Sarah Knutson: Rethinking Public Safety – The Case for 100% Voluntary

(originally appeared on Mad in America website)

(now available in Italian translation on il cappellaio matto website)

Not long after posting this Principle from the 10th Annual Conference on Human Rights and Psychiatric Oppression, the following comments appeared on my Facebook page:

“It would have to be replaced with something else, we need to have strong supports we need to take care of each other.”

“Hey you radicals mental illness is a physical illness that requires the attention of a specially trained medical doctor if don’t like the treatment leave for a dessert[sic] island where you can suffer without disturbing others”

CRPDThese are understandably difficult issues.  Historically, there has been a lot of difference of opinion and genuine debate. In 2006, the United Nations weighed in.  They approved the Convention on the Rights of Persons with Disabilities (CRPD).  The CRPD prohibits involuntary detention and forced interventions based on psychosocial disability.  These are considered acts of discrimination that violate the right to equal protection under the law.  Under the CRPD, people with psychosocial disabilities have the same rights to liberty, autonomy, dignity, informed consent, self-determination and security of the individual and property as everyone else.

Shortly thereafter, forced ‘treatment’ was also held to violate the Convention Against Torture:

States should impose an absolute ban on all forced and non-consensual medical interventions against persons with disabilities, including the non-consensual administration of psychosurgery, electroshock and mind-altering drugs, for both long- and short- term application. The obligation to end forced psychiatric interventions based on grounds of disability is of immediate application and scarce financial resources cannot justify postponement of its implementation.

Forced treatment and commitment should be replaced by services in the community that meet needs expressed by persons with disabilities and respect the autonomy, choices, dignity and privacy of the person concerned. States must revise the legal provisions that allow detention on mental health grounds or in mental health facilities and any coercive interventions or treatments in the mental health setting without the free and informed consent of the person concerned.

Many of us hoped that would be the end of it: No forced treatment, clear and simple.  Nevertheless, the debate goes on.  It seemingly has sped up – rather than let up – over the past several years.  Clearly, many of us are sincerely struggling with these issues.  There are people of conscience on all sides.

 

The Case for 100% Voluntary

For the past ten years, the international community has been progressively moving away from involuntary interventions. This essay is the first in a multi-part series.  It highlights important reasons why the rest of us should follow suit. They are as follows:

1.     These issues are universal, not medical

Life, by nature, is difficult and risky.  Our primary certainties are death, loss, and vulnerability. Pain, suffering, sickness and need are pretty much a given.

The idea is to minimize risk as much as possible, but still keep the essential spontaneity of feeling alive.  This a highly personal undertaking. One is never certain what this means for someone else.

That being said, communities can and should offer support to all who want it. At certain times, any of us might want help to balance: (1) factors that concern others, (2) feasible (medical, natural and community) alternatives; (3) risks and benefits; and (4) personal values and lifestyle considerations. The onus, however, is on would-be supporters to earn and maintain our trust. This is the approach adopted by the United Nations in the CRPD. (Art. 12).

2.     Clinicians are lousy predictors

It’s hard to know in advance who is a ‘danger.’  Clinicians are notoriously poor in predicting suicide or violence.  In individual cases, they barely do better than the toss of a coin.

Equally disturbing, the people they will lock up have not been accused of a crime, much less convicted.  Yet, on flimsy odds, innocent people lose jobs, businesses, careers, homes, custody of kids, and much more.

And that’s not the half of it.  Typically, to lose freedom in society, twelve jurors who have been carefully screened for bias must unanimously agree that someone is guilty beyond a reasonable doubt. In the mental health system, a single clinician with little to lose and a lot to gain makes the call.  By far the safest course is erring on the side of lock up. Guessing wrong means serious harm, distraught families, internal reviews, bad press, lawsuits, potential job or income loss.  Sleepless nights and calls at home should not be overlooked.

3.     Drugs, at best, are problematic

Contrary to popular belief, the choice to refuse drugs is rational.  Even if you meet diagnostic criteria, there are many good reasons to ‘just say no.’ This not just for individuals and families, but for insurers and governments as well.

During the past several decades of increasing drug use, disability rates have sky-rocketed.  Long-term outcomes and relapse rates have worsened overall. Particularly disturbing is the fact that third world countries (where people are too poor to afford the drugs) get dramatically better results.

Even as a first-line of defense in emergency settings, there are serious concerns.  In simple fact, drugs are not harm neutral.  Known effects include death, psychosis, rage, despair, agitation, shaking, vomiting, impulsivity, tics, uncontrollable movements, memory loss, skin crawling, insatiable hunger, rapid weight gain, dulled awareness, impotence, insomnia, hypersomnia, fatigue, mood swings, and the list goes on. Many of us have experienced the drugs creating urges to violence or suicide we never had before.  Some of us have acted this out.

The long-term considerations are equally alarming.  Susceptibility to relapse, loss of brain matter, obesity, diabetes, congestive heart failure, and permanent disability increase as a function of exposure.  Due at least in part to drug effects, the ‘mentally ill’ lose 15-25 years (on average!) of our natural lifespan.

For many people, the health risks of drugs aren’t even the half of it. A lot of what you like depends upon your values. Preferences and comfort differ for, e.g.: relying on drugs vs. learning self-mastery, following rules vs. asking questions, respect for experts vs. internal wisdom, managing feelings vs. experiencing feelings, medical vs. natural approaches, and seeing the source of healing as science vs. human or spiritual connection.

When it comes to drugs, one nutter’s meds are anutter’s poison.

4.     Promising alternatives are not being considered

Many do better with non-medical approaches (or might if these were offered).  Fortunately, the options are legion. (See end notes.) Unfortunately, the alternatives are not well-known by clinicians, politicians or the general public.  They therefore not widely offered or available, and are not considered to be worthy of clinical trials.

This is not ‘the other guy’s problem.’  Vast numbers of us are potentially affected.  One in four crosses paths with the mental health system. (3) One in three currently takes a psychoactive drug. (4) And that hardly scratches the tip of the iceberg of all who are struggling.

What separates ‘the worried well’ from the ‘social menace’?  I’d like to think it was more than my natural affinity for the only approach the doctor on call was taught to offer.

5.     Natural diversity is not a pathology

Human experience cuts deep and scatters wide.  Statistically speaking, there are many shared traits, values, and approaches to life. But outliers are a fact as well.

Our variability is to be expected.  Diversity, not conformity, is the real ‘normal.’ It contributes to the robustness, resourcefulness, and creativity of our species.  While it may not get you dates or jobs in a self-promoting, efficiency-driven, corporate-run economy, it is not a disorder.

To the contrary, it is far more like a subculture than an ‘illness.’ In actuality, scores of us value our internal experience, being true to ourselves and treating others generously.  If we speak truth to power and get fired, this is not just impulsivity, mania or disorder.  It’s having the courage of our convictions. We want a world that’s more than just self-promotion, might is right, and going along to get along.  It’s a beautiful vision.  Many of us are dying (including by suicide) for the want of it.  Far from being a social menace, in the 1960’s, Dr. King argued that such ‘creative maladjustment’ is essential in our quest for a socially just, equitable world.

6.     This is about trauma, not disordered brains

Trauma’ is pervasive and potentially causal. Ninety (90!) percent of the public mental health system are ‘trauma’ survivors.  In effect, vast numbers of vulnerable citizens are growing up without a way to meet fundamental human needs. Things like:

  • reliable access to food and habitable shelter
  • safety of person and property
  • dignity, respect and fair treatment
  • meaningful participation and voice
  • the means to make a living and obtain basic life necessities
  • relational, educational, vocational and cultural opportunities for development
  • support to share and make sense of experience in our way

If the aim is to create a safer world, trauma is a much more pressing problem to fix than ‘chemical imbalances’.  There are numerous reasons for this.  We have not even begun to scratch the surface of the implications of a truly trauma-informed system of care.  As the next essay in this series will address.

7.     Do the math – it adds up to ‘voluntary.’

The primary mechanisms for a safer world are already in place.  We already have a criminal justice system with the capacity for detention, probation, in-home monitoring, geographic restriction, behavioral health treatment, drug testing, ‘no contact’ orders, restorative justice, etc.  We already have civil restraining orders, lawsuits, and mediation.  The essential task is to update these protections – and make them meaningfully available – to address modern needs.

The money we save by making things voluntary (police, hospitals, courts, lawyers, lawsuits, staff/ patient injuries, security, insurance, staffing needs, drugs) will go a long way to making this possible.  We could fund numerous thoughtful, responsive, social justice informed alternatives.

We could invest in a truly trauma-informed criminal justice system, rather than dumping that burden on hospitals and their employees. The change in morale itself is worth the price of admission.  Imagine no locked doors and everyone wants to be there. Violence happens, you call the police. Just like everywhere else.

8.     The continued prejudice against people with psychosocial disabilities is not worthy of a free society.

There’s a saying in twelve-step rooms: Every time you point a finger, there’s three pointing back at you.  Suffice it to say, majority fears and prejudice must stop ruling the day. That is discrimination – and it begets discrimination.

In actuality, people from all walks of life have presented a grave risk of injury to self or others at one time or another in their lives: Wall Street brokers, weapons manufacturers, new parents, drinkers, children, teens, Frat houses, Nyquil users, pot smokers, crack addicts, bungee jumpers, martial artists, car racers, dirt bikers, inline skaters, snake handlers, fire builders, gymnasts, boxers, weight lifters, ragers, ex-cons, insomniacs, equestrians, skiers, diabetics who eat sugar, cardiac patients who drive…  There is no end to the list. Some people (trapeze artists, law enforcement, fire departments, magicians, military, security guards, skydivers, operators of heavy machinery) even make a living from this.

There is no principled way of distinguishing the predisposition to such risks from any other kind of psychosocial diversity.  If you needed any better proof of this, the diagnostic criteria for so-called ‘mental disorders’ are so useless that CMS threw them out in 2013 and told the APA to start over.

In any place but a psychiatric exam room, those seen as a cause for alarm would have the following rights: due process, equal protection, liberty, privacy, security of person and property, free speech, freedom of association, freedom to travel, right to contract, written charges, trial by jury, Miranda, and compensation for unjust takings.  You need these protections more, not less when you’ve committed no crime and are simply having the worst day of your life.

In a society worthy of calling itself ‘free,’ public safety would mean all of us. It would go without saying that service recipients are ‘the public’ just as much as anyone else. We would look at fear and prejudice as the real social menace.  People who use mental health services would not need protection from people like you

So please.  Stop locking us up ‘for our own good’ and calling it a favor.  This only distracts from the real question:  If the crisis services are so great, then why isn’t everyone using them? 

Here’s a litmus test. Think about your last life crisis. Did you use these services? Did they feel like a useful, viable option for you?

Before you say, “No but I’m not [crazy, poor, uninsured…],” stop yourself. Try this instead, “No, but I’m not human.

It has a different ring to it, doesn’t it?

 

This blog is a contribution to the Campaign to Support the CRPD Absolute Prohibition of Commitment and Forced Treatment. To see all of the Mad in America blogs for this campaign click here.

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Click here for supporting resources →

 

 

Sarah Knutson is an ex-lawyer, ex-therapist, survivor-activist.  She is an organizer at the Wellness & Recovery Human Rights Campaign. You can reach her at the Virtual Drop-In Respite, an all-volunteer, peer-run online community that aspires to feel like human family and advance human rights.

Bonnie Burstow on Call to Action

reposted from BizOMadness blog, written by scholar and activist Dr. Bonnie Burstow

The CHRUSP Call to Action and Its Significance

Various instruments of the United Nations have commented on forced treatment, or involuntary confinement, or both (for details, see Burstow, 2015a), and a number of truly critical additions to international law have materialized. Arguably, the most significant of these is the Convention on the Rights of Persons with Disabilities (see http://www.ohchr.org/EN/HRBodies/CRPD/Pages/ConventionRightsPersonsWithDisabilities.aspx). What makes it so significant? For one thing, because this landmark convention puts forward nothing less than a total ban on both involuntary treatment and the involuntary confinement of people who have broken no laws.

To highlight a couple of relevant passages, article 12 of the CRPD states, “State parties shall recognize that persons with disabilities enjoy legal capacity on an equal basis with others in all aspects of life.” Correspondingly, article 14 states:

State parties shall ensure that people with disabilities, on an equal basis with others:

  1. Enjoy the right to liberty and security of the person
  2. Are not deprived of their liberty unlawfully or arbitrarily … and that the existence of a disability shall in no way justify a deprivation of liberty.

What is likewise significant, the guidance provided clarifies that the ban on forced treatment and on voluntary committal is to be seen as absolute (see http://www.ohchr.org/Documents/HRBodies/CRPD/14thsession/GuidelinesOnArticle14.doc).

What we have here in other words is nothing less than a colossal breakthrough.

In line with the CRPD breakthrough, CHRUSP (Center for the Human Rights of Users and Survivors of Psychiatry) has issued a call to action in support of the prohibition (see https://absoluteprohibition.wordpress.com/). I strongly support this campaign both as a human being generally and as a psychiatry abolitionist—hence this article.

First let me say that whether or not one is a psychiatry abolitionist, or to put this another way, whether one sees some value in psychiatry’s tenets and approaches or whether one regards them as both totally foundationless and inherently damaging, there is an onus upon us simply as human beings to find a way to support campaigns of this ilk. When basic rights such as the right to decide what does or does not enter one’s own body and the right not to be confined to a locked ward are at issue, we all of us have a moral obligation to do something to set the situation right. How can it be acceptable to override people’s right to make decisions for themselves?  To stop people from walking about freely—especially when they have broken no law? Nor can the deprivation of such rights be warranted by claims (what follows are several of the standard ones) such as the person lacks the capacity to make decisions for themselves or they are of danger to self or others. As noted in Burstow (2015b), while for sure people may need assistance in making decisions, incapacity per se is a circular institutional construct; and besides that it is indefensible to deprive people of freedom on the basis of prediction, the elites involved in such decisions (read: psychiatric professionals) have virtually no ability to predict dangerousness. Nor for that matter do others.

The long and the short is that the cause is just, liberation from oppression is at issue, and irrespective of any differences in our respective understandings of psychiatry, there is ample reason for us all to place a priority on the current campaign. I am accordingly enthusiastically joining with leaders like Tina Minkowitz (see http://www.madinamerica.com/2016/01/campaign-to-support-crpd-absolute-prohibition/) in urging people to get involved.

That noted, while the campaign in question places a very special onus on all of us, and my major purpose in this article is to support that, I did additionally want to do what no other writer to date has done—to tease out the special meaning that the CRPD and such campaigns uniquely hold for those of us who are abolitionists, whether inadvertently or otherwise. What is especially apropos here is the attrition model of psychiatry abolition.  So what is the attrition model of psychiatry abolition? And as an attrition model abolitionist, how do I understand the current campaign?

Predicated on the understanding that psychiatry abolition is a process and a direction as opposed to a goal which can be quickly attained, the attrition model of psychiatry abolition, as articulated in Burstow (2014) and adopted by Coalition Against Psychiatric Assault (see https://coalitionagainstpsychiatricassault.wordpress.com/attrition-model/)

is a model for determining what actions and campaigns to support and what to prioritize. An operant principle is that active support be predicated on the capacity or tendency of the action or campaign to move society in the direction of abolition. Pivotal to the model are the following defining questions:

1)    If successful, will the action or campaigns that we are contemplating move us closer to the long range goal of psychiatry abolition?

2)    Are they likely to avoid improving or adding legitimacy to the current system?

3)    Do they avoid widening psychiatry’s net? (Burstow, 2014, p. 39).

Now again, while supporting the CHRUSP call to Action is urgent and necessary for the reasons already indicated, the degree of prioritization for an attrition model abolitionist would depend on the answers to such questions. So are there “yes answers” to the questions above? Let me suggest that albeit to varying degrees, in all three cases, yes.

To tackle this one by one, beginning with the first question, any measure which abolishes any integral aspect of psychiatry without question moves society demonstrably in the direction of abolition. Hence the prioritization by Coalition Against Psychiatric Assault, for example, of the abolition of certain “treatments” (e.g., ECT). And does this campaign target the abolition of anything integral to psychiatry? Obviously yes—all use of force and coercion. As such, the first criterion is satisfied.

Which brings us to Question Two: Is the campaign likely to avoid improving or adding legitimacy to the current system? This is the most ticklish of the questions, for a case could be made that the psychiatric system would be improved by becoming less coercive. This notwithstanding, my sense is that eliminating the coerciveness in no way constitutes an endorsement of psychiatry and could in fact function in the exact opposite way—that is, it could lead people to ask themselves: What else should go? It could even in the fullness of time, culminate in a more wholesale questioning of psychiatry—especially once it is seen that eliminating coercion can be accomplished without a plethora of horrid consequences following.

Finally, Question Three: Does the campaign in question avoid widening psychiatry’s net (translation: Would the campaign, if successful, avoid enabling psychiatry to scoop up ever more people?)? Here the answer is a resounding yes. The point is that were this campaign successful, not only would it not widen psychiatry’s net, it would demonstrably narrow it, allowing all those who say “no” to escape psychiatry altogether.

What follows from this analysis, this campaign is in line with abolitionist principles.  And as such, prioritizing this campaign is a natural move for abolitionist groups to consider.

Summarizing Remarks, Invitations, Suggestions, and Warnings

A very important move has been taken by the United Nations in the passing of the CRPD. For the first time in history, there is an international legal clarification that psychiatric survivors must enjoy the same rights as everyone else—that is, force is absolutely prohibited. This is not just “any” organization taking this position, additionally—this is a mammoth mainstream organization which wields both moral and legal clout. Correspondingly, an important campaign is now under way to support the absolute prohibition that is part and parcel of the CRPD. What has been shown in this article is that the prioritization of this campaign makes sense both on a fundamental human rights level and additionally, on a psychiatry abolition level. Given the prestige of the United Nations and given that many countries have already signed and even ratified the Convention, moreover, explicitly wedding this campaign to the Convention itself is itself pragmatic.

My hope is, correspondingly, that many embrace this campaign and join us in actively promoting it. Please consider contributing articles and pictures to the CHRUSP website. Please talk to others. Perhaps create educational events. If your country has not signed the Convention, not ratified the Convention, has added a restriction, or is simply in non-compliance, you or your group might want to take the lead in making the problem known. We have a moment for change here—and my hope is that enough people will face whatever fears stop them and reach out and grab it.  Not that winning this fight will be easy, for countries have a habit of ignoring/evading international law, including contractual obligations which pertain by virtue of being signatories to a convention. All the more reason to double and triple our efforts.

The biggest obstacle that we are likely to encounter is people’s fear of dangerousness. Be prepared to address it. Arguably, the second biggest is people’s sense that vulnerable folk are going to be deserted. A point to be made when talking to others is that the CRPD is clear that supports must be offered. And indeed, if we go about this correctly, the era of the CRPD could well become the era when an unprecedented number of new and exciting support options materialized for people—and, of course, voluntary ones. In this regard, contrary to the common and I would suggest duplicitous equation of psychiatry and services, and besides that “service” and “coercion” are more or less mutually exclusive categories, is not the stranglehold exercised by psychiatry itself one of the principal factors responsible for the paucity of services?

In ending, to comment briefly on a snag. Were this campaign successful—and yes, it is for sure an uphill battle—psychiatry’s likely response will be to step up its misrepresentation of its “treatments.” The point here is that the future of psychiatry would then be more dependent on personal buy-in; and as we know, institutional psychiatry, alas, has virtually no qualms about misrepresentation.

Now some may feel that this last point is a “red herring” or minimally a minor issue since the CRPD explicitly specifies that “informed” consent is necessary. To be clear, indeed it does, but so does almost every piece of “mental health” legislation in the world and that has had no impact whatever on the ongoing and ever expanding production and dissemination of psychiatric misinformation. Ironic though this may seem, the upshot is that in the event of success, stronger monitoring of and stronger reins on psychiatry would be absolutely necessary.

A conundrum to be sure, but hardly one that we have not encountered before.

References

Burstow, B. (2014). The withering of psychiatry: An attrition model for antipsychiatry. In B. Burstow, B. LeFrançois, & S. Diamond (Eds.), Psychiatry disrupted (pp. 34-51). Montreal: McGill-Queen’s University Press.

Burstow, B. (2015a). Canada—A Human Rights Violator (see http://bizomadness.blogspot.ca/2015/09/canada-human-rights-violator.html)

Burstow, B. (2015b). Psychiatry and the business of madness: An ethical and epistemological accounting. New York: Palgrave.

Absolute Prohibition and SDGs

There are different communities of people who relate to this Campaign.  Some of you know a lot about the SDGs – the UN’s Sustainable Development Goals.  For others it is just another alphabet soup.  I’m somewhere in the middle.

The UN is asking for “Crowdsourced Briefs” on topics relating to sustainable development.  I think that it is an ideal opportunity for survivors and allies to make proposals about mental health policy governed by the absolute prohibition of force and coercion; new or traditional social practices to replace mental health services; etc.  What research do you have, what projects are you involved in, that could contribute valuable knowledge to this worldwide process?

The SDGs are a focal point of most of what is going on at the UN right now.  This crowdsourcing is a way to put our ideas out where they can be seen by others on a global scale.

From the website:

Crowdsourced briefs are inputs received from the scientific community around the world, highlighting a specific issue, finding, or research with a bearing on sustainable development in its three dimensions – economic, social and environment – or the inter-linkages between them. The briefs are required to be factual and based on peer-reviewed literature, focusing on the review of up-to-date findings relating to a particular issue, or presenting solutions to a problem or challenge. Key messages from the current scientific debate are normally highlighted for the attention of policy-makers. Selected briefs could be featured in the Global Sustainable Development Report to be reviewed by policy makers at the High-Level Political Forum on Sustainable Development.

Make sure to look at the call for contributions with more details and format.

All that material is from the UN, I don’t endorse it or have anything to do with it but think that it is a good synergy with this Campaign to take the baseline of absolute prohibition of commitment and forced treatment and use that as a jumping off point for positive visions and policy recommendations.

Edit: to answer the question posed by Christine in the comments, it might not be clear from this page alone that the absolute prohibition of commitment and forced treatment is not only a position held by survivors and allies, it is an obligation under international human rights law.  This is why we have a different basis for action now than in 1982, a greater possibility to make these rights real.

The Convention on the Rights of Persons with Disabilities has enacted into international law a prohibition against involuntary commitment and forced treatment, and an obligation on governments to create the supports and services that respect peoples’ rights and freedoms, without any exception. The CRPD is binding law on 161 countries that have ratified it, and now the UN Working Group on Arbitrary Detention has also found that the same prohibition of commitment and forced treatment exists under general international law that applies to all countries. Please see the main page of this Campaign for details.