Human Rights and Mental Health: the Other Side of the Coin

Tom Benjamin, PhD

Tom is an Adjunct Lecturer and career psychologist. He was commissioned by the NSW Government to investigate allegations of human rights abuses in mental health. Tom is President of the Medical Consumers Association, an information resource founded in the 1970s by his UNSW colleagues.

The recent focus regarding human rights in mental health almost exclusively concerns the right of persons with a mental illness to access the best available care. Earlier, reforms were based on the abuses of mental illness diagnoses: in the 1850s, exploitation to seize estates or dispose of inconvenient persons (1), and in the 1950s, misuse against political or cultural dissidents (2).

The pendulum seems to be no longer swinging. Most government inquiries begin with an assumption of a high prevalence of mental illness, seldom tested against any evidence submitted. Position statements, such as from the World Health Organization (3), are from the perspective of persons with a mental illness or ‘treated as such’. They do not specify rights of the general public majority who do not have a mental illness. Further, claims that between 50% to 86% of the population have a diagnosable history of mental illness (4) give the impression that the two perspectives are the same.  

Challenges to these figures in submissions to Australian official inquiries, including the Productivity Commission (5) (6), are rarely mentioned in their final reports or addressed in government policy. Little of this will be brought to public awareness. Mental health providers and influencers provide human interest stories that fuel inquiries. Those who critique can seem unenlightened and uncaring. Celebrities have long urged young people to de-stigmatize and submit to medication as though it were an antidote, antibiotic or vaccine, and the psychiatric labels were harmless, even admirable.

Governments urged to do something about supposed crises are limited to funding and regulation. The paradox is that more protections and subsidies may make matters worse overall. In general medicine we expect a correcting feedback loop: more resources create public awareness, preventive actions, and new treatments, eventually reducing the incidence and impact. In the mental health sector we have created the opposite: an amplifying feedback loop, through stigma reduction campaigns, loosened criteria, and provider regulations which create a cartel structure.

Claimed detection and treatment effect sizes are related to the thresholds for classification of illness (7). Proliferating scales and clinician-ratings can create ‘false positives’. This feedback loop distorts the entire scientific underpinning. Artificially high base rates make even weak diagnostic methods seem accurate and weak treatments seem effective. More sensitive methods likely detect even more ‘noise’.  Over-diagnosed persons might show improvement, whatever treatment or placebo is used. This can be because there was less wrong with them in the first place. It can also reflect the vitalizing effects of popular drugs and talk therapies. Adverse effects might take longer to manifest. Rights are seldom perceived as needing enforcement, as persons over-diagnosed would see little reason to complain.

Insurance, disability, compensation, and medical benefits provisions funnel people who might want to discuss life problems into accepting a formal medical diagnosis to receive a disability classification or Mental Health Treatment Plan (8). Most are unaware that this legally requires them to concede a “mental disorder” that is disproportionate to circumstances, hence abnormal. Bullying or harassment claims commonly require a psychological injury, usually validated by medical diagnosis.

Some of the inflation impact is subtle, such as economic effects. The proliferation of credentials, registration hurdles, and supposed new methods makes it more costly for providers to enter the market and compete (14). Nor are the directly resulting downsides, such as increased wait lists and fees, acknowledged.

Until we revive this other side of the human rights coin we are likely to see these same trends continuing. We may have curtailed the abuses of the old asylums by closing them, but new abuses have been passed to the general population, who may be the true ‘innocent’ party. An accused criminal has ‘a presumption of innocence’ and some comfort from Blackstone’s ratio “that it is better that ten guilty persons go free, than that one innocent suffer”. Should we offer ten persons a wait list for labels and potentially risky, weakly-supported, expensive treatments so that one might benefit? Or, should we extend to the general public ‘a presumption of non-illness’?

References

1 Wise, S. (2012) Inconvenient people: lunacy, liberty and the mad-doctors in Victorian England. Chapter 3 The Alleged Lunatics' Friend Society. London: The Bodley Head. P.65.

2 US Congress (1972) Abuse of psychiatry for political repression in the Soviet Union: Hearing, Ninety-second Congress, second session, Part 1. Washington, D.C.: U.S. Government Printing Office.

3 World Health Organization (1991) Principles for the protection of persons with mental illness and the improvement of mental health care. General Assembly resolution 46/119. 17 December.

4 Caspi A, Houts RM, Ambler A, et al. Longitudinal Assessment of Mental Health Disorders and Comorbidities Across 4 Decades Among Participants in the Dunedin Birth Cohort Study. JAMA Netw Open. 2020;3(4):e203221. doi:10.1001/jamanetworkopen.2020.322

5 Raven, M. (2019) Submission #390 to Productivity Commission Inquiry into Mental Health

6 Consortium of Australian Psychiatrist-Psychologists (2019) Submission #260 to Productivity Commission Inquiry into Mental Health

7 Taylor, H. C., & Russell, J. T. (1939). The relationship of validity coefficients to the practical effectiveness of tests in selection: discussion and tables. Journal of Applied Psychology, 23(5), 565–578. https://doi.org/10.1037/h0057079

8 Medicare Benefits Schedule - Item 80100 M7 - Focussed Psychological Strategies (Allied Mental Health) https://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=80100&qt=item

9 Australian Privacy Principle 12 —Access to personal information https://www.oaic.gov.au/privacy/australian-privacy-principles/australian-privacy-principles-guidelines/chapter-12-app-12-access-to-personal-information

10 Farzadfard, S Ashrafzadeh, F Toosi, M Majd, H Shahabifar, M (2019) Efficacy of treatment with Fluoxetine in children with breath-holding spells. International Journal of Pediatrics; Walsh M1, 11 Knilans TK, Anderson JB, Czosek RJ (2012) Successful treatment of pallid breath-holding spells with fluoxetine. Pediatrics. Sep;130(3):e685-9. doi: 10.1542/peds. 2011-1257.

11 Schwarz, A. (2014) Thousands of Toddlers Are Medicated for A.D.H.D., Report Finds, Raising Worries. New York Times, May 17

12 Caspi A, Houts RM, Belsky DW, Goldman-Mellor SJ, Harrington H, Israel S, Meier MH, Ramrakha S, Shalev I, Poulton R, Moffitt TE. The p Factor: One General Psychopathology Factor in the Structure of Psychiatric Disorders? Clin Psychol Sci. 2014 Mar;2(2):119-137. doi: 10.1177/2167702613497473. PMID: 25360393; PMCID: PMC4209412.

13 Jones, D (2020) A radical idea suggests mental health conditions have a single cause. New Scientist. 22 and 25; January. https://www.newscientist.com/article/mg24532660-500-a-radical-idea-sugg…;

14 Kashdan, T (2014). Why Are Deepak Chopra & EMDR Important for Science and Life? Pseudoscience wastes time, resources, and leads to public skepticism of science. Posted Feb 07, https://www.psychologytoday.com/au/blog/curious/201402/why-are-deepak-chopra-emdr-important-science-and-life