New UN Report: Steps Forward, But No End to Impunity

Dainius Pūras, UN Special Rapporteur on Health, has issued a groundbreaking new report on mental health (click here for the pdf in different languages). He critiques biopsychiatry and its reliance on coercion in depth and with great detail supplied by both his familiarity with the subject and his having listened to a wide range of stakeholders, from his own description. He tells psychiatrists that the profession has to fundamentally change if it wants to continue to exist at all. Yet he pulls his punches, most unforgivably by treating the obligation to end coercive practices as a matter for gradual rather than immediate implementation.

This is a slap in the face to survivors of psychiatric torture and arbitrary detention, and a familiar bait-and-switch: you have the right to not be locked up, but that doesn’t mean you actually have the right to leave, right now, no questions asked! You have the right to legal capacity and to refuse any unwanted treatment, but that doesn’t mean you actually have the right to not be force drugged, now or ever, for any reason! You have the right to non-discrimination, but we’ll conveniently ignore that forced drugging with neuroleptics and other mind-altering drugs is uncontroversially acknowledged to be a form of torture when practiced against anyone who has western psychiatrists willing to say they are sane and not mad, and that all existing arguments to differentiate labeled from non-labeled folks have failed? (Pūras himself acknowledges the invalidity of danger and incompetence libels, and the claim of ‘medical necessity,’ see paras 25 and 64; perhaps because his main audience is clinicians, he rests his arguments on research rather than on the inherent dehumanization involved in applying torture as treatment and subjecting a person to erasure of their will and preferences.)

There is more to say and the report deserves close reading and analysis, which I do not pretend to do here.  My aim in this post is to draw attention to the value and the attendant dangers of Pūras’s approach.

Pūras is an ally in his own way — survivors and critics of psychiatry will find much in his report to support systemic change.  But who and what is left out?  Garth Daniels petitioning to have the forced electroshock stopped NOW. Every single person under inpatient or outpatient commitment, every person who is swallowing pills they hate because if they go mad they will be locked up and worse will happen. All of us who live with the hegemony of psychiatry as an arbiter of good and bad behavior, especially the majority of human beings who for any or all reasons live outside the straitjacketed norms of white male heterosexuality — by choice or by birth or any other reason. Psychiatry’s power, as the social institution in charge of separation and control of mad people, is called into question by this report, yet it remains to be seen if this will lead to further hemorrhaging of its power and its ultimate demise; if we as a society are capable of the radical reimagining of equality and community that many are striving towards from different directions.

Survivors and allied human rights defenders cannot afford to equivocate — we should welcome this report for its opening of space in the health and mental health communities to work on systemic changes in practice, but never accept the limitations of a clinician’s approach to ending abuses by the clinical system itself. The fox does not get to watch over the henhouse. It’s particularly important that Pūras’s report not be taken as the last word on implementation of the CRPD in the mental health context, merely because it has a great deal of value in its critique of the predominant reliance on diagnostic labels and drugs. Those points need to be expanded on, and at the same time we must emphatically reject the suggestion that we can somehow have it both ways on the question of immediate obligation: while acknowledging (para 37) that ‘certain freedoms’ are among the immediate obligations within the right to health (which can equally be viewed as civil rights, which are always immediate), Pūras declines to elaborate on those freedoms, and his recommendations for ending forced treatment and confinement in psychiatry in fact call for progressive realization (paras 65 and 95(f)).

We also must reject something perhaps more subtle reflected in the apparently balanced approach of the report: a failure to relinquish control of the narrative of psychosocial disability to people with psychosocial disabilities ourselves, so that the report contains our narratives within the framework of mental health alongside the narratives of clinicians and other outsiders to the lived experience of disability. (For example see the interplay between diagnosis and diversity in paras 49 and 50.)  This is what we fought to emerge from in the drafting and negotiation of the CRPD: as WNUSP representative to the first meeting I opposed a well-meaning attempt to create a mental health caucus, and instead opted for a Disability Caucus where we had commonality of interest with all people with disabilities in self-representation and overthrowing the hegemony of medical professionals. Nothing about us without us! didn’t mean put us in the same basket with our structural oppressors and treat the narratives as having equal claims to validity, it meant, as we stated and worked in practice: respect the leadership role of people with lived experience in defining our human rights and in crafting the remedies.

The danger is that, by taking in some of the critiques made by survivors and allies, health professionals will reassert their old position speaking for and about us, and our disability community sisters and brothers will once again place people with psychosocial disabilities outside their mainstream. It is not entirely clear to me why and how this can succeed, but perhaps because mental health professionals are separate from other disability-related professions, so we are alone in navigating this interface. Once a separation is made, prejudices kick in that accept lower standards, separate and unequal, because mental health is still seen as somehow different, more difficult, something on the border between disability and criminality, needing to be controlled and contained. (In a similar vein, see my response to articles written by disability rights academics who think that some form of coercive paternalistic intervention needs to be maintained after we get rid of mental health laws. My response is titled CRPD and Transformative Equality.)

Human rights lawyers and advocates need to be vigilant against the temptation to accept a compromise that denies justice to victims of serious and widespread human rights violations. Our allies need to look closely at our analysis and testimonies (see among other resources CHRUSP website and Absolute Prohibition Campaign), and understand that it is not hyperbole to say this. The most egregious violations are those that are ignored in plain sight, that are commonplace and embedded in structural hierarchies and functions of governance within a market economy and a patriarchy that has evolved away from direct control through familial lines. Governance of mad people has become a specialty within governance of populations, and healing or comfort for anyone in distress has somehow been overlaid on that and happens incidentally or as a counter-current. The perceived need of states and societies for such specialized governance is the source of psychiatry’s human rights violations, and must be countered at its root, which is discrimination, so as not to emerge in new guises.

Pūras asserts in one of his finest paragraphs that we have to look at the “global burden of obstacles that has maintained the current status quo in mental health” and not the dehumanizing “global burden of disease.” Yet it is these obstacles and their structural roots that create a situation where ending legalized discriminatory violence can be viewed as a gradual obligation dependent on the creation of ‘evidence-based’ alternatives, as his report recommends. Unlike questions of safety and efficacy, coercion is not a legitimate variable in health policy. It is plainly a discriminatory violation of the rights of people with psychosocial disabilities to health, legal capacity, and freedom from torture, to subject coercion in mental health services to an ‘evidence-based’ assessment or a reduction and eventual elimination that may end up depending on some replacement form of specialized governance, rather than eliminating such social institutions entirely.

Rather than calling for immediate cessation of the specified violations, Pūras recommends “immediate action to radically reduce medical coercion and facilitate the move towards an end to all forced psychiatric treatment and confinement” (para 65, see also para 95(f) in Recommendations, “take targeted concrete measures”). Do we take this and welcome the progressive clinicians willing to work with us on this goal? Do we simultaneously use legal strategies, including class action suits, to call for an end to impunity and set our sisters and brothers free? Will a gradual approach necessarily work against immediate enforcement, if courts take the view of wait and see, or accept that despite the immediate character of the obligation, it is somehow not feasible or would interfere with an orderly process to intervene decisively? We should recall that these are the age-old questions our movement has faced in its modern history and probably before its modern incarnation. We should remind our allies of how long we have been dealing with this, and they should pay attention if their aim is solidarity and not co-optation.

As a survivor I live daily with the trauma. As a once-labeled person and out survivor activist lawyer I find that my experience of trauma is disbelieved or is glossed over as being equivalent to “yes of course she is suffering, that is her mental health condition” or simply as an axe to grind since I advocate the cessation of all psychiatric torture and detention. (A catch-22, since how am I to obtain due reparations including guarantees of non-repetition, if I do not advocate for myself? If I am not for myself, who will be for me?) I also live with what my sisters and brothers bring to me, with my helplessness in the face of their ongoing torture and arbitrary, discriminatory, unjust confinement. Silence equals death; psychiatry kills. That is not an overstatement, either — see the first four pieces in the Absolute Prohibition and ask survivors you know how many of their friends have died from psychiatry, including forced psychiatry. We have a responsibility to not be satisfied with a promise of future change, when it is within the power of courts, legislatures, executive branch, clinicians acting collectively, and perhaps others (see CHRUSP submission on access to justice for arbitrary detention and torture), to end the abuse NOW.