power

It’s Not Just Britney

In the U.S., those deemed “mentally ill” can easily lose basic rights.

Photo: Bruno Vincent/Getty Images
Photo: Bruno Vincent/Getty Images

For the last dozen or so years, I’ve researched mental health, both as a reporter and as a person living inside a head. One big, basic, and easy-to-miss point about mental health — something I’ve come to really understand — is that we are each just one very bad day away from becoming our own version of Britney Spears on that stretcher, hauled out of a mansion in front of the world.

If you were to have that very bad day, here is what you’d probably learn next: Our mental-health-care system is extremely broken. As for where this brokenness comes from and how we can do better than what we’ve got, I’ve filled one book trying to answer such questions and am finishing a second. But if you had to boil it all down, the big issue is this: Right now, our mental-health system is predicated upon force. Force over the individual in question, somebody who has been deemed incapacitated, for example, because of having been diagnosed with a “severe mental illness” like bipolar disorder or schizophrenia. Whether such psychiatric diagnoses are medically meaningful is debated intensely. What psychiatric diagnoses are certainly: legal terms.

So, in the event you are determined to be incapacitated by a court after such a diagnosis, you can be stripped of a whole host of rights. Maybe now you’ve been barred from participating in your own medical decision-making, including psychiatric and reproductive decisions. Maybe you’re barred from making your own financial decisions. Maybe now you’re barred from voting, holding a driver’s license, signing your name to anything, including just a credit card; it can go on and on. Sometimes a court will tell you you’re no longer permitted to see your own children. I’ve heard folks who pay attention to this intersection of disability and the law refer to this event as a “civil death.”

It’s difficult to estimate how many people are caught up in such situations, both because of patient-privacy laws and because data collection in this country pertaining to human-rights violations of the “mentally ill” is extremely poor. There is no centralized database that tracks involuntary commitments, one of the classic ways a person winds up relegated to this lesser legal status. What data does exist suggests they are becoming only increasingly common: A study from last fall out of UCLA found that involuntary commitments over the previous decade outpaced population growth three to one. “This is the most controversial intervention in mental health — you’re deprived of liberty, can be traumatized and then stigmatized — yet no one could tell how often it happens in the United States,” David Cohen, a professor of social welfare who led the study, said in a press release. One recent estimate extrapolated that over a million Americans a year are involuntarily committed.

I’ve interviewed many self-identified psychiatric survivors in recent years, as I’ve attended World Hearing Voices Congress and protests outside American Psychiatric Association annual meetings and so on, traveling here and abroad in search of better answers. Most psychiatric survivors have, at some point, learned the hard way just how much you can suddenly be deprived of. They tend to know what it feels like to become somebody who’s deemed no longer able to make their own decisions. Someone who instead must comply. Often because a doctor said so, or a family member said so, or a court said so, or some or all of the above. Sometimes a person gets placed under a “conservatorship,” like Britney did, or a “guardianship.” Such arrangements have drawn increased scrutiny recently, but really, this situation is much broader: What we’re talking about, at its core, is the potential all of us have to lose basic civil rights — so long as this paradigm of coercive psychiatry persists.

Why and however it happens to you, the basic gist is this: If you wind up consumed by this system, your personhood is seemingly shrunk. And given that you often can’t sign anything yourself, you can’t even hire an attorney on your own to help you. Britney Spears herself is for that reason relying on court-appointed counsel, as many were surprised to learn when they watched the Framing Britney Spears documentary.

Here’s something that people who haven’t experienced a scenario like this don’t tend to know: There’s no real way to prove you do or don’t have some mental illness. These diagnoses remain unsubstantiated biologically, more metaphor than medicine. This was even admitted by the then-head of the National Institute of Mental Health back in 2013. (“Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure,” wrote Dr. Thomas Insel in a post on the NIMH’s website. “In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever.”) The medical mysteriousness of psychiatry’s diagnoses allows for a lot of confusion about these topics, both among experts and the public. This allows for a perpetuation of the status quo, which in practice tends to beget the abuse of power, however constituted — whether that’s the brainwashing of the American public for the profit of Big Pharma or the seizure of Britney’s assets and personhood by those nominally tasked with ensuring her care.

For every Britney Spears, there are an untold number of exceedingly less-famous Britneys trapped in their own private hells, perhaps being controlled by the state or by a family member, all of them stories that are surely as harrowing as Britney’s, if not more so. These are stories that, until we actually recognize the full humanity of “mentally ill” people, we will continue to ignore. Our legal system and medical system are designed to ignore such people. And the public, as well, has long seemed extremely dismissive of the voices of the supposed “insane.” Maybe until last week.

To psychiatric survivors, what’s happened to Britney is everyday, obvious, banal. She is one of them. The press and the public, on the other hand, were astonished last week when they heard the alleged particulars of Britney’s case: How she can’t own a smartphone. How she can’t ride in her boyfriend’s car, let alone marry him. How they won’t let her get an IUD removed so she can have a baby.

All this, of course, has negatively impacted her so-called mental health, according to her — “I cry every day,” she said, also begging to not have to undergo yet another psychiatric evaluation (that’s how little she desires the sort of mental-health care that is on offer). It’s a perfect distillation of the error of our mental-health-care system as constituted: It steamrolls an individual in the name of “public safety,” oftentimes actively damaging them in so doing. It’s a system predicated upon reducing a person’s rights so extremely that, as Britney’s case aptly demonstrates, all the money and fame in the world cannot free you.

This paradigm of coercive psychiatry has been criticized for decades by psychiatric survivors and their allies (clinicians, attorneys, journalists like myself) as being both ineffective and expensive. The United Nations has also blasted this psychiatric framework as violating human rights. In 2013, this special report on torture called on member states to “impose an absolute ban on all forced and non-consensual medical interventions against persons with disabilities, including the non-consensual administration of psychosurgery, electroshock and mind-altering drugs such as [antipsychotics], the use of restraint and solitary confinement, for both long- and shortterm application.” Just last month, the WHO also called for the implementation of a totally new, human-rights focused mental-health paradigm.

In America, however, the coercive approach continues to be all we know and all we fund, really. We tend to overlook the promise of mental-health-care “alternatives” (as they tend to be termed). These include non-judgmental support groups for people who hear voices and for those who are considering suicide, as well as safe houses for those experiencing acute crises. Such approaches tend to be comparatively cost-effective and totally hope-inspiring — and, in my experience, few Americans have ever heard of them.

The day after Britney’s statement to an L.A. court last week, one heard around the world, I called up a psychiatric-survivor activist I’ve gotten to know, Caroline Mazel-Carlton. Mazel-Carlton, who’s also a rabbi-in-training, works for an organization that is revolutionizing mental-health care in western Massachusetts (and beyond), called the Wildflower Alliance. I asked her what she thinks of so many people suddenly rallying around psychiatric patients’ civil rights — or the rights of one patient, at least.

“To me, honestly, it’s just a relief,” Mazel-Carlton said. “Sometimes I even cry, to hear people finally saying, ‘That’s not right. That’s not right.’”

When we spoke, Mazel-Carlton seemed more focused on the actual activism of the day: This week, she and some colleagues testified to the Massachusetts legislature, speaking out against a proposed law that would expand forced psychiatry in their state. Euphemistically termed Assisted Outpatient Treatment or AOT, such laws have been adopted by 47 states over the last two decades. Such laws expand the state’s powers to make medical decisions for a person deemed incapacitated by virtue of insanity, for example, going beyond the time frame of a mandated psychiatric hold in a hospital, which traditionally would be for something like 72 hours. Instead, under such laws, a person who’s been released from the hospital, say, is now controlled and monitored, often on an indefinite basis, by the state.

These AOT laws are near-ubiquitous and represent a doubling down upon this coercive-psychiatry paradigm; in other words, they are the opposite of whatever liberated vision of mental-health care is endorsed, if hazily, by the #FreeBritney campaigners. I’ve wondered if those posting #FreeBritney realize there is already a robust movement for psychiatric patients’ civil rights, one that has been organizing for decades?

“I just want to say to people: Welcome to this movement,” said Mazel-Carlton. “It’s one of the less well-known liberation movements, but we’re really excited to have you if you want to fight by our sides and not just Britney’s.”