Healing means control. That is what I learned when I started medical school nearly a decade ago. It’s a belief embedded so deep in our understanding of medicine that it usually escapes conscious notice. But if you have ever seen a doctor for anything more serious than a cold, you have probably experienced it yourself. The doctor asks questions, pokes and prods, and then locates some aspect of your internal order that has fallen into chaos: blood pressure that is too high or too low; an underactive endocrine system; an overactive nervous one; organs failing; cells turning malignant. When the normal processes of the body fail by deficit or excess, the work of a doctor is to restore order—to regain control.
And what is true for physical ailments, I was taught as I passed through medical school and entered training as a psychiatrist, is just as true for mental ones. Physiological signs—the racing heartbeat of a panic attack, the sluggishness of depression, the boundless activity of mania—are matched by psychological symptoms like distorted thinking, irrational acts, even episodes of psychosis, in which participation in shared reality is all but lost. Working in hospital and emergency services, I discovered that, in psychiatric medicine, the control of symptoms requires the control of people.
In these institutions, I helped treat patients who were a danger to themselves and sometimes others—and unable to understand that this presented a problem. In such situations, the use of violence (effectively imprisoning patients on hospital wards, restraining them to stretchers, forcibly administering medications by mouth or injection) seemed a grim but necessary reality.
One young woman I helped to treat heard the voice of a dragon parasite in her belly commanding her to cut it free. Had she not been kept in the hospital under involuntary treatment for weeks, she might well have tried. After her treatment she returned to a life she was eager to live. As unpleasant as it seemed, without coercive control she might not be alive today.
But psychiatric crises begin outside the hospital. As my training went on, it became clear to me how rare the apparently clear-cut choices we faced on inpatient wards are in the everyday lives of people living with mental illness. The urgency of stopping someone on the brink of inflicting irrevocable harm has too often seemed to justify systemic responses founded on violence. I learned about the full, stark extent of this from one of my supervisors, a psychiatrist who spent decades working with some of the most seriously mentally ill people in New York.
She told me of a patient of hers some years ago with schizophrenia who was slowly becoming more paranoid and less able to care for himself, and who finally stopped making his appointments altogether. With the best of intentions, and spurred by his family’s growing concern, she requested a mobile crisis visit—a response by medical and social workers to non-life-threatening mental health crises. During that visit, the mobile crisis worker, by his account, saw the patient open a drawer containing a knife, so he called 911. When police arrived and the patient would not open the door, they broke it down. Though my supervisor never learned exactly how it happened, the patient died falling from a window. Our apparently caring response to those in crisis—a control underwritten by the threat and use of violence—did not result in healing, but in death.
In my supervisor’s story, I glimpsed the dark side of the compassionate control I was being taught to exercise over my patients. And although her patient’s story was extreme, it was far from uncommon. Mental health advocates estimate that about a quarter of people killed by police each year are suffering from acute mental illness, and many of these killings occur in the context of a 911 call asking for assistance.
When Fear Impedes Help
In the United States, when someone in need or their loved ones ask for help, they are answered by people with guns. And this condition, despite the atmosphere of fear it creates—the everyday harm it inflicts on patients, and our demonstrable failure to accurately predict patients’ violence or suicide—goes largely unquestioned by medical professionals. Our reliance on control has become so habitual and ingrained that it is accepted even amid manifest and continual failure. Even when that failure has a body count.
That body count, I realized not long into my residency, was far larger than even the rolls of those killed by the police. One of my patients, a woman in her 30s whom I knew for two years, has suffered from severe depression since late in college. After nine months of our working together, her father died, and her desire to continue living seemed to evaporate. Talking with her about this, it was only logical, only caring, to ask if she was thinking about suicide. She told me she was not.
In the weeks that followed our conversation, her condition seemed to worsen precipitously. Worried about her rapid weight loss and increasing inability to wake up for work in the morning, I contacted her therapist. I discovered her suicidal thoughts were not only present but extensive, leading her to search online for which method of suicide—jumping from a bridge? an overdose?—would be least painful and most effective. At our next session, I shared this information with my patient and asked her what had made it easier to talk with him than with me. She answered that as a medical doctor at a large hospital, I seemed to her more likely, if she spoke of suicide, to hospitalize her involuntarily. In this assessment, I realized, she was almost certainly correct.
I later learned that she had followed that judgment to a logical conclusion and told the therapist I had spoken with that she would no longer discuss her suicidal ideation with either of us. The prospect of involuntary commitment so frightened her that she withdrew from the relationships that might otherwise have helped her find good reason to live. This was, I discovered, far from uncommon. Studies indicate fears of being forcibly hospitalized erode trust between patients and professionals, making the former significantly less likely to seek out future mental health care and, when they do engage, less likely to speak honestly about their experience, including suicidal thoughts.
As a psychiatrist, I had hoped to explore my patient’s feelings about suicide with her, discover their meaning together, and perhaps find a language for her pain other than death. But insofar as she remained subject to my overriding professional responsibility to control her behavior, her inner world—the allure of dying, grief for her father, rage that he could not care for her—became impossible to meaningfully discuss. Instead of discovering meaning in a dialogic relationship, she faced a simple choice—worse, a choice invested with precisely the agency she felt her interactions with medical professionals had taken from her—whether to live or die. Once again, the control intended to enforce health had pushed someone in pain toward death, not away from it.
My experience with this suicidal patient heightened the contradictions I had begun to encounter as a psychiatrist. In simply possessing the power to coerce my patient, I had cut off the free communication, the genuine relationship from which understanding and healing could come.
‘Dead Zones of the Imagination’
Violence forced the breadth of my patients’ experience—and of those who suffer from serious mental illness in general—into narrow, preset formulations. Patients could not meaningfully influence my actions. The corollary was that I could not understand theirs. I found a phrase from the work of the radical anthropologist David Graeber that described this phenomenon: “dead zones of the imagination.”
The constant threat of asymmetric force—violence invoked at will by one group upon another—creates, Graeber argues, an asymmetry in knowledge. Between equals, relationships demand “debate, clarification and renegotiation”: a constant effort to be open to the other, to understand another person’s interior world. Violence and the threat of violence obviate those demands.
“Violence may well be the only form of human action,” Graeber writes, “by which it is possible to have relatively predictable effects on the actions of a person about whom you understand nothing.”
Those threatened have to constantly anticipate the actions of those deploying force, a process Graeber calls “interpretive labor.” But the inverse is not true: “Those relying on the fear of force are not obliged to engage in a lot of interpretive labor, and thus, generally speaking, do not.” Control does not just produce poor relationships, in Graeber’s view; it produces non-relationships, or systemic, unconscious refusals of humanity and agency.
We see this most explicitly on our society’s margins—consider how police habitually mistreat racial and social minorities, especially those without property or status. But I think the thesis applies just as much to psychiatry, even where practitioners are trained to be minutely sensitive to subtle communication from their patients, constantly engaged in the work of making sense of the experience of another. As I had discovered, at precisely those moments and with those people where this work of relationship is most necessary, it breaks down entirely. We enter the dead zone.
When the Covid-19 pandemic enforced months of solitude outside my work in the hospital, I read Dorothy Day’s autobiography, The Long Loneliness. Its title seemed to fit the moment. I was already familiar with Day’s radical nonviolence. What arrested me completely was the way she applied it to her entire life. In 1940, she wrote:
We are urging what is a seeming impossibility—a training to the use of non-violent means of opposing injustice, servitude and a deprivation of the means of holding fast to the Faith. It is again the Folly of the Cross. But how else is the Word of God to be kept alive in the world. That Word is Love, and we are bidden to love God and to love one another. It is the whole law, it is all of life. Nothing else matters.
These words, in one sense about the war raging in Europe, applied equally to Day’s work providing food and shelter to those without. For Day, to be nonviolent as Christ is—that is, not controlling but generous and responsive to the needs of others—was a call made to every person. Although I did not yet know how, I understood that this call was one I had to find a way to answer in my professional life.
In Search of Loving Community
When the public health restrictions abated more than a year later, I visited my local Catholic Worker house, Maryhouse in New York. It was founded in 1975 as a haven for women asylum patients abandoned during the psychiatric deinstitutionalization process. To this day, the house welcomes women, many living with serious mental illness, to live in community, and, for those who are able and willing, to share in the work that keeps the community running. This is an expression of Day’s nonviolent ethic—and a way of caring for the people I encounter as patients that is radically different from my experiences in institutional medicine.
It is far from the only project of its kind. A few months ago, I made a visit to the Catholic Worker community in the North Philadelphia neighborhood of Kensington, an area marked by extremes of poverty, homelessness and opioid use. There, for almost 30 years, two friends— Mary Beth Appel, a nurse practitioner, and Johanna Berrigan, a physician assistant—have run a small, all-volunteer free clinic. Their patients are mostly unsheltered or very tenuously housed; the majority are opioid users.
The clinic has no security staff and no red tape. The volunteers had warm relationships with almost everyone I saw them meet: relationships of equals, built over many years through mutual understanding and demonstrated trustworthiness. Some of the regular patients, who, Mary Beth would tell me, habitually did disturbing things—robbery, violence, aggression—behaved completely differently in these rooms, or on the street when the clinic workers were around.
The free clinic models what both Dorothy Day and David Graeber wanted: a world in which the hard work of living together, with all the messiness of disagreement, misunderstanding and conflicting aims, can be accomplished. This is a society where everyone (not only the patients) has no choice but to engage in interpretive labor because there is no recourse to systematic, violent control. This is what the commandment of love looks like in daily life. Day described that new society as one “in which it will be easier to be good.”
I think you could also describe that vision as a society where it is easier to be well. That vision doesn’t ensure that the Gospel’s commandment of love is always followed—no more than it was always followed in the houses of hospitality Day founded—nor that it is ever easy to follow. It is, as she said, the “folly of the cross.” But if we do not attempt to follow—worse, if we use violence to excuse ourselves from the commandment itself—love becomes impossible.
I spent my final year of residency trying to find a future place of work that might reflect that vision of a better world: communities building, as Day often said, “a new society within the shell of the old.” I found one, called Fountain House, very close to home. It is a “clubhouse” in Hell’s Kitchen on the West Side of New York, founded by and for people with serious mental illness to support its members in living a satisfying life through social belonging and shared work. In each of the units, members work alongside staff as partners, working out differences together and sharing the community’s work: orienting new members, maintaining the physical space, planning menus, preparing meals, even publishing a weekly newspaper.
In the process, though mental illness does not go away, the most destructive parts—despair, disconnectedness, stagnation—improve. At Fountain House, I saw some of the same people I knew as suffering patients brought into relationships that led them to flourish. I saw firsthand how lacking my formal education was. Treating symptoms—even treating illnesses—is not the same as treating a person. Real healing does not require control. It requires love.
Rejecting violence allows us to build a better world, but not a perfect or easy one. My work at Fountain House includes outreach to homeless people with serious mental illness. The basic survival needs of such people are often so precarious that the shared responsibilities of the community’s life seem closed to them; they may use facilities but not maintain them, or they may draw on resources they cannot contribute to. But we have to be open to relationship with the vulnerable, even though that involves vulnerability ourselves, even if it risks being taken advantage of. To systematically exclude some potential members from our lives would require the control and violence we reject, to numb our imaginations—to re-enter the dead zone.
Love is far harder than control. It takes constant work to be open to another as an other, with interests, needs and desires radically foreign to my own. Love asks, in a way, to cede them a part in how I should live. Building relationships and community means we have to leave behind security. Choosing not to do violence can mean suffering the violence of another, often in the risk of being exploited, but sometimes in the flesh.
The Sermon on the Mount points directly to the Cross. It gives the possibility of offering real help to my advisor’s psychotic patient, not his death at the hands of police. And real relationship with my suicidal patient, not the solitude of incommunicable anguish. To have any hope at all, doctors must give up their power over patients. They must commit to advising, caring, persuading and loving, but not to coerce. To heal the sick, we doctors will first have to be healed not only in ourselves, but in our relationships, our communities, our society.
