Myths bring to mind images Greek gods and primitive cultures. They’re considered vestiges of a pre-modern, pre-scientific era. But they do narrate our world, and colour our science.
People are aware of this. Thus you’re likely to read plenty of myth blogs this Mental Health Week. And surely plenty are good. They often attempt to tackle stigma (although I prefer the word discrimination). They will caution you against blaming people with mental health issues. They will challenge the assumption that people with mental health issues pose a physical threat. And they will implore you to discard beliefs that it is a moral failure. It is a physical illness, after all.
It’s this latter that point – that mental illnesses are just like physical illnesses – that needs further scrutinization. I believe it’s part of an emerging modern myth: that mental and emotional distress are just chemical imbalances.
This week will likely hear this term bandied around. Depression is the result of lowered serotonin levels in the brain. This is fixed by elevating those levels. Schizophrenia is a result of abnormal changes in dopamine function. We have various antipsychotics that serve as a cure. But we know these claims are not wholly true; they are their own modern myths.
We often see myths by looking in the rear vision mirror. But if you stop and look, you’ll see we’re creating our own in the present.
There are many grounds to worry about the physical-mental illness analogy. On a general level, the science does not support it. The DSM is not an objective or scientific account of mental disorder. Rather, it’s based on convention and cultural tides. In psychological terms, the real aim for the DSM – and perhaps this is all that we can reasonably expect at this stage – is to provide reliability, not validity, of diagnosis. However this poses questions about how we ground our diagnoses. The emergence and removal of particular diagnoses testifies to this. Our hysterical treatment of women, confused approach to non-cisgender people, clinical phobia of same-sex relationships, and deplorable approaches to race are evident.
Diagnosis in the DSM does not suggest cause. Thus issues may arise from trauma, behavioural learning as well as biogenetic causes. Of course there are physical substrates for distress. This doesn’t suggest that looking at someone’s amygdala is more useful than addressing that they were sexually assaulted. Explaining trauma responses exclusively in physical terms misses the point. It risks losing the chance to redress the cause, or in some instances could re-traumatize individuals.
This latter point speaks to a tension between biological and social models of disability. The former characterizes the dysfunction and disability within the individual. In this instance, as a result of a chemical imbalance in the brain. The latter shines the light on society. A person’s distress may also be the result of labelling, discrimination and social barriers to participation. By exclusive characterization of distress in physical terms, it hides socially disabling factors. Abuse, violence housing and marginalization are not visible in synaptic misfiring. But we continue with these explanations, with the knowledge that it won’t necessarily help.
So there are real reasons – scientific and social – to question this myth. So I want to ask what the questions: what are the origins of this myth? What is its function?
The origins of this myth cannot be neatly woven or conveniently collapsed into a single thread. There are many causes. There are many histories based on clinical, carer and service user experiences. Therefore different components will prove salient to you. Even so, there are some things we can say.
Much of contemporary imbalance discourse appears a reaction to the past. Psychiatry has a dark intellectual and social history. Its systematic involvement in slavery, eugenics and the Third Reich is often overlooked. Psychiatry has sought to break from this history. It does so by removing the Freudian and speculative explanations that showed no reliability. It also seeks to overturn the long-held idea that mental illness is a social and moral failing. Pulling yourself up by your socks is not necessarily possible. (Disagreement might emerge on the causes and responses)
While this approach seems well-intended, it doesn’t give us a break with the past. History is repeating itself, or as Cole would say, “Time is a Flat Circle“! For while we see a renewed focus on biological explanations, we fail to see psychiatric oppression of women, slaves, homosexual and non-cisgender people are based on these biological explanations!
So what function does this myth play? One is the cultural break with the past. It allows us to feel we have progressed beyond our pre-modern explanations of distress, to something truly scientific. We should be wary though of seductive neuroscience.
Another is the unfortunate role that pharmaceutical companies play in medicine and mental health. It’s important to remember that diagnostic categories and their explanations often came from the drugs. Moncrieff has consistently shown that while medications may provide life-saving treatment for people, this doesn’t confirm the chemical imbalance theory.
Moreover, keeping diseases within an individual also reinforces our liberal and capitalist ideologies. It separates emotional distress or dysfunction from our failures as a society to prevent gender based violence, find secure housing and reduce inequality. It’s a sedative on our collective moral consciousness.
Each of these responses to the origins and functions of the myth are dramatically under-explored. They would and should be open to debate. They are not designed for consumption and uncritical acceptance. It’s an invitation to critically evaluate the discursive construction of distress, during this important week.
Victoria Legal Aid recently undertook representation of a client who was subject to compulsory treatment. The VCAT found that the criteria for a Community Treatment Order was not satisfied that the treatment criteria in Section 5 of the Mental Health Act 2014 (Vic) had been satisfied.
In summary, they found: (1) that the person, while having a past diagnosis of schizophrenia, did not show a present serious disturbance of thought, mood or perception; (2) the person did not need immediate treatment as they demonstrated a capacity for self-care and seeking assistance as well as adequate family/community supports; and (3) that a less restrictive means was available – that being voluntary treatment in the community using the person’s identified supports.
Read VLA’s summary here.
Or read the full transcript here.
News out today from the Vic Gov that $152.5 million will be provided over 2 years for people needing secure housing after escaping family violence. See the press release from Minister Foley (also Minister for Mental Health) below:
Women and children escaping family violence will have greater access to a range of housing options with an initial investment in a housing blitz announced today.
Minister for Housing, Disability and Ageing Martin Foley announced the funding in response to the Royal Commission into Family Violence recommendations that called for the Government to immediately increase crisis and emergency accommodation options, to help victims to remain at home and to redevelop family violence refuges.
The Royal Commission highlighted problems around the lack of appropriate accommodation for victims of family violence, with many being turned away from accommodation. This funding is the first step in responding to the specific housing recommendations of the Royal Commission.
The $152 million package includes:
- $25 million over two years for accommodation for the homeless – this fund will support construction of 180 new units of crisis accommodation and upgrades of existing accommodation
- $21 million over two years to begin redeveloping existing refuges to the new core and cluster model and to provide 24 hour staffing at up to six refuges
- $50 million – rapid housing assistance – provision of 130 new social housing properties as a first stage and headleasing for up to 100 dwellings.
- $16 million in 2016-17 to provide private rental assistance that supports access to private rental
- $40 million over two years to provide flexible tailored responses that meet the individual needs of victims of family violence, including support to stay safe at home.
A Family Violence Housing Assistance Implementation Taskforce will be established, as recommended by the Royal Commission, to provide advice to government on Housing solutions for victims of family violence.
Quotes attributable to Minister for Housing, Disability and Ageing Martin Foley
“We know that Family violence is the main reason for women seeking assistance from homelessness support services in Victoria.”
“The Royal Commission identified the need to change a broken system that allows women and children to be forced from their homes – or worse, feel compelled to stay in a violent home because there is no other option available to them.”
“These increased services will deliver greater support in both bricks and mortar and individualised assistance – an important first step in addressing the housing needs of families who are impacted.”
Quotes attributable to Minister for the Prevention of Family Violence Fiona Richardson
“The lack of safe and affordable housing has rightly been identified as a key challenge of our broken system.”
How much of your freedom do you presume when you voluntarily go to the doctors? Ever thought that they might not let you leave after that flu injection? What if you went there for life-saving treatment, only to be told that they don’t offer what you need? Something that you and others would consider a reasonable request.
These are the dilemmas that voluntary consumers of mental health services face. I want to try to put you in their shoes.
Yesterday I had the opportunity to facilitate a symposium on the rights of voluntary consumers. As a consumer advocate, this issue has been at the forefront of my mind when I work on inpatient and community mental health services.
The Mental Health Act and Voluntary Rights
In 2014 Victoria was hailed as the true leader in mental health reform due to it’s updated Mental Health Act 2014 (Vic) (“The MHA”). It appeared as if the benevolence of policy makers meant that consumers would finally find refuge within the law.
Despite the good intentions of the drafters, I would like to suggest a more complex or counter-narrative embodied by consumers. With the MHA’s exclusive focus on involuntary treatment, it has silenced voluntary consumers who may be experiencing coercion or neglect.
I therefore suggest that in many ways voluntary consumers are comparatively worse-off than their involuntary counterparts: they don’t know what their rights are, and they wouldn’t know how to protect them if they did.
The MHA outlines rights to:
- A written and explained Statement of Rights;
- An Advance Statement, to express your treatment preferences;
- A Nominated Person, to assist in your decision-making processes;
- A Second Opinion from another psychiatrist, where you believe an incorrect diagnosis or treatment plan has been developed; and
- Communicate. That is, to send or receive calls, letters, emails, texts etc.
The only issue here is that it’s not clear whether any of these rights are triggered under voluntary settings.
This creeping doubt means that the government can restrict your voluntary right to smoke – a major source of social and psychological support for people with trauma histories – in mental health settings. It also means that you must be granted leave so that you can exit a service that you voluntarily entered (tort of false imprisonment anybody?).
Some may suggest that there are civil and tort rights such as:
- Trespass, to person (assault & battery), property or land without consent;
- Negligence, if they fail to give you treatment or provide the wrong treatment;
- Defamation or Misrepresentation, if you feel that statements made about you in clinical settings are defamatory (see an interesting article from Grover on this issue); or
- Privacy and Confidentiality, for information that is personal and sensitive to you.
Nevertheless, these rights are virtually unheard of in a clinical setting, and there is no advertisement or empowerment of consumers to utilize them. So in a functional sense, they are not there.
The issue is that the MHA’s focus on involuntary status means that these rights are not triggered or brought into it’s jurisdiction. This is particularly concerning because services are being encouraged to process consumers voluntarily rather than resorting to involuntary treatment. So the rates of voluntary admission might rise, but the protections and rights of consumers might inversely fall.
There are issues with a MHA that essentially grants coercive and police powers to medical practitioners. I’m not saying there is no place for involuntary treatment, but we need to accept that clinical decision-making takes place through texts, institutions and protocols that utilize violence (more of this contentious claim in a later text).
Nevertheless, such MHAs at least provide for the expressed provision and restriction of psychiatric power. Power can therefore be named in some limited sense, and tamed (divided up), with a little left aside for the consumer and carer.
Voluntary consumers don’t have this liberty. Their treatment operates in a lawless environment – there is no clear articulation of their rights. There is no acknowledgement – and therefore restriction – of power in clinical settings. The pamphlets, services and MHAs remain silent or their rights, meaning their concerns are illegible to the law.
If you think this is an overstatement, there are two common ways that the perverse nature of voluntariness plays out.
You’re Voluntary, until You Enter the Service
A common experience I’ve encountered is people voluntarily entering a service in crisis. Perhaps they need certain types of peer support, psychosocial interventions or particular drug regimes that have worked for them in the past (as opposed to the ones that did more harm).
Instead they are told : (1) you have a mental illness; (2) you must take your medication; (3) and you must comply with the treatment plan. Think I’m overstating it? See the opening lines from Dr Mark Cross in ABC’s 2014 Changing Minds:
“The aim for me, in getting people well, is for them to develop insight – understanding that you have a mental illness. And that you require medication, and that you will comply and adhere to a treatment plan.”
They therefore enter with a belief that they have these issues (identified by their rich life experience and carers) and needs, but are instructed that they have those (clinically determined) diagnoses requiring those pharmaceutical regimes. There is epistemological violence occurring here.
They are told they are voluntary, but that they can only enter-exit the service when granted leave, because the doors have been locked (presumably to stop their escape). They are given the impression that the treatment plan they agree to somehow overrides their rights as a voluntary consumer to refuse treatment as well as freely enter-exit the service.
They plead with staff that the medical antipsychotics they are to be placed on have profound side effects for them. They say that the diagnosis (schizophrenia, bipolar, borderline personality disorder, major depressive disorder) does not map onto their experience – a reasonable concern given poor construct validity of psychiatric diagnoses.
So why don’t they just leave? Because there is a threat that if they do so, they will be placed on an Assessment Order and detained involuntarily. So the question remains: how voluntary are they?
You’re Voluntary, So You Can Leave Anytime…
There is a less common or identifiable issue that emerges out of this legal agnosticism. I’ve begun to witness consumers who are told “[Person], you know you are voluntary? So you just can leave if you don’t like the service here…”.
On the face of it, this doesn’t seem so bad. But dig a little deeper and talk to the people in crisis, and you feel how horrible these words must be.
A person who enters a service voluntarily often has no other place to go – that is why they are here. There may be issues of violence, trauma, self-harm or insecure housing. Often they may just need a place to rest, find meaning in what is happening to them, so that they can re-emerge ready to re-engage with the challenges waiting for them.
This requires a certain level of responsiveness from services, or in the words of the NDIS: [real] choices and control for consumers. That means the person shouldn’t have to chose between a potentially traumatic and harmful pharmacological regime, and exiting the service back into the crisis from which they came. But too often these are the options, and there is a responsibilization of consumers who escape only to fall further unwell.
For people who have a history of suicide attempts or self-harm, the threat behind these choices is real: harm in the service, or death outside it. That is the reality they face.
We need to be having a conversation that names these themes and gaps, with an eye towards developing better legal frameworks, or further promoting the ones we have.
We need to ask questions about what types of rights voluntary consumers should have when entering services? Are they the same as those under involuntary treatment? Are they solely negative in nature? That is, are they merely protections from clinical power? Or can we start to articulate positive rights, where people have rights to responsive and agile service. There are so many available psychosocial, peer-based and drug-based approaches to mental distress, but too often services appear to adopt an illness-based response that leaves a person unsatisfied, unwell and traumatized.
Some solutions may be to extend the legal status of Advance Statements to voluntary settings in the MHA. Another would be to reform section 39 of the Charter of Human Rights and Responsibilities Act 2006 (Vic) so that there can be a stand-alone cause of action. Moreover, we could legally test how the principles in section 11 of the MHA apply to voluntary settings.
A legal response might not necessarily be the appropriate one. But in the creation and application of the MHA we have created a legal, human rights and discrimination issue that needs resolution.
This is an informal guide to the law. You should consult a legal service for proper advice and support.
Many consumers have concerns about access to assistant dogs and discrimination in the community. The law governing this falls under the Equal Opportunity Act 2010 (Vic) and the Disability Discrimination Act 1992 (Cth). The most appropriate referral is to the Disability Discrimination Legal Centre or Fair Work Australia.
What Is An Assistant Dog?
An assistant dog – formerly called guide dog – is one that performs tasks or functions that alleviate the effects of a disability. The definition of this has been broadened to mirror “assistant animal” under the DDA 1992.
How Are Dogs Accredited
There is no clear accreditation progress by law in Victoria. There are in other states.
The informal advice I have been given is that it is sufficient for the person to have a letter from a medical practitioner explaining that the assistant animal has assists with the person’s disability. It should also state that the animal has been trained – preferably in hygiene and behaviour standards – as well as the trainer, their qualification and details. These are the standards required under the DDA and are common practice within the Assistance Animal Pass for Victoria.
When Is It Discrimination?
There are two forms of discrimination: direct and indirect.
Direct discrimination (section 8 EOA) is when a person is treated, or is proposed to be treated unfavourably because of a particular attribute (e.g. does not like people who have assistant dogs).
Indirect discrimination (section 9 EOA) is when a requirement, condition or practice (expectation) that appears to be the same for everyone, actually disadvantages a certain people with protected attribute under EOA. Mental Illness and disability is protected under EOA.
This is the same for Federal legislation. Determining which applies is most easily linked to whether the service provider is state based or federally based (funded).
The EOA provides explicit provisions to protect people who may be discriminated against when seeking housing. The person should not be refused, and they should not be made to keep the dog elsewhere or pay an extra charge. However they will be liable for any damage done by the dog.
The EOA and DDA both apply to workplace situations (direct and indirect discrimination). Bu there is also protection under the Fair Work Act 2009 (Vic). The act provides that you can’t make an “adverse action” against someone based on an attribute – one of which is disability. Therefore it may be the case that a person cannot be terminated because of their need to have an assistant dog while at work.
I’ve recently been put onto the Icarus Project – an online platform and movement devoted to critical aspects of mental health. I’ve read some of the resources available, but will seek to summarise some key aspects and provide critical commentary in the resource guide.
See it at: http://www.theicarusproject.net/