Blog contributed by : Tina Minkowitz
Centre for the Human Rights of Users and Survivors of Psychiatry
When we go to a doctor’s office we may feel nervous, apprehensive. We worry about test results, we worry about whether a treatment might do more harm than good. We put our trust in the practitioner provisionally and hope she is trustworthy and competent.
But ‘mental health’ visits can be something else entirely. Only in ‘mental health’ can a doctor end a consultation by advising your family to have you locked up under the supervision and control of medicalized wardens, where you will be forced to take mind-numbing and mind-disassembling drugs.
‘Mental health’ and social failure
‘Mental health’ diagnoses, especially when consultation is initiated by someone other than the person herself, amount to a stamp of social failure, and set in motion a cascade of events leading to delegitimization of the person as a social, legal, political, self-aware human being. Depending on the extent to which the mental health system has developed in a country and permeated all its social institutions, this may take the form of permanent institutionalization or shorter-term processing meant to chasten the individual, after which she returns to sink or swim in the same social environment from which she was cast out as a failure. She might pull herself up by her bootstraps or, with the help of friends, family or independent wealth, be able to stay free.
But increasingly the system doesn’t find short-term chastening sufficient to keep people within acceptable, governable parameters and puts its social failures under court-ordered outpatient supervision and drugging. Many social factors – including housing policy, discrimination in the workplace (e.g. how to answer questions about work history when you have been locked up for months or years at a time?), the impact of severe trauma at the hands of psychiatry in addition to whatever led to your inability to thrive in the world in the first place, the insufficiency of disability pensions and the demeaning self-flagellation that is required to prove you are too disabled to work – contribute to the inability of many individuals to escape the trap of the mental health system.
Mental health system housing programs (from ‘transitional housing’ on the grounds of psychiatric institutions, to supervised group residences, to apartments where tenancy is linked to compliance with drugs and visits from mental health workers, to independent apartments obtained through a mental health agency), along with case management and day programs, touted as necessary ‘follow-up’ after institutionalization, result in long-term involvement with the system and increasing dependency on the system for ordinary social and practical needs. Continuous contact makes people even more vulnerable to repeated involuntary commitment initiated by those whose job it is to monitor their ‘mental health’.
The ideology of the mental health system insists its coercive actions are not violence or abuse, not punishment for social failure, but medical treatment that should, if all goes well, result in cure or successful self-management (management of inconvenient behavior or emotion that are labeled as ‘symptoms’). This is a form of circular reasoning that cannot admit criticism and that reinforces its punitive character by blaming the victim. If they lock you up again, you are deemed to have ‘relapsed’ – someone else’s judgment that your behavior has become inconvenient again is attributed to you and you are expected to feel ashamed. Then in a further act of negation, the punishment is dissembled and re-labeled as ‘treatment’. If you don’t like the drugs, if you resist the chemical straitjacket of neuroleptics and resist being demeaned by violence and ridicule, if you insist on your humanity, you are even more inconvenient to those who now assume the responsibility to ‘care for you’. You must be especially ‘sick’ to ‘lack insight’ into your illness. This is how legal capacity violations and liberty and security of the person violations combine and become interchangeable in the ‘mental health’ setting, the twin libels of ‘danger’ and ‘mental incapacity’ having been instrumentalized to contain and suppress society’s failures.
At this point, someone will ask, what about actual madness, disconnection from consensual reality, how does that impact on the person concerned and on others? Do we just throw up our hands and ignore it, do we cater to this person’s needs and ignore our own, what if we can’t figure out how to help? A class-based society that requires everyone to function as cogs in wheels is not going to have time to step out, to sit with each other and forget about the world going by. Even outliers are expected to have a life path they can identify, or at least to be quiet about their suffering or questioning and not inconvenience anybody. Still they are at risk if they have the misfortune of attracting attention from do-gooders who kill you in the name of love.
The Convention on the Rights of Persons with Disabilities is a human rights instrument that was negotiated by states and depends on states for its ratification and implementation. States rely on routines – on policies, laws, regulations and programs – in order to meet the needs of their population and, simultaneously and inseparably, to keep order. Yet the state itself is an alienated form of political organization of a society, in which individuals’ collective responsibilities towards each other, and our exercise of power and decision-making, are truncated and given over to elites and functionaries. Are ‘mental health’ systems an expression of this routinizing, managerial approach of the state in general to addressing social outliers, suppressing and channeling people’s needs for emotional healing and connection when they are suffering? If so, is it possible to use the CRPD to challenge ‘mental health’ or do we need to go outside this framework?
The CRPD is radical and revolutionary in that it declares that all people have an equal right to legal capacity irrespective of disability, and have a right to use support that must in turn respect the person’s will and preferences. In addition it specifies the right to free and informed consent in the context of health care, and prohibits deprivation of liberty based on disability. We attempted to introduce a provision under the freedom from torture to prohibit forced interventions aimed at correcting or alleviating an actual or perceived impairment; this would have politicized forced psychiatry correctly as state-sponsored discriminatory violence. The provision was not adopted into the CRPD text, but UN Special Rapporteur on Torture Manfred Nowak promoted this standard in a thematic report in 2008. The Committee on the Rights of Persons with Disabilities has acknowledged more generally that forced psychiatric interventions violate Articles 15 and 17 (freedom from torture and right to respect for physical and mental integrity) as well as Articles 12 (equal recognition before the law/legal capacity) and 14 (liberty and security of the person).
The right to legal capacity, including free and informed consent in health settings, and the prohibition of disability-based deprivation of liberty, impose a clear legal obligation on states to abolish forced psychiatric interventions. Yet, aside from the report of Manfred Nowak and parts of a report by the succeeding Special Rapporteur on Torture Juan Méndez, there has been insufficient development in the UN of the critique of forced psychiatry as a violent discriminatory practice. Instead its abolition is viewed as a reform of the mental health system, the underlying ideologies of which are placed side by side with the new paradigm – with the result that the narrative of ‘mental health’ as a service, from which the embarrassing outdated practices of coercion can be lifted and cleansed, remains largely unchallenged.
Abolition of coercion within a human rights agenda
In this year’s Consultation on Human Rights in Mental Health, convened by the Office of the High Commissioner on Human Rights, activists who are users and survivors of psychiatry/persons with psychosocial disabilities uniformly spoke to the need to get out of the mental health box, to be seen as citizens exercising full human rights in public and private, to be fully included in society. Yet those interventions co-existed with others that took a more conventional managerial approach to ‘human rights in mental health,’ some of which were not even aligned with the CPRD standard of complete abolition of coercion (see my blog post on that event). At the same time, TCI-AsiaPacific has criticized activists from the global north for focusing on opposition to psychiatry, which can leave the impression of being united in combat with our enemy to the exclusion of a full human rights agenda. Speaking only for myself, the movement I come out of in the US was a liberation movement of ex-mental patients, using the term not to dignify it but to call attention to society’s shameful trashing of human beings. In the US not only psychiatry but the mental health system as a whole remains the primary obstacle to our liberation. Other countries continue to enact mental health laws that contravene the CRPD, and no country that I know of us has fully committed itself to abolition of coercive mental health interventions. This tells me that the need for uprooting a medicalizing approach to psychosocial disability and psychosocial crisis – i.e. an objectifying and managerial approach to emotions, behavior, and the appearance of social failure – is widespread and goes beyond the global north.
Advocacy for legal change and redress is needed everywhere to ensure freedom and integrity for each one of us; the creation and promotion of healing practices and support for anyone to access is similarly critical. But in order to achieve these changes, we have to change our relationship to the state as social outliers and individuals whose needs have been inconvenient to others. The state needs to accept that there is an irreducible and partly unknowable bedrock of human life and relationships that will always challenge us and cause us heartache. There will always be that edge that frightens us, whether we have gone over or stopped ourselves. This will be a growing edge for humankind, and also result in thwarted creativity when, due to violent suppression or simply a failure of connection, individuals don’t find what they need to make use of their gifts. Acknowledgement of this as part of human life, equally with birth and death and the cycles of nature, is necessary so that we don’t become frustrated with those who don’t heal, who need support again and again. At the same time the principle of ‘recovery’ is worth keeping in mind – the principle that everyone has innate human creativity and will, and can do something new and surprising – so that we don’t give up on ourselves or anyone else.
 That report should be treated with caution, as it is internally inconsistent and parts are contrary to the CRPD.
 While TCI-AsiaPacific characterizes this focus as ‘exclusive’, that has not been the case in my experience in the US or to my knowledge in Europe or other regions.