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Richard Gosden, "Coercive psychiatry, human rights and public
participation", with commentaries by Chris Bowker, Peter Macdonald
and Denise Russell and a response by the author, in Brian
Martin (ed.), Technology and Public Participation (Wollongong,
Australia: Science and Technology Studies, University of Wollongong,
1999), pp. 143-167.
Coercive psychiatry, human rights and public
participation
Richard Gosden[*]
Abstract
Recent surveys in several countries have revealed that according
to a standard psychiatric diagnostic system (DSM), between
20% and 30% of the general populations have mental disorders.
However, the same surveys also reveal that only a relatively
small percentage of people voluntarily seek treatment for
their mental disorders. This situation has given rise to campaigns
of public participation by mental health professionals and
the relatives of mentally disordered people to alter mental
health laws so that more people can be treated involuntarily.
These campaigns to expand the criteria for involuntary treatment
are countered by groups of ex-mental patients who argue that
involuntary psychiatric treatment violates basic human rights.
Claims about human rights violations involving people who
are 'alleged' to be affected by mental illness should have
been examined by a recent inquiry into Human Rights and Mental
Illness. But the Australian Human Rights and Equal Opportunity
Commission inquiry evaded this responsibility by failing to
fulfil the relevant part of its Terms of Reference. In the
public participation struggles over expanding involuntary
treatment, it is evident that mental health professionals
and relatives of mental patients have a distinct credibility
advantage over ex-mental patients in public forums. As a consequence
human rights and civil liberties arguments against involuntary
treatment are steadily losing ground.
Back to: Table of Contents
Commentary by:
Chris Bowker
Peter Macdonald
Denise Russell
Response by Author
Footnotes
Introduction
Public participation in psychiatric issues has been expanding
in recent years along with a growing belief within the medical
profession that a large proportion of people are in need of
psychiatric treatment, but few are receiving it. A recent
survey published in The Medical Journal of Australia[1]
found that 26.4% of 1009 ordinary rural adults in South Australia
had mental illnesses. This result was similar to other research
in Christchurch NZ, which found that 20.6% of the general
population had mental illnesses, and two studies in the United
States which found rates of 20% and 29%. The South Australian
study also found that only 4.2% of the people with mental
illnesses had seen a psychiatrist or psychologist in the previous
12 months. This finding prompted the authors to agree with
US researchers that 'most community residents are not treated
for their psychiatric problems.'[2]
The public participation that accompanies these medical perceptions
has two branches. The first is a dominant movement that seeks
to expand the reach of psychiatric services so that all the
people who are thought to be in need of psychiatric attention
can receive it. The advocacy of this expansion is led by a
powerful coalition of psychiatric professionals combining
with well-organised support groups for the relatives of mentally
ill people.
But this campaign involves more than just lobbying for an
expansion of services. A curious aspect to the problem of
treating more people is that it is not simply a lack of services
that prevents untreated people from receiving attention. More
often it is the unwillingness of these people to be treated.
The resistance of most people to volunteer for psychiatric
treatment gives rise to an ongoing campaign by psychiatrists
and relatives to amend mental health legislation in order
to make it easier to impose involuntary treatment on them.
Not surprisingly, this ongoing campaign to expand psychiatric
coercion is countered by a second stream of public participation.
This second stream is much weaker and has been constantly
losing ground in recent years. It is mostly comprised of former
psychiatric patients who have received involuntary treatment.
Members of this stream have recently begun to call themselves
'psychiatric survivors,' to emphasise the ordeal they claim
to have endured. The psychiatric survivor movement is supported
by a small number of dissident psychiatrists, civil libertarians
and human rights advocates. Their campaign is mainly centred
on making attempts to raise public consciousness about the
perceived fraudulent nature of psychiatric diagnosis, the
injustice of involuntary incarceration and the dangers of
psychiatric treatments.
Psychiatric survivors have to deal with a number of major
obstacles that impede their public participation. The most
serious is a lack of public credibility that is directly linked
to the mental illness labels that have been attached to them.
A further obstacle is the successful strategy of their opponents
to have all mental patients, both past and present, recognised
in public forums as members of a mental health 'consumer'
movement.
Inclusion in the consumer movement causes very serious problems
of recognition for psychiatric survivors because this collective
identity suggests that all mental patients are willing beneficiaries
of psychiatric treatments. The consumer strategy also provides
the opportunity for the mental health establishment to fill
any positions that are created for patients' rights advocacy
with people who are enthusiastic consumers, i.e. voluntary
patients. Voluntary patients are not usually concerned with
psychiatric coercion.
The result is that psychiatric survivors are marginalised
in conventional forms of public participation involving venues
like the mass media, public forums, public inquiries and political
lobbying. Although psychiatric survivors are currently trying
to adapt to this situation by using new avenues, like the
internet, the public participation recounted in this chapter
has largely taken place without their input.
The two case studies of public participation presented in
this chapter involve an inquiry into the human rights of mentally
ill people and a campaign of political lobbying to amend legislation
to make involuntary treatment easier. These case studies have
been chosen because they clearly demonstrate the ascendancy
of the campaign by psychiatrists and relatives. They also
show how high levels of credibility in public forums can compensate
for flawed arguments.
Human rights and psychiatry
Human rights are the theoretical underpinning for both branches
of public participation in psychiatric issues and so, in order
to fully understand the positioning of the participants, it
will be useful to introduce a brief background to the relationship
between human rights and psychiatry.
Under the legislative frameworks that are typical of most
modern democratic societies, psychiatric practices tread a
fine line between benefiting and harming the exercise of human
rights. This is largely because the cultural objectives of
psychiatry and human rights are, to some extent, opposed to
one another. While the basic principle of human rights is
to set limits on the degree of social authority, and social
isolation, which is allowed to be imposed on individuals,
the speciality of psychiatry is to identify, label and modify
deviant individuals so they can be properly fitted into the
social fabric. These fundamental differences sometimes threaten
to turn psychiatry and human rights into antitheses.
Psychiatry has little trouble in establishing its potential
benefit to the exercise of human rights when 'deviant' individuals
acquiesce to a diagnosis of mental disease and seek treatment
for it. A specific article of human rights law that psychiatry
can enhance in this way is Article 12 of the International
Covenant on Economic, Social and Cultural Rights (ICESCR).
Article 12 concerns 'the right of everyone to the enjoyment
of the highest attainable standard of physical and mental
health.'[3] The human rights sentiments
expressed in Article 12 are the basis for the 'right to treatment'
which is often promoted by members of the psychiatric profession
as being the most important human right in regard to psychiatry.[4]
But the 'right to treatment' can have a hollow ring to it
when psychiatry is practised on people against their will.
The psychiatric systems which classify symptoms and define
specific mental illnesses, the methods of diagnosis, and the
treatments for mental illnesses, are all subjects of intense
controversy, both within medical science and outside in the
general community. There are no laboratory tests to identify
or confirm most mental illnesses. Psychiatric diagnoses are
usually made after interviewing people and then subjectively
comparing them to personality profiles sketched in diagnostic
manuals. Many people whose thinking patterns are said to deviate
from the norm deny they have a mental illness or, if they
accept a diagnosis, prefer not to have it treated.
Specific human rights problems arise for psychiatry from
the tendency of most modern industrial societies to have mental
health laws which empower psychiatrists to make clinical judgements
about the mental health of the people they encounter in their
work and to impose treatment on them, without their consent,
if the psychiatrist thinks it is necessary. In 1995, for instance,
there were 7370 involuntary admissions to mental hospitals
in the state of New South Wales[5]
(NSW) which amounted to about one third of the total admissions.
Involuntary mental patients often find themselves in a situation
in which they are incarcerated for an indefinite period without
being charged with a criminal offence, interrogated, coerced
into changing their thoughts and beliefs, subjected to painful
and uncomfortable treatments if they cannot or will not make
the required mental changes, and denied freedom until their
behaviour has been sufficiently modified. Although there are
a number of human rights provisions that appear to address
this type of situation--i.e. the rights to liberty, freedom
from torture, and freedoms of thought and belief--public participation
campaigns concerned with coercive psychiatry, strangely, always
result in further confirmation of involuntary procedures.
UN Principles on Mental Illness
In 1977 the UN Commission on Human Rights appointed a 'Sub-Commission
to study, with a view to formulating guidelines, if possible,
the question of the protection of those detained on the grounds
of mental ill-health against treatment that might adversely
affect the human personality and its physical and intellectual
integrity.'[6] The primary task
given to the two Special Rapporteurs the Sub-Commission subsequently
appointed was to 'determine whether adequate grounds existed
for detaining persons on the grounds of mental ill-health.'[7]
The UN Principles for the Protection of Persons with Mental
Illness and for the Improvement of Mental Health Care[8]
did not emerge until more than a decade later. Unfortunately,
despite the brave start, the final document was repeatedly
rewritten and massaged by numerous committees to such an extent
that the original focus was lost. The primary tasks of attending
to involuntary detention and the risks of treatment were eventually
buried by cross-referencing and other priorities.
The final version of the 'Principles' adopted by the United
Nations General Assembly in 1991 is primarily designed to
protect the rights of voluntary patients, not involuntary
patients. Principle 1 begins with an assertion of the 'right
to treatment.' This right thereafter becomes the basis for
most of the other voluntary patients' concerns, like confidentiality
and protection against discrimination, addressed by
the document.
Where the 'Principles' do address the problems of involuntary
patients, it is done in a way that tends to undermine their
rights rather than protect them. Principle 11, for instance,
deals with 'Consent to Treatment' and specifies that 'No treatment
shall be given to a patient without his or her informed consent,
except as provided for in paragraphs 6, 7, 8, 13, and 15.'
Paragraph 6, however, denies the right of informed consent
to involuntary patients: '... treatment may be given to a
patient without a patient's informed consent if the following
conditions are satisfied: (a) The patient is, at the relevant
time, held as an involuntary patient; ...'[9]
Involuntary admission is not only permitted under the 'Principles'
but the criteria which are specified for correct procedure
are considerably less restrictive than those currently contained
in the NSW Mental Health Act (MHA).[10]
Whereas the NSW MHA requires that a person be dangerous to
themselves or other people before involuntary commitment is
permitted, under the 'Principles' a person can be committed
merely because 'a qualified mental health practitioner' considers
the person's condition is likely to deteriorate, or treatment
will be prevented, without incarceration.[11]
The Burdekin Inquiry
A prominent illustration of the failure of public participation
to properly address the problems of coercive psychiatry is
to be found in the 1991/92 Australia-wide Human Rights Commission
Inquiry into Human Rights and Mental Illness (Burdekin Inquiry).
The Inquiry's Report clearly demonstrates an apparent lack
of significance given to the rights of involuntary patients
when they conflict with the needs of their frustrated relatives.
Under the heading of 'Involuntary Detention,' for instance,
the Burdekin Report observed that,
Even so, after only one more brief sentence on the subject
the report moves on to a lengthy discussion in support of
denying the very same 'fundamental rights' the Inquiry had
just recognised:
This clear bias of the Inquiry towards investigating the
rights of voluntary patients--and the relatives of patients--at
the expense of involuntary patients, doesn't appear to have
been built into the original design of the Inquiry. When the
Terms of Reference are examined it is apparent that coercive
psychiatry was originally intended as a focus. The first Term
of Reference listed the classes of people the Inquiry had
initially intended to deal with: 'To inquire into the human
rights and fundamental freedoms afforded to persons who are
or have been or are alleged to be affected by mental
illness, having due regard for the rights of their families
and members of the general community.'[15]
[emphasis added]
What is meant by alleged to be affected by mental
illness is not defined but an earlier usage of 'alleged mental
illness' can be found in a published dialogue between US patient
rights activist Leonard Roy Frank and American Civil Liberties
Union attorney and mental patient advocate Bruce Ennis. Ennis
explains in the interview that he uses 'alleged mental illness'
because 'I personally have seen no evidence at all that there
is such a thing as mental illness.'[16]
Although the Terms of Reference made no attempt to explain
what was meant by alleged it is unlikely that it would
have been used to question the existence of all mental illnesses
in the way that Ennis used the term. What is more likely is
that in the planning stage of the Inquiry it was thought necessary
to distinguish between certainty in the accuracy of diagnoses
of mental illness when applied to some people and uncertainty
when the diagnoses are applied to other people.
There are at least two ways the Inquiry might have originally
intended to utilise this distinction. The first possibility
may have been an intention to examine the problem of false
positive diagnosis. The misreading of non-pathological thoughts,
beliefs or behaviour as being symptoms of mental illness is
a perennial problem for psychiatry and arises from the subjective
nature of psychiatric diagnostic techniques. The second possibility
may have been an intention to review patients diagnosed with
certain varieties of mental illness--like the infamous 'sluggish
schizophrenia' used in the Soviet Union to control political
dissidents[17]--which are not
generally recognised by international standards but which
some psychiatrists may allege to exist. Perhaps the Inquiry
had originally planned to investigate both problems. There
are well established concerns about Western psychiatric practice
regarding both the problem of false positive diagnosis[18]
and the proliferation of new varieties of mental disease.[19]
Regardless of what the Inquiry's original interpretation
of alleged mental illness might have been, it certainly
seems appropriate that an Inquiry into Human Rights and Mental
Illness should give hearing to any person who might have suffered
the discomfort and humiliation of a psychiatric diagnosis,
and possibly incarceration and imposed treatment, on the basis
of a mere allegation. But despite the nomination of this category
in the Terms of Reference, as it transpired, the Inquiry completely
ignored these people. They were not mentioned in the Inquiry's
report at all outside of the Terms of Reference.
In fact the definitions that were eventually adopted by the
Inquiry made it impossible to recognise people who are
alleged to be mentally ill. The Inquiry chose to use the
term 'consumer'[20] to describe
all of the people who are deemed to have a mental illness,
thereby implying they are all willing participants in a mental
health service industry. This does not necessarily pose a
problem for the recognition of people who are or have been
mentally ill but the description of 'consumer' was totally
inappropriate for those who are alleged to be mentally
ill. Neither false positives nor people diagnosed with non-existent
diseases could satisfactorily be described as consumers.
The inability of the Inquiry to recognise the alleged
group is further apparent in a table published in the Inquiry's
report which classifies the people who made submissions and
were witnesses to the Inquiry[21]
(see Table 1). If the category of 'Consumers' is indeed inapplicable
for those who are alleged to be mentally ill then the
only other categories into which they might fit are 'Concerned
citizens' or 'Others.' Although these two categories made
68 and 28 written submissions respectively, not a single person
from either of these two groups was called as a witness.[22]
Table 1[23]
| Description |
|
|
| Psychiatrists |
|
|
| General Practitioners |
|
|
| Psychologists |
|
|
| Social, Youth, Welfare Workers |
|
|
| Nurses |
|
|
| Professional Associations
|
| -- Psychiatrists |
|
|
| -- Social/Welfare Workers |
|
|
| -- Occupational Therapists |
|
|
| -- Nurses |
|
|
| -- Psychologists |
|
|
| Church Related Organisations |
|
|
| Consumers |
|
|
| Carers |
|
|
| Concerned Citizens |
- |
|
| Federal, State or Local Government
representatives |
|
|
| NGO representatives |
|
|
| Others |
- |
|
Total witnesses: 456
Total submissions: 826
(excluding multiple submissions from individuals or organisations)
It seems apparent therefore that somewhere between the time
when the Terms of Reference were drafted and the time when
the hearings of witnesses began, a mechanism was deliberately
or inadvertently put into place which blocked the people who
are alleged to be mentally ill from influencing the
outcome of the Inquiry.
Moves to extend involuntary psychiatric treatment
in NSW
On 26 May 1995, a letter from Dr Inge Southcott was published
in the Sydney Morning Herald.[24]
Dr Southcott's letter told about her anguish as 'the mother
of a 20 year old schizophrenic man who now lives on the streets.'
The purpose of Dr Southcott's letter was to appeal for changes
to be made to the NSW Mental Health Act (MHA) so that her
son, who 'is harmless and not suicidal,' can be involuntarily
incarcerated in a mental hospital and given treatment. Dr
Southcott's proposal was to remove from the MHA the stipulation
that a person must be thought likely to cause serious physical
harm to themselves or other people before they can be committed
involuntarily.[25]
Her letter was followed five days later by an article in
the same newspaper written by Anne Deveson.[26]
Deveson's article began with a reference to Dr Southcott's
letter and then proceeded to review her own similar experience
with a schizophrenic son who she says 'killed himself from
an overdose of alcohol and sedatives while living on the streets,
psychotic, malnourished, vulnerable.' Deveson's article went
on to endorse Southcott's concern about the difficulties that
the requirement of 'dangerousness' causes to the relatives
of mentally ill people.
Shortly afterwards two more letters appeared in the Herald
written by doctors. They were both supportive of Dr Southcott's
proposal to amend the MHA. The letters had both been written
on the day Southcott's letter was published. One doctor argued
that 'the criteria for instituting compulsory treatment should
be widened'[27] while the other,
after affirming the difficulty of committing involuntary patients
under the existing conditions, went on to demand more mental
health resources.[28]
Five days later Dr Peter Macdonald, the Independent Member
of Parliament for Manly, himself a medical practitioner, made
a speech in the NSW Legislative Assembly outlining his intention
'to lead a crusade'[29] on certain
mental health issues over the next few years. He referred
to Dr Southcott and indicated that amendments to the Mental
Health Act to widen the criteria for involuntary treatment
would be central to his plan.
Several months later, on 26 October 1995, Macdonald introduced
into the NSW Parliament the Mental Health Amendment Bill 1995
which proposed to replace the requirement of dangerousness
for involuntary hospitalisation with loosely-worded criteria
that amounted to incompetence and the perception of a need
for treatment.
In his two speeches to Parliament on this subject, Macdonald
supported his arguments by quoting extensively from correspondence
between himself and Dr Southcott. In this correspondence Dr
Southcott said she had 'last worked in psychiatry in Adelaide
in the late 1970s.'[30] She also
gave an account of her son's symptoms:
-
Our 20 year old son developed a psychosis about three
years ago. He was a top student at his school, a promising
musician, well-liked and respected by his peers. Our relationship
with him was good, and we had hopes that he would be a
well-adjusted adult, able to take his place in society.
Today he is wandering the beaches and streets of Manly,
to all intents and purposes a `homeless youth.'
His psychosis takes the form that he believes he has
to convert all to Christianity because all are doomed
to go to hell. He cannot explain why he believes this
and he seems to think that the world is going to end soon.
He gives away all his belongings and money to people he
believes God is directing him to save, e.g. he gave away
$2000 at Christmas. This was his entire savings.
For a while he was bringing home vagrants and they would
spend the night in his bed while he wandered the streets
looking for more people to save. We lost various possessions
to these people, some of whom were also obviously suffering
from psychosis themselves. He deprives himself of sleep
as he believes he has to be `working' i. e. evangelising.
He has lost all his friends and his relationship with
us is under great strain as he puts his `work' before
all other considerations. But he is not a danger to himself
or to others so he cannot be taken to hospital under the
present Mental Health Act.
The doctors involved say he would probably benefit from
medication for his psychosis and they want to put him
on the clozapine programme but their hands are tied until
such time as he deteriorates further and does something
to actively harm himself or others. Meanwhile his family
suffers, his relationships with all his mates are lost,
he loses all his money, he smells, he neglects all that
he formerly held dear when he was well.
I think it is a disgrace that our society can let this
happen, and I know it is not just my son to whom this
is happening. It involves many other youths who are also
wandering the streets in the grip of mental illness.[31]
It is clear that Inge Southcott wants her son to change back
to the way he was three years earlier but from her own account
there is every indication that he wants to remain the way
he is. If we were to hear his side of the story it is quite
possible he would argue that there is nothing wrong with his
mind and he is only expressing his Christian beliefs. A detached
observer might argue that it would be more rational for Dr
Southcott to change the locks on her doors and lock him out
rather than to attempt to change the MHA to have him locked
up. But apparently her MP, Peter Macdonald, supports her approach
and he has actually used the example of Southcott's son as
the primary justification for proposing his amendments to
the MHA.
In human rights terms, Inge Southcott's role as an anxious
mother campaigning for legislative changes is a matter of
some concern. This is because she appears to be participating
in a co-ordinated effort. She also told Peter Macdonald in
her letter that she was a member of a support group called
the Schizophrenia Fellowship and that this organisation planned
'setting up a discussion group in May to look at further amendments
to the Act especially the scheduling clauses.'[32]
The scheduling clauses provide the legal framework for involuntary
incarceration.
It should be noted that Anne Deveson, the author of the Herald
article which supported Dr Southcott, helped to establish
the NSW Schizophrenia Fellowship and then became the vice-chairperson
of a national organisation, Schizophrenia Australia Foundation.[33]
Deveson has been engaged in high-profile activity on mental
health issues in NSW since the 1980s. She chaired a government-appointed
committee set up in 1988 to review the Mental Health Act 1983,
the findings of which 'were integral to the final draft'[34]
of the amendments to the 1983 Act. She was also the initial
chair of the Mental Health Act (1990) Implementation Monitoring
Committee[35] which was set up
by the NSW government to report on the efficacy of the new
MHA.
Deveson stands out as one of the most influential figures
directing recent NSW initiatives in mental health legislation.
Her occupation is that of film-maker/writer and her expertise
in the mental health area is largely based on her experience
as the mother of a schizophrenic son. The story of her relationship
with this son is poignantly told in her book Tell Me I'm
Here.[36] She portrays herself
in this story as a frustrated, intermittent and sometimes
reluctant carer. Her son died in 1986.
Deveson's subsequent zeal to reform public policy on mental
health issues is outlined in the proceedings of a curious
Symposium on Schizophrenia and Human Rights jointly sponsored
by the Human Rights and Equal Opportunity Commission and the
Schizophrenia Australia Foundation.[37]
The symposium was held in Brisbane in February 1989. It was
curious because at the time there were daily newspaper reports
emanating from the Chelmsford Royal Commission exposing psychiatric
malpractices. Yet most of the speakers at the Symposium chose
to focus attention on a perception that 'the right to treatment'
should have precedence over 'patients' rights.'[38]
This was despite the fact that the human rights principles
summarised in the opening address by Brian Burdekin, the Federal
Human Rights Commissioner, as being the principles most closely
related to mental health issues, did not include a right to
treatment, nor rights for relatives to arrange for involuntary
treatment, but were all concerned with the rights of the individual
to avoid coercion and discrimination.[39]
Deveson's contribution to the Symposium largely consisted
of detailed advice on how members of support groups for relatives
of schizophrenic people might be able to manipulate the mass
media by winning over journalists to their point of view on
mental health issues.
-
Let's say the Schizophrenia Fellowship here in Queensland
decided that its major emphasis next year was going to
be legislation. Well you can plan over a year the numbers
of stories that you plant, you seed, on that particular
topic. It's no use just doing a one-off story. It's an
ongoing campaign that you have to plan and stage ... there
is a need for something to be done about the image of
psychiatrists ... we can lobby governments; so we can
change political awareness ... we need to start setting
a national agenda, and State agendas.[40]
Given the linkages in the sequence of events leading up to
the tabling of Macdonald's Amendment Bill it might be fair
to assume that Macdonald's 'crusade' is closely associated
with Deveson's 'ongoing campaign.'
On November 29, 1995 Macdonald arranged a meeting at Parliament
House with a number of representatives from organisations
with an interest in mental health issues. The purpose of the
meeting was for Macdonald to consult with stake-holders in
order to gauge community support for his amendments. The Bill
was still lying on the parliamentary table and Macdonald had
to decide whether to bring the matter on for debate during
the pre-Christmas session of parliament.
During the course of this meeting Macdonald acknowledged
that he had drafted his amendments in consultation with the
Schizophrenia Fellowship. A representative of the Schizophrenia
Fellowship was at the meeting and presented an argument in
support of the amendments by claiming that the removal of
the requirement for dangerousness is necessary in order to
save people from suicide. He argued that people who have suicidal
relatives with mental illness are consistently failing when
they attempt to have them committed to mental hospitals. The
urgency of his presentation was calculated to induce a belief
that the requirement for dangerousness is causing a virtual
epidemic of suicide.[41]
On inspection, however, his argument is somewhat paradoxical.
There is currently a provision in the MHA which deals with
suicidal people and permits involuntary hospitalisation 'for
the person's own protection from serious physical harm.'[42]
But this is the very clause which Macdonald was proposing
to amend. If it is true that people are having difficulty
in committing their genuinely suicidal relatives to hospital
then the source of the problem is unlikely to be found in
the wording of the MHA. A far more likely cause is the inability
of the relatives to convince doctors and hospital medical
superintendents that suicide is actually intended.
But even this possibility is not supported by statistical
evidence. Normally a person is involuntarily committed to
a mental hospital under the direction of a special doctor's
certificate. But in emergencies, when there is no doctor close
at hand to make the order, there is provision in the MHA for
relatives and friends to take mentally ill people directly
to hospital and ask for them to be involuntarily admitted.[43]
In the years 1993, 1994 and 1995 a total of 174 people were
presented at NSW mental hospitals in this way by relatives
and friends.[44] Of this number
only one person failed to be admitted for not meeting the
existing criteria of being both mentally ill and dangerous.[45]
It therefore seems likely that the issue of suicide was inappropriately
raised in support of Macdonald's Amendment Bill to give it
more urgency. If so it turned out to be a wasted effort.
Macdonald decided not to risk putting his amendments to the
vote in the busy pre-Christmas session of parliament in 1995.
Instead his plan was to negotiate support for the proposal
over the new year break and to bring it to a vote after he
had cultivated a more certain climate for success when the
NSW parliament sat again in April 1996. But in taking this
course Macdonald missed his opportunity.
Under instructions from the Labor government, the NSW Department
of Health set about drawing up its own plans for reform of
the MHA. In May 1996 a public discussion paper,[46]
including proposed amendments, was circulated and comments
from stake-holders and the public were sought. The amendments
are quite wide-ranging and include a number of proposals that
would extend the reach of coercive psychiatry. Amongst these
is a proposal to extend the maximum period of Community Treatment
Orders (CTOs), which provide for involuntary treatment outside
of an institution, from three to six months.
Although Macdonald's main focus on expanding the criteria
for involuntary incarceration was canvassed in the discussion
paper, and public support was clearly sought, no alterations
to this part of the MHA was actually included in the first
draft of the amendments. Even so, it won't be surprising if
Macdonald manages to introduce his own amendment, removing
the criteria of dangerousness, when the Bill comes up for
debate in Parliament--perhaps sometime in 1997.
Conclusion
There is considerable scope for public participation in the
issue of psychiatric coercion involving involuntary hospitalisation
and treatment. However, the interests of the people who are
actually the subjects of this coercion are rarely considered.
The main reasons for this appears to be that these people
are not well organised and their interests have to compete
with those of their relatives. The individuals and organisations
who represent these relatives seem to be consistently well
organised and have high levels of credibility in public forums.
In addition to this, civil liberties and human rights organisations,
while often recognising the need for vigilance in regard to
psychiatric coercion, repeatedly fail to follow through with
initiatives to ensure that just conclusions are reached.
Commentary by Chris Bowker[*]
From the experiences I have had being a consumer representative
for psychiatric services in the Illawarra region, I would
argue that consumer consultation and participation are token.
This is not to say that the consumer group which has been
formed in line with the regulations of the National Mental
Health Strategy is not of value.
The problem is that most of the group are under the control
and supervision of mental health workers so it is difficult
for them to be critical. It is not uncommon for staff to single
out a group member and use their power and influence to co-opt
them. This causes division within the group. It is also difficult
to build membership from the wider community as people do
not want to identify themselves because of stigma and fear.
The ideals of consumer consultation and participation contradict
the norms in psychiatric practice. The common use of coercive
practices and treatment methods has a profound impact on patients
and clients.
This is not always obvious to the health professional. By
the time the patient who is 'treatment resistant' has been
locked in seclusion, labelled, medicated with drugs which
are disabling and have distressing side effects and have had
their basic rights removed, their immobility is perceived
as the treatment having its desired effect.
The patient is perceived as being compliant and stable, whereas
what has actually happened is that patients are left feeling
violated, devastated, helpless and hopeless. If the patient
expresses any grievance, this is interpreted as a cue for
further drug intervention. The patient or client is left with
no choice but to conform to treatment and at best to try to
act 'normal' so that the doctor may reduce the medication.
The two initial goals that the consumer group set are still
on the agenda due to unsatisfactory outcomes. The first was
to communicate to health professionals the need to inform
patients of the side effects of medication. When bodily changes
start occurring such as trembling, blurred vision, agitation,
anxiety, nausea, excessive saliva, muscle stiffness and difficulty
in concentrating, it is important that patients know that
it is the medication causing these effects.
The second goal was to establish a daily relaxation group
on the wards to help the patients to deal with the distress
that the side effects of medication cause.
From the consultations that have taken place, the majority
of medical staff, including doctors, pharmacologists and nurses,
agree that patients are better off not being informed of the
side effects of medication.
In regard to the establishment of a relaxation programme,
the only action that was taken was the purchase of a tape
recorder and a relaxation tape.
It is becoming obvious to me now that if participatory processes
are going to work then fundamental changes in the system will
have to be made. As Phil Ikker, a representative of Aboriginal
and Torres Strait Island people, said at the 1996 National
Consumer Conference in Sydney, 'There is an urgent need to
educate the mental health workers.'
Commentary by Peter Macdonald[*]
I found the chapter quite bizarre and based on flawed assumptions
and half truths. It was almost 'Hansonesque'[47]
in its efforts to lay blame at the feet of others, whether
it be psychiatrists or the families of those with mental illness,
and it assumes paranoid proportions in the context of the
conspiracy theory.
It is this very ideology that has held up appropriate legislation
over the years and indeed it flies in the face of some very
fundamental agreements such as the 'UN principles for the
protection of people with mental illness and for the improvement
of mental health care' which contain two sets of grounds for
involuntary hospitalisation. The first is related to preventive
detention which currently exists under NSW legislation related
to serious physical harm and the second is what is called
'the best interest of the patient detention' which will soon
be included in new legislation.
This resistance to admit one of the realities of psychiatric
illness, which is that those with psychoses have lost touch
with reality, explains Richard Gosden's difficulty in coming
to terms with the real world. His views also reflect a stigmatising
view that mental illness is different from physical illness.
It is not. Treatment decisions should be based on the best
interests of the patient just as one would treat someone in
a diabetic coma or someone who is seriously ill from an accident
or heart attack.
This belief that psychiatric or mental illness is different
is merely based on the anti-psychiatrists' lobby that has
become fashionable following support by the Church of Scientology
and reiterated in the R. D. Laing philosophy that there is
some goodness in mental illness.
It does appear that Richard Gosden has fallen into the trap
of getting out of his depth in an issue which is more complex
than he cares to admit. Of course, there are difficulties
in labelling psychiatric illness which he uses as a basis
for tacitly agreeing with Bruce Ennis that 'I personally have
seen no evidence at all that there is such a thing as mental
illness.' Such difficulties with diagnostic criteria merely
highlight the challenges within the area of psychiatric care.
One other aspect that should be addressed is the discounting
in his chapter of any value in the views of the family members
who live with patients with mental illness. It almost suggests
the outdated theory that it is not the mental patient who
is unwell but the family that has the problem. Reference to
my particular advocacy role in seeking improvements to the
Mental Health Act appear in his mind to have little grounds
because I took into account the concerns experienced by the
families of those with mental illness. In my attempts to introduce
legislation, I received no pressure from the psychiatric profession
but certainly did receive many approaches from both carers
and support groups associated with specific illnesses, such
as the Schizophrenia Fellowship.
At no point in the chapter is there any real understanding
of the torture and agony that people with mental illness do
experience until such time as they are successfully treated.
It is unfortunate that psychosis is associated with a lack
of insight and involuntary treatment needs to be commenced
but such is the reality of the disease. The persistent denial
of these truisms underpins his particular school of thought
and fortunately it does not prevail generally. He dresses
up this lack of understanding in a cloak of 'rights issues'
but fails to be convincing.
Commentary by Denise Russell[*]
Richard Gosden's chapter is a timely intervention in the
debate about the powers of psychiatry and the difficulty in
voicing any criticism. The two case studies bring this out
particularly well. Gosden also correctly highlights the implicit
defusing of any political critique in the new move to call
those who have voluntarily or involuntarily used psychiatric
services 'consumers.'
There are shifts in psychiatry as a profession which in other
ways have the effect of stifling debate. I have in mind here
the focus on biological accounts of psychiatric disorders.
Psychiatry has always encountered problems with its scientific
status and for some decades this century, especially in America,
many thought that this status accrued from its links with
psychoanalysis. In the last two decades there has been a sharp
decline in the influence of psychoanalysis on psychiatry.
In its place psychiatry has linked with genetics, neurophysiology
and computer sciences to try to shore up its scientific status.
These fields have a technical aura in public perception, which
discourages any attempt to assess psychiatry's use of them.
Yet none of these fields has provided information on biological
markers of psychiatric disorders, never mind causes.[48]
If the dominant model does not have a secure scientific underpinning,
what are we doing as a culture if we allow the field to have
so much power?
Could it be argued that psychiatry justifies coercion by
the results that it gets in treating psychiatric disorders?
Not if Breggin is to be believed.[49]
Breggin argues very convincingly that on balance psychiatric
treatments create more harm than good (which is not to deny
that some benefit is attained by some people).
Is the best way forward to prohibit all involuntary treatment
for psychiatric disorders? I think that should be the long
term aim. However it would be difficult to bring this about
without more avenues of social support. These could take the
form of helping people to curb disturbing behaviour to make
them more acceptable to others as well as themselves or they
may offer productive ways of understanding unusual experiences
without pathologising them or a myriad of alternatives in
between. Debate about the desirability of any of these directions
is difficult to get off the ground when there are specific
political impediments to public participation, as mentioned
by Gosden, and when the public are persuaded that it must
be a field for 'experts,' two very effective ways to silence.
The only, rather bleak, hope is that when a sufficient number
of people express concern about the damaging effects of psychiatric
treatment on the body, mind and rights of individuals, change
may come about.
Response by Richard Gosden
The New South Wales Mental Health Act has now been amended.
On 9 April 1997 the Minister for Health introduced a Bill
into Parliament which contained significant variations to
the version which the Department of Health had earlier circulated
for public discussion. The most important variation involved
a loosening of the criteria for involuntary detention. These
amendments have now been passed into law. The new provisions
for involuntary detention no longer require that a person
be thought likely to cause serious 'physical' harm and now
only stipulate that 'serious harm' to the mentally ill person
or others be a possibility. Serious harm is defined in an
explanatory note as including a perceived risk to finances
or reputation.
It remains to be seen whether these amendments will significantly
extend the reach of coercive psychiatry, but it seems as if
the civil liberties of some types of people, like whistleblowers
for instance, might now be at greater risk. Whistleblowers
often find they are referred for psychiatric or psychological
assessment as a condition of continued employment. This tactic
can sometimes be successfully used to undermine a whistleblower's
credibility but under the old legal criteria it was unlikely
to result in involuntary detention. However, if a medical
assessment of delusions or disordered thoughts now only has
to be combined with a perceived risk of damage to a third
party's finances or reputation, then whistleblowing is likely
to become a far more hazardous occupation.
The three commentators on the chapter were chosen for balance.
Chris Bowker and Peter Macdonald represent the two divergent
branches of public participation on psychiatric issues, while
Denise Russell has the advantage of a scholarly overview of
the subject. Chris Bowker's commentary is strongly suggestive
of a long-term campaigner fighting to preserve the constantly
eroding rights of an embattled minority. In reading her description
of the patient role I regret she did not have the opportunity
to contribute more to the chapter than she has. The inside
story she has to tell, particularly in regard to the use of
medication to silence complaints, is one that needs to be
told in more detail.
I agree with Denise Russell's suggestion that involuntary
treatment should be phased out. When one reads the interpretations
of madness given by the few insightful psychiatrists, like
John Weir Perry, who have actually listened to the accounts
given by their patients of internal experiences, one begins
to realise the level of ignorance involved in the practice
of normal biomedical psychiatry. But how could it be otherwise?
The educational preparation for psychiatrists doesn't involve
an understanding of mythology or religious experience, nor
the history of ideas. They aren't even given a coherent theory
of mind to guide them. It is little wonder then that they
have to resort to crude theories of brain pathology. If people
who experience unusual mental activity want to volunteer for
the equally crude biomedical treatments that arise from these
theories, so be it. But no one should be compelled to endure
them.
But Peter Macdonald has a different point of view, and he
does his best to punish me for disagreeing with him. In his
first couple of sentences he applies a number of terms to
express his disdain. 'Hansonesque' is puzzling (a demonstration
of loose associations, perhaps?), but 'bizarre,' 'paranoid'
and 'conspiracy' are more understandable. These terms are
routinely used by medical scientists as diagnostic references
for schizophrenia. Although he appears to be using the terms
here in an informal lay sense, readers should bear in mind
that Macdonald is a medical practitioner as well as a politician.
Medical practitioners have the professional authority to formalise
their opinions about other people and present them as a diagnosis.
It is the ease by which a doctor can translate this kind of
personal dislike for a person into a diagnosis of mental illness,
and then order their incarceration, that makes civil liberties
safeguards so essential in this area.
Footnotes
[*] Richard Gosden is a PhD student
in Science and Technology Studies, University of Wollongong.
His research is concerned with scientific, philosophical and
human rights controversies associated with schizophrenia.
[1]. John R. Clayer, Alexander C.
McFarlane, Clara L. Bookless, Tracy Air, Graham Wright and
Andrew S. Czechowicz, 'Prevalence of psychiatric disorders
in rural South Australia,' Medical Journal of Australia,
Vol. 163, 7 August 1995, pp. 124-128.
[2]. Ibid., p. 128.
[3]. United Nations, 'International
Covenant on Economic, Social and Cultural Rights,' Article
12 (1), reproduced in Satish Chandra (ed.), International
Documents on Human Rights (New Delhi: Mitral Publications,
1990), p. 16.
[4]. See, for example, John Grigor,
'The right to treatment,' in Human Rights and Equal Opportunity
Commission, Schizophrenia: Occasional Papers from the Human
Rights Commissioner, Number 1 (Sydney: Human Rights and
Equal Opportunity Commission, December 1989), pp. 7-14.
[5]. Mental Health Review Tribunal,
Annual Report 1994 (Sydney: NSW Government), p.
74.
[6]. Yo Kubota, 'The institutional
response,' in C. G. Weeramantry (ed.), Human Rights and
Scientific and Technological Development (Tokyo: United
Nations University Press, 1990), p. 115.
[7]. Ibid.
[8]. United Nations, Commission on
Human Rights, 'Principles for the Protection of Persons with
Mental Illness and for the Improvement of Mental Health Care,'
reproduced in Human Rights and Equal Opportunity Commission,
Human Rights and Mental Illness: Report of the National
Inquiry into the Human Rights of People with Mental Illness
(Canberra: Australian Government Publishing Service, 1993),
pp. 989-1005.
[9]. Ibid., Principle 6.
[10]. NSW Mental Health Act 1990,
reprinted as in force at 17 October 1994 (Sydney: NSW
Government Information Service, 1994), Section 9, p. 5.
[11]. United Nations, op. cit.,
Principle 16.1.
[12]. Human Rights and Equal Opportunity
Commission, 1993, op. cit., p. 230.
[13]. 'Insight' is a Catch-22 device
used in psychiatric coercion. A person who rejects the label
of mental illness is said to lack insight into their condition.
Lack of insight means the condition is much worse than would
otherwise be the case and it therefore requires more drastic
treatment for a longer period. Critics of psychiatric coercion
have likened the demand for 'insight' to a torturer's demand
for 'confession.'
[14]. Human Rights and Equal Opportunity
Commission, 1993, op. cit., p. 230.
[15]. Ibid., p. 5.
[16]. Leonard Roy Frank, 'An Interview
with Bruce Ennis,' in Sherry Hirsch, Joe Adams, Leonard Frank,
Wade Hudson, and David Richman (eds.), Madness Network
News Reader (San Francisco: Glide, 1974), p. 165.
[17]. David Cohen, Soviet Psychiatry
(London: Paladin, 1989), p. 44.
[18]. See, for example, David Pilgrim
and Anne Rogers, A Sociology of Mental Health and Illness
(Buckingham: Open University Press, 1993), p. 55.
[19]. See, for example, Stuart A.
Kirk and Herb Kutchins, The Selling of DSM: The Rhetoric
of Science in Psychiatry (New York: Aldine De Gruyter,
1992), pp. 1-16.
[20]. Human Rights and Equal Opportunity
Commission, 1993, op. cit., p. 13.
[21]. Ibid., p. 10.
[22]. It is worth noting the favoured
treatment that was apparently given to psychiatrists and professional
psychiatric associations as indicated by the ratios of their
written submissions to the number of their witnesses.
[23]. Ibid.
[24]. Dr Inge Southcott, 'Anguish
over mental health Catch 22,' letter, Sydney Morning Herald,
26 May 1995.
[25]. NSW Mental Health Act 1990,
op. cit., Section 9(1).
[26]. Anne Deveson, 'Towards a better
treatment of serious mental illness,' Sydney Morning Herald,
31 May 1995.
[27]. Dr Kathleen Bocce, 'Mental
health patients' families have few rights,' letter, Sydney
Morning Herald, 2 June 1995.
[28]. Dr Robert Dixon, letter, Sydney
Morning Herald, 2 June 1995.
[29]. Peter Macdonald, 'Mental health
support and counselling services,' Legislative Assembly
Hansard, 7 June 1995, pp. 46-47.
[30]. Inge Southcott, letter to
Peter Macdonald, April 1994, quoted by Macdonald in 'Mental
Health Bill,' Legislative Assembly Hansard, 26 October
1995, p. 1.
[31]. Inge Southcott, letter to
Peter Macdonald, April 1994, quoted by Macdonald in 'Mental
health support and counselling services,' Legislative Assembly
Hansard, 7 June 1995, pp. 46-47.
[32]. Macdonald, 26 October 1995,
op. cit., p. 1.
[33]. Anne Deveson, Tell Me I'm
Here (Ringwood, Vic.: Penguin, 1991), facing-cover page.
[34]. The Mental Health Act Implementation
Monitoring Committee, Report to The Honourable R A Phillips
MP, Minister for Health on the NSW Mental Act 1990, 'Preface,'
August 1992.
[35]. Ian W. Webster, Chairman of
The Mental Health Act Implementation Monitoring Committee,
letter to The Hon. Ron Phillips M. P., Minister for Health,
attached to ibid.
[36]. Deveson, 1991, op. cit.
[37]. Human Rights and Equal Opportunity
Commission, 1989, op cit.
[38]. John Grigor, 'The right to
treatment', in ibid., pp. 7-14.
[39]. Brian Burdekin, 'Human rights
issues relating to schizophrenia,' in ibid., p. 2.
[40]. Anne Deveson, 'The social
stigma of schizophrenia as an obstacle to the exercise of
human rights,' in ibid., pp. 48-49.
[41]. Representative, Schizophrenia
Fellowship of NSW, Parliament House meeting room, 29 November
1995, personal observation.
[42]. NSW Mental Health Act 1990,
op. cit., Section 9(1)(a).
[43]. Ibid., Section 23(1), p. 10.
[44]. Mental Health Review Tribunal,
Annual Report 1993 (Sydney: NSW Government), p. 76;
Annual Report 1994, p. 74; Annual Report 1995,
p. 58.
[45]. Ibid.
[46]. NSW Department of Health,
Caring for Health: Proposals for Reform--Mental Health
Act 1990, May 1996.
[*] Chris Bowker is the mother of
three children. Currently she is doing a masters degree in
social policy at the University of Wollongong.
[*] Peter Macdonald is an Independent
politician, the member for Manly in the New South Wales Legislative
Assembly since 1991. Previously, he worked as a general practitioner
in a busy suburban practice for more than 20 years. He is
committed to assisting people with mental health problems
and their families by raising awareness of the seriousness
and extent of the illness and making representations to both
levels of government for increased funding and resources for
their care.
[47]. This is a reference to Australian
right-wing populist politician Pauline Hanson--ed.
[*] Dr Denise Russell is a Senior
Lecturer in the Department of General Philosophy at the University
of Sydney, where she has taught courses in philosophy of psychiatry
for many years. Her book Women, Madness and Medicine
was published by Polity in 1995. She has also published several
articles in this area.
[48]. For an extended argument on
this claim see Denise Russell, Women, Madness and Medicine
(Oxford: Polity Press, 1995).
[49]. Peter Breggin, Toxic Psychiatry
(London: Fontana, 1993).
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