The Righteous Generosity that Denies Personal Responsibility

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Untruth is more insinuating than truth and flatters to deceive. An untruth is easy to slip into a passage about a different subject, especially when it is covered in a patina of righteous generosity. It is then not so much unnoticed as unexamined, for who wants to examine righteous generosity? In the case of such untruths repetition is made to play the role of verification: what everyone, or at any rate everyone of a certain standing, says three times is true.

The technique of insinuating untruth was well-illustrated by a recent editorial in the British Medical Journal entitled “Risk of people with mental illnesses dying by homicide.” The object of the authors, by no means a dishonorable one, was to point out that people with psychiatric problems are more likely to die by homicide than are those people without (if, after the publication of Fifth Edition of the Diagnostic and Statistical Manual of the American Psychiatric Association any such strange people can be found to exist).

In the first paragraph of the editorial we read the following:

Popular media reporting portrays mental illness as posing a threat to the safety of others, and these continual stigmatizing portrayals make the violent victimization of an already marginalized section of society more likely.

The last assertion in this passage would be very difficult to prove; but the whole passage connotes that the real problem of the connection between mental illness and violence is the public perception of it, not the violence itself. Again, the implication is that the media are misleading the public, that then reacts by ‘stigmatizing,’ or being unreasonably wary of, people with psychiatric disorders, especially those of a more obvious and unmistakable kind. When, for example, you see a schizophrenic pacing up and down on a platform in a station in the Paris Metro, muttering angrily to himself, it is absurdly prejudiced of you, stigmatizing in fact, to hurry on and keep out of his orbit. No; even though he smells terrible, with that distinctive and indeed unmistakable odor that comes from months of unwashedness, you should behave towards him exactly as you would behave to any other person in the station. Even to notice or admit to yourself that he smells terrible is halfway to the Nazi policy of deliberately killing the mentally ill; therefore you must notice nothing. Compassion is compatible only with a denial of the phenomena.

Let me here quote a few passages from a medical review article with which I happen to be familiar, that considers the subject of the connection of mental illness in general, and schizophrenia in particular, with violence. It is from 2002, but there is little reason to think that things have changed since:

Humphreys et al. estimated that 20% of first admission patients with schizophrenia had behaved in a life-threatening manner prior to admission. Of patients [admitted to hospital with schizophrenia], 9% were violent in the first 20 weeks after discharge. This compares with 19% for depression, 15% for bipolar disorder, 17.2% for other psychotic disorders, 29 per cent for substance misuse disorders, and 25 per cent for personality disorder…

Hodgins in a 30 tear follow-up of an unselected Swedish birth cohort, found that compared with those with no mental disorder, males with a major mental disorder had a 4-fold and women a 27.5-fold increased risk of violent offenses.

The risk of violent offenses among males with schizophrenia was 7-fold higher than controls without mental disorder.  9% of those subsequently convicted of non-fatal violence and 11% of fatal violence had schizophrenia [compared with a prevalence of the disorder in the population of 0.1 - 0.4%, i.e., there was something like a 25 –100-fold increased risk of violent offending].

Admittedly the variation in the statistics should give rise to a certain scepticism; but they all point in the same direction. Moreover, when the fact is taken into account that it is when schizophrenics are actively deluded and hallucinated and therefore behaving at their most bizarre that they are most likely to be violent, the public avoidance of muttering schizophrenics on the Paris Metro is not a manifestation of wrongful stigmatization but of the merest common sense.

If the insinuators of untruth in the British Medical Journal editorial were to argue that while the relative risk of people with mental disorders is high, the absolute risk remains low, one might point out that the same is true of drunken drivers. The relative risk of any drunk driver crashing is very high, but the absolute risk is low (most drunk drivers arrive at their destinations safely on most occasions); but one would not therefore think it prudent to agree to a ride with a drunk driver. And should we not stigmatize drunk drivers merely because most of them arrive home in one piece, without having killed or injured anyone else?

But, say our insinuators of untruth, drunk drivers act voluntarily, which schizophrenia is an involuntary condition, an important distinction. Indeed it is; except that the insinuators of untruth insinuate later in their article a further more socially damaging untruth, namely that the misuse of substances, of which of course alcohol is one, is itself a disorder of precisely of the same kind or category as schizophrenia. For they say:

The highest risk [of people who died by homicide] was found in people treated for substance misuse disorder. Indeed, the risk among these people was so high that it affected, that is to say inflated, the overall statistics of homicide committed against people with all mental disorders.

The central error that in my opinion leads the authors to insinuate this untruth is a very common and damaging one: the elision of what happens to you with what you do. No doubt there is a continuum between these two poles, which is what makes the ascription of personal responsibility often difficult and full of ambiguity (thank goodness, for otherwise life would be dull and uninteresting, and literature redundant); but this is not, or ought not to be, to deny the difference between what happens to you and what you do, unless all judgement of what lies on continua, which is to say practically all judgement, is to be abandoned.  Schizophrenia is at the ‘what happens to you’ end of the continuum, while so-called substance misuse disorder is much nearer the ‘what you do’ end.

The refusal to draw the distinction between what people do and what happens to them is often taken to show a generosity of mind, and certainly it avoids the unpleasant vice of censoriousness. But for every Scylla there is a Charybdis, in this case the treatment of people as if they were mind-free objects, the block, the stones, the worse than senseless things of Marullus in Julius Caesar. Moreover, the failure to make the distinction leads to social policies that extend the power of government with solving the problem: the unacknowledged goal of many of the legislators of the world.