New WHO and UN guidelines: Psychiatry must change completely

AAfter years of work involving hundreds of people in dozens of countries, the World Health Organization (WHO) and the Office of the United Nations 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 Guidance. The agenda of the event is here, and the full video here).

This broadly outlines the current international legal framework with which mental health legislation in signatory countries must comply, and provides examples showing how each element of the law can be implemented and tested.

Currently, the basis of international law is the Convention on the Rights of Persons with Disabilities (CRPD, 2006), to which Australia is a signatory. The complete list is in box 9, p. 124, along with four HRC resolutions and three special rapporteurs whose responsibilities cover the field of mental disorders. In one sentence, the Convention on the Rights of Persons with Disabilities states that no person shall suffer any form of discrimination, loss of freedom or violation of rights because of disability, including mental disorders. There is no wiggle room in this one.

Chapter 1 of Guidance, “Rethinking Mental Health Legislation,” defines mental health, locating its prerequisites in the individual’s physical and social environment. In practice, however, this broad definition attracts little more than lip service. Globally, mental health receives about 2.1% of government health spending, most of which is spent on institutions and physical care: “…the biomedical model, which focuses predominantly on diagnosis, medication and symptom reduction, dominates the current mental health system. As a result, the social determinants that affect people’s mental health are often overlooked…” (Guidance, p. 10).

In presenting the launch, the MC cited three main mistakes that current national laws make regarding mental health: ​​the emphasis on detention and forced treatment; excessive reliance on the biomedical model; and not involving people with mental disorders in decision-making about their management. They are “mistakes” because each is expressly prohibited by the CRPD or betrays a serious misunderstanding of the nature of mental disorder. So, as these characteristics more or less define contemporary psychiatric practice, it is clear that the international human rights community and institutional psychiatry are at odds.

S4. The introduction asks: “Why is it?” Guidance important?” and looks at a number of reasons, reaching some rather harrowing conclusions:

1. 1. “A fundamental shift is needed in the field of mental health… There is an over-reliance on biomedical approaches to treatment options, hospital services and care, and little attention is paid to social determinants and community-based, person-centred interventions…”
   2. “Most mental health legislation does not embrace a rights-based approach. Many people… are not treated equally before and under the law, and are often discriminated against… legislation can be paternalistic… (people) are routinely considered incapable of making decisions… there are no adequate mechanisms to prevent, detect or remedy these and other human rights violations” (i.e. .standard procedures in a mental hospital inevitably 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 refuse treatment in mental health systems. Denial of legal capacity, coercive practices and institutionalization must end.”
   5. “Legislation can… foster a cultural change that promotes social transformation in the field of mental health… away from a narrow emphasis on a biomedical approach to a more holistic and inclusive understanding of mental health…”

In other words, psychiatry got it all wrong. How wrong? With the entirely benevolent aim of publishing this important document, I emailed the editors Australian and New Zealand Journal of Psychiatry to see if they would accept the Guidelines paper as a ‘point of view’. According to their website, “Viewpoint articles are longer pieces (3000 words) that allow for personal perspectives and opinions on issues relevant to the practice and research of psychiatry. They will offer new insights, demonstrate academic rigor and be of interest to the journal’s readership. Attribution: At the invitation of the editor (who can be contacted with the article proposal).” Forty-five minutes later, their reply came: No, thank you. It’s okay, you don’t believe you’re doing something wrong. But back to Guidance.

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

Different ways of being, thinking, feeling, expressing and making sense of the world are part of human diversity: there is no normal or correct way of being. Failure to understand and respect these differences can lead to isolation and discrimination (p. 9).

This is a direct challenge to psychiatry’s insatiable urge to medicalize even the slightest deviation from “normal”, e.g. the relentless drive to diagnose ADHD. They then address the issue of coercion and the loss of freedom of choice, which are part of the structure of psychiatry: “… mental health laws continue to assume the basic propriety of coercive practices, which are considered a legitimate form of ‘patient management’…” (p. 12). Solitary confinement, restraint and shackling are mentioned, particularly in relation to minority and marginalized sub-communities who “…are often denied the little protection that mental health law can provide”. Box 2, p. 15, states “The Case Against Coercion.”

Box 3, p. 19, lists the CRPD’s “rights-based approach to mental health”, including legal capacity, liberty and security of person, free and informed consent, independent living, community inclusion and access to justice. Obviously, psychiatry routinely violates these contractual rights. In fact, current psychiatric practice is the polar opposite of these principles.

All these sins are placed before the pedestal of what they call the “biomedical model”, which I have been saying for years does not exist. It is defined in the Glossary, p. kiii:

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

Despite his central role as the source of all bad things in psychiatry, there is only one reference to this legendary entity, a paper by Brett Deacon from 2013. I quickly found my copy and double-checked it in case I missed something: No, I was right. There is nothing in that paper to say that such a model actually exists. It remains the case that no psychiatrist, or neuroscientist, or philosopher, or psychologist has ever written anything that constitutes a reductionist model of mental disorder. Of course, there are tons of people who believe that all mental disorders are a biological disease of the brain (see Deacon’s paper above and mine here for lists of citations), but believing is not the same as proving. They may believe it, but if philosopher Daniel Stolyar is right (and he usually is), they’re wasting their breath: there will never be a physical manifestation of mental disorder.

Instead of the dark “biomedical model”, Guidance proposes human-centered, rights-based, community-based, and accountable psychiatry. The other two chapters are a detailed explanation of how mental health legislation should be written and tested for compliance with the CRPD and the other eight relevant treaties to achieve this far-reaching goal.

This imposing publication inevitably leads to two conclusions:

1. 1. Psychiatry routinely, systematically violates practically every internationally sanctioned human rights law and treaty, completely without scientific justification; and
   2. Apart from psychiatrists, the world is moving away from the idea that when it comes to mental disorders, the forms and standards of management from a hundred years ago are perfectly fine.

Here’s the dilemma: According to the world’s leading health and human rights bodies, psychiatry must change. How many? This much: “Disenfranchisement, coercive practices, and institutionalization must end.” So far, no one has told psychiatrists and, as my little exchange with the editors has shown, they are not particularly interested. However, knowing psychiatrists, they will fight tooth and nail to resist change, and thus an irresistible force meets an immovable object.

The goal of psychiatry, as we know all too well, is to medicalize everything they can get their hands on. Anyone who doesn’t like this is clearly “anti-psychiatry” (not to mention dangerous, biased, extreme and a tool of Scientology). While the UN authorities will do the right thing, consult widely and slowly build their case, we know that at the slightest hint of a threat, the psych/pharma axis will run screaming to their friends in government to drop a very big hammer on the expulsions.

No doubt mainstream psychiatry around the world will have a collective fit when they see what the non-psychiatrists have planned for them. There is also no doubt that the transition to the practice model is foreseen in Guidance will require major changes in psychiatry. To begin with, any national training program would have to be rewritten in its entirety, but the greatest resistance will come from the attitudes and belief systems of the establishment. A change of this nature will take years and years to implement. In fact, many of the older crew would not be able to adapt and would have to be left in an old people’s home.

But we can be sure of one thing: given her record, institutional psychiatry will not let her down with good grace. I mean, look at the magazine editors: they don’t even want to know that WHO or OHCHR exist. They don’t realize that it is Guidance, as recently reported, is a gun pointed at the collective head of psychiatry. It’s not an encouraging start.