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Tue Apr 2, 2013, 09:50 PM

Mental Illness, Evil, and Blame

Today on DU (and this is no different from any other day I trawl the DU fora...)

An unbelievably repulsive murder is attributed to mental illness, the argument devolves to whether the vile perpetrator will "get off" because of mental illness; and

Yet another sub-thread appears in a post about the Newtown gun massacre, discussing whether and how the mental health status of mass shooters, potential mass shooters, and/or the MSM who report on mass shootings should impact public policy.

Sigh.

We need to discuss some terms here. This is important, people.

First, there's "mentally ill" in the insurance/3rd-party payer definition of the term: This is an individual who manifests a specific set of signs and symptoms, codified the Diagnostic and Statistical Manual created by the APA, to the extent that their treatment is eligible for payment. And that's all it is. It says bupkis about whether said individual is morally, legally, or ethically responsible for any act they may commit, from ordering a cup of coffee they can't pay for to slicing open their own childrens' throats.

Then, there's "mentally ill" in the social definition of the term: This is an individual whose behavior is perceived through a highly negative and disapproving, even stigmatizing, lens, because it appears irrational, destructive, disturbing and/or socially unacceptable, and there is no causative chain or explanation that will allow us to empathize, condone, or understand that behavior.

As in:

'OMG, he was so upset from his girlfriend telling him about how she'd been raped years ago, and then that guy whistled at her and he decked him!' <---We probably do not call this guy 'mentally ill.'

'OMG, she was just walking along on a nice day and suddenly burst into tears and accused a total stranger of spying on her!' <---This gal is likely to be called 'mentally ill' or 'crazy.'

Finally there's "mentally ill" in several legal definitions of the term. And I say "several" advisedly. There are literally hundreds of different definitions in legal codes at all jurisdictional levels that establish mental status in relationship to competence, responsibility for criminal action, and many other purposes of interest to the law.

Please note: there is no MEDICAL definition of "mentally ill." This is because there are dozens and dozens of groupings of signs and symptoms that are regarded as indicative of various disease states involving the brain. Each of these definitions has its own level of validity and consistency (and those two-- validity and consistency, are not the same thing. That complicates it further.) And in many cases there are issues concerning levels of acuity, chronic versus episodic manifestation, and other particulars that make the name of the disease alone a highly imprecise term.

Also, please note that there is no MORAL definition of "mentally ill." I suffer from depression. By the standards of the DSM my insurance company is required to pay for my treatment for that illness. That says nothing about whether I am a person with a strong moral/ethical code that I apply to my own actions, nor whether my hypothetical moral/ethical code would meet your standards of morality or good/evil.

The fact that you can't draw a physical sample or take an image or otherwise establish a unique, reliable status marker for almost all mental illnesses complicates things even further. They're not like diabetes or lung cancer. You can "fake" mental illness if you want to (but... if you want to, you may in fact be mentally ill by some definitions... oh, never mind, let's not go there.) Mental illnesses can be (and very often are) misdiagnosed. Their acuity is misjudged. They're occluded by other disease states or processes.

And even worse: There are few "cures" and even fewer 100% reliable, effective, universal treatments for most mental illnesses. There are plenty of treatments. Some work better than others. Some work well for some people who have a disease, but not so well for other people with the same disease. Some work well for a year, two years, five years... then start to work less well, or not at all. (The good news, though it's not germane here, is that we're learning more about what works and why, and treatments are getting more effective and reliable for many people with many diseases.)

Now let's talk about that small subset of people who have some form of mental illness, by any of the above definitions, and who do horrible, criminal things. Who hurt other people. Who rob, cheat, swindle, assault, rape, kill. Who do things that I think of as "evil." (Why yes, I do have a moral/ethical code...)

To what extent is that "evil" related to the mental illness? And to what extent is a mentally ill person "responsible" for doing these evil things?

I pity the law; I really, really do. And I pity conscientious forensic psychiatrists and psychologists. I know whereof I speak in this, as I spent some years working for a psychologist who had a contract with a state government, and who had to make regular trips to the state's mental institutions to perform forensic evaluations on some people who had done some very, very evil things.

It is possible for someone to be in a delusional state where they are genuinely unaware of what they're doing. It's possible for someone to appear completely functional, and yet be so mentally dysfunctional that they do things their 'normal, conscious' selves would be utterly horrified by.

It's possible for people to be so many kinds of messed up, and do dreadful things, and sometimes, yes, my heart tells me (especially when it's a youngster, or someone with a horrible, horrible history of suffering of their own...) that I can't impute the evil that they do to their own soul. It's the disease, the history, the suffering, that have produced the evil and made the need to act upon it overwhelming.

And, just twice, I have encountered human beings in which I perceived a terrible, chilling emptiness of humanity, an evil so pervasive and intrinsic that I could not see around or through or past it to believe that there was a human soul in there at all. And in only one of those cases was the individual considered "mentally ill" by any definition.

We expect the law to deal with all of these complexities, and act on our behalf to sift through them and do some simple "right" thing that will satisfy all of us. And we expect the law to be meted out "equally" and "fairly." To be applied consistently, transparently, taking into account the civil rights of all concerned. And we expect some kind of public policy based on "mental illness," (by which definition? applied how? by whom? and 'quis custodiet custodios?') to provide a social benefit in preventing crime. When the overwhelmingly vast majority of people with any form of mental illness pose no criminal risk at all.

I sat on a grand jury a few years ago, in a criminal case whose profile was so high I can only describe it in the most general terms. Essentially, a person with a seizure disorder (not a "mental illness," but a physical one) chose to substitute 'natural, herbal' treatments for their Dilantin. Unfortunately, they also chose to drive a vehicle. Three people died.

Some people are mentally ill.

Some people make catastrophically poor decisions.

Some people do evil things.

A few people, a very few (I believe) are evil.

None of these things necessitates any of the others. Making public policy based on assumptions that they do, is not only foolish, it is ultimately counterproductive.

Could we please, please stop throwing around the assumptions? Because the more we do, the worse the chances get that some bright, well-intentioned public servants will come up with a "simple" solution that will make things horribly worse.

wearily,
Bright

16 replies, 5173 views

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Replies to this discussion thread
Arrow 16 replies Author Time Post
Reply Mental Illness, Evil, and Blame (Original post)
TygrBright Apr 2013 OP
elleng Apr 2013 #1
Neoma Apr 2013 #2
liberal_at_heart Apr 2013 #3
TygrBright Apr 2013 #5
Neoma Apr 2013 #4
The Velveteen Ocelot Apr 2013 #6
TygrBright Apr 2013 #7
The Velveteen Ocelot Apr 2013 #11
TygrBright Apr 2013 #12
The Velveteen Ocelot Apr 2013 #13
davidthegnome Apr 2013 #8
TygrBright Apr 2013 #10
winter is coming Apr 2013 #9
caseymoz Apr 2013 #14
libodem Apr 2013 #15
BainsBane Apr 2013 #16

Response to TygrBright (Original post)

Tue Apr 2, 2013, 09:54 PM

1. Thanks, Bright.

The issues you raise are among those for DU to institute this group: http://www.democraticunderground.com/?com=forum&id=1260

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Response to elleng (Reply #1)

Tue Apr 2, 2013, 10:05 PM

2. Beat me to it, lol.

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Response to TygrBright (Original post)

Tue Apr 2, 2013, 10:05 PM

3. we cannot back away from gun control and we cannot back away from increasing access to mental health

treatment. These are uncomfortable issues but we cannot back away from them. My husband suffered from severe depression. He wanted to hurt himself. He got help and got better, but I believe I came very close to losing him. We have a friend who is currently suffering suffering from something I don't know exactly but she is seeing a psychiatrist, and has openly talked about hurting other people. We talked to her boyfriend/roommate today. He said the doctors are making adjustments to her medication and they are trying to get her into some sort of group that would help her focus on positive things like her singing. We have to think about the patients and the public. We have to be brave and face these issues.

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Response to liberal_at_heart (Reply #3)

Tue Apr 2, 2013, 10:16 PM

5. Absolutely. And implicit in "facing" them is acknowledging their COMPLEXITY. And thus...

...eschewing the "simple" solution...

...accepting that we won't always get it right...

...making difficult choices...

...acknowledging that to protect some rights we must infringe on others...

...and a host of other difficult, complicated processes that are only made worse by stigma and assumptions.

determinedly,
Bright

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Response to TygrBright (Original post)

Tue Apr 2, 2013, 10:06 PM

4. K&R.

And bookmarked.

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Response to TygrBright (Original post)

Wed Apr 3, 2013, 12:25 PM

6. The law has some specific definitions of mental illness

when the "insanity" defense is raised:

First, there's the old M'Naghten rule, which holds that a person is legally insane if, as a result of his mental disease or defect, he either did not know that his act would be wrong; or he did not understand the nature and quality of his actions. Most states now follow the rule in the Model Penal Code, according to which a defendant is not responsible for criminal conduct "if at the time of such conduct as a result of mental disease or defect he lacks substantial capacity either to appreciate the criminality of his conduct or to conform his conduct to the requirements of the law."

Under either standard, proof of mere "mental illness," however defined, is not sufficient for an acquittal on the basis of insanity (or, in some cases, a finding of "guilty but insane," in which case the defendant usually goes to a mental institution, and if he ever recovers, is sent to prison to serve a sentence). To be legally insane you have to be so psychotic or delusional that you didn't really understand what you were doing. This is why the insanity defense is rarely successful. Many crimes seem to be so awful that we conclude that the perp must have been "crazy" to have committed them, and often that person is mentally ill according to the DSM, but they are not disturbed enough for a successful insanity defense. Jeffry Dahmer is a good example: Obviously he wasn't normal by any definition of the word, but he did not even raise an insanity defense because he clearly knew what he was doing and that it was wrong.

Because the requirements of the insanity defense are hard to meet, many people who commit terrible crimes that seem really incomprehensible probably are mentally ill, but are not treated as such by the law. Conversely, of course most people who are diagnosed as mentally ill in some respect are completely harmless.

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Response to The Velveteen Ocelot (Reply #6)

Wed Apr 3, 2013, 12:58 PM

7. There is some agreement among many states in re: criminal insanity as a defense

...but that consistency is worth less than non-lawyers generally assume, for the reasons you bring up and more. And some states still follow other rules. On state levels, Supreme Courts base their judgments on the established law for that state, and while they may review precedents from other jurisdictions (including Federal) the established body of interpretation for each state differs. And "mental illness," "incapacity," "insanity" and other such terms are defined in civil as well as criminal codes, sometimes in very confusing terms.

Expecting these complicated issues to be resolved via public policy and judicial interpretation is still pretty futile, and centering the discussion in that arena will perpetuate damaging stigma, promote unrealistic expectations, and result in a high probability of poor public policy full of negative unintended consequences.

Of course, the law MUST have an evolving vocabulary, understanding, and practice in connection with mental illness-- I'm not saying it shouldn't. I'm saying that the rest of us need to lift the discussion OUT of that arena, acknowledge the complexity, and apply it across the many areas where it's needed. The goal should be to build communities that deal positively with mental illness, enable people who suffer from mental illnesses to access help, and promote their recovery over the long term.

Apart from questions of blame, evil, criminality, etc.

But it's a big windmill, and I have a very small toothpick.

regretfully,
Bright

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Response to TygrBright (Reply #7)

Wed Apr 3, 2013, 05:14 PM

11. A trial that's going on right now

in western WI raises some of these issues. The defendant came to his ex-wife's house with her permission to visit their three young daughters. While she was away at work he cut their throats, then called her up to tell her "I've killed the kids." He has raised the insanity defense (would a sane person murder their own children?), and he has been previously diagnosed as suffering from severe depression. He's also threatened to kill the ex-wife and/or the children in the past, but apparently nobody took him seriously, and the ex-wife seemed to think he'd been getting better recently. The prosecution claims he's not insane, just evil; and that he killed the children in order to make the ex-wife suffer as much as possible for leaving him. I'd be surprised if the jury found him insane because there are a lot of elements of premeditation and planning - but what sane person kills their own kids? Yet the legal standard is much different from the medical standard. It's an awful case.

http://www.startribune.com/local/east/201067811.html

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Response to The Velveteen Ocelot (Reply #11)

Wed Apr 3, 2013, 05:33 PM

12. Yes, that was precisely the case I referred to in the OP

The OP was an effort to defuse the barely-coherent rage that consumes me when people make the off-the-cuff assumption that "sickeningly evil" automatically equates to "crazy/mentally ill" and that somehow or other the law is expected to deal with it coherently, consistently, and fairly on that basis.

The man who committed that terrible crime may be mentally ill by a DSM standard, particularly as the APA in its endless quest to get treatment paid for by third-party payers has been 'medicalizing' every conceivable type of disruptive feeling/behavior relationship. He may (although I doubt it) fit one of the many legal definitions related to diminished mental status or capacity, or criminal insanity. But neither of those qualifications actually speaks to whether an actual brain disorder was the predominant basis for his act. Nor yet whether that relates to a diagnosed condition, nor yet whether such a disorder actually rendered him criminally insane by Wisconsin's standard. Nor yet whether qualifying under that standard will "get him off easy" in terms of... what? Punishment for what he did?

Being a person who did what he did is its own punishment. Society's thirst to equate punishment and vengeance with "justice" must not be further integrated into the law, which MUST function above such motivations if it is to advance civilization.

Reading the casual, shocked, uninformed, unthinking references to mental illness and insanity as a factor in that case was a major precipitant of the OP but not the entire underpinning.

pessimistically,
Bright

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Response to TygrBright (Reply #12)

Wed Apr 3, 2013, 06:41 PM

13. It's hard to "win" an insanity case

because juries want to hold the person responsible and they don't want someone who did something really awful to "get off." Some interesting comments here:
http://www.startribune.com/local/west/124545478.html?refer=y

The 1978 case they mention, June Mikulanec, which I remember, was one of the few successful insanity defenses (she stabbed another woman about 90 times because that woman had just married the man June thought was her boyfriend; she claimed Jesus told her to do it). She went to a mental hospital instead of prison, and she's still there. This place is the state hospital for the criminally insane, and it might as well be prison. She will probably never get out.

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Response to TygrBright (Original post)

Wed Apr 3, 2013, 02:57 PM

8. Brilliant and beautifully written

I have often thought about this, particularly recently, in regards to gun control. There is common consensus that, if an individual is mentally ill, they should not be legally permitted to own a fire arm. The issue is that mental illness is a term that is unbelievably broad in it's application. Should someone with minor to moderate depression be treated in the same way as someone with severe depression? I don't know. I'm definitely in favor of stronger legislation, stricter background checks - I even think that there should be a new gun registration act, requiring owners to register yearly like with automobiles - and to pay a (small) fee for each weapon.

Getting back to the topic at hand though... having been myself diagnosed some years ago with post traumatic stress disorder, there are times when I'm blown away by the ignorance in regards to mental illness. There are often broad brush, blanket statements asserting that the "mentally ill" are responsible for all of society's woes. Theft, rape, murder, crimes of war... the list is endless. In reality, I'm generally a harmless individual who simply struggles with depression and anxiety - and I hate being lumped in with people who do despicable things.

That said, when the issue comes up - I often openly admit to having a mental illness. This is not something I am ashamed of, nor should it be a cause for shame for anyone. It is an illness, not a character flaw, not a sign of personal weakness, laziness, cruelty or stupidity. In rational societies we treat illness, we don't condemn the suffering simply for being sick. So I proudly admit to being mentally ill, the mentally ill are an enormous (and growing) group of people who have too often and for too long been mistreated, misdiagnosed, misunderstood - and yes, oppressed politically and socially. This is unacceptable. Understanding, I believe... empathy, is the solution. You display a great deal of both, which I respect and appreciate more than I can say.

You said a lot of what I have thought to myself at various times - and you said it far better than I could have. As I said, beautifully written. Happy to K & R.

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Response to davidthegnome (Reply #8)

Wed Apr 3, 2013, 03:53 PM

10. Wow. Thank you!

I appreciate the kind words. Even more, I appreciate the time and thought you took to share them.

appreciatively,
Bright

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Response to TygrBright (Original post)

Wed Apr 3, 2013, 03:05 PM

9. I wish our justice system were re-structured in such a way that people don't feel that

someone "gets off" because of mental illness. If our goal was that sentences would be protective and possibly rehabilitative instead of merely punitive and decent mental health care were provided, both in prisons and in secure mental hospitals set aside for the severely ill, I think we'd be better off.

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Response to TygrBright (Original post)

Wed Apr 3, 2013, 09:04 PM

14. Occasionally you have someone who's


. . . both mentally ill and unethical, where they'll have delusions and disorganized thinking, and they'll lie. Or worse, the rare case where you have a schizophrenic with a socio-pathic personality. These combos have got to be a nightmare for mental health authorities and law enforcement.

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Response to caseymoz (Reply #14)

Wed Apr 3, 2013, 11:14 PM

15. yep

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Response to TygrBright (Original post)

Thu Apr 4, 2013, 06:33 AM

16. Excellent post

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