Essay

Psychiatry and the socio-political order

Where mental health meets human rights

AT A COMMUNITY consultation forum on mental health in regional Queensland in 2013, the discussion turned to the human rights of people with mental disabilities. The facilitator, medical journalist Dr Norman Swan, looked at me and said: ‘Doctor! You are a psychiatrist, and some people say that psychiatry and the human rights movement are, sort of, antagonistic to each other! What’s your take on human rights?’

My first impulse was to be defensive and make a passionate counter­argument. But I recalled my media training: do not be provoked. Give a neutral or positive – yet honest – response. I said: ‘Psychiatry and human rights can be highly complementary to each other. That is why I’m here, to work with the community to identify ways in which psychiatry and the human rights movement can complement each other.’

After the forum, Norman’s question stayed with me, and I began to study the contemporary discourse around human rights in order to explore and understand its complexities. I spent seven years working towards a doctorate of public health that focused on the intersection of mental health and human rights – and allowed me to reinterpret my experiences in the psychiatric field through a lens of human rights. Now, I’m drawing on some of my most epiphanic memories to analyse and interpret the socio-cultural phenomena that underpin the intersection of mental health and human rights in the context of political, legislative and policy changes in Queensland between 2013 and 2020, and my own firsthand account of the implementation of those changes.

 

NOT LONG AFTER that forum in 2013, I had a vivid dream. I was walking with my wife and daughter in a luxurious resort with magnificent trees, boutique cottages, swimming pools, playgrounds and a picturesque lake. Fragrant flowers bloomed; birds chirped and ducks swam in the lake. People played netball, sipped wine and splashed in the swimming pools. 

We came across a very large and empty swimming pool. There were people at its bottom – dishevelled, emaciated, most of them elderly men and women with very short hair. They were wearing a uniform, as if in prison. I realised that within the resort, this was a mental asylum. I could tell these people had spent many years in that pit – perhaps most of their lives.

Most of them paid no attention to us, completely disconnected from the world. Their vacant stares pierced my soul. But some looked at me with a glimmer of hope; a few extended their arms. They were silently requesting me to pull them out.

I wanted to help. I wanted to free them. But I did not. I pretended I didn’t see them and kept walking. My daughter wanted an ice-cream. My wife wanted to swim. I wanted to read a novel, lying on the sun-kissed grass. I could not spoil my family holiday for those people.

And if I did pull those people out of the pit, where would I take them? It wasn’t just a question of pulling them out; it was about what came next.

Those expressionless faces, pleading eyes and outstretched arms continued to haunt me – in my dream and after I woke up.

Revisiting my dream, I realised that it camouflaged a portmanteau of moments: a childhood memory, an experience I had had in a mental asylum, a soul-shaking image – and a current conflict I found myself in.

I remembered a nameless man in the small town where I grew up in Punjab, India, in 1980. Children called him awara paagal – ‘wandering madman’. I was six, perhaps seven. One day, my father was riding his bicycle, me on the rear carrier, when we saw boys pelting this man with stones. My father stopped, telling the boys to stop bothering him. Another stone flew, and my father stepped towards the boys, scolding and threatening them. When the boys dispersed, my father got back on the bicycle and we headed home. But as I looked back, I saw that the man was following us. We reached home, and he appeared by the gate. My father opened the gate and spoke to him. I was extremely scared. The man was hungry, I heard my father tell my mother; he was begging for something to eat. My parents gave him food; he ate hurriedly and left without saying thanks.

Thereafter, he would come every now and then, ask for food, sit outside our home and leave after eating. My parents were not very religious: when it came to helping this man, it was out of the goodness of their hearts. Did they realise that by performing that act of kindness, they were shaping my life?

The dream rekindled another memory of an Indian mental hospital in the 1990s when I was a junior resident doctor in psychiatry. Once a prestigious institution, it was then in the news for all the wrong reasons. Sixteen patients had lost their eyesight due to undiagnosed and untreated cataracts. And a young woman with bipolar illness was pregnant, allegedly raped by a staff member; it was not until she was in the seventh month that her pregnancy was discovered. She kept her abdomen covered with a shawl and nobody bothered to talk to or examine the patients there anyway. The patients had beds and were given food and regular cocktails of medicines and occasional electroconvulsive therapy. That was about it.

The government had reportedly wanted to relocate the hospital and sell the land. However, media attention on this young woman’s story – and the resulting public outcry – forced the state government to reform, rather than sell, the site. Our professor conducted the inquiry, assisted by us, the psychiatry trainees. We interviewed the patients, approximately 500 of them, reviewed their records and reported the despicable conditions they endured.

During the interviews, one patient – a middle-aged woman, perhaps in her fifties – gave me a piece of paper. On it, she had scribbled a few sentences in Punjabi script. She pleaded with me to post that letter: she had written to her brothers and was confident they would come and secure her release as soon as they received it. The staff nurse told me that she had been admitted to the asylum as a young woman with a brief psychotic episode. Over three decades, she had sent numerous such letters to her brothers – but nobody ever came. I took her letter, put it into an envelope, wrote the rather incomplete address that she had dictated to me and posted it. I was posting it to nowhere, but I was keeping a promise.

My dream of outstretched arms led not just to these memories but also to a haunting newspaper report of the drowning of as many as fifty asylum seekers off Christmas Island in December 2010, the first of many such incidents in those years. In one photograph, the outstretched hand of someone underwater looked like a sinking soul’s last cry for help. In some recess of my mind, the chronically incarcerated persons in a mental asylum coalesced with those helpless asylum seekers, washed away in a furious ocean. Misery of humankind, as well as the word ‘asylum’, might have forged the link in my unconscious mind.

In all this, I recognised the conflict my dream represented; it was between my choosing an easy and relaxed lifestyle, dedicated to my family, or returning to that unfinished task that I had started fourteen years earlier, 12,000 kilometres away, as I posted that woman’s letter. It was about returning to the frontline where mental health and human rights intersect.

If ‘dreams are the royal road to the unconscious’, as Freud wrote, mine certainly was. Those outstretched arms beckoned me. I could do no more for that poor woman in her Indian mental institution, but I could make some difference in the lives of people incarcerated in another mental institution, very close to my new home, in the small town in Australia where I had landed. So I took up the position of clinical director of a mental health service in regional Queensland.

 

THE SERVICE INCLUDED a 200-bed long-stay mental institution, which had existed for more than a century. Inpatients’ length of stay ranged from a few months to several decades. Some had been admitted to the asylum as children with severe intellectual disability and were in their sixties when I met them. Among the most disadvantaged human beings, they had never benefited from any reforms in the system.

There were also inpatients who had been on Forensic Orders (FOs) for years – sometimes as long as two decades – for alleged offences, diverted from the criminal justice system to the psychiatric system through a defence of ‘unsoundness of mind’. Had their charges been dealt with through the normal course of law, some would have served a six-month term, if any. As a result of that defence they were incarcerated in the mental institution for years under the Mental Health Act 2000, ensuring that such patients were never released.

The system imposed a number of conditions: they were ‘not to abscond from the facility’ and ‘not to use alcohol, marijuana or any other illicit drugs’. Every six months, it would be noted during review that those conditions had not been met, as many invariably absconded from the institution, with some smoking marijuana and others having a couple of drinks. At every six-monthly review, the FO would be extended because the patient had either violated the conditions of the FO or the treating team could not prove the person was ‘not an unacceptable risk to safety of the community’.

Clinical staff at such institutions – the psychiatrists and nurses – are often demonised by academics and bureaucrats as well as service users and survivors of psychiatry. And I, too, arrived with a preformed notion that these staff were themselves ‘institutionalised’. Not surprisingly, there was significant mistrust between the administrative staff in bureaucratic positions and the grassroots-level clinical staff. I remained an ‘outsider’ until I started working in one of the long-stay wards as a clinical psychiatrist when we were short-staffed. That is when I got to know the staff and patients, and I appreciated the commitment of the nursing and allied health staff to those in their care. These were conscientious individuals who had dedicated their lives to care for people with severe mental disabilities. But the world outside that small town had changed; different models of service had evolved. Care in the community had become the norm all over the world. And while this institution was downsized, many wards remained untouched due to neglect and poor implementation of policies by the government. While the staff at the asylum did a wonderful job caring for those patients, it was a dismal failure of successive governments that care in the community had never become a viable option for these people.

Institutionalisation was the only model of service to which these staff had been exposed. They genuinely believed that it was in the best interest of the patients if they were kept for many months or years in the mental asylum, even on an involuntary basis. Risk-aversion was rife, as were stories of previous discharge plans gone wrong.

We had many interesting exchanges. I was told about the patient who had overnight leave to stay in a boarding house but suffered such acute anxiety he ended up having a few drinks and returning to the ward in the middle of the night. He was considered a mess. I responded that of course a patient who had spent many years in an asylum would be very anxious about spending his first night in the ‘community’, in a boarding house, and questioned if this made his discharge plan a failure – one not to be revisited for months or even years?

I was told about a patient who was ‘very sexually promiscuous’ and unsafe in the community because she was considered very vulnerable. I replied that she was not acutely unwell, and her bipolar illness was under remission with medication. If her so-called ‘promiscuity’ was her choice, then how could we use her sexual choices as justification for incarceration in a mental institution?

Such direct, respectful debates in the ward rounds helped confront prevailing norms and paternalistic, risk-averse notions that bordered on social control. We discussed the contemporary practice of psychiatry, taking into account psycho-social, cultural and lifestyle factors in addition to a biological understanding of mental disorders. We talked about the recovery paradigm of respecting individual choice, aspirations, hopes and dreams; about the possibility of non-government organisations (NGOs) providing support during a patient’s leave; about the idea of peer-support workers, with lived experience of mental disability, providing support for patients during leave or after discharge.

Such changes could not be introduced by dispatching memoranda from an ‘ivory tower’ office. But making suggestions on the ward rounds helped me challenge staff to think beyond the medical-nursing model and look beyond the confines of the institution. This helped with ‘change management’ on the ground.

Fortunately, we had received Commonwealth Government funding to build four Community Care Units (CCUs), between fifteen and twenty one-bedroom units in community residential facilities in the four districts that formed the catchment area of our hospital. Over a period of four years, almost eighty patients were gradually discharged from the institution, either to the CCUs or to the community, with community mental health service and NGO support. Five out of the nine wards were ultimately closed. And, importantly, ‘closing down’ the long-stay wards of the institution was accompanied by ‘opening up’ of CCUs and a mobile intensive rehabilitation team. In this way, we steered deinstitutionalisation in the twenty-first century, keeping in mind the lessons learned from the twentieth century to ensure that patients were discharged with due planning and proper support.

Of course, it was not easy. There was opposition from the community and media to the idea of rehabilitating highly stigmatised patients in community neighbourhoods. Some staff members, as well as some patients’ family members, spoke out against the closure of what had been the patients’ ‘home’ for decades. However, gradually, the pieces of the puzzle fell together through co-ordinated executive and clinical direction, commitment from the staff and support from the Mental Health Directorate based in Brisbane. Ultimately, even the local opposition was countered by progressive and conscientious individuals and community groups, particularly one local church that advocated for the right of people with mental disabilities to live in the community.

Being involved in this project was one of the most rewarding tasks of my professional life. This portion of my work may have started with that beckoning dream, but it ended with the accomplishment of a long overdue task to protect and promote the human rights of people with severe and persistent mental disabilities.

That work is far from complete. Approximately one hundred long-term residents with severe intellectual disability or severe and complex mental disabilities remained in the institution. There would be no easy way out for those individuals. They were deemed too unwell to be rehabilitated into a community setting with the supports available at the time. The National Disability Insurance Scheme might provide some avenues for supported independent living; some might be moved to nursing homes, once they reached sixty-five years of age. Many others might never be able to leave. Human rights, including rights to social inclusion, adequate standards of living and freedom from stigma and discrimination, continue to be an elusive aspiration for some individuals with severe mental disabilities in this institution – as they do for millions of people with mental disabilities around the world.

 

WHILE THIS REFORMATIVE work was progressing – thanks to the second Queensland Mental Health Plan 2007–2017 – the state of Queensland went through a number of dramatic socio-political changes. In the March 2012 state elections, the Liberal National Party (LNP) coalition enjoyed a landslide victory, winning seventy-eight of eighty-nine seats and reducing the ousted Australian Labor Party to just seven seats. A hefty majority in the Legislative Assembly, coupled with the fact that there is no upper house in the Queensland Parliament, meant the government could frame and implement new legislation with little debate or opposition. In October 2013, tough anti-bikie laws were introduced as a ‘package of reforms’. These laws included mandatory sentences of fifteen years, on top of normal penalties, for serious crimes committed as part of gang activity; ten years’ imprisonment, on top of those fifteen years, for being an office-bearer of an outlawed gang; a new special prison for convicted bikies (in which they would wear pink jumpsuits); provisions authorising locking prisoners in isolation cells for twenty-three hours per day with no avenues for rehabilitation; and the provision to crush motorcycles belonging to those convicted as punishment for certain crimes.

These attracted strong criticism from lawyers’ associations and human rights bodies for shredding the rule of law. Soon after the laws were implemented, examples of their application started to emerge, such as the arrest of five Victorian gang members for eating ice-cream together on the Gold Coast because this violated the Criminal Law (Criminal Organisations Disruption) Amendment Act 2013 by having three or more members of a criminal gang together in a public place.

It was in this socio-political environment that the Queensland Government introduced a new ‘locked-door policy’ for the adult mental health inpatient units in general hospitals on 10 December 2013. As the clinical director of mental health for one of the sixteen districts in Queensland, the first I heard about this policy was through a news item in The Courier-Mail. The lead paragraph read:

Hundreds of mentally ill patients – including killers and rapists deemed unfit to incarcerate for their crimes – are absconding each year, forcing state-run facilities to adopt a new locked-door policy.

And it continued:

Locksmiths will be required at some units to meet the department’s December 15 deadline for securing their facility after maintaining an open-door policy despite accommodating perpetrators of heinously violent acts.

While we learnt this from the morning newspaper, the Queensland Health directive came only later that day. In my service, many of the wards in the long-stay institution were already locked. The general hospital had two acute adult mental health inpatient wards – an open ward and a locked ward. The open-ward patients were admitted on a voluntary basis with depression, anxiety, suicidal ideation or other stressors. Sometimes ‘low-risk involuntary patients’ were transferred from the locked ward to the open to prepare them for discharge into the community while being provided with therapeutic interventions and support.

To implement the locked-ward policy, locks were installed on the previously open ward. Fences were raised. The voluntary patients – who could previously go out for fresh air or a walk – now had to wait for someone to let them out. Overnight, the milieu of psychiatric wards transformed from therapeutic to custodial. This was happening in Queensland while the rest of the world was implementing the United Nations Convention on the Rights of Persons with Disabilities (CRPD). If the CRPD was supposed to be the ‘dawn of a new era’ of disability rights, Queensland seemed instead to be going in the opposite direction.

As a clinical director, I followed this directive – locked the wards and raised the fences – even as our other work towards deinstitutionalisation was underway. This was a classic example of political priorities and a risk-averse agenda governing the health system, ignoring internationally accepted principles of least restrictive mental healthcare, the entire evidence base and the collective wisdom of experts.

Now, more than seven years later, acute adult psychiatry wards in Queensland continue to be locked. Those organisations that criticised the blanket locked-door policy in the beginning seem to have forgotten the issue. The world has moved on and life goes on outside those locked doors.

IN 2014, THE Queensland Government also became involved in what came to be known as the ‘contracts dispute’ with the state’s senior/specialist medical officers (SMOs) – a dispute that would ultimately have major consequences for my own circumstances and trajectory as well as violate the right of Queenslanders to access health services. The government attempted to introduce a series of changes, including converting public-sector SMOs from permanent jobs to performance-based contracts under which the government could unilaterally vary hours and pay. SMOs could be arbitrarily dismissed, with no unfair dismissal provisions, and they would no longer have access to the Industrial Relations Commission.

The Australian Medical Association strongly opposed these changes, and more than a thousand SMOs threatened to tender mass resignations should the government go ahead. The government dug in its heels and Premier Campbell Newman said that new specialists would be recruited from interstate or overseas if doctors resigned.

After months of negotiations, the government ultimately backtracked on some conditions but went ahead with the new contracts. SMOs did not resign en masse, but a significant number left the Queensland public sector, moving to private practice or interstate.

There were dire consequences in terms of access to health services – especially for the medical specialities and regions that already struggled with recruitment, such as rural psychiatry. Six of the twenty psychiatrists in my service resigned. The recruitment of psychiatrists from overseas was not as easy as the premier had imagined. After months of juggling and cross-covering, months of sleepless nights worrying about rural mental health services operating without sufficient psychiatric cover, I decided to walk away. I was offered a position at a metropolitan service, which I took; I could not bear the stress of working as a clinical leader with such gross understaffing – for which there was no end in sight. Very invested in my job, I regretted quitting – but I had to leave for my own mental health.

On 31 January 2015, the incumbent LNP lost the state election. The new Labor government annulled the controversial contracts to reinstate the previous employment conditions for the SMOs. But it took Queensland Health years to recover and to compensate for the loss of senior doctors, especially in the rural and regional mental health services.

IN 2013, THE LNP government had commenced a review of the Mental Health Act 2000, and the Labor government continued these consultations in 2015. As I was studying international human rights law as part of my doctorate, I made a personal submission to the Mental Health Bill in 2014, highlighting the principles of the UN CRPD, which Australia had signed and ratified in 2008. The Queensland Mental Health Commission employed me as part-time consultant in 2015 to contribute to their own submission to the bill. I observed how the consultation process improved the final version of the Mental Health Bill by incorporating some human rights protections into the legislation. I also noticed that the process of legislative reform depends upon, and is limited by, the political will and prevailing discourse in the media and throughout society.

After many rounds of consultations and numerous drafts of the Mental Health Bill, the Mental Health Act 2016 (MHA 2016) was passed by the Queensland Parliament in September 2016. The act was seen as a positive development with better human rights protections, intended to minimise coercion in mental health care by including a variety of procedures that were less restrictive than compulsory/involuntary psychiatric treatment in inpatient units and in the community. However, recent evidence indicates that rates of compulsory treatment have increased in Queensland after the MHA 2016 was implemented. Possible reasons behind this unintended consequence may include a paternalistic and restrictive culture in Queensland mental health services, a lack of well-resourced and systematised voluntary alternatives to compulsory treatment, and risk aversion among both clinicians and society. It is also likely that the reform process did not go far enough to become an effective legislative lever in the quest for change. An increase in the prevalence of illicit drugs such as ice (methamphetamine), which lead to both rising rates of drug-induced psychiatric disorders and their severity, could be another reason for an increase in involuntary treatment rates.

The MHA 2016 is also limited by the fact that it continues to focus on involuntary treatment provisions and has little emphasis on ensuring access to mental health services or promoting the economic, social and cultural rights of people with mental disabilities.

Subsequently, a dedicated Human Rights Act 2019 (HRA 2019) has been passed by the Queensland Parliament: this gives every person the ‘right to access health services without discrimination’ and requires that ‘a person must not be refused emergency medical treatment that is immediately necessary to save the person’s life or to prevent serious impairment to the person’. But the Act’s focus on the right to health is very narrow, as the right to health can best be promoted by ensuring prevention and early intervention, not merely by ensuring access to emergency services.

Some other provisions of the Act – such as equality before the law, freedom from forced treatment and freedom of movement – might help with protection of civil and political rights. Given the absence of a federal human rights act or charter in Australia – the only country among Western democracies that lacks this mechanism – a human rights act at state level is a welcome step. It is expected to embed a culture of human rights protection and promotion into the machinery of government, and public entities will have to consider the human rights implications of all laws, policies, decisions and actions. The impact of this act on the mental health system remains to be seen.

 

AFTER TWO YEARS as medical director in a metropolitan service, I resigned and stepped down to a clinical and academic psychiatrist role. But before I stepped down, I had an opportunity to act as Chief Psychiatrist of Queensland for a few months in 2017, providing interim cover while the position was recruited. The Office of the Chief Psychiatrist is responsible for legislative implementation, policy and clinical governance in state-wide mental health services. And in this position, I encountered the tightrope walk required to balance the conflicting priorities of the human rights of people with mental disabilities, the rights of victims of crime involving perpetrators with mental disabilities, the rights of children at risk of harm due to the mental disabilities of their parents/guardians, and the rights of clinicians working in an overburdened system – all while keeping in mind both community and media interest and the prevailing socio-political context.

Working in psychiatry for more than two decades has made me well aware of that need for balance. Often, one set of human rights for a person is in direct conflict with another. For example, when a person with severe depression is acutely suicidal or someone with anorexia nervosa is refusing to eat despite being at acute risk of cardiac complications and death, their right to autonomy is in direct conflict with their right to health and right to life. Similarly, someone with acute exacerbation of schizophrenia or meth­amphetamine-induced psychosis – who believes that strangers are conspiring to kill them or who hears voices commanding them to kill – encounters a conflict between their right to autonomy on the one hand and the right of the community for safety on the other. I have had patients who were treated involuntarily while they were acutely suicidal but were later thankful for the lifesaving treatment they received at the right time. I have also seen patients who committed serious crimes when acutely unwell and were left with a lifelong regret for hurting innocent people or those very dear to them.

During my twenty years in psychiatry, I have dealt with a variety of issues related to identity, intimacy or loneliness. I have lost a small number of patients to suicide – a devastating outcome. Arguably the most daunting part of a psychiatrist’s job is meeting the parents of young suicide victims: what answers do you provide parents whose child has killed themselves in the prime of youth? Often, as families struggle with their grief, loss, confusion, and sometimes guilt and anger, they ask psychiatrists and other mental health professionals why their loved ones did not receive compulsory treatment when they were so mentally unwell. Every situation involving the human rights of a person with mental disability has to be assessed and managed based on its own unique circumstances. Compulsory treatment can be overused in psychiatry or used in a way that does not respect the inherent dignity of the individual. But there are some circumstances where compulsory treatment is required as a last resort, with strong safeguards in place.

Most of all, my experiences in psychiatry have taught me that mental health systems can only exist within the wider socio-economic-political-legal context. People often come into contact with the psychiatric system after a long journey that may see their rights to housing, education, employment, social inclusion and, most importantly, access to healthcare – physical as well as mental – obstructed. In this way, the issue of the human rights of people with mental disabilities is much broader than a question of voluntary or involuntary treatment in psychiatric wards. Social attitudes towards mental disability – those that stigmatise and discriminate, or those that are accepting and inclusive – are expressed through our system’s democratically elected representatives. These determine how legislative and policy frameworks are prepared, how those provisions are implemented, and how mental health services are structured and delivered. Sensationalist media coverage of mental disabilities and risk-aversion in political circles often reflects ignorance and prejudice in society. In addition, social inequities and the violation of economic, social and cultural rights can predispose people to mental health issues. Social and emotional wellbeing issues of Aboriginal and Torres Strait Islander peoples due to dispossession, cultural disintegration and trans-generational transmission of trauma are a striking example of this. Attempts to protect and promote the human rights of people with mental disabilities, therefore, must begin by addressing social inequities, social attitudes, stigma and discrimination to strive towards a fair and equitable society.

I often return to the question posed by Norman Swan at that forum in 2013. I have learnt through my research as well as clinical experience that psychiatry can be synergistic with the human rights framework by focusing on mental health promotion, prevention and early intervention; a recovery paradigm rooted in the values of individual dignity, choice, control, connection and hope; and the promotion of broader economic, social and cultural rights.

This broadly conceived human rights discourse – when integrated into mental health legislation, policy and practice – is the surest path to enhancing mental health, and all health, for all of humanity.

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