Key to understanding the report is that it makes three central claims:
The first claim is that, as above, the Special Rapporteur does not agree with the science of bio-medical psychiatry. 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’s 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, and the report suggests 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 slip in and so 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.