Every society I can think of has some means of keeping the mad from harming themselves, or excusing them from the consequences of their actions. I can recall presentations from Egyptian forensic psychiatrist discussing the interface they have to make with the religious courts of that nation.

Society tends to delegate this to my profession. For good or ill. If wet on the person in front of us, we probably do more good than harm, for the experiments with total deinstitutionalization, be they in Italy or San Francisco, tend to fail.

For a good and just society wants people cared for when vulnerable. There are those who say that being good and just are an oppression: my answer to that is that the homeless are often victimized, are often mad, and the mad homeless are the most hurt. Our duty to minimize pain means at times we are paternalistic. But this does require great care.

It is a rare psychiatrist who does not feel the weight of responsibility for patient safety; a perception reinforced by society in the form of newspaper headlines following adverse events. Most psychiatrists can recall critical incidents in which they believe an individual’s health, indeed their life, would have been at risk had compulsory admission not been an option. They acted, in such cases, not just to contain immediate danger, but in consideration of the patient both before and after the acute episode. They believed that this individual’s past and future selves would not wish the choices they made while experiencing, for example, persecutory delusions, to lead to permanent, irreparable consequences. However, it is also important to remember how serious—and open to abuse—the power to detain individuals in inpatient psychiatric care can be. Deprivation of liberty is never trivial. And few can be unaware of the dark history of human rights abuses perpetrated by mental health professionals in the past—such as those under National Socialism remembered at last year’s Royal College of Psychiatrists International Congress by Germany’s Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde. The mental health system does not sit outside of the society in which it exists. History has shown that society’s evils often become, sooner or later, psychiatry’s evils.
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There is, however, an increasingly vocal movement that would not consider this sufficient. From this perspective, any use of compulsory admission in mental health care is in direct violation of basic principles of human rights: a position that, according to the interpretation of the Committee on the Rights of Persons with Disabilities is supported by the UN Convention on the Rights of Persons with Disabilities (CRPD). As a group of concerned mental health professionals wrote in The Lancet Psychiatry in 2015: “Article 12 Section 2 of the CRPD says ‘States Parties shall recognize that persons with disabilities enjoy legal capacity on an equal basis with others in all aspects of life’. The Committee consequently asserts that henceforth substituted decision-making, compulsory treatment, involuntary admissions, and diversion from the criminal system process on the grounds of mental disability […] should be abolished.” The authors went on to express concern that “instead of enhancing human rights, several fundamental rights, such as the enjoyment of the highest attainable standard of health, access to justice, the right to liberty, and even the right to life, might instead be violated”.

This is the usual use of the UN to remove from a local community any power to control and contain, to allow for shelter, to protect. In the name of human rights. As if these are unalienable by tyrants or the a state run by secular beadles.

The greater danger is that we wlll start talking about that which we do not know. I know a lot about psychiatry, and the more I know the less certain I am. Which makes me quite relieved that I am no longer of the US AACP.

The American Association of Community Psychiatrists (AACP) has approved a position statement asserting that climate change poses significant threats to public health, including mental health.

The statement, adopted last month by the AACP Board of Trustees, further asserts that psychiatrists are “uniquely positioned to help reduce barriers to addressing climate change, such as denial, hopelessness, and behavioral passivity, and to enhance efforts to communicate the public health and mental health risks of climate change through mechanisms that result in sustained behavioral change.” (See box for complete text of the AACP statement.)

“As community psychiatrists, we tend to view our work through two primary lenses,” said AACP President Michael Flaum, M.D. “One is a population health lens, thinking about the health of communities; and the other focuses on the most vulnerable individuals in that community. We feel that from both of these perspectives, the instability that can be expected from the direct and indirect effects of climate change, including the consequences of increasingly frequent and severe climate-related disasters, demands our immediate attention. We want to be proactive about this, rather than responding to each Katrina or Sandy as if they were not anticipatable.”

The position statement was brought to the AACP by an informal but growing group of psychiatrists calling themselves the Climate Psychiatry Alliance.

The ethics of my craft, as all crafts, must relate to our prime directive. Which is to cure at times, to contain often, and to comfort always. We are physicians. We are not climate scientists: and the idea that my profession, which deals with the ugly messiness of our fallen nature, is trying to signal virtue when the doctor often has to contain against the patient’s will is specious.

My old professor said that we were the refuse centre, We restore, at times in part and often without all the tools that are available, those who society refuses to consider. For fear, for shame, and from prejudice. This is worthy enough.

Let those without virtue or ethics signal their adherence to the fashions of our age. We have work to do. We have more power than knowledge. We need to work, but with care.