Paper: A Clinical Response

Dr F Ian Curtis MB, BS Hons, FRANZCP, FAChAM (RACP retired) former clinical lecturer in Psychiatry, University of Quensland.

Ian Curtis is an Australian psychiatrist and a Fellow of the College of Psychiatry. He has practiced Clinical consultation-liaison and forensic psychiatry for over four decades in Sydney and Brisbane. Curtis has also worked in the public health sector as a senior administrator.

Jaye Watson-Curtis BA, MA provided research assistance in writing this paper.

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The Minkowitz paper argues for people utilising mental health services (referred to in that paper as madpeople) to be auspiced by United Nations Conventions of disability and human rights. These “madpeople” are redefined as persons with disabilities (“Persons with Disabilities” UN 2004) and allied with an attack on medical psychiatry to secure success for a “No-Force” campaign eliminating “coercive psychiatry” and “legal disqualification”. Minkowitz sees an historic opportunity for the “No-Force”/”user/survivor” movement to base psychological suffering in a disability perspective. The inclusion of needy people with mental health problems -under disability provisions is practical and probably is already implicit in many treatment protocols.

In 1972, Dr Thomas Szasz proposed the view that mental illness was unlike any other illness. Psychiatric treatment, voluntary or not, was unlike any other treatment. Mental illness was a mythology and treatment was social action. It followed that involuntary psychiatric treatment was torture.

Szasz despaired for modern man that “skills acquired by diligent effort may prove to be inadequate for the task at hand almost as soon as one is ready to apply them”. Many people find life disappointing and they seek the security of stability, even if that is purchased “only at the cost of personal enslavement”. The healthy, adaptive alternative was a -”learning life” committed to meeting challenges successfully.

Some people only learn one set of skills or at most a few. This leaves them solving the same old problems repeatedly and unsuccessfully. Human life was “a social enterprise” requiring greater flexibility in personal conduct. Szasz pointed out that some people require a personal instructor for this way of being and others do not.

Modern Psychiatric Practice

The idea of coercive psychiatry may have been more relevant earlier in history. There are still some elements of restraint, seclusion, and some treatments which obscure informed consent. However, generalisations in the Minkowitz paper confuse the historical past with contemporary practice.

Modern psychiatric practice is governed by principles of care, conduct, and ethical standards. Historically, one can sympathise with No-Force advocates. But coercive psychiatry in the extreme form implied by the Minkowitz summary resides in a past based in desperate ignorant attempts to help people. Those remaining areas of concern are monitored by official visitors and are subject to mandated consultative second opinions and sentinel event notices in many countries.

Eleven principles of psychiatry, as outlined by the Royal Australian and New Zealand College of Psychiatry (2004), are enshrined in that institution’s Code of Ethics:

• Psychiatrists shall respect the essential humanity and dignity of every patient.
• Psychiatrists shall not misuse the inherent power differential in their relationships with patients, either sexually or in any other way.
• Psychiatrists shall provide the best possible psychiatric care for their patients.
• Psychiatrists shall strive to maintain patient confidentiality.
• Psychiatrists shall seek informed consent from their patients before undertaking any procedure or treatment.
• Psychiatrists shall not misuse their professional knowledge and skills.
• Psychiatrists shall continue to develop and share their professional knowledge and skills with medical colleagues and trainees in psychiatry.
• Psychiatrists shall share the responsibility of upholding the integrity of the medical profession.
• Psychiatrists have a duty of care to the health and well-being of their colleagues, including trainees in psychiatry.
• Psychiatrists involved in clinical research shall adhere to ethical principles embodied in national and international guidelines.
• Psychiatrists shall strive to improve the quality of, and access to, mental health services, promote the just allocation of health resources and contribute to community awareness of mental health and mental illness.

The Minkowitz paper, with its emphasis on users/survivors distorts the practical picture in the real world and the necessary systems evolving to ensure the minimising of suffering from mental health harms.

A repeated emphasis on madpeople suggests emphasis directed at functional psychoses such as schizophrenia, major depression, and bipolar affective disorder. Dismissal of these illnesses is not supported by the science base which provides data on predispositions, causation and natural history/course in line with other illnesses.

Serious mental illness can also present covertly. A depressive person can present with normal behaviour. Many people with mental illness hide their suffering or they use their intelligence to swap types of suffering. An example of this would be a person with severe generalised anxiety disorder who self-treats with alcohol. Similarly, many illicit drug addicts begin life anxious, severely depressed or mentally ill.

Many physical illnesses of the brain present with psychiatric symptomatology. There are practical needs for a trained helper disciplines such as psychiatry and psychology to make the correct diagnoses to minimise the harms from illness. A host of previously fatal illnesses have become practical problems for continuing management and containment because of advances in treatment.

The polemical sections on “coercive psychiatry” over-simplify the clinical situation. Forced surgery, sleep deprivation, and mechanical restraints are historical oddities except insofar as societies must continue to be alert to the abuse of power.

Modern practitioners of psychiatry are trained and aware so as to avoid generally coercive practices in psychiatry. However, there is still legislation for involuntary detention for psychiatric examination and treatments in urgently practical circumstances.

Certainly, not all involuntary examinations are necessary.

Criminal activity is no more likely to occur within the mentally ill population than in the general population. The presence of a mental illness in a person does not predispose to crimes against persons or property. Why then should people be deprived of liberty and rights because they manifest different mental content? But there are occasions when the abnormal mental content of an ill person will result in a causal relationship between the mental health status of that individual at the subject time and some unintentional unlawful act. These isolated cases are left to the fact-finders of the judicial process.

There are of course dangers, as Minkowitz points out, in providing some people with excuses for bad behaviour. Along with that goes the inherent risk that behaviours be repeated because society’s response has been insufficient or ambiguous.

People who are sufferers in the true sense because of mental health harms must be directed towards help rather than being placed in situations of deprivation where further trauma and loss of trust in human nature occurs.

People will still present in mental pain and in trouble. People do develop health conditions which make them dysfunctional or deprive them of the necessary controls and discriminative judgment to function adequately in community. These people, as Minkowitz points out, become a problem to themselves and/or to other people. .

It would require detailed negotiation amongst all the social, judicial, and other stakeholders to devise new systems for assisting those people. Minkowitz surely would not want vulnerable people to be dealt with solely by police in a necessarily robust manner.

The Australian National Mental Health Survey

The Australian Bureau of Statistics ascertained the prevalence of mental and substance-use disorders for Australia by way of a 1997 Australian national survey of mental health and well-being. This first Australian national household survey replicated the 1990 United States national comorbidity survey published in 1994 and the 1993 United Kingdom survey of psychiatric morbidity published in 1997. All surveys addressed three questions:

1. How many adults suffered from mental disorders?
2. How disabling was their psychiatric impairment?
3. What health services did they use and want?

Close to 23% of adult Australians reported having at least one psychiatric disorder in the previous 12 months. Some 14% suffered from a disorder when interviewed. About one-third of people with a mental disorder in the 12 months prior to the survey actually consulted about it as a problem. Most had seen a general practitioner, not a specialist.

About 1 in 6 people in the Australian community met criteria for a mental health disorder during that year. About 10% met criteria for active illness preceding the interview. Total prevalence was 22.7% using the International Classification of Diseases 10 (1CD-lO) and 20.3% using the Diagnostic and Statistical Manual (DSMIV).

Women had higher rates of mood/anxiety disorders and lower rates of substance disorders. The elderly had lower rates for all disorders except cognitive impairment. The young had higher rates of substance use disorders. Currently married had lower rates for all disorders. Disorders were more frequent in those with less education. The employed had lower rates for all disorders: About 4% of people admitting to suffering from conditions suffered from 2 or 3 or more diagnoses at the one time (comorbidity).

Specialist psychiatry tends to deal with people suffering from the more complex problems. General practitioners deal with most sufferers. Without any form of protective legislation some people with complex problems and even their families will suffer badly.

Correctional Services

More people may end up in correctional custody under a Minkowitz model. Correctional institutions are not noted for promoting mental wellbeing. Suicide is the leading cause of death amongst adult offenders in custodial settings. Inmates are up to ten times more likely to die from suicide than their counterparts in the general population. Custody-related deaths may account fqr up to three-quarters of all deaths amongst custodial clients who have not yet gone to trial and up to one-third of all deaths amongst sentenced prisoners.

In 2003 some English studies looked at non-fatal suicidal behaviour and found that over one-quarter of male prisoners on remand had attempted suicide. Half of the female prisoners on remand had attempted suicide in their lifetime. In the week prior to the interview, 23% of female prisoners had thought of suicide. Those who attempted suicide were in poorer general, physical, and mental health.

Mortality was examined in a twelve-year follow-up of 3000 young offenders undergoing their first custodial sentence in Victoria, Australia, in 1998-1999. Overall risk of death from any cause was nine times higher amongst male young offenders.

During the opening of a new prison in Scotland, a study examined the workload of the local hospital emergency department. During the first year of life of the new jail, 22% of 103 emergency transfers for treatment were for deliberate self-harm.

Utilisation of Psychiatric Services

It will be noted that the Mental Health Survey in Australia indicated that only about one-third of people with a so-called mental disorder in the twelve months prior to the survey had actually consulted medically about it. Most of these people had seen a general practitioner not a specialist psychiatrist. General practitioners are carrying the main burden of relieving the suffering of people with compromised mental health.

Most of the psychiatry being practiced, certainly in Australia, is being done by general practitioners. General practitioners are not so lacking in work that they go out and drag people in against their will in order to treat them with psychiatry. Most hospital admissions for psychiatric assistance are voluntary.

A majority of these people are approaching medical healers in an informed way within a voluntary treatment system about which they are increasingly well-informed. Many people now access information sources including the internet before consulting medical doctors. The number of people consulting alternate healers ranging from psychological counselling to naturopathy through to acupuncture and so on probably exceeds that attending on medical practitioners. (The scientific data are not available to quote actual numbers).

Many people move from alternate therapies to more western-style medicine. Other people become disillusioned with westernised medicine and move to alternate therapists.

Involuntary detention for examination or treatment

With regard to involuntary initiatives, there can be some sympathy with the views of Tina Minkowitz. Most people with mental illnesses are not causing crimes. They are not hurting other people. Involuntary treatment orders may not be necessary very often.

The practical situation is that the people subject to involuntary treatment orders often have a long period of conflict with police and other social agencies together with multiple attempts by various people and agencies to treat them. Involuntary orders are often a belated, ineffective last resort.

However, we have had real life examples of abuse in Australia. In some public sector organisations in Australia, whistle-blowers and other employees who become a thorn in the side of the bureaucratic powerbrokers can be compelled to have psychiatric examinations even in circumstances where their information provided to authorities about defects in the system was proven to be correct.

The nervous system and other bodily systems occupy the same physical spaces. It is inevitably required at some stage within the life cycle of every human being, that there be a diagnostic approach to discern which bodily systems are breaking down. For example, an elderly person with a silent heart attack of myocardial infarct may well present with psychiatric symptoms because of blood clots migrating into the cerebral cortex. People with multiple sclerosis can present with psychiatric symptoms. Almost any physical illness may present psychological reactions and pains.

Presently, extremely powerful illicit drugs cause mental and behavioural suffering, particularly in young people. How are we to deal with drug-induced psychosis with phencyclidine, methylamphetamine, and benzodiazepines (among other drugs) where people generate great dangers for themselves?

We have had the tragedy in Australia where people with these disturbances go out in public armed with a knife or some such weapon and are dealt with most severely by police.

Suicidal people suffering from functional psychotic illness such as major depressive disorder can survive with a helpful intervention. When these people recover (as they do with modern treatment) they are usually grateful for the assistance received. If they have been well managed within a modern paradigm, they will also learn something about themselves and their biological predispositions so as to protect them during further illness episodes.

People who are consulting psychiatrists, psychologists, and other mental health workers usually do so on a voluntary basis. They only persist with that helping process if they decide that the process is of relevance.

In the public sector, the usual complaint is that the public sector people have done the compulsory examination too quickly and ceased the involuntary examination order and discharged the person too early. There are regular complaints that public sector voluntary treatments are truncated because of resource constraints.

There can be some sympathy with aspects of the Minkowitz paper and there are still areas which could be addressed by No-Force advocacy. But the old mental hospitals referred to by Erving Goffman in Asylums (1961) have been closed. There were abuses of the power imbalance between attendants and clients in those days. However, the old mental hospitals were not invented because supervisors, psychiatrists, and attendants wanted jobs. Like the mainstream medical psychiatric services now, mental health services existed because there was a market for them.

If all the mental health facilities were emptied and closed today, clients, relatives, police, and indeed the judiciary tomorrow “would raise a clamour for new ones” (Goffman 1961:334).

Conclusion

Combining legitimate criticism with over-generalisation is a problem in the Minkowitz paper. If the disability model assists people to learn mental healing, then we can all wholly support it. But we must provide adequately for people who have been deprived of mental health and who are in recovery. They require adequate resources with all of the agreed rights as part of our shared human condition including adequate housing and sustenance. Historical oddities and overgeneralisations jeopardise credibility.

Years ago I was fortunate enough to be the guest of indigenous New Zealanders of the Northlands of the North Island of New Zealand where I learned a terminology, which I have never forgotten. The Maori health workers talked about “Voice, Choice, and Safe Prospect”. I foresee a world where the constructive aspects of No-Force and other advocacy would require that people who have had their mental health compromised in some way should have, along with the rest of us, a voice in their destiny, an exercised right to choose their path, and a consistent experience of safe prospect where they can anticipate within the limits of the fates that tomorrow will be secured as was today.

If we want this for mental health, we must all work together to ensure that a fair share of the community’s resources is devoted to people who are suffering or who are in recovery from mental health harms.

I agree that many people will be assisted more by social action focused by counselling psychologists, occupational therapists, and social workers. Along with non-government services and other agencies, we can work at demedicalising many of the conditions which currently are dealt with by general practitioners and specialist psychiatrists.

November 2005

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