In June 2017, a report was read (download it here, it’s free) to the United Nations on the subject of mental health. This was the third annual report of the UN Special Rapporteur for health, or to give his full title, The UN Special Rapporteur on the Right of Everyone on the Enjoyment of the Highest Attainable Standard of Physical and Mental Health. This is a post that has existed since 2002, and you can read more about it here.
The report author, Dainius Pūrasis, is a university professor at Vilnius University, Lithuania. His background and experience is extensive and varied and this is not his first post at the United Nations.
The report is striking, to say the least. It is “…the result of extensive consultations among a wide range of stakeholders, including representatives of the disability community, users and former users of mental health services, civil society representatives, mental health practitioners, including representatives of the psychiatric community and the World Health Organization (WHO), academic experts, members of United Nations human rights mechanisms and representatives of Member States” (p3). Despite the global focus, all of this report seems to apply directly to the UK.
The Special Rapporteur sets out his position: “For decades, mental health services have been governed by a reductionist biomedical paradigm that has contributed to the exclusion, neglect, coercion and abuse of people with intellectual, cognitive and psychosocial disabilities, persons with autism and those who deviate from prevailing cultural, social and political norms” (p4).
Key to understanding the report is that it makes three central claims:
- The first claim is that, as above, science of bio-medical psychiatry is both dominant and reductionist. Throughout the report, psychiatry is described as resting upon poorly evidenced frameworks and that the primary result (purpose?) of these are a ‘narrowing of diversity’. Diagnoses are specifically mentioned in this regard. The report references a number of texts that are worth following up, a few of which are UK-based, such as ones by Joanna Moncrieff and by Anne Cooke, both of whom have been mentioned on this website in the past. It describes the abuse of evidence and the influence of pharmaceutical industries.
- The second claim is that the Special Rapporteur believes there is a grave contradiction between mental health laws which enable detention and forced treatment on the basis of illness and the human rights act/disability rights (this is not the first time the UN have indicated this). It is clear that the UK Mental Health Act (1983/2007) would come under this criticism. Not only does the report state that it is a contradiction, but that all such coercive practices should cease and the laws that support them be changed. Far from being a compromise that we must somehow live with, the report suggests that it is our professional imperative to prevent forced treatment and other coercive practices from occurring. The report specifically details ways in which the twin aspects of illness and dangerousness, necessary conditions for the use of the Mental Health Act, are both such thoroughly undermined concepts that in any case it should be impossible to apply the Act.
- The third claim is that there is essentially no public health approach for mental health. Mental health services are aimed at those with symptoms of distress/illness and there is no societal-level attempt at mental health promotion. The report suggests some priorities in this regard.
The report is in plain English, but digesting its implications is probably more difficult. For mental health nurses who identify as being ‘critical’, most of the arguments have at least some familiarity, although it is astounding to see them so well-articulated from such an exulted position! Some readers may have pored over another UN report by a different Special Rapporteur – the one for Torture or Other Cruel, Inhuman or Degrading Treatment or Punishment – in 2013, because it seemed to imply that all forced treatment should be banned. That report should certainly be widely read, there seem to be many unequivocal statements within it and it shows that this new report is part of an increasingly clear line of argument from the UN and not attributable to one ‘wildcat’ Rapporteur in 2017. There was much discussion about it on sites such as Mad in America. Careful reading arguably reveals there was a loophole, allowing the phrase ‘therapeutic purpose’ to be used to ‘trump’ the more clear statements throughout the rest of the report (see page 4). There may be readers of this latest report who are hoping for a similarly reassuring concession; one suspects they will be disappointed.
The criticism that there is no public health approach to mental health is thought-provoking and as we (a university-based Critical Mental Health Reading Group in the UK) discussed this we decided it would be like a smoking cessation programme that offered 1:1 advice, nicotine replacement therapy, cessation support groups, respiratory nurses and even hospital beds, but no advertising ban, no sport-sponsorship ban, no smoking in public places ban, no taxation, no legal battles with tobacco companies, no age-related sales restrictions, etc. However, in the report, the social factors that are listed as being determinants of poor mental health include such a diversity of highly prevalent adverse conditions that it is clear that a public health approach to mental health would be nothing short of a radical change in social and economic policy, with a far greater focus on the lives of women and children. It would encompass a new understanding of health for “families, schools, workplaces, communities and health and social services” (p16). Therefore a public health approach to mental health is a radically political agenda of social change – it simply could not be otherwise. De-stigmatisation campaigns and a ‘recovery model’ are definitely not a response that could be offered as an adequate response to this report. The report’s call for the overturning the MHA very carefully leaves no space for talk of ‘the least restrictive option’ or ‘best interests’ or ‘when there is no alternative’, either.
The all-important question is whether it will have any influence. The UK is a member state of the UN and arguments that we are radically out of step with the views of the UN must have some traction here, but we do not know if there are actually any obligations to a report like this. Perhaps this is a little similar to weapons inspections in Iraq – ignoring the UN turned out to be extremely ill-advised in the longer term, but it was possible for our government to do so at the time. It seems likely that the power that this report has is the power that we choose to give it. We can give it power by airing it, sharing it, discussing it and repeatedly making it clear that here in the UK we have a legal system towards mental health that the UN believes is fundamentally against human rights. We could and should be making our profound personal discomfort known about that; arguably it is a professional duty to share it with colleagues and service-users alike. Please refer to 3.4, 4.1, 4.2, 4.4, 14, 16.1, 16.6, 17.1 and especially 9.3 and 16.4 of our NMC Code of Conduct if you are in doubt.
Despite the enormous gap between the vision and the reality, to read this report is to pause, breathe deeply and to wonder if, even in a cynical world, change is not as impossible as it might seem. Could there really be a time when it would be illegal to force treatment upon or detain someone on the basis of their mental health? Can services be radically altered and resourced accordingly? Could we ever provide a service not dominated by spurious diagnostic categories and their dubious associated target and funding streams? Could we focus on doing something about the toxic environments and roles in which people are expected to live rather than just mopping up the damage? There is much to talk about.
This UN report is the document that should be being read right now on every ward and in every community mental health team in the UK.
Feel free to leave comments below.
Jonathan Gadsby, September 2017