COMPULSORY PSYCHIATRIC TREATMENTRISKY BUSINESS

Mary O’Hagan

WHAT IS COMPULSION?

Mental health legislation establishes the circumstances in which a person with ‘mental disorder’, who hasn’t committed a crime, can be detained or treated without their consent.

The criteria include:•Mental disorder•Danger to self or others•Incapacity to refuse treatment

WHAT IS RISK?

Possibility of harm, loss or dangerFactor involving uncertain danger, hazard

Risk is located in the future

APPROACHES TO RISK

Cause of danger

The gods

Fate

Nature

Response to danger

Supplication

Acceptance

Control

RISK AND MAD PEOPLE

INTRAPERSONAL RISK

Harm to self•Internalised stigma and hopelessness•People in contact with mental health services 20 times more likely to kill themselves than general population.

RISK AND MAD PEOPLE

INTERPERSONAL RISK

Mad as perpetrators Weak statistical correlation between madness and violence. Other factors are stronger such as age, history of violence, gender and substance abuse.

Mad as victimsMuch more likely to be victims than perpetrators.

RISK AND MAD PEOPLE

ENVIRONMENTAL RISK

As causes of madnessTrauma, deprivation, social inequality, loss

As consequences of madnessTrauma, deprivation, social inequality, loss•Social stigma and discrimination•Unsafe, unhelpful, coercive services

APPROACHES TO RISK AND MADNESS

WIDER COMMUNITY

An unsustainable consensus•Mad people a risk to others•They cannot take responsibility for their actions•The community has ceded responsibility to services•Services entirely responsible for controlling risk

Mental health leaders collude with this consensus

The scene is set for the wide acceptance of compulsion

APPROACHES TO RISK AND MADNESS

MENTAL HEALTH SYSTEM

A contestable dominant paradigmCompulsion supported by belief in biological pathology that destroys autonomy and needs correction with treatment.

Poor powers of prediction•Serious violence by mad people too rare to predict well•Debatable if compulsion reduces suicide rate

A narrow conception of risk•System driven by risk to institutional & professional reputation•Little regard for risks to consumers

COMPULSION - RISKS TO CONSUMERS

DISCRIMINATORY CRITERIA IN MENTAL HEALTH ACTS

Danger to othersPreventive detention can happen despite no crime (only with mad)

Danger to self Compulsion can happen despite competence (only with mad)

Competence ‘The criteria for non-voluntary treatment should focus on the

mentally ill person’s capacity to understand that he or she is ill and the benefits that might result from treatment.’ Ryan et al

COMPULSION - RISKS TO CONSUMERS

INHUMANE TREATMENT

Hospitals Experienced as unsafe and uncaring

Seclusion, restraints, forced injectionsExperienced as re-traumatising and as punishment

COMPULSION - RISKS TO CONSUMERS

CORRUPT REVIEW PROCESSES

Review Tribunals processesIntimidating and humiliating

Review Tribunal decisionsOne in 20 applicants get off order in NZLanguage to justify decisions does not appear in Act in NZ

COMPULSION - RISKS TO CONSUMERS

QUESTIONABLE TO HARMFUL OUTCOMES

Medications can be life-depleting and life-shortening

Compulsion re-traumatises and corrupts therapeutic trust

Undermines autonomy and creates overdependence

Compulsion lowers social status and increases stigma

‘Compulsory community treatment results in no significant difference in service user, social functioning or quality of life compared with standard care.’ Kisely et al. Cochrane Review

THE RISKS TO REFORM

RECOVERY POLICY

National policies in all English speaking countries founded on recovery, but no reduction in compulsory treatment.

Compulsory treatment not compatible with recovery:•Self-determination and personal resourcefulness•Collaborative relationships (shared risk, positive risk)•Choice of services•Equal participation in society

ALTERNATIVES TO COMPULSION

Stop colluding with discriminatory community consensus

Recovery focus - crisis prevention focus & ‘the life I want’

Advance directives

More and better crisis options

Robust systemic and individual advocacy

‘Compulsory responsiveness orders’

Separate healing function from control function

AN END TO MENTAL HEALTH LAWS

Treatment and detention without consent rare and brief

Emergency interventions have the comparable threshold as physical medicine

Rethink assumptions about human responsibility for crimes

Humane recovery oriented criminal justice system

THE ROAD TO HELL...GOOD INTENTIONS

‘Of all the tyrannies a tyranny sincerely exercised for the good of its victims may be the most oppressive...for those who torment us for our own good will torment us without end for they do so with the approval of their own conscience...’ CS Lewis