COMPULSORY PSYCHIATRIC TREATMENT RISKY BUSINESS Mary O Hagan

2. WHAT IS COMPULSION? Mental health legislation establishes the circumstances in which a person with �mental disorder�, who hasn�t committed a crime, can be detained or treated without their consent. The criteria include: Mental disorder Danger to self or others Incapacity to refuse treatment

3. WHAT IS RISK? Possibility of harm, loss or danger Factor involving uncertain danger, hazard Risk is located in the future

4. APPROACHES TO RISK Cause of danger The gods Fate Nature Response to danger Supplication Acceptance Control

6. RISK AND MAD PEOPLE INTRAPERSONAL RISK Harm to self Internalised stigma and hopelessness People in contact with mental health services 20 times more likely to kill themselves than general population.

7. RISK AND MAD PEOPLE INTERPERSONAL RISK Mad as perpetrators Weak statistical correlation between madness and violence. Other factors are stronger such as age, history of violence, gender and substance abuse. Mad as victims Much more likely to be victims than perpetrators.

8. RISK AND MAD PEOPLE ENVIRONMENTAL RISK As causes of madness Trauma, deprivation, social inequality, loss As consequences of madness Trauma, deprivation, social inequality, loss Social stigma and discrimination Unsafe, unhelpful, coercive services

10. APPROACHES TO RISK AND MADNESS WIDER COMMUNITY An unsustainable consensus Mad people a risk to others They cannot take responsibility for their actions The community has ceded responsibility to services Services entirely responsible for controlling risk Mental health leaders collude with this consensus The scene is set for the wide acceptance of compulsion

12. APPROACHES TO RISK AND MADNESS MENTAL HEALTH SYSTEM A contestable dominant paradigm Compulsion supported by belief in biological pathology that destroys autonomy and needs correction with treatment. Poor powers of prediction Serious violence by mad people too rare to predict well Debatable if compulsion reduces suicide rate A narrow conception of risk System driven by risk to institutional & professional reputation Little regard for risks to consumers

14. COMPULSION - RISKS TO CONSUMERS DISCRIMINATORY CRITERIA IN MENTAL HEALTH ACTS Danger to others Preventive detention can happen despite no crime (only with mad) Danger to self Compulsion can happen despite competence (only with mad) Competence �The criteria for non-voluntary treatment should focus on the mentally ill person�s capacity to understand that he or she is ill and the benefits that might result from treatment.� Ryan et al

15. COMPULSION - RISKS TO CONSUMERS INHUMANE TREATMENT Hospitals Experienced as unsafe and uncaring Seclusion, restraints, forced injections Experienced as re-traumatising and as punishment

16. COMPULSION - RISKS TO CONSUMERS CORRUPT REVIEW PROCESSES Review Tribunals processes Intimidating and humiliating Review Tribunal decisions One in 20 applicants get off order in NZ Language to justify decisions does not appear in Act in NZ

17. COMPULSION - RISKS TO CONSUMERS QUESTIONABLE TO HARMFUL OUTCOMES Medications can be life-depleting and life-shortening Compulsion re-traumatises and corrupts therapeutic trust Undermines autonomy and creates overdependence Compulsion lowers social status and increases stigma �Compulsory community treatment results in no significant difference in service user, social functioning or quality of life compared with standard care.� Kisely et al. Cochrane Review

19. THE RISKS TO REFORM RECOVERY POLICY National policies in all English speaking countries founded on recovery, but no reduction in compulsory treatment. Compulsory treatment not compatible with recovery: Self-determination and personal resourcefulness Collaborative relationships (shared risk, positive risk) Choice of services Equal participation in society

21. ALTERNATIVES TO COMPULSION Stop colluding with discriminatory community consensus Recovery focus - crisis prevention focus & �the life I want� Advance directives More and better crisis options Robust systemic and individual advocacy �Compulsory responsiveness orders� Separate healing function from control function

22. AN END TO MENTAL HEALTH LAWS Treatment and detention without consent rare and brief Emergency interventions have the comparable threshold as physical medicine Rethink assumptions about human responsibility for crimes Humane recovery oriented criminal justice system

23. THE ROAD TO HELL...GOOD INTENTIONS �Of all the tyrannies a tyranny sincerely exercised for the good of its victims may be the most oppressive...for those who torment us for our own good will torment us without end for they do so with the approval of their own conscience...� CS Lewis