Reimagining Crisis Support

I began talking about the need to de-medicalize crisis support in September 2018 after learning from lawyer Alberto Vásquez that the Peruvian legal capacity reform, which remains the clearest and most advanced in its fidelity to the Convention on the Rights of Persons with Disabilities, left only one basis for involuntary mental health interventions outside the context of criminal proceedings – as involuntary hospitalization in situations characterized as a medical emergency.  

The application of the CRPD to medical emergencies is itself a dimension of legal capacity reform that has to be fulfilled.  The standard of ‘legal capacity at all times’ and ‘best interpretation of will and preferences’ (when it is not feasible to determine the person’s will) could suffice for actual medical emergencies – say, when a person is unconscious and could bleed to death, to justify lifesaving treatment notwithstanding the non-manifestation of consent or refusal.  

But in the context of psychiatry I was concerned that the CRPD would be incorrectly applied, in particular that the obligation to respect a person’s manifestation of will at all times including in situations of emergency or crisis would be ignored, and the criterion of ‘best interpretation’ invoked when it was not warranted.  

The framing of crisis as a medical emergency implies a need for urgent medical intervention and assumes the appropriateness of such intervention.  For this reason, especially in light of the legacy of psychiatry as segregation and coercive control, it was highly likely that psychiatrists would view situations where the person is unclear or ambivalent about what they need, struggling to express new and difficult feelings and perceptions, or reacting strongly against the presence of a psychiatrist or mental health worker, as a failure to manifest their will, and that they would proceed with medical intervention as the default course of action without ascertaining that the person welcomes such a response.  Forced interventions would thus be likely to continue, requiring case-by-case redress after the fact.  

It was clear that the challenge to a medical narrative had to be incorporated into the CRPD normative framework.  It could not be left to a debate about the type of services to be offered.  

The stimulus to take on the topic of crisis support in greater depth was a conversation I had with Israeli human rights advocate Sharon Primor at a conference in Hong Kong in April 2019.  Our dinner companions enjoyed watching us spar, as she challenged me to set out positive policy as an alternative to forced psychiatry.  I started to write a list of the needs in crisis situations and the kinds of responses that would have to be in place for comprehensive policy to take the place of the medical coercive psychiatric system.  I posted some notes on Academia.edu (under the title ‘Towards Positive Policy’) as a draft for people to comment on, and out of this developed the skeleton concept of de-medicalized crisis support based on Article 12 (support for decision-making) and Article 19 (support for practical necessities of living in the community).  

The premise of de-judicialization came a few months later during a conversation with Michelle Funk of the World Health Organization and Catalina Devandas, Special Rapporteur on the Rights of Persons with Disabilities, about what a legislative framework might look like for de-medicalized crisis support.  It became clear to me that there cannot be any legislative framework that treats crisis support as a mandated action in response to defined situations; to do so would carry over the managerial approach of mental health legislation that is incongruent with providing support as act of respect and solidarity among fallible individuals who are all vulnerable in their shared humanity.  Crisis support needs to be made available as a positive entitlement of the individual, in the same manner as other disability-related support such as personal assistance, to bring to full fruition the social model of disability for people with psychosocial disabilities. 

This paper presents a framework for crisis support based in the social model of disability, and then branches out into exploration of broader social change and actions that can help to bring about this crisis support – de-medicalized and de-judicialized – on the ground.   It began as narrative of an initial graphic representation that one colleague calls a mind map, which was to be developed into a hyperlinked website with text and references on the various components.  The two-part mind map, which differs in some particulars from the outline of this paper, is attached here as Appendix I. 

The concept in skeleton form is found in the paper, ‘Positive policy to replace forced psychiatry, based on the CRPD’, and was presented in an even more pared-down version in a one-page intervention at the 2019 CRPD Conference of States Parties; the latter is also attached, as is a related essay, ‘Discernment as process, not precondition’.  

I use the term ‘crisis’ as a shorthand, understanding that it is problematic – similar to ‘psychosocial disability’, it can be misunderstood as a euphemism for the old paradigm of mental illness.  I use the term in two ways.  First, it allows me to think about the complex social situation that is happening when anyone thinks about invoking psychiatric commitment, with the differing motivations and perceptions of all concerned.  That starts from the problem I am aiming to solve - what is going on when this happens and what can we do instead?  How can we divert the good motivations into a different channel, while rejecting the violence, segregation and making anyone an outcast from community or intersubjective relations?  This is a social crisis that has personal as well as political dimensions for everyone involved.

Second, sometimes though not always the person who is targeted for such intervention has been experiencing her own sense of urgency and distress.  Understanding this urgency and distress as crisis allows us to reframe it apart from the question of whether anyone is trying to violate her human rights.  This is a personal crisis that has social and political dimensions.  

In view of the social and interpersonal dimensions of crisis, whether we start out understanding it from the social or the personal point of view, community is both the background of any crisis and a participant in it.  This does not mean that the community around a person has any ownership of her personal crisis or her decisions.  It means that there is potentially a restorative or transformative justice need in relation to the social (including interpersonal) and political dimensions. 

Justice and healing cannot be led by mental health professionals.  On the contrary, that sector needs to make reparations for its profound violation of the fabric of community through its violent practice of psychiatric commitment and forced intervention with drugs and electroshock, practices that subjugate and terrorize its victims and render society as a whole vulnerable to its political and ideological influence.  The first step is to end the violations and step aside; the mental health sector cannot be either directly or indirectly in charge of a new paradigm.    

This paper is itself a bridge between different ways of engaging with the traumatic events that led me to bear witness as a survivor of psychiatric violence – from law and policy generated deductively from the necessity for abolition, to a more situated practice that ultimately blends seamlessly with a need for radical change in all areas of society.  This is in one sense intersectional but in another an expression of an underlying universality that converges from many directions.   

I have written most of the paper during the globally shared yet vastly disparate and isolating world of the COVID-19 pandemic and, in the US, an uprising against racist police violence and other systemic racism, known as the Movement for Black Lives.  Crisis support has received attention since it is apparent that police responses to someone experiencing personal crisis can be life-threatening.  The concept of social-model crisis support presented here dovetails with that serendipitous national conversation that draws on theory and practice of the prison abolition movement and psychiatric survivor movement, as well as with the human rights framework for robust equality that is set out in the CRPD.