10/8 Mental Health Ethics

True or False: It’s helpful to use the language preferred by individuals or communities when communicating about/with them. Language is constantly evolving.

True obvi

mental health

a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community

True or False: Mental health is the absence of distress or disorders and only about feeling well emotionally

False; Mental health is NOT just the absence of distress or disorders, NOT just feeling well emotionally, but ALSO being able to fulfill someone’s social role

True or False: Everyone has mental health

True

mental health conditions (MHCs)

conditions that fundamentally shape how people think, feel, and act, which can cause impairment and distress

True or False: MHCs are sources of suffering requiring medical treatment and cannot be meaningful forms of neurodiversity

FALSE; MHCs CAN be sources of suffering requiring medical treatment but can ALSO be MEANINGFUL forms of neurodiversity for some people

• ex: 1 in 5 adults in the USA hv a mental health condition

What are some types of MHCs in the DSM?

• mood disorders like depression and bipolar

• anxiety disorders

• psychosis and schizophrenia

• trauma-related and dissociative disorders

• personality disorders

• eating disorders

• substance use disorders and addictions

• related neurodevelopmental diagnoses (ex: ADHD)

mental health ethics

the study of value-laden issues related to psychological health, illness, and disability

• includes psychiatric ethics

• spans the broader study of ethical issues at the intersection of MH + education, employment, and criminal legal system

psychiatric ethics

the study of value-laden issues in the biomedical treatment of mental health conditions

ex: with psychotropics or electroceutical therapies

why does mental health matter in bioethics?

• mental health conditions can, but do not by default, impact someone’s capacity

• people w mental health conditions in crisis are sometimes treated involuntarily, which is a significant ethical issue

• mental health conditions can shape someone’s lived experiences and values, which inform the course of their medical treatment and how they define a fulfilled life

Ethical Issues in the History of US Psychiatry

Between 1800s-1900s

There were 32 state hospitals: large rural facilities to house and treat people with MHCs, intellectual disabilities

Ethical Issues in the History of US Psychiatry

By mid-1900s

• concerns about neglect and abuse of patients in these facilities, such as depicted in One Flew Over the Cuckoo’s Nest (1962)

• decreasing interest in funding public welfare programs + introduction of psychiatric meds led to deinstitutionalization

Ethical Issues in the History of US Psychiatry

Today

concerns about houselessness + routing people w MHCs into criminal legal system + lack of access/shortages of MH services

involuntary treatment (McMillan 2013)

inpatient treatment of someone in a mental health crisis who cannot freely consent + who is at serious risk of harming self or others

True or False: Involuntary treatment is an act of paternalism, justified under benefiticence

True; treating the patient against their will is necessary because it is thought to protect them and ensure their well-being

What did Wipond (2023) warn about involuntary treatment?

It causes further psychological trauma and makes people less likely to access mental health care in the future

Psychiatric survivor (CSX) movement

in the wake of deinstitutionalization, and in the face of continued concerns over involuntary treatment, a global civil rights movement from the 1970s —> today to resist psychiatric harms

what did the psychiatric survivor (CSX) movement promote?

patient-controlled alternatives to psychiatry like peer support and peer respites (breaks)

what did the psychiatric survivor (CSX) movement advocate for?

the recovery model, which stipulates that patients are empowered to take an active role in their own healing

what did the Mad Pride events in the psychiatric survivor (CSX) movement aim to do?

destigmatize MHCs as meaningful forms of neurodiversity rather than strictly forms of pathology

Overcoming obstacles to shared decision making (SDM)

True or False: Even patients whose capacity is limited by a mental health condition should be engaged in decisions about their care, in a way that’s scaled to their understanding and capacity (which may fluctuate)

True

True or False: Data suggests that psychiatrists don’t consistently engage in shared decision making, and some prefer a paternalistic approach

True

True or False: Patients who don’t agree with their diagnosis don’t understand that a medication would be helpful for symptoms they find troubling

False; Patients who disagree with diagnosis may still understand that a medication would be helpful for symptoms they find troubling (the trouble w “insight” in clinical settings)

Conditions like schizophrenia are highly ____, and experiences like hearing voices are ____ (i.e. treated as something to eliminate with treatment as a source of distress)

stigmatized, pathologized

What did Eleanor Longden say about centering lived experience and auditory hallucinations?

They can offer helpful insight into people’s recovery in a positive way, even ones that are frightening or threatening

***WILL BE ON EXAM: WATCH THE TED TALK

Eleanor Longden’s TED talk: The Voices in My Head

Core Argument: Auditory hallucinations should be treated as meaningful, metaphorical expressions of underlying psychological trauma to be decoded and collaborated with, rather than a purely physical brain disease to be chemically suppressed or feared.

Key Evidence:

• The Traumatizing Cure: When harmless internal commentary began tracking Longden's college life, a rigid psychiatric system responded with a text-book diagnosis of schizophrenia, massive sedation, and institutional isolation. This biomedical framing stripped her of agency and reinforced a message of absolute hopelessness.

• Voices as a Psychic Mirror: Longden discovered that her voices were not random chemical glitches, but an intricate defensive response to severe childhood trauma, grief, and unexpressed pain. The hostile and dictatorial tone of the voices directly mirrored her own repressed emotional state.

• Radical Collaboration: Rather than trying to fight, ignore, or eliminate her voices (which only made them more aggressive), she achieved recovery by actively listening to them, validating their underlying fears, and negotiating boundaries—transforming them into cooperative allies.

• A Shift in Clinical Empathy: Her breakthrough occurred when she found practitioners who abandoned clinical pessimism. Instead of asking a paternalistic "What is wrong with you?", they approached her with engaged curiosity, asking "What happened to you?"

Notable Note: Longden went from being a heavily medicated, institutionalized patient who was told she would be "better off with cancer than schizophrenia," to successfully earning her master's degree and becoming a prominent international mental health research psychologist.

Mental Health Ethics in the Community

True or False: Housing shortages/houselessness, food insecurity, lack of access to care, and poverty worsen psychological distress and make ppl with serious MHCs even more vulnerable or ill

True; 44% of people in jail and 37% of people in prison have a MHC

What are some other important ethical debates?

• should people be able to access medical aid in dying for psychiatric diagnoses that cause severe and persistent suffering?

• should we use psychotropics only to treat dysfunction and alleviate suffering, or to enhance neurotypical people’s function/mood?

• under what conditions if any, are restraints (chemical or mechanical) ethically permissible for patients in mental health crisis?

MHE Summary

• mental health conditions pose challenging issues for bioethics, often related to capacity and autonomy

• mental health ethics spans issues within and beyond clinical settings

• the history of psychiatric care in the US is ethically fraught, as we have grappled over time with how best to meet the needs of people w MHCs

• involuntary treatment is one of many pressing ethical issues, calling to question how best to care for people in crisis

Guidry-Grimes 2020 Overcoming Obstacles Shared Decision Making

Core Argument: Shared decision making (SDM) is a persistent ethical imperative in psychiatric care; the four common clinical barriers used to deny it—incapacity, poor insight, clinician pessimism, and conflicting goals—can and must be overcome to honor patient dignity.

Key Evidence:

• The Paternalistic Reality: A 2009 survey revealed that 44% of psychiatrists still default to a paternalistic approach. They eagerly bar patients with schizophrenia from making critical medical or legal decisions (like prescriptions or hospitalizations)—the very choices patients care about most.

• Redefining Insight and Capacity: Decisional capacity fluctuates and is rarely entirely erased by a diagnosis. Furthermore, a lack of clinical "insight" into a diagnosis doesn't mean a patient cannot identify their own goals; a patient may reject a thought disorder label but still actively partner to choose a treatment that "calms their nerves".

• Engaged Curiosity: Clinician bias and "therapeutic pessimism" (especially surrounding personality disorders) can be dismantled by replacing countertransference with "engaged curiosity"—the active humility to realize a provider has more to learn about a patient's lived experience.

• Clinical vs. Personal Recovery: Clinicians often define recovery as symptom suppression, while patients prioritize self-esteem, hope, and meaning. Peer-run software networks like CommonGround prove that care plans can satisfy both by tailoring medications to support the patient's personal life goals.

Notable Note: Over three-quarters of psychiatrists surveyed reported that they would automatically withhold decision sharing the moment a patient exhibited basic diagnostic criteria like shallow affect, depression, or thought disturbances.