Lock ‘em up.

Time for a debate on incarceration.

In traditional rural societies, people with severe mental disturbance were either given a job of looking after the animals, which often meant they lived with them, or they were pushed out on to the road, where they didn’t last long. In cities, they could do the same or, if too troublesome, they were locked in poorhouses and later in purpose-built asylums. In the 19^th Century, the program for building asylums was enormous because as fast as they were built, they filled up. Equally traditionally, the “treatment” of the unfortunates who were locked away was abominable. Aggressive patients were generally kept locked in cells, even shackled to the walls, for very long periods, and townspeople could come to the hospital and pay the keepers to look at the inmates screaming, moaning and rattling their chains. Treatment consisted mainly of bleeding, purging and blistering with mustard poultices and the “recovery” rate was terrible. In revolutionary France, two physicians, Jean-Baptiste Pussin and Phillipe Pinel, were convinced the “treatment” was worse than the disease and began unlocking patients as the basis of their “moral therapy.” Despite dire predictions, many of them actually improved but apparently the lesson needs to be relearned every generation or so.

Anybody with any interest in the field of mental health should see two very readable history books. The larger, by Andrew Scull [1], who is now in San Diego, looks at the whole field of psychiatry in the US, while Anne Harrington [2], of Harvard, focuses on the search for biological causes of mental disorder. A reviewer said of the latter:

[I]t’s a tale of promising roads that turned out to be dead ends, of treatments that seemed miraculous in their day but barbaric in retrospect, of public-health policies that were born in hope but destined for disaster.

Objectively, it seems we leap from one “miracle cure” to another but one part of the story hasn’t changed since Pinel: the way the larger society feels it has the right to snatch mentally-troubled people from the streets or from their homes, lock them away and force them to take whatever “treatment” is in vogue. Despite all the time and money and prestige poured into the search for the “biological cause and treatment” of mental disorder, until recently, practically nobody asked why we still lock up the mentally-disordered. We are constantly told mental conditions are of the same nature as physical illnesses but, if that’s true, why are physically-ill people able to refuse treatment when the “mentally ill” can’t? There is no convincing argument for this contradiction: the only reason is “That’s the way it’s always been.”

Obviously, the next question is: “Should incarceration continue?” Is there something about mental disorder which says it must be treated differently from all other human states, by suspending the sufferer’s most fundamental human rights indefinitely? Prisoners in Queensland have more rights than people detained under the Mental Health Act. I’ve never seen any half-sensible attempt at answering that question but it may fall by the wayside before long as there is mounting pressure simply to dispense with it. In recent years, an important international convention and several UN bodies have said it is time to get rid of all involuntary treatment, including for mental disorder. The 2006 Convention on the Rights of People with Disabilities (CRPD) states quite clearly that there is no place for involuntary treatment and it must be phased out. More recent reports by the UN Special Rapporteur on the right of everyone to the highest attainable standard of physical and mental health say the same (here and here). There is a difference between involuntary treatment and treatment without full consent: obviously, a person brought to hospital while unconscious can’t give informed consent but has a reasonable expectation that common sense would prevail.

If that’s not enough, the UN Convention Against Torture (UNCAT) covers all detained people and their treatment, and mental patients are both detained and treated. Torture is defined by the person on the receiving end, not by the perpetrator: the intention doesn’t matter. All that counts is whether the victim experiences it as torture, and many patients experience psychiatric treatment as torture. Therefore, it has to stop. That should be the end of the story but since countries like Australia specialise in slithering out of their international obligations, it is still the case that large numbers of people who have broken no laws are locked up and their human rights suspended in the very long term. Even though everybody says they mean well, they’re only doing it for the benefit of the poor mental people, I’m not aware that there has been anything like a serious debate on the matter.

Compounding the loss of their freedom, detained patients can be placed in “seclusion,” meaning solitary confinement. This is intended to be a short-term measure, usually a few hours or days, restricted to people who are violent or uncontrollably noisy and disruptive. All too often, it becomes long term. I don’t know any figures but it has happened that people have been kept in “seclusion” for years, and often shackled as well. It has to be remembered, which it never is, that this is very, very expensive. I saw one man who had spent decades in and out of high security wards, including long periods in seclusion and many months shackled to his bed. Using figures provided by the department, I worked out that his “treatment,” which had been spectacularly unsuccessful, had cost about $14million. That’s a lot of money. What it meant was that thousands of people who needed short term treatment got nothing. This happens a lot in psychiatry, where a small proportion of troubled people get the great bulk of funds and attention, while the majority get very little (power law distribution, sometimes called the 80:20 rule although in psychiatry, due to private hospitals, more like 90:10). While the various medical associations bleat about chronic underfunding, lack of money isn’t the problem, it’s misallocation of funds that needs to be addressed.

A lot of this comes about because psychiatrists are incapable of admitting that their treatment isn’t working (because if it doesn’t work, it could mean that the model is no good, which nobody is allowed to say). Invariably, their response is “More of the same.” If 20 ECT doesn’t work, give 40, then another 40; one lady I met had had 392 ECT over 15yrs with no effect apart from bankrupting her. And more of the same leads directly to what is now called “Long-term seclusion,” LTS to the in-crowd. Some people are not just kept in a locked ward and forced to take large doses of drugs, but are actually kept in a single room with no contact with other patients or with nature for years.

In a seminar last week, the local college of psychiatrists discussed a case of a woman in her fifties who emerged from six years in seclusion. Now she didn’t start her career in psychiatry in the seclusion cell of a locked ward, stunned on half a dozen drugs. Like everybody else, she started as an outpatient on one drug, then two, then three, then in an open unit, then moved to a closed unit, more drugs, change all the drugs, double the doses, in the lock up, out again, back in and there she stayed for six years. Finally, it occurred to the staff that perhaps they should move her out again. Over about 4 months, this happened and she now lives in supported accommodation in the community and is apparently quite happy. Interesting story but … Yes? So? Isn’t that normal? Shouldn’t discharge planning start the day of admission? There was no indication in the talk that anything had changed, no miracle drugs or therapeutic epiphanies. They were not doing anything we weren’t doing thirty years ago. It seems the staff simply decided “Well, six years is long enough, let’s get her out so somebody else can have a go.”

At some point, the speaker mentioned that California (whose population is about six times bigger) has no patients in LTS. It seems that some years ago, the governor simply decided to ban long term seclusion. Granted, at least 15% of inmates in the vast California prison system are seriously mentally ill and are getting long term seclusion that way, but their hospitals seem to be able to manage without it. As, for large parts of my career, did I, just because it wasn’t available. So: if some psychiatrists can manage without this medieval punishment, is there any reason why all can’t? (this is also true of ECT [3]). Yes, there is a reason. On the very rare occasions psychiatrists asked me how I managed without seclusion or without ECT, I replied: “I talk to them.” That always ended the conversation.

One thing we can be sure of: if and when the debate over locking people up takes place, the institution of psychiatry will be squealing that it is indispensable, essential, vital, effective, safe, and patients are oh so grateful afterwards. All without offering any evidence at all, just because there is none. However, I think it goes deeper as involuntary treatment, incarceration and seclusion play an important role in the narrative of a “scientific biological psychiatry.”

Mainstream psychiatry says mental disorder is a genetic disturbance of brain function. Patients have no control over the direction of their lives just because they got a bad deal in the genetic lottery. It also says that whatever patients think is the cause of their woes, it isn’t that. They may think that problems at work have caused depression but psychiatrists, being trained in this sort of thing, know that, really, the depression caused the problems at work and when the depression is properly treated, all those problems will melt away. This was carefully explained in an interview earlier this year by Prof. Ian Hickie, where he made it quite clear that depression causes bad life events, not the other way around:

Hickie: ... you are depressed. That's why you're having trouble with intimate relationships, kids, work, finances ...

Interviewer: ...it's not that your work stress is causing your depression. You're having issues at work because you're depressed ... a lot of people do think that depression is caused by life events.

Hickie: This is the number one myth ... The depression came first ... (the crisis in life) is not the cause (of the depression), it's the consequence … for most people, (childhood) is not the cause (of depression) … people come in and (ask), what caused it? I (say) we're never really going to know the answer to that.... let's not dwell on that, okay? Let's stop blaming your mum. Let's stop, because we'd probably never really going to know.

Moreover, the genetic disease of the brain distorts thinking, it makes them want to talk about irrelevant stuff like bad bosses at work, difficult husbands, being mistreated at school and all that when all they have to do is fill in the questionnaire, answer a few more questions, then collect the prescription. If they get annoyed or even refuse proper treatment, well, that’s their diseased brains talking and we can’t let a diseased brain make vital decisions, can we?

If, however, people were free to choose who they saw for mental problems, how many would go for the talking cure compared with drugs? That is, in order to stop people voting with their feet, psychiatry must have the power to detain them and impose their version of treatment by force.

Worse still, if they went to talk therapists and then got better without drugs, as most would, what would that say about the “diseased brain” trope? For psychiatrists committed to the biological narrative, as the good Prof. Hickie is, that would not be good news.

The biocognitive model for psychiatry says that the urge to dominate is an integral part of human life. Hard-wired in all humans is powerful biological drive to dominate that needs to be trained and disciplined right from birth, otherwise we’d all be at each other’s throats (as though we’re not, but that’s a separate matter). Now psychiatrists are actually human, which says their biological drive to dominate is just as strong as everybody else’s, and that’s pretty strong. In fact, medical training tends to select against passive or submissive people. Medical students choose themselves, mostly on the basis of wanting to help people and make their lives better, which can easily become an urge to take charge – but always for the best of intentions, of course. On balance, therefore, you would expect psychiatrists to be more inclined to dominate and control people than the average citizen, or even the average physician, and I think this is the case. Of course, the other side of the human drive to dominate is a drive to avoid it, a fierce need to oppose being forced into submission. To paraphrase Newton’s Third Law, for every human force to dominate, there is an equal and opposite human force to resist. You can’t have one without the other.

This is equally true in psychiatry as in the playground. On one side, practically every interchange in psychiatry involves a more or less dominating psychiatrist equipped with a doctrine that says: “I know best. Nothing you believe about yourself is worth listening to. If you argue, that’s because your brain is diseased and we have to fix it.” On the other side is a more or less resistant patient who feels “The hell you do.” Since the social power structure is heavily, if not totally, on side with the psychiatrist, we have a recipe for trouble. If the patient reacts badly to being pushed around or interrogated, then the psychiatrist reaches for the alarm bell on the basis that the patient’s sick brain is playing up. What the psychiatrist doesn’t do is ask: “Oh dear, did I just mess that up?”

The power structure creates friction, which is manifest as anger and aggression, which, in a self-reinforcing loop, invites repression and convinces the psychiatrist that patients are dangerously unpredictable. Now I don’t think this came about by forward planning, aka conspiracy. My (long) experience of small towns in Australia and village life in traditional societies (southern Thailand, early 1980s) says that people are generally tolerant of mental disorder except for threatening or violent behaviour or sexual misconduct. Then the person will be removed, but cities are different. People seem to be much less tolerant, mainly because they don’t know the disturbed person and don’t know what to expect or how to control them. Removal is probably going to involve force and then detention, even though the sufferer has broken no laws. One thing leads to another until we have an entrenched system where swarms of deeply controlling people make their living from a captive population. In a hospital, nursing and other staff, domestic and management outnumber psychiatrists by perhaps 40:1 but they all need those patients coming through the door. Politicians meddle with this vast structure at their peril.

As mentioned, under the UN Convention Against Torture, torture is defined by the recipient, not the perpetrator. Solitary confinement is deemed torture, so seclusion, which is solitary confinement by a different name, amounts to torture and is therefore banned. QED. But when the decision to seclude a mentally-disturbed person is left to a profession composed of fairly domineering but intensely self-righteous people who (believe me) are hostile to questioning or criticism, and whose incomes depend on having lots of severely disturbed/dangerous people around, then you have the ingredients of a dangerous cocktail.

A final question regarding the woman who endured six years of defined torture: If she could be moved so easily after the decision, how come she was there so long?

References:

1. Scull A (2022) Desperate Remedies: Psychiatry and the mysteries of mental illness. London: Penguin.

2. Harrington A (2020). Mind Fixers: Psychiatry's Troubled Search for the Biology of Mental Illness. New York: Norton.

3. McLaren N (2017). Electroconvulsive Therapy: A Critical Perspective. Ethical Human Psychology and Psychiatry 19: 91-104. DOI: 10.1891/1559-4343.19.2.91