The New WHO and UN Guidance: Psychiatry Must Entirely Change

After years of work involving hundreds of people in dozens of countries, the World Health Organisation (WHO) and the United Nations Office of the High Commissioner for Human Rights (OHCHR) have released their joint production, Mental Health, Human Rights and Legislation: Guidance and Practice (WHO/OHCHR, 2023, referred to as the Guidance. The agenda of the launch event is here, and the full video here).

This outlines in considerable detail the current international legislative framework with which mental health acts in signatory nations need to comply, and provides examples to show how each element of the law can be implemented and tested.

At present, the foundation for international law is the Convention on the Rights of Persons with Disabilities (CRPD, 2006), of which Australia is a signatory. A full list appears in Box 9, p124, along with the four HRC resolutions and three special rapporteurs whose responsibilities cover the field of mental disorder. In one sentence, the CRPD states that no person shall suffer any form of discrimination, loss of liberties or infringement of rights by virtue of a disability, including mental disorders. There is no wriggle room in this.

Chapter 1 of the Guidance, “Rethinking Legislation on Mental Health,” defines mental health, locating its preconditions in the individual’s physical and social environment. In practice, however, this broad definition attracts little more than lip service. Around the world, mental health gets about 2.1% of government health spending, the majority of which is spent on institutions and on physical care: “…the biomedical model, which focuses predominantly on diagnosis, medication and symptom reduction, prevails across existing mental health systems. As a result, social determinants that impact people’s mental health are often disregarded …” (Guidance, p. 10).

In introducing the launch, the MC listed what he called three major mistakes that current national laws make regarding mental health: the emphasis on detention and involuntary treatment; the over-reliance on the biomedical model; and the failure to involve people with mental disorders in deciding their management. They are “mistakes” because each one is explicitly prohibited by the CRPD or betrays a serious misunderstanding of the nature of mental disorder. Thus, as these features more or less define modern psychiatric practice, it is clear the international human rights community and institutional psychiatry are on collision course.

S4. of the Introduction asks: “Why is the Guidance important?” and looks at a number of reasons, reaching some fairly blistering conclusions:

1. 1. “A fundamental shift is required within the field of mental health … There is an overreliance on biomedical approaches to treatment options, inpatient services and care, and little attention given to social determinants and community-based, person-centred interventions…”
   2. “Most legislation on mental health fails to embrace a rights-based approach. Many people … are not treated equally before and under the law, and are often discriminated against … legislation may be paternalistic … (People) are routinely deemed incapable of making decisions… no adequate mechanisms to prevent, detect, or remedy these and other human rights violations” (i.e. standard mental hospital procedures unavoidably violate human rights).

…

1. 4. “The international human rights framework requires a transformation in the way mental health services are provided. All persons should be able to exercise their right to give free and informed consent to accept or reject treatment in mental health systems. Denial of legal capacity, coercive practices and institutionalization must end.”
   5. “Legislation can … foster a cultural shift that promotes social transformation in the realm of mental health … away from a narrow emphasis on biomedical approaches towards a more holistic and inclusive understanding of mental health …”

In other words, psychiatry has got it all wrong. How wrong? With the entirely benevolent aim of publicising this important document, I emailed the editors of Australian and New Zealand Journal of Psychiatry to see if they would accept a paper on the Guidelines as a “Viewpoint.” According to their website, “Viewpoint articles are longer pieces (3000 words) that allow for personal perspectives and opinions on issues relevant to psychiatry practice and research. They will offer novel insights, show academic rigour, and be of interest to the journal’s readership. Authorship: At invitation of Editor (who can be contacted with an article proposal).” Forty-five minutes later, back came their answer: No thanks. That’s fine, you don’t believe you’re doing anything out of place. But back to the Guidance.

Chapter 1 describes the state of mental health legislation and gives the relevant international agreements pertaining to health and disability. It starts with the definition: “Mental health is a state of physical, mental, emotional and social well-being, determined by the interaction of the individual with society…” Already, Chapter 1 page 1, we see the sides shaping up for a cosmic brawl. Is mental disorder a genetic disturbance of brain function, or is it not? You can’t have it both ways although, with their spurious biopsychosocial model and their eclectic psychiatry, they tried. The Guidance continues:

The different ways of being, thinking, sensing, expressing, and making sense of the world are part of human diversity: there is no “normal” or “right” way to be. A failure to understand and respect these differences can lead to isolation and discrimination (p. 9).

This is a direct challenge to psychiatry’s insatiable drive to medicalise the slightest deviation from “normal,” e.g. the relentless drive to diagnose ADHD. They then take up the issue of coercion and loss of freedom of choice, which are part of the fabric of psychiatry: “… mental health laws continue to assume the underlying correctness of coercive practices, which are deemed to be a legitimate form of ‘patient management’ …” (p. 12). Solitary confinement, restraint and shackling are mentioned, in particular with respect to minority and marginalised subcommunities who “…are often denied the few protections mental health legislation may provide for.” Box 2, p. 15, sets out “The case against coercion.”

Box 3, p. 19, lists “CRPD provisions for a rights-based approach to mental health,” including Legal capacity, Liberty and security of person, Free and informed consent, Living independently, Inclusion in the community, and Access to justice. Manifestly, these rights, established by treaty, are routinely breached by psychiatry. In fact, current psychiatric practice is the polar opposite of these principles.

All of these sins are laid before the plinth of what they call the “biomedical model,” which, for years, I’ve been saying doesn’t exist.  It’s defined in the Glossary, p. xiii:

The biomedical model of mental health is based on the concept of mental health conditions being caused by neurobiological factors. As a result, care often focuses on diagnosis, medication, and symptom reduction, rather than considering the full range of social and environmental factors (and) may not address the root causes of distress and trauma.

Despite its central role as the fount of all things bad in psychiatry, there is only one reference to this fabled entity, to a paper by Brett Deacon from 2013. Quickly, I found my copy and rechecked it in case I’d missed something: No, I was right. There is nothing in that paper that says such a model actually exists. It remains the case that no psychiatrist, or neuroscientist, or philosopher, or psychologist, has ever written anything that would amount to a reductionist model of mental disorder. Sure, there are heaps of people who believe that all mental disorder is a biological disease of the brain (see Deacon’s paper above and mine here for lists of quotes) but believing is not the same as proving. They may believe it but, if philosopher Daniel Stoljar is right (and he usually is), they’re wasting their breath: there never will be a physical account of mental disorder.

In place of the shadowy “biomedical model,” the Guidance proposes a human-centred, rights-based, community-based and accountable psychiatry. The other two chapters are a minutely detailed exposition of how mental health acts should be written and tested for compliance with the CRPD and the other eight relevant treaties in order to achieve this far-reaching goal.

This imposing publication leads inevitably to two conclusions:

1. 1. Psychiatry is routinely, systematically breaking practically every internationally-sanctioned law and treaty on human rights, entirely without scientific warrant; and
   2. Psychiatrists apart, the world is moving away from the idea that, when dealing with the mentally troubled, forms and standards of management from a hundred years ago are just fine.

This is the dilemma: according to the preeminent health and rights bodies in the world, psychiatry has to change. How much? This much: “Denial of legal capacity, coercive practices and institutionalization must end.” So far, nobody has told the psychiatrists and, as my little interchange with the editors showed, they’re not particularly interested. However, knowing psychiatrists, they will fight tooth and nail to resist change, and so the irresistible force meets the immovable object.

Psychiatry’s goal, as we know too well, is to medicalise everything they can get their pudgy hands on. Anybody who doesn’t like this is obviously “anti-psychiatry” (not to mention dangerous, biased, extremist and a tool of the scientologists). While the UN bodies will do the right thing, consulting widely and slowly building their case, we know that, at the slightest hint of a threat, the psychiatry/drug company axis will run squealing to their friends in government to drop a very large hammer on the upstarts.

There’s no doubt that mainstream psychiatry worldwide will have a collective fit when they see what non-psychiatrists have planned for them. There’s also no doubt that moving to the model of practice envisaged in the Guidance will require wrenching change in psychiatry. For a start, every national training program would have to be rewritten in its entirety, but the biggest resistance will come from the attitudes and belief systems of the establishment. Change of this nature would take years and years to put into practice. In fact, many of the older crew wouldn’t be able to adjust and would have to be dropped off at the old folks’ home.

But we can be sure of one thing: given its record, institutional psychiatry will not give in with good grace. I mean, look at the journal editors: they don’t even want to know the WHO or OHCHR exist. They don’t realise that the Guidance, as as issued recently, is a gun pointing at psychiatry’s collective head. It’s not an encouraging start.