COMPULSORY PSYCHIATRIC TREATMENT
RISKY BUSINESS
Mary O’Hagan
WHAT IS COMPULSION?
Mental health legislation establishes the circumstances in which
a person with ‘mental disorder’, who hasn’t committed a crime,
can be detained or treated without their consent.
The criteria include:
• Mental disorder
• Danger to self or others
• Incapacity to refuse treatment
WHAT IS RISK?
Possibility of harm, loss or danger
Factor involving uncertain danger, hazard
Risk is located in the future
APPROACHES TO RISK
Cause of danger
Response to danger
The gods
Supplication
Fate
Acceptance
Nature
Control
RISK AND MAD PEOPLE
INTRAPERSONAL RISK
Harm to self
• Internalised stigma and hopelessness
• People in contact with mental health services 20 times more
likely to kill themselves than general population.
RISK AND MAD PEOPLE
INTERPERSONAL RISK
Mad as perpetrators
Weak statistical correlation between madness and violence.
Other factors are stronger such as age, history of violence,
gender and substance abuse.
Mad as victims
Much more likely to be victims than perpetrators.
RISK AND MAD PEOPLE
ENVIRONMENTAL RISK
As causes of madness
Trauma, deprivation, social inequality, loss
As consequences of madness
Trauma, deprivation, social inequality, loss
• Social stigma and discrimination
• Unsafe, unhelpful, coercive services
APPROACHES TO RISK AND MADNESS
WIDER COMMUNITY
An unsustainable consensus
• Mad people a risk to others
• They cannot take responsibility for their actions
• The community has ceded responsibility to services
• Services entirely responsible for controlling risk
Mental health leaders collude with this consensus
The scene is set for the wide acceptance of compulsion
APPROACHES TO RISK AND MADNESS
MENTAL HEALTH SYSTEM
A contestable dominant paradigm
Compulsion supported by belief in biological pathology that
destroys autonomy and needs correction with treatment.
Poor powers of prediction
• Serious violence by mad people too rare to predict well
• Debatable if compulsion reduces suicide rate
A narrow conception of risk
• System driven by risk to institutional & professional reputation
• Little regard for risks to consumers
COMPULSION - RISKS TO CONSUMERS
DISCRIMINATORY CRITERIA IN MENTAL HEALTH ACTS
Danger to others
Preventive detention can happen despite no crime (only with mad)
Danger to self
Compulsion can happen despite competence (only with mad)
Competence
‘The criteria for non-voluntary treatment should focus on the
mentally ill person’s capacity to understand that he or she is ill and
the benefits that might result from treatment.’ Ryan et al
COMPULSION - RISKS TO CONSUMERS
INHUMANE TREATMENT
Hospitals
Experienced as unsafe and uncaring
Seclusion, restraints, forced injections
Experienced as re-traumatising and as punishment
COMPULSION - RISKS TO CONSUMERS
CORRUPT REVIEW PROCESSES
Review Tribunals processes
Intimidating and humiliating
Review Tribunal decisions
One in 20 applicants get off order in NZ
Language to justify decisions does not appear in Act in NZ
COMPULSION - RISKS TO CONSUMERS
QUESTIONABLE TO HARMFUL OUTCOMES
Medications can be life-depleting and life-shortening
Compulsion re-traumatises and corrupts therapeutic trust
Undermines autonomy and creates overdependence
Compulsion lowers social status and increases stigma
‘Compulsory community treatment results in no significant
difference in service user, social functioning or quality of life
compared with standard care.’ Kisely et al. Cochrane Review
THE RISKS TO REFORM
RECOVERY POLICY
National policies in all English speaking countries founded on
recovery, but no reduction in compulsory treatment.
Compulsory treatment not compatible with recovery:
• Self-determination and personal resourcefulness
• Collaborative relationships (shared risk, positive risk)
• Choice of services
• Equal participation in society
ALTERNATIVES TO COMPULSION
Stop colluding with discriminatory community consensus
Recovery focus - crisis prevention focus & ‘the life I want’
Advance directives
More and better crisis options
Robust systemic and individual advocacy
‘Compulsory responsiveness orders’
Separate healing function from control function
AN END TO MENTAL HEALTH LAWS
Treatment and detention without consent rare and brief
Emergency interventions have the comparable threshold as
physical medicine
Rethink assumptions about human responsibility for crimes
Humane recovery oriented criminal justice system
THE ROAD TO HELL...GOOD INTENTIONS
‘Of all the tyrannies a tyranny sincerely exercised for the good of
its victims may be the most oppressive...for those who torment
us for our own good will torment us without end for they do so
with the approval of their own conscience...’ CS Lewis