I’d like to put a name to why we so badly need to reform our legal approach to treating the severely mentally ill. That name is Rebecca Smith, an elderly homeless woman who lived in lower Manhattan in the 1970s and 1980s. Friendly and talkative, she developed relationships with people passing by on their way to work and was well-known in the area. Those in the neighborhood sometimes gave her food or money. She received formal public benefits from New York City for a while but, like many homeless people, struggled to clear the bureaucratic hurdles necessary to maintain that status. Smith’s daughter, having lived with her mother’s schizophrenia since childhood, worked for more than a decade to get her off the streets, to no avail. Smith spent much of her time in a cardboard box.
The winter of 1981–82 was forecast to be particularly brutal. Officials with New York’s Human Resources Administration became concerned for Smith, who was older and, like almost everyone living on the streets, suffered from various chronic health problems. They tried to get her off the streets before the weather got really bad, offering her various places to sleep. She turned them all down. Like many people with severe mental illness, Smith had a deeply disordered sense of personal risk. Some concerned city workers began the process of involuntarily committing her. But the O’Connor v. Donaldson Supreme Court case, decided in 1975, had established a precedent that the mentally ill could be treated without their consent only if they were proved to be a clear danger to themselves and others; that decision was part of a broad anti-psychiatric trend in American politics, and many additional barriers were erected in the judiciary and the states against involuntary treatment. Those concerned for Smith’s well-being pressed on, under the logic that her refusal to take shelter constituted a clear danger to herself. But the legal process to execute a psychiatric commitment had grown complicated and difficult; before a judge finally signed off, Smith froze to death, in January 1982. Her body was found, literally frozen stiff, in her cardboard box.
In Rebecca Smith, we see the absurdity of activists’ appeals to freedom and autonomy in opposition to involuntary treatment. The lack of short-term freedom inherent to involuntary medicine is unfortunate but, in context, represents a much smaller price to pay than the alternative. There is no such thing as autonomy or freedom in death. Nor is there freedom that stems from psychosis. Mental illness hijacks the brain and destroys the very possibility of liberty. We all recognize that if I sign an exploitative contract while under the influence of, say, an illness like Alzheimer’s or dementia, that contract should not be considered valid—the most basic prerequisite of making such a choice is operating with a clear mind.
I often ask people to consider this hypothetical. If you found a friend sleeping in filth under a bridge, and you knew him to be under the influence of a powerful drug, would you just walk away and leave him there, under the logic that he was simply expressing his freedom? You wouldn’t. You would intuitively recognize that the influence of the drug makes genuine freedom impossible. And yet every day, we walk by people who have been crushed by schizophrenia, bipolar disorder, or other mental illnesses and live in squalid, dangerous conditions on the streets. Those claiming to be their advocates forbid doing what’s necessary to ensure effective treatment of those conditions.
But the psychotic self is not the self. Take it from me: I have struggled with bipolar disorder for more than half my life, and much of that struggle involves trying to put back the pieces after my bipolar self once again destroys everything I care about—my finances, my career, my friendships, my romantic relationships. Why would I act so self-destructively, if I were freely deciding what to do? And would you really be willing to tell me to my face that my bipolar self—paranoid, aggressive, ruinously impulsive, afraid of everything and everyone—is the “real me”?
Fixing the system won’t be easy. The O’Connor precedent, which invokes a constitutional right, is not easily maneuvered around. America’s mental-health system is a tattered patchwork that varies dramatically from state to state. But beyond those practical considerations remains a stubborn reality: romanticizing the notion of a life of freedom on the streets is a cruel insult. There are many kinds of freedom. None looks like a frozen corpse in a cardboard box.
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