Bruce Arrigo’s Punishing
the Mentally Ill sets out to demonstrate that "decisions reached by
law and psychiatry are, knowingly or not, always and already linguistically
structured to punish the mentally ill" (p. 190).  He builds his case on
eight postulates, each of which is defended in one of the book’s eight
chapters.  While building his case, he folds in Foucault’s social control
theory, principles of chaos theory, Derridean deconstructionism, and Lacanian
psychoanalysis.  Essentially, he contends that the decisions of mental health
courts, whether on matters of civil commitment or criminal confinement, are
predicated on an unconscious social desire to punish the mentally ill citizen
for being different from the non-mentally ill majority.  The book offers key
insights and is a genuine contribution to post-modern approaches. 
Unfortunately, due to problems with its structure, discussed below, it is often
needlessly dense and obscure.  As a result, it probably alienates a general
audience, which is a pity, because Professor Arrigo’s points deserve a
hearing.  Properly organized, they would be accessible to a much broader
readership.

The book begins
with an examination of civil commitment law and practice from the mid-seventies
forward, in the United States.  Civil commitment refers to involuntary hospitalization
for psychiatric observation, assessment, and treatment.  Arrigo suggests that
the primary force driving commitment is paternalism.  This paternalism is a
consciously embraced value of the psychiatric and legal communities (the "clinicolegal"
community), enshrined in parens patriae and the doctrine of the police
power of the state.  Roughly, the state acts as a parent to those citizens
unable to fend for themselves (e.g. via child protection legislation, or civil
commitment criteria for the mentally ill), and the state also reserves the
right to police the citizenry so that broader peace and security are
maintained.  Clinicolegal paternalism results in pitting the rights of the
mentally ill "against the demands of an organized society" (p. 187). 

A tension is
created between the broadly legal value of liberty and the broadly psychiatric
value of treating the helplessly dangerous and ill person.  This tension
results in the rather tragic consequence of the mentally ill being abandoned. 
Patients are forcibly treated until they are no longer dangerous, at which
point they are at liberty to refuse treatment.  This results in discharge from
the hospital, consequent deterioration, readmission involuntarily once they are
re-certifiable, and so on.  This revolving door is the consequence of the
competing values of liberty and treatment, and the net effect is punitive on
psychiatric citizens–a "legacy of abandonment" (p. 10).  This is all
on top of the purely pragmatic consideration that "the best available
evidence shows that these interventions are only minimally better than doing
nothing at all" (p. 4).

Arrigo then
moves on to contend that advocacy, the practice whereby the mentally ill
individual has representation in a clinicolegal setting, is itself informed by
the very same paternalism which already undergirds clinicolegal practices and
decisions.  The advocate’s function is to make every effort to discern and
represent the wishes of the patient in the civil commitment hearing or criminal
trial.  However, what non-psychotic could possibly enter into and fully
understand the true desires of the psychotic?  Where communication fails, the
advocate must infer, and those inferences are inevitably colored by what the
advocate perceives to be in the best interests of the client.  Thus,
advocates represent not their clients but only themselves.  This results in a
situation where the advocate complicitly goes along with the machinations and
values (i.e. paternalism) of the hearing, leaving Arrigo to wonder "what
room, if any, is legitimately left for the disparate voices of the
psychiatrically disordered" (p. 53).

Not only is
paternalism a predominant value in clinicolegal practice, leading to the
abandonment and squelching of psychiatric citizens and their perspectives, but clinicolegal
processes balance "competing and conflicting liberty rights by first
reducing psychiatric differences to sameness" (p. 187).  Arrigo refers to
this as "identity politics."  In clinicolegal practice, the
perspective of psychiatry is considered to be predicated upon science and is
therefore deferred to as the rational and objective standard to which all
reasonable persons, with a command of the relevant facts, would assent (pp.
67-70).  That perspective asserts that the psychiatric citizen is different by
virtue of disease.  By a course of treatment, the disease can be managed, much
like the blood sugar level of a diabetic can be kept within a healthy
physiologic range.  Thus, the psychotic is really just like us, and via
treatment, "health" can be "restored."  The possibility of
the psychotic being a different sort of human being, rather than a
sick-but-like-us human being, is thus not even entertainable in principle.  We
are left with an individual who, by virtue of disease, is in desperate need of
treatment, is unable to comprehend this desperate need (or give meaningful
consent), and who is forced to accept treatment in much the same way that
life-saving injections are forced on terrified children with earnest resolve. 

What initially
looks like treatment of the needy and helpless starts to resemble social
sanitization by the policing of difference, and psychiatry’s true vocation is
revealed as "a function of public hygiene" (p. 79).  Thus begins Arrigo’s
incorporation of Foucault’s social control thesis into his project.  Using
principles of chaos theory, he suggests that an alternative way of conceiving
the mentally ill, by viewing them and all people as part of a larger,
non-linear system, would eliminate the false barrier of normal vs abnormal (or
mentally healthy vs. mentally ill), and efforts at social stability could be
geared toward other non-linear root causes of suffering, such as poverty.  Arrigo’s
argument became impenetrably jargon-laden when discussing the application of
chaos theory to Foucault, and the end-notes were insufficient to bring clarity
to his excessively technical fourth chapter.

Arrigo’s
argument then looks at how the social control thesis is enacted.  First, social
control is legitimized by the very presence of the clinicolegal apparatus, able
to claim authority in the name of advancing science and legal thought.  Second,
Arrigo suggests that the mentally ill consciously or unconsciously assent to being
policed.  He illustrates this point by providing the stories of three
individuals with whom he had interacted as a mental health outreach worker (pp.
114-118).  The stories themselves are exceptionally moving and demonstrate
starkly how very abandoned some members of our society are by the current clinicolegal
state of affairs in the United States and Canada.  On a personal level, I found
myself moved by what I took to be a deep compassion on Arrigo’s part, and this
motivated me to continue slugging through some rather dense prose.

Arrigo
concludes his argument using a combination of Lacanian and Derridean thought. 
He seeks to demonstrate that clinicolegal speech acts, in the form of mental
health court decisions, represent a coherent narrative of protecting the sick
at the conscious level.  However, this narrative is rooted in unconscious
cultural assumptions, retrievable to consciousness through a careful study of
the language used and not used (or not permitted), in clinicolegal settings. 
While the conscious narrative enshrines Derridean binary oppositions such as
well vs. ill, and competent vs. incompetent, the unconscious narrative reveals
the enshrined belief that, essentially, the mentally ill individual suffers a
lack.  The unconscious presumption of this lack in the mentally ill "fails
to convey the fullness of their identity, humanity, and being.  This is the
presence of punishment, first and foremost assuming a discursive linguistic
form" (p. 190).  More explicitly put, "mental illness does not
exist independent of an array of social, political, economic, and historical
factors that are spoken.  Once uttered as such, the discourse assumes a reality
that becomes more ‘real’ than the individual to whom the label is
assigned" (p. 193, emphasis Arrigo’s).

While the
social constructionist perspective is extremely important within psychiatric
and legal thinking, and I find much of Arrigo’s contribution novel, this is not
a book I can recommend to a general audience, largely for reasons related to
its structure.  First, the book is jargon-laden.  This isn’t necessarily a
fault, but when the jargon goes undefined, or is not defined until several
pages later (a pattern which repeats itself with exasperating frequency here),
then it becomes a fault.  This is especially the case in a book which seeks to
illuminate important social concerns.  Second, the book invokes numerous
technical concepts while making little to no effort at acquainting the reader
with these concepts.  For instance, rather than showing how chaos theory
extends Foucault, Arrigo seems to simply invoke chaos theory and declare it
thus.  After a very pithy summary of Foucault, he lapses into impenetrably
dense prose about "Attractors" (p. 94) and "The Fractal Geometry
of Social Control" (p. 98).  I could make nothing of it.  In chapter 6, Arrigo
invokes Lacanian symbolic forms that are then explained in a very cursory,
unsatisfying fashion.  Not until chapter 8 does Arrigo provide what in chapter
6 would have been a most helpful primer. 

Essentially, if
Arrigo had defined his terminology as he introduced it, taken the time to
adequately introduce his audience to the technical concepts he incorporates,
and moved his discussion of Lacanian thought, a very difficult and at times
impenetrable book would have been challenging but engageable and important.  For
want of some careful editing, Bruce Arrigo’s "Punishing the Mentally
Ill" largely alienates those who could most benefit from exposure to these
important ideas, in particular, politicians, judges, lawyers, psychiatrists,
social activists, and ironically the mentally ill themselves, for whom he
passionately advocates.

© 2004 Robert Tarzwell

Robert Tarzwell,
M.D., B.A. is a third year psychiatry resident at Dalhousie University in
Halifax, Nova Scotia, Canada.  He is interested in dynamic psychotherapies
which focus on emotional experiencing as the primary therapeutic mechanism of
action.  He is also interested in evolutionary approaches to psychiatry.

Categories: Ethics