In and out of the car this morning, I caught some snatches of a radio talk show on the problem of "the mental health profession"--specifically how to answer the question of quality control, the measure of effective treatment. I was struck by how little this issue seems to have changed since I first paid attention to it some 30 years ago. Apparently we still have loads of cases where the patient will have one view of whether the outcome was successful; the "therapist" (but cf. infra) will have a different view; and a third-party evaluator yet a different view altogether. The questions are: should we be doing a better job of articulating standards for success or failure in the mental health biz? And if so, how and by whom?
I have to confess, I love this stuff, perhaps particularly because it seems so hard. I also plead guilty to having flirted back in my younger days with some of the wilder excesses of the anti-psychiatry movement--most visibly Thomas Szasz and R. D. Laing (though I gather Szasz detested Laing, and it didn't take me long tofigure out why). But I had a psychiatrist friend in those days (we made music together on Wednesday nights) who did his best to set me straight: "Look," he would say, "there are some people who are just nuts."
I think I came to believe he was probably right; at least I wasn't disposed to argue the point. My Wall Street Journal this morning tells me of a man, descendant of an old New England family, who was fired from a Gloucester Massachusetts fish-processing plant for ""attempting to put nuts and bolts into the fish." "One big loose screw," the commentator remarks, and I think the pun may have been unintentional. Anyway he--the former fish procesor, not the commentator--later accosted "a popular local teacher [and] smashed her skull with a rock, dragged her to a hiding place, pushed her face into the ground and left her to die in the thick growth." And on a lighter note, a headline in today's American Bar Association newsfeed says: "Jesus Christ’ Excused From Jury Duty for Being Disruptive:" no class A felonies noted.
I suspect my old bud would have consigned both of these to the "just nuts" file. But this--our music making phase--was also a time when it was easy to find stories about how the old Soviet Union was clapping people into nuthouses for the offense of annoying the Powers that Be.
In the United States, this stream of inquiry proved to be a peculiarly treacherous channel of eddies and undercurrents because of its intersection with the campaign for women's rights. We all knew --know--stories of women who were carted off to the loony bin for no offense greater than simply being themselves. On the other hand, we knew of psychiatrists who would give the girlies a fistful of Valium and pat them on the head and tell them to calm down and go home, while the girlies (ahem) were shouting LISTEN TO ME YOU BOZO I AM IN PAIN. I know my psychiatrist bud made it clear--without ever breaching client confidence--that he spent a fair amount of his time with women who seemed just generally disappointed with life, and I don't think he thought they were "nuts," even though they might have been "just."
One of my favorite law-teaching cases in those days was something called Ortelere v. Retirement Board (looks like it is still in the lineup)--the story of a New York school teacher who retired and quickly died leaving a husband by all appearances rather near destitute. Apparently just before death she had made some kind of voluntary "pension election" which was, from his view, catastrophic. The question was: could the pension payor claim the protection of the election, or must it pay a pension to the husband anyway? A (divided) New York court ruled against the election, citing "serious mental illness, namely psychosis."
I'm one who always believed that the job of the contracts teacher is to make simple things complicted, and in the case of Ortelere, this task is about as difficult as dynamiting whales in a barrel. Who are we protecting here, anyway, "her," or her dependent husband? And who are we to say she didn't know damn good and well what she was doing. And by the way--the particular psychosis cited was something called "involutional melancholia." It was fun to point out that "involutional melancholia" stood in the legions of mental illness in those days alongside "homosexuality"--and that both were later struck from the regimental roster on grounds that they were not mental illness at all.
I don't have much to add to the conflicting crosscurrents already surfaced, except to mention one hobbyhorse of mine. That is: I think some of these issues would go away if we simply narrowed our definition of "therapy." Apparently one fascinating datum in the literature of psychiatric "cure" is that a lot of different techniques seem to work, and that the more powerful determinant seems to be the skill of the particular purpose.
Follow this line of reasoning very far and you come to the ironic insight that maybe some people would be cured just as well by their bartender or their Labrador Retriever. Suggestions like this are oft offered in jest, but I don't see anything funny about them. Indeed, a lot of life's agonies can be eased by a steady, patient and compassionate friend. Calling these interventions "therapy" may just confuse the issue.
For whatever it may be worth, most of my students considering Orteleree wanted to allow the poor widower a pension, but they weren't comfortable with making it rest on the premise that the decedent was somehow nuts. For myself, I haven't taught this sort of stuff in years (I moved on to other stuff). But from listening to the conversation this morning, I suspect I could have pretty much the same conversation today.