Executing The Mentally Ill

Posted on 2012/06/05 by James

This is happening tomorrow by the way. A mentally ill man is being executed in Ohio. The story is here. The basis of the execution is that Abdul Awkal killed two people. As far as I can tell, he did not plead insanity. However, while in prison, he has been diagnosed with PTSD as well as Schizoaffective disorder. And the condition is recognized by the courts, only, not enough to warrant an appeal. And the biggest difficulty that I find in this case is that the diagnosing psychiatrist says that Abdul Awkal is so detached from reality that he does not know why he is being executed. If this is all true, then the state is executing someone who has no understanding of his crimes.

Hearing this prompted me to think about executing anyone with a severe mental illness. There are three ways of looking at how mental illness might be involved in a homicide, the mental illness was present at the crime and persists during the stay in prison, the mental illness presented in prison, and the mental illness dissipated after medication while in prison.

I won’t debate the technical details of the death penalty, like cost. Instead, I’m interested in the overarching idea of it. The two prominent arguments are justice and deterrence. So I will look at those two.

Justice is sometimes thought to be served by matching a penalty with the crime. At least, this is the common reading of justice and goes by the name of retributive justice. It is the old eye for an eye style of justice, only it focuses on paying back to an individual the harm that s/he inflicted on another. It is an individual to individual style of justice. Under this idea, the government acts as a moderator in settling harms between people. This has some grounding to it. The early forms of justice were between families, where if one family or fiefdom injured another, the victim would retaliate. An arbiter was established by the state to, in a sense, keep things civil and later to prosecute crimes where the victim had no family to respond. It is a system that has some merit to it in that it satisfies some personal injury. If someone robs you, they should pay you back. This has been abstracted in modern law and developed into another form of justice.

Restorative justice views crimes not as personal acts, but as acts against the entire community. We can thank the philosopher John Locke and its later codification into our own constitution for this view. This view, the social contract view, the individual not injures an individual, but breaks a trust/contract with the entire community. We rely upon everyone being well behaved in order to carry on without arming ourselves with guns and gating our doors. When someone breaks this trust, he threatens everyone and the community seeks punishment to repair the injury. This kind of justice sits behind the motivation for community service. The person who committed a crime is not serving the victim, he is serving the entire community.

Both of these arguments can bolster the death penalty. Under retributive justice, it is rather obvious. If you kill a person, you must pay with your life. It is an equivalency relationship. Under restorative justice, it gets a little harder. Life imprisonment can also do the trick since you are removing the individual from society and not allowing them back into the contract. But, the death penalty can also be argued for on this ground. Homicide is an act that violates the most sacred tenets of the social contract, that one must permanently remove that person from society.

And this leads into the second argument, deterrence. Under retributive justice, deterrence isn’t an option. It is a person to person, victim to criminal, relationship. The death penalty isn’t deterring future crimes against that particular family or group of victims. Instead, we commonly understand the argument to be a deterrence for all murders against anyone. The prospect of losing your own life if you commit a crime is great enough to prevent you from violating the social contract. That’s the theory at least. But for now we’ll proceed with taking it as a given. It makes it more interesting that way.

Now down to business with mental illness. I’m going to assume that there is some detachment from reality, through psychosis, a very extreme mania that boarders on psychosis, of a fundamental lack of engagement with social constructs (severe autism). This is because other serious mental illnesses, like OCD, do not furnish delusions that muddy the waters of the social contract. OCD and other serious mental illnesses can be hell, but the mind is still fairly rational and aware of what it is doing, even if it can’t stop it.

The first option is a persistent state before and after the crime and punishment. This means that the individual does not have any idea of why things are happening to them and no realistic conception of what they did or why it was wrong. They committed a crime on unrealistic grounds and continue to exist on those grounds. In this case, retributive justice would still say execute the individual since it is an equivalence relation. And I’ll just state it out right, it will recommend the death penalty in all cases. However, our modern idea of justice involves a sense of fairness and proportionality. We factor in motivations to differentiate between voluntary and involuntary homicide as well as between homicide and manslaughter. We’ve graded the scales of murder by accounting for various factors. So even though I’ve run across the idea of retributive justice in arguing for the death penalty, adopting it would dispense with a lot of our legal realities. And so I won’t be talking about it further.

The other idea of justice, restorative justice, has a much harder time with this. Since it is based on the social contract, one must be aware of that social contract to participate in it. If someone is persistently not in contact with it in terms of how his actions interact with it, it’s hard to say that one can even punish them. The social contract works by people agreeing to it, if you don’t agree to it, it’s hard to say that you can really punish. It shows that this sense of justice is a little off our conceptions, but think of it like someone being in another country. When there, you abide by those laws and are punished accordingly, not by your country’s laws. Our sense of justice might say that those laws are unjust, but at the very least, it does tell us where the law can enter. And the law is the foundation of when the death penalty can apply.

Finally, deterrence. Here, the death penalty really does not succeed. In terms of preventing more crime from a specific person, the individual can be transferred to a psych ward. And for deterring other people, it doesn’t make sense. Killing someone who is unaware of the social contract will not deter other people who are unaware of the social contract. And it doesn’t apply to mentally normal people either, since they will not be in a disconnected state.

The second possibility, criminally insane at the murder, but medicated and stabilized afterwards, follows a similar path as the above case. Restorative justice just cannot justify killing the individual because at the time of the murder, the other person might have as well been in another country. There is no rational connection with the social contract and therefore justice shifts more towards rehabilitation than punishment. That is, it focuses on getting the individual back into the social contract so that laws can be reapplied. Deterrence also fails as well. Just like the above case, the legal idea of deterrence would only apply to those who are not rational, who will not heed the execution at all. Of course, one could always make the case that people will then fake mental illness. But it’s hard to fake psychosis and manias. It’s not just talking weird, it’s an entire pattern of behavior and reaction. And, of course, you can always make the rules tighter for what qualifies if you’re a hardliner.

The final one is a lot more interesting. This is where someone is sane and rational at the time of the murder, but mental illness presents later on. In this scenario, someone is engaged in the social contract and willfully kills someone. But then that person loses contact with reality. Under restorative justice, this is a really grey area. Because while the state has perfect right to execute someone when their sane, if that person no longer has contact with reality or the social contract, it can be said that the person slips outside the jurisdiction of the state. Think of it like this, if you run away to Canada, you have to be extradited. When out of contact with reality, you’re in Canada (sorry to any Canadian readers for equating your country with severe mental illness). On the other hand, one can say that the presentation is just because enough time lapsed between the trial and the execution and it should proceed anyways. That is, just because you no longer know why you did something, that doesn’t erase the fact that at one point you did.

However, we must tease out whether it is a prejudice against mental illness or something more solid. For instance, imagine that someone is on death row and a horrible kitchen accident lobotomized our murder. In this case, for me at least, I no longer see any restoration that would be gained by executing this person. Here’s the possible reason why, identity. It’s the same body, but not the same mind. For instance, if you have a murderer and a dry cleaner and switch their brains, which body would you execute. I’m sure (hope too) that 100% said that if we must execute someone, it should be the murderer’s brain in the dry cleaner’s body. A similar case might be made for someone who goes criminally insane in prison while awaiting execution. While disconnected from reality, it could be said that a different person/identity is in that body. Same brain, same body, but different identity through chemical imbalances. But, there is a caveat to this argument. If someone develops a severe mental illness and disconnects from reality, and then through medication comes back, then they would be eligible to execute under restorative justice. However, if the individual cycles through psychotic phases and non-psychotic states, all bets are off on that one. There is simply no bright line defining whether the person is the same before the illness and then after. And to me, it seems a little malicious to time the execution for when the person will be sane.

And coming to a close, there’s deterrence. If we again look at our lobotomized prison chef, we see the cracks in deterrence here. The criminal element is gone and in its place is someone who is not a part of the social contract and is disconnected from reality. It’s very hard to see how our chef would deter anyone, rather, I think we would pity the individual. And I think that the permanence of the situation as well as the identity transformation makes us see the chef as a different human than the criminal. In which case, we would be executing an innocent man who in a previous life committed a crime. Again though, if medication succeeds, then it could be thought of as a deterrent. But up until that point, it appears unfair.

That’s about as far as one can take theories of justice. Restorative justice still relies a bit on retributive justice, so both can substantiate the death penalty. But it gets difficult with restorative justice since the death doesn’t really restore anything. A life in prison making license plates does more for society than death. And it’s also an older theory of justice. One that has been supplanted by things like Rawlsian (John Rawls that is) social contract theory. Under that, and it’s a strong force in modern law, the death penalty is very hard to justify since one would have to believe that they should be executed if they killed someone. The details are too long for this, but it essentially requires an extreme masochist to warrant the death penalty. And the waters get murky with Social Benefit theory (previously known as Utilitarianism). Where the death penalty, after number crunching, isn’t nearly as beneficial as making a life sentence work for his entire life. And these theories just make it hard to justify killing anyone, let alone someone who is mentally ill.

© James Claims and A Canvas Of The Minds 2012. Unauthorized use and/or duplication of this material without express and written permission from this blog’s author and/or owner is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given to James Claims and A Canvas Of The Minds with appropriate and specific direction to the original content. This work is protected under a Creative Commons Attribution-Non-Commercial-NoDerivs 3.0 Unported License.

Experiences with Free Mental Health Care

Posted on 2011/10/23 by James

I live in the USA, where health care is not free or taken care of by the state. But I’ve been lucky to experience free mental health care through my university.

In the UW system that I’m a part of, our tuition goes to pay for University Heath Services. A place where basic health problems can be dealt with and referrals can be obtained. When I had a back injury, I went there to receive free x-rays and a lot of vicodin for the pain. It’s free and open to the population of students and graduate students. Some 30,000+ people have access and it’s only 2 floors of medical services with labs on one floor. Yet, no lines, hardly any wait. Any cough, sniffle, etc… can be seen and if serious, can be treated. They also have their own pharmacy with reduced rates for common drugs so it’s like having insurance on top of it all.

In addition to this, there’s another floor for mental health. They provide short term care and emergency care. I’ll tell a little bit about how I got involved in it. Last december, things were going poorly, I had so much anxiety that I couldn’t even enter certain buildings on campus. The failure to make it to classes made my depression at the time even worse, which made my anxiety worse, and so forth. At the end of the semester, I finally worked up the courage to try and drop the classes, I couldn’t. I was depressed and I figured that I had something wrong with me. But that story wasn’t bought by the Dean. Locked in a situation where I was failing, unable to make it to classes, barely able to make it out of the house, and then finally turned away by the Dean, I planned to kill myself. The only hope that I had was that there was UHS there.

So I called, and they got me in immediately. And by immediately, I mean I went there, told them that I was feeling suicidal, and in 15 minutes they had me in a room with a consultant seeing if I was eligible for services. I qualified.

Being free, they do not accept everyone, they have to make sure that it’s serious, like my case. I’ve known other people who have been turned away, one who was depressed from a vitamin D deficiency. She got help from UHS though. But also, by being free, they saved my life. If anyone’s read my blog, I’ve been through insurance hell of trying to find a psychiatrist. I couldn’t have gone through that when I was that depressed. Plus, I don’t like hospitals, so that option would have been a far cry from what I really wanted. Instead, they gave me a free way out.

Included in the free ride, I received 10 free therapist visits and access to a psychiatrist. The staff was highly qualified and ready to help. In fact, I think they were more than happy to help since I was bipolar and most hadn’t really gotten to work with someone who had such a serious disorder. I’m sure most of them get anxiety disorders. And being free and accessible, they really turned my life around.

From my psychiatrist I received needed medical treatment and an experienced ear to tell my symptoms to. But what really shined was my therapist. He provided me with really high quality care and plenty of resources on what to do. His emphasis was on cognitive behavioral therapy. The strategies were incredibly helpful in managing my anxiety, now to the point that I barely panic when going into a test situation. Both Mr. A and Mr. F are responsible for helping me on the path to getting better.

They’re also responsible for saving my life. Free health care gave me access to the tools that I needed at the time to get better without the added stress of cost or number crunching. The focus was solely on me and getting better. If I had to crunch the numbers, I would have become more depressed over the costs and might not have sought the necessary treatment. Rather, I’d have tried to go it alone and never received medical treatment. In short, I’d probably be dead.

And this is of particular importance because of the number of individuals not receiving treatment. The National Institute of Mental Health reports that of individuals with any mood disorder, half receive treatment, but only one fifth receive minimally adequate care over 12 months. With anxiety disorders, only four in ten receive treatment, and 12% receive minimally adequate care. Schizophrenia does far better, nearly two thirds receive care for their disorder. And in general, with a 12 month prevalence of some mental illness at 36%, only 12% receive care.

This demonstrates a horrible discrepancy between the reality of mental illness and the treatment that is received. I was lucky, I had free access. I was in the one fifth. But without free access, I’d likely no longer be here. So I owe my life to UHS and Dr. A and Dr. F for providing their services.

© James Claims and A Canvas Of The Minds 2011. Unauthorized use and/or duplication of this material without express and written permission from this blog’s author and/or owner is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given to James Claims and A Canvas Of The Minds with appropriate and specific direction to the original content. This work is protected under a Creative Commons Attribution-Non-Commercial-NoDerivs 3.0 Unported License.

Organizing the Chaos

Posted on 2011/10/03 by James

Mental illness often presents us with a mental chaos. Panic disorders disrupt the everyday flow of life with high anxiety; generalized anxiety disorders present falsities about what we should be afraid of. Bipolar disorder with the disorder of moods, and schizophrenia and psychotic symptoms generously give false beliefs. All of the above in some way disorganize the mind as well as everyday life, and it is often the chore of reigning it back in that helps in the battle against these disorders. Personally, I have most of the above. I have panic attacks as well as generalized anxiety disorder, along with bipolar 1 and paranoia. And I thought that I would share two of the structures that I use to keep my mind organized and also ask others to share how they keep the chaos reigned in.

Why is organization the focus of my attention? It may be especially puzzling when discussing coping with either highly localized events like panic attacks or broadly general symptoms like anxiety or paranoia. There are two reasons, a biological one and a pragmatic one. Biologically speaking, these three disorders all in some way are effected by the structure of the hippocampus. The region of the brain responsible in part for memory and responses to new events. It’s the latter that I find interesting. In a paper by VanElzakker a similarity between bipolar disorder and schizophrenia is found in the CA3 region of the hippocampus, the part responsible for the intake of new information. This area is abnormal in both disorders in similar fashions. Additionally, it is thought that the hippocampus is partly responsible for pathological anxiety. To me, this implies a tentative stance that control over novel experiences (ones outside of one’s normal life) ought to be controlled in some manner. This is where organization comes in. One needs to control the environment that one is in such that novel experiences are no longer new and unpredictable. Rather, they are part of the expected flow of daily life.

The pragmatic dimension of this is that organizing one’s thoughts and behaviors seems to work. Imposing order from the outside seems to get results on all these symptoms. It’s not a cure-all, but it can soften the edges, which is often good enough. So some of what is below are things that I’ve found for myself, and others suggested by my psychologist. There are two approaches that I’ve usually used to organize my mind, acclimation to environments and writing. These are just two that I use, but I’d love to hear more about how others do it too.

Acclimation to environments was suggested by my psychologist. It works in several ways. If I know that I’m going to experience something that may traumatize me or set off my panic, what I often do is try to get access to the location that it will be at. There I get comfortable with the surroundings as a place until it feels safe. I do this rather than simply taking on everything at once, new location, new experience. It can be too much. Rather, I organize my thoughts in such a way that the novel event is no longer so novel, it’s just a happening that occurs in a safe place. The other thing that I do is using locations as a way to organize my behaviors. For instance, I use the undergraduate lounge in the philosophy department as the locale for studying. My general apprehension about studying or writing tends to die down if whatever I’m working on is supposed to happen. So rather than being a usual mess of anxiety over what to do first, I have a location where everything will get done at some time. There, I no longer feel anxiety over getting things done. Instead it’s the place that I feel things get accomplished, so my thoughts are organized into that role automatically.

It takes some time to get used to an area. I often need to form a habit in order to organize my thoughts and associate them with a certain area. But after the habit is formed, it’s easy to keep it going. I simply go there and get it all done. My anxiety and depression dissipate by simply walking through the door. A downside to this is access and isolation. If I cannot get to the room, it becomes unexpected and I start to melt down. So selection is key to enforcing this.

Writing is the second thing that I’ve only recently discovered to be helpful even in times of high anxiety and mood swings. While sick recently, I experienced a lot of mood swings which is chaotic to say the least. Additionally I had a test that caused a lot of turmoil in my anxiety. It turned me into a wreck. My thoughts were racing every direction they could take. Everything from random things to be anxious about to self destructive thoughts about how much of a failure I was. But with writing I found that my moods calmed down and my thoughts were forced into an organized structure. Even with all the buzzing confusion, just starting to write whatever came into my head began the process of organizing the flurry into a coherent stream. At first, the writing was disjointed, but it organically came together as my thoughts became focused on what to write next.

It also distracted and coerced my anxiety into a structured format that I could explain to myself. The act of explaining my mind to myself proved to be just as useful as the organization of my thoughts. Writing was meditative in forcing me to reflect on everything that I was thinking and coming to a rational conclusion about what was happening. All these scary events that could throw me off became organized into a rationalized stream. It was wonderful, it took the edge off of everything that was happening and provided an outlet for the anxiety. It was also productive, I felt like I had accomplished something, which also boosted my spirits.

So I’ll leave it there with the two things that I do. It’s hardly a comprehensive or exclusive way of approaching organization. Rather, I’d like to hear what you do to organize your thoughts when they become the chaotic mess.

At What Point Do We Stop Medicating

Posted on 2011/09/26 by James

There is an awful lot of talk about medication in mental health. After all, when you have a mental illness, one wants to get back to a mentally healthy state. I’ll skip over the philosophical questions about what really is healthy and what is ill. Rather, I’m interested in the question of at what point do we stop medicating our illness?

The question was raised to me by my girlfriend. She pointed out that I tend to rely on my medication to control my moods. Feeling anxious, take a klonopin. Nearing panic, take xanax. Depressed? Cigarettes and coffee. Manic? Extra antipsychotics. Psychiatrists provide us with differing arsenals of medication to control our moods in various ways. This is of course a necessary thing to keep us within our bounds. Having bipolar means I need to clip the tops and bottoms off of my moods. But that wasn’t the question she was criticizing. It’s that I have too much control over my moods. I don’t ride through them, I fight them as though they are an alien presence.

Both of us have different behaviors toward our mental health. I tend to fall on the side of pharmaceuticals to control my moods toward my ideal mental health. But she rides the wave. She lets her moods rise and fall and accepts them. She’s even all but rejected medication. She takes a minimal amount of antidepressants to cut off the suicidal thoughts and that’s it. Instead of going further than that, she allows herself to fall into depressions as just a part of her natural rhythm. For her, being mentally healthy is sort of like living a healthy life style. One eats well, exercises, but gets sick and doesn’t fuss unless antibiotics are needed. She takes her antibiotics, but if she gets sick she doesn’t reach for the nearest cold medicine, she just stays in bed and lets it pass. To stretch the metaphor, some of us do need our antibiotics, but to what degree do we just accept getting sick as our natural state of being healthy? So I take her question to mean more about that. Is it mentally healthy to constantly attempt to control moods using medication? Or is there some point that riding the wave is what is supposed to be mentally healthy.

I don’t have the answer to that question of which is healthier. Nor am I proposing that these are mutually exclusive ways of approaching our mental health. In fact, I think we need a bit of both. But the question is still out there, what is healthier? Control oriented, or acceptance oriented approaches? And this ties into defining what we mean by mental health. What do we consider to be mentally healthy. After we figure that out, I think that we can start to determine just how much medication we need and when to stop. So this will end more as a question than an answer, are you an acceptance person who lets the sick days come and go and try to prevent them from getting too bad, or are you a control person like me, where I try to stop getting sick ass much as possible? At what point do we stop using medication for our illness? And which do you think defines a healthier mental state?