Coercive Psychiatry, Human Rights and Public Participation

from 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.

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.

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,

"Involuntary detention--for any reason and under any circumstances--is an extremely serious matter involving curtailment of several fundamental rights the most important of which is the right to liberty. The Inquiry received extensive evidence on this subject, particularly from consumers."[12]

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:

"Difficulty in Gaining Involuntary Admission--Families and other carers are faced with a dilemma when the person for whom they are responsible has lost touch with reality and has insufficient insight[13] into his or her condition to accept the need for treatment."[14]

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 [23]). 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]

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.

Total witnesses: 456

Total submissions: 826 (excluding multiple submissions from individuals or organisations)

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

[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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