Psychiatric patients are routinely treated
against their will. Legally enforceable
psychiatric protection orders would protect
patients from coercive psychiatric
interventions
The avowed desires of patients and doctors
conflict more often in psychiatry than in
any other branch of medicine. People known
as "mental patients" are routinely subjected
to "diagnostic" and "therapeutic"
interventions against their will. Many such
people see being committed
(sectioned) and treated against their
will as a personal violation -- a
"psychiatric abuse" -- and want to
protect themselves from future
involuntary psychiatric hospitalisation and
treatment. At present former psychiatric
patients, even when legally competent, have
no means to defend themselves from such a
contingency.
Mental health laws -- reflecting the
point of view of psychiatrists and
society -- protect (or are said to
protect) mentally ill patients from the
dangers they pose, because of their
illness, to themselves and others. Many
mental patients view -- and have always
viewed -- psychiatrists as posing a danger to
them. Respect for the self defined interests
of such patients requires that the law
protect them from further unwanted
psychiatric interventions.
The psychiatric
protection order
Courts recognise the validity of
"psychiatric wills" (psychiatric advance
directives) only when they prospectively
authorise treatment; courts do not recognise
them when the "psychiatric testator"
rejects psychiatric "help." To
remedy this defect, especially when
patients are released into the community
after a period of involuntary
treatment for mental illness, I propose a
new legal safeguard: the psychiatric
protection order. Such an order, similar to
the protection order used in
domestic conflicts, would make it a
criminal offence to impose involuntary
psychiatric interventions on people
protected by the order.
In free societies only psychiatric patients
are routinely treated against
their will. (Public health laws
explicitly serve the interests of the
public, not the therapeutic needs of
particular persons.) Competent
patients with uraemia are not treated
against their will and can use a "medical
will" to protect themselves from undergoing
dialysis. If psychiatry were like any other
medical specialty competent
patients with schizophrenia would not be
treated against their will and could
protect themselves with a
psychiatric will from being treated.
But they cannot: neither
psychiatrists nor the courts recognise
the validity of the psychiatric will.
Mental health laws trump psychiatric
advance directives.
Not by coincidence the history of
psychiatric interventions forcibly imposed
on patients is long and depressing. In a
letter he wrote to me in 1988 Karl
Menninger summarised the history of
psychiatry with these sad words: "Added
to the beatings and chainings and baths
and massages came treatments that were
even more ferocious: gouging out parts of
the brain, producing
convulsions with electric shocks, starving,
surgical removal of teeth, tonsils, uteri,
etc." To this list Menninger might
have added the use of straitjackets,
tranquillising chairs, confining chairs,
cold baths, emetics, purgatives,
Metrazol shock, inhalations of carbon
dioxide, and neuroleptic drugs.
Freedom from
enforced psychiatry
From the beginnings of the specialty,
psychiatric patients have had no opportunity
to free themselves from their
protective-oppressive relationship with
psychiatrists. In this brief paper I focus
on a single issue: the desire of
some psychiatric patients to free
themselves, once and for all, from what
they regard as an
abusive relationship with the psychiatric
profession. The Anglo-American legal system
has always denied this option to
these patients. This denial resembles the
denial of slaves' opportunity, in a slave
society, to leave their
master; of the wife's opportunity,
in traditional marriage, to leave her
husband; and of citizens' opportunity, in
the modern totalitarian
state, to leave their country and its
rulers. These people may enjoy all manner of
benefits and privileges, but they
cannot, without the permission of the
repressive authority, leave the system
for good.
The English and
American legal systems maintain the
fiction that the relationship between a
family member responsible for
committing a "loved one" and the
incarcerated individual -- as well as that
between psychiatrists and
involuntarily detained patients -- is
always one of "care" and "treatment." It
can be otherwise only in "unfree,"
"totalitarian" countries; such was
the case in the Soviet Union and is now the
case in China. That self serving
rationalisation is at the core of the
problem facing us.
Anglo-American law assumes, as a matter of
fact, that the relationship
between a person and a legal agent of the
state is adversarial. Justice Potter
Stewart of the US
Supreme Court famously remarked: "To
force a lawyer on a defendant can only lead
him to believe that the law
contrives against him."The law student is
taught the duties and roles of both
prosecuting attorney and defence
attorney. Both jobs are legitimate
and proper.
In contrast Anglo-American psychiatry
assumes, as a matter of law and
psychiatry, that the relationship between
a person and a psychiatric agent of the
state is therapeutic.
Forcing psychiatrists on mental
patients is routine practice, and the patient
who protests is likely to be given a
diagnosis of paranoia. The medical student
is taught only the duties and roles of the
psychiatrist making diagnoses and
providing treatment. The psychiatrist has
no other legitimate duties or roles; only
the job of the
coercive psychiatrist is legitimate and
proper. The psychiatrist who tries to help
the coerced "patient" to reject
the patient role is ostracised, or worse.
The gatekeepers: the family
We are hypocrites if we ignore who the
parties are that support the enactment of
mental health laws and deny patients the
option of rejecting psychiatric services.
Everywhere the supporters of mental health
laws are psychiatrists and the relatives of
so called mental patients. In the
United States the relatives are now also
in control of a powerful lobby, the
National Alliance of the
Mentally Ill, that legitimises the abuse
of family members (mainly adult children) as
the care of "loved ones.
"Organisations of former psychiatric
patients -- who call themselves "victims
of psychiatric abuse" -- are not
among the parties clamouring for
more psychiatric coercions or "services."
People subjected to involuntary
psychiatric hospitalisation and treatment
often feel victimised in much the same
way as do wives (less often
husbands) who are abused by their
spouses. Until recent times women had no
effective protection from their abusers,
whom the law defined as their protectors. In
many parts of the world women are still in
that situation. Similarly, in the
days of Dickens children were not
protected from abuse by their parents.
Specific treatments
may have changed since this 1818
drawing, but psychiatric patients are
still forced to undergo unwanted
interventions
We in the West now recognise that the family
is not just the primary locus of affection,
care, and security for its
members: it is all too often also the
source of the most insidious danger to
their physical and spiritual wellbeing.
We acknowledge this unhappy fact and
accordingly speak of "battered" children,
spouses, parents, and
grandparents. In the conflicts that often
arise between adults living together as
married couples or lovers, legal
separation, divorce, and the so called
protection order exemplify the legal
system's acknowledgment of the problem
and the need for legally sanctioned and
enforceable mechanisms to remedy it. A
protection order mandates
physical separation between the parties and
makes it a criminal offence for the
denominated threatener to impose
their mere presence on the threatened
person. I suggest that we similarly
acknowledge the unhappy
fact of "battered mental patients" and the
need to protect them from their batterers.
In the absence of a protection
order the power relations between
psychiatrist and involuntary patient will
continue to generate
"psychiatric abuse," rationalised
as protection and treatment. Indeed, it is
precisely because psychiatrists reject
advance psychiatric directives authorising
abstinence from further treatment (a request
that non-psychiatric doctors
accept) that makes a legal mechanism such
as the psychiatric protection order
necessary.
Legalise
"divorce" between psychiatrists and
patients
Psychiatrists object to efforts to treat
patients as responsible moral
agents and cite the prevention of harm as
a basic social mandate of psychiatry.
Typically, they argue that people
who would have committed suicide
but for their involuntary detention would
thereby have been deprived of the
option of changing their minds once
they had recovered from depression. A
similar argument could be made
against last wills or, indeed, any
decision that profoundly affects one's
future, such as marriage or having
children. The standard psychiatric
justification for "therapeutic" coercion
either ignores the familiar conflict
between liberty and security or,
more often, equates (involuntary)
psychiatric treatment with ("true")
freedom. Elsewhere I have examined and
discussed this and related problems in great
detail and proposed reconciling
psychiatry with liberty.
Human memory is notoriously short and
selective. We have forgotten that until
recently -- even in the United Kingdom and
the United States -- people could not
divorce.
In some countries women still cannot
divorce their husbands. For a long time
the law, supported by religion, ranked
the sanctity of
marriage more highly than the need to
protect the wife from her abusive husband
and so prohibited divorce. To make
matters worse, the law deprived her of
her voice.
The history of the "marriage" between mad
people and their doctors shows a
similar pattern. Since the beginning of
mad doctoring in the 18th century, the
law, supported by medicine (psychiatry),
has ranked the "health" of mad people
more highly than the need to protect
them from the abusive psychiatrist
and prohibited them from divorcing their
psychiatrist. This is still the case.
(The psychiatrist is free to leave
the patient, typically by forcibly
"marrying" the patient to another
psychiatrist.) And again the law
deprived, and still deprives, the victim
of his or her voice. Only writers were,
and are, willing to face the realities of
psychiatry, illustrated for example by
James Thurber's miniature masterpiece,
The Unicorn in the Garden.
Summary points
Many psychiatric patients are denied the
right to refuse treatment they don't want
"Psychiatric wills" are recognised by courts
only when patients use them to authorise
treatment, not when they use them
to reject the possibility of treatment
Like protection orders that protect wives
from abusive husbands,
"psychiatric protection orders" would
protect patients from coercive
psychiatric interventions
Doctors, politicians, and journalists
assert that mental illnesses are real
diseases and that psychiatrists are
regular doctors. If that
were true there would be no need for
psychiatric protective orders.
