Introduction
Psychiatric
human rights violations are often denied
and trivialized, even distortedly re-defined as “human rights” and “right to
necessary health help”. The UN convention for the rights of persons with
disabilities, CRPD, is changing that.
CRPD demands an absolute prohibition of forced psychiatric treatment and involuntary
commitment. These are important requirements in giving people with psychosocial
disabilities equal human rights. In this text, I will look at different aspects
of the CRPD related to that demand. I will illustrate with some references to
Norway, the country where I live, showing ways in which the Norwegian Mental
Health Act does not comply with the convention. I will also share some further reflections.
Towards the end I have written a short version of my own experiences from
forced psychiatry. Mental health laws
may vary between countries, but some elements are prevalent: the laws are typically
directed specifically towards people with psychosocial disabilities and involve
forced treatment and involuntary commitment . This text is written for the Campaign
to Support CRPD Absolute Prohibition of Forced Treatment and Involuntary
Commitment (17). Procrastinations must stop –
CRPD-based law reforms must begin!
Norway and the CRPD
Norway
ratified the CRPD June 3rd 2013, but came up with some
interpretative declarations of article 12, 14 and 25 that undermine central
parts of the convention (1). Norway uses
these declarations to try to defend the Mental Health Act and forced
psychiatric treatment. In February 2015, the president of the Norwegian
Psychological Association, Tor Levin Hofgaard, wrote an article asking for a
clarification from the government whether health personnel violate the human
rights when they follow the coercion regulations in the Mental Health Act (2).
He referred to a report sent to the authorities in December 2013 by the then Equality
and Anti-Discrimination Ombud - LDO,
Sunniva Ørstavik (3). The report said that the Mental Health Act is discriminatory
and does not comply with the CRPD. LDO also urged Norway to quickly withdraw
its interpretative declarations. In public, the LDO report was met with a noisy
silence by the authorities. So, as time
had went on, Hofgaard asked for the mentioned clarification. Anne Grethe Erlandsen, State Secretary in the
Ministry of Health and Care Services, answered on behalf of the Norwegian authorities:
“Vi bryter ikke menneskerettighetene” / - We are not violating the human rights
(4). That answer is absolutely not right.
Norway uses
much coercion in psychiatry. In spite of reduction strategies, the use of
coercion stays at stably high levels (3: p.6-8; 5: p.20-23). Also, reduction
strategies instead of CRPD-based abolishment strategies do not go to the core
of the issue. Norway is used to see itself as a human rights protective nation
and often does not hesitate to criticize other countries for their human rights
violations. So it is maybe hard for the authorities to take in that the state
of Norway is actually accepting torture
and other severe human rights abuses in its own mental health system, via the
Mental Health Act. Point 42 of the CRPD
General Comments No 1 says as follows:
“As has been stated by the Committee in
several concluding observations, forced treatment by psychiatric and other
health and medical professionals is a violation of the right to equal
recognition before the law and an infringement of the rights to personal
integrity (art. 17); freedom from torture (art. 15); and freedom from violence,
exploitation and abuse (art. 16). This practice denies the legal capacity of a
person to choose medical treatment and is therefore a violation of article 12
of the Convention. States parties must, instead, respect the legal capacity of
persons with disabilities to make decisions at all times, including in crisis
situations; must ensure that accurate and accessible information is provided
about service options and that non-medical approaches are made available; and
must provide access to independent support. States parties have an obligation
to provide access to support for decisions regarding psychiatric and other
medical treatment. Forced treatment is a particular problem for persons with
psychosocial, intellectual and other cognitive disabilities. States parties
must abolish policies and legislative provisions that allow or perpetrate
forced treatment, as it is an ongoing violation found in mental health laws
across the globe, despite empirical evidence indicating its lack of effectiveness
and the views of people using mental health systems who have experienced deep
pain and trauma as a result of forced treatment. The Committee recommends that
States parties ensure that decisions relating to a person’s physical or mental
integrity can only be taken with the free and informed consent of the person
concerned.“ (6: #42)
Neglected harms and traumas - and the need for
reparations
Long-term studies have shown higher recovery rates for
people who were not on neuroleptics and on very low doses (14, 15). The list of
potential harmful effects from neuroleptic drugs is long, including tardive dyskinesia, brain damage, cognitive decline, neuroleptic-induced supersensitivity
psychosis, Parkinsonism, sexual dysfunction, weight gain, diabetes,
demotivation, anxiety, aggression, suicide, akathisia [ an extreme form of
restlessness which in itself can lead to suicide], neuroleptic malignant syndrome
— a potentially lethal complication of treatment etc (14, 18). In
a research summary on possible harms from forced psychiatry done by nurse and
researcher Reidun Norvoll, she listed the following main categories: 1) violation of autonomy and of psychological
and physical integrity. Deprivation of freedom of movement (deprivation of
freedom). 2) Physical harm and death. 3) Violence and abuse. 4) Trauma,
retraumatisation and posttraumatic stress syndrome. 5) Offences/violations,
loss of dignity and experiences of punishment. 6) Psychological agony in the
forms of shame, anxiety, feeling unsafe, anger, powerlessness, depression and
loss of self esteem. 7) Social problems
and loss of social identity. 8) Loss of access to own coping skills and
of possibilities to self development. 9) Loss of access to voluntary treatment.
10) Harmed therapeutic relationships, resentment against- and distrust in mental
health services. (7: p. 16; 8: #5.3).
It can be
hard to process traumas that are not acknowledged and understood as such by
society in general. When mental health services represents the abuser and
as it is officially seen as the mental health helper, one can be left in a very
lonely situation trying to handle psychiatry-induced traumas. I think, as part of the implementation of
CRPD, there should be provided access to help and support to those who struggle
with traumas and other harms from forced psychiatry. I imagine a reality where it is possible for
everyone to ask for help when they feel they need it, knowing that they have
the CRPD on their side; that the state can not expose them to torture and other
terrible human rights violations for being in mental pain (!).
When the
necessary abolishment of discriminatory mental health laws and the prohibition
of forced psychiatric treatment and commitment has become reality, I think that
representatives from politics and psychiatry should publicly perform statements
about- and apologies for -the severe human rights abuses that have been going
on for so long towards people with psychosocial disabilities. After all the societal acceptance, silence and
denial of these kinds of abuses, I think such an acknowledgement and apology is
of significant importance for starting reparation work. Compensations is also a relevant part of this. At the same time, there should be no pressure
towards victims of forced psychiatry to forgive and get over. I strongly recommend survivor and lawyer Hege
Orefellen’s appeal on the urgent need for effective remedies, redress and
guarantees of non-repetition regarding torture and other ill-treatment in
psychiatry (9). Her appeal was held during a CRPD side-event about article 15
and its potential to end impunity for torture in psychiatry (10). Also, in
Guidelines on article 14 of the CRPD, point 24 (a-f) one can read about “access
to justice, reparation and redress to persons with disabilities deprived of
their liberty in infringement of article 14 taken alone, and taken in conjunction
with article 12 and/or article 15 of the Convention” (11).
Danger- and treatment criteria
The
Norwegian Mental Health Act has, in addition to its danger criteria, a
criterion called the treatment criterion, which does not require danger to
oneself or others. The treatment criterion allows for psychiatric coercion if
the person is claimed to have a severe mental disorder, and application of forced psychiatry is seen
as necessary to prevent the person from having his/her prospects for recovery
or significant improvement seriously reduced; alternatively that it’s seen as very
possible that the person’s condition in the very near future will significantly
deteriorate without coercion (12: Section 3 – 3. 3 a). A very wishy-washy
criterion indeed, which is much in use. In 2014 the treatment criterion alone
was used in 72% of the cases among people commited (16: p.37).
Both the
treatment criterion and the criteria regarding danger to oneself or others
discriminate against people with psychosocial disabilities in that disability,
or ‘serious mental disorder’, is a
premise for psychiatric coercion to apply. In other words, this discrimination
is a violation of CRPD article 14 which says that the existence of a disability
shall in no case justify a deprivation of liberty (13). Secondly, as the Mental
Health Act allows for forced psychiatric treatment, it violates the right to
personal integrity (art. 17); freedom from torture (art. 15); and freedom from
violence, exploitation and abuse (art. 16). (6:#42).
Points
13-15 in the Guidelines on article 14 are also relevant in this context:
“VII. Deprivation of liberty on the basis of
perceived dangerousness of persons with disabilities, alleged need for care or
treatment, or any other reasons.
13. Throughout all the reviews of State party
reports, the Committee has established that it is contrary to article 14 to
allow for the detention of persons with disabilities based on the perceived
danger of persons to themselves or to others. The involuntary detention of
persons with disabilities based on risk or dangerousness, alleged need of care
or treatment or other reasons tied to impairment or health diagnosis is
contrary to the right to liberty, and amounts to arbitrary deprivation of
liberty.
14. Persons with intellectual or psychosocial
impairments are frequently considered dangerous to themselves and others when
they do not consent to and/or resist medical or therapeutic treatment. All
persons, including those with disabilities, have a duty to do no harm. Legal
systems based on the rule of law have criminal and other laws in place to deal
with the breach of this obligation. Persons with disabilities are frequently
denied equal protection under these laws by being diverted to a separate track
of law, including through mental health laws. These laws and procedures
commonly have a lower standard when it comes to human rights protection,
particularly the right to due process and fair trial, and are incompatible with
article 13 in conjunction with article 14 of the Convention.
15. The freedom to make one’s own choices
established as a principle in article 3(a) of the Convention includes the
freedom to take risks and make mistakes on an equal basis with others. In its
General Comment No. 1, the Committee stated that decisions about medical and
psychiatric treatment must be based on the free and informed consent of the
person concerned and respect the person’s autonomy, will and preferences. Deprivation of liberty on the basis of actual
or perceived impairment or health conditions in mental health institutions
which deprives persons with disabilities of their legal capacity also amounts
to a violation of article 12 of the Convention.” (11: #13-15)
The laws that
apply to people in the rest of society regarding acute situations and in the
criminal justice system, must apply to people with disabilities too in
non-discriminatory ways. The CRPD’s demand for absolute prohibition of forced
treatment and involuntary commitment means that it applies both in criminal justice-
and civil contexts. (11: #14, 16, 20-21, also 10-12). For people with
psychosocial disabilities who come in contact with the criminal justice system,
necessary support must be provided to ensure the right to legal capacity, equal
recognition before the law and a fair trial. Forced psychiatric treatment and involuntary commitment can not be applied as sanctions for criminal
acts and/or for the prevention of such.
Replacing substituted decision-making with
supported decision-making
Substituted
decision making must be replaced by supported decision making systems. Giving
access to supported decision-making for some but still maintaining substitute
decision-making regimes, is not sufficient to comply with article 12 of the
CRPD (6: #28). From General Comment No 1:
“A supported decision-making regime comprises
various support options which give primacy to a person’s will and preferences
and respect human rights norms. It should provide protection for all rights,
including those related to autonomy (right to legal capacity, right to equal
recognition before the law, right to choose where to live, etc.) and rights
related to freedom from abuse and ill-treatment (…).” (6: #29)
Some who agree with the CRPD in that diagnostic criteria for coercion
should be abolished, still seem fine with the idea that ‘mental incapacity’
can be used as criteria for psychiatric coercion. This is not in line with the
CRPD, which neither accepts disability criteria for the deprivation of freedom
nor psychiatric coercion. Here is a relevant point to note, from General
Comments No1: “The provision of support
to exercise legal capacity should not hinge on mental capacity assessments;
new, non-discriminatory indicators of support needs are required in the
provision of support to exercise legal capacity.” (6:#29 i)
I was not
suicidal when psychiatry put me under the Mental Health Act and decided I
should get forced neuroleptic “treatment”. I had never been suicidal. The
former mentioned treatment criterion is the criterion that was used on me. Forced psychiatry, with its locking me up,
restraining me, drugging me, and keeping me on CTO when discharged from
hospital, certainly did not make my life better in any way– everything became indescribably much
worse. I experienced forced psychiatry as one long punishment for having mental
problems. After having been on neuroleptics for a while, my cognition, my
intellectual abilities, were severely affected and reduced - and so was my
language: from usually having a rich vocabulary I could just utter short,
simple sentences. My body became rigid and lost its fine motor skills so I
couldn’t dance anymore. A period I also had akathisia, a terrible restlessness
which made me walk endlessly back and forth, back and forth. I’m trained a
professional dancer and having my dance abilities medicated away was a big loss
in itself. The medication took away my vitality, my sensitivity. My emotions
were numbed. My personality faded away.
Then a severe depression set in - just a complete state of hopelessness
- and for the first time in my life I became suicidal. Again and again I said
to the staff, psychologists, doctors: - I can not be on meds. I tried to have
them understand that the neuroleptics were destroying me and my life. They communicated to me that they thought I
was being fussy. They were a big wall that just would not listen to me.
Respectlessly enough, some even told me –yes,
told me -that I was doing
better. The doctors said I would need to be on meds for the rest of my life.
That was a message which just manifested the complete hopeless situation. From
entering psychiatry, indeed having mental problems, but being a vital,
thoughtful, and expressive person who was dancing several times a week,
psychiatry had coercively medicated me away
from myself and iatrogenically made me severely depressed and suicidal . In
effect a slow form of forced euthanasia . One day, while on CTO, shortly after
a new forced injection in the buttocks with those horrible meds, I did a
dramatic suicide attempt. I was put back into the hospital. I am very glad that
I survived. Because unbelievably, a couple of months later, I was told that
someone had made a bureaucratic mistake: the coercion documents had not been
renewed in time, so there was nothing they could do to hold me back. Of course
they would recommend me to stick to the treatment (Ha!) and not leave the
hospital too fast (Ha!). I left the hospital the same day. It took me about half
a year to become myself again, to be able to think and speak freely, to get my
sensitivity, my emotions back, to dance, to feel human again, to feel life. I
have never been in a mental hospital since then. I have never had another dose
of neuroleptics. And I have never been suicidal again. More than a decade later, I am still traumatized
by my experiences from forced psychiatry.
Conclusion
I am very
thankful to the CRPD committee for their important work. The CRPD represents a paradigm
shift, and there is clearly a resistance out there to accept the full width and
depth of the convention. That human rights and non-discrimination applies
equally to people with disabilities should not be seen as a radical message in
2016, but sadly, it still is. Societies with their leaders need to realize that
systematic, legalized discrimination and abuse of people with disabilities is
based on tradition and habitual ways of thinking –not on human rights. That
something has been brutally wrong for a long time does not make it more
right. Forced psychiatric treatment and involuntary
commitment need to be absolutely prohibited.
Thank you
for your attention.
References:
1) MDAC: Legal Opinion on Norway’s
Declaration/Reservation to the UN Convention on the Rights of Persons with
Disabilities http://mdac.org/sites/mdac.org/files/norway_declaration_-_legal_opinion.pdf
2)
Tor
Levin Hofgaard: Bryter vi
menneskerettighetene?
3)
In
Norwegian: Equality and anti-discrimination ombud (LDO): CRPD report to Norwegian
authorities 2013 – summary http://www.ldo.no/globalassets/brosjyrer-handboker-rapporter/rapporter_analyser/crpd--2013/crpd_report_sammendrag_pdf_ok.pdf
4)
Anne
Grethe Erlandsen: Vi bryter ikke menneskerettighetene http://www.dagensmedisin.no/artikler/2015/02/27/vi-bryter-ikke-menneskerettighetene/
5)
In
Norwegian: LDO’s report to the CRPD committee 2015 – a supplement to Norway’s
1st periodic report http://www.ldo.no/globalassets/03_nyheter-og-fag/publikasjoner/crpd2015rapport.pdf
6)
Link
to download of CRPD General Comment No 1: http://www.ohchr.org/EN/HRBodies/CRPD/Pages/GC.aspx
7)
In
Norwegian: Equality and anti-discrimination ombud (LDO): CRPD report to
Norwegian authorities 2013- full version
http://www.ldo.no/globalassets/brosjyrer-handboker-rapporter/rapporter_analyser/crpd--2013/rapportcrpd_psykiskhelsevern_pdf.pdf
8)
NOU
2011: 9. Økt selvbestemmelse og rettssikkerhet — Balansegangen mellom
selvbestemmelsesrett og omsorgsansvar i psykisk helsevern. 5. Kunnskapsstatus
med hensyn til skadevirkninger av tvang i det psykiske helsevernet. Utredning
for Paulsrud-utvalget https://www.regjeringen.no/no/dokumenter/nou-2011-9/id647625/?q=&ch=12
9)
Hege
Orefellen: Torture and other ill-treatment in psychiatry – urgent need for effective
remedies, redress and guarantees of non-repetition https://absoluteprohibition.wordpress.com/2016/02/06/hege-orefellen-on-reparations/
10)
CRPD
13: WNUSP side event on Article 15: Its Potential to End Impunity for Torture
in Psychiatry http://www.treatybodywebcast.org/crpd-13-wnusp-side-event-on-article-15-english-audio/
11)
Link
to guidelines on article 14 of the CRPD under “Recent Events and Developments” http://www.ohchr.org/EN/HRBodies/CRPD/Pages/CRPDIndex.aspx
12)
Norwegian
Mental Health Act translated to English http://app.uio.no/ub/ujur/oversatte-lover/data/lov-19990702-062-eng.pdf
13)
CRPD
Convention http://www.ohchr.org/EN/HRBodies/CRPD/Pages/ConventionRightsPersonsWithDisabilities.aspx#14
14)
Via
Mad in America / ‘Anatomy of an Epidemic’ (Robert Whitaker): List of long-term outcomes literature for
antipsychotics http://www.madinamerica.com/mia-manual/antipsychoticsschizophrenia/
15)
Lex
Wunderink et al: Recovery in Remitted First-Episode Psychosis at 7 Years of
Follow-up of an Early Dose Reduction/Discontinuation or Maintenance Treatment
Strategy. Long-term Follow-up of a 2-Year Randomized Clinical Trial http://archpsyc.jamanetwork.com/article.aspx?articleid=1707650
Bruk
av tvang i psykisk helsevern for voksne i 2014 (report on the use of coercion
in psychiatry in Norway 2014) https://helsedirektoratet.no/Lists/Publikasjoner/Attachments/1161/Rapport%20om%20tvang%20IS-2452.pdf
17)
Campaign
to Support CRPD Absolute Prohibition of Forced Treatment and Involuntary
Commitment https://absoluteprohibition.wordpress.com/
18)
RxISK
Guide: Antipsychotics for Prescribers: What are the risks? http://rxisk.org/antipsychotics-for-prescribers/#How_likely_are_the_listed_side_effects_of_antipsychotics_to_happen
Other:
Status
of Ratification Interactive Dashboard - Convention on the Rights of Persons
with Disabilities http://indicators.ohchr.org/
