You shouldn’t have to go to jail for mental health treatment

R. Horton

Last week I tweeted a link to a Texas Observer article by Emily DePrang about sexual assaults in Harris County jails. DePrang had written about two Bureau of Justice Statistics studies that showed the Harris County Jail on Baker Street had sexual assaults that are higher than national averages.

One survey reported rates of sexual victimization as reported by inmates, and found that inmates reported higher than average rates of victimization from other inmates. The other survey was based on official reports of sexual violence in jails and also reported higher than average rates for the Baker Street jail. DePrang did not discuss, in her short post, all the statistical and methodological limitations of the studies in question.

To my surprise, Alan Bernstein, the director for public affairs at the sheriff’s office tweeted me, saying he hoped someone would fact-check DePrang’s article as it had many mistakes, so I asked him what the mistakes were, and he sent me a list of items he felt were misleading. Later, the Texas Observer agreed to publish his response to the article (his published response was slightly different from what he sent me).

For the most part, his response pointed out the limitations of the study. Also, he noted that only one of four jails in Harris County had a higher incidence of sexual assault, and he also noted that jail had a high percentage of inmates who are under treatment for mental illness. In his note to me, Bernstein asked, “Is touching a clothed inmate’s thigh sexual violence? Maybe so. But this is one of the actions considered sexual victimization in the study.” I will just say that I consider any unwanted touching of my upper thigh over or under clothing to be sexual assault, even if the “violence” seems minor.

In trying to separate the signal from noise, though, what interested me most was not the definition of sexual violence or even the limitations of the study but the fact that the jail had so many inmates on medications. The Houston Chronicle quoted Sheriff Adrian Garcia saying, “The Harris County Jail has been referred to as the largest psychiatric facility in the state of Texas” and “More than 2,000 inmates … are on psychotropic medications on a daily basis.” And in Bernstein’s response, posted on the Texas Observer site, he said:

That building houses the jail system’s inmates with acute mental illness. In fact the statistician who worked on the 2011 study tells us that two-thirds of the surveyed inmates in the so-called “high” rate building had “psychological stress disorders.” We don’t know how that was determined, and we would never allege that people with mental illness fabricate allegations more often than anyone else.

I’m not sure what “acute” means in this context, but I suspect anyone on medication is assumed to have an acute mental illness. Given the number of prescriptions written for antidepressants and anti-anxiety medications these days, I suspect a fairly high percentage of the general population is acutely mentally ill, according to these assumptions. Even someone being treated for mild depression, though, will experience unpleasant side-effects if doses are missed, as they are likely to be missed inside a jail. We should be concerned both about lack of treatment for mental health and the over-prescription of  drugs for depression and anxiety. Withdrawal sometimes leads to aggressive behavior and could account for some problems. On the other hand, mental illness is also stigmatized, and those receiving treatment may become targets for abuse at the hands of other inmates.

Fortunately, I found more information on treatment of the mentally ill in Harris Country jails in excellent article by DePrang titled “Barred Care.” According to the article, the jail “treats more psychiatric patients than all 10 of Texas’ state-run public mental hospitals combined.” And why is that? Because no one else is treating those patients. Again from the article: “Harris County has one of the most underfunded public mental health systems in a state that consistently ranks last, or almost last, in per capita mental health spending.” Some people get so desperate for relief, that they break the law just so they can go to jail and get treatment.

The program in the jail is commendable. The funding priorities of our state government are not. In 2003, the Texas legislature slashed funding for mental health services in Texas. According to DePrang’s article, “In Harris County, the number of law enforcement calls about people in psychiatric crisis jumped from fewer than 11,000 in 2003 to more than 27,000 in 2012.” So, the Harris County jail has a high number of mentally ill as a result of deliberate action of our state’s lawmakers. This should make us all angry. Cutting funding for mental health services only to force the mentally ill into jails is cruel and expensive. No matter what sends people to jail, many will never really recover from the stigma and the trauma of the experience.

What should be done? We should lobby our lawmakers to restore funding for mental health services in Texas. We should stop blaming the mentally ill for their problems. We should resist the temptation to treat even minor difficulties with powerful and addicting drugs. We should insist that Texas expand Medicaid as part of the Affordable Care Act (this would cost the state nothing) so that people can receive basic medical care and avoid crisis.

In short, we should learn to heal each other. The person with a mental health crisis tomorrow could be you.

Do all ethicists have a messiah complex?

R. Horton

Last May, Nathan Emmerich wrote a column warning that bioethicists must not become a “priestly caste.”In the column, he warns that giving bioethicists moral authority over all practices in medicine and healthcare will have an anti-democratic effect and hinder public discourse.

He may have overstated the authority that bioethicists generally have, but it is true that some see their job as handing down judgment on various practices in medicine and research while others, frankly, would be happier to just accept the opinion of “experts” in order to avoid having to take full responsibility for their ethical decisions. The ethical expert has arisen because of rising demand. After making a thorny decision, who would not want to be able to say, “My decision was reviewed and approved by experts in ethics”?

Ethicists will do well to resist a priestly role. If you begin to believe that something is morally correct simply because you believe or say that it is, then you should apply for sainthood, not a position as an ethics consultant. When Euthyphro is asked if he knows he is doing the right thing, he replies, “The best of Euthyphro, and that which distinguishes him, Socrates, from other men, is his exact knowledge of all such matters. What should I be good for without it?” Euthyphro considers himself an expert on matters of morality and dismisses any suggestion that his opinions might be challenged. As he attempts to explain himself, his logic breaks down. Ethicists as experts would do well to open themselves to challenges from all corners as Emmerich suggests.

All this is further complicated, though, by Eric Schwitzgebel’s finding that ethicists are no more ethical than non-ethicists. Comparing ethicists and other professors, Schwitzgebel and his colleague, Joshua Rust, found that both ethicists and their colleagues reported that the ethicists were no more ethical than their colleagues. This is not terribly surprising. I may think I am a pretty ethical person but not be willing to say my colleagues in metaphysics are a bunch of thieves and charlatans. By the same token, they may think I am pretty ethical but have enough self-respect not to sell themselves short.

Of further harm to the reputation of ethicists, Schwitzgebel says ethics courses do not appear to have much affect on the ethical behavior of students. He notes that many of us who teach ethics do no claim that it will make our students behave more ethically. This is probably true in most philosophy departments, but ethics courses in law schools and business schools, for example, are designed to prevent unethical behavior down the road.

It isn’t likely that any type of ethics course can cause an unethical person to become more ethical, but courses can have an effect on ethical behavior. Courses in specific disciplines can provide a framework for codes of behavior in a particular field such as law, business, psychotherapy, or medicine. Through such courses, students can become well versed in expected norms as well as actual regulations from laws or professional codes of behavior. In addition, students can learn to examine cases and apply accepted principles of their fields to various situations they may encounter during their careers.

Theoretical courses give students a larger ethical toolbox to examine conflicts that arise in their careers and also in their daily lives. Few ethics professors have had students say that, thanks to the ethics class, they have stopped lying and cheating, but most of us have had students tell us that they now see questions in a new light. Rather than simply relying on instinct or prior teaching, students learn new ways to frame ethical problems and new approaches for identifying possible ethical harm. If nothing else, we give the students who are already ethical a greater vocabulary for articulating their actions and beliefs.

With any luck, ethicists, ethics instructors, and students will all leave the class with a bit of humility. The ethicist who believes his or her own hype as a moral authority has passed into dangerous territory. At best, the ethicist has the tools to examine ethical problems with greater detail and nuance. In the end, people eventually have to act, and a thorough ethical analysis can help guide them.

But ethics courses have a greater importance. Imagine a society where no one ever studied or discussed ethical theory or ethical decisions. It is impossible to imagine such as society, I think, because we do have to make decisions, and that requires thinking about them in detail. Some people would always rely on their “gut feeling,” but others would worry and ponder and ruminate. And they might seek the counsel of others who have spent time worrying and pondering and ruminating. And soon we would see the rise of a priestly caste and a separate group of committed but imperfect thinkers devoted to analyzing ethics in both theory and practice. We would make many mistakes, and many people would be hurt, but at least we would be trying.

At least we are trying.

Why I Am Afraid To Die

R. Horton5 Comments
Ben Jonson's Lucretius
Ben Jonson’s Lucretius (Photo credit: Catablogger)

My interest in the topic of this blog arose several years ago from a conversation with a scholar visiting from China. She had studied Christianity in China and was interested in meeting Christians in the United States and learning more about their beliefs and culture. She admitted to me that she felt some disappointment to learn that a promise of a blissful eternity did not seem to decrease the fear of death for most American Christians. If life is filled with pain and challenges, why would Christians not welcome a release to a joy of eternity?

Lucretius would not be surprised by their fear. He noted that those who boast of fearlessness in the face of death will react to death in pretty much the same way everyone else does. He says:

“These same men, exiled from their country and banished far from the sight of their countrymen, stained with some foul crime, beset with disease heralding approaching death, keep going all the same. To whatever situation they come in their misery, in spite all their talk, they sacrifice to the dead, slaughter black cattle, and lay out offerings to the gods of the dead.”

Of course, we also know some turn to suicide, which may or may not reflect a loss of fear of death. It may only mean a fear of the misery of life has overtaken a fear of death, but I will return to that idea later.

On the other side, I can remember discussions with Christians describing the attitude of suicide bombers in armed conflict. I have heard at least a few people who equate a willingness to die for a cause with a lack of respect for the value of life rather than a lack of fear in the face of death. If we value our lives, must we fear death? Is there a greater moral advantage to reducing the fear of death or to emphasizing death as a loss of something of great value, life?

Epicurus
Epicurus (Photo credit: Ian W Scott)

Epicurus, who inspired Lucretius, felt our lives would be enhanced if we could extinguish, or greatly reduce, our fear of death. Epicurus said, “Death, the most dreaded of evils, is nothing to us, because when we exist, death is not present, and when death is present, we do not exist.”  Death is a harm because it robs us of the good of life, but it is a harm that is impossible to experience. Some will say that they don’t fear being dead but fear the process of dying, but Thomas Nagel points out succinctly and convincingly that we “should not really object to dying if it were not followed by death.” Both Nagel and Epicurus argue that death is bad because it deprives us of life, but no amount of life is sufficient to eliminate the harm. No matter how long we extend life expectancy, we will view death as a harm to us.

S. Collings Boswell & Johnson 448
S. Collings Boswell & Johnson 448 (Photo credit: Wikipedia)

Of course, some of us face death with more equanimity than others. Scottish author James Boswell visited Scottish philosopher David Hume on his deathbed and was impressed by Hume’s serenity. Boswell mentioned Hume’s calm to Samuel Johnson, but Johnson refused to believe Hume was not covering his fear. In response, Boswell tells us, “The horror of death which I had always observed in Dr. Johnson, appeared strong tonight. I ventured to tell him, that I had been, for moments in my life, not afraid of death; therefore I could suppose another man in that state of mind for a considerable space of time.” Johnson responded, “The better a man is, the more afraid of death he is, having a clearer view of infinite purity.” Our fear of death may, indeed, aid our moral development.

Brush drawing of German philospher Martin Heid...
Brush drawing of German philospher Martin Heidegger, made by Herbert Wetterauer, after a photo by Fritz Eschen (Photo credit: Wikipedia)

While he doesn’t have much in common with Samuel Johnson, German philosopher Martin Heidegger also sees some advantages to our uneasiness with death. When we contemplate our own annihilation, he says, we are filled with dread, which forces us to confront what is authentic. When we are projected into Nothing, we are transcendent. If we were not “projected from the start into Nothing,” we could not relate to “what-is” or have any self-relationship. Only through confronting annihilation do we have any hope for authentic existence.

It may be that our dread gives both our life and our actions meaning. Suicide, which is often seen as a failure to negotiate life, is not necessarily so. Indeed, Simone de Beauvoir sees suicide a possible way to will ourselves free, even in the most horrific situations. She says, “Freedom can always save itself, for it is realized as a disclosure of existence through its very failures, and it can again confirm itself by a death freely chosen.”  If we do not fear our own death, however, this act of defiance and control has little meaning. Willing ourselves free through suicide is only meaningful if it is a triumph over something, and this is not to be taken lightly.

Simone de Beauvoir (9 January 1908 – 14 April,...
Simone de Beauvoir (9 January 1908 – 14 April, 1986) was a French author and philosopher. (Photo credit: Wikipedia)

Fear of death propels us forward through life, even in the face of injury, disease, and extreme hardship, and as it propels us forward it also gives meaning to our struggle. By working to overcome our fear, we establish ourselves as free beings capable of making meaning of our own suffering. And if we will ourselves free and full of meaning, we will strive for others’ freedom as well. Indeed, Beauvoir says we extend our own freedom through the freedom of others.

As a final note, let me say that part of willing freedom for others is an effort to remove obstacles that make suicide seem like a triumph. It is for this reason we should work to promote human capabilities and, specifically, to relieve the pain and suffering of depression.

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The Proper Way to Grieve for a Child: Cicero’s Example

R. Horton1 Comment
Epictetus stated he would embrace death before...
Epictetus stated he would embrace death before shaving. (Photo credit: Wikipedia)

In advising us on how to respond when we encounter someone who has lost a child or suffered an equally calamitous loss, the stoic philosopher, Epictetus said, “Don’t reduce yourself to his level, and certainly do not moan with him. Do not moan inwardly either.”  These negative emotions are dangerous to us and to others, so we must be sure to keep them in check.

This sounds harsh, but Epictetus also advises us not to beat ourselves up when we do give over to grief. He says, “Some who is perfectly instructed will place blame neither on others nor on himself.” Epictetus assures us that death is not to be feared, and our terror of it comes from within, but blaming ourselves for our feelings is also pointless.

Scottish philosopher David Hume, reflecting on the nature of tragedy in art, makes a comment about the best way to comfort a parent who has lost a child. Hume says, “Who could ever think of it as a good expedient for comforting an afflicted parent, to exaggerate, with all the force of elocution, the irreparable loss which was met with by the death of a favorite child?” I’m sure Hume is right that we shouldn’t exaggerate the loss, but I would also advise against minimizing the loss in any way, which is what Cicero’s friend, Servius Sulpicius Rufus,  did after the death of Cicero’s daughter, Tullia.

David Hume
David Hume (Photo credit: Wikipedia)

Sulpicius said, “If you have become the poorer by the frail spirit of one poor girl, are you agitated thus violently? If she had not died now, she would yet have had to die a few years hence, for she was mortal born.” Sulpicius sounds harsh in this instance, but this is actually offered only after he introduced the topic, saying, “If I had been at home, I should not have failed to be at your side, and should have made my sorrow plain to you face to face. That kind of consolation involves much distress and pain, because the relations and friends, whose part it is to offer it, are themselves overcome by an equal sorrow.” If he had been available, he would have comforted Cicero and perhaps avoided the need for such harsh and critical words later, apparently.

Cicero, Kopiezeichnung einer Büste aus London ...
Cicero, Kopiezeichnung einer Büste aus London (Herzog Wellington) (Photo credit: Wikipedia)

Cicero expressed his gratitude for the comforting words laced with recrimination, but also acknowledged their ineffectiveness, saying, “For I think it a disgrace that I should not bear my loss as you – a man of such wisdom – think it should be borne. But at times I am taken by surprise and scarcely offer any resistance to my grief, because those consolations fail me.”

Cicero had also been writing consolations for himself, and he felt himself the inventor of this type of self-help. He said, “Why, I have done what no one has done before, tried to console myself by writing a book.” (This is quoted by Han Baltussen in the Nov. 2009 issue of Mortality in an essay titled, “A grief observed: Cicero on remembering Tullia.”) Unfortunately, Cicero’s Consolations have not survived the passage of time, so we can only infer what they may have said. In a letter to Titus Pomponius Atticus, Cicero remarked that he wrote in order to heal, but his writing also kept him out of public view, preserving the privacy of his grief and avoiding a vulgar display of emotion.

Cicero also took his turn in consoling others, Baltussen notes, “In the examples where Cicero aims at consoling others, we find a subtle approach, developing, as it were, a ‘philosophy of empathy,’ in which he consciously or unconsciously takes personal and political aspects into account. He shows great sensibility in narrowing or widening the emotional gap between him and the consolee.” Cicero noted that one task as consoler was to establish that he needed consolation himself, as he was grieving for his friend’s loss. I think this goes a little beyond mere empathy. Cicero actually feels his own sorrow upon hearing of the sorrow of a dear friend. He understands the friend’s pain because it is a magnified form of his own pain.

I personally feel that Cicero’s struggle with his grief highlights a social failure to deal with grief constructively. Can we not manage to express and process grief openly without fear of censure from friends and counselors? Since the time of Cicero, we have developed grief therapy, expressions of support for the bereaved, and paid lip service to the process of healing. Yet, we still criticize those who can’t “get it together” within a short time. Sadness is seen as weakness, especially for men, and we do not tolerate prolonged grieving. Cicero was lucky to have friends and the ability to spend time grieving and writing his consolations. Men with less power would have had no option but to keep working without respite.

Grief
Grief (Photo credit: tombellart)

As for me, I don’t know the best way to console others, but I’ve thought a little about what kinds of consolations have helped me in the past, and these are the things that I appreciate. First, recognize that my pain is of such a magnitude that it obscures the horizon, and I can’t see beyond it. Second, do acknowledge the enormous value of the life I have lost. Third, do remind me that the person I lost had life filled with wonder, love, accomplishments, and happiness. Fourth, remind me also that this person is in a state of peace with no more struggle, pain, or discontentment. Finally, and perhaps most importantly, assure me that I am not alone in the world, my grief is justified, and that a future is possible.

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The Ethics of Caring and Seasonal Depression

R. Horton2 Comments

I don’t know if it is the changes in the weather, the length of the days, or what, but we

The suicide
The suicide (Photo credit: Wikipedia)

sometimes find the world slipping away from us. As we reach, objects, people, and activities seem to continuously recede into the distance just beyond our grasp. We forget how to be engaged with even the most basic tasks. Seasonal changes can leave us feeling depressed and melancholy. As the poet Phillip Larken put it:

The trees are coming into leaf
Like something almost being said;
The recent buds relax and spread,
Their greenness is a kind of grief.

For reasons that aren’t completely understood, spring seems to bring a surge of depression and suicides, but winter gets all the attention for warnings about seasonal depression. Some researchers have noticed that suicide spikes coincide with increased pollen production.  Apparently, allergies release cytokines, which affect appetite, activity, sex drive, and social engagement. There may be a philosophical question in there as to the difference between having “depression” and having a response to allergies that looks a heck of a lot like depression. Sufferers of either will probably not worry the distinction too much.

Some theorists suggest that suicide peaks in spring because of a “broken promise effect.” When spring doesn’t bring the joy and energy it generally promises, the depressed are moved to suicide. Others have suggested that springtime brings more energy and agitation (and a corresponding drop in melatonin), especially to people with bipolar disorder, that moves them to act against their own lives.  Still others speculate that springtime increases in serotonin give people the energy to kill themselves.

I don’t want us to turn away from people who are depressed during the holidays. Rather, I just hope we can remember that some of us occasionally feel depressed and hopeless throughout the year. The extra effort we make through the holidays may be worth making year round.

Still, I know it is true that many of us mourn with greater intensity during the holidays as we count all those who are no longer with us and grieve for our losses, so maybe we should be a little extra careful during December. A little care can go a long way to avoiding a holiday crisis. But we should remember to keep caring and reaching out during the new year, into spring, and for the rest of the year. When we help each other, we are all stronger.

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The Ethics of Grief

R. Horton3 Comments

It seems each time I attend a funeral, I overhear someone being criticized for grieving too subtly, too gregariously, too privately, or while dressed inappropriately. I dismiss the critics as judgmental and ignorant cranks who should have better things to do. We all know that each person grieves differently. We should all be allowed to grieve in our own time and in our own way.

But I wonder whether there is am improper way to grieve. Many of us tell our loved ones not to cry for us when we are gone. We’d rather imagine they will have a party to celebrate our life. We would like for them to pay tribute to us through their own joy. And when people ask us to do this, we promise them we will, even though we know we won’t. We make an impossible promise out of respect for those we love.

But some people take such promises seriously. This past week, I came across a paper by Amy Olberding that discusses different approaches to grief by Seneca and Zhuangzi. In letter 63, Seneca counsels his friend, “We, however, may be forgiven for bursting into tears, if only our tears have not flowed to excess, and if we have lost a friend, nor let them overflow.  We may weep, but we must not wail.” But Seneca goes on to confess that he wailed excessively over the loss of his friend, Annaeus Serenus.

Seneca
Seneca (Photo credit: tonynetone)wailed excessively over the loss of his friend, Annaeus Serenus.

He admits the power of his grief, but admonishes himself, “I must be included among the examples of men who have been overcome by grief.  Today, however, I condemn this act of mine.” In describing Seneca’s position, Olberding says grief for Seneca is “a form of self-injury that neither effect relief from pain nor alter the event that stimulated it.” As a Stoic, Seneca claims that death should not be seen as an injury, so it is wrong to grieve something that is not actually harmful. Many Christians find themselves in a similar state. Should we not celebrate someone’s passage to a blissful eternity?

English: Zhuangzi dreaming of a butterfly (or ...
English: Zhuangzi dreaming of a butterfly (or a butterfly dreaming of Zhuangzi) (Photo credit: Wikipedia)

And Zhuangzi, the Daoist, finds himself in a similar state. Zhuangzi taught that death is a mere transition to another state and nothing to grieve at all. Olberding says the Daoist views death as part of a “global harmony that sustains the natural world.” But when Zhuangzi’s wife died, he also reacted with extreme emotion. He said, “I with my sobbing knew no better than to bewail her. The thought came to me that I was being uncomprehending towards destiny, so I stopped.” Unlike Seneca, Zhuangzi did not express any self-recrimination over his grief.

Whether we consider it appropriate or not, the feeling of grief when something of great value is lost is universal. We are shocked when someone seems unaffected by the loss of someone who should be valued. With later reflection, we can reassess our grief and our loss more rationally and understand death in a larger context, especially if we have, indeed, learned to live without our valued loved one.

In Buddhism, Kisa Gotami also learns to reevaluate her grief after some reflection and guidance from the Buddha and her neighbors. Kisa Gotami had a young son who died, and she carried his body from person to person seeking aid to revive him. Finally, she was directed to the Buddha who asked her to obtain a mustard seed from every house where no one had lost a child, spouse, parent, or friend. After she couldn’t gather even a single seed, she judges herself for being selfish in her grief while remaining ignorant of the suffering of others.

The Buddha tells her, “In whatever manner people think a thing will come to pass, it is often different when it happens, and great is the disappointment; see, such are the terms of the world.” Even when death is expected, it is painful, but surprise intensifies the pain. The loss of young and healthy friends, siblings, and children often shatters the narrative people tell themselves about how the world works.

The advice of Seneca, Zhuangzi, and the Buddha all seem to be good advice, so long as we acknowledge that no human can suppress an immediate expression of extreme grief when faced with loss of someone so valued. As time passes, we may benefit from reminders that death is a transition, that death is universal, and that we can, indeed, live on after our loss. I do realize there are cases where survivors do not seem able to live on after loss, and compassion should move us to try to help those who are crippled by grief or loss of support.

It is true that people grieve in their own way and their own time, but compassionate care, free from judgment, might help people reach acceptance of the reality of a world that often seems to lack moral order, fairness, and predictability.

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