Sascha Callaghan | The University of Sydney (original) (raw)
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Papers by Sascha Callaghan
The Australian and New Zealand journal of psychiatry, Jan 24, 2015
Australian & New Zealand Journal of Psychiatry, 49(9) Prevention of autoenucleation is key; m... more Australian & New Zealand Journal of Psychiatry, 49(9) Prevention of autoenucleation is key; mental health practitioners should be alert to delusions about eyes (Large and Nielssen, 2012) and regularly assess a patient’s risk of self-harm or self-mutilation. Once autoenucleation has occurred, ongoing psychiatric review and close observation are required to prevent further self-harm. Declaration of interest
The recent report of case of a pregnant woman who refused life-saving cancer treatment while heav... more The recent report of case of a pregnant woman who refused life-saving cancer treatment while heavily pregnant has once again ignited debate within the community about how we should resolve conflicts between a mother's rights and those of her unborn child.
![Research paper thumbnail of Suicide Risk Assessment: Where Are We Now?[Letter]](https://attachments.academia-assets.com/72464438/thumbnails/1.jpg)
](We applaud Ryan and Large for their timely editorial reviewing suicide risk factors. 1 We agree t... more We applaud Ryan and Large for their timely editorial reviewing suicide risk factors. 1 We agree that, with current knowledge, we do not know how to combine risk factors to produce a reliable predictor of suicide risk in the short to medium term. However, we note that many risk factors for suicide are also risk factors for suicide attempts. 2 For adolescents, attempts occur at a rate of between 400 and 3000 for each suicide. 3 Therefore, detection of suicide risk factors also contributes to identifying those who are at risk of attempting suicide, something not discussed by Ryan and Large. Suicide attempts lead to medical morbidity and family suffering and are a considerable burden on emergency departments. 4 We find Ryan and Large's advice that, "here and now, clinicians should not be conducting 'comprehensive suicide risk assessments'" problematic. They do not provide a meaningful alternative. We are concerned that medical practitioners who read the editorial will abandon asking about suicide altogether. We are unclear what the authors define as constituting "psychological crisis" and wonder how feasible it would be for general practitioners to make crisis plans with possibly a large number of their patients. We are also interested in the opinion of medical indemnity organisations regarding the authors' advice to not conduct comprehensive risk assessments, in the event that a patient who presents with suicidal thinking comes to any harm.
Objective: To analyse, and explain to Australasian psychiatrists, recent proposed changes to the ... more Objective: To analyse, and explain to Australasian psychiatrists, recent proposed changes to the terms of coercive treatment for mental illness in Tasmania and Victoria and to place the proposals in the context of a broader human rights framework that is likely to impact the future shape of mental health legislation more generally.
Methods: The Australian law reform proposals are reviewed against the requirements of numerous human rights instruments, including the recently ratified United Nations Convention on the Rights of Persons with Disabilities. Ethical and legal arguments are made to support the proposed changes and to introduce others, taking into account academic commentary on mental health law and recent empirical work on the ability to usefully categorise patients by their likelihood of harm to self and others.
Results: The Victorian and Tasmanian draft mental health bills propose a new basis for compulsory psychiatric treatment in Australasia. If they become law, coercive psychiatric treatment could only be applied to patients who lack decision-making capacity. The Tasmanian draft bill also sets a new benchmark for timely independent review of compulsory treatment. However both jurisdictions propose to retain an ‘additional harm’ test which must be satisfied before patients may be treated without consent. This differs from non-psychiatric cases, where if patients are unable to consent to medical treatment for themselves, they will be entitled to receive coercive treatment if it is in their best interests.
Conclusions: The proposed changes under the Tasmanian and Victorian draft mental health bills will ensure that, in line with local and international human rights obligations, only patients who lack decision-making capacity may be coercively treated for mental illness. However the continuing ‘additional harm’ criteria may breach human rights obligations by imposing a discriminatory threshold for care on patients who are unable to consent to treatment for themselves. This could be avoided by replacing the ‘additional harm’ test with a ‘best interests’ test.
First paragraph ... In 2012 we reported that Australian mental health legislation was on the verg... more First paragraph ...
In 2012 we reported that Australian mental health legislation was on the verge of a revolution. That revolution has begun. It has been clear for some time that the criteria for detention and involuntary treatment for mental illness would need to be revised and remodelled in light of the requirements of the United Nations Convention on the Rights of Persons with Disabilities (‘CRPD’). Article 12, one of the key provisions of the CRPD, requires states parties to replace involuntary treatment provisions in mental health laws with a new model of ‘supported decision-making’. While there is still some debate about exactly what a supported decision-making model would entail in mental health, in broad terms it requires that treatment decisions must be made by the person themselves as often as possible – rather than through involuntary orders made by doctors and tribunals – with support being made available to assist the person in making decisions if they wish. It also requires that substituted decision-making, including via involuntary treatment orders, may occur only in very limited circumstances, if indeed it is to be permitted at all. In any case, substituted decisions must reflect the person’s known ‘will and preferences’ (using the language of the CRPD) rather than paternalistic formulae such as the ‘best interests’ tests traditionally used in guardianship schemes.
Objective: In some Australian states clinicians and mental health tribunal members are already re... more Objective: In some Australian states clinicians and mental health tribunal members are already required to assess a person’s decision-making capacity before involuntary treatment can be applied. Professionals in other jurisdictions will likely soon be required to do the same as mental health law reform in most Australian jurisdictions makes the assess- ment of decision-making capacity a central component of the process of providing unconsented psychiatric treatment. We provide a guide to the legal issues around the capacity to refuse psychiatric treatment to assist with this task.
Method: We review the legislation in the four Australian states most advanced in the mental health law reform pro- cess and use examples from clinical practice and the common law to describe how decision-making capacity should be assessed by these statutory standards.
Results: Clinicians and tribunal members will primarily be required to judge whether a person with mental illness can understand the information relevant to the treatment decision and whether he or she can use or weigh that information to come to a decision. A person with a mental illness is presumed to have capacity, but that presumption can be rebut- ted. Capacity is specific to the decision at hand and cannot be determined by the nature of the decision made.
Conclusions: The information provided should assist clinicians and tribunal members to make determinations of deci- sion-making capacity around treatment refusal in the context of mental illness.
Involuntary psychiatric treatment is currently permitted in all Australian jurisdictions. In alm... more Involuntary psychiatric treatment is currently permitted in all Australian jurisdictions. In almost all, Tasmania being a recent exception, this is so regardless of the person’s ability to make his or her own decisions about treatment. In recent years mental health legislation has come under pressure from several quarters, most urgently, as a result of Australia’s ratification of the United Nations Convention of the Rights of Persons with Disabilities. While interpretation of the Convention is not yet settled, the UN High Commissioner for Human Rights and the UN Disabilities Committee have both indicated that supported decision-making regimes must be instituted in place or substituted decision-making arrangements and that involuntary treatment is no longer permissible under the CPRD.
This article argues that in order to give effect to the provisions of the CRPD, new supported decision-making regimes must be incorporated into mental health legislation but that these must admit a limited role for substituted decisions, including involuntary treatment, where a person lacks decision-making capacity. We argue that such a scheme can, and must, respect the rights, will and preferences of the person affected. Furthermore, we suggest that failing to account for it in law will jeopardise rights more than it protects them.
Mental health laws in many jurisdictions currently permit coercive treatment for persons with men... more Mental health laws in many jurisdictions currently permit coercive treatment for persons with mental illness who are thought to be at risk of harm to themselves or others. These laws are often used to provide involuntary treatment to persons who are thought to be at risk of suicide. In this article we argue that legislated coercive psychiatric treatment should not be triggered by an assessment of the likelihood of harm, including a likelihood of suicide, but should be available only where a person is found to lack capacity to make their own decisions about their own health risks, after appropriate support has been given. We suggest that current opposition to this approach may find its origin in factors including uncertainties about the idea of vulnerability and its relationship to capacity as well as tendency to minimise the real costs of psychiatric treatment and coercion against the aim of suicide prevention. Given the limits of suicide risk assessment, we argue that a public policy that allows involuntary preventative detention of competent persons thought to be at risk of suicide, places too great a burden on all persons living with mental illness to be justified. We suggest that we are better placed to serve the interests and respect the human rights of people with mental illness if we respect and support the right of persons to make decisions, rather than focussing on perceived vulnerabilities and calculations of suicide risk.
Australian and New Zealand Journal of Psychiatry, 2012
The Full Court of the Australian Family Court dealt with an application to intervene in a case of... more The Full Court of the Australian Family Court dealt with an application to intervene in a case of transsexualism treatment for children in Re Jamie [2012] FamCAFC 8. Jamie was born a nonidentical twin and was genetically male. However, when Jamie was two and a half years old, she began to identify as a female. By the time she started school, she lived exclusively as a female, wore girl's clothes, went to the girl's toilet, and was treated by her teachers and classmates as a girl.
Objective: The purpose of this paper is to use the circumstances surrounding the trial of Antony ... more Objective: The purpose of this paper is to use the circumstances surrounding the trial of Antony Waterlow to consider the statutory mechanisms for coercive treatment of people with mental illness in Australasia. Method: The facts in R v Waterlow are examined in the light of a review of Australasia's mental health legislation and recent empirical work on the ability to usefully categorise patients by their likelihood to harm others.
The Australian and New Zealand journal of psychiatry, Jan 1, 2012
Matthew Large, Christopher James Ryan, Sascha Callaghan (2012), Hindsight bias and the overestima... more Matthew Large, Christopher James Ryan, Sascha Callaghan (2012), Hindsight bias and the overestimation of suicide risk in expert testimony, The Psychiatrist [Letter]
The Australian and New Zealand journal of psychiatry, Jan 24, 2015
Australian & New Zealand Journal of Psychiatry, 49(9) Prevention of autoenucleation is key; m... more Australian & New Zealand Journal of Psychiatry, 49(9) Prevention of autoenucleation is key; mental health practitioners should be alert to delusions about eyes (Large and Nielssen, 2012) and regularly assess a patient’s risk of self-harm or self-mutilation. Once autoenucleation has occurred, ongoing psychiatric review and close observation are required to prevent further self-harm. Declaration of interest
The recent report of case of a pregnant woman who refused life-saving cancer treatment while heav... more The recent report of case of a pregnant woman who refused life-saving cancer treatment while heavily pregnant has once again ignited debate within the community about how we should resolve conflicts between a mother's rights and those of her unborn child.
We applaud Ryan and Large for their timely editorial reviewing suicide risk factors. 1 We agree t... more We applaud Ryan and Large for their timely editorial reviewing suicide risk factors. 1 We agree that, with current knowledge, we do not know how to combine risk factors to produce a reliable predictor of suicide risk in the short to medium term. However, we note that many risk factors for suicide are also risk factors for suicide attempts. 2 For adolescents, attempts occur at a rate of between 400 and 3000 for each suicide. 3 Therefore, detection of suicide risk factors also contributes to identifying those who are at risk of attempting suicide, something not discussed by Ryan and Large. Suicide attempts lead to medical morbidity and family suffering and are a considerable burden on emergency departments. 4 We find Ryan and Large's advice that, "here and now, clinicians should not be conducting 'comprehensive suicide risk assessments'" problematic. They do not provide a meaningful alternative. We are concerned that medical practitioners who read the editorial will abandon asking about suicide altogether. We are unclear what the authors define as constituting "psychological crisis" and wonder how feasible it would be for general practitioners to make crisis plans with possibly a large number of their patients. We are also interested in the opinion of medical indemnity organisations regarding the authors' advice to not conduct comprehensive risk assessments, in the event that a patient who presents with suicidal thinking comes to any harm.
Objective: To analyse, and explain to Australasian psychiatrists, recent proposed changes to the ... more Objective: To analyse, and explain to Australasian psychiatrists, recent proposed changes to the terms of coercive treatment for mental illness in Tasmania and Victoria and to place the proposals in the context of a broader human rights framework that is likely to impact the future shape of mental health legislation more generally.
Methods: The Australian law reform proposals are reviewed against the requirements of numerous human rights instruments, including the recently ratified United Nations Convention on the Rights of Persons with Disabilities. Ethical and legal arguments are made to support the proposed changes and to introduce others, taking into account academic commentary on mental health law and recent empirical work on the ability to usefully categorise patients by their likelihood of harm to self and others.
Results: The Victorian and Tasmanian draft mental health bills propose a new basis for compulsory psychiatric treatment in Australasia. If they become law, coercive psychiatric treatment could only be applied to patients who lack decision-making capacity. The Tasmanian draft bill also sets a new benchmark for timely independent review of compulsory treatment. However both jurisdictions propose to retain an ‘additional harm’ test which must be satisfied before patients may be treated without consent. This differs from non-psychiatric cases, where if patients are unable to consent to medical treatment for themselves, they will be entitled to receive coercive treatment if it is in their best interests.
Conclusions: The proposed changes under the Tasmanian and Victorian draft mental health bills will ensure that, in line with local and international human rights obligations, only patients who lack decision-making capacity may be coercively treated for mental illness. However the continuing ‘additional harm’ criteria may breach human rights obligations by imposing a discriminatory threshold for care on patients who are unable to consent to treatment for themselves. This could be avoided by replacing the ‘additional harm’ test with a ‘best interests’ test.
First paragraph ... In 2012 we reported that Australian mental health legislation was on the verg... more First paragraph ...
In 2012 we reported that Australian mental health legislation was on the verge of a revolution. That revolution has begun. It has been clear for some time that the criteria for detention and involuntary treatment for mental illness would need to be revised and remodelled in light of the requirements of the United Nations Convention on the Rights of Persons with Disabilities (‘CRPD’). Article 12, one of the key provisions of the CRPD, requires states parties to replace involuntary treatment provisions in mental health laws with a new model of ‘supported decision-making’. While there is still some debate about exactly what a supported decision-making model would entail in mental health, in broad terms it requires that treatment decisions must be made by the person themselves as often as possible – rather than through involuntary orders made by doctors and tribunals – with support being made available to assist the person in making decisions if they wish. It also requires that substituted decision-making, including via involuntary treatment orders, may occur only in very limited circumstances, if indeed it is to be permitted at all. In any case, substituted decisions must reflect the person’s known ‘will and preferences’ (using the language of the CRPD) rather than paternalistic formulae such as the ‘best interests’ tests traditionally used in guardianship schemes.
Objective: In some Australian states clinicians and mental health tribunal members are already re... more Objective: In some Australian states clinicians and mental health tribunal members are already required to assess a person’s decision-making capacity before involuntary treatment can be applied. Professionals in other jurisdictions will likely soon be required to do the same as mental health law reform in most Australian jurisdictions makes the assess- ment of decision-making capacity a central component of the process of providing unconsented psychiatric treatment. We provide a guide to the legal issues around the capacity to refuse psychiatric treatment to assist with this task.
Method: We review the legislation in the four Australian states most advanced in the mental health law reform pro- cess and use examples from clinical practice and the common law to describe how decision-making capacity should be assessed by these statutory standards.
Results: Clinicians and tribunal members will primarily be required to judge whether a person with mental illness can understand the information relevant to the treatment decision and whether he or she can use or weigh that information to come to a decision. A person with a mental illness is presumed to have capacity, but that presumption can be rebut- ted. Capacity is specific to the decision at hand and cannot be determined by the nature of the decision made.
Conclusions: The information provided should assist clinicians and tribunal members to make determinations of deci- sion-making capacity around treatment refusal in the context of mental illness.
Involuntary psychiatric treatment is currently permitted in all Australian jurisdictions. In alm... more Involuntary psychiatric treatment is currently permitted in all Australian jurisdictions. In almost all, Tasmania being a recent exception, this is so regardless of the person’s ability to make his or her own decisions about treatment. In recent years mental health legislation has come under pressure from several quarters, most urgently, as a result of Australia’s ratification of the United Nations Convention of the Rights of Persons with Disabilities. While interpretation of the Convention is not yet settled, the UN High Commissioner for Human Rights and the UN Disabilities Committee have both indicated that supported decision-making regimes must be instituted in place or substituted decision-making arrangements and that involuntary treatment is no longer permissible under the CPRD.
This article argues that in order to give effect to the provisions of the CRPD, new supported decision-making regimes must be incorporated into mental health legislation but that these must admit a limited role for substituted decisions, including involuntary treatment, where a person lacks decision-making capacity. We argue that such a scheme can, and must, respect the rights, will and preferences of the person affected. Furthermore, we suggest that failing to account for it in law will jeopardise rights more than it protects them.
Mental health laws in many jurisdictions currently permit coercive treatment for persons with men... more Mental health laws in many jurisdictions currently permit coercive treatment for persons with mental illness who are thought to be at risk of harm to themselves or others. These laws are often used to provide involuntary treatment to persons who are thought to be at risk of suicide. In this article we argue that legislated coercive psychiatric treatment should not be triggered by an assessment of the likelihood of harm, including a likelihood of suicide, but should be available only where a person is found to lack capacity to make their own decisions about their own health risks, after appropriate support has been given. We suggest that current opposition to this approach may find its origin in factors including uncertainties about the idea of vulnerability and its relationship to capacity as well as tendency to minimise the real costs of psychiatric treatment and coercion against the aim of suicide prevention. Given the limits of suicide risk assessment, we argue that a public policy that allows involuntary preventative detention of competent persons thought to be at risk of suicide, places too great a burden on all persons living with mental illness to be justified. We suggest that we are better placed to serve the interests and respect the human rights of people with mental illness if we respect and support the right of persons to make decisions, rather than focussing on perceived vulnerabilities and calculations of suicide risk.
Australian and New Zealand Journal of Psychiatry, 2012
The Full Court of the Australian Family Court dealt with an application to intervene in a case of... more The Full Court of the Australian Family Court dealt with an application to intervene in a case of transsexualism treatment for children in Re Jamie [2012] FamCAFC 8. Jamie was born a nonidentical twin and was genetically male. However, when Jamie was two and a half years old, she began to identify as a female. By the time she started school, she lived exclusively as a female, wore girl's clothes, went to the girl's toilet, and was treated by her teachers and classmates as a girl.
Objective: The purpose of this paper is to use the circumstances surrounding the trial of Antony ... more Objective: The purpose of this paper is to use the circumstances surrounding the trial of Antony Waterlow to consider the statutory mechanisms for coercive treatment of people with mental illness in Australasia. Method: The facts in R v Waterlow are examined in the light of a review of Australasia's mental health legislation and recent empirical work on the ability to usefully categorise patients by their likelihood to harm others.
The Australian and New Zealand journal of psychiatry, Jan 1, 2012
Matthew Large, Christopher James Ryan, Sascha Callaghan (2012), Hindsight bias and the overestima... more Matthew Large, Christopher James Ryan, Sascha Callaghan (2012), Hindsight bias and the overestimation of suicide risk in expert testimony, The Psychiatrist [Letter]