The Righteous Generosity that Denies Personal Responsibility

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.

Theodore Dalrymple

Theodore Dalrymple is a retired prison doctor and psychiatrist, contributing editor of the City Journal and Dietrich Weissman Fellow of the Manhattan Institute.

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  1. says

    This is a very essay by Dr. Dalrymple, although one detects in it a measure of that gentle circumlocution that is fundamental to the psychiatrist’s art. The point he makes is no less valid because of this, and it is by no means a criticism to point out that the subtlety is perhaps a bit protective of an underlying truth.

    Psychiatry makes effective use of taxonomy, classifying various disorders as thought disorders, mood disorders, personality disorders, etc. The literature from which he quotes is a good example of this. Such classifications may be useful for purposes of therapy, or research, or the characterization of specific individuals. For the rest of though, it is more practical to realize that many mental illnesses are disorders of socialization; that it matters not whether someone is bipolar or schizophrenic or has an antisocial personality. It is no slur or stigma to realize that such disorders adversely affect these people’s ability to function in society and often leads to behaviors that imperil themselves or others. It may shock, but should not surprise anyone, that as they read this, there is possibly someone reading about James Holmes, or Jared Loughner or Eric Harris, and saying to himself “damn, I wish I could do that.”

    Pretending that thought disorders or severe depression cannot pose significant public hazards, is not a form of therapy for the affected person. Waiting for a delusional or enraged person to push a commuting stranger onto the tracks just ahead of a subway train is not conducive to any type of reasonable policy. There is not a lot in the clinical presentation of schizophrenia or mania that justifies extending the benefit of the doubt as a matter of enlightened policy or communal compassion. Treat the mentally ill, care for them, sympathize and even sacrifice for them, but do not pretend that they are not ill, or that mental illness is something that will conform to good intentions and dorm-room bull-session pieties.

  2. Anna Paulin says

    ‘Psychiatry is probably the single most destructive force that has affected American Society within the last fifty years,” Dr Thomas Szasz, Lifetime Fellow, American Psychiatric Association (APA).

  3. says

    So why then, Doctor Daniels, did you and your colleagues stand by and let the Major administration (when you were working as a consultant psychiatrist in Birmingham in the British Midlands) implement the Care in the Community Policy? Is there any evidence that you and your colleagues took any collective action to stop it?

    Personal responsibility?


  4. Alphonsus Jr. says

    Anna, modern psychiatry takes third place to 1) the Hippie Council, aka the Judas Council, aka the Second Vatican Council of 1962-65, and 2) television.


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