What Do We Owe the Insufferable?
When mental illness exhausts our emotional capacities
In “The People v. Insanity,” (The Dispatch, August 6, 2025) Emmett Rensin examines some uncomfortable questions surrounding mental illness, criminal responsibility, and society’s conflicting responses to the mentally ill, especially those who behave disruptively to a degree that they end up in legal trouble. Rensin’s primary focus is on the insanity plea, however, I am more interested in the non-legal aspects of Rensin’s analysis and the application to our social and clinical lives. Rensin makes a case that our collective discomfort with the insanity defense reflects “an ancient dilemma” that philosophers had recognized and grappled with without much success: “the mad present a problem for our moral intuitions, and we do not know, and perhaps are not even comfortable discussing, what we ought to make of them.”
To illustrate this, Rensin recounts his own psychiatric history. Beginning in adolescence, he experienced escalating psychiatric symptoms, showing signs of mania, paranoia, aggression, and eventually full-blown psychosis. During college, believing a scarf possessed mystical powers, he broke into someone’s apartment to retrieve it, leaving the occupants frightened and terrified. He heard divine commands to crash his car, which he obeyed, nearly killing another driver. Later, convinced he was being poisoned or monitored through hidden cameras, he considered stabbing his roommate preemptively and attempted self-surgery with a bread knife to remove an imagined threat from his neck.
Eventually diagnosed with schizoaffective disorder and treated with medication, Rensin reports he has achieved relative stability over the years. Yet he emphasizes that even stable, he remains “difficult, particularly to those who care about me.” His wife understands that his disorganization and poor executive function result from a psychiatric illness, but…
“Still: It exhausts her. And it frustrates her. And she can’t help getting angry with me because no matter the cause, I am making her life more difficult, and nothing breeds resentment so readily as being hurt and then being told you’re not allowed to hate it, because if you do then you’re a bigot.”
This tension extends to public encounters with the mentally ill. Rensin criticizes activists who respond to public discomfort with homeless mentally ill individuals by “simply lecturing the public about how bad and embarrassing and frankly ableist they are.” This approach, he suggests, “hardens the public’s hearts” and pushes them toward punitive solutions.
Rensin rejects the common therapeutic narrative that mental illness is a “foreign invader” separate from one’s true self. When his therapist suggested forgiving himself because his destructive behavior wasn’t his fault, Rensin calls this “the moral reasoning of a child.” Instead, he insists:
“The real me is a lunatic; the real me is unfit to live among other people. The medicated me, the stable me, is better, but it is artificial, sustained by psychopharmacology and therapeutic intervention.”1
When a friend asked how she could trust he wouldn’t stop medication or relapse, Rensin could only answer honestly: “Well, I guess you can’t.”
The political dimensions are no less uncomfortable. Conservatives advocate mass institutionalization for the severely mentally ill, yet dismiss individual criminal defendants’ insanity claims as malingering. Liberals and leftists, committed to deinstitutionalization and autonomy, respond by “pretending that mental illness never results in antisocial behavior, much less violent crime.” They repeat that the mentally ill are more likely to be victims than perpetrators, which is technically true only because “the mad are victimized so frequently that it dwarfs their more modest propensity toward criminality.” These commentators seem to be engaged in “respectability politics,” an attempt to distance relatively stable people with depression or ADHD from more troubling cases. Severely mad individuals are embarrassing to advocacy efforts aimed at reducing stigma.
The tension Rensin identifies is not with mental illness per se, but rather when mental illness coexists with and contributes to behaviors that strain and exhaust our capacities for sympathy, compassion, and care. States of mania and psychosis leading to violent crime are just one dramatic example because of the harm involved and the fears this generates. But the basic problem of dealing with someone who exhausts others and wears out their emotional capacities plays out at collective, individual, and clinical levels. At each level, we face a version of the uncomfortable truth. There is a tension between recognizing a disturbed person’s compromised agency and seeing them as deserving of compassion and care, while extending to them the roles and responsibilities we reserve for those we trust and rely on. There is a misalignment between being ill and being pro-social. There is a difference between caring for someone and living with them as an equal.
This qualification warrants repetition and elaboration. I am not talking about all or most individuals with mental health problems, psychiatric disorders, mental disabilities, “madness,” or neurodivergence, etc. I am talking about a subset of them, which perhaps is quite small but also quite real, and which finds poor representation in our public narratives in the age of destigmatization. I am also not talking about the distinction between “serious” mental illness vs other sorts of mental illness, or psychotic vs non-psychotic conditions. I am talking instead about what Rensin touches on but doesn’t fully delineate: those with mental disorders who are emotionally difficult to live with, who drive those who care for them to exhaustion and frustration, to the very limits of what they can tolerate and beyond. People with mental illness can be likeable and good-natured. I am not talking about such folks. I am also not talking about people who are perceived by clinicians to be difficult and disagreeable because, say, their problems are poorly responsive to treatment and clinicians are projecting and displacing their own frustration onto the patient. I am not talking about patients who are labelled “difficult” simply because they question or disagree with their doctors, advocate for themselves, or have complex medical needs that are being dismissed. I am talking about the ones that are genuinely challenging and vexing, the interpersonally difficult, the ones who alienate almost everyone close in their lives.
What do we owe to people who, through vagaries of genetics, upbringing, and life choices, are not just mentally ill but also difficult, unlikeable, demanding, needy… insufferable?
To have a genuine partnership requires treating the other person as a moral equal. A healthy relationship between adults presupposes things such as mutual accountability, shared agency, reciprocal vulnerability, and moral standing. When mental illness significantly impairs these capacities, partners can either maintain the fiction of equality, getting angry at behavior they cannot fully control, or adopt what philosopher P.F. Strawson called the “objective stance,” viewing the person as a malfunctioning collection of mechanisms rather than a moral agent. We can suspend our ordinary reactive attitudes toward others, treating them instead as something to be managed, contained, treated, or perhaps avoided. It is a shift from interpersonal engagement to detached clinical engagement. It can work well for some time; this is the classic “sick role,” and it allows for care and recovery. When the illness is discrete and episodic, temporary suspensions of reactive attitudes are often the right answer. But when we are dealing with behaviors that are chronic, when the recovery is partial and unreliable, there is often no good answer.
Holding someone accountable and responsible requires that they have agency, that they could have done otherwise, and that they have the capacity to recognize and respond to moral reasons. Many psychiatric conditions impair these capacities, but often only partially, intermittently, or in specific domains. This demands very difficult calibrations on the part of the loved ones. A partner must simultaneously, for example, hold the person responsible enough to maintain a genuine relationship, make allowances for impairment to avoid cruelty, protect herself from harm from behavioral disruptions and dysregulations, and accept that she cannot predict which version of him she’ll encounter on any particular day.
Paradoxically, her anger and resentment may be the only thing affirming his status as a moral agent, preventing the relationship from degenerating into just a relationship between a sick person and their caregiver. When we consistently excuse someone’s behavior, we implicitly declare them incapable of being held to our moral standards. This is appropriate for small children or people with severe cognitive disabilities but dehumanizing for an adult we are supposed to be in a relatively equal relationship with.
It is not surprising then that such patients often end up isolated and alone. And that may be alright, if they could manage things on their own, but they can’t because they are still ill and impaired. They keep ending up in emergency rooms or being picked up by the police. Anyone who can leave, leaves. The people who can’t leave or are too committed to leave (parents, wives, husbands, children), find themselves resentful and burdened, and they carry on until they can no longer, and the healthcare system or the legal system has to step in.
This is where the focus on autonomy simply sidesteps the problem. The people who just need to be left alone do well by themselves. They build a life for themselves on their own terms. But the genuinely ill and disabled usually cannot.
And then, there are situations when even mental health professionals give up on certain patients.
Psychiatrists fire them. Therapists won’t work with them. Therapy groups block them. Group homes evict them. Community mental health centers treat them with reluctance. These patients often end up in facilities defined by their inability to refuse: emergency rooms, state psychiatric hospitals, and jails. Patients get progressively worse care as they move through systems of care.
What leads even professionals to give up? Often some combination of verbal aggression and threats, sexually and racially inappropriate behaviors, constantly refusing treatment offered or available while constantly demanding help, disruption of treatment environments, and extreme neediness that leads to professional burnout and dread.
This is the uncomfortable truth of clinical practice: some patients are genuinely difficult and disagreeable, sometimes because they are mentally ill, and sometimes because that’s who they are as people and mental illness brings out the worst of them. These patients also genuinely need help, care, and treatment. Their problem is that practically no one can tolerate and put up with them for any extended period.
These are certainly extreme cases, and it’s not entirely polite or comfortable to talk about them. It is also true that our judgments about who is “likeable” or “difficult” are contaminated by all sorts of prejudice. But pretending they don’t exist only worsens the state of affairs. I remember seeing a patient once as a consult on the medical floor. The internist was convinced that she was psychotic because she had driven the nursing home staff to the end of their ropes. I spent an hour watching a competent, caring nurse trying to change her wound dressings, and this woman burned through every bit of good will. At the end of the hour, the nurse was exhausted and frustrated and done, just done. The woman was not psychotic, she was exasperating. Imagine someone in the 99th percentile of being exasperating. That was her. Unfortunately for everyone involved, she was old, weak and immobile, needed 24/7 nursing care, but no one could stand her and she seemed incapable of recognizing that and changing her behavior. Such patients end up in the long-term care facilities where their needy, irksome nature is balanced only by the deep indifference of the staff.
I think people often underestimate how powerful likeability is as a moderator of the quality of care received. Clinicians want to help people and want to be seen as helpful, and likeable patients make that easy. There is, for example, a dramatic difference in how clinicians treat likeable patients with borderline personality and unlikable patients with borderline personality.
Over the years I’ve had to pay special attention to my own feelings of frustration. Possibly some of the most productive work I’ve done is with patients where I had to recognize and work through my exasperation. That experience also leads me to think that the healthcare system gives up too easily. Healthcare systems are not designed around the prospect of providing care to deeply unlikable and unsympathetic people. They are at times designed to provide care to those perceived to be dangerous. But dangerous and difficult are not the same things, and what works for one doesn’t work for the other.
Patients at the extreme end of exasperating require clinicians at the extreme end of compassionate and tolerant. They require saints. Saints are hard to find, but institutional and structural changes can help make up for that. Current burnout and resource scarcity make the problem worse… clinicians might have more capacity for challenging patients if they weren’t already depleted. I say this jokingly, but only half-jokingly: medicine needs something analogous to SWAT teams or SEAL Team Six, not for handling the dangerous but for handling the demanding and the disagreeable that exceed the capabilities of most clinicians.2
The problem is two-fold; no one wants to really acknowledge that such people exist, and no one really wants to work with them. We run into the limits of the human substrate of medicine. (When it started becoming apparent that AI may be able to provide some forms of clinical care in the future, one of my first thoughts was: this may be a lifeline for those patients whom humans cannot tolerate. LLMs have, at least for now, near-infinite attention and patience.)
Ultimately, issues like the insanity plea and reliable provision of care to those in need are easier to solve because they involve collective responsibility and our ability to figure out how to overcome our emotional limitations to do the right thing. The interpersonal issues at the individual level are a different beast entirely. The best hope we have there is in the development of ways to prune our psyches, to soften our sharp edges enough to allow those who love us to bear with us.3
See also:
I don’t quite agree with Rensin on this. As Roy Dings and Anna Golova put it, “As there is no uncontested concept of ‘self’, nor of ‘mental disorder’, the ‘self-illness’ relation is riddled with ambiguity.” [‘Is it me or my illness?’: self-illness ambiguity as a useful conceptual lens for psychiatry]
Marsha Linehan’s original DBT program with all four components (individual therapy, skills training groups, phone coaching, consultation team), not the watered-down version that is commonly encountered, is one such attempt.
Psychodynamic psychotherapy is, in my opinion, currently the only treatment that meaningfully attempts to do so.
I have been pondering this issue for a while, particularly in Australia, where debates around public disability services have become highly politicised. In public discourse, psychosocial disabilities are often viewed as less impairing than physical or intellectual disabilities. However, a person with a severe physical or intellectual disability who is likeable, easy to get along with, and able to communicate their needs and concerns clearly and respectfully will generally have a much easier time accessing help and services than someone who is demanding, rude, belligerent, and—as you put it—“exasperating”.
People will go out of their way to help someone in need who is likeable. And despite the idea that we are an increasingly individualistic society, the ability to engage respectfully and effectively with others remains essential to living well in society—particularly when someone needs to interact with services on a regular basis. When I discuss these cases with others and point out that a person’s support needs are high because of their difficulty relating to people, the immediate response is often that the person needs to “learn” to ask for help in appropriate ways, and that services and support should be withheld until they do. But if natural consequences were sufficient for this individual to learn socially acceptable behaviour, it would have worked by now. They cannot learn social norms through natural consequences—that is precisely why they are disabled. It would be akin to suggesting that a paraplegic could get around better if people stopped “enabling” them by providing wheelchairs or assisting with transfers.
This article will probably attract some criticism (but hey, what else is new!), yet I think it is the most important and timely piece you have written. We have to talk about this issue, because ignoring it does not solve anything and, in many ways, is making things worse. I recently read a study that found that just 0.1% of callers to a suicide crisis phone line accounted for over 60% of calls received, with these frequent callers receiving an average of 160 hours of counselling per year (https://journals.sagepub.com/doi/full/10.1177/00048674251361753). I can’t help but think that if those hours were delivered as focused, intentional, long-term psychotherapy, the burden on crisis services might be reduced—although getting people to engage in regular therapy instead of repeated crisis-line use is a challenge in itself.
In any case, thank you for highlighting this issue. I work with clients who fall into this category, and supporting them requires an honest and realistic acknowledgement of their difficult interpersonal style, compassion for their struggles, compassion for the challenges faced by carers and service providers, hope that change is possible with time, perseverance, and resources, very clear boundaries, and a good sense of humour.
This piece made me think a lot about a number of things. There are gradations among the people you talk about- those who are violent and commit actually crimes, others whose personalities make dealing with chronic illness more challenging for those around them.Those whom we really fear and those whom we would prefer not to deal with.
I think a fundamental question you raise is not being able to treat someone as a moral equal. I think when we get to that point, as clinicians or family members, we have a problem both for ourselves and the ill person. Not being held morally accountable and not being a full partner leads to a power imbalance, to shame for the patient and resentment for the clinician or other party. And Psychiatry does people a disservice if we deliver the message that mental illness implies a lack of accountability.
Donald Winnicott's paper "The Use of an Object" comes to mind- the idea that the job is to withstand the attempt to destroy the other person- but then to circle back later and say, "hey, you know you almost destroyed us." Clare Winnicott wrote about her experience working with evacuated children in Britain in WWII, and described having to put a violent child outside the door until he could get himself in control. (Face to Face with Children: The Life and Work of Clare Winnnicott.)
This may be an ideal, but it seems like when someone is this difficult the thing to discuss is how difficult they are, and how alienating that is. When we can't do that, or our countertransference gets the better of us, at least to part with the message of how we see the problem, and try not to inflict harm.