Do our current mental health laws help or hinder suicide prevention?

David Webb

Centre for Disability ResearchLancaster University

June 16 2010

Overview

1. Assumptions of mental health laws• danger to self and/or others due to ...• “mental illness” which ...• requires involuntary detention and ...• involuntary psychiatric treatments which are ...• effective, safe and necessary

2. Three critiques of these assumptions:• scientific validity/evidence• human rights analysis• common sense argument

3. Conclusion – a Suicide Prevention Act• involuntary detention can be justified• but only to a safe place• which therefore must prohibit psychiatric force

Contexts

Mental health laws

•Victoria’s Mental Health Act (1986) as the case study here

•the sole purpose of MHA is to give legal sanction to involuntary detention and psychiatric treatment

•shares common key features of most other mental health laws

• currently under review ... but status quo assumptions prevail ...

• compare with UK Mental Capacity Act and Mental Health Act

Human rights principles

•Victoria’s Charter of Human Rights (similar to UK’s)

•UN Convention on the Rights of Persons with Disabilities (CRPD)

Victoria’s Mental Health Act

 Section 8 – Criteria for involuntary treatment

(a) the person appears to be mentally ill; and

(b) the person's mental illness requires immediate treatment and that treatment can be obtained by the person being subject to an involuntary treatment order; and

(c) because of the person's mental illness, involuntary treatment of the person is necessary for his or her health or safety (whether to prevent a deterioration in the person's physical or mental condition or otherwise) or for the protection of members of the public; and

(d) the person has refused or is unable to consent to the necessary treatment for the mental illness; and

(e) the person cannot receive adequate treatment for the mental illness in a manner less restrictive of his or her freedom of decision and action.

1. Scientific Validity/Evidence – “mental illness”

Psychiatric diagnosis

• hotly contested, current scientific status = hypothesiso chemical imbalance of brain myth

• not equivalent to physical illnesso cannot be reduced to biological/medical explanationso not terminal diseases – i.e. medical emergencies

• not good predictor of either violence or suicide

Psychiatric treatments

• efficacy is exaggerated (esp. long term) o placebo effects, suppresses symptoms only, unpredictability etco not good protection against suicide

• iatrogenic harm is understated, suppressedo addiction, many “side effects”, including permanent brain damageo can trigger psychosis and suicidality

1. Scientific Validity/Evidence – danger to self/others

• psychiatrically labelled no more likely to be violent than otherso i.e. without other factors also present, esp past history and drugs

o i.e. just like everyone else

o if society was serious about pre-emptive detention, the evidence is clear – lock up young, drunk men

• but more likely to be victims of crime

• and more likely to self-harm and suicideo but suicide is a psychological decision

o not the consequence of some notional medical illness

• serious mistake to conflate these two, as most MH laws doo danger to others is illegal, suicide (and self-harm) are not

o locking these people up together is dangerously stupid

1. Scientific Validity/Evidence – necessity of treatment

• the effects of treatment with consent versus without consento efficacy – e.g. impact on placebo effect?

o safety – e.g. increased risk of iatrogenic harm?

• efficacy and safety of involuntary treatment is hardly researchedo how extraordinary – why not?

o the little that does exist suggests it is not very effective

• if viewed as a medical intervention, which is not unreasonable, then it would not be permitted with so little evidence

• involuntary treatment as chemical restraintso i.e. to subdue the person rather than treat an illness

o not permitted in criminal justice system (capsicum spray?)

o “if it’s not voluntary, it’s not treatment”

1. Scientific Validity/Evidence – summary

There is currently little scientific evidence that:

• psychiatric diagnosis is a genuine medical, biological illness

• psychiatric treatments do anything more than suppress symptoms

• psychiatric treatments are safe, esp. long term use

• mental illness causes violence

• mental illness causes suicide

• involuntary interventions work

Refs: See Bentall, Whitaker, Moncrieff, Healy, Szasz and many others

2. Human Rights – the right to refuse treatment

Section 10 – Protection from torture and cruel, inhuman or degrading treatment

A person must not be—

a)subjected to torture; or

b)treated or punished in a cruel, inhuman or degrading way; or

c)subjected to medical or scientific experimentation or treatment without his or her full, free and informed consent

Victoria’s Charter of Human Rights protects the right to refuse medical treatment as a fundamental civil and political right

• includes coercive, not just involuntary, treatment

NB - medical experimentation (“clinical innovation”) is common practice in mental health – OK, but never without consent

2. Human Rights – the limitation of rights

Section 7 – what they are and when they may be limited

(2) A human right may be subject under law only to such reasonable limits as can be demonstrably justified in a free and democratic society based on human dignity, equality and freedom, and taking into account all relevant factors including—

Sometimes stated in plain language as any limitations of rights must bereasonable, necessary, justified and proportionate

a) the nature of the right; and

b) the importance of the purpose of the limitation; and

c) the nature and extent of the limitation; and

d) the relationship between the limitation and its purpose; and

e) any less restrictive means reasonably available to achieve the purpose that the limitation seeks to achieve.

Article 12 (2) - Equal recognition before the law

States Parties shall recognize that persons with disabilities enjoy legal capacity on an equal basis with others in all aspects of life

Article 25 (d) – Health

[States Parties shall] Require health professionals to provide care of the same quality to persons with disabilities, including on the basis of free and informed consent ...

CRPD = Convention on the Rights of Persons with Disabilities

•underlying principle is prohibition of any discrimination on the basis of disability – including medical diagnosis/status

•makes no mention of the limitation of rights (but see ICCPR)

2. Human Rights – the UN Disability Convention

The nature of the right Fundamental – the right to liberty

The importance and purpose of the limitation

High – to prevent suicide

Nature and extent of the limitation

Severe – loss of liberty

Requires careful criteria for assessing suicidality, plus checks and balances to protect against misuse etc etc

Relationship between limitation and its purpose

Strong – ensures safety of suicidal person

Any less restrictive means reasonably available to achieve the purpose that the limitation seeks to achieve

Could be reasonably available and achieves purpose with minimal restriction (but requires checks and balances as noted above).

2. Human Rights – Analysis of Involuntary Detention

The nature of the right Fundamental – right to refuse medical treatment and to physical and mental integrity

The importance and purpose of the limitation

Questionable – psychiatric diagnosis/treatment poor for assessing/preventing suicide

Nature and extent of the limitation

Extreme and risky – loss of physical and mental integrity, risk of suicide

Relationship between limitation and its purpose

Weak – little evidence that it saves lives, significant evidence that it can cause harm

Any less restrictive means reasonably available to achieve the purpose that the limitation seeks to achieve

Less restrictive means possible (but are unreasonably unavailable), weak link between limitation and purpose

2. Human Rights – Analysis of Involuntary Treatment

3. Common Sense Argument – the lived experience

• suicide is best understood as a crisis of the self

• first requirement of suicide prevention is a safe space (sanctuary)

• the psychiatric ward is often the last hope for help ... but ...

• psychiatric force is an assault ... on the person, on the selfo many describe it as rape or torture

• the psychiatric ward is not a safe space

• sanctuary and psychiatric force contradictory, mutually exclusive

• psychiatric force causes suicideo not always, but sometimeso either on its own or by pushing already suicidal people over the edgeo people escaping the psych ward in order to kill themselveso “I’d never even thought of suicide until I came to the psych ward”o numbers are unknown – simply not researched at all!

• involuntary treatment is the more severe infringemento controls/alters who you are, not just where you are

3. Common Sense Argument – a contrary view

“Forced treatment saved my life”• valid personal testimonial• potentially potent argument in favour of mental health laws

The pragmatic argument that mental health laws save lives:• based on status quo assumptions not evidence• good intentions not sufficient (UN Special Rapporteur on Torture)• requires a gruesome calculation• does it save more than it kills?• we don’t know!• and what would be an acceptable ratio?

But also ...

“You might think you can waive your rights, but you are not entitled to waive mine.”

Conclusions

• status quo assumptions and good intentions are not sufficient

• inadequate scientific evidence to justify involuntary medical interventions to prevent suicide (or violence)

• human rights analysis gives reasonable justification for detention to prevent suicide – with great caution, checks and balances etc

• but not for involuntary treatment, under any circumstances

• common sense argument agrees with human rights analysis

Replace (i.e. abolish) Mental Health Act with Suicide Prevention Act

• sole purpose is to help prevent suicide

• only human rights “limitation” is power to detain someone to safety

• no discrimination on basis of disability (i.e. medical diagnosis/status)

• no medical treatment without full, free and informed consent

Final comments

• perhaps the most damning of all the criticisms of mental health laws is that many people who may need help actively avoid the system that is supposed to be there to help them

• because of the threat of psychiatric assault

• current mental laws are the primary source of “stigma” – i.e. discrimination – against those who experience psychosocial disability by making us 2nd class citizens

• they sustain and feed the fears and prejudices about madness in society and are the primary obstacle to much needed reforms

• chicken-egg scenario – we won’t get rid of mental health laws until we have alternatives, but alternatives will not be developed until we get rid of mental health laws

• like many others who have experienced them, I live in fear of these laws

Bentall on Coercion

“four compelling reasons why coercion should be avoided” (p 273)

1. Could only be justified if doctors reliably knew patient’s best interest• i.e. genuine medical emergency – e.g. blood transfusions• psychiatry’s “track record is appalling”

2. Obviously wrong if medical treatments ineffective• psychiatry’s contested diagnostic system and treatments• often not just ineffective, but also frequently harmful

3. Intrinsically damaging to mental health (also physical health)• diminishes self-efficacy, self-empowerment etc• victimisation, (re-) traumatises people

4. Damages therapeutic relationship• people avoid rather than seek help• suspicion, mistrust etc

Bentall on why coercion persists (p 275)

“sustained by powerful financial and political forces”

“services have developed an increasing aversion to risk”

“fuelled by unrealistic perceptions (perpetuated by the mass media) of the dangerousness of patients suffering from psychosis”

“an unrealistic expectation that psychiatrists should be able to protect the public from random acts of violence”

“politicians ... have increasingly exploited our anxieties about public order, promising to protect us from danger”

“few votes to be won from making psychiatric services better but plenty to be won from appearing to defend ordinary people from dangerous madmen”

Bentall on the professional rivalries

Is the problem simply psychiatry vs (clinical) psychology?

“The solution to the problem of psychiatric unaccountability is not to place some other kind of mental health professional in an equally unaccountable position, but to recognize that the tribal boundaries that have imposed their structure on mental health services are destructive and no longer relevant” (p 286)

Bentall’s suggestion for a resolution to this problem ...

Bentall on the “consumer movement” (p 287)

“Perhaps the greatest force for good in modern mental health care is therefore the rise of an organised and increasingly vocal consumer movement”

“But we can go much further. There is no reason why consumer should not have a decisive presence on committees appointing, psychiatrists, psychologists and nurses.”

“Perhaps then we really would see services that people in distress would want to make use of”