By Susan Inman Guest Blogger with an Introduction by Marvin Ross
On Monday, I discussed the recognition that Erin Hawkes-Emiru is receiving from British Columbia via their Courage to Come Back designation. As I pointed out, Erin was able to recover in large part because of forced treatment which she credits with saving her life. I was then going to write about the United Nations convention on the rights of people with disabilities which does not allow for the policies that saved Erin and saved countless others. However, Susan beat me to it in her article on the changes being proposed in BC which should concern us all as similar attempts are always being proposed in other jurisdictions. This is what Susan has to say:
BC Ombudsperson’s recommendations for improving involuntary treatment:
mostly good but also alarming
BC Ombudsperson Jay Chalke has released a new report: Committed to Change: Protecting the Rights of Involuntary Patients under the Mental Health Act. Most of its recommendations for protecting the rights of involuntary psychiatric inpatients are sensible. Chalke’s investigation, which led to this report, revealed that too often many of the procedures prescribed in the BC Mental Health Act aren’t being followed. Most of these involved failures to complete necessary legal documentation. Chalke’s plans call for retraining of hospital staff and physicians on these protections and regular audits of hospitals to ensure compliance is occurring.
However, Chalke has moved far beyond ensuring that current procedures are followed. He is now proposing that we introduce lawyers into involuntary care in ways that will likely be disastrous for many of the vulnerable people he is trying to protect. The new policy would see patients not just receive information about their options in regard to involuntary care, but actual advice (Recommendations #21 – #24). The supposedly independent staff supplying rights information and advice and then eventual legal counsel will be the taxpayer-funded services of the Community Legal Assistance Society (CLAS) , a branch of the Legal Services Society (Legal Aid BC). CLAS is not “independent” as the Ombudsperson requires. CLAS has a record of extreme opposition to contemporary, evidence-based psychiatry and therefore cannot give unbiased advice as required.
Last year, CLAS released a document about involuntary treatment, Operating in Darkness, that Chalke references in his report. A careful reading of the CLAS document shows how it is informed by an anti-psychiatry belief that involuntary treatment violates human rights. CLAS is the group, in the current charter challenge to BC’s Mental Health Act, that argues that all involuntary medical treatment of psychiatric patients, both inpatient care and mandated outpatient care, should be abolished. CLAS falsely claims, as will be discussed below, that proven antipsychotic medications are ineffective in helping recovery from psychosis and aiding release from involuntary hospitalization.
Chalke is clearly knowledgeable about mental illnesses. He writes that people who are detained are “suffering and in need of immediate treatment but, perhaps because of that illness, are unwilling or unable to accept it. In these situations, the state can step in with the greatest power it has – the right to remove a
person’s liberty by detaining and treating them.”
CLAS’s approach to severe mental illnesses is different than Chalke’s. In its 181-page document, it never acknowledges the existence of people who, when they become psychotic, are unable to understand that they need treatment. It is people with psychotic disorders, often schizophrenia or bipolar disorder, who often end up needing involuntary treatment at certain points as they try to manage these severe brain disorders.
CLAS’s approach to mental illnesses
CLAS’s Operating in Darkness strongly supports the controversial interpretation of the UN Convention on the Rights of Persons with Disabilities (CRPD) and its opposition to involuntary treatment. This interpretation is made by the CRPD Committee that is overseeing its implementation. Readers may think that because Canada ratified this document, provincial mental health acts that allow involuntary treatment are defying its principles. CLAS fails to mention that since Canada’s 2006 ratification, it has continued to maintain the right to use substitute decision makers (such as physicians) in cases where a person lacks the capacity to make a decision.
CLAS also never mentions that the CRPD Committee calls for the elimination of all mental health acts. CLAS never grapples with the consequences of these kinds of policies, which are the increasing incarceration of people with mental illnesses. The CRPD Committee goes even further and calls for the elimination of the “not criminally responsible” defense. This would mean that forensic hospitals, which treat people whose mental illnesses are understood to have caused their crimes, would be eliminated. Anyone convicted of crimes leading to incarceration, no matter how mentally ill they were or are, would be regarded as fully responsible for their actions and forced into the general prison population.
CLAS’s descriptions of medical treatments for mental illness do not reflect the neutral position the Ombudsperson wants. CLAS implies that medical treatments are worse than useless. It argues that anti-psychotic medications “do not combat psychosis like antibiotics combat bacteria” and instead are just used to “have a sedative effect that alters behavior.” This description fails to mention that antipsychotic medications are used to get people out of psychosis.
Psychosis is a condition characterized by delusions, hallucinations, and disorganized speech, thoughts or behavior that can make it impossible for people to manage daily life. CLAS’s source for its information is a psychiatrist for madinamerica, a site that rejects standard, evidence-based psychiatric practices. It focuses on the views of “psychiatric survivors,” people who believe they suffered from encounters with psychiatry and medications they didn’t need. CLAS’s approach to mental illnesses resembles the ideas promoted by this group. Its advice will encourage patients to reject involuntary treatment and to use CLAS’s legal services in review panels and in court challenges.
Vast research supports the benefits of antipsychotic medications to help people manage to live with severe psychotic disorders. One of the largest longitudinal studies (over 8,000 people) and longest (20 years) was recently conducted in Finland. In following up on patients treated for first episode schizophrenia, researchers found that “The lowest risk of re-hospitalization or death was observed for patients who received antipsychotic treatment continuously….”
Besides ignoring research that doesn’t fit with madinamerica’s views, CLAS also ignores testimony of people living with schizophrenia. While its document is full of comments from selected patients who don’t want involuntary treatment, it fails to include testimony from the growing number of people living with psychotic disorders who describe how involuntary treatment benefitted them. Some like Joseph Bowers ( have been learning to live with their illness over many years. Bowers writes,
I’m near seventy, healthy, a husband and father who is retired with enough money coming in. None of this could have happened without involuntary treatment. My civil liberties were not taken away when force medicated and treated. I was instead liberated from the tyranny of serious psychosis.
Vancouver based peer support worker and author Erin Hawkes recounts in her article “Forced Medication Saved My Life” the agony of her psychotic episodes before antipsychotic medication restored her sanity.
In this BC Schizophrenia Society educational video, Vancouver peer worker Bryn Ditmars describes what it was like to be psychotic and believe he was the messiah. Ditmars and a psychiatrist from Vancouver’s Early Psychosis Intervention program, as well as a parent, offer the kind of information that madinamerica and CLAS avoid.
Bowers, Hawkes and Ditmar, like many people in psychosis, had anosognosia, a brain based inability to understand that they were ill. Anosognosia is the reason psychotic people usually don’t want treatment. CLAS and madinamerica writers won’t acknowledge the existence of this condition, because once it is accepted, the flawed thinking in using a human rights argument to ban involuntary treatment can be seen. Leaving people trapped in psychosis and untreated is not a policy that a just, responsible society adopts; it ignores people’s rights to be treated and recover.
CLAS does mention the lack of adequate psychosocial treatments in psychiatric units. Introducing people to these additional treatments during this time can not only make the stay in the hospital more therapeutic, but can give them ideas about what to pursue in the future. However, CLAS supports the inclusion of the Hearing Voices Network. The Vancouver Hearing Voices Network’s study group, funded by taxpayers, studies the works favoured by those who agree with madinamerica’s approaches. For instance, this announcement advertises the kind of writer the group favours, in this case Will Hall. Hall is best known for explaining why and how people should stop taking anti-psychotic medications.
While CLAS’s anecdotes reject or minimize the value of antipsychotic treatment, my experiences in the community are very different. Antipsychotics, and brief involuntary treatment when needed, have allowed my daughter and her friends who live with schizophrenia to enjoy stable lives.
Why we need to learn from the US’s mistakes
The current situation in BC is part of a larger struggle in Canada, the US and internationally. Influential but misguided human and disability rights groups, with perspectives like those of CLAS, have exerted a wide influence on mental health legislation, policies and services. The US provides the most extreme example of what happens when these perspectives are allowed to be in control of federal government policies.
Despite its mandate to provide care for people with serious mental illnesses when it was established in 1992, the US Substance Abuse and Mental Health Services Administration (SAMHSA) experimented with promoting an increasingly de-medicalized approach to mental illnesses. It actively supported anti-psychiatry groups and policies. When a Congressional committee began investigating SAMHSA after the Sandy Hook massacre, it was headed by a lawyer. The investigations revealed that SAMHSA hadn’t include any psychiatrists or physicians among its over 500 federal employees; this discovery led to it appointing its first Chief Medical Officer, Dr. Elinore McCance-Katz. McCance-Katz eventually quit and wrote an expose ( in which she described the alternative beliefs, similar to those that CLAS supports, that dominated this powerful organization. In her article, “The Federal Government Ignores the Treatment Needs of Americans with Serious Mental Illness,” she wrote:
There is a perceptible hostility toward psychiatric medicine: a resistance to addressing the treatment needs of those with serious mental illness and a questioning by some at SAMHSA as to whether mental disorders even exist—for example, is psychosis just a “different way of thinking for some experiencing stress?”
The policies at SAMHSA had resulted in much less access to treatment for serious mental illnesses. The consequences are that individuals with serious mental illnesses like schizophrenia and bipolar disorder are now ten times more likely to be incarcerated than in a hospital bed. Finally, during the end of the Obama administration, Congress took action that resulted in the establishment of an Assistant Secretary of Health and Human Services. Appointed to that position, McCance-Katz now heads SAMHSA and a major goal is the treatment of serious mental illnesses. McCance-Katz not only recognizes the existence of anosognosia, but educates the workforce and the public about it.
One of SAMHSA’s major focuses now is the development of Assisted Outreach Treatment (AOT) programs, the extensively researched programs that reduce homelessness, re-hospitalizations and interactions with the criminal justice system. This is exactly the kind of program that CLAS actively opposes. In its challenge to the BC Mental Health Act, it made clear that it not only wants to stop any inpatient involuntary treatment, but opposes mandated outpatient treatment programs that now operate under extended leave services. People in these programs have shown that they need this additional support to avoid continual relapses. Participants are regularly assessed to see if mandated treatment is still needed.
In the US, prisons have gradually become the new mental institutions and federally funded legal advocates contributed to this problem. In its inception in 1986, the US Protection and Advocacy for Individuals with Mental Illness Act (PAIMI) was designed to protect this population from all kinds of abuses. It operates in the kinds of roles suggested for CLAS in the Ombudsperson’s recommendations. However, despite the intention, legal advocates focused on and became very skillful at blocking efforts to provide mandated treatment. PAIMI legal advocates persuade ill people who have been hospitalized to avoid treatment. In front of a Congressional committee, Joe Bruce ) explained how PAIMI legal advocates in Maine persuaded and assisted his very psychotic son to reject medications and get out of the hospital. The son went home and killed his mother whom he believed to be an al Qaeda operative. Once he was treated with medications he’d previously been persuaded he didn’t need, he came out of psychosis. He talked to reporters about how he misses his mother.
What Should Happen
The BC Ombudsperson’s recommendation for funding CLAS to provide rights advice to involuntary inpatients is dangerous. CLAS’s opposition to all involuntary psychiatric treatment will surely mean that they won’t simply provide information on rights and options for appeal. When we see how CLAS views contemporary psychiatry, we can understand how vulnerable people will be persuaded to resist treatments they need. Clinicians, like social workers and nurses, who have a background in working with patients with mental illness, can be trained to provide this service in a neutral manner. This would be much easier and less expensive than trying to train lawyers and legal advocates about severe mental illnesses if they are already ideologically opposed to involuntary treatment.
If, as recommended in the Ombudsperson’s report, legislation is proposed to hire CLAS to supply legal advocates to provide advice, to argue at every review panel, and to pursue court challenges of review panel decisions, there should be extensive publicity about these plans. Impartial lawyers on review panels are already present to ensure legal procedures are followed.
Investing significant funds to greatly expand the role of lawyers in mental health care will come at the expense of already underfunded mental health services.
For instance, for several years there has been great interest in having evidence-based cognitive remediation programs implemented in BC. The common cognitive losses accompanying schizophrenia and other psychotic disorders are extensively researched; these losses frequently appear before any other symptoms or any treatments begin. Cognitive losses include difficulty with concentration, problem-solving, short term and working memory, and judgment. It is these losses that are considered to be the biggest factors in the ongoing and widespread disability of this population.
The many families that I know who are supporting people with severe mental illnesses did not hear about any consultations that occurred in creating these alarming recommendations. Family caregivers for people with severe mental illnesses should be consulted about the services they want protected, those that need to be implemented, and their opinions about those that pose dangers. People struggling with severe illnesses are part of a population who are unable to represent themselves in contentious public debates, and they are certainly not represented by the psychiatric-survivor community with whom CLAS communicates.
Life is hard for people who, through no fault of their own, develop serious brain disorders. The larger community must ensure that misguided policies don’t make life even harder.