Sibylla Bostoniensis

In response to my post about Violence and Mental Illness atheist_cheese asks a great question:

I ask this with all good intent, and agreeing that the best course of action is to set up a system that meaningfully supports all vulnerable people, even ones who themselves have harmed, harm or are inclined to harm others. I also ask this as a nursing student who is trying to decide if working in mental health is for me:

where is the line between mental illness and personal responsibility? All your example scenarios were fairly, hm, clear cut? How about someone who is mentally ill and abuses their SO/spouse in a way that is connected to their mental illness? (Abuse can of course, come from people who aren't mentally ill, and certainly people like Lundy Bancroft seem to insist that most of it Is Not At All Related, but that's another thing). Am I doing some false conflating here? I get the feeling there's something I'm not getting here.

There totally is something, and you're very astute to tune in to it, because it's very hard to see. I hope you won't mind my using your question as a jumping off point.

When you ask about "personal responsibility" I think what you're asking about is to what extent one can or should consider an individual morally or legally "responsible" for their conduct.

The term for that – for the state of being "responsible" for the crimes or other wrongs one has commited – is culpability.

I.

Culpability comes in a bunch of varieties. There's moral culpability, which is whether or not someone should be considered morally wrong for something they did. We might distinguish ethical culpability, as whether or not someone should be considered to be in violation of an ethical code. There's legal culpability, which is whether or not someone should be considered responsible before the law; and in our system, that is further divided into the criminal (called criminal culpability) and the civil (civil liability). We might also say there's such a thing as emotional culpability, which is whether or not someone should be considered to have earned the animus of others. And there may be others I haven't thought of.

In effect, atheist_cheese's question is a asking me what I am saying about culpability and mental illness.

I'm not. Or at least, I haven't so far.

atheist_cheese, I can't quite tell from here, as you posed the question, whether it was just kind of incidental to the post, in a sort of, "oh, hey, you seem to think about these things, how about this other topic", way, or whether it was a sort of implicit, "yeah, but what about" in response to the post.

If the latter, you may have been thrown for a loop because it's entirely possible that, given our society, you've literally never encountered someone doing what I did in that post: discussing violence and mental illness and not be saying something about culpability.

In our society the rhetorical function of bringing up mental illness in discussion of violence has just about exclusively been to excuse violence. That is, the relevance of mental illness in the commission of crimes is thought merely to be the argument that mental illness is exculpatory.

Given that, you might well have read what I wrote and thought, "But I can't quite figure out what she thinks about culpability from this; it is unclear." Well, yes. It is not clear from what I wrote in that post what I think about culpability because I said nothing about culpability in it.

Our society has this bad habit: we don't discuss mental illness' role in crime to discuss mental illness. We discuss it as a proxy for the issue of whether or not someone should be "held responsible" for their acts. That is, in discussions of violence, and more broadly crime, mental illness is considered only significant of culpability or lack thereof. It is as if our society tries to turn all discussions of violence and mental illness into in the question, "Well, do we hold them guilty or not?"

What I wrote doesn't do that.

What I wrote about mental illness and violence is entirely orthogonal to that question.

It does not address the question of whether or not mental illness is or should be considered excuplatory. It does not address whether or not someone who commits violence that is in some sense symptomatic of their mental illness should be found guilty of a crime. It doesn't say one way or the other. Nor does it comment on whether we should consider them wicked or innocent for what they did. Nor does it say anything about what emotional responses – anger? disgust? pity? sorrow? frustration? fear? hatred? – are appropriate to have towards such violence, or to the people who commit it.

Nothing I wrote addressed what our society should or should not do with or to these people when they commit violence.

I did not address the question of culpability. And I didn't for several reasons.

II.

The first reason I didn't address culpability is that there are other discussions we need to be having. We have a crying need to have discussions about mental illness and violence which aren't just about culpability. It's not that culpability isn't an important topic. It is. It's just that the discussion of culpability sucks all the oxygen out of the room.

(atheist_cheese, I want to acknowledge that you expressly agreed with the importance of providing supports for all, including those who harm others. I'm still going to belabor this point, if only for the edification of other readers.)

Discussion of culpability is about the assignment of blame. Blame is not a worthless idea, but assigning blame is almost entirely distinct from solving problems.

Here are some things that we will never talk about so long as culpability is allowed to derail all other discussions of public policy, mental illness, and violence (or other crime):

• The role of child abuse in the subsequent PTSD-related violence of adults.

• The role of economic privation and insecurity, including homelessness, in the expression of mental-illness related violence.

• The role of medication insecurity in mental illness recovery and lack thereof. I'm coining that term right here, to mean the precarity of reliable access to psychiatric medication due to everything from affordability to prior authorization schemes by insurers to faults in the manufacturing and distribution chains that supply medications to CVS not being able to keep their computers running

• Umpteen zillion other things I'm not going to get into here.

These are things that might well command a public policy response, but get edged out of the discourse by the "Yes, but is it their fault?" discussion.

To a first approximation, culpability is about what happens after someone has committed a crime or other wrong: culpability is a conceptual tool we use to decide how to respond, as individuals or as a society, to unacceptable behavior after it's happened.

I was writing about – and am primarily concerned with – what happens before someone commits violence.

It is my considered position that the very best possible response a society could have to a violent crime would be to go back in time and make it so that it never happened in the first place. Given that the obstinately irreversible inexorable arrow of time does not permit that, we are left attempting to prevent that which has yet to happen.

We must never kid ourselves: there is nothing we can truly do to make whole what is rent when violence happens. We can ameliorate the consequences. We can sanction the perpetrator, and attempt to "even the scales" by means of punishment, on some abstract, conceptual level. We can attempt to provide the victim with "satisfaction". We can demand the perpetrator compensate the victim to ease their lives, living with what was done to them and the enduring damage they contend with.

But we can never make someone unraped, unassaulted, unwounded, unmurdered. For all our medical miracles, if you spend a month in the hospital recouperating from being stabbed, there is nothing we can do to give you back those thirty odd irreplaceable days of your life that you might have spent doing anything else more pleasing or useful than healing. For all that we can do to succor the minds of those who have been traumatized, we cannot give you back the minutes, hours, years you lost to the often chronologically ravenous sequelae.

We cannot call the bullets back. We cannot make it that the violence never happened. And all the criminal sentences, all the wrongful harm awards, all the court proceedings in the world can never truly make right was was wronged. Our mere human laws and courts, as vital as they are, are an ultimately feeble attempt to do the impossible. No one is ever truly "made whole" by them.

As I see it, the moment of the act of violence is the point of failure: everything that follows – cops, courts, judgments, punishments, civil sanctions - is an attempt to put Humpty-Dumpty back together again. It's just mopping up the blood, and attempting to recover from the catastrophe. The only true success in dealing with violent crime is that which keeps it from happening.

This is the other reason why I am so ardently passionate about mental health treatment in the service of the prevention of violent crime. It seems nakedly obvious to me that the best way to protect and promote the mental health of the greatest number of people is to prevent them becoming the victims of violent trauma by treating those who might otherwise victimize them.

(This is the place where it's traditional for someone to make the excluded middle fallacy argument "But you can't prevent aaaaaaaall violence through treatment." Actually, we don't know that's true, but granting it for the sake of argument: so fucking what? If we can't prevent all of it, we shouldn't treat any of it?)

It seems obvious to me that we, as a society, have a moral responsibility to provide treatment to those whose mental illnesses make them more of a danger to others, not just out of a responsibility to those with the mental illnesses, but to all of society.

From that perspective, the question of whether or not someone "should be held responsible" after they have committed an act of violence is deeply, tragically, utterly besides the point.

atheist_cheese, I am explaining all this because it's an answer to a question you didn't ask, but maybe is latent in what you did, which is: How do you – how does anyone – handle providing services – succor – to people who have maybe done reprehensible things? This is one of the two critical answers: if it takes being willing to be charitable to those who have done reprehensible things in the past to prevent them doing reprehensible things in the future, I am personally willing to show up and do that, if only for the sake of potential future victims.

But not only for the sake of potential future victims. More on which below.

So, as I was saying, I wrote what I did in that previous post without discussing culpability because culpability expands to engulf discussion of mental illness in the context of crime, to the point of excluding these other discussions we as a society need to have.

III.

Here we come to another false dichotomy embedded in how our culture conceptualizes mental illness, crime, and culpability: that of prevention versus punishment.

Our society has this idea that if you're in favor of one, you must be against the other, as if they were mutually exclusive. Violence prevention is posed - by both Right and Left – as an alternative to punishment, as oppositional, as antithetical to punishment. The Right poses it thus to scorn it. The Left poses it thus – that divide-by-zero thing again – as a substitute for addressing the problem.

But punishment vs. prevention is a false dichotomy, in several ways. For instance, one of the primary functions of punishment is to prevent further crime, by being a deterrent. Through its deterrent function, punishment is itself an attempt at prevention (among other things). When the Right scorns prevention as "soft on crime", they're scorning what we might describe as types of prevention other than punishment; they're quite in favor of prevention when it's through punitive "tough on crime" policies.

The fact that I push back on the narrative hegemony of mental-illness/culpability/punishment to make a space for discussing prevention doesn't mean I'm suggesting we should substitute prevention for punishment – or even that I think punishment is wrong. I actually have an attitude towards punishment that I think will surprise a lot of folks – more on which subsequently.

I don't buy into the idea that we have to choose. The pitting of punishment vs prevention is a false dichotomy because they're not exclusive. Sure, there are places where punishment and (non-punishment) prevention conflict, but by and large there's nothing about punishing that prevents prevention activities, such as treatment.

I mean, seriously: I provided psychotherapy to people while they were serving prison terms.

(And, as an aside, an unfortunate and subtle effect of conceptualizing punishment and treatment as mutually exclusive, is that it lets correctional institutions – prisons – off the hook for providing treatment. It establishes a cultural norm of correctional institutions not being expected to provide mental health care to inmates. When you think of punishment as exclusive of or alternative to treatment, then it doesn't violate your expectations when a prison doesn't provide mental health care for inmates. I think it would help our society if we did expect our prisons to provide mental health care as part of their charters, and objected when they don't.)

Before proceeding, I want to take aim at two other problematic popular lines of thinking about mental illness and culpability.

There is an unconsidered assumption many people have that the process of figuring out how to respond to violence (or other crimes or torts) by people with mental illness starts with assessing culpability. An attitude of, "Well of course first we have to know if they're at fault." This can arise from two other underlying erroneous assumptions.

One such assumption is that society's only available response to antisocial behavior is punishment. If you are unaware of treatment and other prevention as potential societal responses to mental illness and violence, then you may well work from the assumption that the only response society has is after-the-fact of violence, responses of punishing the crime. But, since mental illness is sometimes exculpatory, and it's wrong to punish somebody who is not culpable, when the only response society has is punishment, then (it erroneously follows) you have to figure out whether somebody is culpable before doing anything (i.e. punishing).

The other is the assumption that before you can treat somebody, you have to assess culpability to determine whether they are worthy of being treated. This too can arise from buying into the false dichotomy of punishment vs. treatment (or other prevention). If you believe punishment and treatment are mutually exclusive, then you (i.e. society) have to pick one before doing either. And that requires determining culpability to determine whether the perpetrator is worthy of treatment, or to be relegated to punishment – as if one can't be both deserving of punishment and worthy of treatment.

To state the obvious, lest it go unsaid: we do not hold trials in hospitals. It has been a principle of medical professions around the world for centuries, if not millennia, that it is not the place of medical treaters to pass moral judgment on patients and give or withhold medical treatment thereby. When they roll Dzhokhar Tsarnaev, bleeding from a gunshot wound, into the emergency room you're working in, you sew him up. And this is as true for psychiatric care as any other kind of health care.

We absolutely do not need to discuss culpability to discuss the moral imperative of treatment. Not even of the violent mentally ill. Culpability is, in fact, completely beside the point.

And this is the other critical thing, in answer to the question of how one provides mental health care to people who have done reprehensible things: healthcare – mental or otherwise – is not something we only provide the good and the worthy.

(Well, to a first approximation. This is the USA, where we have a nasty tendency to provide healthcare only to those who can pay for it, which, in a society as beholden as ours is to the Protestant Work Ethic and the related idea that God's assessment of a person's virtue is readable in their bank statements, is pretty much tantamount to reserving healthcare for (one definition of) the virtuous.)

I think often people have a gut sense that health care, and mental health care, is a form of being nice. And they don't want to be be nice to Bad People; the idea that anyone might be nice to Bad People is very upsetting to many: it feels like a repudiation of the idea that the Bad People are Bad. Like: "Wait, if you are providing health care to this person, you are being nice to them! If you are willing to be nice to them, you must not think they are Bad People. Your provision of care to this person indicates you disagree with me that this is a Bad Person! How can you disagree that this is a Bad Person?!"

In which, to answer: "No, it's not that I disagree that this is a Bad Person. (Though maybe I don't agree, either.) It's that I disagree that healthcare is being nice and that I disagree that only non-Bad People deserve healthcare."

atheist_cheese, this is one of the things I heard in your question, especially in the part where you observed my previous examples were "clear cut". What they were (superficially – though not actually) "clear cut" about was culpability: they were examples where one can make the argument that these were not Bad People. When you contrast it with the example of someone whose mental illness contributes to domestic violence, you're asking, "But what about Bad People?"

To which my answer has to be, "What about them?"

If you're asking, or just wondering, "What about people you can't convince yourself aren't Bad People?" my answer is: I don't try to convince myself people aren't Bad People before I treat them. I don't care whether my patients are Bad People. I treat patients you might well consider Bad People, because I think even "Bad People" deserve health care. Because Bad People – and that's not a mental category I use myself, though I recognize what other people mean by it – are people.

To put a super-fine point on this: this gets Kantian in a hurry. I take this one entirely personally. I'm an atheist. I'm Ashkenazi. Knowing what I know about how many Americans feel about the moral capacity of atheists and moral rectitude of Jews, pretty much the last thing I want of society is for it to be acceptable to allocate healthcare on the basis of moral judgment. "Christ-killing amoral degenerates can wait until the blood bank has served everyone else": no. I really appreciate that should I present at an emergency room with a-fib, I'm not asked if I've accepted the Lord into my heart as a precondition of them paging the on-call cardiologist.

(Now someone out there is thinking, "But–! But you're setting up an equivalence between disapproving of murder and antisemitism! Murder is actually wrong! Disapproving of murderers is nothing like disapproving of Jews!"

No, see, I am not setting up that equivalence: the antisemites are. And, to varying degrees, they don't agree with you with that Jews != murderers proposition. That is why, if and when they are in a position to decide whether or not to provide someone with health care, I want them to be in a system which holds them responsible to treat the goddamned patient, even if they think the patient God-damned. So that is how I conduct myself as a treater – and promote as a conduct standard for treaters.)

I am concerned that I may have strayed into the realm of hypocrisy. I don't work in an ER; nor do I work in a hospital with people so ill and out of control that they can't be out on the streets. While I have worked with prison inmates, they were in the treatment program more-or-less voluntarily. I talk a good game – but I wonder if I don't talk a better game than I walk. There have been patients I have refused to work with, though not due to the severity of their violent crimes or personal repugnance at their character; the limiting factor is usually strong evidence that the patient can't respect my boundaries sufficiently that I'm safe and can profitably work with them, or an inability on my part to establish psychotherapeutic rapport (which is, aside from being necessary for psychotherapy to work, necessary for the safety of the therapist).

I would be remiss to claim it's always easy to work with people who have done very bad things. But my experience suggests it's much, much easier than our culture would suggest one expect it to be.

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I haven't, so far, actually answered atheist_cheese's question. Instead I've spent about 3,500 words explaining that I didn't answer atheist_cheese's question, and why I didn't answer it in my previous post.

I'm not going to answer it in the next part, either, in which I continue to explain why I did not answer, only for a different reason, but one which involves understanding how it is we think about culpability.

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