In a previous article, I described the current organization of mental health services in Lebanon, emphasizing the gap between institution-based public services and expensive private services. In both domains, the legislative vacuum is striking and leaves room for potential abuse of power against persons with mental health conditions (MHC).
 

As stated in the UN Convention on the Rights of Persons with Disabilities (CRPD), mental health legislation is essential for protecting the rights of persons with MHC by promoting equity in access to care, community integration, regulation of involuntary admissions, and prevention of human rights violations and discrimination.[1] In this context, the proposed mental health law currently submitted to parliament constitutes an important step towards achieving these aims. After reviewing the rationale for mental health legislation, I will briefly discuss the proposed law, including its strengths and weaknesses.

Mental Health Legislation: Current Practices in Psychiatry and Clinical/Ethical Dilemmas

The only Lebanese legal provision that deals specifically with the treatment of persons with MHC is the Welfare Act and Protection and Treatment of Mentally Ill Patients (Legislative Decree no. 72-9/9/1983). A previous study in 2009 by lawyer Nizar Saghieh et al.,[2] highlighted its non-conformity with international standards. However, the existence of this decree is widely ignored by psychiatrists and institutions of care. Moreover, the law regulating incapacity dates back to Ottoman times and uses terms such as “the idiot” and “the insane” to refer to persons with MHC. The absence of an up-to-date and enforced legislative text presents three main issues for consideration.

Access to Community-Based Mental Health Services

The Ministry of Public Health (MOPH) fully covers psychiatric hospitalization and some psychiatric medication, but it does not yet have a coverage system for outpatient services. Such hospitalization often results in the institutionalization of persons with chronic MHC in the long run (e.g., schizophrenia). This is partly the consequence of the lack of mental health care in public primary health care settings, such as outpatient facilities for treatment, follow-up, and social rehabilitation. This philosophy of care presumes mental illness to be incurable and incompatible with community integration, and echoes the approach to psychiatric treatment in the 19th century inspired by the “moral treatment” of Pinel.[3] There are currently three main psychiatric institutions in Lebanon where many patients are chronically institutionalized.
 

Current recommendations of care emphasize the importance of social rehabilitation in the recovery of people with chronic MHC, and point to the harmful consequences of institutionalization.[2] In line with these recommendations, the recently launched National Mental Health Program within the MOPH plans to integrate mental health care into primary health care. A mental health law would assert the rights of patients to freely access this community-based care and help implement this long term project.

 

Involuntary Admission and Treatment

Rarely, persons with MHC may pose a risk to themselves and to others because of impaired decision-making abilities. However, these are only in severe cases of psychiatric illness. Voluntary treatment in the least restrictive environment should always be favored in line with the principle of liberty and autonomy of the person.[2] There are currently no legal procedures/criteria to minimize the use of involuntary admission which can be executed based on the report of a single psychiatrist, and often at the request of the family.

When a patient refuses to go by themselves to the hospital, the psychiatrist may send a “mobile team” to the patient’s house in order to bring them to the hospital, in coordination with the family. These mobile teams are registered as private companies, and are available round the clock. They usually consist of one or two nurses, nursing assistants and other accompanying male staff.

Psychiatric emergencies do exist. In severe psychiatric illness (the deterioration of the illness often being the result of the lack of available outpatient follow-up and rehabilitation), patients may represent an imminent risk of harm to themselves or to others. In the absence of any established procedures, psychiatrists may turn toward the mobile teams as the only solution to a critical situation.

However, this procedure can be easily abused, as there is no independent judicial body that a patient can rely on to monitor the indications, length and maintenance of their stay, and to protect their rights. This renders the patient in a state of dependence not only toward the psychiatrist, but most of all, towards their family members. The latter can indeed resort to the psychiatrist and the mobile team to bring the patient involuntary to the hospital whenever they feel the patient is relapsing, or simply not conforming to their social or normative standards. This process, however, should be monitored by a legal third party.

 

Respect of the Rights of the Patients and Their Dignity

There is currently no inspecting body to monitor psychiatric hospitals or inpatient units in order to ensure that the rights of patients are being protected. Studies have revealed that the lack of supervision over institutions is the most frequent cause of abuse against persons with MHC.[4] It can allow for human rights violations, especially concerning the use of seclusion and physical constraint, isolation from the external world for long periods of time, violation of privacy, and the employment of unpaid labor. Moreover, there are currently no legal frameworks or standardized procedures regarding the use of electroconvulsive therapy (ECT).

 

Brief Review of the Proposed Mental Health Law

 

The submission of a mental health draft law to parliament represents an important leap forward, given the absence of any effective legislation. Between 2008 and 2009, the proposed law was prepared by the Lebanese NGO, Institute for Development, Research, Advocacy and Applied Care (IDRAAC), through a grant from the European Union and with the coordination of the Office of the Minister of State for Administrative Reform and Development (OMSAR). The proposed law, however, remained widely unknown to psychiatrists and to the public.

The following is a brief review of this law project from a clinician’s point of view, serving as an introduction to future extensive studies that would conduct an in-depth analysis on how it promotes patients’ rights and autonomy, including the areas that would need improvement.

 

Main Strengths of the Proposed Law

 

Basing the rationale for this law -as stated in the preamble- on the necessity to conform to international human rights and recommendations, notably the CRPD.

Emphasizing the importance of free access to community-based health care through the creation of outpatient facilities for psychosocial rehabilitation by the MOPH and the Ministry of Social Affairs (MSA), shifting the resources away from institutionalization (Articles 4-5).

Creating an inspection committee within the MOPH to monitor private services and public institutions with regards to patient’s rights. This committee would also be responsible for reviewing cases of involuntary admission and receiving complaints of patients and their families (Articles 6-8). However, there is no mention of the penalties imposed on the institution in case of human rights violations.

Restricting involuntary admissions to cases that meet two strict conditions, both of which need to be present:

There is a risk of serious imminent harm on self or others; and

The risk of harm is caused by a mental health condition that requires immediate care and medical supervision, and one that has impaired the ability of the patient to consent to treatment (Article 11).

 

Establishing procedures for involuntary admissions, mainly by obliging the hospital’s ethics committee to inform the inspecting committee of MOPH about the involuntary admission within 48 hours. The ethics committee should also confirm that the admission was necessary. (Article 19).

Restricting the decision of maintaining the involuntary admission to a court competent in personal matters. This court should review the psychiatrist’s report every 15 days and agree (or not) to maintain hospitalization (Article 19).

Stating the conditions and procedures for the exceptional use and monitoring of physical constraint and seclusion (Article 24).

 

Shortcomings of the Proposed Law:

 

The law’s definition of the “mentally ill” is ambiguous. It reads: “Every person that suffers from a transient or permanent, partial or total, disturbance in his cognitive, emotional and behavioral abilities” (Article 2). It does not stipulate that the determination and assessment of a mental illness should never be made on the basis of professional or family conflict, or non-conformity with moral, cultural or political values. It does not further specify the legal responsibility of the psychiatrist to refrain from basing an assessment only on past medical history of mental disorders.

Institutionalization can still be possible if the family “is not able financially or psychologically to take care of the patient” (Article 9). However, the law does not suggest that assistance be provided to help the family take care of the patient at home. There is some analogy with orphanages or institutions of care, where children are placed because of their parent’s poverty, rather than for being orphans. In both cases, this is in contradiction with decades of research that established the harm of institutionalization. Moreover, in that same article, some words used such as “release the patient from the institution”, still carry the stigma surrounding mental illness and do not refer to the patient as an autonomous subject.

The proposed law does not mention the modalities by which the patient can be brought to the hospital in case of involuntary admissions. The decision to maintain involuntary hospitalization is made by a single psychiatrist within the institution, whereas international standards recommend the approval of two different psychiatrists (Article 18).

In listing the patient’s rights inside the facility (Article 12), the proposed law does not mention the right to freedom from forced labor and exploitation, the right to personal dignity and privacy, and the right to a safe and hygienic environment in the hospital. There is no mention of the necessity to inform the patient as soon as possible after admission of all their rights with an explanation of those rights and how to exercise them.

There are no precisions about the procedures of electroconvulsive therapy (ECT) that should be standardized across hospitals and facilities (Article 25).

 

The Necessity of a Public Debate and Civil Society Implication

 

The mental health proposed law remains unknown to wide segments of civil society, and to most mental health professionals. This lack of awareness perpetuates the exclusion of persons with MHC from the public scene. For decades, these persons have suffered from being isolated in institutions and keeping them out of sight (and out of mind) by this same society adds insult to injury. The debate about the mental health law should be a public one: mental health professionals, patients and their families should be informed about this law and participate in its revisions. It is not only a matter of legal or political experts.
 

The proposed law might modify the balance of power in the mental health field by shifting the resources from institutions to community-based health care. This shift might create resistance from different religious, professional or political actors involved in the current system. Raising public awareness about the importance of enacting a mental health law and reviewing the law project with all actors involved, would anticipate the potential obstacles to law implementation. It would also give persons who have been at the margin of society for such a long time the opportunity to raise their voices and be heard.

 

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[1] United Nations General Assembly Resolution 62/170. (2007). Convention on the Rights of Persons with Disabilities.  

[2] Saghieh N, Saghieh R. (2009). Mental Health in the Lebanese Legislative System: A Study of Legislations and Policies and Their Impact on Children and Youth. (Article in Arabic). Arab Resource Collective.

[3] Foucault M. (1972). Naissance de l’asile. In : Histoire de la folie à l’age classique. Paris, Editions: Gallimard.
[4] Goffman E. (1991). Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. UK, Penguin Books.