Mental Health: from “bad” to “mad”: Medical power and social control

This is a section from the report filed by the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health to the UN Human Rights Council (A/HRC/44/48)

Summary of full report: In the present report, submitted pursuant to Human Rights Council resolution 42/16, the Special Rapporteur elaborates on the elements that are needed to set a rights-based global agenda for advancing the right to mental health. The Special Rapporteur welcomes international recognition that there is no health without mental health and appreciates the different worldwide initiatives to advance all elements of global mental health: promotion, prevention, treatment, rehabilitation and recovery. However, he also emphasizes that despite promising trends, there remains a global failure of the status quo to address human rights violations in mental health-care systems. This frozen status quo reinforces a vicious cycle of discrimination, disempowerment, coercion, social exclusion and injustice. To end the cycle, distress, treatment and support must be seen more broadly and move far beyond a biomedical understanding of mental health. Global, regional and national conversations are needed to discuss how to understand and respond to mental health conditions. Those discussions and actions must be rights-based, holistic and rooted in the lived experience of those left furthest behind by harmful sociopolitical systems, institutions and practices. The Special Rapporteur makes a number of recommendations for States, for organizations representing the psychiatric profession and for the World Health Organization.

Over-medicalization and threats to human rights

A. Context: from “bad” to “mad”. Medical power and social control

27. Many people from traditionally marginalized groups in society, such as people living in poverty, people who use drugs and persons with psychosocial disabilities, have been entangled by a holy trinity of labels: (a) Bad people/criminals, (b) Sick or mad people or patients, or (c) A combination of the two. Those labels have left such communities vulnerable to excessive punishment, treatment and/or therapeutic “justice” for conditions or behaviours deemed socially unacceptable. The result is an exclusionary, discriminatory and often racist pipeline from schools, streets and underserved communities into prisons, hospitals and private treatment facilities, or into communities under treatment orders, where human rights violations may be systemic, widespread and often intergenerational. The global mental health discourse remains reliant on this “mad or bad” approach and on laws, practices and the attitudes of stakeholders excessively dependent on the idea that mental health care is mostly about preventing behaviours that might be dangerous or require interventions based on medical (therapeutic) necessity. Those advocating rights-based approaches infused by modern public health principles and scientific evidence challenge the “mad or bad” dichotomy as outdated, discriminatory and ineffective.

28. The many global efforts towards decarceration and decriminalization are welcome, but attention should be paid to the attendant politics and policy shifts towards the phenomenon of over-medicalization, which raises significant human rights concerns. Whether confined or coerced on public safety or medical grounds, the shared experience of exclusion exposes a common narrative of deep disadvantage, discrimination, violence and hopelessness.

29. This pernicious form of medicalization presents challenges to the promotion and protection of the right to health. Medicalization occurs when a diversity of behaviours, feelings, conditions or health problems are “defined in medical terms, described using medical language, understood through the adoption of a medical framework, or treated through medical intervention”^[1]. The process of medicalization is often associated with social control as it serves to enforce boundaries around normal or acceptable behaviours and experiences. Medicalization can mask the ability to locate one’s self and experiences within a social context, fuelling misrecognition of legitimate sources of distress (health determinants, collective trauma) and producing alienation. In practice, when experiences and problems are seen as medical rather than social, political or existential, responses are centred around individual-level interventions that aim to return an individual to a level of functioning within a social system rather than addressing the legacies of suffering and the change required to counter that suffering at the social level. Moreover, medicalization risks legitimizing coercive practices that violate human rights and may further entrench discrimination against groups already in a marginalized situation throughout their lifetimes and across generations.

30. There is a concerning tendency to use medicine as a means to diagnose and subsequently dismiss an individual’s dignity and autonomy within a range of social policy areas, many of which are viewed as popular reforms to outdated forms of punishment and incarceration. Medicalization deflects from the complexity of the context as humans in society, implying that there exists a concrete, mechanistic (and often paternalistic) solution. That reflects the unwillingness of the global community to confront human suffering meaningfully and embeds an intolerance towards the normal negative emotions everyone experiences in life. How “treatment” or “medical necessity” is used to justify discrimination and social injustice is troubling.

31. A dominant biomedical approach has led to States justifying their authority to intervene in ways that limit the rights of individuals. For example, medical rationales should never be used as a defence or justification for policies and practices that violate the dignity and rights of people who use drugs. While efforts to move responses to drug use away from criminalized models towards health-based ones are welcome in principle, it is important to raise a caution about the risk of medicalization further entrenching rights abuses against people who use drugs. Medicalized responses to address addiction (particularly when framed as a disease) can reflect parallel coercive practices, detention, stigmatization and the lack of consent found in criminalized approaches. Without human rights safeguards, these practices can flourish and can often disproportionately affect individuals who face social, economic or racial marginalization.

32. Forced interventions in mental health settings have been justified because of determinations of “dangerousness” or “medical necessity”. Those determinations are established by someone other than the individual in question. Because they are subjective, they require greater scrutiny from a human rights perspective. While people worldwide are fighting for the unshackling of people with serious emotional distress, the physical chains and locks are being replaced by chemical restraints and active surveillance. The gaze of the State and the investment of resources remain too narrowly focused on controlling the individual with “medical necessity”, commonly invoked as grounds to justify such control.

33. Despite the absence of biological markers for any mental health condition^[2], psychiatry has reinforced biomedical and acontextual understanding of emotional distress. Because of the lack of a comprehensive understanding of the aetiology of, and treatment for, mental health conditions, there is a growing trend that urges a transition away from medicalization^[3]. There are growing calls within psychiatry for a “fundamental rethinking of psychiatric knowledge creation and training” and a renewed emphasis on the importance of relational care and the interdependence of mental and social health^[4]. The Special Rapporteur concurs but calls on organized psychiatry and its leaders to firmly establish human rights as core values when prioritizing mental health interventions.

34. When considering initiating treatment, the principle of primum non nocere, or “first do no harm”, must be the guiding one. Unfortunately, the burdensome side effects resulting from medical interventions are often overlooked, the harms associated with numerous psychotropic drugs have been downplayed and their benefits exaggerated in the published literature^[5]. The potential for overdiagnosis and overtreatment must therefore be considered as a potential iatrogenic effect of current global efforts to scale up access to treatment. Additionally, the broader human rights and social harms produced by medicalization, such as social exclusion, forced treatment, loss of custody of children and loss of autonomy, warrant greater attention. Medicalization affects every aspect of the lives of persons with psychosocial disabilities; it undermines their ability to vote, work, rent a home and be full citizens who participate in their communities.

35. It is now widely recognized that the mass incarceration of individuals from groups in marginalized situations is a pressing human rights issue. In order to prevent mass medicalization, it is essential to embed a human rights framework in the conceptualization of, and policies for, mental health. The importance of critical thinking (for example, learning about the strengths and weaknesses of a biomedical model) and knowledge of the importance of a human rights-based approach and the determinants of health must be a central part of medical education.

References