3 days ago
Psychiatry cannot be allowed to dominate debate on Mental Health Act
Recent public debate around long-awaited reform of the Mental Health Act, 2001 has predominantly consisted of doctors and commentators creating moral panic over legal changes they claim will erode doctors 'right' to force treat people.
Let's be clear: the Mental Health Act, 2001 will continue to allow people to be involuntarily confined and force treated. Let's also have some clarity that under the current system, mental health outcomes are very far from satisfactory. Indeed, despite the now accepted deconstruction of 'mental illness' as simply a diagnostic construct, this system is now largely upheld because of legislative frameworks.
It begs the question, should those within the system and seeking to uphold it be allowed to constantly dominate the discourse around reform? Let's get to the heart of the real issue here — psychiatry and its wish to retain its legal powers. Psychiatrists use a legal defence of medical necessity for forced treatment but this is increasingly untenable.
As Dr Pat Bracken, the highly respected independent consultant psychiatrist, has written: If psychiatry is going to take away people's liberty and use invasive methods of treatment, then it needs to be 'confident that we can predict outcomes, and happy that we understand how our treatments work and for whom.' His conclusion – and the now widely accepted scientific reality, is that psychiatry cannot reach this efficacy standard.
The treatment on offer for people who are severely unwell and distressed is not, as some may erroneously believe, intensive therapy that seeks to get to the root cause of the issue. Rather it is drugs and sometimes electricity. There may be psychological interventions but these are few and far between.
Of course there are situations where people need acute care and medication to stabilise them, but traumatising environments that use powerful psychotropic drugs should not be the only answer when someone is in distress. People in this system are guinea pigs, labelled treatment resistant if drugs don't work, lacking insight and branded non-compliant if they don't agree with doctors and do what they are told.
Debate in Ireland is regressing as is our move towards a rights-based system. Just this week it has been reported that the Cabinet has signed off on an amendment brought to Cabinet that someone who is involuntarily admitted to an acute psychiatric unit can be detained for up to 42 days, an increase on the 21 days previously proposed under the bill. This is a flagrant move in the wrong direction with no debate and no rationale given.
In this paper recently Dr Suzanne Crowe argued that people experiencing psychosis do not know they are ill and have no insight into their psychiatric condition. This contention assumes that viewing people through a psychiatric lens is the legitimate view, ergo if a person does not subscribe to this view 'psychiatric illness', then this means they have no insight and therefore must have their liberty taken away to be sufficiently chemically restrained.
People who are struggling, who are different, who are living in a chaotic family or community, who have extraordinary experiences, who are in deep emotional distress may not have 'insight' into the limitations of psychiatric diagnosis but the way to help them and those around them is not to lock them up as second-class citizens, take away their liberty and assault their personhood.
Insight is so very important, but it is a two-way concept. In order for these 'psychotic people' to receive the help and human engagement they may need for healing, it is important that those tasked with providing care also develop insight. Insight into the multiple perspectives, experiences and circumstances that cause people to warrant support; insight into the need to provide choices that might be more conducive to people wanting to engage, and insight into the damage the 'medical model' paradigm of care causes.
This is about a fundamental right to health. Moving towards a rights-based legal system, as outlined in the UN Convention on the Rights of Persons with Disabilities, to which Ireland is a signatory, means treating people as rights holders, not as mere subjects of legal or state control.
Consent
Unquestionably, evidence-based care should be at the core of cancer or heart, or any other type of health treatment. Therefore, it cannot be the purview of just one highly contested profession (psychiatry) to impose what is increasingly seen as a dogmatic ideology onto people who are already in a vulnerable state.
This is not to say psychiatry should not be part of a suite of measures available to people, but mental health care should be based around consent and choice — a right to choice should be enshrined in legislation, and requisite funding must be put into things like family work, peer support, peer-run grassroots organisations, community development, non-medical crisis houses and open dialogue.
Choices should not be viewed through the sole lens of a psychiatric classification system that prescribes meaning to people's struggles, distress, environmental outcomes and extraordinary experiences. These choices have long been mandated as part of the post-psychiatry paradigm for mental health service provision, and the new paradigm is awash with international examples of best practice.
In other words, there are examples of how we can do things better. Certainly, things cannot get much worse for people in distress.
In 2013, the UN Special Rapporteur on Torture explicitly stated that forced psychiatric treatment may amount to torture or ill-treatment, especially when not evidence-based. Doctors may be offended that their well-intentioned treatment is causing harm, but advocates cannot dampen the quest for change and justice to appease psychiatrists.
Because the harsh truth is that while some coercive practices might not always meet the legal threshold for torture, they do often qualify as inhuman or degrading treatment. Surely if there is even a question that 'care' could be considered as something akin to torture, this requires radical debate and reform.
Jennifer Hough is a human rights and social justice advocate
Dr Líam Mac Gabhann is Associate Professor in Mental Health Practice at Dublin City University
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