Introduction

In many, if not all countries, the law enables people to be subject to involuntary psychiatric hospital treatment when they are suffering from a psychotic disorder and they are considered to be a danger to themselves or to others (see, e.g., Mielenterveyslaki 1990/116, 8§). International ethical guidelines for psychiatric treatment direct, as well as commit, individuals with psychotic disorders to involuntary psychiatric treatment in such cases (see. e.g., Council of Europe, 2004, Articles 17–19; MI Principles, 1991, Principle 16). Involuntary treatment often utilizes antipsychotic medication with the goal of reducing or removing psychotic symptoms. The involuntary use of mind-altering medication is accepted in laws and ethical principles guiding psychiatric treatment (Council of Europe, 2004, article 28:1; MI Principles, 1991, Principle 11:6; Mielenterveyslaki 2001/1423, 22b).

This chapter examines how cognitive liberty is affected when a person is diagnosed as psychotic. I explore what cognitive liberty ultimately protects in this situation, taking into account that from the perspective of psychiatry, delusions and hallucinations are considered to be symptoms of psychosis and are viewed as something that the sufferer has the right to be treated for. According to diagnostic manual DSM-V (2013, 819), delusions are false beliefs “based on incorrect inference about external reality that is firmly held despite what almost everyone else believes.” Hallucinations are defined as “perception-like experiences that occur without an external stimulus” (DSM-V, 2013, 87). Like all other mental disorders, psychotic disorders are also, according to DSM-V (2013, 20–21), usually associated with significant distress or disability.

The experiences of patients undergoing involuntary treatments vary. A large proportion of people subjected to involuntary treatment have, in hindsight, concluded that they have benefited from the treatment (Lönnqvist et al., 2014, 741). On the other hand, there are patients who feel that the involuntary treatment has infringed their cognitive liberty (see, e.g. Stenlund, 2018, 1; Uudempaa maailmaa toivoo Joni, 2018). Also, the antipsychiatric movement has argued that the patient’s internal freedom of thought is being restricted by compulsory psychiatry (see Gosden, 1997; Szasz, 1990).

Cognitive Liberty as a Human and Fundamental Right

In this chapter, cognitive liberty is understood as a bundle of different rights for believing, thinking, and expressing opinions, and the focus is on the internal dimension of these rights. The human and fundamental rights concerning believing, thinking, and expressing opinions are numerous. We can talk of freedom of religion, freedom of belief, freedom of conscience, freedom of thought, freedom of opinion, and freedom of expression (see ICCPR, 1966, articles 18–19; Rainey et al., 2014, 411–413, 435). When the bundle of these rights is examined both from the perspective of internal and external dimensions, a broader term, “freedom of belief and opinion” is used in this chapter. When I focus on the internal dimension of these rights, I discuss the forum internum dimension or cognitive liberty.

When cognitive liberty is understood as a bundle of these freedom rights, we can say that it is a human right inscribed in the international human rights conventions, that protects the rights of people to search for truth, the meaning of life, and for connectedness with other people (see ICCPR, 1966, article 18–19). These rights belong to all people based on their humanity. The starting point is that a person has, and should have, freedom of belief and of opinion even when they are experiencing mental health challenges or have received a psychiatric diagnosis (see MI Principles, 1991, Principle 5:1).

However, the standing challenge is that in discussions about cognitive liberty, and in the definition of different rights of belief and opinion, the background assumption has been that the subjects of cognitive liberty are mentally healthy adults. Due to this, conceptions about the contents and limits of cognitive liberty contained in human rights theory seem to conflict with laws on psychiatry and the praxis of mental health work (see Stenlund, 2014, 89–91; Stenlund & Slotte, 2018).

Forum Externum and Forum Internum

Human rights concerning freedom of belief and opinion have both an external and an internal dimension. Cognitive liberty in essence refers to the internal aspect of these rights.

In human rights theory, the external dimension of freedom of belief and opinion is called the forum externum. Forum externum literally means “an external forum”: the exercising of one’s freedom of beliefs and opinions among other people. In other words, it means acting upon and expressing beliefs and opinions. When someone is a churchgoer, or stops another person on the street to tell them about “the good message,” uses religious symbols, or reads the Book of Mormon in the commuter train or at home, they exercise the forum externum dimension of the freedom of beliefs and opinions. They also act within the forum externum dimension when taking part in a demonstration, voting, or expressing their views on social media (see Partsch, 1981, 214, 217; Tahzib, 1996, 26–27, 87. Further reading Stenlund, 2013, 2014).

The internal dimension of freedom of belief and opinion, or forum internum, refers to events taking place in the person’s “internal forum.” When a person ponders whether to believe in God, or when they pray a silent prayer in their minds they act within the forum internum dimension. Similar actions are when they ponder about the meaning of their lives or about the nature of the world. In some discussions, membership in religious communities has been considered to belong to the forum internum, but at its narrowest, it has to do with the dimension of freedom of belief and opinion that protects the internal workings of the human mind: how and what a person thinks, believes, and ponders (see Evans, 2001, 68, 72–74; Nowak, 1993, 314–315; Partsch, 1981, 214, 217; Rainey et al., 2014, 412; Tahzib, 1996, 25–26. Further reading Stenlund, 2013, 2014; Stenlund & Slotte, 2018).

According to human rights conventions, a person’s forum externum dimension may be restricted if a person exercises these freedoms in a way that poses a threat to other people’s rights. Thus you cannot do and say anything you please in the name of the freedom of belief and opinion. The situation regarding the forum internum dimension is different. It is defined in human rights conventions and the human rights theory examining these conventions as an absolute human right, that cannot be restricted in any situation or for any reason. It has been suggested that the right to free thinking, to opinion formation, and the right to any content of one’s mind is absolute. It has been claimed that manipulating a person’s mind or affecting the mind with involuntary medication is in breach of this absolute right (Evans, 2001, 68, 72–74; ICCPR, 1966, Article 19:1; Nowak, 1993, 314–315; Partsch, 1981, 214, 217; Tahzib, 1996, 87–88. Further reading Stenlund, 2013, 2014; Stenlund & Slotte, 2018).

Forum Internum and Involuntary Psychiatric Medication

How should we perceive the forum internum dimension of freedom of belief and opinion that is cognitive liberty in individuals with mental illness? If the human rights conventions and human rights theory were interpreted literally, we should think that a person should have the right even to so-called sick thoughts or psychotic delusions. In human rights theory, it has been claimed that even delusions are a kind of thought or opinion that people have a right to hold in their minds (Stenlund, 2013).

However, in practice most people who are guided by legislation and by ethical principles don’t think this way. In psychiatric care people can be forcibly medicated against their expressed will, in order to reduce or remove psychotic symptoms, which are at the same time inner beliefs, thoughts, and experiences. The laws guiding mental health work allow these kinds of restrictive measures. The tensions and contradictions between human rights theory and the laws and praxis of psychiatry reveal that people whose mental health is shaken have not been taken properly into account when developing the human rights theory regarding freedom of beliefs and opinions (Stenlund, 2013, 2014, 89–91; Stenlund & Slotte, 2018).

This tension concerning the rights of people with psychotic disorders reveals that it is unclear what the forum internum dimension, i.e., cognitive liberty, fundamentally protects. Legal cases decided in Europe and the United States have not been able to solve these deep problems (see Stenlund, 2013; Stenlund & Slotte, 2018). Moreover, Jan-Christoph Bublitz (2013) observes that “not even the outspoken and critical legal commentaries define [forum internum’s] contours in more detail.”

In this article I present three different ways of understanding the freedom of belief and opinion, and the cognitive liberty contained in these rights. How freedom of belief and opinion is understood substantially affects what we try protect in the case of a person with a psychotic disorder, and how the freedom of belief and opinion is valued in relation to other human rights (see more about different conceptions of freedom, Stenlund, 2014, 92–320).

Cognitive Liberty as a Negative Liberty

When posing the question “When is a person free?” most people perhaps first suggest a scenario where the person is not restricted, that they can do whatever they please at that moment. This way of understanding liberty is the so-called classical way of understanding the rights to freedom that encompass freedom of belief and opinion. Freedom of belief and opinion is realized, according to this viewpoint, when other people do not interfere with an individual’s beliefs, thoughts, and opinions using concrete, biological, or legal means, but leave the person free to think and do as they please. This right to liberty is like a shield that protects the thinker from attacks originating from other people. This kind of concept of liberty is often called “negative,” since its essence consists of the lack of obstacles and lack of boundaries, i.e., that a person is permitted to be and to act without outsiders concretely interfering with or restricting their being and action (see Berlin, 2005, 169–170; Feinberg, 1973, 7–15). When freedom of belief and opinion is understood as a negative right, the forum internum or cognitive liberty primarily protects the contents of thought and belief that the person already has in their mind (Stenlund, 2014, 103, 326; Stenlund & Slotte, 2018). In human rights theory, the forum internum is classically defined according to this understanding of freedom. The tensions in relation to the use of involuntary antipsychotic medication arise especially from the viewpoint of negative liberty.

Involuntary Treatment as a Limitation to Cognitive Liberty

In the case of a person with a psychotic disorder, negative freedom of belief and opinion is actualized when the person is not obstructed from acting based on their beliefs and opinions and they are free to think whatever they choose (Stenlund, 2014, 101). The negative understanding of liberty is central in our legal system and sense of justice. This can be seen in the way that involuntary psychiatric treatment is commonly considered as a restriction on the person’s freedom rights. If a person is forced into treatment it is considered problematic per se (Stenlund, 2014, 106–117).

During involuntary treatment, freedom of belief and opinion may be restricted in a number of ways. The patient’s movements may be restricted, so that they cannot go to the places that would be essential for their practice of religion or opinion. Their communication with people may be restricted. Similarly, their belongings can be confiscated in the event that the mental health staff considers that these restrictions are to protect their health and the well-being of other people. As to the forum internum dimension of the freedom of belief and opinion, i.e., cognitive liberty, the most interesting restriction is as presented above, that a patient receiving involuntary treatment may be forced to use psychiatric medication, and when deemed necessary these medications may be administered as injections regardless of the patient’s opposition to it (Stenlund, 2014, 117–122; see Council of Europe, 2004, article 28:1; MI Principles, 1991, Principle 11:6; Mielenterveyslaki 2001/1423, 22a–22j§).

Forced medication is often justified by the claim that medication is in the patient’s best interests, but from the viewpoint of the negative understanding of liberty this is meddling in the forum internum dimension of freedom of belief and opinion, i.e., to the dimension of right, which should never and under no justification be restricted (Stenlund, 2014, 121–129; Stenlund & Slotte, 2018).

Sufficient Competence as a Requirement

Even as involuntary treatment is generally considered to be restricting the freedom of the person, this restriction is often considered as justified from the viewpoint of the negative understanding of freedom. The reason is that negative freedom is not considered to be the only important value, and other values and rights are prioritized above it in situations where a person is not considered to be competent enough to decide on their own affairs (Stenlund, 2014, 129–153; Stenlund & Slotte, 2018).

Thus, in law, the negative sense of the freedom of belief and opinion requires sufficient competency. A person is considered competent if they adequately understand the consequences of their actions and the nature of reality in order to make decisions about themselves. Only an adequately competent person can decline treatment or give their approval for the treatment. So in essence involuntary (or more precisely, non-voluntary treatment) means that when lacking competency the person is treated regardless of what their opinion on the issue is. On the same basis, their religious or ideological practices can be constrained if it is determined that it is harmful to them. It is thought that these restrictions are justified paternalism (Stenlund, 2014, 129–153; see Beauchamp & Childress, 1989, 69, 79).

According to the so-called antipsychiatric point of view, negative freedom should be valued more than the right of the person to well-being, and it should not be interfered with even when it is determined that the person is a danger to themselves. If a person poses a danger to other people, then according to the antipsychiatric standpoint the situation should be dealt with in the same way as in other situations, where a person’s threatening behavior or violence is forcibly curbed by the police and juridical sanctions. The antipsychiatric view states that society should not commit anyone to treatment on the grounds that they do not understand their own best interests and is “messed up in the head,” for that is underestimating the person’s own responsibility for their behavior and choices (see, e.g., Szasz, 2008, 112–117).

The opposition between involuntary treatment practices based on the paternalistic use of power and the antipsychiatric way of leaving people to their own devices is clear, though the former clearly reflects the mainstream in Western societies. The paternalistic use of power is accepted in law. Many people who have been subjected to involuntary treatment have, a posteriori, been grateful that paternalistic use of power was applied to them. Nevertheless, a proportion of patients are very much against involuntary treatment, not only during treatment but after treatment as well, i.e., even when they are in an adequately competent state (see Kaltiala-Heino, 1995, 84, 112–113; Lönnqvist et al., 2014, 741).

The Relation of Competence to the Forum Internum

When viewing freedom of belief and opinion from the negative perspective, the challenge seems to be the conflict between the praxis of paternalistic use of power and the forum internum dimension. In involuntary psychiatric treatment the executed involuntary medication aims for the patient’s best interests, but it is accomplished by attempting to affect the person’s thoughts and beliefs through biological means. The fact that those thoughts and beliefs have been defined as symptoms of an illness is not significant, because in the human rights theory the forum internum dimension is viewed as protecting absolutely all kinds of beliefs and thoughts. The idea is that a human being must have an absolute right to any mental content (Stenlund, 2013, 2014, 82–89, 121–129; Stenlund & Slotte, 2018).

If the forum internum dimension must not be restricted in any situation, why is forced medication being practised? Usually the justification is that it is necessary in order to protect the person, and that the person should not be left abandoned. However, this good reason is not, in principle, justified because restricting absolute rights such as the forum internum is not allowed for any situation or for any reason (Stenlund, 2013, 2014, 82–89, 121–129). The question arises as to whether sufficient competence can be a requirement for the forum internum dimension. However, as Mari Stenlund and Pamela Slotte (2018) ask, is it possible that some human beings could fall completely outside of the realm of rights which should belong to everyone? Does it follow from a person’s incompetence that they do not hold rights that are generally considered absolute? If so, are these rights genuinely absolute? Two options remain: first, it is possible that forced medication must be stopped because it is a breach of human rights. Given how the forum internum dimension is defined, and what it is thought to protect, prohibiting forced medication would be logical. The second option is to specify more precisely what is meant by freedom of belief and opinion and the forum internum dimension or cognitive liberty contained therein. If full abolition of involuntary medication seems unethical and careless toward people with mental health disorders, it is worth pondering if the freedom of belief and opinion can be understood from different viewpoints apart from the negative one.

Cognitive Liberty as Authenticity

Particularly in philosophical discourse, the concept of liberty is sometimes understood from the viewpoint of authenticity. Freedom of belief and opinion understood as authenticity protects people’s right to beliefs and opinions that are genuinely their own and formed by themselves. (On the concept of authenticity, see Brison, 1996; Dworkin, 1985, 353–359; Guignon, 2004; Oshana, 2007; Scanlon, 1972). When freedom of belief and opinion and cognitive liberty are understood from the viewpoint of authenticity, the primary targets of protection are the thinking and believing processes which are intended to be authentic (Stenlund, 2014, 186, 326; Stenlund & Slotte, 2018). When the right to freedom of belief and opinion understood in this way is actualized, the beliefs and opinions can be granted “a certificate of authenticity.”

While in the negative understanding of freedom of belief and opinion, the restrictions on these rights are understood as concrete biological or legal restrictions, in the understanding of freedom emphasizing authenticity, psychological means and reasons might also restrict the freedom of belief and opinion. For example, manipulating other people psychologically or with so-called religious brainwashing is understood to distort a person’s authentic beliefs and thoughts and therefore infringe on their rights to freedom of belief and opinion, especially in the forum internum dimension, or cognitive liberty (see Beltran, 2005). Different mental health problems, especially disturbances of a psychotic level, can also be seen as factors restricting a person’s cognitive liberty.

Psychosis as a Threat to Cognitive Liberty

Freedom of belief and opinion is understood from the viewpoint of authenticity in many discourses on the philosophy and ethics of psychiatry, though in these discourses attention is usually given to the patient’s freedom, autonomy, and agency in general. What is being evaluated in assessing the effects of different mental health problems is the question of to what degree the beliefs and thoughts are really a person’s own beliefs and thoughts, and to what degree they are distorted by the mental health disorder, and therefore in essence foreign or inauthentic to that person (see, e.g., Erler & Hope, 2014).

Psychosis, particularly, is often considered as a foreign or outside force that makes the person inauthentic and distorts their beliefs so that they become delusional. So psychotic delusions are understood as products of “a psychotic self” that has been distorted into inauthenticity, and not as authentic views of the genuine self (see, e.g., Gutheil, 1980). Jonathan Glover (2003, 537–538) suggests that serious mental health disorders can even change the core of a human being. Under part of the freedom of belief and opinion. we can reason that from the viewpoint of authenticity, psychosis (or when understood more broadly also other mental health disorders) are like external forces that violate the person’s forum internum, i.e., their cognitive liberty.

Some people who have experienced psychosis perceive it to be like a foreign entity that has seized them in its grip. Luciane Wagner and Michael King (2005) noticed in their study that many people who have experienced psychosis regarded their disorder as something distinct from their being, and that they had difficulty understanding their psychotic thoughts. Alexandre Erler and Tony Hope (2014) reported a patient suffering from bipolar disorder, who saw the darkness as a stranger who “lodged within my mind” and as an “outside force that was at war with my natural self.” In a study by Eeva Iso-Koivisto (2004, 11, 98) it similarly was discovered that some people who have experienced a psychosis try to differentiate the psychosis from themselves.

When psychosis is considered to be this kind of external force imposing itself to the forum internum dimension then psychiatry seems to try to liberate the person. Even involuntary treatment and use of involuntary antipsychotic medication are seen only as an effort to free the person from the power of the psychosis (see Gutheil, 1980, 327; Kaltiala-Heino et al., 2000, 213). From this point of view, the conflict between involuntary medication and protecting the forum internum dimension subsides, since the goal of the medication and other involuntary treatment is not to restrict, but instead to return, the patient’s cognitive freedom.

An Idealistic Understanding of Humanity?

Even if the authenticity point of view for cognitive liberty seems to be sensible to some people who have experienced psychosis and to some parties offering psychiatric treatment, there exist various problems in this approach.

First of all, not everyone who has experienced psychosis has perceived it as a foreign threat. Some persons consider it as a genuine part of their life, and internal life, or as authentic suffering (see Stenlund 2014, 215–218). Second, there is danger in the conception that some actions that appears restrictive on the surface, such as involuntary treatment and the involuntary use of medication therein, would be freedom-increasing in the end. When expanded, such a conception might justify even totalitarian use of power (see Berlin, 2005, 180). Third, the view of humanity underlying the authenticity point of view seems to be very idealistic. Therein it is assumed that humans form their beliefs independently of each other—or at least that this kind of independence is presented as a criterion of genuine humanity. Evil, suffering, dependence, susceptibility to influences, and senselessness on the other hand, are presented as qualities or experiences that are not part of genuine human experience. We can ask whether this kind of understanding of humanity is realistic.

The nature of cognitive liberty appears quite differently, depending on whether it is examined from the point of view of a negative understanding of freedom, or from the point of view of authenticity; to the questions of involuntary treatment and the use of involuntary medication the answers may be opposite depending on the point of view chosen. However, when the focus is on antipsychiatric medication, many questions regarding the psychiatric praxis and societal structures are left without attention (see Stenlund, 2017a). The key question isn’t necessarily whether to medicate or not, but that of how to support a person’s ability to think, believe, and live according to their values, while living with others.

Cognitive Liberty as Capabilities

Freedom of belief and opinion can also be understood from the perspective of the capabilities approach. In this view, freedom of belief and opinion is meant to protect the person’s capability of making choices concerning the beliefs they follow, as well as the ways of life they consider valuable and which are worthy of human dignity (see Stenlund, 2017a). The right to freedom, in a way means the right to the tools with which persons can act, and to good opportunities or “working spaces” in which people can use those tools in a meaningful way.

This kind of approach to the freedom of belief and opinion is in line with current human rights discussion where different civil, political, economic, social, and cultural rights are considered to be interdependent and interrelated, and are understood as giving rise to positive and negative obligations on the part of other actors (see Stenlund & Slotte, 2018). It is emphasized that freedom is both negative and positive in its nature. To be free, a human being must not only be free from interference by other people. They must also have various resources with which they can lead the kind of life they desire (see Nussbaum, 2006, 287; Sen, 1999, 3–11).

The capabilities point of view has been developed by Amartya Sen (1999, 2009) and Martha Nussbaum (2006, 2011), among others. Nussbaum has listed central capabilities which should be secured for all people. Among these capabilities are several that are pivotally connected to the freedom of belief and opinion. First of all, the freedom of belief and opinion is connected to the capabilities to use the senses, imagination, and thought. Second, it is connected to practical reason, which means the capability of forming conceptions about a good life and how to pursue it. Third, a key to the freedom of belief and opinion is the capability of associating with others. Also, the capability of controlling one’s environment and the expression of one’s emotions are significant capabilities linked to the freedom or belief and opinion (Nussbaum, 2011, x, 18–19, 33–34). When freedom of belief and opinion is understood according to the capabilities approach, cognitive liberty protection focuses on the abilities of the human mind, instead of the contents of the mind or the belief and thought processes (Stenlund, 2014, 326; Stenlund & Slotte, 2018).

Psychosis and Treatment from the Capabilities Point of View

From the capabilities point of view, several questions are central for people recovering from a psychotic disorder, questions which are left in the sidelines by the negative liberty and authenticity approaches. First, the capabilities approach emphasizes that persons whose actions are based on delusions can find it hard to reach their goals, because the world does not seem to work in the way they assume. Also, forming social relationships may prove to be difficult if the person understands reality very differently from the people around them. There can be difficulties in understanding and being understood, and an atmosphere of chaos may arise. Therefore the person may have difficulties in living the kind of life that they wish for themselves (see Bolton & Banner, 2012, 94; Gillet, 2012, 242).

Second, in many cases, psychosis includes the deterioration of cognitive abilities, such as difficulty in concentrating and lowered motivation. In the context of the capabilities theory, these can be factors interfering with the fulfillment of human rights and which might be alleviated with suitable psychiatric treatment (see Kuosmanen, 2009, 11). It must be mentioned that it is unclear to what extent such difficulties are caused by the psychosis, as opposed to life crises and stigmatization, or to the undesired effects of psychiatric medication. Antipsychotic medication can lower the person’s motivation and the ability to feel longing and pleasure (see Gøtzsche, 2015; Kapur, 2003; Whitaker, 2016).

From the point of view of the capabilities theory, a tendency to psychotic delusions and hallucinations can also be seen as a problem, one that will require significant personal struggle, drain energy, and narrows possibilities for choice. Even if the persons themselves consider, for example, the voices they hear as symptoms of a mental health disorder to which they should pay no attention, their “voices” may occasionally become so strong, and communicate about themes that seem so significant, that they put extraordinary strain on the person (see Gillett, 2012, 242; Romme & Escher, 2010, 22–24). Some people with a tendency to have delusions can also refrain from developing new ideas in order to avoid delusional thinking. For example, John Nash is said to have avoided politically oriented thinking after learning to identify and to be aware of his tendency toward paranoid thinking (Nasar, 1998, 353, 356; Radden, 2011, 127–128;). If someone’s delusions and hallucinations have been related to religion they may feel the need to put themselves at a distance from anything religious in order to stay sane (see, e.g., cases presented by Iso-Koivisto, 2004, 85, 91). In these ways, mental health difficulties can become an obstacle to a person continuing to live as an adherent to a persuasion of a religious or political nature, and as a person who develops new thoughts.

It must be noted that psychotic experiences are not unequivocally and solely negative and capabilities-reducing experiences. Some people perceive that during periods of psychosis they become more aware of their life and its meaning. Sometimes psychotic experiences are life-enriching. They can also be positive crises that direct the person to see the meaninglessness of his or her earlier life, and to make choices that lead in new directions (Fulford & Radoilska, 2012; Iso-Koivisto, 2004, 84; Kapur, 2003, 13, 18; Roberts, 1991;).

Experiences of psychoses can therefore, in some cases, also add to cognitive liberty understood as a capability or set of capabilities. This does not necessarily mean that people should be encouraged to go through psychoses. Understanding the plurality of the psychosis experiences nevertheless helps us to see that psychoses can be something else, besides just experiences that are solely bad, to be avoided, and immediately treated to eliminate them (Stenlund, 2014, 277–279; 2017a). A wider approach to psychoses can also shed light on which kinds of treatments and support are seen as sensible and possible. The perspective in the treatment can focus on the quality and the meaningfulness of the person’s life, instead of only observing symptoms and trying to control them.

What Abilities Should the Forum Internum Protect?

It seems that different conceptions of freedom of belief and opinion protect different things, especially when it comes to the forum internum dimension of these freedom rights or in other words, cognitive liberty. Whereas negative liberty primarily protects the contents of a person’s mind, the viewpoint emphasizing authenticity is interested especially in whether a belief and thought process that led to it has originated from the self. When viewed from the perspective of the capabilities approach, the focus is on the abilities of the person.

When the forum internum dimension, i.e., cognitive liberty, is examined, especially from the perspective of the rights of psychotic people, the capabilities approach seems the most reasonable. When the focus is on the abilities of the person we can see that the forum internum dimension protects something crucial, simultaneously avoiding the carelessness of the negative understanding of freedom and the looming threat of totalitarianism from the authenticity point of view, where freedom is restricted in the name of freedom (see Stenlund, 2017a).

However, what kinds of abilities the forum internum dimension protects requires clarification. It would seem that the protection includes, at least, those cognitive abilities that are connected to competency. It would violate the forum internum if such abilities of the person would be destroyed in psychiatric treatment or in other settings. Also, emotional life could, at least for some parts, be included within the sphere of protection of the forum internum. From the capabilities perspective it can be argued that actions that irreversibly destroy the person’s ability to believe and to think, and their ability to a rich emotional life, are absolutely forbidden and against human rights. For example, some brain surgical “treatments” (the so-called lobotomy procedure, for example), fortunately are no longer among the treatments used in modern psychiatry and can be considered as contrary to absolute human rights (Stenlund, 2014, 305–310; 2017b).

Additionally, the capabilities approach makes it possible to assess the risks of other psychiatric treatments and the side-effects they pose to capabilities. For example, the undesired effects on thought and affective life are an important point of consideration, and psychiatric treatment should not be pursued at all possible cost. The labeling of patients as mentally ill, and the relatively few opportunities for such patients to impact their society are, in the capabilities approach, key topics for discussion regarding the freedom of belief and opinion and its core area—cognitive liberty (see Stenlund, 2017a).