Is Conspiratorial Thinking A Psychiatric Sickness? What Are The Boundaries Between Rational Thought And Illness?

Illness, Crime and Punishment

Guest Blog By Joseph Meyer 

I think it was Ronald Reagan who said more than 40 years ago that some people make the choice to live homeless under bridges and in public squares. I have been reflecting on Reagan’s words and the history of psychiatric institutionalization as a political weapon used by authoritarian governments of the past. Together with a desire to cut taxes, a concern for the civil liberty of free choice is partly responsible for laws that make it difficult for family members of adults with psychiatric illnesses to get them off the streets and into treatment for delusions and their sometimes conspiratorial thinking that makes them reject help. 

Whether motivated by free choice or psychiatric illness, conspiratorial thinking that preceded and catalyzed behaviors like the recent invasion of the US Capitol building is going to have legal or psychiatric consequences for the individuals actively involved.

Today, beliefs in conspiracies promoted by QAnon and like groups can be thought of as ‘delusional.’ Others often use that word in informal conversation to describe odd thinking and a Google search returns this definition from the Oxford English Dictionary:

‘An idiosyncratic belief or impression that is firmly maintained despite being contradicted by what is generally accepted as reality or rational argument, typically a symptom of mental disorder.’

During the political divide of the last four years or longer, that definition of delusional thinking would seem to fit conspiratorial thinkers, whether or not they have a psychiatric illness. 

Recently, a large group of clinicians concerned about the psychiatric health of Donald Trump signed onto a letter calling for a rethinking of the Goldwater Rule that considers it unethical for psychiatrists to assess the behavioral symptoms of public figures who are not their patients from a distance and without a formal examination. Today’s conspiratorial thinking and activism raises questions about the difficulty of setting boundaries between what is normal and abnormal behavior.

How does one decide where the boundaries are between rational thought and clinical illness? How does the boundary affect public policy?

Are Fervent Believers Of Conspiracies Mentally Ill?

My guess is that psychiatric illness is over represented among the fervent believers of conspiracies, thus accounting for the beliefs and behaviors of some. Maybe US Representative Marjorie Greene, who only a few years ago tweeted that ‘Jewish space lasers’ may be the cause of wildfires in California, has a serious psychiatric illness.

But, I don’t know.

We need to use empirical research and knowledge to make more intelligent decisions about the boundaries between thinking motivated by illness and that motivated by free choice, so that we can write better public policy about the appropriateness of medical treatment or criminal culpability. When a political movement leads to widespread conspiratorial thinking promoted by Greene, white supremacists, and other groups culminating in a takeover of the US Capitol Building, it is more likely motivated by a group choice rather than an illness: it is, I think, a choice of prejudice.

Many politicians want to forgive and forget statements made by colleagues that may have motivated conspiratorial thinkers to invade the US Capitol building. They might say those statements were based on a rational belief that conspiratorial fraud invalidated the election results. Yet, if conspiratorial thinking is an outcome of rational thought, then persons responsible for acting on that kind of thinking are fully culpable for violating US laws.

But, what about a minority of rioters who may have been motivated by delusional thinking that is a symptom of psychiatric illness? In a fair world they should be considered less culpable to the extent that their actions can be attributed to illness, in the same way that injuries resulting from a car crash caused by a heart attack or stroke are not criminal.

To regard symptoms of psychiatric illness as criminal and the symptoms of non-psychiatric illness as non-criminal is prejudicial. 

We Need Policy Based on Science and Non-Prejudicial Thinking

Symptoms of psychiatric illness are unique among medical conditions in that arbiters are often non-clinicians. Our response is typically a legal one spearheaded by armed police officers, prosecuted by district attorneys, overseen by judges, and convicted by jurors. The symptoms of psychiatric illness, being behaviors that look willfully inappropriate to us, have led to a choice in our society that persons with a history of psychiatric illness are culpable unless they can prove their actions were motivated by insanity. I use the word choice, rather than decision, to emphasize that a legal approach to the behavioral symptoms of psychiatric illness is a willful choice our society has made. It’s a choice based on a simplistic type of thinking that is similar to that of conspiratorial thinkers. In the title of his book, ‘Crazy’, Pete Earley is referring to this bizarre thinking that has informed public policy as it applies to persons with psychiatric illness in the United States. 

What we need is more intelligent policy based on science and non-prejudicial thinking.

To the extent that we see the actions of persons with psychiatric diagnoses as the symptoms of illness and divert them away from the criminal justice system, we are making a choice in favor of recognizing that behaviors might be the symptoms of psychiatric illness. Admittedly, we cannot be certain that behavior by a person with psychiatric illness is caused by the illness, just as we can’t be sure that a murderer who was under 18 at the time of a crime is less culpable due to a less than fully developed brain.

But, we have the choice of erring on the side of a less or more punitive approach. 

The Insanity Defense Reform Act of 1984 shifted the burden of proof in insanity cases from the prosecution to the defense, after John Hinckley attempted to assassinate Ronald Reagan and was found not guilty by reason of insanity. A different standard is applied to those under 18 at the time of a crime, who have no burden of proving their underage brain is responsible for their behavior. They are simply exempt from execution or life sentences without parole. Defense attorneys hesitate to attempt an insanity defense, or even mention the presence of psychiatric illness, because they know jurors are sometimes more rather than less punitive in their attitudes toward such defendants. Persons with psychiatric illness are over-represented in prisons and on death row in the United States, where more are being confined and treated than in hospitals. 

Trusting Parents Opinions

Advocates for diversion are typically dominated by police officers, attorneys, and judges since they are the ones managing the problem of psychiatric illness. Their rhetoric reveals that they look at psychiatric illness through a legal lens rather than a medical one. Protecting the rights of adults to refuse treatment, even if it means the endangerment of being homelessness and potentially victimized by predators, is a higher priority than involuntary treatment that violates civil liberties. Although the word ‘imminent’ is defined by the Oxford English Dictionary as ‘about to happen,’ judges often seem to interpret it as meaning ‘immediate.’ If they don’t see that a person is a danger to themselves or others right now in their courtroom, they may release them over the objections of parents who are the caregivers that know their children the best. One alternative approach would be to trust the opinion of parents who have sacrificed much to care for their ill children into late adulthood, if there is no evidence of abuse.

Instead, guardianship law often places heavy burdens on parents while providing such little control of their adult children’s living arrangements or medical treatment that pursuing it is not even worthwhile. 

Even in the absence of serious crime, discussions of diversion often reveal limits to openness about the types of offenses can be diverted—if a person with psychiatric illness calmly cooperates when met by flashing lights, sirens, and armed officers they will probably try to divert them, if a bed is available. If no bed is available or they lash out, they are more likely to be booked into jail for assault or some other infraction by a police officer who may have no education beyond a high school diploma. Highly educated clinicians may not be involved until a person has already entered the criminal justice system and been booked into jail. 

But, even clinicians like EMTs and emergency room physicians often look at psychiatric illness differently than other illnesses, sometimes questioning why they are even invited to serve on diversion committees. They may refuse to treat the behavioral symptoms of psychiatric patients in their hospitals, instead calling security to evict psychiatric patients from the building. If a psychiatric patient is initially diverted to a medical setting, lashing out while experiencing paranoia or psychosis may result in a felony charge that puts them into a non-therapeutic jail environment that is traumatizing and may worsen the symptoms of their illness.

Death Penalty And Individuals With Psychiatric Issues

Nurse associations have supported laws to toughen penalties for assault, EMTs have asked for the right to carry guns on the job, and guards are now allowed to arm themselves in psychiatric hospitals where guns were previously prohibited. 

As a parent and caregiver for a person with psychiatric illness, I know it is difficult to consistently look at behaviors through an empathetic lens as symptoms of illness. It is easy to get impatient and become more punitive, perhaps picking up the phone to dial 9-1-1 and begin involvement with the criminal justice system. 

Prejudicial attitudes toward those with the symptoms of psychiatric illness follow them all the way until death.  Despite opportunities to overturn the death penalty for persons with serious psychiatric illnesses as cruel and unusual, the US Supreme Court has upheld its constitutionality, most recently using an argument that we cannot be certain that persons with psychiatric illness are unable to fully appreciate the seriousness of their offenses. Meanwhile, they abolished the death penalty and even life imprisonment for those under 18 at the time of their offenses partly by arguing they might not fully appreciate the gravity of their offenses. The difference, like many choices that affect the lives of persons living with psychiatric illness, is one of prejudice—refusing to intervene on behalf of the psychiatrically ill with their invisible disabilities because they might be fully responsible for their actions; intervening on behalf of those under 18 because they might not be fully responsible. Prejudicial thinking means capital punishment is unlikely to be abolished for those with psychiatric disabilities before it is abolished for everyone. 

Here’s are two opportunities for reflection: 

1. What keeps you, the reader, from committing a terrible crime? Do strong moral values help you resist thoughts of murder or do you not even entertain such thoughts because you have a healthy brain? I think it is probably the latter. 

1. Pretend you are locked in a room with two other people, a typical 17-year old and a person with an active psychotic disorder caused by an organic brain disorder and known as a psychiatric illness. Neither of them has a criminal record. You must hand one of them a loaded gun to keep for the next 24 hours. Which one do you choose to hand the gun? What was the basis of your choice? If your choice was based on a belief that a person with a psychotic disorder with no criminal history is a bigger threat due to their illness, then why are they held to a higher level of culpability than a 17-year old by being eligible for execution and life without parole in our legal system? 

We need to be smarter and less prejudiced in the way we look at those living with psychiatric illness. Maybe the craziness of today’s conspiratorial thinking is a wakeup call for reforms that will prompt us to do better in the future. In the words of the late British psychiatrist, R.E. Kendell, ‘not only is the distinction between mental and physical illness ill-founded and incompatible with contemporary understanding of disease, it is also damaging to the long-term interests of patients themselves.’