Head Cases

Are you mentally ill? What if you had to prove it in court? Is anyone really ever mentally ill? Is there such a thing as mental illness, as distinct from insanity?

Thomas Szasz, a "Psychiatric Abolitionist," has taken the witness stand as an expert in some notorious murder cases. I wonder what he would have made of John Brown. Szasz is the subject of a new collection of writings by both his supporters and his critics, which is discussed here at Reason Online.

Amid all this terminological disputation, it is important, though not always easy, to keep in mind the real-world consequences of these ideas. Defenders of psychiatry can be remarkably blithe about those consequences. The American University sociologist Rita Simon, co-author of a book on the insanity defense, uses barely two pages of Szasz Under Fire to defend the practice, which she does simply by asserting that “a few individuals,” because of “a mental disability or disease,” lack “the minimal capacity for rational and voluntary choices on which the law’s expectation of responsibility is predicated.” She leaves unexamined the question of how the legal system should determine whether it is confronting such an individual. At the end of her very brief essay, she offers more cause for doubt by approvingly quoting legal scholar Alan Stone’s statement that the insanity defense “purports to draw a line between those who are morally responsible and those who are not, those who are blameworthy and those who are not, those who have free will and those who do not.” As Szasz notes in his reply, purport usually suggests a pretense of some sort.

In any event, how should a court decide whether someone like Darlin June Cromer is a paranoid schizophrenic or merely a racist murderer? And if it decides she is a schizophrenic, is that diagnosis enough to show that she should not be held responsible for strangling a 5-year-old-boy? In theory, the jury in her case could have decided that she was a schizophrenic but still responsible for her actions, since the legal definition of insanity — which generally requires that the defendant either did not know what he was doing, did not know it was wrong, or could not stop himself — is not the same as the criteria for a psychiatric diagnosis. Cromer’s repeated attempts to kidnap black children, her explanation of her motive, and the fact that she tried to hide the body all suggest she knew what she was doing, which presumably helps explain why the jury found her guilty. But the defense argued that her appalling actions and statements all were symptoms of her disease—indeed, that they were so appalling they had to be. “If she isn’t crazy,” one of the expert witnesses asked, “who is?”

Similarly, Lieberman complains in his essay that, when it comes to individual responsibility, Szasz “makes no exception for a woman who drowns her five children.” This reference to Andrea Yates implies that the nature of her act proves she was not responsible for it — a standard that would give a pass precisely to those guilty of the most horrendous crimes.

Still, surely there are people who commit what would ordinarily be considered crimes when they are mentally incapacitated: a sleepwalker who assaults a stranger while acting out a dream, say, or a Huntington’s patient who throws a dish at his caretaker. Szasz’s reply to Simon would have been stronger if he had explained how such cases should be handled. And if some people diagnosed as schizophrenics do in fact suffer from an incapacitating brain disease — a possibility Szasz concedes — presumably they too should be held less culpable than people in full possession of their faculties.

But as Szasz notes, if psychiatrists were interested merely in identifying and treating the brain diseases underlying certain forms of insanity, their field ultimately would be swallowed by neurology. Their agenda is far more ambitious than that, as illustrated by their attachment to the calculatedly ambiguous term mental disorder, which the American Psychiatric Association continues to use even while complaining that it “unfortunately implies a distinction between ‘mental’ disorders and ‘physical’ disorders that is a reductionistic anachronism of mind/body dualism.” Given the sweep of the APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM), which takes in misbehavior ranging from rudeness to murder, it’s fair to read this caveat to mean that anything bad people think, feel, say, or do can be interpreted as a symptom of a disease. In practice, psychiatrists often distinguish between “severe” disorders thought to have a physiological basis and the myriad sins, foibles, bad habits, and eccentricities cataloged by the DSM. But their training, terminology, diagnostic framework, and billing practices imply that all these are medical problems appropriately handled by physicians. As Kendell notes, “the inexorable expansion of the concept of mental illness” despite a “fragile empirical basis” leaves psychiatrists “vulnerable to accusations of unjustified medicalization of deviant behavior and the vicissitudes of daily life.”