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By Elizabeth M. Lynch, July 5, 2017

Courtesy of Asian Journal

Last week, a local court in Henan, China held that the involuntary commitment of a gay man in a state-run mental hospital was a violation of China’s Mental Health Law.[1]  The court required the hospital to make a public apology and to compensate the man 5,000 yuan (approximately $735)  for his mental anguish.  Across China, and in much of the West, civil rights groups have hailed this decision as historic; a victory against forced gay conversion therapy; a step forward for LGBT rights in China.

But is it?  The very fact that the court decided to hear the case – let alone find in the victim’s favor – is significant.  In China, to get to a trial date, you have to first make it past the Case Filing Division (立案庭), a department within the court system, staffed by judges, that examines, behind closed doors, the papers to see if the case should move forward. More politically-charged cases are often rejected by the Case Filing Division and thus, never make it to court.  But here, this case – a politically-charged case where the plaintiff claimed that he was involuntarily committed because of a diagnosis of “sexual orientation disorder” –  was accepted by the local Case Filing Division and thus, was considered important enough to be heard.  And the fact that a court held against a government-run hospital is a pretty big deal.

Courtesy of LGBTQ Nation

But the Court’s decision is not the sweeping condemnation of forced gay conversion therapy that the headlines make it out to be.  If anything, it shows the weakness of China’s Mental Health Law and the fact that involuntary commitment is still too easy a task with little to no immediate safe guards.

The Court’s Decision Does Not Mention Gay Conversion Therapy

Although the plaintiff raised the issue that he was being involuntarily committed for what he claimed the hospital diagnosis as a “sexual orientation disorder”, those are not the facts as the Court saw it.  Instead, the Court noted that the plaintiff was involuntarily committed for an anxiety disorder, never mentioning the plaintiff’s sexuality.  Further, its decision in favor of the plaintiff had nothing to do with the efficacy, morality or legality of gay conversion therapy.

Instead, the Court focused on Article 30 of China’s Mental Health Law, the provision that limits involuntary commitment to cases where the patient is in danger of harming himself or harming others.  Here, the Court noted the hospital’s written diagnosis which stated that while the plaintiff had suicidal thoughts, he was not going to act on those thoughts.  It was this act – the commitment of the plaintiff when he was not a threat to himself or others and in clear violation of Article 30 – that the Court admonished, not that the plaintiff was forced to undergo a mental health treatment to “cure” his homosexuality.

Under the Mental Health Law, Involuntary Commitment is Still Too Easy & Will Continue to Unlawfully Occur

If anything, this case lays bare the weaknesses of China’s Mental Health Law.  Enacted five years ago, the Law was seen as stopping the involuntary commitment of individuals who did not have a mental disorder, or if they did, not one that needed commitment.  In China, involuntary commitment was all too easy of a way for the police to deal with and silence political dissidents or anyone they considered to be “trouble.”  And initial drafts of the Law continued to permit involuntary commitment  if the individual’s behavior was deemed to be “disturbing public order” or “endangering public safety.”  But, in a victory for mental health advocates, the final version did not  include that basis.  Instead, involuntary commitment was limited to where there is a real possibility of harm to self or others.

But what the Mental Health Law did not change is the deference that the law gives to family members.  Article 28 of the Mental Health Law still permits family members to involuntarily commit an individual that the family member suspects has a mental illness.

Here, after the plaintiff attempted to divorce his wife, she and the plaintiff’s brother brought him to the mental hospital and recommended commitment, as they unfortunately have a right to do under Article 28. As family members, they were immediately declared the plaintiff’s guardians and thus were able to sign the involuntary commitment documents.

And that is the other problem with the current Mental Health Law, the ease by which a guardian is appointed. While the Mental Health Law gives a tremendous amount of power to an individual’s guardian, it provides no method for how that guardian should be appointed.  Instead, it is necessary to look to the General Principles of Civil Law which discusses guardianship for individuals with mental illness.

Unfortunately, the General Principles does little to flesh out the appointment process.  Instead, it makes clear the level of abuse that can occur.   Article 13 of the General Principles requires the appointment of an agent ad litem (a guardian) for mentally ill individuals who are “unable to account for his own conduct.”  But the law does not flesh out what “account for his own conduct means.”  Some individuals with mental illness may still be able to lead a relatively normal life and just need help in certain aspects.  But the General Principles is much more black and white; much more all-or-nothing and do not allow for that gray area that provides for some independence for an individual with slight assistance from a guardian.

Additionally, the General Principles provides no formal or independent process by which a guardian is appointed.  Basically, if a person wants to be a family member’s guardian, she can just declare herself as such (Article 17 of the General Principles pretty much limits guardians to family members although there is a provision for a work unit member).  Based on the General Principles and what happened in the case here, the process for guardianship in China is not an appointment process but rather a declaration one.  And there is no court oversight of this declaration of guardianship. Hence the ability of a soon-to-be ex-wife to declare herself guardian and commitment her gay husband to mental institution in a society that isn’t always the friendliest to LGBT lifestyles.

Finally, although the Mental Health Law does permit the patient to contest his diagnosis and demand a second opinion (see Article 32), that evidently did not happen here.  The Court did note that the commitment was over plaintiff’s objections, but there is not mention if there was a second opinion of his diagnosis as should have happened when the patient contests.  And again, without immediate judicial oversight of the commitment process, an increasingly massive failure of the Mental Health Law, abuse of involuntary commitment will continue.  Here, the plaintiff was only able to escape  after he was able to call a friend who called the police and then the police intervened and freed the plaintiff.  But if he wasn’t able to make that phone call, it is unclear when he would have been released.

What this case shows more than anything is that involuntarily committing – especially a family member – is still too easy and, five years after the passage of the Mental Health Law, is still being to readily abused.

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[1] China Law & Policy was fortunate to review a copy of the four-page decision.  This post is based upon our review of that decision.

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By Elizabeth M. Lynch, July 24, 2013

Over at the new blog – China Law Translate – Jeremy Daum has translated two recent mainland articles about individuals with mental illness and the impact of China’ new Mental Health Law (articles are here and here). 

On October 26, 2012, after working on a draft law for close to 27 years, China finally passed its first Mental Health Law; that law took effect on May 1, 2013.  Unfortunately, much of the focus of the foreign press about the new law has largely been on the changes to involuntary commitment and whether those changes will reduce the threat that political dissidents  will be wrongfully and involuntarily committed.  What’s been less of a focus has been the law’s impact on its actual target audience: those with diminished mental capacity. 

And that’s why Daum’s two translations – both recently published articles from the Chinese pres s – are interesting.  Both focus on the plight of the mentally ill.  Both examine the all too prevalent practice of caging severely mentally ill individuals. 

The pictures that accompany the articles – photos of individuals chained and in cages, some of whom are stark naked – are shocking to say the least.  And it would be easy to conclude that this reflects the callousness of a culture toward the mentally ill.  But nothing could be further from the truth – if anything, the caging of these individuals is a result of the dire situation of mental health care in China, especially in the rural areas. 

In “Cage People,” the Chinese reporter estimates that in Hebei Province alone 100,000 severely mentally ill individuals (usually considered people with schizophrenia, bi-polar disorder, etc.) are kept in cages as their only form of treatment.  Although the reporter gives no citation for this number (thus use this number with caution), the use of restraints and cages has been well documented in other sources.  In a 2011 World Psychiatry article entitled Mental Health System in China: History, Recent Service Reform and Future Challenges which examined China’s first experimental national mental health program – known as 686 Program and adopted in 2004 – the authors note the need for the program to include support for unlocking and freeing mentally ill individuals and finding treatment for them.

Lack of Mental Health Professionals

More than anything, this caging is a last resort in a system that has provided little financial support and few specialists in mental health.  China estimates that over 100 million people suffer from some form of mental illness; 16 million of those suffer from severe mental illness.  According to Mental Health System in China, China only has 16,103 licensed psychiatrists and 24,793 licensed psychiatric nurses;  in other words, 1.24 licensed psychiatrists for every 100,000 people and 1.91 licensed psychiatric nurses for every 100,000 people.  China is far below the  global average, where there are 4.15 psychiatrists and 12.97 psychiatric nurses per 100,000 people.  Id.  As a result, it’s not surprising that 91.8% of all the mentally ill in China never seek help.  For those with severe mental illness, 27.6% never receive any type of help and 12.0% of the severely mentally ill only visited non-mental health professionals.  Id.  

Social workers, who are key in a community-based mental health care system, are few in China.  However, China is rapidly expanding its program, with the goal of training 3 million social workers by 2020.  See Renne C. Lee, UH Aids China in the Developing Social Work Profession, Houston Chronicle (Mar. 4, 2013).

Disparities between Urban and Rural Life in China – extends to mental health care

Disparity Between Rural and Urban Areas

But what makes that shortage even worse is that since the economic reforms, there has been a brain drain from the rural clinics to more profitable hospitals in the urban areas.  See Yanzhong Huang, The Sick Man of Asia, Foreign Affairs (November/December 2011).  Even though the Chinese government has recognized the need to institute a community-based care model for mental illness, where patients are not all hospitalized but instead are treated while remaining in the community, the Chinese government still expends much of its resources on psychiatric hospitals.  See Mental Health System in China.  This inherently means that money will flow to the urban areas. 

Lack of Adequate Insurance and Funding to Rural Health Care Services

Finally, even with the reforms of health care funding, especially in the rural areas, mental health care is still too expensive for many Chinese.  According to WHO, only 2.35% of China’s total health budget is spent on mental health (in the U.S. 5.6% of the national health care spending is on mental health – see Washington Post article);  as of 2011, less than 15% of China’s population had insurance which covered mental health (although 45% of US mental health patients cite cost as a major burden).  See Mental Health System in China. 

Due to these factors, many severely mentally ill in the rural areas have only their families to take care of them.  With little to no treatment, these families sit by while their relatives’ illness only gets worse.  As a last resort, these families resort to restraints, not because they want to but because they have no choice. 

Does the Mental Health Law Change the Current Situation?

Chapter IV of the Mental Health Law– “Rehabilitation from Mental Disorders” – creates a community based model of care which should limit

All for One, One for All – Community Based Mental Health Services

hospitalization to only necessary situations.  This type of model allows those with diminished capacity to be integrated into society and is in line with China’s commitments under the Convention on the Rights of Persons with Disabilities (which China has ratified and the U.S. still has not).  Rural and village governments are required to assist those families obtain the services they need.  This assistance includes financial assistance. 

Unfortunately, the law leaves the funding of what could be a useful framework to the local areas.  For already impoverished villages, they just don’t have the resources to carry out their responsibilities.  As Daum’s translation of “The Need to Promote the Mental Health Law” demonstrates, even when families apply for their legal mandated “Minimum Subsistence Allowances,” the local fund is often inadequate and does not enable them to seek the medical help their relative needs; there will still be out of pocket costs that are too high for many villagers.   

As Huang Xuetao, a lawyer at the Equal Justice Initiative, noted in the article, the hopeful prospects of the Mental Health Law are diminished by three things: (1) the lack of education to the people about the protections of the new law; (2) the lack of funding for mental health care and (3) the government’s  lack of attention to the matter. 

Until those factors change, especially the last two, China’s Mental Health Law will not achieve its objectives.  However, these frank articles in the Chinese press – soon after the Mental Health Law took effect – might be a positive sign that change is on the way. 

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By Elizabeth M. Lynch, December 11, 2012

Don’t think that we missed this one.  China Law & Policy just hasn’t had the chance to write about it.  At any rate, after 25 years of discussion, and two rounds of very vocal public comments in the past year, on October 26, 2012, the Standing Committee of the National People’s Congress finally passed its Mental Health Law (“MHL”).

One of the major improvements to the law since earlier drafts is the removal of the provision that specifically permitted involuntary commitment if the individual’s behavior was deemed to be “disturbing public order” or “endangering public safety” (see interview with Prof. Michael Perlin about this issue here).  Earlier drafts which included that clause were vigorously attacked by both Chinese and foreign experts noting that such a provision would give carte blanche to the police to involuntarily commit anyone who expressed a dissenting view.  As Chinese Human Rights Defenders (“CHRD”) highlighted in its seminal report on China’s mental hospitals, The Darkest Corners: Abuses of Involuntary Psychiatric Commitment in China, some of China’s many mental hospital “patients” are in fact dissidents who were involuntarily committed outside of any court process for expressing their dissenting views.

Deletion of this provision is certainly a step forward there are still aspects of the adopted law that make it far less than ideal and demonstrates the continued need for better protections for the mentally ill in China.

Family members are still able to commit an individual against his or her will

In addition to voluntary commitment, Article 28 of the Mental Health Law still permits family members to involuntarily commit an individual that the family member suspects has a mental illness.  In effect, the Mental Health Law places the family in a separate sphere that assumes that family will not abuse the process.

But if the goal of the Mental Health Law is to “protect the lawful rights and interests of those with mental disorders” (MHL, Art. 1) and to integrate those with mental disorders into society, then allowing family members to involuntarily commit individuals runs against these goals by putting those with mental illness or disorders at the mercy of their family.  This also runs counter to the Convention on the Rights of Persons with Disabilities (CRPD) which requires that the rights of those with mental disabilities be on equal footing with the rest of society (see CRPD, Article 3(a)).  China has signed and ratified the CRPD but the new Mental Health Law is not in keeping with many of the CRPD’s provisions let alone its spirit.

No Court Oversight of the Commitment Process

International human rights law, which the CRPD adopts repeatedly through reference, is clear that any decision to deprive one’s liberty, including on health grounds, is challengeable before a court or other judicial body (see United Nations Commission on Human Rights, Report of the Working Group on Arbitrary Detention (Dec. 2005) Para 63-66).

China’s current Mental Health Law creates a system for involuntary commitment that is completely devoid of any court oversight.  When an individual appears at a mental hospital – either voluntarily, brought by a family member, or in the case of homeless individuals, by the police (MHL, Art. 28) – he or she is examined by one of the hospital’s psychiatrists.  If the psychiatrist determines that the individual suffers from a severe mental illness and that he or she demonstrates either harm to him or herself or harm to others, then involuntary commitment is required (MHL, Art. 30 – the law here uses “应当” which has the same effect of the use of the word “shall” in English laws, making involuntary commitment mandatory if the facts apply).

There is no provision to challenge the hospital psychiatrist’s diagnosis in a court of law or even before an independent arbitrator.  Instead, if the individual or its guardian disagrees with the initial assessment, he or she can request that the hospital provide a different psychiatrist to do an second assessment or go to another mental hospital to request a second opinion (MHL, Art. 32).  It is questionable if another doctor in the same hospital will be a true independent opinion or if he or she will just agree with his colleagues.

Similarly, even if the patient or his family requests an evaluation from another mental hospital, (1) under the Mental Health Law, there is no obligation that this hospital do the assessment and (2) it is not clear that the doctors in that hospital will be any more independent.  These doctors will still be state employees and colleagues of the original doctors.

If after the second opinion, the patient or his family still disagrees with the assessment, it is only at that point that he or she can go outside of the system and hire an independent psychiatrist of his or her choosing (MHL, Art. 32, ¶3).  However, the law makes no mention as to what to do if this third opinion disagrees with the two opinions provided by the state.  Article 35 of the Mental Health Law forbids involuntary commitment where the second opinion disagrees with the first, but makes no mention of what to do with the third opinion.  Without court involvement, presumably it will not be sufficient to overturn the prior opinions and free the individual.

Guardians Are Too Easily Appointed and Too Difficult to Remove

The Mental Health Law provides a tremendous amount of power an individual’s guardian but provides no method for how that guardian should be appointed.  Instead, it is necessary to look to the General Principles of Civil Law which discusses guardianship for individuals with mental illness.

Unfortunately, the General Principles does little to flesh out the appointment process.  Instead, it makes clear the level of abuse that can occur.  Article 13 of the General Principles requires the appointment of an agent ad litem (a guardian) for mentally ill individuals who are “unable to account for his own conduct.”  But the law does not flesh out what “account for his own conduct means.”  Some individuals with mental illness may still be able to lead a relatively normal life and just need help in certain aspects.  But the General Principles is much more black and white; much more all-or-nothing and do not allow for that gray area that provides for some independence for an individual with slight assistance from a guardian.

Additionally, the General Principles provides no formal or independent process by which a guardian is appointed.  Instead, it appears that basically, if a person wants to be a family member’s guardian, she can just declare herself as such (Article 17 of the General Principles pretty much limits guardians to family members although there is a provision for a work unit member).  Based on the General Principles, the process for guardianship in China is not an appointment process but rather a declaration one.

Article 17 of the General Principles does contemplate a court action where the individual or someone else might disagree with the declaration of guardianship.  But it would be better to involve the court at the initial stage and require it to review guardianship decision to give the relationship any legal effect.  In fact, the Article 12(4) of the CRPD requires such a process – that an impartial authority or judicial body review all decisions to limit an individual’s legal capacity, such as the appointment of a guardian.  Without judicial oversight of the guardianship process, the process is subject to abuse and the individual with mental illness is again denied his ability to function equally in society with others.

Conclusion

In reality, the Mental Health Law does little to foster an environment where those with mental illness can lead an independent life and be accepted by society.   Furthermore, although the law discusses the very real (and dire) need to increase the number of mental health professionals in China, that has remained aspirational.  As of yet, the Chinese government has remained silent on how much money and what incentives it will provide to achieve that goal.  Providing adequate and sufficient medical assistance for those suffering from mental illness is just as important to making sure that those individuals will be able to lead a full life.

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* Jeremy Daum drafted this translation within days of the Mental Health Law’s promulgation.  It wasn’t until now that China Law & Policy had the chance to publish this translation.

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By Elizabeth M. Lynch, October 24, 2011

On Monday, the Standing Committee of the National People’s Congress began its review of China’s new, draft Mental Health Law.  The draft – originally issued on June 10, 2011 and opened for public comment – has received much criticism both at home and abroad, in particular, Article 27 of the draft which permits involuntary commitment where an individual exhibits behavior that “disturbs public order” (扰乱公共秩序).

Prof. Michael Perlin

The Chinese government appears intent on ratifying the new Mental Health Law by year’s end, but the question remains, how will the new law change the current landscape?

Below, Prof. Michael Perlin, professor at New York Law School, Director of the Mental Disability Law Project, and author of the recently published “International Human Rights and Mental Disability Law: When the Silenced are Heard,” analyzes China’s new draft Mental Health Law, paying particular attention to its interplay with the Convention on the Rights of Persons with Disabilities (CRPD), a treaty China has ratified.

Click here to listen to the interview with Prof. Michael Perlin or read below for the entire transcript.
Length: 31 minutes (audio will open in another browser)

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[01:31] EL: Thank you Prof. Perlin for joining us.

[01:33] MP: Happy to be here.

[01:34] EL:  Let’s begin by talking about your new book, specifically Chapter Four which discusses the use of mental disability law to suppress political dissent.  How long has China been using involuntary commitment to suppress dissent?

[01:47] MP:  We knew that it has been going on back at least 40 years, it may be before that, we don’t know.  This was written about first and most extensively by Robin Munro who brought most of this to the public attention and he gave some very, very serious examples of the misuse of state-sanctioned psychiatry in support of commitment of people who by any sort of standard, normative reason would not have needed commitment.

The use of involuntary commitment to squash dissent is not new in China and can be traced back to Cultural Revolution days.

[02:17] Sometimes it was done for political reasons, sometimes it was done for financial reasons.  There is this whole other set of cases where people wanted to get rid of a relative because they wanted to take over a business or something.  That was not unfamiliar to those who knew about this in the United States about the same time.  But clearly it was being used to suppress political dissent.

[02:40] When I wrote Chapter  Four of this new book, a lot of it flows from an article I’d done about four or five years before in the Israeli Law Review.  When I did that research, it was kind of interesting to me.  Most people know, or people who are interested in this whole general area, know that the former the Soviet Union, this was very common.  And there were exposes, the World Psychiatric Association sends a delegation in the late 80s, early 90s, there were quite a few books written about it and articles.  But China at that point nobody seemed to pay that much attention to, and it was pretty clear that the same kind of things were going on in China as were going on in the Soviet Union.  Fast forward, the Iron Curtain fell, some of the abuses – not all – in the former Soviet Union had been remediated to some extent. But again what was happening in China was pretty much under the radar.

[03:40] It became known, interestingly, with regard to what is seen as the persecution of the Falun Gong.  Is it a political group? Is it a kind of exercise? Is it meta-physical? I can’t answer that but it seemed very, very clear to me and to most neutral observers that practitioners and adherents were being singled out, and they were being marginalized as mentally ill.  One of the things, we’ll talk about it latter, is why do governments do this and I will discuss that in a few minutes but it seemed to me that China in many ways was paralleling[the experiences in the Soviet Union]

[04:25] What is interesting to me is that in this new draft act [China’s draft Mental Health Law], of which I am enormously ambivalent I should tell you, I think…and I have sent some comments to other people about it….I think there are some other things that are better than China has had before but an awful lot of it strikes me as very problematical.  [Much of it] would not only not meet constitutional standards in a Western country but also I think pretty clearly does not comport with the UN Convention on the Rights of Persons with Disabilities which China has ratified.

[04:58] It seems to me that  [in] this new law, Article 27  — about the disturbance of public order  — should be a red flag.  What does that mean?  We are sitting here on the corner of West Broadway and Leonard Street and how far are we from Wall Street where there is an occupation going on that seems to be spreading.  Is this disturbing the public order?   One could read the pages on Facebook and an awful lot of American citizens think it is.  Is something like this was being done in Beijing or Shanghai would, could everybody be dragged away to a psychiatric hospital?  Under the strict language of the Act, yeah, it probably could.

[05:36] EL:  Well, in terms of  that, and you sort of mentioned it in your answer.  The Chinese government itself has the power under even the criminal law, arguably; I mean maybe it is not directly stated in the criminal law but they use the power to detain people indefinitely.  Why do they choose to, for example Falun Gong and other dissidents, why do they choose to use a mental health analysis instead of using the criminal law when they are basically an authoritarian state.  Why did the Soviet Union do that, why does China continue to do that?

[06:13] MP:  It seems to me that there are at least three main reasons for that Elizabeth, and that truly is a great question.  First of all, there are always some, albeit minimal, procedural safeguards in the criminal process.  They

The criminal process in China has its limits

are not always adhered to.  … I spent some time working in China with criminal defense lawyers and I was teaching them how to, pedagogically, how to do certain things but I also spent much more time learning and I realized that it is not a lot those of us who have practiced criminal defense work in New York or New Jersey would go “oh my God”  [to much of what goes on in the criminal trial process in China] but at least there is a something there.  There is nothing there on the psychiatric commitment side.  So that’s number one.

[06:56] Number two, when there is a hearing, when there is an adjudication, there is usually a limit to the sentence.  It may be a draconian sentence, it may be for many more years than we would think make sense.  But at least there is a number there.  Psychiatric commitment is, in these jurisdictions indefinite.  And I should say, after the CRPD [the Convention on Rights of Persons with Disabilities], the Convention is ratified, I don’t think indefinite commitment without clear judicial review passes muster under the international human rights law.

[07:31] But the third I think is the most important.  Because I think  [psychiatric commitment] stigmatizes.  We know that if we call somebody a mental patient, he will be discredited.  And if he has political motives, that will mean, well, we can ignore them.  I use this example, I think, in that book, about someone in Romania (when Romania was a completely authoritarian state) who was picked up, and his psychiatric charge was [that] he was carrying a sign saying that the prime minister of the country must go; the [rationale was], “Well if he thought he was serious that someone would listen to him, he must be crazy.”  It’s a self-fulfilling prophecy.  It’s a loop.  But I think those three reasons together are really it.

[08:14] EL:  Right now, before…..I know they [China] have the draft [mental health] law published right now and it was opened for comments back in the summer, but before that.  Right now how does involuntary commitment work [in China]?  Are there laws in place?  Who makes the decision if an individual should be involuntarily committed?  How does it work?

[08:33] MP:  The decisions is made basically by the State.  Someone gets picked up; very, very often family will call and ask: take my relative and send him to the hospital.  And there is no independent assessment.  In 1985….I should say to your listeners, I have been a professor since the mid-1980s but I was a real lawyer before that.  I practiced 13 years both as a criminal defense lawyer and as an advocate for persons with mental disabilities.  I filed an amicus brief in the U.S. Supreme Court in 1985 in a case called  Ake v. Oklahoma in which the Supreme Court ruled that a person who is indigent had a right to a psychiatric evaluation at state expense if he was putting forth the insanity defense.  The idea being that this is something that can’t simply be done, can’t be decided on the say-so of the state doctor.

[09:32] In China it is always done on the say-so of the State doctor.  There is virtually no sense of independence.  There is also no lawyer appointed.  One of the issues that I think is really important; we know this, we know that both among the United States and in other nations, serious mental health reform only happens when there are lawyers assigned to represent patients.  I know that sounds very lawyer-centric.  Pardon me, I plead guilty to that.  But if you were to go to the United States and go state-by-state and see where has there been reform, where has there not, it’s an easy question.  Where have there been lawyers like in New York, the Mental Hygiene Legal Service, like in New Jersey, the Division of Mental Health Advocacy law office, like in DC, the Public Defenders Service/ Mental Health Division, that’s where it happens.  In other nations, where you have it: Israel is a nation that has a robust public defenders office doing these things and they are enormously successful.  Where there are no lawyers, reform doesn’t happen.

[10:29] There are no lawyers doing these cases on the ground in China.  I believe that after ratification of the CRPD, this needs to happen.  Commitment must be subject to the judicial process at every step.  That is demanded by the CRPD and it’s not in the draft [Mental Health Law] much less in the older law.

[10:49] EL:  So to clarify, the draft mental health law that has been proposed has no provisions for a lawyer to be appointed.

[10:57] MP: Correct.

[10:58] EL: And there is no independent review of a state’s decision.

[11:00] MP:  One can ask for a review but it is absolutely, utterly optional.  There is no sense that it is obligatory, it is not mandatory.

[11:09] EL:  Now, in terms of involuntary commitment, you say that the decision is made by the state.  Would that be – what division of the state?  Is that the Ministry of Public Security or is it not clear?

[11:21] MP:  It’s not clear.  You have sort of two different ways it could happen.  The Ministry of Public Security and

An Ankang Hospital in China

this whole Ankang hospitals that are really shrouded….I mean, I heard about them….oh my goodness…I’d been doing mental disability work my whole career.  I’ve been doing international human rights mental disability work for 11 years.  I’ve been going to Asia for nine years.  But it wasn’t until about four or five years ago that I even heard about these hospitals.  And they operate…there is virtually no way to find out what’s going on in them and that ministry is Public Security.  The others go through the Ministry of Health, I believe.

[12:00] EL:  So the Ankang hospitals are within the Ministry of….?

[12:05] MP: Of Public Security.  And those involve people who are seen as being criminally dangerous.  It’s a very, very murky line between criminality and other kind of dangerous behavior.  Very often, it’s what you choose to call it.  But there is very little, there is no review, and there is very little outsider involvement.  It’s like a world in and of itself.

[12:33] EL:  And in terms of that line between criminality and involuntary commitment….One of the things that is being heavily criticized both by foreign scholars and even Chinese legal scholars is this continued use of “disturbing public order.” And that’s included in the new draft mental health law.  My question is….just to get to the people who write this law.  Is there any sincerity in the use of this term?  Does the Chinese government believe that….I mean is there sincerity in the belief that perhaps the expression of a different opinion is evidence of mental illness?  And how do they get doctors on board with that?

[13:13] MP:  It’s very hard for me to tell what was in their minds.  There is no record of this.  And you can come

Occupy Wall Street - Political Protest or Endangering Public Saftey?

with multiple explanations Elizabeth. On one hand you can look at it just plain meaning.  Endanger public safety means somebody is standing in the middle of a main street screaming at cars, right?  That could cause an accident.  And that you and I would agree might endanger public safety.  And that’s one possibility.

[13:42]  [This is another:] … In this study that was done by the Equity and Justice Initiative of Psychiatry and Society Watch that was published recently which analyzes this commitment system in China, it is replete with example of people who were picked up and psychiatrically hospitalized because basically they were seen as dissident.  It’s an over-used word.  I am very concerned in any jurisdiction but especially, especially, in a jurisdiction that has this kind of track record of locking people up for disagreeing politically.  I am very concerned that this kind of language, like in Article 27, is far too overbroad and I see that as a really troubling issue.

[14:29] Why do state psychiatrists go along with it? This is something I have been trying to deal with for 20 years in terms of thinking about it and you don’t know.  I remember reading one study in which the researchers said – well you know if we went along for the ride we would get more vacation days or get a nice home at the beach – something like that.  Which sounds so depressingly banal, right, but it also in fact may be so.

[14:57] Some may also feel as if they[examining psychiatrists] are an arm of the state.  I have heard, I have been in meetings, just so your listeners know, I have been mainland China five or six times and have done quite a bit of work there and I have been at meetings with psychiatrists and I’ve tried to listen to what people say.  Very often….most recently I was in Beijing in June this summer, and I heard a psychiatrist say – “oh well, you know, I can kind of look at this guy in the eyes and I will know if he needs to be institutionalized.”  That kind of behavior was repudiated when I started practicing law, I heard doctors say that.  That’s been repudiated in the States for the last twenty or thirty years.

[15:42] Very, very much of what I heard on this last trip to Beijing – Yogi Bera said it is déjà vu all over again – very much of what I heard was very close to what I heard in the early 1970s when I started practicing law in New Jersey.

[15:55] EL:  Well in that regards, and this is a little maybe off topic because it’s not as much related to law, but has there been efforts….I know that there are a lot of rule of law projects from the US in China to help strengthen the legal profession.  Have there been efforts to maybe create….strengthen the professional mindedness of the psychiatry profession in China?  Has there been any attempts to do that and hopefully through that way, develop a grassroots feeling of independence?  Or is that something that might just be too difficult?

[16:26] MP: If this was a TV show rather than podcast, your listeners would be seeing my face at this moment.  Yeah, kind of, maybe, a little bit, not much.  I know the World Medical Association has taken seriously some of these issues.  There’s a psychiatrist in Mamaroneck, New York, Dr. Abraham Halpern, one of my heroes.  Abe has been working on some of these issues for the last 30, 40 years.  Mostly he is focusing on things like organ transplants now.  But he has been a gadfly to the World Medical Association encouraging it, as has  Dr. David Matos of Canada.  But generally not so much.  I don’t see this…..

[17:05] There is an interesting subtext issue here.  One of the things I write about, and I discuss it extensively in this book, is what I call “sanism.”  Sanism is the kind of irrational prejudice like racism, like sexism, like homophobia, in which we stereotype people with mental disabilities, we trivialize them, we typify them, we don’t take them very seriously.  We treat them as less than people.  Because of that, we generally – we meaning society – pay much less attention towards what psychiatrists do with purportedly “crazy people” than we do when there are other violations.  When people mistreat women, when people mistreat children, when people mistreat gays, there is a predictable and appropriate outrage on page one on all the blogs.  It doesn’t happen here.

[17:55] Internationally there is only one organization, a group called the Mental Disability Advocacy Center located mostly in Budapest, a couple of other sites in Europe, that is doing this work on a global level.  I am working with my friend and colleague Yoshi Ikehara who is head of the Tokyo Advocacy Law Office (as I said before we went on the air) to create a Disability Rights Tribunal for Asia and the Pacific.  But there is very little else that is being done.

[18:19] This is a population that people, even people who see themselves as traditional liberals –  traditionally progressive, traditionally focusing on social justice – which just as well go away.  They think it is yucky.

[18:34] EL:  In terms of….focusing on the international efforts, you had mentioned the CRPD, what international law is out there that would push China forward in this regards?  Since China has ratified some of the treaties, what can be done on an international level besides just issuing reports that they are in violation of the treaty?

[19:01] MP:  That’s the hardest question Elizabeth; it’s the most important question.  This treaty which has been on the books for three years….

[19:10] EL: And this is the CRPD?

[19:12] MP: Yes.

[19:12] EL: Which stands for?

China has signed & ratified the CRPD but does it follow it?

[19:13] MP: Which stands for the Convention on the Rights of Persons with Disabilities, is without any question the broadest document ever written on behalf of this population.  Importantly it repudiates the medical model and substitutes a social model of disability.  In other words, this is not simply “we have sick people”; this is, “society deals with this population a certain way, [and we need to] figure out what to do.”

[19:35] Irony, off to the side, what is so interesting to me is how the role of psychologists is so limited in this draft act [China’s draft Mental Health Law].  The CRPD moves away from the medical model, [and,] as such, psychologists – non-physicians – the use of them, the reliance on them should increase, not decrease.  One of the things that I am seeing between the lines with my magic decoder ring on is that there are struggles between the psychiatric trade associations and the psychological trade associations in China; the psychiatrists have much more political clout, much more legislative clout, so this is basically guild stuff.  That’s there.

[20:14] So, going back to what you said before.  It’s clear to me and I write about that extensively in the book, there are many articles that talk about due process basically, that talk about freedom from torture, freedom from cruel and unusual punishment, ant-discrimination, access to justice, on and on – and again I would be happy to send you some more recent things that I have written about it since I’ve written the book – and it seems to me that China is failing at all those.

[20:45] But then comes the question, and so what?  What are you going to do?  What can you do?  One of the reasons why Yoshi and I are devoting so much time to the creation of what we call DRTAP, the Disability Rights Tribunal for Asia and the Pacific, is because in Africa there is a commission on human rights; in Europe there is a court on human rights; in Latin America there is a court on human rights, in each case, a court or a commission.  There is nothing in Asia.  There have been seminars, there have been meetings, there is this group called the ASEAN , to which seven nations belong; some [groupings of nations] belong to other [pan-Asian groups that deal with other issues], but there is no Asian-wide tribunal.  Why? Good question.  People talk about “Asian values,’ [but] I reject that [as the reason why there is no human rights body in Asia] and I could talk about that later if you want me to.

[21:31] But without that, a person can, ostensibly, theoretically, appeal any kind of a decision directly to the Human Rights Council of the United Nations.  That’s pretty difficult for anybody to do.  It’s difficult for a person in a nation with a developed economy, what we call the first world, it is certainly, virtually impossible for someone in China to do without a lawyer, especially somebody is not in Beijing or Shanghai or one of the major cities.

[22:03] I went to Xi’an a couple of times to do some work and I talked to a lawyer who said: “Prof. Perlin, I’m not sure if you understand. In our province, we get to court by horseback”. This was in about 2007, 2008; this is not 20 years ago.  There basically, they have at this point in time, almost no legal recourse.  What you can do is [appeal to] the court of public opinion.  We’re trying to do that.  But again I am very saddened and disappointed that this issue has not sort of spread beyond the small circle of people who take this seriously, who care about it, who write about it, who foment about it.  I think some of the reason for that Elizabeth is sanism, that these people are just simply seen as not human, not as important.

[22:45] EL:  So are you saying that this issue hasn’t spread beyond the small group that focuses on it, so a lot of maybe the US’ projects in China, do they….are there US rule of law project that are pushing this?  Is it also I guess in some way our fault?

[23:01] MP:  Yeah it is.  Oh clearly it is our fault.   … I am on the Chinalaw LISTSERV, as you are, and if you spend a month there you will see there are certain topics that get written about a lot.  Some very serious topics.  Certainly there are serious human rights issue dissidents, things of that sort, but most of it goes to business law.  And that that does not go to business law, a lot go to things that are extremely important like environmental law.  Anyone like you or I who have spent time in China know how serious these problems are.  But there is virtually no attention paid [to the issues we are discussing here].  You and I could sit down after this is over and count on one hand the people who have done substantive posts in the last three years about this issue on that LISTSERV, and we would  have a couple of digits left over.  So yeah, I think that I can fault those generally interested in the “rule of law”  or “just society” for not taking this seriously enough.  Well you know everyone has their priorities, we can’t do everything and that’s true.  But this is an area that virtually no one is taking seriously.

[24:05] EL:  Back to China, in terms of the new draft mental health law, you said that you are extremely ambivalent about it.  Could you talk more about your feelings about what is good, what’s not good.

[24:18] MP:  The fact that there is a law; the fact that it sort of talks about the fact that there has to be some kind of structure to this; and the fact that at least there will be something to assess, something to test.

[24:30] But let me laundry list some things that I think are problematic.  First of all, I don’t think whomever drafted it ever looked at the CRPD.  It does not appear to me that that was ever done, and that should have been.  Elizabeth, when I talk to people — I am very fortunate, I have gone and done human rights law on every continent (except for Antarctica,  the penguins still haven’t asked for me)  — I’ll say to people now, when you re-write your law – I was in Argentina two or three weeks ago and I spoke to the World Psychiatric Association and I spoke to people from several nations and I said exactly the same thing – if you are rewriting your law, on the left side of your desk, you need the CRPD and for every section you write, go and look at the cognate section [of your local law] and ask, “Are we in line with this or not?”.

[25:16] EL: Well let me just interrupt for a second about that, I know there has been a lot of talk about the criminal procedure law, who has assisted in drafting that, do you have any idea which agencies of the government have assisted in drafting the Mental Health Law, if there has been any famous academics…is there any transparency about that?

[25:36] MP: I don’t know.  It may have happened, but I simply don’t know or it is something that I am just not a part of those conversations.

[25:45] As I said before, again call me lawyer-centric, I think there needs to be appointment of counsel…period.  Article 29 through 32 talk about maybe commissioning a forensic mental disability evaluation agency for second opinions in some cases.  But without a counsel, I don’t think it’s really going to make very much difference.  I think any part, every aspect of commitment has to be subject to the judicial process every step of the way.

[26:16] There are lots of other things that I sort of saw going through it.  On Monday, in my class on survey of mental disability law, we talked about the topic of sexual autonomy, the rights of persons to have some kind of sexual freedom, and I have written about this in an article I wrote in the Washington Law Review a few years ago about sexuality issues in Asia and in China, you might find that of some interest.  Nothing about it there.

[26:43] Their criteria for commitment are not really clear.  There has to be a causal relationship between mental illness and risk and dangerousness.  That is never spelled out.

[26:52] There is nothing about the institutionalized patient’s right to refuse medication, a huge, huge issue.

[27:03] There is a whole thing in Article 24 about when relatives can send a “suspected mentally disabled person” to the hospital.  Without criteria that is really, really problematic and I think that is an issue that needs to be dealt with.  Very, very often, somebody will come to a psychiatrist and say “doctor, my brother, sister, whatever is crazy” and that becomes sort of the fact in evidence, even though there’s no  [actual] evidence before [the psychiatrist.”].  That’s where we start out and I think that’s really a serious, serious issue.

[27:34] As I said before the “endanger public safety language” in Articles 26 and 27 is  especially problematic, especially, Elizabeth, given China’s history.  Article 28 talks about “diagnosis” but “diagnosis” is not “risk assessment”.  A person can have what we would call in the States an Axis 1 diagnosis – schizophrenia, bi-polar depression, major depression – and that does not mean they are committable because [to be committable], you have to have with that, as a result of that, the likelihood of serious danger to self or others.  That is not spelled out at all.

[28:14] The possibility, everybody has ballyhooed in Article 29 about this sort of duplicative examination…I am not convinced at all that it is going to be really independent.

[28:27] Starting in Article 30 it talks about forensics but I am really puzzled because there is nothing else in here about the criminal process.  It is just not clear to me what that is.

[28:38] I think rights need to be enumerated.  If you go to Article 34 we also have to articulate the fact, and again this is constant both with the CRPD and all developments of the last forty-plus years that the right to treatment has to be in the least restrictive alternative.  We have to talk about community treatment.  We have to talk about de-institutionalization.  We have to talk about congregate care, halfway house, on and on.   That’s not here anywhere.

[29:03] Psycho-surgery is discussed in Article 39.  Absolutely not.  That should never be an acceptable treatment.

[29:09] I was puzzled again as I said to you by the lack of….how psychologists appear to me to be squeezed out.  Again, I see this as kind of guild-mentality; it troubles me a lot.

[29:25] What can be done about this, I’m not that smart.  I have sent my comments in to other people who hopefully have the ear of those who do listen.  Hopefully something will happen.  But I looked in file before you got here but I have not heard back, gotten anything substantive on this in the last two months.

[29:41] EL: Well that’s what I want to ask you in a close out question basically.  There has been actually some verbal criticism by Chinese scholars about the draft mental health law and highlighting a lot of the things you have mentioned including the endangering public safety, disturbing public order issue.  Do you think the Chinese government will listen to any of this criticism?  Do you anticipate that the draft will change before it is adopted?  Or are these things that the Chinese government hasn’t been able to get past yet?

[30:15] MP: I wish I knew, Elizabeth.  I say jokingly I’m smart, I’m not that smart.  There will be some changes.  I think if they made no changes at all that would be a public relations disaster because that would mean we are ignoring everybody, we are doing just what we want, and take a hike.  There will be some changes.  I’ll say some of it will be better.  How much of it?  Ten percent?  A quarter?  I don’t know.  I wish I could be more optimistic and say – oh they are going to listen to everything we say – no, get real, they’re not.  But I am hopefully that it will be incrementally better and the way that it is written will give us more and people who are on the ground more to work with.

[30:59] I’m very sensitive to the fact, I go to China once a year, at the very most twice a year, I live in New Jersey, I work in New York, I am a foreigner, I am an outsider and all I can do is listen and learn and share some ideas.  It has to be done by the people on the ground.  I certainly spend a good deal of time talking to them and I hope that as a result of that something happens.  I remain….I’ve been doing this work for a long, long time…I remain an unflaggingly optimistic guy so I hope it is going to happen.

[31:30] EL: Okay, well, I guess we will find out.  It is suppose to be passed by year end.  Thank you very much Prof. Perlin for your time and your knowledge.

[31:40] MP: Thank you, Elizabeth, it was a pleasure.