Psychiatry and the misuse of power: the powerless role of the psychiatric patient
Almost 30 years ago, a rebellious British psychiatrist named Ronald Laing declared: “I’m still more frightened by the fearless power in the eyes of my fellow psychiatrists than by the powerless fear in the eyes of their patients” (1). The quote effectively captures the huge and enduring power differential between those deemed to be mentally ill and the psychiatric professionals employed to help them.
The central reasons for this stark imbalance of power will be outlined, with reference to both formal mental health legislation and the Western psychiatry’s spurious assumptions about the primary cause of “mental illness”. Moreover, the invidious position of psychiatric patients within Western societies will be discussed.
"I’m still more frightened by the fearless power in the eyes of my fellow psychiatrists than by the powerless fear in the eyes of their patients"— R. Laing
The laws of Western societies fundamentally discriminate against those deemed to be mentally disordered. The legislation referred to in the following account will outline the legal framework as it applies to England and Wales; although different in the detail, the mental health laws in the USA and other Western countries tend to adhere to similar principles.
In bygone times, family members and religious organisations assumed the responsibility for looking after people believed to be suffering some form of insanity. However, since the late 18th century, a sequence of laws was passed that, incrementally, extended the powers of medical doctors in the management of the mentally disordered. This process culminated in the Mental Health Act (1959), when the state effectively surrendered its role in determining who should be incarcerated in psychiatric hospitals. By the start of the 21st century, the government developed an irrational preoccupation with the potential threat posed to public safety by people with mental health problems, and in 2007 made revisions to the Mental Health Act that delegated further powers to psychiatric professionals.
The upshot is that psychiatrists now have the powers to compel someone to be confined in hospital for ‘treatment’. By permitting the incarceration, without trial, of people who have usually not committed any crime, those labelled as mentally ill are denied the rights afforded to all other citizens – with the possible exception of suspected terrorists! As such, the current legislation fails to adhere to the United Nations’ convention on the Rights of Persons with Disabilities (2006) which states that, ‘The existence of a disability shall in no case justify a deprivation of liberty’ (Article 14) (2)
The perils of collusion between the state and medicine
Over 40 years ago, Thomas Szasz (3) described the distinction between ‘Institutional Psychiatry’ (involving coercion and an overarching goal of protecting society) and ‘Contractual Psychiatry’ (characterised by cooperation and a primary desire to help the person seeking help). Importantly, Szasz highlighted how the views, and subsequent behaviours, of psychiatrists are substantially shaped by the government of the day, as well as drawing parallels between the witch-hunts of medieval times and the approach adopted to people labelled as mentally ill.
More recent observers have echoed the view that people categorized as mentally ill risk being blamed for the ills within society – in effect, modern-day witches – with professional psychiatry acting to legitimise the exclusion of unwanted or troublesome sections of the community (4). Dubious assumptions and stereotypes regarding people with mental health problems undoubtedly fuel these discriminatory practices (5)(6).
Community Treatment Orders
The revisions to the Mental Health Act (2007) emerged at a time when the government wished to be seen as protecting its citizens from the risk of violence assumed to be posed by mentally ill people. The policymakers’ inflated views of risk were likely to have been shaped by the psychosis-violence stereotype and the spurious assertions of traditional psychiatrists that ‘schizophrenia’ is caused by a biochemical imbalance in the brain that can be rectified by medication compliance. Such a context spawned the introduction of Community Treatment Orders (CTOs).
Under a CTO, patients previously detained in hospital under a section of the Mental Health Act can have restrictions placed on them upon discharge, typically involving an imperative to take medication; non compliance can result in their forcible return to hospital. An important implication of this piece of legislation is that a person who has not committed any crime, and who retains the wherewithal to make his own informed decision about the pros and cons of taking medication, can be coerced into ingesting prescribed drugs – treatment which is likely to trigger unpleasant side effects and which may realise little or no benefits – or face coerced re-admission to a psychiatric hospital.
Despite initial expressions of concern, the majority of psychiatrists in the USA, New Zealand and Canada appear to support the concept of CTOs (7). In the UK, the use of CTOs has increased year-on-year since their introduction in 2008 (8). Worryingly, black people are overrepresented, comprising 15% of the CTO population yet less than 3% of the general population (9). Furthermore, there is no evidence that the patient accrues any clinical advantage from a CTO (8).
An advance decision (previously referred to as an “advance directive”) is a means by which adults can highlight the specific treatments they do not wish to undergo should they, at some time in the future, lose the wherewithal to make their own decisions. Any doctor or clinician who subsequently ignores the refusal enshrined within an advanced decision risks prosecution.
The concept of an advance refusal of treatment has long been recognized in clinical and legal circles in relation to physical health problems where it constitutes a reliable way of shaping future service responses. So for example, any competent person could today produce a written advance decision – it needs to be in writing if it refers to a life threatening situation – stating that under no circumstances does he want to receive chemotherapy for cancer, and be confident that his request would be respected if, at some point in the future, he is afflicted with cancer and does not have the mental capacity to make his own decisions.
For people with mental health problems, the evidence suggests that the prospect of completing an advance decision to refuse specific treatments in the future is an appealing one (10). Unsurprisingly, people with recurring psychiatric difficulties welcome the opportunity to shape service responses in light of their previous experiences. Alas, this empowering piece of legislation around advance decisions is corrupted by the Mental Health Act; if a psychiatrist labels you as “mentally ill” and detains you in hospital under section, any directives described in an advance decision can be ignored without the clinician risking legal censure.
The consequences of being labelled as mentally ill
Person without psychiatric label
Unjustly seen as significant risk to others
No inflated perceptions of risk to others
At risk of incarceration without having committed a crime
Can only be incarcerated if committed a crime
At risk of incarceration without a Court trial
No risk of incarceration without a Court trial (unless a suspected terrorist!)
Excluded from valued social roles
Not excluded from valued social roles
Elevated levels of abuse and harassment from others
No elevated levels of abuse and harassment
Can be forced to take (often toxic) medication while living in the community or face incarceration
Must give consent before any treatment/medication is administered
Advance decisions to refuse treatment can be ignored
Advance decisions to refuse treatment must be respected
Psychiatric patients: the 21st century witches
Despite the increasing recognition that psychiatric diagnoses are virtually meaningless (11), when a psychiatrist labels a person as mentally ill a whole range of stigmatizing and discriminatory consequences are likely to ensue (see table).
In Western cultures, someone describing unusual experiences (for example voice-hearing or extreme suspiciousness) is likely to be perceived as harbouring some internal biochemical imbalance that requires treatment with medication. One consequence of this assumption is that the person already struggling with these unusual experiences is forced to choose between either accepting the dominant psychiatric view that the cause is a brain defect, or dismissing this view and risking coercion into treatment or the withdrawal of support. Overwhelmed by emotion, and feeling vulnerable, many sufferers will passively accept the ‘expert’ psychiatric explanation (12).
Psychiatric professionals employ a range of strategies in their efforts to ensure that patients adhere to prescribed treatment (13). If persuasion (involving discussion of the pros and cons of the available options) does not achieve compliance, interpersonal leverage is applied, often in the form of the ‘will you take this medication for me’ approach. If the patient continues to be uncooperative, professionals may resort to inducements (‘If you take your medication I will be in a position to support your benefits application’ or threats (‘You leave me no choice but to section you if you continue to refuse your medication’). Ultimately, the Mental Health Act may be deployed so as to legitimise compulsory treatment.
So psychiatric patients are commonly forced to choose between either showing ‘insight’ by acknowledging they suffer with brain defects (thereby exposing them to interventions that are often both damaging and ineffective) or rejecting the biochemical imbalance view and facing abandonment or coercion into treatment. The parallel with the medieval witch-hunts is striking.
Laura Delano - the effects of psychiatric labelling
(1) Laing, R.D. (1985). Wisdom, Madness and Folly: The Making of a Psychiatrist. New York: McGraw-Hill Book Company.
(2) United Nations’ Convention on the Rights of Persons with Disabilities http://www.un.org/disabilities/default.asp?id=274
(3) Szasz, T.S (1973) – The Manufacture of Madness: a comparative study of the inquisition and the mental health movement. Routledge & Keegan Paul
(4) Summerfield, D. (2001). Does psychiatry stigmatize? Journal of the Royal Society of Medicine, 94, 148 – 149.
(7) Churchill, R., Owen, G., Singh, S. & Hotopf, M. (2007). International Experience of Using Community Treatment Orders. Institute of Psychiatry: London.
(8) Health and Social Care Information Centre (2013). In-patients formally detained in hospitals under the Mental Health Act, 1983 and patients subject to supervised community treatment, Annual figures, England, 2011/12.
(9) Care Quality Commission (2012). Monitoring the Mental Health Act in 2011/12.
(10) Sidley, G.L. (2012). Advance decisions in secondary mental health services. Nursing Standard, 26 (21), 44 – 48.
(11) Bentall, R.P. (2009). Doctoring the Mind: why psychiatric treatments fail. London, Penguin. (see p. 89–109)
(12) Coles, S. (2013). Meaning, Madness and Marginalisation. In S. Coles, S. Keenan & B. Diamond (Eds.), Madness Contested: Power and Practice (pp 42 – 55). PCCS Books.
(13) Szmukler, G. & Appelbaum, P. (2008). Treatment pressures, leverage, coercion and compulsion in mental health care. Journal of Mental Health, 17(3), 233 – 244.