Reducing involuntary treatment for people who hear voices

Voices Vic | Prahran Mission

for people who hear voices

Guidelines for the Victorian Mental Health Tribunal Produced by Voices Vic, UnitingCare Prahran Mission In partnership with an expert advisory committee May 2014

Read more at www.voicesvic.org.au

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Reducing involuntary treatment for people who hear voices: Guidelines for the Victorian Mental Health Tribunal.

Š 2014, Voices Vic, Prahran Mission.

Published on the Voices Vic website: www.voicesvic.org.au

Written by Indigo Daya, Voices Vic Program Manager, in consultation with the Voices Vic team and specialist advisors, including: Dr Dominika Baetens, Deputy Director, St Vincents Hospital Liz Carr, Acting Director, Victorian Mental Illness Awareness Council Meg Kenyon, Participant Consultant, Prahran Mission Initially NO, Peer Researcher, Voices Vic, Prahran Mission Fi Robinson, Peer Project Worker, Voices Vic, Prahran Mission Cath Roper, Consumer Academic, University of Melbourne Dr Neil Thomas, Director National eTherapy Centre, Swinburne University

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Contents Section 1: Background____________________________________________________________ 5 Language used in this document __________________________________________________ 6 About Voices Vic _______________________________________________________________ 7 About this document ____________________________________________________________ 7 Victoria’s new Mental Health Act 2014 _____________________________________________ 8

Section 2: Summary & Checklist ___________________________________________________ 9 Summary of general considerations for the Tribunal _________________________________ 10 Checklist for tribunal decisions about involuntary treatment criteria ___________________ 12

Section 3: Objectives & principles in detail _________________________________________ 15 Extract of objectives & principles of the Act ________________________________________ 16 Promoting recovery ____________________________________________________________ 17 The least possible restrictions on human rights & dignity _____________________________ 20 Preference for voluntary assessment and treatment _______________________________ 22 Best possible therapeutic outcomes ______________________________________________ 25

Section 4: Making decisions about involuntary criteria in detail ________________________ 27 Criteria (a) The person has mental illness__________________________________________ 28 Criteria (b) Harm to self or others ________________________________________________ 34 Criteria (c) Immediate treatment _________________________________________________ 38 Criteria (d) No less restrictive means available _____________________________________ 39

Section 5: References & attachments ______________________________________________ 42 References ___________________________________________________________________ 43 Attachment 1: Treatment effectiveness for psychosis in Australia _____________________ 45 Attachment 2: New recovery framework for Australia _______________________________ 46 Attachment 3: The Voices Vic approach ___________________________________________ 48

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The Hospital Years After going officially ‘crazy’ at university, I finally ended up in a psychiatric unit in 1998. By that point I was trapped inside a confusing world of alien conspiracies, paranoia, voices and traumatic flashbacks. Given the terror I felt at my realities, I was actually glad to be given the label ‘schizophrenia’.

No label properly describes human experience, though, and throughout the next five years doctors made valiant (but futile) attempts at finding one that fitted. Eventually they settled on ‘Schizoaffective Disorder’ (something my psychiatrist still believes I wear). My time in ‘the system’ almost broke me.

I lost my confidence, self esteem and – most importantly – hope for the future. I became a shell and those around me thought that I would never recover.

Breakthrough After years of going in and out of hospital, I was lucky enough to find out about my local Hearing Voices Group. Through this group, I began to rebuild my self esteem and untangle the voices and beliefs that plagued me.… I started to realise that my voices were my way of making sense of what had happened to me. I began to see a life outside the mental health system and – with support – made the decision to find it.

As Things Are Now …. I’m no longer on my own. I’m part of an international movement of change to challenge the stigma, misunderstanding and oppression of people who are struggling to cope with their unusual experiences. I don’t have all the answers, and am still working out how to deal with some of my own issues, but I’m on the path.

Rachel Waddingham is the Manager of Voice Collective, a peer support program for young people and prisoners that works across London. She is internationally respected as a recovery trainer and speaker, and author of the blog www.behindthelabel.com Reducing involuntary treatment for voice hearers | Guidelines for the Mental Health Tribunal

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Section 1 Background

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Language used in this document In this paper we refer to ‘hearing voices’, ‘people who hear voices’ and ‘voice hearers’. ‘Hearing voices’ in a mental health setting is more commonly referred to as ‘auditory hallucinations’. We also refer to ‘unusual beliefs’ rather than the clinical terminology of ‘delusions’.

These terms have been developed by consumers as part of the process of reclaiming power and ownership over personal experience and recovery.

We call it ‘hearing voices’ because while it may seem like hallucinations to others, it feels like hearing voices to us.

Hallucinations are classed as a common symptom of psychosis. Psychosis is a set of symptoms seen in mental illness diagnoses such as schizophrenia, mood disorders such as depression or bipolar disorder, or dissociative disorders.

It should also be noted that ‘voice hearer’ has, over time, come to represent other types of sensory hallucination besides the auditory, including visual, olfactory and other sensory experiences for which no external stimuli is present.

We make no judgements about language in this paper, but in keeping with the principles of consumer leadership we have chosen wherever possible to use the language preferred by voice hearers themselves.

In circumstances where research or statistical data relates specifically to ‘psychosis’ or ‘schizophrenia’ rather than ‘hearing voices’, we use the terminology of the source document for the sake of accuracy.

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About Voices Vic Voices Vic is Victoria’s consumer-led specialist service for people who hear voices, and a program of Prahran Mission.

We provide peer support and systemic advocacy for people who hear voices and have other unusual experiences. We also conduct research into peer-led recovery programs, partner with clinical and community mental health services, and provide training and recovery expertise to the mental health sector. You can read more about our work in attachment 3.

Victoria has one of the highest rates of involuntary treatment in the world (Burns & Dawson, 2009),

with no justifiable reason.

We all share an ethical responsibility to change this situation.

About this document This paper has been prepared for the Mental Health Tribunal by Voices Vic, to provide guidance to the consideration of involuntary treatment for voice hearers.

Preparation of this document follows a meeting with members of the Mental Health Review Board in July 2013, release of the new Victorian Mental Health Act 2014, and consultation with a range of stakeholders and experts.

This document aims to provide a consumer and peer work perspective on involuntary treatment for people diagnosed with psychotic disorders which, we hope, may assist in the reduction of involuntary treatment orders for people who hear voices.

The Mental Health Tribunal is an independent statutory tribunal established under Section 152 of the Victorian Mental Health Act 2014 (the Act).

The primary function of the Tribunal is to decide whether people being treated as involuntary patients meet criteria in the Act in order for involuntary treatment to continue. If the Tribunal does not believe those criteria are met it discharges a person from involuntary status, enabling that person to make their own decisions regarding treatment.

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Victoria’s New Mental Health Act 2014

Victoria’s new Mental Health Act was passed by parliament in April 2014 and comes into effect on 1 July 2014.

The Act provides new protections and a greater recovery focus for consumers.

In a media release on 20 February 2014, the Hon. Minister Mary Wooldridge stated:

“Importantly, the legislation promotes and enables voluntary treatment in preference to compulsory treatment wherever possible…”

(State Government of Victoria, 2014)

The preference for voluntary treatment in the new Act is supported by a number of mechanisms to protect people’s rights to dictate their own treatment. These include: 

Presumed capacity: a presumption that the person has capacity to give informed consent (s70)



Advance Statements: where the person can specify their treatment preferences in writing in advance, and these must be taken into account by treatment providers (s19)



Nominated person: to provide support and help represent the interests of the person (s23)

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Section 2 Summary of Considerations & Tribunal Checklist

The recovery movement began in the 1970s primarily as a civil rights movement aimed at restoring the human rights and full community inclusion of people with mental health issues.

Recovery approaches are viewed by the consumer movement as an alternative to the medical model with its emphasis on pathology, deficits and dependency.

There is no single description or definition of recovery because recovery is different for everyone. However, central to all recovery paradigms are hope, selfdetermination, self-management, empowerment and advocacy. Also key is a person’s right to full inclusion and to a meaningful life of their own choosing, free of stigma and discrimination.

Personal recovery is defined within this framework as ‘being able to create and live a meaningful and contributing life in a community of choice with or without the presence of mental health issues’.

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Summary of general considerations for the Tribunal…

These two pages are a summary of general considerations, based on the objectives and principles of the Act. All of these considerations are outlined in detail on pages 20 – 35 of this document.

Promoting Recovery

Recovery is not about symptoms, it’s about having a life worth living. It involves hope, self-determination, selfmanagement, empowerment and advocacy. The Act, and government policies across Australia and internationally, endorse recovery as the central goal of mental health treatment. More on page 17.

Recovery is not necessarily about the elimination of ‘symptoms’ such as hearing voices or unusual beliefs. People can and do learn to live well with hearing voices. We can offer support to help people achieve this. More on page 29.

Involuntary treatment can harm people’s potential for recovery. Involuntary treatment can damage, rather than promote, many of the key aspects of recovery. More on page 18.

The least possible restrictions on human rights and dignity There are many less restrictive treatment options which are not well used by Victoria’s public mental health services, despite strong evidence and availability. These include talking therapies such as CBT and ACT and peer support. More on page 20.

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…Objectives and principles of the Act

Preference for voluntary treatment and assessment

Involuntary treatment can deprive people of health and life  

Psychiatric medication can have varied and serious impacts on physical health and mortality.

If involuntary drug treatments are used, services have a duty to proactively protect the physical health of people. More on page 22.

Refusal of treatment may be rational and reasonable.   

Has treatment been effective for the person in the past?

Does the treatment have a chance of causing serious physical health impacts?

Does the treatment impair people’s ability to think or feel? More on page 23.

The best possible therapeutic outcomes.

Medication can be helpful for some people but not for everyone (in fact, not the majority). Around two-thirds of people diagnosed with psychosis do not experience good recovery with medication (Morgan, et al, 2010). More on page 25.

The NICE standards recommend treatment that includes oral antipsychotics, psychological therapies (family intervention and CBT) and peer work. If the person wants to try treatments without medication, the guidelines advise saying that treatment is more effective when both talking therapies and medication are used, but to proceed following the person’s wishes with a plan to review within 4 weeks (NICE, 2014). More on page 26.

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Checklist for tribunal decisions…

Criteria (a) The person has mental illness Tribunal Checklist (a)



Hearing voices has not been taken as the only sign of mental illness



Unusual beliefs, particularly those of a religious, political, cultural or sexual nature, have not been taken as signs of mental illness



Medication side effects or normal responses to diagnosis are not being presented as symptoms that form the basis of diagnosis and involuntary treatment.

Tribunal Checklist (b)

 Would the person be more agreeable to space and time in lieu of treatment?

 If the person is listening to or talking with voices, has the tribunal asked the reason why?

Attempting to make sense or change the relationship with voices may be a helpful sign of recovery we can support.

 Does the person set limits or boundaries with the voices?

 Does the person obey the voices or do they form their own opinions about action?

 Have there been recent life stressors that have impacted the person’s wellbeing?

Hearing voices is not, on its own, a sign of mental illness.

Many people hear voices and live well with them. Voices are associated with many spiritual and cultural belief systems.

Voices can even be helpful in people’s lives. More on page 28 Unusual beliefs (delusions) and unusual behaviours are not necessarily signs of mental illness. Freedom of expression and the right to hold opinions without interference (s15) and cultural rights and beliefs (s19) are protected under The Charter of Human Rights and Responsibilities Act 2006 (Vic).

More on page 29

Many factors considered symptoms of mental illness may in fact be side effects of medication, or normal responses to diagnosis and other symptoms. Questionable ‘symptoms’ include: flattened affect (flat emotions, low motivation), confused thinking and poor concentration, social withdrawal, lack of care with hygiene and appearance, increased suicidal thinking, increased signs of depression and/or anxiety when diagnosed with psychosis. More on page 32.

Criteria (b) Because the person has mental illness, the person needs immediate treatment to prevent (i) serious deterioration in the person’s mental or physical health; or (ii) serious harm to the person or to another person; and The requirement for immediate treatment should be a very rare occurrence. Safe space and time may be just as effective.

More on page 34.

Perceived ‘deterioration’ may actually be helpful processing of experience. Taking time to listen or talk to voices may be a positive sign of working through a difficult experience. However obeying voices, or allowing them to dominate the majority of one’s life, is a sign that more support is needed. It’s also possible the person may be temporarily responding to difficult life stressors and requires only short term support. More on page 35.

The risk of serious harm is frequently overestimated. Hearing violent or commanding voices does not imply that a person wants or intends to cause harm to themselves or others. The intent of the person is what matters, not the content of the voices. This cannot be assumed – we must ask. More on page 35.

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…about involuntary treatment criteria & voice hearers

Criteria (c) the immediate treatment will be provided to the person if the person is subject to a Temporary Treatment Order or Treatment Order; and

Tribunal Checklist (c)



Delays in the provision of involuntary treatment are not allowable under the Act. If treatment is involuntary the service must not keep the person waiting. More on page 37.

Criteria (d) There are no less restrictive means reasonably available to enable the person to receive immediate treatment.

Talking therapies are less restrictive and rarely harmful.

Talking therapies are substantially under-utilised in Victoria , despite having an evidence base for use with voices. Talking therapies are not physically invasive or sedating. They do not impair cognitive or emotional capacity. They do not include any of the physical health risks associated with medication. More on

Tribunal Checklist (d)



Have the person’s wishes been seriously considered? Has all possible effort been made to tailor treatment to the person’s wishes?



Have talking therapies and/or peer support have been offered to the person, and asked whether these are preferred by the person?



Have a range of different talking therapies have been offered to the person?



Would a lowered dose of medication, a different type of medication, or fewer types of different medications be more acceptable to the person?



Has a trauma history has been taken and support offered to the person?



Has the Tribunal considered the potential harms of involuntary treatment if the person has a history of trauma?

page 38.

Reduced medication doses – or a reduced number of different medications – are both less restrictive treatment options. A person may be willing to agree to treatment if the impact of side effects is reduced through lowered doses or reduced numbers of medication. More on page 39.

Trauma informed treatment should be standard practice.

Past trauma is very common amongst people who hear voices.

Despite guidelines from the Chief Psychiatrist, most people are not asked about trauma or assisted in understanding how it may impact their mental health. This should form part of all treatment. More on page 39.

Has the Tribunal checked with the provider that treatment is available immediately?

These two pages are a checklist for use by the Tribunal in assessing involuntary treatment and whether alternatives are available. All of these items are outlined in detail on pages 36 - 41 of this document.

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Compassion not Compulsion The long term harm caused by using these procedures [involuntary, or forced, treatment] is not looked at. I have written in some detail about my experience of forced treatment when I was eighteen years old, elsewhere (May 2002). My experience, conversations with other people who have been in-patients, and practice as a clinical psychologist, tells me that the use of force has two main negative effects. Firstly it can set up, in the person inflicted with force, a deep resentment toward health care workers. A fundamental trust is broken and the person is likely to be reluctant to seek mental health care support in future crises. Hence we have Assertive Outreach; whole teams set up to work with this group of disaffected people and a growing market for secure hospital provision, to take the use of force to its logical conclusion, long-term internment. The second effect of the use of coercion if it doesn’t provoke outward anger and mistrust is these feelings can be internalised so that the person learns not to trust themselves. They give up on their right to an active role in their life assuming a dependent ‘sick role’. One becomes institutionalised. Both scenarios have a negative effect not just on the person and the community as a whole. We lose out on the potential of people who have been psychotic to contribute to our society. We guiltily write them off and blame all the passivity or challenging behaviour on the ‘mental illness’.

Rufus May works as a clinical psychologist in the UK Bradford Assertive Outreach team. He is one of the organisers of a monthly public meeting about different peaceful approaches to mental health called Evolving Minds. His interest in recovery from psychosis and other difficulties is rooted in his own experiences of psychosis when he was 18 and subsequent recovery journey. www.rufusmay.com Reducing involuntary treatment for voice hearers | Guidelines for the Mental Health Tribunal

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Section 3 Objectives & Principles

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Extract of objectives & principles of the Act

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Objectives & Principles of the Act

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Promoting Recovery

Recovery is endorsed as a concept and aim of mental health service delivery within the Act – and in state and federal government policy.

This Act has the following objectives: …

to promote the recovery of persons who have mental illness Recovery can be understood in two ways: ‘clinical recovery’, which implies the elimination or control of symptoms, and ‘personal recovery’ which is about having a life worth living, often in spite of so-called symptoms. Clinical recovery is what mental health services have traditionally focused on. Personal recovery is what is meant when we talk about recovery today. Across the world mental health services are increasingly focusing on ways to enhance recovery.

In August 2013 the Australian Health Ministers’ Advisory Council launched “A National Framework for Recovery Oriented Mental Health Services” in which the central factors of recovery are outlined as: …hope, self-determination, self-management, empowerment and advocacy. Also key is a person’s right to full inclusion and to a meaningful life of their own choosing, free of stigma and discrimination. (Commonwealth of Australia, 2013. See attachment 2.)

These principles must be used to guide decision making around involuntary treatment and suggest there is much we can do in shifting our attitudes away from involuntary treatment and towards greater choice and self determination.

Recovery is not about the elimination of ‘symptoms’ such as hearing voices or unusual beliefs.

Many people live rich and fulfilling lives while still hearing voices or having beliefs which are somewhat different to the general population. Involuntary treatment should be based on the impact that these unusual experiences have, rather than on their presence alone.

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The majority of the Voices Vic team still hear voices. To many we would be considered ‘actively psychotic’. Yet we have learnt ways to take control over the experience and get on with our lives. Some of us even hear supposedly ‘dangerous’, ‘commanding’ voices. But we do not feel compelled to act on them – we just see them as signs of stress or difficult emotions and it’s an indication to look after ourselves.

Hearing voices is often meaningful and related to difficult life experiences. It can support recovery to shift our focus from trying to eliminate ‘symptoms’ to helping people make sense of them and live with them instead.

People frequently have relationships with their voices which are meaningful (Beavan, 2011; Chin et al., 2009).

The content and character of voices is often related to past events, ongoing life experiences, views of self and broader social relationships (Gilbert et al., 2001; McCarthy-Jones et al., 2012; Thomas, Farhall & Shawyer, in press) At Voices Vic we support people to make sense of their voices within the context of their life and beliefs, and then to set boundaries with their voices. We teach people:  

To listen to their voices, since ignoring them does not generally reduce distress To respond to their voices with assertiveness, but never to obey them.

To us, recovery is not about getting rid of voices, but about changing the relationship with them so you can get on with work, study, relationships and life.

Involuntary treatment can harm people’s potential for recovery.

Involuntary treatment takes away, rather than promotes, many of the key aspects of recovery, including: 

Self-determination



Self-management



Empowerment



A meaningful life of one’s own choosing

Involuntary treatment can damage people’s belief in their own ability and capacity as well as reduce self-esteem and confidence. These impacts make it harder for people to recover and become independent. Because of this, involuntary treatment should be an absolute last resort rather than a common Reducing involuntary treatment for voice hearers | Guidelines for the Mental Health Tribunal

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occurrence and we must always carefully weigh the harm done by involuntary treatment with any potential predicted benefits.

In contrast, use of the new protections offered within the Act can promote recovery.

Promoting self-determination: The use of advance statements & supported decisionmaking provides opportunities for people to express and determine their preferred treatments. In contrast, having one’s own wishes ignored or contradicted can damage a person’s self-esteem and motivation to work towards their future. The Tribunal holds an essential role of ensuring that the person’s wishes are upheld wherever possible.

Promoting self-management: Supporting a person to take the lead in developing their own treatment plan is an important part of building self-management capability. In contrast, having others decide one’s course of treatment can damage confidence and capacity to recover with independence.

Promoting empowerment: A sense of empowerment can be nurtured by supporting people to learn, practice and master life skills and coping skills and work towards making sense of their experiences. Even if the choices people make are not ideal in the opinion of others, or are even seen as risky, there is important learning and growth which occurs during the process of making and living one’s own choices. One of the principles of the Act states: Persons receiving mental health service should be allowed to make decisions about their assessment and recovery that involve a degree of risk.

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Objectives & Principles of the Act

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The least possible restrictions on human rights and dignity Restrictive practice includes  Involuntary treatment/monitoring in the community  Involuntary use of medication  Involuntary use of electroconvulsive treatment  Hospital Low dependency unit – with leave  Hospital low dependency unit – without leave  Hospital high dependency unit Extremely restrictive practice includes  Seclusion  Chemical restraint  Bodily and mechanical restraint  Emotional restraint

The Act has the intent of minimising the use of all restrictive practice.

There are less restrictive and less harmful specialist treatments that can be used to treat psychosis.

These treatments are evidence-based and available, yet they are rarely used by Victoria’s public mental health services.

There are less restrictive and evidence-based treatment options to involuntary medication, such as talking therapies and peer support – yet they are rarely used in Victoria. Instead, treatment is often equated with medication alone.

The majority of people find it helpful to get therapies which let them discuss their voices in detail (e.g. Goodliffe et al., 2009; Newton et al., 2007) Therapy trials have consistently shown that providing people with time to discuss their voices is associated with levels of psychotic symptoms reducing. Two separate and large scale meta-analyses of data from randomised controlled trials of cognitive-behaviourally based talking

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therapies involving direct discussion of psychotic experiences both show reduced voices symptoms (Wykes et al., 2008; Jahur et al., 2014).

Meta-analysis for CBT for psychosis showed a 26% reduction in hospital admissions (National Collaborating Centre for Mental Health [NCCMH], 2009).

The 2014 National Institute of Clinical Excellence (NICE) clinical practice guidelines for the treatment of adults with psychosis and schizophrenia explicitly recommends that psychological therapy (cognitive behavioural therapy) is ROUTINELY offered to ALL patients with schizophrenia-related diagnoses. This includes during acute and recovery phases, and should be offered alongside rather than after antipsychotic medication.

A recent trial by Morrison et al (2014) found that CBT could be safely and effectively delivered to people choosing not to take medication.

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Objectives & Principles of the Act

Preference for voluntary assessment and treatment My choice‌

The Act requires all parties to aim for voluntary assessment and treatment as the FIRST preference.

This may mean that the Tribunal will need to disallow treatment orders in favour of the person’s preferred treatment option, or even no treatment at all.

In making a decision it is important for Tribunal members to understand the potentially harmful impacts of involuntary treatment and why it must never be a preferred option.

Involuntary treatment can deprive people of health & life.

Many involuntary drug treatments have serious physical health effects on consumers, including potentially a significantly reduced life expectancy contributed to by medicationinduced diabetes, obesity and cardiovascular problems.

While medication side effects are not the only contributors to reduced mortality (smoking, socioeconomic disadvantage and reduced attention to physical health for people diagnosed with mental illness also play roles), the impacts of medication are a factor that is easily modifiable and must be taken into consideration.

In Australia, on average, people diagnosed with schizophrenia

die between the ages of 50 to 59 years; that is 20 – 25 years younger than the general population. (Vicserv, 2008) Involuntary treatment with medication plays a role in contributing to this deprivation of the right to life.

Further, health services have a duty to consider the mortality impacts for all patients.

Psychosis impacts on individuals not only in terms of the symptoms of the illness, but from side effects of medication used to treat psychosis. (Morgan et al, 2011) Yet section 9 of the Charter of Human Rights (Vic) states: Every person has the right to life and has the right not to be arbitrarily deprived of life.

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Protecting physical health in the context of involuntary drug treatments.

Should a provider and the Tribunal agree that involuntary treatment is necessary with medication that already does, or is likely to, contribute to obesity, diabetes or other physical health issues, there is duty to provide adjunct treatments to minimise these impacts for the person.

The principles of the Act state: Persons receiving mental health services should have their medical and other health needs, including any alcohol and other drug problems, recognised and responded to; We strongly recommend that the Tribunal includes appropriate recommendations in their orders to protect the physical health of people subjected to involuntary drug treatments.

These could include, but are not limited to, professional support from one or ideally all of:    

A qualified dietician A qualified exercise physiologist or physiotherapist A qualified health psychologist A primary care physician to monitor physical health

Refusal of treatment may be rational and reasonable.

Refusal of treatment is often treated as a sign of ‘lack of insight’ and further evidence of severe mental illness or the need for involuntary treatment. This presents a circular trap for a person who has legitimate concerns about their diagnosis or treatment:

 to argue against one’s psychiatrist is to provide evidence of being unwell,  but to not argue is to leave oneself open to unwanted, and potentially harmful, treatments that may impact health, mortality, weight, sexual drive, ability to think clearly and ability to feel emotions. This is neither rational nor reasonable.

We must exercise extreme care to ensure we do not take away people’s right to ask reasonable and rational questions.

This is an important area of consideration for members of the Tribunal. All persons have the right to question their diagnosis and treatment, and indeed, while medical professionals will generally do their best, it must also be accepted that professionals will not always get it right, or have the full picture.

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When the genuinely serious impacts of many treatments are considered, refusal may in fact be an indication of quite rational thinking.

The following questions need to be asked and answered satisfactorily for the Tribunal: ? Has the treatment been effective for this individual? If it is not effective, will it be stopped or changed? For many people diagnosed with psychosis, antipsychotic medication treatment is not effective (see attachment 1).

Continuing treatment without demonstrated benefit, and in the face of physical health risks, is not a reasonable course of action. ? Does the treatment have the chance of causing, or has it already caused, significant physical impacts? These may include: obesity, diabetes, cardiovascular problems, severe sedation, sexual dysfunction and many more.

Treatment which causes these impacts may be considered as a violation of section 14 (freedom of thought) and section 9 (right to life) of the Charter of Human Rights and Responsibilities Act 2006 (Vic). ? Does the treatment impair ‘cognitive function’, also known as the ability to think clearly? Or does it impair the person’s ‘affect’, the ability to feel emotions? Clear thinking and the capacity to feel emotions is necessary for recovery, particularly for talking therapies. Involuntarily removing a person’s ability to think or feel may also be considered as a violation of section 14 (freedom of thought) and section 10 (cruel treatment) of the Charter of Human Rights and Responsibilities Act 2006 (Vic).

Section 71 (4) of the Act states: In determining whether there is no less restrictive way for the patient to be treated, the authorised psychiatrist must have regard, to the extent that is reasonable in the circumstances, to all of the following—

(a) the patient's views and preferences about treatment of his or her mental illness and any beneficial alternative treatments that are reasonably available and the reasons for those views and preferences, including any recovery outcomes that the patient would like to achieve; (b) the views and preferences of the patient expressed in his or her advance statement; (c) the views of the patient's nominated person

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Objectives & Principles of the Act

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Best possible therapeutic outcomes

Medication can be extremely helpful for some people but not for everyone. In fact, not for the majority.

Over-medication which impairs cognitive and emotional function can prevent rather than foster genuine recovery.

Many consumers report feeling ‘like zombies’ on their medication; people cannot work out their issues and develop new coping skills if they cannot think or feel. Heavy medication which has this effect is a form of chemical restraint rather than effective treatment and is not consistent with the Principles of the Act.

While many find medication helpful, medication does not help everyone, and the proportion that have a good response is small (Marques et al., 2011).

Australian statistics tell us that around 63% of people diagnosed with psychosis do not experience ‘good recovery’ on current treatment regimes (Morgan et al, 2011, attachment 1). With these statistics it is not possible to predict that involuntary drugbased treatment will lead to recovery for a particular individual.

Three quarters (77.4%) [of people diagnosed with psychosis] complained of medication side effects. The most common side effects included daytime drowsiness, drier or more watery mouth, weight gain (an average of nine kilograms in the past six months), inner restlessness, trembling or shaking of limbs and inability to relax. (Morgan et al, 2011) Sixty percent (61.0%) [of people diagnosed with psychosis] had impairments attributed to medication side effects. Almost one third (29.9%) said the impairments had a moderate or severe impact on their daily lives. (Morgan et al, 2011)

There is no justification for continued involuntary treatment which does not have any demonstrable benefit for the person.

Many consumers are involuntarily treated with medication for years without the medication having any demonstrable or significant beneficial effect. If medication cannot be demonstrated to have been helpful for a person in the past, there is no justification for enforcing its continued use. In fact, the only effect of such involuntary treatment is continuing to expose a person to unwanted and potentially harmful side effects.

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These facts do not mean that medication does not have its place in treatment. Many people find medication useful for varying levels of symptom reduction, while others find it a useful adjunct to treatments such as talking therapies. However: Medication alone is insufficient to support recovery – it cannot help us to get control over symptoms, learn coping skills, build our confidence or empowerment or ability to self-manage, or to find meaning or address past trauma or to build healthy relationships with others Medication does not have a beneficial effect for many people Medication harms the physical health of many people There are treatment options besides medication The Act protects and promotes people’s right to choose their own preference for treatment

Treatment guidelines recommend more than medication.

The NICE standards (UK) recommend treatment that includes oral antipsychotics, psychological therapies (family intervention and Cognitive Behavioural Therapy) and peer work.

If the person asks to try treatments without medication, the guidelines advise saying that treatment is more effective when both talking therapies and medication are used, but to proceed following the person’s wishes with a plan to review within 4 weeks (NICE, 2014).

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Section 4 Assessing Criteria under the Act

Under the Act a person’s situation must meet ALL four of the involuntary treatment criteria for an order to be made. In plain language these criteria can be summarised as: (a) Having a mental illness; AND (b) Being at risk of serious deterioration or harm to self or others; AND (c) Requiring immediate treatment; AND (d) No less restrictive options are available.

This section outlines the factors that need to be considered for voice hearers in relation to each of these criteria.

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Criteria (a) The person has mental illness

Making decisions about involuntary treatment criteria What is mental illness?

The Act defines mental illness as:

“(1) Subject to subsection (2), mental illness is a medical condition that is characterised by a significant disturbance of thought, mood, perception or memory.”

The areas likely to be under disagreement in this definition are:

“Significant” and “disturbance” Both are subjective terms and therefore open to interpretation. It is quite likely that people may disagree with treatment providers about the significance of the impact of their experience and about whether in fact it qualifies as a ‘disturbance’.

It is important for Tribunal members to give people the chance to explain why they think as they do. What may seem strange or even bizarre to some people may be quite normal to another. Further, some level of ‘disturbance’ of thought, mood, perception or memory is common to all people, regardless of mental health status.

Hearing voices is not on its own a sign of mental illness.

Large scale population studies indicate that up to 4% of the general population hears voices (Johns et al, 2002; Wiles et al, 2006). Yet the 12 month prevalence of psychosis is only around 0.45% of the population (Morgan et al, 2011). This suggests that approximately 9 out of every 10 voice hearers live well with their voices without ever being diagnosed with a mental illness. So, yes, hearing voices can be a normal human experience.

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The accepted medical manual for defining diagnostic criteria for mental illness in Australia is called ‘The Diagnostic Statistical Manual 5’, or DSM5 for short. The DSM5 contains detailed criteria for determining whether in fact an experience does qualify as a mental illness.

With regard to voice hearers, the DSM5 requires at least two ‘positive’ symptoms in order to be diagnosed with schizophrenia (in the previous edition the symptom threshold was only one symptom). Hence, hearing voices alone is not enough to diagnose someone, and therefore also not sufficient to require involuntary treatment (APA, 2013).

Unusual beliefs (‘delusions’) and unusual behaviours are not necessarily a sign of mental illness Some people consider their voices to be a part of their spiritual or cultural belief system, such as with shamans, healers and connections with ancestors, while others see voices as a gift, like those who hear the voice of a deceased loved one.

Some people, such as psychics and mediums, even use their voice hearing experience as a central and positive aspect of their lives and work.

None of these people would be diagnosed as having a mental illness solely on the basis of this experience of hearing voices – and in fact doing so would be a breach of sections 14 and 19 of the Charter of Human Rights and Responsibilities Act 2006 (Vic) which relate respectively to freedom of thought, conscience, religion and belief and to cultural rights.

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In subsection (2) the Act states that “a person is not to be considered to have mental illness by reason only of any one or more of the following— That the person expresses or refuses or fails to express a particular: (a) … political opinion or belief; (b) … religious opinion or belief; (c) … philosophy; (d) … sexual preference, gender identity or sexual orientation; That the person engages in or refuses or fails to engage in a particular: (e) … political activity; (f) … religious activity; That the person engages in: (g) … sexual promiscuity; (h) … immoral conduct; (i) … illegal conduct; (j) … antisocial behaviour; That the person: (k) … is intellectually disabled; (l) … uses drugs or consumes alcohol; (m) … has a particular economic or social status or is a member of a particular cultural or racial group; (n) … is or has previously been involved in family conflict; (o) … has previously been treated for mental illness.

All of these factors are basic human rights protections and must be carefully considered

by Tribunal members. Additional considerations for the Tribunal: a) ‘Bizarre’ delusions are no longer a definitive ‘symptom’. The DSM5 excludes the previous edition’s criteria of ‘bizarre’ delusions from the diagnosis of schizophrenia because of its poor reliability (APA, 2013). Deciding whether a belief is ‘bizarre’ is inherently subjective and can have no place in determining whether someone should be subject to involuntary treatment. b) Unusual beliefs are common in the general population. In the USA there are a large number of people who believe in alien abduction (in fact there are hundreds of support groups in the US for this experience); many people believe in psychic experiences, government conspiracies and more. The Charter of Human Rights and Responsibilities Act 2006 (Vic) protects freedom of expression and the right to hold Reducing involuntary treatment for voice hearers | Guidelines for the Mental Health Tribunal

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opinions without interference (section 15), and cultural rights and beliefs (section 19) are also protected. A person’s beliefs are private, protected under law, and have no place in assessing involuntary treatment. c) Religious beliefs are common and enshrine the notion of hearing spiritual voices.

The 2011 census (ABS) reported that 77.7% of the Australian population has religious beliefs. The central religious texts of Christianity, Islam and Judaism, the Bible, Koran and Torah, all consistently report instances of religious figures who hear voices, most commonly the voice of God. These faiths are based to a large degree on the belief that hearing the voice of God is possible. Religious belief is protected under section 14 of the Charter of Human Rights and Responsibilities Act 2006 (Vic) and in Subsection (2) of the new Mental Health Act. Hearing spiritual voices may be considered protected under law and should have no place in assessing involuntary treatment. d) Unusual beliefs don’t predict recovery. Unusual beliefs (sometimes referred to as delusions or ‘poor insight’) are not predictive of whether people with a diagnosed mental illness will recover, and hence it is questionable to include them as criteria for involuntary treatment.

Unusual beliefs are commonly held in nonclinical voice hearers who cope well with the experience (Daalman et al., 2011).

When hearing voices is the focus of therapy, overall levels of positive symptoms, insight and beliefs about the origins of voices at the beginning of therapy do not predict the successfulness of therapy (Thomas et al., 2011).

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Unusual Beliefs or Stories Some examples to consider…

“Several years into my treatment at a particular hospital I was made aware of a case note in my file. This note by my treating psychiatrist mentioned delusional thinking evidenced by my description of an art exhibition I had recently done – and as a result my dose of antipsychotic was increased. I understand that the description of my art exhibition would have sounded unusual, maybe even mad: I described hundreds of business cards, written in blood, cut and burned, and displayed on the walls of the foyer of the Australian Ballet. However no effort was made to verify my story. The exhibition was real. I was not delusional. Yes, it was ‘bizarre’ … it was a piece of art.” (Indigo Daya) One consumer was considered delusional because his voices told him that he was being followed and all of his movements recorded. This belief was the foundation of his treatment. Yet later it became apparent that he was the subject of a Traffic Accident Commission (TAC) investigation and was in fact under surveillance.

Another consumer has shared with Voices Vic that he hears the voice of God and sometimes the voice of a trickster who pretends to be God. This does not overly distress him, and he practices what he calls ‘discernment’. He assesses what the voice has said against his knowledge and faith, and then makes a logical decision about whether to ignore a voice, or to take its advice on board. For example, he says that the voice asking him to do something that makes no sense or that could be harmful is not likely to really come from God, but when the voice asks him to pray or to act in more compassionate ways towards others, he considers this to be real and takes the advice on board. This man is currently considered by his psychiatrist to have psychosis and is on a CTO because he believes he can hear God – yet his actions fit within the realm of common spiritual belief and demonstrates a good capacity for rational and safe decision making.

Many factors considered to be symptoms of mental illness may in fact be side effects of medication, or normal responses to diagnosis and other symptoms.

Many of the symptoms considered to be signs of mental illness are also commonly recognised as side effects of medication. It is a circular argument, and clearly contrary to the intent of the Act, if unusual behaviour, thoughts or feelings which are actually caused by treatment are misrepresented as symptoms and used to justify further such treatment.

Other factors which may be considered as symptoms may actually be normal and reasonable responses to diagnosis, symptoms and treatment.

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‘Symptoms’ which need to be questioned The factors below may be mistakenly considered as symptoms, when they may actually be side effects or responses to treatment. 

Flattened affect (flat or reduced emotions, apathy, lack of motivation): common side effect from antipsychotic medication, also a common human reaction to situations in which we have no power



Confused thinking (difficulty following conversations, concentration and memory): common side effect from antipsychotic medication, particularly from high doses



Social withdrawal (losing interest in activities, relationships and sex): common reaction to lack of hope, experiences of stigma and discrimination, loss of confidence in self, fear of involuntary treatment or judgment of others. Sexual dysfunction is a common side effect of medication



Lack of care with appearance and hygiene: common human reaction to lack of hope, may also be a consequence of excessive sedation from medication



Increased suicidal thinking or behaviours: potential side effect from antidepressant medication



Increased signs of depression and/or anxiety in people diagnosed with psychosis: For many people, the development of symptoms of depression or anxiety may not be indicative of deteriorating mental illness, but in fact a normal and understandable reaction to being diagnosed, involuntary treatment and/or losing hope for the future

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Criteria (b) because the person has mental illness, the person needs immediate treatment to prevent:

Making decisions about involuntary treatment criteria

The requirement for immediate treatment should be a very rare occurrence.

Very often consumers indicate that what they most desire and need during a crisis is time and safety. In other words, not immediate treatment, but an immediate safe space.

A counter balance to this is the pressure on psychiatric hospitals to treat and discharge patients as quickly as possible. While this is understandable in the context of a costconstrained health system, it is not a justification for enforced treatment at the expense of individual human rights and genuine, long-term recovery.

Voice hearers want to discuss their voices in greater detail than occurs in routine care (e.g. Coffey & Hewitt, 2008) Voice hearers report benefits of talking with others who have shared lived experience beyond that available from routine care (e.g. Goodliffe et al., 2009; Thomas, Fossey, Dance & Daya, in preparation)

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What looks like ‘deterioration’ may really be something we should support.

Is this a helpful, albeit difficult, part of the person’s recovery?

What is perceived as ‘deterioration’ may actually be helpful processing of the voices experience that could enhance recovery. For example, a person taking more time to listen or talk to their voices may be a positive sign of working through a difficult experience. This is a process that can be supported with talking therapies and/or peer support. However obeying voices, or allowing them to dominate the majority of one’s life, is a sign that more support is needed.

Is this just a short term and/or meaningful response?

Perceived ‘deterioration’ may also be a short-term and meaningful response by a person to difficult life stressors, for example financial pressure, interpersonal conflict or triggers related to past trauma. In these instances only short term support may be required, and what may be most useful is support to help the person understand their reactions and develop new coping skills. Longer term involuntary treatment is not indicated here.

In what ways are self-management being encouraged?

Self-management is a central concept to recovery and worth considering in relation to the idea of ‘deterioration’: Self-management approaches focus on enabling the person to solve problems, set goals, identify triggers and indicators of deteriorating health, and respond to these themselves instead of always relying on clinician-led intervention. The common theme is a structured approach that develops over time and through experience (Crepaz-Keay 2010).

Is there an impact on the person’s life?

The concept of ‘deterioration’ also needs to compare the person’s reported experience, versus the actual impacts on their life and those around them. For example, a person may report hearing more voices, but if this is not distressing to the person, or causing any actual harm, then it cannot necessarily be taken as a sign of ‘deterioration’.

Is there really a problem?

Many of the people who come to Voices Vic tell us that they find their voices to be helpful guides or supportive companions. For most of these people we can see no risk of harm from listening to their voices, although we do recommend setting set some boundaries with the voices, and always making one’s own decisions.

Most of these people are receiving involuntary treatment, and as a result they are no longer willing to be honest with their treating clinicians and they feel they have to pretend to be someone they are not. For these people, involuntary treatment has damaged therapeutic trust and left them feeling there is no-one in clinical services that they can talk to. These are not the kinds of outcomes that anyone wants.

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The risk of serious harm is frequently overestimated.

For this criteria it is important to understand that hearing a voice that makes dangerous commands is not necessarily an indication that the person intends to do something harmful. The person’s experience, the sense they make of that experience, and the actions they intend to take as a result, all need to be taken into account.

There is a significant, yet often not well discerned, difference between:     

hearing a dangerous command versus considering following a dangerous command versus wanting to follow a dangerous command versus intending to follow a dangerous command versus actually following a dangerous command

It is only the latter two of these options which pose an immediate and serious risk.

Involuntary treatment on the basis of the other factors is in fact intruding into the human rights space of freedom of thought. All humans may at times have thoughts which are dangerous or harmful – but it is only when we act on thoughts that there is a legal or moral issue.

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‘DANGEROUS’ VOICES

Recovery-oriented ways of thinking & working…

At Voices Vic we know many voice hearers who have heard violent commanding voices for decades without ever acting, or even intending to act, on those voices. “Oh, my voice has been telling me to kill myself for years… but of course I wouldn’t do that!”

One person we know at Voices Vic hears a voice she used to call ‘the suicide voice’. It would tell her to kill herself, and she would often act on these commands and overdose, and one time sat on the train tracks.

Through peer support this person came to understand that the intent of her voice was not actually for her to die, but to stop her from feeling unbearable emotional pain. She began to notice that she only heard this ‘suicide voice’ after her feelings had been hurt by another person.

In peer work we discussed how there are many other options to take away pain – such as seeking support, self-soothing, and being with loved ones. She changed the name of this voice to ‘the takeaway’, to remind herself that the voice only wants to take away her pain, not for her to die. Now, when she hears the voice, she does not act on its commands, but instead asks herself why she is in pain, and what she can do to feel loved.

In all of these cases, the voice hearers have been able to gain a better understanding of their voices by listening to them with supportive help, accessing psychological therapies or peer support, and learning not to be frightened of their voices. While still hearing supposedly ‘dangerous command hallucinations’, all of these people are leading safe and fulfilling lives.

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Criteria (c) the immediate treatment will be provided to the person if the person is subject to a Temporary Treatment Order or Treatment Order;

Making decisions about involuntary treatment criteria

If treatment is not provided immediately then involuntary treatment must not be approved.

Delays in the provision of treatment are not allowable in the context of involuntary treatment.

The Tribunal needs to confirm whether the service has the capacity to provide treatment immediately in order to approve orders.

If treatment is not immediate, an order cannot be made.

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Criteria (d) there is no less restrictive means reasonably available to enable the person to receive the immediate treatment.

Making decisions about involuntary treatment criteria

Talking therapies are less restrictive and are rarely harmful.

There are many less restrictive and evidence based treatment options available which are not commonly used in Victoria. In particular, talking therapies now have significant evidence for their effectiveness.

Whilst it may be true that not all public mental health services employ sufficient therapists to offer these treatments to all patients diagnosed with psychosis, this is not a sufficient basis upon which to deprive patients of their human rights or treatment choices. Such therapies can be sourced through private therapists or alternative clinics where needed.

There are a number of evidence-based talking therapies which assist recovery for people diagnosed with psychosis.

These include: o Cognitive Behavioural Therapy (CBT) o Acceptance and Commitment Therapy (ACT) o Family Intervention Therapy

Other therapies which are showing positive research outcomes and are generally accepted as good practice include: o Narrative therapy o Peer support o Mindfulness therapy

Talking therapies are substantially less restrictive in that they are not physically invasive, sedating, and do not impair cognitive or emotional abilities, and do not include any of the physical risks associated with medication, such as diabetes, obesity, and cardiovascular problems.

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Reduced doses of medication – or a reduced number of different types of medications -- are both less restrictive treatment options.

Many consumers who refuse drug based treatment may be willing to accept medication treatment if doses are lowered such that extreme side effects are reduced to a more tolerable level. Lower doses are potentially just as effective as higher doses in many instances and can be explored as a less restrictive option.

While it relatively common in Australia for people to be prescribed multiple different antipsychotic medications at the same time, in the UK this practice is not recommended in the clinical treatment guidelines from NICE, except for short periods (NICE, 2014).

This provides a sound argument for people to request at least only one antipsychotic medication at a time.

Trauma informed treatment should be, but is not always, standard practice.

Trauma-informed practice is recommended in the Service Guidelines for Gender Sensitive Care issued by the Office of the Chief Psychiatrist of Victoria (2011): A trauma-informed approach is based on the recognition that many behaviours and responses (often seen as symptoms) expressed by people are directly related to traumatic experiences, which can be related to mental health, substance abuse, behavioural and physical health concerns (National Centre for Trauma-Informed Care, page 7).

In particular, trauma-informed services take care to avoid practices that may exacerbate or retrigger previous experiences of trauma‌ (page 7) Many people who hear voices have a history of trauma and this should be taken into account in treatment planning.

Averages from 6 studies of schizophrenia found a prevalence of emotional abuse at 47%, emotional neglect at 51%, and physical neglect at 41%. (Read, et al.

2008) The single most significant predictor that an individual will end up in the mental health system is a history of childhood trauma, and the more severe and prolonged the trauma, the more severe are the psychological and physical health consequences. (Prof. W. Middleton, in Kezelman & Stavropoulos, 2012) Reducing involuntary treatment for voice hearers | Guidelines for the Mental Health Tribunal

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The service guidelines recommend that treatments promote people’s choice and empowerment as vital to successful treatment, that trauma histories are obtained, and appropriate treatment is provided.

In many scenarios involving both short and long term issues, the experience of being listened to and heard is fundamental, and far more constructive and therapeutic than medicating someone just because they are temporarily upset….

(Prof. W. Middleton, in Kezelman & Stavropoulos, 2012) People with complex trauma will often respond better to treatment when they are empowered in ways that are unique to them, and the professionals and institutions should not underestimate the patient’s ability to be very useful and active in their own treatment. Also more often than not if you begin by treating the patient as an adult with basic human rights, more often than not the patient will rise to fill that adult role. This decreases the need to restrain, over-medicate, and treat patients in a punitive way. (Stillwell, T, in Kezelman & Stavropoulos, 2012) Where people have a history of trauma, the impact of involuntary treatment may be particularly damaging psychologically and should be carefully considered.

“As a child I was abducted and raped; it was horrific. Yet when I experience involuntary treatment I am taken from my home by strangers, locked into a scary building, forced to strip, given substances against my will, and left to feel violated.

In essence, involuntary treatment almost exactly replicates my childhood trauma. I am forced to live the horror all over again. As you might imagine, this has never felt therapeutic. It has felt like a frightening re-traumatisation. No-one in mental health ever asked about my history of trauma or offered me counselling. I had to find this myself through peer support.” (Daya, I)

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Section 5 References & Attachments

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References APA (2013). Highlights of Changes from DSM-IV-TR to DSM-5. Retrieved from: http://www.dsm5.org/Documents/Forms/AllItems.aspx Kezelman, C. and Stavropoulos, P. (2012). Practice guidelines for treatment of complex trauma and trauma informed care and service delivery. Adults Surviving Child Abuse (ASCA).

Australian Bureau of Statistics (2011). 2071.0 - Reflecting a Nation: Stories from the 2011 Census, 2012–2013. Retrieved from: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/2071.0main+features902012-2013 Beavan, V. (2011). Towards a definition of “hearing voices”: A phenomenological approach. Psychosis, 3, 63-73.

Beavan, V., & Read, J. (2010). Hearing voices and listening to what they say: The importance of voice content in understanding and working with distressing voices. Journal of Nervous and Mental Disease, 198, 201-205.

Charter of Human Rights and Responsibilities Act 2006 (Vic). (Austl).

Chin, J. T., Hayward, M., & Drinnan, A. (2009). Relating to voices: Exploring the relevance of this concept to people who hear voices. Psychology and Psychotherapy, 82, 1-17.

Commonwealth of Australia. (2013). A national framework for recovery-oriented mental health services: Guide for practitioners and providers. Canberra: Australian Government Department of Health and Ageing. Retrieved from: http://www.ahmac.gov.au/cms_documents/National%20Mental%20Health%20Recovery%20Framewo rk%202013-Guide-practitioners&providers.PDF Crepaz-Keay, D 2010, Self-management of mental health problems, Mental Health Foundation, London, Retrived from: www.euro.who.int/__data/assets/pdf_file/0018/124560/E94377.pdf.pdf.

Daalman, K., Boks, M. P. M., Diederen, K. M. J., de Weijer, A. D., Blom, J. D., Kahn, R. S., & Sommer, I. E. C. (2011). The same or different? A phenomenological comparison of auditory verbal hallucinations in healthy and psychotic individuals. Journal of Clinical Psychiatry, 72, 320–325.

Goodliffe, L., Hayward, M., Brown, D., Turton, W., & Dannahy, L. (2010). Group person-based cognitive therapy for distressing voices: views from the hearers. Psychotherapy Research, 20, 447-461.

Johns, L.C., Nazroo, J.Y., Bebbington, P., and Kuipers, E. (2002). Occurrence of hallucinatory experiences in a community sample and ethnic variations. British Journal of Psychiatry, 180, 174 – 178.

Mental Health Act 1986 (Vic). (Austl.).

McCarthy-Jones, S., Trauer, T., Mackinnon, A., Sims, E., Thomas, N., & Copolov, D. (2012). A new phenomenological survey of auditory verbal hallucinations: Evidence for subtypes and implications for theory and practice. Schizophrenia Bulletin. Advance online publication, 23 December. doi:10.1093/schbul/sbs156.

Morgan VA, Waterreus A, Jablensky A, Mackinnon A, McGrath JJ, Carr V, et al. (2011). People living with psychotic illness 2010. Canberra: Australian Government Department of Health and Ageing. Retrieved from: http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-pubs-p-psych10 National Collaborating Centre for Mental Health (2009). Schizophrenia (update): Full guideline. London: British Psychological Society and Royal College of Psychiatrists.

Pistrang, N., Barker, C., and Humphreys, K. (2008). Mutual help groups for mental health problems: a review of effectiveness studies. American Journal of Community Psychology, 42, 110 – 121.

Read, J., et al. (2008). Child Maltreatment and Psychosis: A Return to a Genuinely Integrated Bio-PsychoSocial Model. Clinical Schizophrenia & Related Psychoses, October 2008.Romme, M.A.J. (1996).

Understanding Voices: Coping with auditory hallucinations and confusing realities. Gloucestor: Handsell Publishing.

State Government of Victoria, Department of Premier and Cabinet. (2014). New Mental Health Act puts people at the centre [Press release]. Retrieved from: http://www.premier.vic.gov.au/mediacentre/media-releases/9179-new-mental-health-act-puts-people-at-the-centre.html.

Thomas, N., Farhall, J., & Shawyer, F. (in press). Beliefs about voices and schemas about self and others in psychosis. Behavioural and Cognitive Psychotherapy.

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Voices Vic | Prahran Mission Thomas, N., Rossell, S., Farhall, J., Shawyer, F., & Castle, D. (2011). Cognitive behavioural therapy for auditory hallucinations: Effectiveness and predictors of outcome in a specialist clinic. Behavioural and Cognitive Psychotherapy, 39, 129-138. van der Gaag M, van Oosterhout B, Daalman K, Sommer IE, Korrelboom K (2012). Initial evaluation of the effects of competitive memory training (COMET) on depression in schizophrenia-spectrum patients with persistent auditory verbal hallucinations: A randomized controlled trial. British Journal of Clinical Psychology, 51, 158-171.

VICSERV (Psychiatric Disability Services of Victoria). (2008). The VICSERV Propositions: a Framework for Influencing. Victoria: Self-published. Retrieved from: http://www.vicserv.org.au/publicationsresources/publications.html Wiles, N.J., Zammit, S., Bebbington, P., Singleton, N., Meltzer, H., and Lewis, G. (2006). Self-reported psychotic symptoms in the general population. The British Journal of Psychiatry, 188, 519 – 526.

Further reading Burns, T. & Dawson, J. (2009). Community Treatment Orders: How ethical without experimental evidence?

Editorial, Journal of Psychological Medicine, 39 (10): 1583-1586.

Chadwick, P., Sambrooke, S., Rasch, S., & Davies, E. (2000). Challenging the omnipotence of voices: group cognitive behavior therapy for voices. Behaviour Research and Therapy, 38, 993-1003.

Coffey, M., & Hewitt, J. (2008). “You don’t talk about the voices”: Voice hearers and community mental health nurses talk about responding to voice hearing experiences. Journal of Clinical Nursing, 17, 1591-1600.

Farhall, J., Thomas, N., Shawyer, F., & Bacon, T. (2013). Beyond cognitive therapy: Applications of acceptance and mindfulness based therapies to psychosis. In N. Thomas (Chair). Beyond CBT for psychosis: Thinking differently about psychological intervention. Symposium conducted at the Australasian Schizophrenia Conference, Melbourne, Australia.

McLeod, T., Morris, M., Birchwood, M., & Dovey, A. (2007). Cognitive behavioural therapy group work with voice hearers. Part 2. British Journal of Nursing, 16, 292-295.

Mental Health Legal Centre (2009). The right to health & mental health service provision in Victoria.

Retrieved from: http://www.communitylaw.org.au/mhlc/cb_pages/HRrights.php Newton E, Landau S, Smith P, Monks P, Shergill S, Wykes T (2005). Early psychological intervention for auditory hallucinations: An exploratory study of young people's voices groups. Journal of Nervous and Mental Disease, 193, 58-61.

Newton, E., Larkin, M., Melhuish, R., & Wykes, T. (2007). More than just a place to talk: Young people’s experiences of group psychological therapy as an early intervention for auditory hallucinations.

Psychology and Psychotherapy, 80, 127-149.

Penn DL, Meyer PS, Evans E, Wirth RJ, Cai K, Burchinal M (2009). A randomized controlled trial of group cognitive-behavioral therapy vs. enhanced supportive therapy for auditory hallucinations. Schizophrenia Research, 109, 52-59.

Pinkham AE, Gloege AT, Flanagan S, Penn DL (2004). Group cognitive-behavioral therapy for auditory hallucinations: A pilot study. Cognitive and Behavioral Practice, 11, 93-98.

Shawyer, F., Farhall, J., Mackinnon, A., Ratcliffe, K., Sims, E., Johnson, L., Thomas, N., Castle, D., Trauer, T., Mullen, P., & Copolov, D. (2012). A randomised controlled trial of acceptance-based cognitive behavioural therapy for command hallucinations in psychotic disorders. Behaviour Research and Therapy, 50, 110-121.

Trower P, Birchwood M, Meaden A, Byrne S, Nelson A, Ross K (2004). Cognitive therapy for command hallucinations: randomised controlled trial. British Journal of Psychiatry, 184, 312-320.

Wykes T, Hayward P, Thomas N, Green N, Surguladze S, Fannon D, Landau S (2005). What are the effects of group cognitive behaviour therapy for voices? A randomised control trial. Schizophrenia Research, 77, 201-210.

Wykes, T., Parr, A.-M., & Landau, S. (1999). Group treatment of auditory hallucinations: Exploratory study of effectiveness. British Journal of Psychiatry, 175, 180-185.

Wykes T, Steel C, Everitt B, Tarrier N (2008). Cognitive behavioral therapy for schizophrenia: Effect sizes, clinical models, and methodological rigor. Schizophrenia Bulletin, 34, 523-537.

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Attachment 1: Treatment Effectiveness for psychosis in Australia The data on this page is taken from the national study, “People living with psychotic illness 2010” (Morgan et al, 2011) and comprises the largest national study on psychosis in Australia.

The best available data on treatment effectiveness makes it clear that we cannot assume involuntary medical treatment will result in a better outcome for consumers.

The likelihood of treatment effectiveness must be weighed carefully against the potentially severe impacts of involuntary treatment on physical health, mortality, emotional wellbeing and people with trauma histories.

When we cannot assume treatment will be effective, the weight of deciding to restrict a person’s liberties is even more significant.

63% of people diagnosed with psychosis and undergoing treatment are not experiencing good recovery.

31% are experiencing continuing chronic unwellness, in spite of treatment.

Course of “Illness”

63%

Morgan et al. (2011)

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Attachment 2: New Recovery Framework for Australia Recovery as a concept and aim of mental health service delivery is now endorsed across Australia.

In August 2013 the Australian Health Minister’s Advisory Council launched “A National Framework for Recovery Oriented Mental Health Services”.

Understanding recovery concepts is central to decisions about involuntary treatment.

Executive summary The national framework for recovery-oriented mental health services provides a vital new policy direction to enhance and improve mental health service delivery in Australia. …All people employed in the mental health service system regardless of their role, profession, discipline, seniority or degree of contact with consumers will use the framework to guide their recovery-oriented practice and service delivery. This includes practitioners, leaders, volunteers and people in administrative, policy development, research, program and service planning and decisionmaking positions (page 1).

Recovery: The Concept …. central to all recovery paradigms are hope, self-determination, self-management, empowerment and advocacy. Also key is a person’s right to full inclusion and to a meaningful life of their own choosing, free of stigma and discrimination.

Some characteristics of recovery commonly cited are that it is:  a unique and personal journey  a normal human process  an ongoing experience and not the same as an end point or cure  a journey rarely taken alone  nonlinear—frequently interspersed with both achievement and setbacks (page 11).

Addressing tensions A recovery orientation requires services to confront the tension between maximising choice and supporting positive risk-taking—or the dignity of conscious risk-taking on one hand and duty of care and promoting safety on the other. Striking a balance requires an understanding of the illusory, damaging and sometimes discriminatory nature of the goal of reducing harmful risks (Slade 2009a, pp. 176–179).

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Australian provisions governing involuntary mental health intervention do not preclude people from consenting and participating in treatment choices, to the extent that is possible in the given circumstances. The concepts of self-determination, personal responsibility and self-management and the goals of reclaiming control and choice are pivotal regardless of a person’s legal status.

Australian mental health statutes emphasise the importance of working collaboratively with a person and their family irrespective of whether they are receiving treatment voluntarily or involuntarily and irrespective of whether that treatment is in hospital or in the community (page 20).

Critical appraisal in decision making about risk and its management Recovery-oriented approaches encourage critical appraisal of the criteria and questions used in evaluating risk and in determining risk-management arrangements, including the need for involuntary intervention (Slade 2009a, pp. 184–189). In considering the least restrictive treatment alternative possible, practitioners and services should also consider whether, to the extent it is possible in the given circumstances, the proposed involuntary intervention:  increases or decreases the person’s ability to self-regulate and self-manage their emotions and behaviour  respects the person’s choice, values and preferences  enables the person to perform as many life skills as possible and connect with their regular life  maximises the person’s connection with close relationships, support networks and community  augments the person’s positive sense of self and draws upon their strengths  offers opportunities for a person to learn new skills, maximise their potential or connect with their inherent strengths.

Another important consideration is how a treating team’s decision to use coercion will be interpreted by the person and their family members. This is particularly important when working with Aboriginal and Torres Strait Islander peoples, Forgotten Australians and people from immigrant and refugee backgrounds who have experienced high levels of trauma as a result of having been forcibly removed from people important to them, particularly from family. Close contact with others may be key to healing and recovery. (page 21)

Download framework documents from the Australian Health Minister’s Advisory Council website: http://www.ahmac.gov.au Or follow these hyperlinks: Guide for Practitioners & Providers Policy & Theory

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Attachment 3: The Voices Vic Approach We believe Hearing voices is a common human experience.

Voices are not the problem— the distress, confusion and lack of meaning are the problem.

Medication can be useful for some people, but: 



 

Medication alone is not enough – we need talking therapies, peer support, housing, jobs, safety and respect Too much medication can be counterproductive. We need to be able to think and feel in order to recover We have the right to make choices about the treatments that are best for us We need to be properly informed and proactively supported regarding the physical health risks of medications

Opportunities to find your OWN voice & to explore your voices with support & safety

Peer support in a new randomised trial

Recovery is not about getting rid of your voices, but about changing your relationship with them.

Everyone can recover.

We deliver Peer support for individuals and in support groups.

Connecting with others – you are not alone

Learning through information talks, training courses, and conferences about hearing voices.

Research about recovery from voices and the value of peer work.

Partnerships that are consumer-led but which bring together voice hearers, family, community and clinical workers in new collaborations.

Peer workers with lived experience &

Community awareness campaigns to reduce the fear and misunderstandings about voices and voice hearers

Bringing together groups of voice hearers

extensive training & support

to share stories, hope & what works

Systemic advocacy to improve recovery outcomes, choices, human rights & understanding for voice hearers.

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How we work with voices We acknowledge each person as the expert on their own experiences. We promote ways of living with voices.

We explore people’s voices in the context of their life history – when they started, what might have triggered them, whether the person has experienced trauma and whether that may relate to the voices.

We connect people with specialised trauma therapy support services when voices seem related to trauma histories.

We help people make sense of their voices using voice profiling techniques, sharing stories with others, and looking for metaphorical meanings rather than literal meanings.

We help people to change their relationship with their voices: learning to set boundaries with the voices, treat them with compassion rather than fear or anger, challenge what the voices say, and try new ways of responding. We support people to have dialogues with their voices so they can practice new ways of responding and feeling strong.

We connect people to other voice hearers so they feel less alone. We encourage people to share stories about their voices and to learn from each other. We generate hope.

A little more In 2010 Voices Vic won a Victorian Public Healthcare Award for its work.

In 2012 Voices Vic won a TheMHS (The Mental Health Services) Conference Gold Achievement award.

In November 2013 Voices Vic hosted the largest consumerled recovery event in Australia’s history: The World Hearing Voices Congress.

“The hearing voices group has been tremendously helpful for me. After spending almost 5 years living reclusively, it has enabled me to meet some new people and make friends, it has also enabled me to talk about the real experiences of hearing voices and psychosis.”

“I feel uncomfortable all the time, hearing people’s thoughts, but not here, I’m fairly comfortable. I think it’s a good thing there’s other voice hearers here.”

“My voice is a part of me but it isn’t entirely me.” “…it’s just brought me relief that I haven’t had for, like, 15 years… all this build up …it’s just given me some relief that I’ve never found in any other avenue in society.”

“I think strategies is a key thing about the group because we talk a lot about what works for us and what doesn’t. There’s such a wealth of knowledge of people who have been living and thriving and surviving with these things for so long.”

Extracts from research transcripts, Thomas, Fossey, Dance & Daya, Voices Vic qualitative research project, in press.

85% of the Voices Vic team hears voices and almost all of us have had involuntary treatment which we experienced as harmful.

In the past each of us has been told that we would never recover.

That wasn’t true.

Let’s start working from a place of hope instead of fear.

Let’s support freedom and recovery.

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