When is it appropriate to schedule someone into compulsory care when he or she is out of touch with reality? The horrific attack at a busy and normally safe Sydney shopping mall will renew this conversation. That is my prediction, before the formal investigation and review procedures have concluded – and I admit to ignorance on the details of the assailant, now deceased.
However, there was one line in the reporting that immediately brought this question to mind, and that was the person who set about knifing shoppers had ‘a history of schizophrenia’. The reason this report brought this uncomfortable question to mind was that I and others in Community Health Services wrestled with it in the 1980s. In this State of NSW, we were moving away from institutionalised care to more localised care, particularly group homes.
The Community Psychiatric nurses started to find situations where patients (or ‘clients’ as they became to be known) were doing well in their placements – so well, that they believed they no longer needed their medications. The ongoing concern of the mature nurse carers were that some of these people had well-established patterns of losing touch with reality when ‘off their meds’. On average, there was (in our case) a high percentage of them ‘crashing’, which meant them finding themselves on the street, disoriented, and in dangerous conflict with others. Sometimes others would also be at risk in some way.
But the law changed so that scheduling these people back into a context where their medication use could be monitored became much harder. We sadly had too many of these people on our ‘W-W-W’ list, where W-W-W meant watch (as closely as we could), wait, and wonder. The team I had were very faithful in doing whatever they could to keep a constructive relationship with these clients. But the further they were from their meds, the harder it became.
It seems the situation has not been resolved in the interim since I left health services. The underlying conflict parallels others in our society – for example, the rights of transgender women (biological men) versus the rights of biological women; or sexual discrimination rights versus rights of expression of religion.
In this most current sad event, we have the rights of personal choice (not taking meds) in contrast to the right to safety of others. I note this was the same mess that occurred during Covid with functionally enforced injections.
This will not be solved while our law and mental health services are increasing dominated by what Philip Rieff called ‘the triumph of the therapeutic’ – that is, personal feelings that trump principles of community justice. More recently, Theodore Dalrymple’s Spoilt Rotten: The toxic cult of sentimentality. Dalrymple challenges the role of sentiment, in the modern sense, in deciding moral questions. He describes current sentimentality as ‘an excess of emotion that is false, mawkish, and over-valued by comparison with reason’. This is in contrast to the traditional use which represented a personal trait of responsiveness to others.
If sentimentality, driven by an anthropology based in Romanticism, is occurring still, then part of the challenge is working to differentiate between illness and psychological distress. If someone is struggling with a physical disorder, medical treatment of some kind can be prescribed.
But if the disorder is of another kind, but is presented as an ‘illness’, what then? Where does the moral responsibility lay? For example, how often must an addict refuse help before they are held fully accountable for their actions? Is it too easy for those in authority to excuse moral consequences on the sentiment given to the ‘unwell person’? Is this an example of what Oscar Wilde apparently noted (as quoted by Dalrymple): ‘…a sentimentalist is simply one who desires to have the luxury of an emotion without paying for it.’
This takes us to deep considerations of who we are as persons in relationship with each other. For example, how might we respectfully restrain someone who is either physically unwell and psychologically detached from reality, or even more complicatedly, becoming detached from reality without physical ailment? Dalrymple comments that ‘…the legal doctrine that psychological damage is not conceptually and judicially different from physical damage is both sentimental about the nature of mankind, and highly advantageous to the legal profession.’
Do we need to reassess our view of human nature to make better decisions about how we deal with what now is such a broad category of persons – those who are ‘mentally ill’? Is part of this the increasing trend to both blame the State, and expect the State to fix everything? And is this complicated because the bonds between families, and between parents and children, are being weakened by the policies of the State? Are those who desire more control (because ‘they know what is good for us and how to keep us safe’) aware that the family stands between the State and absolute power? Does this drive some of their use of romantic sentimentality?
And so, a man on a deadly rampage will be analysed, dissected, and probably be used to increase State control on everyone’s life. Instead, if perhaps the romanticised and sentimentalised version of human nature was adjusted closer to reality, we could have a system which more clearly dealt with the responsibilities of individuals in place and time.
