In hundreds of cities around the world, angry mobs have blockaded government offices or parliaments, or even brought cities to a halt, protesting over rules requiring everybody to wear masks or stay home unless immunised against Covid. The fury these emergency measures have provoked is unprecedented; people have attacked police, security and health staff, apparently unaware that there is nothing new in these measures. Every country in the world has had far, far more burdensome restrictions in place for the past hundred years.
Every day, in every country, people who have not broken any laws have practically the whole of their human rights suspended indefinitely, without a formal judicial hearing, all on unsworn hearsay evidence and with practically no right of appeal. Nobody has waved a placard on their behalf, nobody stormed parliament or blockaded an entire city, as in Ottawa. Nobody listens to them, TV reporters don’t queue to hear their stories but mostly they’re not allowed to speak to the media. Their phones are confiscated, no access to the internet or email, their visitors are limited or even searched, reading and writing material is censored. They can be locked in small rooms for long periods, wrestled to the ground, stripped naked, injected with drugs they don’t want, all with no right of redress.
And most bizarre of all, nobody cares. If you tell anybody that this happens in our country, they are outraged but when you explain that these unfortunates are civilian psychiatric patients, everybody dismisses it. “Oh stop worrying,” they say with a laugh, “we’re doing it for their good.” Is that true?
As long as there have been records, society’s treatment of the mentally-disturbed has been appalling. Most histories of psychiatry gloss over the institutionalised brutality visited upon their charges’ heads because it was done with good intentions. The institution of psychiatry itself simply ignores its atrocities but the real question is this: Why do the atrocities keep recurring? If being compelled to wear a mask in public is enough to cause a riot, why does society accept that brutal treatment of the mentally-troubled is reasonable and justified? What is the authority, what is the justification? This is where it gets a bit confusing because they are different issues.
The authority for suspending the civil rights of the mentally-disturbed comes from specific legislation enacted for that purpose. As bad as it may sound, legislatures can do that: ultimately, your human rights are only what the men with the guns say they are. But the justification is something else again so we can look at the pandemic to get an idea of what it means.
Most legislators know nothing about medical conditions. In early 2020, when it became clear a deadly viral illness was spreading rapidly, governments asked their epidemiologists what they should do. The advice said: “This is a highly infectious condition which causes serious illnesses with a substantial death rate. Unprecedented measures are needed to contain the infection before it gets out of control.”
That was the justification for the restrictions enacted by one legislature after another because without restrictions, the illness and death rates would have been very much worse. Historically, this is well accepted. I recall that during the polio epidemics in the early 1950s, sick people were quarantined but such was the fear that everybody accepted it as essential. It was the same with TB and leprosy: infected people were sent to sanitoria for treatment, partly for their benefit but mainly to stop it spreading. Where I grew up, regular chest X-rays were compulsory for all adults until the late 1950s.
In each condition, the justification for the loss of civil liberties was straightforward: an infected person has a duty not to infect others, and other people’s right to health overrides the sick individual’s right to move about freely. Everybody accepted that the greater public good outweighed the individual’s temporary loss of rights. There was also the practical matter that if sick people wandered at large, the health services wouldn’t be able to cope and the death rate would be much higher. What would have happened to a person who refused treatment? I don’t know, probably they would have been put out the back somewhere and left to die. In the late 1960s, as a medical student, I saw people who refused treatment for cancers. They were allowed to go home to die in peace.
But when it comes to mental disorder, what is the justification for the unparalleled restrictions authorised by the legislation? In Queensland, where I live, people detained under mental health legislation have fewer rights than convicted prisoners yet they haven’t been through anything like an impartial judicial process. There must be a most powerful reason for these measures, but what is it? What is the evidence that convinces legislatures that the mentally-troubled should routinely be treated more harshly than any convicted criminal in the country? To be justified, it must produce a powerful and measurable benefit for either the society or for the individual.
The first possibility is that mentally-troubled people are infectious but we needn’t waste time on that idea. There is no general medical evidence to justify detention of mentally-disturbed people.
Next possibility is the theme so dear to the febrile scribblers of the Murdoch media, that mentally-disturbed people are dangerous and need to be locked up so citizens aren’t strangled in their beds at night. There are two objections to this idea. First, preventive detention doesn’t exist on the law books. People can’t be locked up on the possibility they may commit offences otherwise there’d be very few bankers on the loose. Second, there is no evidence that individually or as a group, mentally-disturbed people are more dangerous than undiagnosed people. People with a diagnosis of chronic psychosis tend to collect convictions but these are mostly minor, such as refusing to move or piddling on a cop’s leg. For sure, there are dangerous people out there but most of them are perfectly sane and far too clever to attract attention as the mentally-disordered do. We can conclude there is no legal basis and no criminological evidence to justify detaining non-criminals.
Third possibility: Detaining the mentally-troubled produces a general benefit for the society as a whole, like preventing hate speech or blocking developers from bulldozing cemeteries. That doesn’t work. These types of restrictions are very specific, directed at a single purpose only, and society has moved away from them.
Possibility #4: We are a caring society that does not want to see the mentally-disturbed wandering around in distress, so we lock them up to make sure they get the treatment they need to become well-adjusted, productive members of society. That could possibly be true if we were indeed a caring society but we’re not. However, this argument actually has traction in individual cases. During mental health tribunal hearings, psychiatrists often say they have safe, effective treatment to relieve the individual’s distress.
Of course, there is no objective evidence to support this type of claim. We know that people who have been on long-term psychiatric drugs die, on average, decades younger than their undrugged peers. This is a drug effect, unrelated to diagnosis. It’s not the condition that kills them, it’s the treatment.
My experience of tribunal hearings is that this claim is batted around freely but more importantly, the non-medical members of the tribunal find it irresistible. None of them want to be seen as the person who denied a sick person effective treatment. My further experience is that arguing against it is a waste of time as the lawyers say “Well, Prof. X says it’s safe so we have to go with the weight of authority.” Kowtowing to authority also saves them the effort of having to sift through and weigh up reams of complex evidence, as in “think independently.”
Fifth and final possibility: There are strong theoretical grounds to believe that detaining people and subjecting them to involuntary treatment produces a better outcome than not doing so. Put this way, it’s ludicrous but it’s the sort of thing legislators listen to, especially when it comes from respected professors, but it needs to be examined.
First we need to ask: Better outcome for whom? There is no evidence that forcing people to take treatment against their will leads to a better result for them, their families or for the larger society. Sure, it’s good for the drug companies and for job security of the staff of hospitals and services but that’s a different issue.
Second, and more to the point, which particular theory are we talking about? It’s all very well to say “We believe on theoretical grounds that they should be locked up,” and that would probably convince the average legislator, but we’re talking about human rights here. There is a treaty called the Convention of the Rights of People with Disabilities, CRPD, which has a lot to say about locking up people who have broken no laws. Also, the recent reports of the UN Rapporteur on the rights of the disabled spoke strongly about this. Any such theory would have to be supported by overwhelming evidence, as strong as, say, the theory of gravity. It’s difficult to argue against gravity so what theories does psychiatry have?
First option is the well-known biological theory of mental disorder, which goes back several hundred years in the form of “mental disease is brain disease.” Here we run into a problem. Despite the vast sums of money spent on biological research in psychiatry (Thomas Insel said about $20 billion in his 13 years as director of NIMH), psychiatrists somehow forgot to write a theory that could justify it. Nobody has ever written anything that could amount to a reductionist theory or model of mental disorder. The biological approach to mental disorder is an ideology of mental disorder, not a science. It cannot be used to justify involuntary treatment.
We needn’t spend much time on the next two theories, Freudian psychoanalysis and behaviorism. As theories, both of them have been discredited although they survive as technologies, psychoanalsysis as dynamic psychotherapy, and behaviorism as CBT. Technologies are not theories, so that won’t work. In any event, neither of them addressed the question of detaining people for treatment and it would have gone against their grain anyway.
Fourth, we have the well-known and widely-supported biopsychosocial model, attributed to the late George Engel, of Rochester, NY. Engel was a gastroenterologist, not a psychiatrist, and he hardly mentioned mental disorder but psychiatrists have eagerly embraced his model. Trouble is, while Dr Engel gave his model a memorable name, he forgot to fill in the details. He didn’t say what it models. Is it a model of mind? Mental disorder? Personality or personality disorder? Is it a model of mind-body interaction, or of treatment, or just what? He never said, but it gets worse: beyond the three word name, there are no other details. His model consists of three words only.
I have argued that he made an elementary philosophical mistake but that’s beside the point. What counts is that anybody who says there is a biopsychosocial model in psychiatry and claims to know what it does is repeating a falsehood. That spurious model can never be used to justify detention and enforced treatment.
This is all rather sad, pointing to a science of mental disorder without a model of its subject matter. Philosophers of science would say that immediately disqualifies psychiatry as a science but fortunately, we have a new cab off the rank. At about 80,000 words, the biocognitive model is somewhat larger than all the theories available in today’s psychiatry combined. It is a highly developed computational theory of mind which leads to a model of personality, and thence to models of mental disorder and of personality disorder. As the author, I can state flatly that there is nothing in that work that could possibly justify detention and enforced treatment of mentally-disordered people. Indeed, there is a lot that says we shouldn’t be doing it.
So that’s it. End of the line. We have to conclude that there is no medical evidence, no legal basis and no criminological evidence to justify involuntary treatment. There is no evidence that treatment is necessarily better than no treatment, and plenty that says it isn’t. Finally, there is no theoretical justification for taking this draconian step.
In the era of “evidence-based psychiatry,” what’s left? We know society’s answer, and it’s just this:
“That’s how it’s always been. We lock innocent people up because we’ve always done it in the past, and changing that policy is just too much trouble. So, since the mentally-disturbed don’t have many votes or lots of rich relatives who can influence politicians, we’ll just keep doing it. And if they complain, we can always get a psychiatrist to say that complaining is typical of the insane and they need more treatment, not less.”
Problem solved, to the satisfaction of those who don’t suffer.
But human rights are more important than bureaucratic convenience. And even though in the hard-edged world of rational medicine, human rights don’t count as evidence, we look forward to somebody, anybody, who claims to support an “evidence-based psychiatry” producing some evidence, any evidence, that can support this heinous state of affairs. Failing that, we need to ask whether this medieval practice should continue.
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.