Introduction by Croakey: Should a health care intervention ever involve a violation of human rights?
And how can we enshrine human rights in the care of people with severe mental illness, while making sure that all patients and staff are safe?
These questions have recently been the subject of much discussion, especially following the recommendation of the Royal Commission into the Victorian Mental Health System to:
act immediately to reduce the use of seclusion and restraint in mental health and wellbeing service delivery, with the aim to eliminate these practices within 10 years.” (Recommendation 54)
Below, mental health and human rights advocate, Simon Katterl, asks us to consider if we have the framing of this debate all wrong. What if we take a step back and ask ourselves if the “impossible” is not the imperative.
This is the last lived experience perspective article in Croakey’s Speaking Our Minds series, however, Katterl, who has worked tirelessly to help bring you these valuable insights, will return in a post next week. to reflect on what has been learned.
Simon Katterl writes:
There have been many sliding doors moments for me. I often reflect that when I have called for help, such as when I’ve been suicidal, help is what I’ve received. My mum, friends and mental health professionals have acted as my supports, while ensuring every step on this journey was my supported choice.
However, I know that there are others who, instead of help, have received profound harm. They have entered the system seeking help, often following their own trauma, but in the end, they’ve been left more hurt by the trauma of their involuntary mental health treatment.
A last resort
Victoria’s mental health system has made small steps towards improving these experiences. They are investing in new approaches to mental and emotional support, have introduced new mental health laws (though their changes are minor), and are replacing ineffective regulators that have failed to protect human rights.
Compulsory treatment is said now to be used only as a ‘last resort’, and seclusion (aka solitary confinement) and restraint (physical, mechanical and chemical) are aimed to be eliminated by 2031.
Even if these measures are taken, they fall well-short of international human rights standards as well as the expectations of many people who use the mental health system.
Not far enough for some, too far for others.
‘Idealistic, and right up there with pink elephants flying’. That’s how the Victorian Branch President of the Australian Medical Association described the Victorian Governments efforts to implement a key recommendation of the 2019 Royal Commission into Victoria’s Mental Health System – to eliminate seclusion and restraint.
The President went on to ask “How are we meant to manage these people if we can’t use medical or chemical restraints?”, and suggested that lives would be put at risk by the effort to move away from these practices.
I found this response deeply unhelpful and it reinforced my sadness about the cultures underpinning parts of our mental health system. It highlights that some perceive staff occupational health and safety to be mutually exclusive with the human rights of people already detained within mental health units.
Staff do experience significant occupational health and safety risks in the mental health system. There are reports of assaults in addition to verbal abuse and threats. This sits within the context of a system that has been chronically underfunded for decades, with staff stress levels and burnout high.
The evidence suggests – as does the Victorian AMA president’s comments – that the mental health sector believes that seclusion and restraint are necessary to manage conflict. It’s a belief that is particularly strong in Australia, with evidence suggesting that nurses do it in response to their own sense of fear and to ensure safety for others.
Overcoming a false binary
The logical outcome of these conversations is that the public views it a choice between consumers’ human rights and the staff’s occupational health and safety. While I believe that we need to privilege and consider far more deeply the implications of violating human rights as opposed to regulating work conditions, I also think this is a false binary.
Initiatives like Safewards promote another way. Originally developed in the UK in 2014, Victoria implemented a program of activities to reduce containment (of consumers) and create safety for all (including staff).
The program – which includes taking an organisation-wide approach to implementing language and culture change, less restrictive responses to conflict, and opportunities for mutual recognition and expectations – was independently evaluated as being effective for reducing seclusion events and reducing conflict between staff and consumers using the service.
Speaking about Safewards, mental health nurse and Centre for Mental Health Nursing head, a/Professor Bridget Hamilton tells me that:
Safewards tells us that there is considerable hope for changing the conflict status quo in any ward; the model and the interventions make the most of anticipating flashpoints that can lead to escalation, and resetting environments and relationships that are welcoming and welcomed. Harm for patients and nurses is not the only option” (personal communication)
Harm to patients and nurses is indeed not the only option (and shouldn’t be an option). In 2017, colleagues Felicity Gray, Cath Roper and Piers Gooding were commissioned by the United Nations Rapporteur on the Rights of Persons with Disabilities to review alternatives to coercion, revealing hundreds of successful efforts to reduce coercive practices across mental health environments.
Winds of change
There is a gradual recognition within psychiatry of the need to change. The World Psychiatric Association has now pushed for psychiatrists and mental health systems to vigorously pursue alternatives to coercive mental health care.
Similar and more ambitious initiatives have been developed by the World Health Organization’s Quality Rights initiatives, which will drive a global shift away from force. There is a growing recognition, as was articulated by the Lancet Psychiatry Commission that the ‘use of compulsion needs to be seen as a system failure’.
However, at the same time, views from the profession in Australia are more conservative. While acknowledging that seclusion and restraint does harm, the Royal Australian and New Zealand College of Psychiatry fall short of full elimination and have disagreed with more substantive law reform.
This sits within a broader division within the health system and profession. On the one hand some clinicians believe a human rights-based approach unnecessarily impinges on clinical decision-making. On the other hand some put the profession within the purview of human rights norms, including the need to eliminate rights-breaching practices (see also the other doctor who commented on the proposed reforms in Victoria — a psychiatrist who supported elimination).
The Victorian AMA President’s incursion into the debate reflects this tension between different visions of clinical practice and the mental health system. The place of, and relation between, safety and human rights is central to these competing visions.
Building a safe, human rights-based system
A future mental health system built on safety, will be one built on human rights. That’s not where we are at. The current mental health system is violent, predominantly towards the people who are forced to use it. My experience as an advocate taught me this. My opportunity to participate in research reinforced it. Our laws, rules and culture sanction this violence.
The only pathway to safety for all in the mental health system is to recognise and eliminate the violence inherent to the system. We can do that, but it requires greater introspection from parts of the mental health system. If we do this well, one day we’ll all marvel at the pink elephants flying.
*Simon Katterl has lived experience of mental health issues and has used predominantly private as well as community public mental health services. Simon’s work focuses on mental health laws, governance, regulation, and systems design.
For assistance:
Lifeline 13 11 14 www.lifeline.org.au
Suicide Call Back Service 1300 659 467 www.suicidecallbackservice.org.au
beyondblue 1300 224 636 www.beyondblue.org.au
13Yarn: 13 92 76 13yarn.org.au
Kids Helpline 1800 551 800 kidshelpline.com.au
QLife: 1800 184 527 https://qlife.org.au/
Check-In (VMIAC, Victoria): 1800 845 109 https://www.vmiac.org.au/check-in/
Lived Experience Telephone Line Service: 1800 013 755 https://www.linkstowellbeing.org.au/
Acknowledgements
The #SpeakingOurMinds series of articles was conceived and organised by mental health and human rights advocate Simon Katterl and is edited by Dr Ruth Armstrong.
It is published to coincide with Mental Health Week 2022 (October 8-15) as a vehicle to privilege the voices of lived experience.
Bookmark this link to follow the series.
The series is supported by Mental Health Carers Australia, Simon Katterl Consulting, Tandem, First Nations Co, and Mind Australia. The supporters respect the independence of the authors and the editors.
On Twitter, follow #SpeakingOurMinds.
Competing rights shows that ‘human rights’ can’t cope with our social nature. On to care ethics!