Global psychiatry’s attempt to excommunicate the former UN Special Rapporteur on the right to health

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Between 2014 and 2020, the UN published three reports on mental health, prepared by the special rapporteur on the right to health (Dainius Puras). These called for a radical change in the practice and organization of mental health care across the world. The UN Office of the High Commissioner on Human Rights declared the work “groundbreaking”:

In 2017, the Special Rapporteur issued a ground-breaking report addressing the “global burden of obstacles” in mental health settings and in the field of psychiatry. The obstacles are: 1. the dominance of the biomedical paradigm; 2. power asymmetries which impact all levels of the decision-making in mental health policies and services, and 3. the biased use of evidence in mental health. (UN OHCHR)

The reports were generally well received by country representatives at the UN Human Rights Council. The work sparked various news headlines across the world such as “Austerity and Inequality Fueling Mental Illness, Says Top UN Envoy” (The Guardian, UK); “Why Combatting Depression Involves Addressing Inequalities” (The Wire, India);  “Why Mental Health Is a Human Right” (The New Statesman, UK). They also sparked various academic commentaries, some more sceptical than others, such as the Australian and New Zealand Journal of Psychiatry: “Responding to the UN Special Rapporteur’s Anti-Psychiatry Bias.”

Our new study “Conflict and Antagonism in Global Psychiatry,” published in Sociology of Health and Illness, systematically examines more formal responses to the report. The responses we examined tended to be in the form of open letters addressed to the UN High Commissioner or to Puras directly, unsolicited. Using discourse analysis—a method of analyzing strategies used in texts to assert or claim power—our study shows how psychiatric organisations attempted to undermine the special rapporteur and his detailed country-based inspections which led to his call for a radical change towards rights-based care in mental health.

We searched extensively for any formal written organisation-level responses. We found and analysed 13 responses, most of which were hostile criticisms of the reports, written in open letter form by medical or psychiatric organisations such as the World Medical Association, the European Brain Council, the International College of Neuropsychopharmacology and so on. One very positive letter was written jointly by the British Psychological Society and Mental Health Europe, and included signatories from over 50 organisations representing psychology, psychotherapy, user-survivor organisations and charities. A fairly neutral comment from the Canadian Ministry of Health is the only explicitly governmental response we found; and the Federation Global Initiative on Psychiatry published a relatively balanced statement. The majority of organisations were based in Europe or were global such as the World Psychiatric Association and World Medical Association. We found no formal responses from organisations representing USA, Australia, New Zealand, China, Japan, The Nordic Region nor any responses from the Global South.

Although it might be argued that the UN mental health reports reflected a fairly middle-ground position and that the call for rights-based approaches in mental health was not novel at the time, the overwhelming tone of the letters from psychiatric and medical organisations was hostile. The UN reports seem to have provoked anger and disdain, reflecting a longstanding broken dialogue within the mental health professional field.

A common linguistic strategy across these letters was to set up a stark contrast between the scientific and the unscientific. The special rapporteur himself and, by association, the United Nations, was consistently represented as unscientific while current practice in psychiatry was presented as intrinsically scientific and inherently ethical. The special rapporteur is frequently accused of presenting his claims in a biased, unscientific fashion.

…[The] lack of a consistent view leaves the reader baffled, and reinforces the sense that statements are made for inflammatory rhetorical effect, with no systematic or disciplined link to the scientific evidence. (European College of Neuropsychopharmacology)

Citations of the scientific literature are largely biased in the direction of purely ideological perspectives, again with no scientific evidence. (European Brain Council)

In turn, the letters argue forcefully that the true scientific position in fact favours current biomedical practices in psychiatry—those practices which the special rapporteur criticises. Yet in doing so, the claims made in these letters often fail to meet their own scientific standard in their failure to cite evidence:

Treatment with psychotropic medications is presented as useless if not harmful, ignoring the bulk of evidence on its effectiveness [no citations]. (European Psychiatric Association)

It has been robustly demonstrated that the introduction of antipsychotic, mood stabilizing, and anti-anxiety medications in the 1960s enabled many people with chronic mental illness to leave the asylums and, for the first time live productive recovery-oriented lives… [no citations]. (International College of Neuropsychopharmacology)

As well as rejecting the scientific basis of the special rapporteur’s claims, the letters we analysed went on to suggest that the UN recommendations were in fact likely to cause harm themselves:

These statements… taken on their face, would significantly—and recklessly—limit the treatment options available to patients and considerably increase the sum total of patient suffering. (European College of Neuropsychopharmacology)

They claim that the proposed move away from biomedical models and towards rights-based care would damage patient trust in psychiatrists. Moreover, the criticisms of psychiatric practice presented in the UN reports are described as “slanderous”, lacking nuance, unfair, implying that the UN had been captured by a dangerous anti-psychiatrist, a nefarious ideologue.

We fear that the personal views of the Special Rapporteur, which are not reflective of the vast majority of his colleagues in the mental health professions nor of the extensive body of data that has been collected about the efficacy of psychiatric treatments hold the potential for causing substantial harm. (World Psychiatric Association/World Medical Association)

This assumption [that Psychiatry is reductionist, enslaved to industry and guilty of human rights violations] is absolutely slanderous as it attacks an entire professional community without distinction and—what is more—is absolutely not evidence-based. (European Brain Council)

The biopsychosocial model is instead held up in these letters as an overarching solution to disagreements in psychiatry; depicted as a model which can unify all forms of mental healthcare under one church without the need for dissent or conflict between different schools of psychiatry. If only the special rapporteur were reasonable, he would agree. In using this idea as a unifying trope, any criticism of the biomedical model is presented as a kind of wicked betrayal of an otherwise united psychiatry.

Biological, psychological and sociological approaches are, of course, complementary, and biomedical hypotheses do not, at all, contribute to coercion or abuse. (European Brain Council)

Psychiatrists worldwide recognize the invalidity of this dichotomy [medicalised vs non-medical treatments] and the necessity for a combined biopsychosocial model for understanding and treating mental disorder. (World Psychiatric Association/World Medical Association)

The binary structures deployed in these open letters are strategic. Scientific versus unscientific. Ethical versus unethical. Evidence-based versus ideological. Psychiatry united under one banner versus individual deviants (the anti-psychiatrist). These rhetorical strategies deflect criticism and have been commonplace in mental health debates for some time. Some of the tactics are well-rehearsed.

In our article, we try to characterise some of these familiar strategies. We can see tactics we might describe as the “martyr and the enemy” in which the special rapporteur is characterised as the real enemy of mental health and psychiatrists as his victims. We also see a form of “excommunication” in which the powerful psychiatric organisations rhetorically position the defector as a rogue, an anti-psychiatrist, an internal threat to psychiatry that needs to be weeded out and put in his place. The special rapporteur appears to pose a particular threat in this instance because he was given a voice by a recognisably powerful organisation, the United Nations, triggering particularly defensive responses.

To have their efforts [psychiatrists] so carelessly disparaged, and stigmatised as a “culture of coercion, isolation and excessive medicalization” (para. 88)—by no less than the Human Rights Council of the United Nations—is a grave injustice, and one that cannot be allowed to stand. (European College of Neuropsychopharmacology)

We also see forms of “circular argumentation” in that to be classed as scientific you must cite evidence; but evidence is only scientific if it is produced by or approved of by members of biomedical psychiatry organisations which are, by default, scientific organisations who do not need to cite evidence themselves because they are scientific authorities.  Similarly, the psychiatric organization is authoritative (by virtue of a large membership and important scientific mission); the individual criticizing them is unscientific and unimportant with no authority; yet this unimportant, unknowledgeable individual is victimizing psychiatric organisations.

We also see in these letters a tactic known as “strategic ignorance”, in which the psychiatric organisations appear to be completely ignorant of any evidence that psychiatric medicines do harm—a tactic enabling denial of liability; alongside an apparent unknowing of the many financial conflicts of interest among authors of the evidence that they selectively cite. It is unlikely that evidence of harm from psychiatric treatments or financial conflicts of interest among psychiatric researchers are unknown to the letter authors. Yet rather than engage with this, the authors strategically construct arguments as though they are unaware of any such issue.

Finally, we see a tactic we might call conceptual “bullshitting” in which “rituals of politeness are foregone entirely, and we are faced with the raw assertion of power or authority in brusque gestures and commanding tones”.  The insistence on the redemptive qualities and widespread acceptance of the biopsychosocial model and psychiatric pluralism seem to fall into this domain, given that psychiatry has, in practice, remained dominated by biomedicine going under the guide of the biopsychosocial model—referred to by some as “bio-bio-bio” model of madness.

In spite of these hostile reactions to the special rapporteur reports, nearly all of the letters also express a wish to be involved in leading the development of good mental health practice. Indeed, in 2020, the World Psychiatric Association published a position statement “Implementing Alternatives to Coercion: A Key Component of Improving Mental Health Care” which is broadly in line with the UN recommendations. The statement recognises “the substantive role of psychiatry in implementing alternatives to coercion in mental health care” and “the WPA wishes to emphasise that implementing alternatives to coercion is an essential element of the broader transition across the mental health sector toward recovery-oriented systems of care.” Not long after this, in 2021, the WHO published “Guidance on Community Mental Health Services: Promoting Person-Centered and Rights-Based Approaches”.

Why lambaste the UN and the special rapporteur if these reforms were already in the pipeline? Perhaps the UN reports shamed psychiatry into speeding up an agenda which was taking too long to implement; perhaps these organisations would have liked to have been the ones seen to be leading the way. Whatever the reason, the dramatic demands for the special rapporteur to “withdraw his report” or for the report not to be “allowed to stand” do not appear to have had any impact: the special rapporteur reports continue to be held up by the UN as “groundbreaking” and gradually (if perhaps not fast or widely enough) many of the recommendations are beginning to bear fruit.

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Editor’s Note: this post was originally posted on Mad in America, and is reposted here with permission