyone else doesn't know, but it seems probable that Neely (i) was making threats to injure other passengers, (ii) without cause or reason, and (iii) acting in a manner indicative of someone about to do something completely irrational. For the safety of other passengers, Penny sought to restrain Neely in a manner that would not generally result in serious harm to Neely, but in this instance did. Describing this as a murder (which FdB does elsewhere in the piece) seems calculated to offend, but even stating that Penny deserves to be charged with involuntary manslaughter seems highly subject to debate.
My late grandfather was a brilliant and compassionate psychiatrist who explained decades ago that the drive for de institutionalization without an adequate infrastructure for outpatient care and supervision would inevitably lead to the present catastrophe. The man was spot-on. This essay was brilliant and on fire.
Please keep writing about this. The people who are against involuntary commitment and involuntary treatment don't have severely psychotic family members.
My nephew who is 6'3" was down to 100lbs from his psychosis. He thought he was a machine and lit a can of gasoline in his bedroom. He was hospitalized and they released him even though his sister had 51/50d him. He wanted to go put dirt on his 3rd degree burns to heal it.
He also walked through a shopping mall in a ski mask talking about killing people. He says it's like being in a bad dream and not being able to wake up. What he sees and hears and smells seems totally real.
He's been involuntarily committed for almost 2 years now and is being transitioned to a less restrictive facility. Without the involuntary commitment he'd probably be dead.
It's so awful that this has become an in thing for the woke lefties. There's a huge difference between "their" mental illness and severe psychosis.
I have a successful professional services business in a top 10 metro area and I am respected member of the community. I’m also bipolar and the only thing that separates me from Neely or Brown is the 1800 mg of Lithium Carbonate I take everyday.
These NGO types with shady liberal arts degrees have no idea what it is like to have a mental illness or care for someone who does, and don’t seem to care about the kind of hell they are celebrated for condemning those who do to.
It’s the perfect status game for the non-profit types. They get to profess to care about a group that cannot speak for themselves, generally speaking, and rail against the latest buzzword in their circles. They don’t even have to pretend to assist this group as they have defined down the seriousness of mental illness.
It would be a brilliant grift if it didn’t lead to untold suffering for the mentally ill, their loved ones, and anyone affected by it.
It’s really sad stuff. One thing Rosen’s book showed me is just how far back the rot goes when thinking about these issues on the left. His chapter on French Intellectuals and psychosis is so damning.
My mom is schizoaffective.
It’s very strange for me to go into bipolar support groups (which I am as well) and hear them talk about how they were “forced against their will” into involuntary commitment.
My mom can be roaming the streets telling people god wants her to die and there’s no help. She’s run a car into a wall because god says so and there’s no help. She’s been homeless and starving while ranting and there’s no help.
It’s a simple question, one that they ask the person with the mental illness, not witnesses. “Do you plan on harming yourself or others?” And when they say “no,” they take them at their word—bloody head and wrecked car in the back.
Even once admitted, you are given the same questions again, if no, back on the streets you go.
And if you ARE admitted, it’s a measly 72 hours, then where shall they put you? Oh, back on the streets.
I don’t trust the tales of involuntary commitment trauma. They had to answer yes multiple times. If you say “yes I plan to hurt myself” and then talk about the helium tank in your closet, that’s what inPatient is for, and what is more traumatic: a hospital stay while awake or a three month coma and explaining to your friends and family why you made a makeshift helium mask?
Fucking enrages me when these people try and make it even HARDER for people like my mom to get help. This is exactly why schizophrenics and the like commit violence. Before the act of violence, their loved ones had likely been begging for help for months or years. The system won’t help until violence has been committed, and that help is jail.
Thank you for your piece.
"You think involuntary treatment obstructs freedom? Schizophrenia obstructs freedom. You think involuntary treatment tramples on autonomy? Bipolar disorder tramples on autonomy. You think involuntary treatment denies personal choice? Schizoaffective disorder denies personal choice."
Romanticism is perhaps the ultimate Luxury Belief.
This is one of your best newsletter pieces recently. Bravo.
Throughout my early twenties I was exposed to a lot of anti-psychiatry politics and mad studies analysis. The liberal arts anarcho-leftism that I had immersed myself in had me blindly convinced that the correct way to think about “madness” was as an oppressive social construct designed to punish difference and deviance from bourgeois social norms. The completely ignorant and righteous adoption of these positions is deeply embarrassing to me now. And my heart races with anger when I continue to encounter these positions in left organizing spaces, publications, etc. These people do nothing to advance the changes to systems of care and treatment that are desperately needed to bring true relief to those who are suffering most. If anything they hinder them (especially the mad activist lawyer types).
While doing my nursing degree I was placed to complete my final practicum on a hospital-based Assertive Community Treatment team (in my program we had little choice over where we completed our practicums). I came into it with the totally deluded and righteous belief that it would only deepen my prior convictions - I couldn’t have been more wrong. I wound up working on the ACT team for many years and encountered so many people whose struggles mirrored those that Freddie so eloquently describes in this piece. People who refused life saving treatments owing to their delusions, people who engaged in dangerous and harmful behaviour (like eating glass or batteries) who did not want to die or harm themselves but acted upon psychotic beliefs that led to self-injury and personal neglect. I also experienced first hand how difficult it can be to get someone a hospital bed in a psych ward even when they are agreeable to going. I spent hours waiting in EDs with my clients advocating *with them* for an admission.
We need to remain critical of mainstream psychiatry while also advocating easier access to more humane treatment. You can do both. You can say: there’s lots that’s fucked up about our psychiatric and mental health systems now; and people are suffering and they need all of the medical care and socio-economic support we can offer. Psych wards can be horrible places, but also life saving ones. They can and should be more humanely designed - but we need them. We also need more R&D into psychiatric medications and we need this R&D to be government led and funded because pharmaceutical companies won’t take the risks required to develop novel treatments and, yes, there are real problems with their data. The material interests of the pharmaceutical industry severely compromises the quality and trustworthiness of the information they make public about their drugs. The fact that studies with pharmaceutical industry funding are far more likely to report positive findings has been well documented. But this is not just true for psychiatric drugs- this is a problem for basically all drugs. And acknowledgement of this problem doesn’t mean that we should abandon the project of investigating any and all treatments (pharmaceutical, psychotherapeutic, material, social, etc) that could bring some relief to the profound suffering that people with severe and persistent mental illness face.
I can’t tell you how much I appreciate your persistent voice on this topic, Freddie. I can barely bring myself to engage with it publicly because of the profound intellectual dishonesty that often animates it.
As an aside - would you consider reviewing Rachel Aviv’s book “Strangers to Ourselves”?
Beautiful piece. My wife is a service provider (being a bit vague on purpose), and last week she encountered a clearly mentally ill man lying on the floor of his public housing unit, pissing and shitting himself, bed bugs crawling all over his body. The apartment smelled rancid. She could surmise that someone was bringing him bottled water and McDonalds every day, essentially the bare minimum he needed to not die. She took him to the hospital, and a few hours later he was discharged and brought back to his home. In one sense the man was free and his most basic needs were provided for. But I can't imagine saying this man was free in any true sense of the word.
"Jordan Neely didn’t deserve to die. I don’t know what a prison abolitionist like those in this Twitter thread does with Daniel Penny, but I’m happy to say he should go to prison. "
Good point.
Are prison abolitionists really prison abolitionists? Or do they really propose assigning guilt and innocence, depending on how many Wokemon points are allocated to perpetrator and victim, respectively?
"Howard clubbed Taylor to death with an aluminum baseball bat, but Howard is a Native American with one leg and Taylor listened to Rush Limbaugh for a while, but his maternal grandma had a drinking problem, but that's not enough so Howard gets off this time."
Somewhat related to your argument, there's been a lot of discussion of Dianne Feinstein for obvious reasons lately. Everyone has seemingly come around to admitting finally openly that yes, she has advanced dementia. But the discourse around who's "fault" it is that she's still serving is just...weird. It seems patently obvious to me that those with dementia cannot recognize their own shortcomings, cannot really know anything is wrong with them. Therefore, (separate from my own negative feelings towards her), the fault must lie on her family and staff, who should be stepping in and making the morally upright and proper decision when she cannot, even if that means making her sign a resignation letter under false pretenses.
But a lot of people are really holding onto this cognitive dissonance, arguing "well, okay, she does have dementia, but it's still her fault she chose to run for another term - her fault she hasn't resigned. None of that is on anyone else." And...I just can't compute. It's like they're so bought into the idea that every adult is a capable individual who can make autonomous choices and holds full moral responsibility for their own actions that they ignore the plain evidence in front of their faces.
As a person with Bi-polar disorder, and growing up with a social worker mom who ran day treatment centers for the seriously mentally ill, and someone who had a bi-polar dad, I agree. Involuntary confinement/treatment has to be part of the picture. My dad, suffering from a severe bi-polar episode, was confined in a California jail for over a year, doing lovely things like smearing feces on the walls in protest. We confine now all the time, we just wait for the crime first, and then give substandard care. Some people need long-term confinement in healthy institutions, followed by supportive housing/care as they recover and stabilize. This need will not go away. My dad was actually at his healthiest when he was released from jail into a correctional mental institution, where he put his organizing skills to use in the library. He seemed happy. Years later, he was very unhappily confined to a crappy CA private nursing home, with substandard mental health care, where he eventually died.
So yes, I agree with your arguments, even if your essay had me thinking of that cartoon that says, "I can't go to bed yet, someone is wrong on the internet."
A good friend of my brother-in-law actually did have a Kafka-esque time getting out of psychiatric treatment after voluntarily committing himself. Yes, I know, anecdotes aren't data. My point here is: he and his friends are not going to easily be swayed towards the "involuntary confinement is often necessary", because a visceral, ugly, and immediate story like that has a way of overshadowing other things. Including similarly visceral and ugly stories that happened to strangers who didn't get what they needed.
I wonder how many activists are spurred on by similar stories . The left* likes to believe trauma grants some kind of special wisdom and understanding the non-traumatized will never have, but it seems to me it has the opposite effect: if not properly treated, it is a blazing light that does not reveal, but obscures and blinds.
* EDIT: per Finster's point below, I should clarify I mean a particular activist, romanticist strain of it currently dominant in most nominally left-wing organizations and think tanks
I’ve been in the unfortunate situation of seeing first hand the ignorance and pure terror of mental illness unhinged. When I was 20 I was in a home with a friend of mine’s brother who was severely schizophrenic and suffering from delusions. It escalated so bad that at one point I watched him put a .22 caliber pistol in the mouth of an infant. Everyone protected him from being committed. He was “just having an episode” and his whole family seemed to be used to it. I tried to call the police and found myself at the hands of violence trying to protect the child who was under his roof. This was back in the early 2000s when the baker act still had power. Unfortunately I wish I could tell you this had a happy ending. It didn’t. Years later this man when to prison for killing a baby... his family said of course it was someone else’s fault. SMH...
"I don’t know what a prison abolitionist like those in this Twitter thread does with Daniel Penny, but I’m happy to say he should go to prison."
I am surprised that so few commenters have questioned this tangential statement of belief. I don't know anything about the incident that anyone else doesn't know, but it seems probable that Neely (i) was making threats to injure other passengers, (ii) without cause or reason, and (iii) acting in a manner indicative of someone about to do something completely irrational. For the safety of other passengers, Penny sought to restrain Neely in a manner that would not generally result in serious harm to Neely, but in this instance did. Describing this as a murder (which FdB does elsewhere in the piece) seems calculated to offend, but even stating that Penny deserves to be charged with involuntary manslaughter seems highly subject to debate.
My late grandfather was a brilliant and compassionate psychiatrist who explained decades ago that the drive for de institutionalization without an adequate infrastructure for outpatient care and supervision would inevitably lead to the present catastrophe. The man was spot-on. This essay was brilliant and on fire.
Please keep writing about this. The people who are against involuntary commitment and involuntary treatment don't have severely psychotic family members.
My nephew who is 6'3" was down to 100lbs from his psychosis. He thought he was a machine and lit a can of gasoline in his bedroom. He was hospitalized and they released him even though his sister had 51/50d him. He wanted to go put dirt on his 3rd degree burns to heal it.
He also walked through a shopping mall in a ski mask talking about killing people. He says it's like being in a bad dream and not being able to wake up. What he sees and hears and smells seems totally real.
He's been involuntarily committed for almost 2 years now and is being transitioned to a less restrictive facility. Without the involuntary commitment he'd probably be dead.
It's so awful that this has become an in thing for the woke lefties. There's a huge difference between "their" mental illness and severe psychosis.
I have a successful professional services business in a top 10 metro area and I am respected member of the community. I’m also bipolar and the only thing that separates me from Neely or Brown is the 1800 mg of Lithium Carbonate I take everyday.
These NGO types with shady liberal arts degrees have no idea what it is like to have a mental illness or care for someone who does, and don’t seem to care about the kind of hell they are celebrated for condemning those who do to.
It’s the perfect status game for the non-profit types. They get to profess to care about a group that cannot speak for themselves, generally speaking, and rail against the latest buzzword in their circles. They don’t even have to pretend to assist this group as they have defined down the seriousness of mental illness.
It would be a brilliant grift if it didn’t lead to untold suffering for the mentally ill, their loved ones, and anyone affected by it.
It’s really sad stuff. One thing Rosen’s book showed me is just how far back the rot goes when thinking about these issues on the left. His chapter on French Intellectuals and psychosis is so damning.