"Sorry" to disrupt you

Might an apology be a disruptive innovation for transforming how we respond to poor mental health and wellbeing?

In early 2024 the Royal Australian and New Zealand College of Psychiatry (RANZCP) issued a statement of apology “to the survivors and their whānau, for the harm experienced in state care and for our failure as a group of doctors to have acted to prevent this.”[1]

While it has evoked some criticism, I think was both welcome and significant. It was carefully considered and frank. Importantly I like to think it indicated the RCANZP’s commitment to co-creating a very different future where such adverse practices had absolutely no place.

An apology can be seen as representing a first and essential step in mending a damaged relationship – acknowledging shared values, and the fact that there are genuine regrets when behaviours and actions fall short of meeting those shared values. Implied is a commitment to work better together; to make greater efforts to live up to those shared values. The apology affirmed a commitment to building and ensuring trust and confidence in an important relationship.

The role of apology and reconciliation

This compelling gesture (as well as the criticism it aroused) has caused me to reflect upon the role of apology and reconciliation as potential catalyst towards a fundamental transformation of our approaches in how we respond to poor community mental health and wellbeing. At the very least it would provoke valuable and potent new conversations.

The RCANZP statement appeared to recognise this too: “Psychiatrists have an important role to play in acknowledging historical harmful practices and committing to learn from them, so the mistakes of the past are not repeated.”

Why an apology to play a role in transformation ?

This isn’t a new idea. Mike Slade in his book “Personal Recovery and Mental Illness: a guide for mental health professionals”[2], argued that the first step towards genuine partnership around any new policy agenda in psychiatry should be to call for a public apology for the wrongs done in the name of psychiatric treatment.

An internet petition launched in Australia, supported by Mike Slade’s thesis, calls for an apology for the damage caused by treatments since the mid 1800s. The petition notes (for example):

Oppressive, incorrect and unproven medical theories underpinning damaging treatments which have been harmful physically and psychologically.
The creation (and jealous ownership) of a body of dubious ‘knowledge’ based on research service users/patients had no involvement in or choice about, and which has been given legitimacy to overrule people’s own self-knowledge and expertise by experience.
The creation of stigmatising services which isolate people from their families and friends and wider society, and then make it hard to recover self-belief, purpose, meaning, health and social status.

I also have to acknowledge here the late Christopher Hitchens. After hearing his erudite and compelling argument as to why the institution of the Catholic Church owed the world an apology I found it impossible to suppress the striking parallels I was seeing with our own institutional mental health systems in developing, providing and sustaining responses to poor mental health[3].

But what might institutional psychiatry have to apologise for?

The idea of an apology from psychiatry, while not common does have precedents. In 2010, the German Psychiatric Association apologized for its role in supporting holocaust era crimes (albeit 65 years after the events)[4].

The American Psychiatric Association (APA) apologised to Hindus for labelling Hare Krishna’s as destructive cultists and loosely linked Hindu swamis to Satan worship in a report published in 1989[5].

In 2021, the American Psychiatric Association (APA) released the “APA’s Apology to Black, Indigenous and People of Color for Its Support of Structural Racism in Psychiatry”[6]. The letter from its Board of Trustees aimed to acknowledge the institution’s shameful racist history.

Closer to home in Australia, Professor Alan Rosen has argued the case for why psychiatry owes an apology to Aboriginal and Torres Island peoples[7]:

“Over many years, psychiatric professionals have dominated the lives of people with mental illnesses. We have been responsible for their forced separation and disconnection from their families; incarceration in remote regions; their being humiliated, stigmatised and sequestered as moral lepers; their loss of identity as people, denying them their human rights, their dignity and entitlement to full membership as citizens. The case for regret and apology for the past suffering of Aboriginal Australians with a mental illness is pressing.”

While presented as a critique, rather than an apology per se, Allen Francis, a psychiatrist who chaired the taskforce charged with developing the Diagnostic and Statistical Manual of Mental Health Disorders Version 4 (DSM 4) in the early 1990s, felt compelled to rebel, and has written a book titled “Saving Normal” – arguing against the continued medicalisation of normality[8].

It is an uncomfortable, revealing, but not a difficult exercise to propose additional wrongs and injustices, visited upon people by psychiatric professions, where an apology may be appropriate – if not overdue.

For example:

An apology seems reasonable enough for the pervasive, systematic violations of human rights by American psychiatrists through much of the last Century. Evidence supporting such a claim is based in 15,000 pages of documents obtained from the CIA under the Freedom of Information Act.[9]
The UN Convention on the Rights of People with Disabilities has now established that the deprivation of liberty based upon a psychiatric diagnosis (eg. compulsory treatment, seclusion…) is contrary to international human rights, is intrinsically discriminatory, and unlawful. Neither is such unlawfulness mitigated where additional grounds (such as the best interests of the person or safety of the community) can be used to justify psychiatric force[10]. In spite of this, “deprivation of liberty based upon a psychiatric diagnosis” remains a common practice in New Zealand. Our use of compulsion and solitary confinement (“seclusion”) is one of the highest of OECD countries. This is especially so for Māori where seclusion rates have been shown to be 39% higher than non-Māori.[11]

Even a “Sorry, we disagree…” would provide some transparency and be better than silence.

I think an apology may be due to the thousands of people whose experience of rejection, isolation, discrimination and stigma were heightened through psychiatry deeming homosexuality a mental illness which indicated the need for treatment to achieve a cure. A further apology seems wanting for the sheer arrogance of asserting that “this is something we can cure”. Homosexuality was removed from DSM as a diagnostic category in 1973. Dr. Robert Spitzer, who invented a so-called preparative therapy to “cure” homosexuality for those “strongly motivated to change”, eventually recanted: “I believe I owe the gay community an apology…”[12]

I certainly think an apology is owed to the 50,000 plus people who were subjected to the horrific procedure, euphemised by the pseudo-scientific label “pre-frontal lobotomy[13]”. This involved the crude severing of connections to and from the pre-frontal cortex of the brain. The last “procedure” was carried out in 1967; the patient died from a brain haemorrhage…

I think psychiatry should perhaps beg forgiveness for the introduction of the obscene term “life unworthy of life”. This emerged from a paper written by a German psychiatrist (Professor Alfred E. Hoche), pre-Adolf Hitler, titled: “Permitting the Destruction of Life Unworthy of Living”[14]

An apology to women (ie. half the human race) should probably be at the top of this list. Historically, psychiatry has contributed to the oppression of women by labelling ordinary female experiences as mental illness, reinforcing patriarchal norms, and enabling social control. In the 19th and 20th centuries, behaviours like dissatisfaction or resistance to gender roles were pathologized as "hysteria" or similar disorders, which often invalidated women's realities and justified their oppression, confinement or medication[15]- and even hysterectomies to cure them of “insanity”[16].

Some form of apology is becoming evidently overdue to the millions of people required to consume often toxic cocktails of chemicals designed to alleviate the symptoms of psychotic and depressive illnesses. While these appear to have been effective for some, we cannot continue to ignore growing evidence that suggests that for many 1) their effectiveness is commonly no better than placebos, and 2) the metabolic impact of long-term use can lead to “adverse effects” (eg. metabolic syndrome, cardiovascular issues, agranulocytosis…); the most extreme of which can be premature death

Dr. Ashley Bloomfield, the former Director-General of Health acknowledged that "We have now some quite good evidence that racism at a range of levels does determine access, experience and outcomes in the healthcare system"[17]. Māori are commonly referred to as “vulnerable”. This is not an inherent quality but something of a colonial inevitability experienced by indigenous people around the world. While 17% of the population, the prevalence of mental distress among Māori is almost 50% higher than among non-Māori. Māori are more likely to be compulsorily treated under the Mental Health (Compulsory Assessment and Treatment) Act 1992, to experience solitary confinement (“seclusion”) and/or be treated within forensic services.

An apology to Māori is not misplaced here. Aotearoa / New Zealand, all it represents and stands for, and the whole population will be further disadvantaged, should Māori remain “vulnerable”.

These terrible things cannot be relativised as the bizarre and extreme activities of outliers or results attributed to one or two poor practitioners. Nor should they be sanitized and accommodated as being reflective of a developing science, slow to reach its maturity, but learning from its mistakes.

Learn from mistakes

Arguably the development of health care (including psychiatry) has been able to learn from mistakes, from trial and error, from experiment and review. However, psychiatry holds a special place in that it seems to have very much institutionalised and exploited the role of credentialed authority, power and status in its development and establishment of “expertise”. How else could anyone have seriously considered the insertion of a small chisel into a patients nose, which was then tapped with a hammer into the brain to “scrape” away connections across the prefrontal lobe as a surgical procedure?

In eventually conceding the ineffectiveness of these formative practices and procedures, the role of power, status and social values granted to these early physicians, that gave sanction (even a Nobel prize[18]) and legitimised these attempts, has been rarely examined or questioned.

Beware dogma and doctrine

Where dogma and doctrine are permitted to dominate thinking, it too easily can cause intelligent people to say the most silly things (eg. “Patient engages in writing behaviour…”[19]; “You need to get a job; it will be therapeutic…”[20]), and arrive at overly hasty, reactive solutions (eg. “our staff are at risk of assault; we will issue them with helmets”[21]). It also gives cause to essentially good people to perform the cruellest acts (such as removing children from Aboriginal parents…), and exercise power in the most profound way and, in the name of “therapy” (eg. to take away a person’s liberty and/or impose solitary confinement (seclusion).

Drawing its origins from, and invoking values, principles and practices of medicine and science, institutional psychiatry has become a powerful global force that now shapes how we understand ourselves, our emotions, and the way we think, from a perspective of power and influence. A medical model provides the most dominant framework for the way in which we now understand and respond to and treat mental illness.

In a troubling totalitarian twist, psychiatry has also developed and retains a convenient repository for any challenge or close examination. It has been called “anti-psychiatry”.

For nearly two centuries, medical models have provided the most dominant framework for 1) the way in which society understands mental illness, and 2) the shaping of archetypal views and perspectives in our culture.

Such a status quo is arguably running out of time.

It can’t remain viable and valid in a world of rapid, volatile and continuous change. Prof. Peter Hawkins (Henley Business School) is adamant that “learning today must happen at a rate equal to or greater than the rate of change in your environment - or your approach will eventually fail.”[22] The failure is also predicated upon basically ignoring an “un-holy trinity” that all business and public services must respond to better:

How do we

Do more
At higher quality
With less resource?

This is not temporary thing; nor I believe is it a conundrum that is going to pass anytime soon. It equally – perhaps more so – applies to commercial endeavours.

An alternative, a transformed mental health and wellbeing system, would have to frame challenges and responses to those challenges, in another way.

It would be a way that is far more informed by the lived experiences of people experiencing trauma and chronic “problems in living”, their family / whānau, and the community.
It would be more “lived experience led” but informed by the voice of experts.
It would ensure spaces in which other perspectives can assume a legitimacy that has been traditionally overlooked. In fact the voice of experts may need to be willing to assume a role that, while still important, may be more ancillary than central.

For me, this is being genuinely, authentically person-centred and community focused (terms that are at real risk of becoming mere cliches). This is how we connect with social / wider determinants of health, promoting a stronger focus “upstream” where issues of poverty, racism, poor housing, violence and abuse, cultural alienation, employment, education have all been shown to be strongly correlated to poor mental health – as well positive mental health when they are addressed.

One for the voters

Government’s too must better recognise their responsibilities to the mental health of people and communities. Not by just by providing “more funding” or sponsoring the next “plan”, but by not introducing nor supporting policies and legislation that actually damage mental health. We now have to move away from a paradigm of predominantly seeing medical problems with social implications to understanding that these are predominantly social problems with medical implications.

This is the platform upon which engagement, connection and partnerships would be the fundamental “tools of trade”.

Attributions

[1] https://www.ranzcp.org/news-analysis/statement-on-the-royal-commission-of-inquiry-into-abuse-in-care-new-zealand

[2] Slade, M. (2009). Personal Recovery and Mental Illness: A guide for mental health professionals. Cambridge University Press: Cambridge

[3] Christopher Hitchens contribution to a debate about whether or not the Catholic Church is truly a “force for good” in our world. https://www.youtube.com/watch?v=yuGjcCByVyc

[4] https://www.cchr.org/documentaries/age-of-fear/psychiatrists-admission-to-holocaust.html

[5] https://www.hinduismtoday.com/modules/smartsection/item.php?itemid=856

[6] https://blogs.sussex.ac.uk/psychology/2021/02/03/the-american-psychiatric-associations-apology-to-black-indigenous-and-people-of-color-performative-action-or-genuine-atonement/

[7] https://www.psychology.org.au/news/media_releases/15September2016/

[8] Frances, A. (2013). Saving normal. Harper Collins

[9] https://www.amazon.com/CIA-Doctors-Violations-American-Psychiatrists/dp/0976550806

[10]http://www.un.org/disabilities/documents/reports/ohchr/a_hrc_34_32_mental_health_and_human_rights_2017.docx.

[11] https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2017/vol-130-no-1454-28-april-2017/7225

[12] https://www.nytimes.com/2012/05/19/health/dr-robert-l-spitzer-noted-psychiatrist-apologizes-for-study-on-gay-cure.html

[13] https://www.npr.org/templates/story/story.php?storyId=5014565

[14] http://germanhistorydocs.ghi-dc.org/sub_document.cfm?document_id=4496

[15] How Radical Women Changed Psychiatry in the 1970s. https://www.psychologytoday.com/us/blog/hygieias-workshop/202003/how-radical-women-changed-psychiatry-in-the-1970s

[16] Institutionalizing Femininity: A History of Medical Malpractice and Oppression of Women Through

19th century American Mental Asylums. https://pdxscholar.library.pdx.edu/cgi/viewcontent.cgi?article=1272&context=younghistorians

[17] https://www.stuff.co.nz/national/health/113917099/racist-health-system-no-cure-for-sick-maori

[18] In 1949 Dr. António Egas Moniz received a Nobel prize in physiology for his development of the prefrontal lobotomy

[19] https://pubmed.ncbi.nlm.nih.gov/4683124/ While this research is now considered “flawed”, it has influenced critical thinking on how people think about mental illness, psychiatric diagnosis, and the impact of the environment of mental health institutions – for both patients and staff.

[20] Personal communication

[21] https://www.nzherald.co.nz/nz/helmets-for-dunedin-mental-health-staff-after-nurse-kicked-punched-by-patient/IPW7MSPYADK5E36AW7RLN3EIYY/?c_id=1&objectid=11899616

[22] Peter Hawkins, (2018) Professor of Leadership, Henley Business School. Beyond the heroic CEO: the changing challenge of leadership.

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