Forced Sedation – an assimilation policy of the Commonwealth’s “mental” health project for Indigenous people

Photo: Supplied.

“Mental” illness labels are increasingly greasing the wheels of shiny new cars that take people further away from Country, says LeVive.

Public reactions to the article, “Why did the ‘settlement needle’ not make it into the Northern Territory Royal Commission report” were mixed, with a revealing split between medical professionals and the general public. For physicians, half agreed that duty of care had been compromised, while the other half shielded the safety of solo or interacting blends of psychotropic medications. Interestingly, two anaesthesiologists used the term “chemical straight jacket” after duly considering the case illustration of the Aboriginal young man who was given sedative injections inside a police van and hospital emergency room. One medical specialist urged reporting all members of the medical team who treated and attended that case to the Australian Health Practitioner Regulation Agency (AHPRA).

Within the general public, some pointed to questionable chemical restraint practices in aged care facilities, mental health wards and refugee detention centers. And there were, of course, the predictable sneering remarks about Aboriginal children, which exposes complex justice challenges related to broader racist and hate beliefs in Australian society. Collectively, these responses reveal imperialist practices steeped in what Associate Professor Peg LeVine terms as “the politics of exclusion”.

Recently, I again sat down with LeVine, the source of the “settlement needle” story revelations, to take a more detailed look at the issue of forced chemical sedation of Indigenous people in the “protective care” of the State.

Jack Latimore (JL): Peg, one aspect of the “settlement needle” story that never made it into the article was the fact that there is institutional support for these questionable practices and policies. The article asked why there was no mention of chemical restraint in the final report of the Royal Commission. You’ve since pointed my attention to recommendation 15a of the report and how two suggestions intended to address mental health may inadvertently increase the cruel practice of forced sedation for Indigenous children, youth and adults.

Peg LeVine (PLV): On paper, the Royal Commission’s final report appears to strengthen Indigenous access to the Australian government’s Medicare system and Pharmaceutical Schemes. After all, it seems reasonable to seek “better access” to healthcare for Indigenous people. But a critical question tied to a long history of cultural inclusion and exclusion remains: Better access to what and initiated by whom, for whom? Never has a two-tiered system of Medicare been seriously considered that safeguards Aboriginal perspectives on “wellbeing” and protects eco-cosmological systems of connection so vital to collective wellbeing. I think the fact that the Royal Commission’s final report rubberstamped the “Pharmaceutical Benefits Scheme” – alongside the pre-existing Medicare scheme – is evidence of their collusion in assimilation policies. And yet, the sad part of that story is how they have come to believe they are doing the right thing.

JL: Do you think the Royal Commission consulted reliably with an interdisciplinary team informed by Indigenous world views before making their recommendations?

PLV: Of course not. They did not even respond to my call for an urgent impartial review of forced sedation – the settlement needles. And they seem to be uninformed by research advanced by social scientists that shows how “social class bias” is a key factor leading to the mistreatment of Indigenous people globally in mental health. While this factor is as ubiquitous as race bias, it is more difficult to detect since clinicians and policy makers can lack insight into their own social biases. Canvass our national university mental health training programs and you will see how place, space and time is choreographed for assessment and treatment schemes: usually indoors, one-on-one, and time limited. Those practices were simply not normed on Indigenous experiences. Textbook theories of attachment in “social” and medical sciences are urban bound. We need wellness practices that ‘main-stream’ other. After all, emotional and physical attachment is as wide as the sky and land-water scape and as deep as ancestral spirits. I have drawings by boys who I saw inside the Alice Springs detention centre; some soothed and cried themselves to sleep at night when imagining a special ridge of land. But I can tell you their pain is dismissed once they are labeled as bad kids.

JL: Can you tell me more about this last statement, “social class bias”?

PLV: I refer to a quote by the African American civil rights activist Jesse Jackson, “When blacks are unemployed, they are considered lazy and apathetic; when whites are unemployed, it’s considered a depression.” It is like this in mental health. When I reviewed cases of children treated inside and outside the Aboriginal Congress Alice Springs, I found links between health practitioners’ interpretations about a client, such as  “non-compliant, avoidant or resistant” and their diagnosis and treatment of clients. I read one report where one GP called a child a “ratty kid” and soon prescribed a major antipsychotic tranquiliser to that child he diagnosed with conduct disorder; there was no critical review of that medication for years to follow. That GP worked for the Aboriginal Congress. And yet, he was doing what he was taught to do with the tools the system endorsed, which were endorsed by his organisation.

JL: How does a “politics of exclusion” operate in the current Australian Government Medicare and Pharmacology scheme?

PLV: To talk about exclusion is to talk about oppression – something a civilised government would deflect discussing.  The term “civilized oppression” was coined by the sociologist Jean Harvey in a book by that title. She shows how processes of oppression occur in subtle everyday ways because they’re embedded in everyday norms, habits, and social symbols that are not to be questioned. For instance, few question the insertion and display of a Christian cross on sacred land because it has become part of the landscape that emerged from assimilation processes and policies that took root. Before and after get smudged. Similarly the language used in policy development waters down (if not white washes) the facts.  If you go into Wikipedia and review the term “hooding”, you’ll discover it is a torture device. And yet the term “spit” conveniently changes the perpetrator dynamic in the practice of hooding. The term ‘spithood’ implies the child is the perpetrator and the hooder is the victim in need of protection. Social pressure is put on the child to apologise publicly for spitting. The context by which force that removed all agency from a child who spits is never under review and members of that system are freed from their apology to the child.Torture is torture, plain and simple. And the term, “restraint” is interesting, too.  The cases I reviewed involved physical force and chemical force. To say restraint, again, shifts the victim-perpetrator dynamic such that the person who received the abusive force was in need of restraint. This type of mentality often justifies abuse. Force is force.

Sadly, civilised oppression is pervasive. Not even the Royal Commissioners – after all the human rights violations they  witnessed – challenged the Medicare system of mental health.  The term “wellbeing” might as well be spray painted graffiti on a rusted truck in the Clay Pans for Indigenous communities in Alice Springs. After all, “mental” illness labels are increasingly greasing the wheels of shiny new cars that take people further and further away from Country.

Our government bases its mental health Medicare bulk bill scheme on “evidence-based” data that is culturally biased – and demoralising. Basically, the primary mental illnesses funded by Medicare were determined by population norms that excluded Aboriginal people – urban and remote. On top of that, Aboriginal Community Controlled Health centres have become economically dependent on bulk bill schemes for mental health.

In 2017, I watched how the clinical psychology team’s membership and protocols were restructured at the Central Aboriginal Congress. The disproportionate growth in clinical psychologists who are funded under the Medicare scheme moves forward a more pronounced system of tokenism. Aboriginal specialists are not funded equally and so their presence is eroding, as it is considered that they are not a good economic investment. Equal representation is needed alongside equal pay or the tokenistic system will remain. Indigenous wellbeing perspectives can’t work in a class system where one-lone Indigenous specialist is assigned to “mental health” case meetings so an agency can appear culturally inclusive. We need an urgent review into the cultural reliability of our “evidence-based” data that informs our mental health Medicare bulk bill scheme, including those mental illness categories funded by Medicare, which are connected to treatment protocols – including forced sedation. If evidence-based were to include population norms that include Aboriginal people – urban and remote – then Aboriginal Community Controlled Health could function as originally intended.

Right now, two schemes – Medicare and Pharmacology – go hand-in-hand to potentially decrease social power in Indigenous youth.  When an Aboriginal child is placed on psychoactive medications, onlookers such as educators, social workers, police, justice workers, families, lawyers often point to harder evidence that the child has a “mental disability” – which compounds her or his minority status in the scape of Australian culture and leaves the child vulnerable to more frequent mistreatment and greater class oppression. This is what I mean by the politics of exclusion.

JL: So what if we diagnosed children with Posttraumatic Stress Disorder (PTSD) more regularly and then treated them?

PLV: Well, it is rare that a trauma-responsive assessment is the first port of call for an Aboriginal child. And I contend that being trauma-informed is different from trauma-responsive. Since the Royal Commission, the term trauma-informed is the rage; suddenly staff in detention centres are required to “attend a mandatory agency workshop on trauma” so they can become informed when what children need is a responsive staff and responsive care.  As it now sits, the term ‘trauma-informed’ is a government or agency box ticker. Let me explain. Even if a child’s history of witnessing and/or experiencing violence and poverty is considered – as current “trauma-informed” schemes should require – the child still ends up with a mental illness called PTSD. That is probably better than a ‘conduct’ disorder since those symptoms cluster under complex trauma. The reality, however, is once a mental illness is entered into the database for Medicare funding purposes, the pharmacology scheme is primed too. And population data on Indigenous mental illnesses is impacted. In the multiple reports I reviewed, Indigenous children were likely to be put on anti-depressants and/or various tranquilisers used for psychosis – even when trauma was mentioned.

Image: One of LeVine’s clients at a smoking “welcome to Country”. LeVine says the boy was removed from his country and language at a young age and placed “on heaps” of medication. No health worker ever thought of what it would mean for him to be welcomed. He said it was the best day of his life because they were “kind to me”. Photo: Supplied

JL: You told me that some of your colleagues have advised you to give up your push to have your Royal Commission report acknowledged formally, since your report is published. Why don’t you take their advice?

PLV: The easy answer is that I have a duty of care as a human being, clinician and researcher to assist the Universal Declaration of Human Rights Article 27, where “Everyone has the right to freely participate in the cultural life of the community … to share in scientific advancement and its benefits.”  I see these rights violated by the very fact that “cognitive” sciences and therapies have been advanced by a paucity of Aboriginal-normed studies.

We need to scrutinise our “evidence-based therapies” that are delivered to Aboriginal people and safeguard against those that “exclude” Indigenous theories of consciousness and ecological well-being. Equally, we need to examine the delivery of “healing” methods framed as “trauma-informed” or “community-informed” as some I have reviewed lack sound assessment processes and culturally-reliable health research.

Above all, I have an ethical responsibility to the Indigenous young man who told me what happened to him, particularly after I reviewed the hospital records in his case. I recall clearly the day we went walking along the dehydrated Todd river in Alice Springs. His voice and body were trembling when telling me about “getting the settlement needle”.

I had not heard that term before that day. I knew the term “forced sedation” that Canadian First Nation people use to describe their experiences with police and how that term has been used by coroner reviews of deaths in custody. However, the word “settlement” reverberates in “sub-Mission” history.

I met this young man mostly in outdoor natural space – particularly since he had been traumatised and tortured in confined spaces. The hospital was not the first institutional setting where he had experienced extreme fear, helplessness and being alone. He had been in Don Dale and was too scared to tell his story aloud during the Royal Commission hearings. And yet his story matched the story of another young man who had been assigned to detention. Their childhood histories held similar threads – and by the time they are 8 years of age, they adopted the flight/fight patterns seen in veterans after exposure to cruelties of war. But the Indigenous children’s deviant behaviours were not held in the context of war survival – despite these boys trying to survive everyday with only a child’s defence capacity in a social and health system steeped in hostility and class bias.

We know that war veterans use numbing substances like alcohol and marijuana and exhibit socially unruly behaviours; their actions are usually considered in a trauma context. But when an Aboriginal child is sent to a physician or psychologist – inside or outside a community-controlled organisation – for being socially unruly, the American-centric system of mental disorders  is used to cluster symptoms into “mental” illnesses. Usually attention-deficit disorder and/or conduct disorder are assigned by the age of 9; most children I reviewed were put on psychoactive medications without formal consideration of the impact on their hormonal, emotional, and developmental wellbeing.  I saw little to no evidence of contextual trauma being reviewed carefully and insightfully, or insight into how a clinician’s closed door practice could impact feelings of safety and symptom presentation.

JL: You’ve previously suggested that there may well be a pattern of chemical restraint contributing to Aboriginal deaths in custody. What might an inquiry looking into chemical restraint in that context consider, and why?

PLV: If we fail to widen the range of possible risks when investigating Aboriginal deaths in custody, we fail Aboriginal victims and their families. I think there is a direct link to forced sedation and deaths that is not being considered routinely.

When there is a death in custody, administration of “settlement needles” needs to be reviewed carefully with an inquiry that looks beyond dose and type of psychoactive medication. A critical unbiased review of  the sequence of events before, during and after administration of the drugs needs to be standard practice.  My proposed range extends far beyond the imaginations of most coroners, physicians, and well meaning health professionals and lawyers.

I came to my conclusions after reviewing sequenced details of one of my Aboriginal clients, including hospital notes secured through freedom of information consent. I wanted to understand the circumstances by which my client came to be injected forcefully in the van and hospital with psychotropic sedatives. I wanted to know the sequence of chemical and physical restraint that contributed to his memory loss over the 24-hour period during and after his release from hospital, including his memory loss while in the police holding cell.

He reported to me that three days after the forced sedation, he was scared because he could not control his shaking (tremors), his speech (slurred speech), and weird body movements (extrapyramidal side effects), including twisted posture (dystonia); collectively, these symptoms are often associated with improper dosing of, or unusual reactions to neuroleptic/antipsychotic medications. He reported loss of memory and other side effects that spanned his custody period. I was unable to find documentation of a medical review. There was no follow-up recommended in the hospital release documents I read.

The harrowing question became more and more pressing: How might procedures such as these be related to an Aboriginal person’s death in custody?

Such a kind of question is more standard in my international work in genocide, torture and trauma because I document unimaginable acts of human cruelty in my research and clinical practice. My client survived to tell his story so that the sequenced history could be tracked. But what about other Aboriginal people treated as guilty before proven innocent by police who make allegations to hospital staff who then act accordingly?  In the case of my client where his hands and feet were cuffed with sedatives and psychoactive drugs injected without consent or Indigenous consult – he was released wobbly by the hospital into the custody of police while drifting in and out of consciousness. In such a state he was put in a cell without any on-going medical monitoring. That, I claim, is a recipe for death. He was a lucky victim-survivor.  This is a time to pause and review impartially, rather than another policy intervention to “develop guidelines” for so-called chemical restraint.

Deaths in custody risk factors related to chemical and physical force seem to range across five dimensions: Adverse reaction to medication that leads to heart or respiratory failure; fatal falls related to unsteadiness connected to neurological drug action and/or overdose; a self-inflicted suicide act that leads to death; homicidal act that gets framed as suicide or fatal fall or drug reaction, or “causes unknown”.

Suicide by hanging in detention centres is well documented.  In any death in custody, we need to finely document the sequenced human-dynamic exchanges preceding that type of death. I cannot emphasise enough the need for a standard practice following any Aboriginal death in custody to include a detailed “sequenced” review of events by an unbiased committee. Without such a review, social ills will roam free. This is a time to pause before concluding again that an Indigenous person has a “mental” illness, without equally assessing and treating social illnesses and acts of human cruelty. In that context, homicide has to be seriously considered before “unknown causes” is registered.

I realise that homicide is a blasphemous thing to imagine, think and propose. After all, we want to think that such things only happen to victims who lived under the Khmer Rouge or Nazi forces, or in detention in Guantanamo Bay. Unless we take it as our ethical responsibility to peel back the social taboos in order to investigate cases of deaths in custody we will have failed in our duty of care.

Again and again, global history has shown unimaginable acts of cruelty being endorsed by – or covered up by – those who hold social power across political, justice, and religious institutions – in the name of “shaping a civil society”.

JL: Surely this issue must have come under scrutiny in past reports of the experiences of Aboriginal people in detention?

PLV: Have a look at Chapter 8 Custodial Concerns in the 1996 report Indigenous Deaths in Custody that followed the 1991 RCIADIC report. The ’96 report published by the Office of the Aboriginal and Torres Strait Islander Social Justice Commissioner cites one condition related to “Aboriginal deaths in police cells and vans” and points to the paucity of proper assessment procedures. The report makes passing mention of the Royal Commission’s recommendations on medication 152g (vii) and states, “In the case of the juvenile who died at Sir David Longlands Prison, the family believed that the deceased was being over-sedated (34QLD)”.

There needs to be more than passing comment. There needs to be a formal and impartial review into chemical restraint.