Bringing Human Rights Home

Tina Minkowitz, Esq.
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The United Nations calls on countries to repeal their mental health laws that authorize involuntary commitment, and to ensure that mental health services are based on free and informed consent of the person concerned.  Forced psychiatric drugging and electroshock – not only when done to political prisoners who are certified sane, but also as routinely practiced against people labeled with mental health diagnoses – can amount to torture.

These astounding developments have come about in a relatively short period of time, thanks to the influence of users and survivors of psychiatry on international law.  We have developed ways of articulating and presenting our claims for justice that fit the human rights framework and found a receptive audience.  Theories of justice based on non-discrimination and the social model of disability are having influence throughout the UN system, reflecting the evolution of human rights law.

Significantly for people in the United States, there are UN mechanisms we can use right now to advocate against forced psychiatry.  Recently, the expert committee that monitors the Convention Against Torture issued concluding observations to the Czech Republic that included recommendations to ensure free and informed consent in mental health services.  They are following the example of the Special Rapporteur on Torture, whose 2008 report to the General Assembly said that intrusive and irreversible medical treatments aimed at correcting or alleviating a disability, including psychiatric drugging and electroshock, could amount to torture or ill treatment if enforced or administered without the free and informed consent of the person concerned.

Our sisters and brothers in Czech Republic with support of the European Network of (ex-) Users and Survivors of Psychiatry advocated to the Committee Against Torture in a written submission and by going in person to speak with the committee in Geneva.  They were particularly motivated to stop the use of cage-beds, an extreme form of restraint that led to a woman’s suicide, but did not stop there.  Understanding that cage-beds are the tip of the iceberg, ENUSP emphasized that all forced drugging, restraint and coercion of any kind had to be abolished.

The United States is a party to the Convention Against Torture, and its report is due to be submitted shortly.  That means we have an opportunity to do some advocacy and potentially obtain similar recommendations.  There is a growing movement in the United States to hold our own country accountable to international human rights standards including the recommendations made by treaty monitoring committees.  This could be the first time that the psychiatric survivor movement might get recommendations we can use.

Please visit www.chrusp.org for more information and watch this space for news, updates and further analysis.  You are welcome to suggest questions or topics on human rights for me to comment on.  I can’t promise to take up every suggestion but will consider them.

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

21 COMMENTS

  3. Thanks for this Tina. I’ve blogged previoulsy about our fight in Ohio to stop legislation that would expand involuntary outpatient commitment. Person’s not “adhering” to a treatment plan would be subject to psychiatric hospitalization which includes forced drugging. Ultimately Federal Legislation is needed to stop this but in the mean time we’re trying to defeat it State by State.

  4. Great to see you blogging on this site, Tina. I am really impressed with your work involving the UN. One difficult problem, though, as you know, is that there is great resistance in the US legal system, especially our corrupt Supreme Court, to taking international law into account at all.

    Keep up the good work!

  6. Perhaps I’m simply too jaded and cynical these days to believe this scale of change could be possible…but won’t the UN Convention signatories still be able to make the argument that with respect to “emergency situations” (harm to self or others) that consent is not required, because the Patient is not capable of giving consent?

    (sincerely hoping I’m wrong here, that would truly be amazing).

    • To reply to this and your other post – I will get into these questions in more detail in future blogs, because it deserves a full explanation.

      Basically the argument is along three prongs.

      1 – Forced psychiatry, that is anything done without the person’s own free and informed consent, is an act of violence and not a legitimate medical treatment. There are reasons why forced psychiatry should be put under even greater scrutiny than ordinary medical treatment: it interferes with freedom of thought, consciousness, personality, conscience. It is highly controversial both in the medical paradigm itself and in terms of the well documented harms it causes and the dubious benefits. In this type of situation, if there is any question about the person’s consent it should not be done.

      (And I agree with you that we need to pay attention to the quality of information provided, as well as to the circumstances under which consent is given, if there is intimidation its not free.)

      2 – Locking up a person for any period of time on the basis that the person may be dangerous to themselves or to others, is not allowed in the U.S. and most other countries unless the person is given a psychiatric diagnosis. This is discrimination.

      Theoretically it would be possible for a country to enact laws like this that would operate without any psychiatric diagnosis & be applicable to everyone. But as a colleague in Ireland found recently, when a group of people starts talking about having a general “danger law” applicable to the whole population and not just the mad community, they see how huge a violation of civil liberties it is and would not want to do it. (I do think it’s a real danger though, for countries having a strong right wing movement.)

      And there are alternatives that we can explore. For me, giving psychiatry the power to legally imprison anyone, or giving anyone this power “in the person’s best interest” is just not acceptable and never will be.

      3 – Depriving anyone of the right to make decisions for themselves, by saying they lack the capacity to give consent, is another form of discrimination based on disability. Instead of treating the person as if she is not really there and having someone else make the decision (whether a court, a doctor or a surrogate decision-maker), we have to use supportive ways to explore with the person what he or she actually wants. This is related to principles of accessibility and reasonable accommodation, and in the c/s/x movement the practice of Intentional Peer Support (created by Shery Mead) fits well with this human rights framework.

      I see I’ve written at length and hope this begins to answer some important questions.

      • Tina,

        Thank you for your reply. I look forward to reading your future posts.

        I agree with all of your points above, however, my concern is that public policy makers will continue to pander to public “fear” (of persons such as myself being “dangerous”) than the rights of alleged “crazy people”.

        My family all work in the legal profession, and they were simply stupefied by the facade of the apparent appeals process.

        – If you express a wish to go to Court – this is ‘held against you’;
        – If you question their explanations (no matter how politely) this results in you staying longer;
        – Even my own advocate confirmed that going to Court may result in me staying longer, as the Judge would be entitled to commit me for 30 days, as opposed to the more likely 15 days. This is not due process.
        – My Doctors sought to tell me which country I should live in, that I should quit my job, pack up my apartment and move back to the UK from NYC (in what other part of medicine would Doctors presume to make such decisions on behalf of their adult patients?!).

        There is no due process, only the pretense of an appeal system designed to help people sleep a bit better a night, after introducing legislation to lock people up.

  7. In terms of items I would like to see addressed at some point:
    – Doctors cannot tell a patient false/misleading info, e.g an explanation for their illness unless it’s factually correct, (i.e. the “chemical imbalance” metaphor) this does not coincide with informed consent;
    – Doctors also should not be allowed to tell patients that they have to accept taking medication for “the long term, if not the rest of their life” unless they can demonstrate this is in fact backed up with research, and balances this with information about the potential long term effects of taking such medication for the long term.
    – emergency hospitalization needs to be for the shortest period of time possible. They have to genuinely only take that option if there is no other less restrictive option available. The standard procedure to keep someone in for 15 days (in NY) is not justifiable unless the patient is continuing to actively show threats of harm to self or others.

    In short, Doctors cannot “lie” to or use helpful paternalistic metaphors to convince/coax patients into taking medication. This is simply not informed consent.

  8. I would add that failure to comply with medical advice should NEVER be a cause for forced admission, and this threat needs to be 100% removed. Even if there is a “harm to self or others” clause, it should have to be invoked each and every time a person is considered for an involuntary hold. Failing to comply with a “release agreement” to take drugs is often used as a pretext for re-hospitalization or is held over patients’ heads as a threat for noncompliance. No enforced treatment is best, but this is essential if we can’t get to the ideal.

    The other aspect of informed consent is an honest reporting of alternatives. This should include a wide range of medical and non-medical services, including a Soteria-like option, talk therapy, Open Dialog, homeopathy, naturopathy, nutritional advice, meditation, spiritual counseling – anything that has been shown to be potentially helpful. These options also need to be made available to sufferers through realistic funding mechanisms, because simply mentioning options the client can’t use isn’t very helpful, either. But at this point, no other options besides medication and “case management” (a big part of which is policing medication compliance) is ever even mentioned in most acute care settings.

    We have a LONG way to go to meet this UN standard!

    —- Steve

    • Steve,

      I agree with you also about honest reporting of alternatives, and about making alternatives available “through realistic funding mechanisms”. If there is only medication and “case management” (and electroshock… and psychosurgery… and the new technologies for delivery of medication to those who have a hard time remembering to take it…) then on the systemic level there is no true free and informed consent. Making alternatives widely available and affordable is an essential part of what needs to be done.

      Tina

  9. It’s a nice sentiment, and the UN moral authority thing that Tina has worked to bring about it useful, but it still is set to remain the case for the rest of my life and my grandchildrens lives even, that there will be nowhere to run, if you are targeted for ‘help’ (read destruction) by the Church of Psychiatry and its fanatics.

    I agree with some of the other comments though, good to see Tina here at MIA.com

  10. Great work. I have testified in numerous cases as an expert witness, and I am happy to say that in about 70% of these, the commitments are stopped or reversed. The little research that is there is quite clear about the lack of evidence. I will begin to blog about how psychologists and other professionals should begin to market themselves as professionals who will help inform the courts about what is needed. So often Judges are begging and thanking me for the testimony, as they have wanted someone like me to highlight there must be another way.
    Enjoy the read…
    Toby

    There are few studies that have attempted to determine the effectiveness of Outpatient Commitment Orders (OPC) by comparison to the tens of thousands of OPC ordered. In one of the first thorough reviews of empirical studies of OPC, Dr. Kathleen Maloy concluded in 1992, there was “almost no valid empirical evidence in support of the effectiveness of involuntary outpatient commitment vis-à-vis treatment compliance, success in the community for people with severe and persistent mental illness.”
    Maloy, Analysis: Critiquing the Empirical Evidence ; Does Involuntary Outpatient Commitment Work? Mental health Policy Resource Center (1992).

    This acknowledgement by Maloy in 1992 led Duke University researchers in North Carolina in 1999 and 2001 to examine if OPC reduced hospitalizations. They, and Swartz and his colleagues, concluded “outpatient commitment had no clear benefit unless it was sustained for at least six months and accompanied by high-intensity community services and supports”, and there were no significant differences in hospitalizations between the non OPC controls and those under commitment at the one year mark.
    Swartz MS, Swanson JW, Hiday VA, et al: A randomized controlled trial of outpatient commitment in North Carolina. Psychiatric Services 52: 325-329, 2001.
    Swartz MS, Swanson JW, Wagner HR, et al: Can involuntary outpatient commitment reduce hospital recidivism? Finds form a randomized trial with severely mentally ill individuals. Am J. of Psychiatry 156: 1968-1975, 1999.

    In turn, the Bellevue Outpatient Commitment Study was conducted in 2001, which was the only controlled study that explicitly provided and offered enhanced community services to both groups. They reviewed if commitments were necessary for individuals to continue with treatment if they were offered it without the OPC. They concluded “individuals provided with voluntary enhanced community services did just as well as those under commitment orders who had access to the same services.” Researchers found no additional improvement in patient compliance with treatment, no additional increase in continuation of treatment, and no differences in hospitalization rates, lengths of hospital stay, arrest rates, or rates of violent acts.
    Steadman HJ, Gounis K, Dennis D, et al: Assessing the New York City involuntary outpatient commitment pilot program. Psychiatric Services 52:330-336, 2001

    This lead Drs. Kirsley and Campbell, who were highlighted by the Cochrane Database of Systematic Reviews, the gold-standard of peer reviewed psychiatric research, to look at the number of outpatient commitment orders (OPC) it would take then to prevent one re-hospitalization. They concluded “it takes 85 OPC orders to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent a future arrest.” Thus, 84 people would need to be subjected to a non-required forced treatment program in order to reduce just one re-hospitalization.
    Kisely S, Campbell LA, Preston N. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. The Cochrane Database of Systematic Reviews 2005, Issue 3.

    This was confirmed by researchers not only here in the United States, but across the world as well. In 2007, at the Institute of Psychiatry in Maudsley, UK, they conducted “the most comprehensive and through review of outpatient commitments” and concluded, “it is not possible to state whether or community treatment orders (CTOs) [the equivalent to OPC] are beneficial or harmful to patients.”
    Churchill, R., International experiences of using community treatment orders, by the Institute of Psychiatry at the Maudsley (UK), Section of Evidence based Mental Health-Serv. Research Dept., March 2007.

    Then more recently in April, 2012, researchers in Israel tracked 163 (51%) schizophrenia patients compulsory admitted to the hospital and 157 (49%) patients that left the hospital against medical orders. There was no difference in baseline clinical symptoms, demographics or outcome measures, and the non hospitalized group did not lead to any significant difference in rehospitalization, incarceration or length of stay for those that were rehospitalized.
    Krivoy, A. Fischel, T, Zahalka, H et al Outcomes of compulsorily admitted schizophreni patients who agreed or disagreed to prolong their hospitalization. , Comprehensive Psychiatry, Apr., 2012 (in press).

    In Contrast, the State of New York began investing their own OPC, under Kendra’s Law and the Assisted Outpatient Treatment (AOT) program; however, their results were mixed, whereby the New York State Office of Mental Health in 2005 and later 2009 stated the AOT drastically reduced hospitalization, homelessness, arrest, incarcerations and adherence to medication compliance ; whereas, non contracted independent researchers in 2004 had just indicated that their sample of the AOT group and control group “did not differ significantly (with) rates of hospitalizations, homelessness, dangerousness and arrest/incarcerations.” One additional major conclusion was that the AOT forced treatment group was significantly “less satisfied” with treatment than those not under commitment.
    Duke University School of Medicine et. al. (June 2009). New York State Assisted Outpatient Treatment Program Evaluation.
    Perese, E.F. , Wu, Y.-W. B., & Ranganathan R. (2004). Effectiveness of Assertive Community Treatment for Patients Referred under Kendra’s Law: Proximal and Distal Outcomes International Journal of Psychosocial Rehabilitation. 9 (1), 5-9.

    • This reminds me of the saying “Better 100 guilty men go free, than 1 innocent man go to jail”…

      Unfortunately, the Psychiatric profession, in conjunction with the public sector have concluded the opposite to be appropriate with respect to people like us.

      Why and how is this justified?

      Are there any research reports on the *success* of inpatient emergency treatment? (I’m particularly interested in relation to “harm to self”) does it actually prevent suicides?

      • It nearly reduces me to tears. How dare these sickening brain rapists rape 100 people’s brains to prevent just 1 person ‘doing something’.

        How dare these people violate so many innocent people. How dare they! They need to be tried and imprisoned for crimes against humanity.

  11. Tina, thank you so much for your work!!

    Your input is a truly great (hugely needed) addition to MadInAmerica.com

    Wonderful contrast from the last blogger here writing about his version of “Human Rights” (was a very windy, 5-part series… his incredibly misplaced APA stump-speech for more universal ‘access’ to psychiatric ‘care’).

    Very interested in staying updated on your progress…

    Please post often!

  12. Thanks everyone for your comments. I’m not sure what kind of a schedule I will keep for the blog, but anticipate at least once a month. I’m glad to be here on MIA. For those following the posts, please see my reply to Anonime that addresses some questions others may have as well.

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