When they don't know they're ill, how can we blame them for what they do?

All together now, say Anosognosia!
This little poke at the establishment divides itself into two parts:1) questioning the claim that anosognosia is a brain disease that psychiatrists say shows that many people with schizophrenia and bipolar disorder can't understand that they are mentally ill. And 2) whether we are correct to let people with an intractable brain disease be freed from responsibility for their acts.

First, according to the neurologists, we seem to be talking about those with a brain “freezeup”-those who are so out of reality they don't know they are sick. And therefore they can thwart the norms and rules of society, refuse to take medicine, fall under the spell of their hallucinations and run afoul of the law. They don't know what they're doing, so why blame them? Well, they may just know more than researchers say they do.

In my experience, for the minority of people with schizophrenia who are profoundly affected, I find people do not act so blindly. Instead, I think they know they're different but they can't change their thinking and behavior--it's wired into their brains. And it's reinforced by society. They won't admit something is wrong with them because of how we react to them. They don't like what medicines make them feel like so they won't take them. They are non-compliant on purpose, not innocently. They can be manipulative and forcefully clear in expressing what they want and don't want to a doctor, counselor or disputing parent. We observe them as young men and women fully able to draw themselves up with whatever dignity and self respect they have to tell off their doting parents and doting doctors and underage social workers. We keep trying to change and repress their behavior. They want to have a good time now and then by drinking beer or smoking a joint. And they catch hell. “What do you want from us?” they seethe. “Look at the life you have for us.” I heard it the other night at the relatives support group-- a parent told how his son screamed back at him: “You don't know what I'm feeling! Give me some space!” Yep, they need space.

And if they are ill, should we hold them responsible for their acts?

This is sanctified territory to talk about blaming. Does someone's mental illness relieve him of responsibility for his acts? That is, is he helpless to change his ways because of a disorder called anosognosia? I think we have to accept that some people because of the illness, whether they know what they do or not, must be treated differently in society and under the law. And our courts are trying here in Schenectady to make allowances, to provide alternative hearings and sentencing and substituting treatment for jail when possible. The prison system hasn't awakened yet, it still treats prisoners who are mentally ill with disdain and a harshness unreserved for any other group; its use of solitary confinement for large numbers of these prisoners is one of the great injustices of our times.

In many other respects people with mental illness are expected to conform to society's rules and norms. We want them to thrive, live among us as independently as possible, accepted by their neighbors, landlords, employers, shopkeepers. Blessed with good treatment, most people with severe brain illness can at least partially recover, reshape their behavior and become responsible citizens.

Still, we know those with schizophrenia and the other severe mental illnesses lack insight, they lack skill in judgment, they act impetuously, they think in their own confining terms and fail to see the larger world around them. Those traits usually don't disappear and mean that someone who is brain-disordered will need life-long help and support. Those who can't live safely and peacefully in society may need to be separated from the others, in humane ways. In NY State we have Kendra's law as a method of shifting someone into outpatient treatment and then into more confined care if he doesn't respond to treatment. Even then, say advocates of a sterner policy, those who demonstrate they are dangerous should not be allowed to live among us. Too many tragic episodes are the clear result of not identifying these individuals ahead of time and putting them in custody.

The view is demonstrably contrary to law and policy, how the courts have ruled on these issues and how police agencies enforce the law. It's the most common complaint heard from families of the mentally ill around the nation that the state won't act to protect their son or daughter, husband or wife from hurting themselves or others. Rising against this are assorted voices in the consumer movement, unwilling to accept that dangerous behavior of a few threatens all of us. They oppose all restrictions on individual liberty and will accept the occasional violence and other personal tragedies as costs to be borne in order to uphold one's priceless liberty. But by letting someone off the hook, they breed contempt for the very people they seek to defend. Society, too, must be blamed for failing to come to grips with the reality that these powerful diseases have devastating effects on the mind. (Roy Neville)