Brendan Daugherty, Katherine Warburton, and Stephen M. Stahl
Have you ever walked down the street and seen someone with mental illness, agitated and yelling, or lying on the sidewalk, and wondered why? Have you ever wondered why, despite myriad reforms from bold thinkers and progressive governments over centuries, does this still occur? Why, despite miraculous technology, comfort, and opportunity for the majority of the Western population, do people living with serious mental illness continue to miss out on a good life? Or even a humane one?
Take the case of a recently arrested man later admitted to a state hospital. In a condition of homelessness and untreated symptoms, he was standing in a fast-food restaurant in an agitated state, yelling at what he perceived to be a manifestation of the devil. The police were called, and when they arrived, they noted that this individual was missing an eye, which he reported to them he’d removed himself as he provided an unintelligible explanation related to a conflict with the devil. The police, understandably, felt the individual was in need of mental health care, and put hands on him to take him into custody, at which point the terrified man took out an imaginary phone to call the “police,” and reported into this delusional device that he was being attacked by an agent of the devil. He proceeded to fight for his life, and in the process lashed out physically leading the officers to charge him with two felonies and book him into custody. He was found incompetent to stand trial (did not have the cognitive capacity to participate in the court process), sent to a hospital for restoration to competency and in the process received mental health services. The devil disappeared after a month on antipsychotic medication, the patient was sent back to court, sentenced to a short term in prison, and then discharged back into homelessness. Treatment soon ceased. He returned to the very conditions that led to his arrest. Only now he had one additional burden; as a convicted felon he was denied the already scant social and mental health services in the community.
The historian Grob stated about the failed state of institutional care, “to attribute bad results to evil people or to condemn an entire society may prove psychologically and intellectually satisfying.”1 It would be easy to blame the failure of institutionalization on immoral superintendents, for instance. Or the failure of deinstitutionalization on disorganized governance. It is not so simple. Why then does “good” policy repeatedly fail those with psychotic illness? Why, despite well-intentioned reforms, policies, and treatments, does care for the seriously mentally unwell have a recurrent tendency towards maltreatment?
Societal Treatment of Psychotic Disorders is a Sisyphean Task
Sisyphus was a deceitful King. He was eternally punished by Zeus, requiring him to push a boulder to the top of a hill, only for the boulder to roll down every time he neared the top.
Credit: Gerard Van der Leun
In this paper, we suggest that society’s treatment of people with psychotic illness is a Sisyphean task – constantly regressing to a baseline of maltreatment. We define maltreatment as neglect, abuse, or other forms of harm. We suggest that, even when treatment is appropriate for some with psychotic disorders, society struggles to maintain this. Many will deal with absent or improper treatment. For some, conditions today are no better than they were centuries or millennia ago.
The criminalization of individuals living with serious mental illness in the United States is a current example of this type of regression to inhumane treatment, but the pattern is global. Institutional care in the nineteenth century is but one example where good intention in mental health policy went awry. Deinstitutionalization in the twentieth century is another. While it is possible to identify isolated examples of positive reform and therefore dispute the degree to which maltreatment exists, we demonstrate the pattern of regression to maltreatment and its ongoing existence.
When the people of the twenty-second century gaze back to now, will they consider psychiatry as a benevolent institution capable of advocating for the vulnerable insane? Or perhaps a misguided tool of social control, unable to correct the neglect and mistreatment that has recurrently haunted the profession? We suggest that deeper consideration of history will help guide us toward the former.