Should We Lock People Up?

But that’s what we’ve always done.

A colleague I’ve known forever, now slowly disengaging after a lifetime of mixed academic and public psychiatry, asked:

I know you are against involuntary treatment, but what should we do about obviously psychotic people behaving in a dangerous manner in public with risk of harm to themselves and/or others. I’m talking about manifestly psychotic people who will not listen to reason, negotiate or stop behaving in a seriously disturbed manner (e.g. a manic person insisting on directing traffic in the middle of town). Even the Quakers, who set standards for the humane treatment of the mentally ill, found it necessary, at times, to restrain people and sedate them against their will. In your opinion, who should do what about overtly psychotic people imposing their psychosis on other people.

The UN Convention on the Rights of Persons with Disability (CRPD) states:

Art 15(1): 1. No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment [1].

People who have experienced involuntary psychiatric treatment regularly label it “torture.” Torture is defined by the victim, not the perpetrator. The UN Guidelines on human rights in mental health legislation, issued by World Health and the Human Rights Commissioner in 2023, states:

The CRPD sets obligations on States Parties to revisit their mental health systems to end all forms of coercion and to develop non-coercive responses that respect the rights of service users. This implies rethinking the role of legislation – from a focus on restrictions of rights to the provision of support to guarantee them [2, p27].

In repeated reports [e.g. 3], the recent UN Rapporteur on mental health etc., Prof Dainius Puras of Lithuania, strongly opposed the excessive medicalisation of mental disorder as it ignores the social determinants, such as poverty, oppression, abuse and deprivation, etc. It leads to “.. the inappropriate use or over-prescription of psychotropic medications and the use of coercion and forced admissions …” [3. Pt 66]. In turn, this results in “…a vicious cycle of discrimination, disempowerment, coercion, social exclusion and injustice…” [3, pt 80].

That would seem to the be the end of the matter: international human rights law says the world must move to a model of mental health care that does not include deprivation of liberty and enforced treatment. Except it isn’t happening. The psychiatric profession is openly hostile to any suggestion that its power to detain and inflict treatment on people who have broken no laws should be restricted in any way [e.g. and predictably: 4]. Governments, as I’ve said often enough, don’t care. All governments know that while they win no votes for being nice to mental people, it’s easy to lose votes from not being tough enough, so that’s where they drift. Without getting bogged down in definitions, we can agree on certain points:

1. There are people who, apparently under the influence of mental disorder, act in a manner dangerous and/or seriously disruptive to self and others;

2. Society has determined that, regardless of their expressed wishes, it is appropriate to deal with them outside the judicial system;

3. Historically, management falls to the medical profession [5];

4. Since psychiatry has no published theories of mind or personality and no models of mental or personality disorder, it has no basis in science [6]; nonetheless …

5. Society leaves to psychiatrists the authority to determine what is mental disorder and how it is to be managed;

6. Despite nods in the direction of “patients’ rights,” and buttressed by weighty legislation, psychiatric treatment of these people consists overwhelmingly of coercive management in a custodial setting;

7. Currently, mainstream psychiatry is almost exclusively biological in orientation, justified by an unwritten “biomedical model,” with lip service only paid to psychosocial factors.

A few psychiatrists will whinge about points 4 and 7. We needn’t take any notice of them until they produce copies of their favourite models which, despite their truculence, they never do. Putting that aside, psychiatry claims to be “evidence-based.” Evidence-based practice (EBP) is the “…process of using the best available scientific evidence to inform clinical decisions. It involves integrating research, clinical expertise, and patient preferences to improve patient care.” That’s a bit silly as “patient preferences” lie firmly outside the field of science, but it sounds better than “Shut up, we’re the experts here.”

Next question: Evidence for what? I look outside my window now and see evidence, lots of it, but how do I decide what’s evidence and what’s nonsense? Evidence is evidence for something, and that’s where the model comes in. It sorts the pearls from the ordure, it tells us “This is relevant, but that’s coincidence or misleading or not science, etc.” However, since psychiatry doesn’t have a model, it’s flying blind, guided only by the psychiatrist’s inclinations, aka prejudice. For example, 19yo Ms GK was taking seven (7) different psychiatric drugs, including three (3) antipsychotics (in her short life, she had been prescribed at least 25 different drugs, while steadily getting worse). She complained of a lot of abdominal symptoms, including bloating and cramping pain, constipation alternating with bouts of smelly diarrhoea, etc. She was told she had “Somatising Disorder” and needed more drugs. In fact, she had a partial bowel obstruction due to faecal impaction caused by her many drugs and responded well after drug withdrawal and other specific treatment.

In the absence of a model of mental disorder, psychiatrists see what they want to see and treat how they like, but they call it “evidence-based” to stop criticism. The rationale is “We give the treatment that works,” but that carries no weight: all physicians believe their treatment works, that’s why they do it, regardless of any damage it may be doing, e.g. antidepressants causing suicides. The belief comes before the facts; when the treatment fails, they don’t ask “What did we do wrong?” they ignore or suppress the facts, blame the patient and double the treatment. And patients don’t like it, which is why they resist and are then forcibly detained.

Psychiatrists will say: “But we don’t detain the patient and order treatment, the mental health tribunal does that.” This can’t be taken seriously. With only the rarest of exceptions, tribunals order what the hospital asks for. They are a complete waste of time and money. The process of detaining a patient, which once took one practitioner about three minutes, now takes half a dozen highly-paid people hours to listen to the recycled reports then pick up the rubber stamp. Tribunals are “quasi-judicial,” meaning they have the appearance but not the substance of a judicial process; they operate in secret with practically no rights of appeal; they are intensely supportive of mainstream psychiatry; they cost a fortune (in Queensland in 2023, $19million) and do not change the outcome; they dilute responsibility instead of focussing it; they use unsworn and hearsay evidence to deprive people of practically the whole of their human rights for as long as they like; the great majority of patients have no legal representation or, when they do, the lawyers are simply adversarial; patients rarely see or understand the documents submitted about them; and even fewer patients understand what’s going on over their heads. Oh, and if you think psychiatrists are hostile to questioning or criticism, wait until you try to get something out of the tribunals or, quel horreur, question them.

Finally on this point, there is no evidence that involuntary treatment is worse than no treatment. Apart from the natural experiments afforded by countries with little or no mental health services, there has never been a sufficient trial of “masterly inaction.” My experience, working in public hospitals and in private, in isolated areas and in urban regions, is that detention and involuntary treatment are seriously over-used (by which I mean abused) by mainstream psychiatry, and the reason is “risk management.” However, it is not the risk to the patient or the risk the patient represents to other people, it is the risk to the hospital: “If we don’t detain this person and something goes wrong, we’ll be exposed, so we’ll bang him up.”

In turn, that comes precisely from what Dainius Puras was talking about in his lengthy and carefully-considered reports: it is the reliance on the “biology” of mental disorder, while ignoring psychosocial factors, that leads psychiatry to enforce treatment. In brief, mainstream psychiatrists don’t know their patients as people, and don’t believe that anything so airy-fairy as (snigger, smirk) psychology can influence mental disorder, so they believe there is no option but to lock everybody up and spray them with drugs. However, that means the true causative factors aren’t addressed and the patients become resentful and mistrustful, so the whole thing enters the vicious circle Puras identified: Far too many people are detained for far too long for inadequate or wrong reasons by a system that is heavily biased against the patients and is intolerant of being challenged. In brief, modern psychiatry is a system designed to make things worse, with the fortunate benefit of making psychiatry seem indispensable.

For the many people who say “You can’t make an omelette without breaking eggs,” it’s important to look at psychiatry’s ghastly history [5]. As I said, psychiatrists always think they’re doing the right thing, that’s given, but it can’t be taken at face value. It’s not just that they always think they’re doing the right thing, it’s that they believe they can’t do the wrong thing, and anybody who criticises is either stupid, malicious (“anti-psychiatry”) or a deranged patient who clearly needs more treatment, not less. Anybody who gains the trust of a detained patient of mainstream psychiatry will hear the same things: “Nobody listens to me, they don’t take any notice when I say their treatment isn’t working, they get angry and threaten me. It’s noisy here, I can’t get exercise, the food is crap and I’d rather take my chances outside.”

In 1973, there was a paper published in the journal Science which caused uproar in psychiatry. Psychologist David Rosenhan’s famous experiment with “pseudo-patients,” titled On Being Sane in Insane Places, raised serious questions on whether psychiatrists actually knew what they were doing (it’s now freely available online). Since he died some twelve years ago, there have been doubts about his methods and, in fact, whether it actually took place, but they miss the point. What counts is that what he described was accurate, and there is more evidence from as long ago as 1897. In that year, one of the pioneering women reporters in the US had herself admitted to the women’s asylum on Blackwell’s Island, presumably now Roosevelt Island, in the East River between Manhattan and Queens. Writing as Nellie Bly, Elizabeth Cochrane Seaman described her experiences in a series of articles, later published as a book, Ten Days in a Mad-House [8]. This had a huge effect on public opinion but it’s still relevant.

While she was still in the notorious Bellevue Hospital, another patient said to her: “The doctors refuse to listen to me and it is useless to say anything to the nurses.” After her second of four interviews with a doctor, Bly said: “I felt sure now that no doctor could tell whether people were insane or not, so long as the case was not violent.” When arriving at the asylum, she was horrified by what she saw: “…how much easier it would be to walk to the gallows than to this tomb of living horrors! … Who would not rather be a murderer and take the chance for life than be declared insane, without hope of escape?” Of the regular beatings and wanton violence of the nurses, she said: “It was hopeless to complain to the doctors, for they always said it was the imagination of our diseased brains, and besides we would get another beating for telling … we knew the doctors would not help us.” However, it was the dire self-certainty in the doctors that they could do no wrong that crushed her:

I always made a point of telling the doctors I was sane and asking to be released, but the more I endeavoured to assure them of my sanity, the more they doubted it…. ‘Try every test on me .. and tell me am I sane or insane?”… They would not heed me, for they thought I raved.

The dreadful food, the numbing cold of the draughty halls, the noise and foul smells, the brutal attitudes of the staff, the violence, the unpleasant and ineffective treatment … How many times do we have to hear this? As Nellie Bly noted in Chapter 12 of her report, there were 1,600 women incarcerated on the Island but she was sure that many of them, especially those who didn’t speak English, were perfectly sane:

What, excepting torture, would produce insanity quicker than this treatment? Here is a class of women sent to be cured. I would like the expert physicians who are condemning me for my action, which has proven their ability, to take a perfectly sane and healthy woman, shut her up and make her sit from 6 A.M. until 8 P.M. on straight-back benches, do not allow her to talk or move during these hours, give her no reading and let her know nothing of the world or its doings, give her bad food and harsh treatment, and see how long it will take to make her insane. Two months would make her a mental and physical wreck.

Every enquiry into mental health services anywhere in the world dredges up the same complaints but it will continue, it will never stop as the failures are built into the system. Part of it comes from psychiatry’s intractably self-righteous attitude: “We’ve got the science so we can’t be wrong. Anybody who criticises us is either a fool or malicious. Or both.” I criticise. In the first place, psychiatry doesn’t have the science. In a rather testy exchange in our small critical psychiatry group (Jan 25^th 2025), I said:

At the risk of sounding like a cracked record, there is no "biomedical model." It does not exist. No psychiatrist has ever penned anything that would amount to a reductionist model of mental disorder. The whole thing is ideology …

This provoked a well-known professor:

It’s ridiculous to say there is no biomedical model. You may think they are wrong, but there are many biomedical models of psychiatric phenomena. It’s like denying the existence of Scientology…

On being invited to name some of these models and provide full references, all that arrived was this:

Anyone familiar with any biomedical model of mental disorder can immediately reject your hypothesis. For example, anyone who has heard a theory that argues depression is caused by a chemical imbalance can say with certainty at least one biomedical model of mental disorder exists. It may not be true, but it exists.

It exists, but it’s wrong. Sorry everybody, my fault. I assumed that everybody would understand that the expression “scientific model” meant “valid.” On his basis, we could say that possession states, or spells and other witchcraft, etc., are scientific models as, even though they’re wrong, they do exist. But when it comes to psychiatry, the “chemical imbalance” trope is not a model, it is just a vague hope to be explored, and I don’t think that’s a sufficient “scientific basis” to justify involuntary treatment. So I’ll stand by my statement: “No psychiatrist has ever penned anything that would amount to a reductionist model of mental disorder.” I’m waiting for somebody to prove me wrong.

The second reason psychiatry can’t deliver a humane service is much deeper: humans are not humane. The natural state of Homo sapiens is to form dominance hierarchies, where those at the bottom get crushed so that those at the top can feel better about themselves [9]. People who are stripped of their civil rights, locked up, denied their own clothes and possessions, told when and where to eat or sleep, and forced to take drugs they don’t want, just are at the bottom of the hierarchy, even below convicted prisoners. 130 years after brave Nellie Bly’s experiment, it still doesn’t get worse than being banged up in a mad-house. Once in that position, people are utterly exposed, they can’t defend themselves because that’s what hierarchy means. As we know from Phillip Zimbardo’s infamous Stanford prison experiment, from Stanley Milgram’s experiments, and from history, simply putting a person in a position of dominance encourages them to act in a repressive manner. This is genetic. All too easily, they slip across into gratuitous abuse or violence. It’s all very well to say “That shouldn’t happen,” but the temptation is too strong, the excuses to be repressive too readily at hand. “It was only a joke” becomes “They deserved it” and then “You swine, I’ll show you.”

The case for involuntary treatment is that sometimes, it seems necessary, especially when people misuse stimulant drugs. In any single case, we can’t tell the future, we don’t know what will happen so we act from caution. Fair enough, but let’s do so from a humane position where even the floridly psychotic person is treated as a person, not as a biological preparation. Working alone in the bush, with no facilities to detain people, I had to gain their trust, so that’s what happened. I almost never used detention. If I can do it, so can all the clever psychiatrists in the city but they can’t be bothered, not least because they’d have to admit they’re wrong.

The case against involuntary treatment is that it is inherently abusive: it necessarily demeans the detainee; it is over-used; used for the wrong motivation; it brings out the worst in the detainers; and it breaches all notions of human rights. Oh, and it’s never been studied according to the standards of the “evidence-based” science used to justify it, so we don’t actually know whether it works. But apart from that, it’s fine.

References:

1. UN OHCHR (2006) Convention on the Rights of Persons with Disabilities. 12 December 2006, resolution A/RES/61/106. https://www.ohchr.org/en/instruments-mechanisms/instruments/convention-rights-persons-disabilities

2. UN OHCHR/WHO (2023): Mental health, human rights and legislation: guidance and practice. Geneva: WHO/UNHCR. https://www.who.int/publications/i/item/9789240080737

3. Puras D (2020). UN Human Rights Council. Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. UNHRC Document A /HRC/44/48. Final report: July 16^th 2020, UN Doc. A/75/163. At: https://undocs.org/A/75/163

4. Hickie, I, (2019). Building the social, economic, legal, and health-care foundations for “Contributing Lives and Thriving Communities”. The Lancet Psychiatry. https://doi.org/10.1016/S2215-0366(19)30378-5

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

6. McLaren N (2024). Theories in Psychiatry: building a post-positivist psychiatry. Ann Arbor, MI: Future Psychiatry Press. Amazon.

7. Rosenhan DL. 1973. On being sane in insane places. Science 170;70: 250-58. See Wikipedia http://en.wikipedia.org/wiki/Rosenhan_experiment for a brief commentary.

8. Bly Nellie (1897) Ten Days in a Mad-House. New York: Ian L Munro. https://en.wikipedia.org/wiki/Nellie_Bly (available online).

9. McLaren N (2023): Narcisso-Fascism: The psychopathology of right wing extremism. Ann Arbor, MI: Future Psychiatry Press. Amazon.

The whole of this material is copyright but can be quoted or transmitted on condition the author is acknowledged.