"Well I Don't Know About This Involuntary Treatment Business!" He Said, Stepping Into the Emotional Safety of a Closed Tab

I will not allow you to reside in pleasant ignorance about that which makes you uncomfortable, sorry

I knew I would receive a lot of angry and loud criticism over my recent New York piece on involuntary treatment, and I got it; I also knew that I would receive a lot of private and quiet praise for it, and I got that too. The basic structural reality of our national conversation renders a lot of otherwise thoughtful people afraid to talk about this issue. There’s a real fear of being seen as stepping outside of orthodoxy, and the issue is deeply, painfully, irreparably complicated - and we don’t do complicated, anymore. We have a sneering contempt for the idea that any issues are hard deeply baked into American political culture. So this is an issue on which I see a lot of avoidance and dissembling, a desire not to call attention to arguments like mine. Many people just don’t want to deal with any of this, decent politically-active types who think I make sense but who feel unequipped to engaged and feel that the risks of crossing the screaming activists crowd are just too high.

Unfortunately, the anti-involuntary treatment crowd never develops better material. And in particular, they fail again and again to answer the essential question of what to do when treatment and resources are available but refused. I cannot tell you how many times I have had the same basic exchange -

“We need more voluntary programs and services.”

“Yes, we do, but what do we do with severely ill people who have access to housing and treatment and refuse them because their illness has prevented them from acting rationally? What do we do when those people are at significant long-term risk because of that refusal, whether they meet the O’Connor standard or not? What do you do when a badly sick person just keeps saying no?”

“We need more voluntary programs and services.”

They have. no. answer.

I have been writing professionally for 16 years; I was an activist long before that. I have been arguing politics my entire life, and I’ve engaged repeatedly on just about every issue of controversy I can think of. There is no issue on which there is more resistance to alternative opinion, less willingness to concede complexity and difficulty, more incuriosity, more refusal to confront tradeoffs and downsides, or less ability to address the necessity of choosing least-bad options than the question of involuntary treatment for the severely mentally ill. I have no faith that this will ever get better; I have to try.

Here’s some tired criticisms of my piece and my responses to them.

“We need more resources and programs and funding. Then there’ll be no more problems.” Do we need more resources, programs, and funding? Yes. Can those things, themselves, fix our problems? No, no, no. They can’t. When the problem is people who refuse treatment when given access, as was the case with Jordan Neely, saying that we need more voluntary resources is nonresponsive. It’s simply not an answer! More voluntary resources do not do a single damn thing for people who will never accept voluntary treatment. If you dig into the historical record, you find all manner of examples of severely mentally ill people who refused care and who ended up dead, in prison, or living a wretched existence on the streets. What do we do about them? The relentless repetition of demanding more funding and more voluntary care provides no more answers. What happens when you present voluntary care to someone who will turn it down and immediately regress into a life of pain, danger, and depravation? How many times are you allowed to ask them if they want help? And what do you do if they say no again and again and again, and you have to watch them suffer? What happens when you’re watching them die? Do you ever think to change your approach? These people have no answers for any of this. They just have cliches and emotional bullying.

Here’s a good example from a piece in The Guardian by Ruth Sangree.

Some alternatives do have the potential to generate positive outcomes without further traumatization. Working on guaranteeing access to safe and affordable housing, as well as providing access to quality, voluntary mental health care, could play a huge role in improving the quality of people’s lives. But that would require rejecting the mayor’s preferred “law and order” narrative in favor of something more nuanced: a vision of treatment that is more deeply rooted in personal autonomy, compassion and community care.

How does that answer the challenge of Jordan Neely and people like him, at all? Again, Neely not only had access to care, he had a legal obligation to receive that care, and he simply walked away because there was no security in his program. There are many people like him, who are offered accommodations by the system and refuse them because of their illness. What would “a vision of treatment more deeply rooted in personal autonomy, compassion, and community care” have done for Neely, such that he wasn’t rotting to death in the subway system? Nothing. Nothing at all. They have no answers. They have no answers.

“Instead of being involuntarily treated, people with severe mental illness should live independent and autonomous lives of freedom and self-direction in Candyland.” It’s remarkable, the degree to which people identify various concerns with involuntary treatment and then trail off about the alternative. There’s an assumed future for people freed from involuntary treatment that resembles, I don’t know, walking the Earth like Samuel L. Jackson in Pulp Fiction, like homeless schizophrenics become wandering mystics if left to their own devices. Where do you think they’re going to go, once you allow them to refuse treatment? Big Rock Candy Mountain? Are they going to move in with you? No, here’s where they’ll end up: living in a state of constant suffering and danger on the streets, in prison, or dead. That’s where they’ll go. There is no magical sanitarium in the mountains where they’ll go, voluntarily. They’re just going to end up like Jordan Neely did - deranged, constantly abusing dangerous drugs, emaciated, experiencing repetitive respiratory illnesses and minor infections, and subject to the endless threat of violence and arrest. That’s not freedom. That’s not autonomy.

“You’re saying that all mentally ill people are violent!” No, and I said very explicitly that that’s not my point. I said what the research, experience, and common sense say: that the severely mentally ill are significantly more dangerous to the people around them than those without severe mental illness are. And there is not one of my critics who does not know that viscerally and intuitively when they’re not talking shit on the internet. I promise, these people get scared if a psychotic person gets on a subway train with them and starts screaming. I promise. Their peacocking lack of concern online does not impress me.

I don’t know bro, maybe I know things you don’t? maybe I’ve marinated in this broken culture for more than half of my life?

“You complain too much about liberals and lefties!” I complain about liberals and lefties because, here, they’re my problem. Yes, a lot of conservatives would close every shelter and send every homeless person to a penal colony, turn them into Soylent Green, if they could. Conservatives are inhumane and wrong. That’s a given. I have no ability to influence them. Maybe I have some small shred of an ability to influence people whose good intentions have gone badly awry when it comes to involuntary treatment. And it’s liberals and lefties who dominate the discursive space of psychiatric medicine, the parts of government that deal with social services, and the nonprofit and activist worlds, for all of the same reasons that the left-of-center dominates many spaces that are driven by the college educated. When NAMI puts out a public policy reports, the document was almost certainly written exclusively by left-of-center people. When a blue ribbon panel of psychiatric experts comes together, they are overwhelmingly likely to be majority Democrats. When an activist group shows up to protest at city hall over municipal efforts to confront homelessness, they will on average be about three miles to the left of the American center. And that means that I have to address issues among liberals and leftists. They are the problem here. Conservatives are a problem, but they’re not the ones sticking their fingers in their ears and insisting that every homeless person ravaged by schizophrenia will magically decide to embrace treatment if only we spend more money.

It’s contemporary progressives who have embraced this bizarre, ahistorical assumption that left approaches to public order are all essentially hardcore libertarianism. And it’s contemporary progressives who embody the thinking “this reality is imperfect, therefore we must reject it and pursue a perfect alternative, which must necessarily exist and be achievable.” It’s contemporary progressives who insist that voluntary resources must be sufficient to solve public mental health problems because involuntary care is icky. It’s contemporary progressives who refuse to entertain the notion that there’s a difference between what people want and what they need, that sometimes some people - like, say, those whose conscious will has literally been hijacked by brain malfunctions - need to be cared for by society in an assertive way. It’s contemporary progressives who have created a cult of limitless deference to “marginalized” people, defined the marginalized in the most capacious way possible, and browbeaten anyone who questions if this is best for society.

And, more generally, it’s contemporary progressives who have infused American mental healthcare with New Agey girlboss woowoo, stuffing every inch of the space with toxic positivity and undermining the very idea of a mental illness as something bad, painful, and destructive. It’s contemporary progressives who have made navigating the various institutions of psychiatric medicine a gauntlet of stepping around “live, laugh, love” horseshit that’s dressed up as therapeutic. It’s contemporary progressives who have made going to therapy, a medical practice performed for medical purposes, into a checklist item for Bumble profiles. It’s contemporary progressives who insist that every 14 year old on TikTok who has developed a mysterious case of sudden-onset dissociative identity disorder really, truly has it, and you’re a monster if you suggest otherwise. It’s contemporary progressive who have made neurodevelopmental disorders cool, who have turned mental illness into a lifestyle brand, into a meme. It’s contemporary progressives who have gentrified disability. I am entitled to be angry about this. I have paid the cost. I have earned it.

Do you know what it’s like, to have slogged through this for more than two decades now, to go looking simply for structure and support when it comes to managing a difficult health condition, and to show up to an online “affinity group” where the facilitator immediately starts talking about decolonizing the idea of sanity? Can you understand why I, as a 43-year-old man, might feel angry and mistreated to have to yet again wade through that sort of thing on my way to basic resources that help me stay healthy? Do you dig me, Charles?

“Psychiatric hospitals are universally terrible! I know this because of movies that were released decades ago written by screenwriters who know nothing about mental healthcare.” This is one of the most consistently destructive aspects of all of this - a widespread assumption that all psychiatric facilities are horrible, filthy, oppressive places, based on no evidence whatsoever, expressed with total confidence. I ask people this all the time - how do you know they’re all so bad? And the answer is always some version of “everybody knows….” But everybody does not know; you, in fact, don’t know. I have slept in five of them, in my life, and they weren’t nice but they weren’t anything like Arkham Asylum, either. Have you conducted some sort of systematic review of our nation’s psychiatric hospitals? No? Then where are you getting this information? Simple: from movies. From movies that are, usually, decades old. Please, be honest. If you aren’t getting your information from some sort of rigorous investigation into the current state of real world hospitals, why are you so convinced that they’re all terrible? How do you know?

I suspect that the general truth is that there are better and worse facilities. And I know that for many people the biggest fear is not the facilities themselves but the people who are housed within them, which is a grim kind of paradox. I also strongly suspect that average conditions in psychiatric hospitals are vastly better than they were when the public understanding of such facilities was developed. But, for one thing, the anti-psychiatry cultists who complain about these hospitals don’t want them to be reformed but rather dismantled, so they have no interest in updating their priors; as ever, the establishment media is more than happy to help them in this regard, for some bizarre reason. For another, there’s the broad progressive resistance to ever acknowledging that anything ever gets better, which is seen as some sort of identity crime. It’s the same reason people can’t admit, say, that representation of minority groups in TV and movies has vastly improved in the past five years or so, or that Black women have made great educational and professional strides in recent decades, or that the Hispanic uninsured rate has almost halved since the passage of the Affordable Care Act in 2009. We don’t know how to interact with improving conditions, rhetorically. And since there’s certainly more room for improvement in the quality of these facilities, nobody wants to be the one to point out that it is not in fact the case that the average American psychiatric hospital is like the one in Twelve Monkeys.

By the way, if you’re someone who’s a big proponent of voluntary inpatient treatment and a big opponent of involuntary inpatient treatment, you might consider that most places that do one are places that do the other. So it’s not exactly coherent to insist that there’s good voluntary hospitals and universally bad involuntary hospitals. These are often the same facilities with different wards, or even voluntary and involuntary patients housed together. Or should no one be inpatient at all, even voluntarily? Do you know how sick some people are?

“Housing first! Housing first! Stop talking about mental illness! Housing first!” Housing cannot save someone whose mental illness compels them to make destructive decisions. Go ahead and offer housing to a severely mentally ill person and watch as they say “no thanks.” What do you do then? In the early 1980s there was a homeless schizophrenic woman named Rebecca Smith who lived in a box in lower Manhattan. She was known to be a real character in the neighborhood. But one year, a particularly brutal winter was forecast, and people in the local community and in the city government were concerned. Smith was offered several places to live, not just shelters but more permanent options, along with access to mental health treatment. She resisted for the usual reasons schizophrenics resist - her illness prevented her from understanding the risks she was under or the nature of the choice she was making. It was clear that she was going to die on the street if she was allowed to keep living in her box, so an effort was made to have her involuntarily committed, an effort to save her life. But because years of do-gooding had erected tall barriers to involuntary treatment, it took ten days to secure the judge’s order. When they came to carry out that order, they found her frozen to death in her box. Frozen stiff. Because the system cared more about her “autonomy” than it did about her life. But, hey, at least she died with all of her rights. Isn’t that something?

Housing cannot solve the problems of people whose mental conditions have deteriorated to the point that they are constant dangers to themselves. I don’t know why the “housing first” people can’t confront this fact.

“But what about lobotomy! What about electroshock!” Well, to begin with, the last lobotomy was performed almost 60 years ago. But more importantly here, the lobotomy was pushed heavily by people who were opposed to long-term inpatient medicine for mental illness. William Freeman, the doctor who most relentlessly pushed lobotomy (and performed more than 3,000 himself) was a fierce advocate of closing the asylums. And he had just the way to keep freed patients docile. No, I’m afraid lobotomies are a historical sin that lie on the shoulders of the anti-commitment side, not the pro side. As far as electroconvulsive therapy, what about it? Obviously, it’s a serious procedure, but then people have serious problems, and some patients with treatment-resistant depression find that it’s the only thing that provides real relief. More importantly, it’s now a 100% voluntary procedure, so voluntary that patients typically sign rafts of informed consent forms before it takes place. Nobody is receiving involuntary electroconvulsive therapy in this country, nobody. And the procedure is now performed under sedation, so your lurid fantasies about what it looks like are incorrect. I’m glad that this procedure exists, given how horribly difficult it is to treat certain kinds of depression, but for the record this has limited relevance for a conversation about involuntary treatment. Again - a combination of fantasy and a refusal to update priors.

“I just want to dunk on Eric Adams.” Fuck you. This is bigger than you and it’s bigger than your efforts to be the most lacerating lefty among your cohort of overeducated and underinformed young strivers. Be bigger than this please.