Editor’s Note: Over the next several months, Mad in America is publishing a serialized version of Peter Gøtzsche’s book, Critical Psychiatry Textbook. In this blog, he discusses the way psychiatry violates international ethics laws by engaging in forced treatment and other abuses. Each Monday, a new section of the book is published, and all chapters are archived here.
The textbooks were rather silent about this important issue, which is remarkable, as forced treatment is highly controversial.7:314
As power corrupts, there needs to be a power balance in human relations. However, involuntarily admitted patients are powerless. This extreme power imbalance is a recipe for disaster, and there is nothing psychiatric patients fear more than forced treatment. Some psychiatrists have administered electroshocks to the patients they disliked the most, and doctors have regularly prescribed shocks for those patients who were fighting, restless, noisy, quarrelsome, stubborn and obstinate.1:106
There is a high risk that forced treatment is being used to benefit staff rather than patients to make their work less stressful, which is the major reason for the popularity of psychosis pills when they appeared in the 1950s.1 In Europe, the oversight of forced treatment comes under the convention prohibiting torture, and a committee has observed that deliberate ill-treatment of patients in psychiatric establishments still occurs.583
I have provided a long account of the abuses in another book7:314 and shall only comment on a few issues here.
The European Committee for the Prevention of Torture has noted that, on inspection, it all too often finds that fundamental components of effective psychosocial rehabilitative treatment are underdeveloped or totally lacking, and that the treatment consists essentially of drugs.
The laws about forced treatment are highly problematic. In many countries, a person considered insane, or in a similar condition, can be admitted to a psychiatric ward on an involuntary basis if the prospect of cure or substantial and significant improvement of the condition would otherwise be significantly impaired.
Are there any treatments that can cure insane patients or lead to such substantial improvements that the patient’s condition would be significantly impaired if she is not forced to go to hospital immediately? I don’t think so, and, considering the abuse that takes place at psychiatric wards, this clause should be removed from the law of all nations, also because its premise is false.
The other lawful reason for forcing drugs on people is if they present an obvious and substantial danger to themselves or others. This is also an invalid argument. Psychiatric drugs cause suicide and violence7,8 and they cannot protect against violence unless the patients are drugged to such an extent that they have become zombies. According to the National Italian Mental Health Law, a reason for involuntary treatment cannot be that the patient is dangerous. This is a matter for the police.
Rare cases like forced feeding for life-threatening anorexia are already covered by other laws than those that apply specifically to psychiatry. And severe mania where the patient may be busily spending his entire wealth can also be handled without forced hospitalisation and treatment. For example, an emergency clause could be introduced that removes the patients’ financial decision-making rights at short notice. Furthermore, a few difficult cases cannot justify that massive harm is inflicted on the patients in general,7 which also makes it difficult to recruit good people to psychiatry. No one likes coercion, and it destroys the patient’s trust in the staff, which is so important for healing and for the working environment in the department.
Some patients have found that they should avoid mentioning certain things to their psychiatrist when hospitalised because it may lead to additional diagnoses and more medication, which the psychiatrist will rarely be interested in stopping again.
What should a patient do if she is convinced that the drug and not the disease is the cause of her symptoms? If she says anything about having the dose reduced, she might end up having it increased, or having another drug prescribed on top of the current one, with the argument that she lacks insight into her disease. Many of the about 1000 emails I have received from patients and relatives describe exactly this.
As for all interventions in healthcare, the overriding question is whether forced treatment does more good than harm. I have no doubt it does vastly more harm than good and that we will never be able to prevent the widespread abuse if we keep it. There are no randomised trials that have compared the use of force with no use of force but we know enough already. Mechanical restraint and ECT can be fatal; and, as explained earlier, psychosis drugs, other psychiatric drugs, and contact with a psychiatric ward kill an enormous amount of people.
One of psychiatry’s unfortunate fads is community treatment orders, often called assisted outpatient treatment in the United States, which are legal regimes making outpatient treatment compulsory. A 2014 Cochrane review didn’t find any differences in service use, social functioning or quality of life compared with voluntary care or brief supervised discharge.584 In clinical practice, this initiative has also failed. After the UK had introduced these treatment orders, hospital admissions increased.585 Another problem has been the great variation in their use, with some areas discharging 45% of the patients with treatment orders and others none at all. Some psychiatrists find treatment orders unethical and many patients find them stigmatising.
In 2007, the UK mental health charity, Mind, expressed many concerns.586 If a community patient’s distress is manageable, the professionals may well argue that the set-up is working and should be continued, but at what point will it be stopped? Without the natural cap on hospital detention provided by the finite number of beds, these orders will be used for too long and for too many people, like a “lobster pot”—easy to get into but very difficult to ever get discharged from. Community treatment orders mean that many people who do not wish to take drugs for the rest of their lives are no longer able to make that decision. There is no escape from this Catch-22. If the patient remains well, this is taken to mean that the drugs are working, and if not, forced drugging is often increased, causing even more misery and more deaths. Many people consulted by Mind felt their relationships with professionals would be harmed by the increased threat of compulsion, with those professionals being turned into “Mental Health Act police officers.”
The therapeutic relationship is what matters the most, and if you have been a cop and have used force, it becomes nearly impossible to change that role into the role of the physician as a healer and advocate for the patient.7:327 This is why psychiatrists should stay out of the job of being police. Another reason is that violence breeds violence. Loren Mosher testified in a Supreme Court case in Alaska and reported that in his whole career he had never acted as a police officer. He formed the kind of relationship and an ongoing treatment plan, which was acceptable both to him and the patient, and which avoided their getting into a fight.
Lawyer Jim Gottstein convinced the court to rule that the government cannot drug someone against their will without first proving by clear and convincing evidence that it is in their best interests and there is no less intrusive alternative available. Gottstein used scientific data to prove that it was not in the patients’ best interest to treat them forcefully.7:328
Psychiatrists usually say that it would be impossible to practice psychiatry safely without having the option of using forced drugging, restraints with belts and straps, and seclusion. But this is false. Studies have shown that, with adequate leadership and training of staff in de-escalation techniques, it is possible to practice psychiatry without using force.587,588
Psychiatrists should consider that some patients don’t tell them about their thoughts, how they feel, and what they experience, because they are afraid that if they are honest, it could lead to forced treatment. This is not a healthy therapeutic relationship and reminds us of the living conditions in concentration camps where it is important to never provoke the guards, which will lead to harsh punishment.
It is not laudable either that the staff often “justify” their actions by saying that, were it not for the forced treatment, the patient might have died. The evidence tells us the opposite; forced treatment kills patients.7 A patient told me that she likened forced treatment to rape and that there cannot be good rapes. This patient was raped by a man in her family when she was only nine years old and became terrified when the staff subjected her to forced treatment.
When I lectured in Australia in 2015, I was told that only 3-5% of the patients come off the treatment orders again and I met with a doctor who had been on such an order on and off for 20 years. He gave me a copy of an evaluation by a psychiatrist who in 1995 deemed him insightless because he had alerted the community to the brain-damaging effect of psychosis drugs! Another person I met was a psychiatrist who was considered insane by her colleagues, also because she spoke out about psychiatric drug harms. They tried to have her involuntarily confined to hospital but failed.
In 2014, the Danish Ministry of Health issued a licence to kill. It allowed psychiatrists to use extraordinarily large doses of psychosis drugs for forced treatment and said that this applies especially to patients who have been in prolonged treatment and where smaller doses have been tried without a good therapeutic result.589 It’s insane. These patients should have their drug withdrawn. Giving more of what was already not working doesn’t help, it kills.
Since forced treatment is not evidence-based but culture-based, it is no surprise that practices vary enormously between countries. Involuntary hospital admissions in Europe range from 12 per 100,000 inhabitants in Italy to 233 in Finland.587 Once admitted, rates of coercion also vary enormously. In Austria, mechanical restraint is used 45 times more often than in the Netherlands, where forced drugging is also used very little.590
The fundamental human right to equal recognition before the law applies to everyone, also to people with mental disorders. This is clear from the Universal Declaration of Human Rights, the International Covenant on Civil and Political Rights and the United Nations Convention on the Rights of Persons with Disabilities, which has been ratified by virtually all countries.184
In 2014, the Convention specified that member states must immediately begin taking steps towards the realisation of the rights by developing laws and policies to replace regimes of substitute decision-making by supported decision-making, which respects the person’s autonomy, will and preferences. At all times, the individual autonomy and capacity of persons with disabilities to make decisions must be respected, which means that “mental health laws that permit forced treatment must be abolished.”
The Convention makes it clear that “unsoundedness of mind” and other discriminatory labels are not legitimate reasons for the denial of legal capacity, and that the concept of mental capacity is highly controversial in and of itself.7:335
Everyone who argues for forced treatment and involuntary detention should read a heartbreaking book, Dear Luise, 234 which I have summarised7:337 and briefly mentioned in Chapter 7, Part Five.
In his foreword, “You need to be strong in order to be vulnerable,” former Danish Prime Minister Poul Nyrup Rasmussen describes the book as heart-breaking. It truly is. It could be used as a screening test for doctors who contemplate to become psychiatrists. If they get through it without crying, they should find themselves another job.
Luise’s best friend at the care home, who stayed in the room next to her, suddenly collapsed at the floor and died within a few minutes. Luise was completely shattered and all she said to her mother was: “I’ll be next,” which she became six months later. She and her mother protested against her treatment. The psychiatrist didn’t care and killed her with a depot injection.7:337
The level of ignorance and the lack of respect for Luise and her mother who knew a lot about the drugs was astounding. Luise’s mother did everything she could to prevent Luise from being overdosed and begged the staff not to overdose, but Luise died from an overdose.
When Luise’s mother complained to the authorities after the death, the system replied that Luise had received the highest standard of specialist treatment while it congratulated itself with its first-class homicide which they called a “natural death.” Many relatives have experienced that psychiatrists killed their loved ones, and in Denmark they have united in the association Death in psychiatry, which demonstrates in front of the hospital every year on Luise’s death day.
The book, which has been translated into English,234 describes virtually everything that is wrong with psychiatry including making incorrect diagnoses. Whenever I open it again, I get overwhelmed with sadness because I know the author and also that many psychiatric patients are abused and die under similar circumstances as Luise and her best friend. Luise was a slow metaboliser, and her mother had begged the psychiatrists never to use a depot injection, which was what killed her daughter.
Being treated humanely is difficult in today’s psychiatry. If you panic and go to a psychiatric emergency ward, you will probably be told you need a drug, and if you decline and say you just need rest to collect yourself, you might be told that the ward is not a hotel.591
This is bad medicine. Impending psychoses can sometimes be fended off before they develop if we provide patients with the shelter and rest they need. There should be 24-hour support facilities without any compulsion, so that the hospital is no longer the only place patients in acute crisis can go to.592 There could be refuges with the possibility of accommodation and the money should follow the patient and not the treatment.
Psychiatry seems to be the only area in society where the law is systematically being violated all over the world—even Supreme Court and Ombudsman decisions are being ignored.8:328,593,594
We studied 30 consecutive cases from the Psychiatric Appeals Board in Denmark and found that the law had been violated in every single case.594,595 All 30 patients were forced to take psychosis pills they didn’t want, even though less dangerous alternatives could be used, e.g. benzodiazepines.165 The psychiatrists had no respect for the patients’ views and experiences. In all 21 cases where there was information about the effect of previous drugs, the psychiatrists stated that psychosis pills had had a good effect whereas none of the patients shared this view.595
The harms of prior medication played no role either in the psychiatrist’s decision making, not even when they were serious, e.g. we suspected or found akathisia or tardive dyskinesia in seven patients, and five patients expressed fear of dying because of the forced treatment. An expert confirmed our suspicion that a patient had developed akathisia on aripiprazole (Abilify) but on the same page, the expert—a high-ranking member of the board of the Danish Psychiatric Association—recommended forced treatment with this drug even though it was stopped because of the akathisia.595
The power imbalance was extreme. We had reservations about the psychiatrists’ diagnoses of delusions in nine cases, and there is an element of Catch-22 when a psychiatrist decides on a diagnosis and the patient disagrees. According to the psychiatrist, the disagreement shows that the patient has a lack of insight into the disease, which is a proof of mental illness. The abuse involved psychiatrists using diagnoses or derogatory terms for things they didn’t like or didn’t understand; the patients felt misunderstood and overlooked; their legal protection was a sham; and the harm done was immense.595
The patients or their disease were blamed for virtually everything untoward that happened. The psychiatrists didn’t seem to have any interest in traumas, neither previous ones nor those caused by themselves or their staff. Withdrawal reactions were not taken seriously—we didn’t even see this term, or a similar one, being used although many patients suffered from them.
It is a very serious transgression of the law and of professional ethics when psychiatrists exaggerate the patients’ symptoms and trivialise the harms of the drugs to maintain coercion, but this often happens, and the patient files can be very misleading or outright wrong.7,121,234,595 In this way, the psychiatrists can be said to operate a kangaroo court, where they are both investigators and judges and they routinely lie about the evidence,7:329 where after they sentence the patients to a treatment that is deadly for some of them and harmful for everyone.
In Denmark, when the patients complain about this unfair treatment, which isn’t allowed in any other sector of society, it is the same judges (or their friends that won’t disagree with them) whose evidence and judgments provide the basis for the verdicts at the two appeal boards, first the Psychiatric Patients’ Complaints Board, and next, the Psychiatric Appeals Board. It doesn’t matter the slightest bit what the patients say. As they have been declared insane, no one finds it necessary to listen to them. This is a system so abominable that it looks surreal, but this is the reality all over the world.
In one of the textbooks, under the section, “The Violent and Aggressive Patient,” the authors mentioned some drugs that, in rare cases, can cause motor restlessness and increase restlessness and aggression. These drugs are benzodiazepines, amphetamine, anabolic steroids, and testosterone.17:821
It is inexcusable that the authors did not mention that depression pills, methylphenidate and psychosis pills can also cause such symptoms and did not mention akathisia either, one of the most dangerous drug harms. This is yet another example that psychiatrists protect their guild.596
Further ahead, the authors noted that studies suggest that the patients’ aggression can be seen as a reaction to conflicts among the staff, and they said that a newer study pointed out that increased patient autonomy can reduce violent behaviour and the use of coercion.17:828 We all know it can reduce aggression to respect other people. This is what international diplomacy is about, and no scientific studies are needed to confirm this.
However, the respect for the patients lasted only one page. On the next page, we are told that not using psychotropic drugs for patients that are agitated, aggressive or violent and where belt fixation might be needed should only occur exceptionally and then accompanied by a clear argumentation for this in the patient file. A table with suggested interventions included lorazepam, olanzapine, ziprasidone or haloperidol in the acute phase, and clozapine, antiepileptic drugs, depression pills, or ECT in the follow-up phase. This is a prescription for death and for creating zombies.
The book mentioned the rule about using the least intrusive treatment, but then argued that some patients are permanently incompetent, i.e. permanently lack the ability to consent, and that these include mentally ill people with mental disabilities, chronic mentally ill people, and mentally ill people with long-term illnesses, and that the issue is whether the patients can give a reasonably meaningful informed consent.17:927 As noted above, these arguments have been rejected by the United Nations Convention on the Rights of Persons with Disabilities.184
The same book had a section about forensic psychiatry where it was argued that randomised trials studying the effects of using force cannot be carried out for ethical reasons.17:926 This is wrong. There are good intentions behind using force in psychiatry, but the harms are massive, and it is not at all clear if force, on average, benefits or harms the patients. Most likely, it is harmful. Therefore, it is ethically acceptable to do randomised trials. During a trial, half of the patients will avoid coercion, and when the trial is over, perhaps all future patients will avoid coercion. What is unethical is to continue subjecting patients to force against their will.184
The book argued that, during forced treatment, one should only use medication in usual doses and with the fewest possible harms.17:929 This contradicts what other authors wrote in the same book 277 pages earlier, that it is appropriate in some cases to increase the dose of psychosis drugs above the approved interval.17:652
To see the list of all references cited, click here.
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