Guest Blogger Dr. Jesse Hellman: More Thoughts On Rachel Aviv's Article on Involuntary Treatment

Jesse has wanted to do a guest blog post for a while now, and The New Yorker article finally got him blogging. I wrote a brief post yesterday, but he does a more thoughtful analysis of this complicated and provocative issue. Clink is off somewhere.. I am looking forward to hearing her thoughts after the holiday.
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In “God Knows Where I Am” Rachel Aviv sees the protagonist Linda’s
refusal of treatment as an expression of her illness. The moral
impasse she describes for our profession, though, is real: denial of
the need for treatment, or of one’s illness, can be an expression of
that illness; the refusal of treatment can also be a valid position
which we understand and support.

Mental functioning can be variable, at times better and at times
worse. At times the craziest thoughts are held in check, or do not
manifest themselves, while at others they hold total sway. The
underlying assumptions of our society are shared by us, and these
shape our reaction to the illness that Linda has. Other societies,
with different traditions and philosophical underpinnings, are
comfortable with very different stances.

Before Linda was discharged from the hospital the staff did everything
they could to dissuade her, and to provide for her safety. She
rejected every effort to provide housing and support. The hospital
argued that she was too sick to make decisions which even included not
allowing the staff to notify her sister and daughter. After her death
the family sued, stating that insufficient effort had been made to
protect her. The hospital then argued she was not sick enough to
justify stronger measures. What was true?

When we look at a complex issue, or event, we naturally can only see a
part, and our response is shaped both by what we see as well as the
assumptions we carry. What weight to we place on independence versus
the rights of others? What extrapolation can we make to an unusual
thought, in that do we see it as the harbinger of insanity or of
artistic creativity? Do we value religious musings or find them
suspect?

Aviv lets us see that while a part of Linda’s functioning might have
been creative, artistic, perceptive and so on, it was increasingly
shaped by an imagination which was not tempered by reality. It was as
if she was in a dream but could not awake, a dream which increasingly
dominated the most important parts of her ability to survive.

So what is the proper role of society when confronted by such illness?
What if her fantasies had shifted from thinking spies were all around
her to imagining the world could only be saved if she were to shoot
her congresswoman?