Human Rights Abuses in Mental Institutions Common Worldwide, Perlin Says
Despite improvements in recent years, people with mental illnesses regularly suffer infringements on their human rights, and state-instituted psychiatry is often used to oppress political dissidents in nations around the world, according to New York Law School professor Michael Perlin, an expert on mental disability law who spoke at a talk co-sponsored by the American Constitution Society, the Human Rights Program, and the Institute for Law, Psychiatry, and Public Policy Feb. 22.
Perlin is the director of the Mental Disability Law Program and leads the International Mental Disability Law Reform Project at the Justice Action Center at New York Law School.
Perlin said his travels in countries including Latvia, Bulgaria, Uruguay, and Nicaragua "have really clarified to me our societal blindness to the ongoing violations of international human rights law in the context of the institutional commitment and treatment of persons with disabilities.
"I think the issues I'm discussing today matter-I think they should matter to all citizens who take human rights seriously and those who care about how we treat those who remain-in many, many nations-locked away in facilities that violate any sense of human decency," he said. "Circumstances that I have seen around the world are beyond shocking the conscience."
The gray areas of mental disability law have allowed for the abuse of the most vulnerable, he noted.
"It may seem puzzling because psychiatric treatment is medical treatment; we assume it's undertaken for benevolent purposes," Perlin said. "Yet if we consider the well-documented history of the use of state psychiatry in the Soviet block, in China and elsewhere, we are forced to confront the reality that for many years institutional psychiatry was a major tool in the suppression of political dissent."
Even in the United States the standards for civil commitment are lower than those for criminal imprisonment; the Supreme Court found that the standard of "beyond a reasonable doubt" was not necessary for civil commitment in Addington v. Texas.
Furthermore, international groups such as Human Rights Watch and Amnesty International have ignored issues pertinent to the human rights of people in mental institutions for decades, only recently giving them attention, Perlin said. Disabled people were not mentioned as a protected category in international human rights code until "literally the last few years," and the first scholarly article written about disability rights as a human rights issue was published in 1993.
Perlin said protections may be even more important for people with mental disabilities than for people with other types of disabilities.
"Like other people with disabilities, they face degradation, stigmatization, and discrimination, but unlike most others with other disabilities, many people with mental disabilities are routinely confined against their will in institutions, being deprived of their freedom, their dignity, and their basic human rights," he said.
Despite an "explosion of interest" in the last decade, questions remain, some of which Perlin addresses in his most recent research.
"To what extent has institutional state-sponsored psychiatry been used as a tool of political suppression, and what are the implications of this pattern and practice?" Perlin asked.
Michel Foucault first addressed the oppressive use of state-sponsored psychiatry, but the earliest noteworthy modern work was Sidney Bloch and Peter Reddaway's 1985 "shattering" book, Psychiatric Terror: How Soviet Psychiatry Is Used to Suppress Discontent. In it, Bloch and Reddaway explain how the Soviet Union used an extremely broad definition of schizophrenia and other mental illnesses to label political dissenters as delusional.
"A patient's conviction that the state must be changed was seen as an indicia of mental illness," Perlin said.
Placing dissidents in psychiatric hospitals rather than prisons served three points: it avoided the already limited procedural safeguards of a criminal trial, stigmatized people to subordinate them, and confined dissenters indefinitely. By 1989 conditions had begun to improve in the Soviet Union, according to Perlin, but tools of coercive psychiatry still were used in what some call the "criminalization of dissent." And this practice was not limited to Russia; the expression of political opinions was perceived as delusional throughout the Soviet block.
Furthermore, a study of China authored by Robin Monroe five years ago found "hyperdiagnosis" of dissidents and nonconformists as mentally ill.
"If you protest politically, you demonstrate by that an absence of instinct for self-preservation, or if you pursue a legal complaint against a corrupted or repressive official, that's a sign of mental illness," Perlin said.
Since these studies were conducted, new laws have been passed by nations as well as by international governing organizations. The United Nations adopted the Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care, called the MI principles, which provide basic international guidelines. The MI principles do not speak specifically to the issue of state psychiatry as used for political suppression, but the European Convention for the Protection of Human Rights has been interpreted in that context. For example the Wintwerp case of 1979 found that a person cannot be detained by states because his views or behavior deviate from norms of society, Perlin said.
Four years earlier a similar case, O'Connor v. Donaldson, was heard in the U.S. Supreme Court with basically the same conclusion. Court decisions are not always adopted, however. The ruling from the first mental disability law case brought before the U.S. Supreme Court, Jackson v. Indiana in 1972, still has not been implemented by about half of states, Perlin said. In Jackson the Justices found that "if a person is incompetent to stand trial and will be incompetent in the foreseeable future, he can't be kept in a facility, a maximum security facility designed to have him regain his competence to stand trial when he won't."
Despite recent regulations, facilities in many countries continue to breach human rights standards and hold people who do not have mental illnesses. In some cases psychiatric hospital staff may not even be aware there are international guidelines to be followed.
"So psychiatry as a tool of political suppression may no longer be the problem that it was in the 1980s, [but] violation of international human rights law continue unabated," Perlin said. "We cannot underestimate the extent of our societal blindness to the ongoing violations of international human rights law in this context."
Perlin attributes the continued neglect and lack of protection against improper treatment suffered by people with mental disabilities to socio-attitudes he calls "saneism" and "pretextuality."
"I define saneism as an irrational prejudice of the same quality and character of other irrational prejudices that cause and are reflected in socio-attitudes of racism, sexism, homophobia, ethnic bigotry," he said. "It infects jurisprudence in lawyering practice; it's largely invisible; it's largely socially acceptable; it's based predominantly on superstition, on myth, on de-individualization, on stereotype."
Pretextuality involves "the way courts accept, either implicitly or explicitly, testimonial dishonesty and engage similarly in dishonest and very often meretricious decision making." For example, expert witnesses may distort their testimony to achieve desired ends.
"In the past I have written regularly about these attitudes in domestic contexts to try to expose their power-the way they infect judicial decisions, legislative decisions, administrative enactments, jury behavior, and public attitudes and the way that these factors undercut any efforts at creating a unified and coherent body of mental disability law jurisprudence, the way these factors contaminate scholarly discourse and lawyering practices alike," he said. "There is now no longer any question in my mind that these same factors infect international mental disability law practice in the same ways that they infect domestic practice."
Perlin said many questions remain that might be excellent fodder for student research: Has the political use of psychiatry been limited to nations with a history of totalitarian governments? Do admissions to institutions in the former Soviet Union now conform to due process? What is the impact of China's growing economy on mental health issues? Perlin said psychiatric incarceration still occurs in China for "re-education," although international criticism of the practice is on the rise.
Perlin questioned whether political leaders care enough about these issues. He noted that Turkey's "barbaric" use of electroshock treatment without sedation had received attention in Europe during Turkey's application to join the European Union. Still, "this issue is not high on the agenda" in most countries.
Providing high-quality legal services to those who are institutionalized because of mental disability may even make some of these problems disappear, Perlin suggested. Most of the world does not provide institutionalized people access to counsel, even when mandated.
"I think the absence of these safeguards suggests to me that promises of authentic reform may still be largely illusory," he said.