Mental Illness, Evil, and Blame

[TygrBright]

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