Involuntary Detention of Patients Suffering from Mental Health Disorders - Essay Example

Involuntary Detention of Patients Suffering From Mental Health Disorders Involuntary detention allows people in imminent danger of harming themselves or others to be admitted to a psychiatric facility against their will. Ultimately, individuals could be confined who are deemed threatening to the social or political order. The perceived need for involuntary detention arises out of a social contract, wherein the State and the profession of psychiatry join forces to protect the public from individuals who are seen as both terrifying and burdensome. Involuntary detention presently benefits neither the mentally ill, nor the public at large, whose safety is not enhanced. Ideally, the practice of involuntary commitment would evolve as a balance between civil freedom and the need to care for those who could not adequately manage their own safety. Involuntary Detention of Patients Suffering From Mental Health Disorders There is an increasing interest in an international code of ethics and set of standards for the use of State and professional power to care for individuals with mental illness (Belkin, 2004). In recent years there has been a marked increase in the proportion of individuals with mental disorders detained in hospital involuntarily, compared to those admitted on an informal basis.1 Over the centuries, acceptable use of psychiatric expertise to justify forced detention and hospitalization has been center stage to the efforts of either celebrating or proscribing the power of psychiatrists' asserted knowledge.2 The establishment of the asylum itself was part of a significant 19th-century shift from the use of religious authority in politics to the development of humanitarian objectives for government. 3 The union between mental health practices and expectations for the organisation of political and social life is progressively more articulated in the expanding authority and legality of human rights discussion and institutions.4 The care of people with psychiatric disorders is changing. Where long-term stays in asylums used to be the staple of the mental health system, the political focus has now shifted to care in the community and a breaking down, both symbolically and physically, of the walls of the psychiatric hospital (Bartlett & Sandland, 2003).5 And, the law is also changing with a new Mental Health Bill published in 2002, which proposes to completely re-write the current system of mental health law. Proposals have been put forward to extend the legal controls over persons with severe personality disorders who are perceived as dangerous.6 Hopefully, new legislation will promise greater protection of the human rights of individuals with mental health disorders. The fundamental dilemma in mental health is that of balancing the individual's autonomy and civil liberties with the desired need to protect both the individual and the public from perceived threat or risk.7 For individuals who work in mental health care and for those who live with a mental health illness, our work and our lives intersect with the legal system around a complex and delicate decision-making process (Curtis, 2001). In certain situations, people with a mental illness can be forcibly admitted to a psychiatric hospital or institution against their will (Goldbeck & Mackenzie, 1997).8 This process of involuntary commitment essentially allows any person that is in imminent danger of harming himself or someone else to be admitted to a psychiatric hospital against his will or over his protests. The notions of voluntary and involuntary are not distinguished in black and white, but include many shades of grey. There is a continuum of voluntary to involuntary, which could be described as follows: active cooperation, passive cooperation, ambivalence, silent objection, irrational opposition, and rational refusal (Cahn, 2006; Gratzer & Matas, 1994; Hiday & Goodman, 1982; Kapp, 1994). A patient might move along this continuum in either direction during the course of his illness. Furthermore, the patient might accept some treatments, refuse others, or change his mind with due process. Models of community-based treatment have helped shape the current law which is based on the idea that someone cannot be detained or confined without an extremely good cause. It also limits the duration of involuntary commitment, and ensures that no one individual may make commitment decisions. Currently, the standard for commitment is based on how dangerous the mentally ill person is.9 The mechanism of involuntary commitment is also open to abuse as a method to confine individuals who are threatening to the social or political order. Psychiatric wills are advance directions for an eventual involuntary treatment in psychiatry.10 From a civil rights perspective, involuntary commitment creates a class of people who, at the discretion of a police officer, can be taken briefly into police custody and then placed in a sort of preventive detention, or what amounts to as involuntary incarceration (Curtis, 2001). The need for involuntary detention arises out of a social contract, wherein the State and the profession of psychiatry join forces to protect the public from a group of people who are seen as both terrifying and burdensome. In practice, however, people continued to be committed involuntarily for reasons having more to do with social control than psychiatric treatment. Is there any evidence that persons with mental illness are actually more dangerous to others than random members of the general public These questions are starting places for looking beyond common assumptions about role that involuntary incarceration plays in the interplay between civil rights and civil protections.11 Furthermore, relatives of mentally ill patients often wish involuntary treatment far more than any other group of interested persons (Cahn, 2006; Lawrie, 1999). 12 Presently, in a climate where the rights of the individual have encroached so heavily on the rights of others, relatives frequently suffer the most from threatening, frightening, and/or frustrating behaviour of the mentally ill individual. In the past, it was much more acceptable to take the problems caused by patients out of the hands of relatives by having the patient hospitalized, sometimes for long periods of time. Today, with the shorter duration of stay in hospital, patients are more likely to be repeatedly troublesome to their relatives.13 In general, once the person is under involuntary detention, treatment may be instituted without further requirements. The Mental Health Act (1983) allows involuntary treatment of the individual if he is suffering from a mental disorder which is expressed to a degree that it is appropriate to receive medical treatment, and treatment is necessary in the interests of health or safety of the patient or for the protection of other individuals in society (Royal College of Psychiatrists, 1997; Schering Health Care, 1983). 14 Few would argue that when there is an actual or obvious danger to self or to others due to an individual's mental illness, involuntary detention and treatment is necessary.15 Arguments surface, however, when one considers the nature of the detainment, the kind of treatment is indicated, and situations when the danger seems less obvious. As long as it is statistically proven that psychiatrists are no better than others in predicting dangerousness, it is likely that the law will not allow psychiatrists to restrict the liberty of patients to refuse treatment on the basis of potential danger alone. Only in the cases of patients who repeat the same patterns of dangerous behaviour and which respond favourably to psychiatric treatment but have reoccurrence of these behaviours when the patient discontinues such treatment may there be justification in treating a patient against his will on a preventive basis. La Fond (1992) remarks that: "States may use police power to enact laws empowering public officials to forcibly confine any citizen considered mentally ill and dangerous to others or to himself. In modern times this special system of social control, which amounts to 'preventive detention,' has generally been applied almost exclusively to the mentally ill. The criminal justice system assumes a citizen is innocent until proven guilty and generally will only incarcerate an individual who is convicted of a crime or to ensure an accused's presence at trial. In sharp contrast, the coercive mental health system confines a mentally ill person because a mental health expert predicts that, unless restrained, the mentally ill person will commit a dangerous act--such as committing suicide or assaulting an innocent person--sometime in the future." (p., 25) The fundamental question is why we take one group of people, those labelled with mental illness, and deny them the basic rights that other citizens take for granted How ethically justifiable is it to confine people against their will, to subject them to procedures against their will, or to overrule their life choices on the basis of an apparent medical diagnosis (Chamberlin, 1994) The ethical system that drives the involuntary detention is founded on the idea that the group in power knows what is best for another group, the one lacking power. Chamberlin (1994) notes that in the history of our civilization, people in power say that they know what is best for those they rule over, even if those unfortunate individuals think they know best what they want.16 Those who would overrule, on the basis of "incompetence," the dreams of others, are usually concerned with safety issues, and pay little regard to happiness. Chamberlin (1994) goes on to argue that if we are truly concerned with protecting people we may deem to be incompetent, should not we also protect their right to pursue happiness as well as their right to be safe She further questions that if there are so many other forms of power; why is this goal only reachable through coercion Many of the people who are subjects of coercive psychiatry already have been subject to trauma. Involuntary detention and/or treatment exacerbate post-traumatic stress, and may in and of itself create that syndrome. Psychiatric institutions have a long history of functioning as quasi-jails for individuals who have been admitted involuntarily or "committed" or who have been charged as criminals but have been found to be too mentally ill to be cared for in prisons or other detention centres (Cahn, 2006). There is still the problem, however, of the use or perhaps abuse of psychiatric facilities for the detention of persons considered mentally ill by the public as an acceptable alternative to imprisonment.17 As Chamberlin (1994) points out, it is the task of the persecuted to reveal their oppression; it should not also be their task to develop alternatives. Psychiatric diagnosis is a process of denying the real meaning that supposedly dysfunctional behavior has to the individual. What is really helpful is the process of helping the person to understand that thoughts, feelings, and emotions do have meaning within the context of that person's own life and experiences. Unlike involuntary psychiatric detainment and forced treatment, this kind of individualized help is impossible without the active involvement of the individual being helped. People who take responsibility for their own recovery are ultimately the ones who get well. Choice is essential. The public tends to regard hospitalization as a treatment in itself.18 The belief that involuntary treatment or detention will further improve the patient's mental condition remains a highly controversial issue. Certainly it is ethical to treat involuntarily patients who are in overt distress because of their illness, such as in the case of severe depression or paranoid delusions. But, the more ethical approach is for the psychiatrist to allow the patient to make some decisions for himself, or at least to have a continuing dialogue with the patient to try to persuade him to accept treatment on a voluntary basis (Cahn, 2006). There is also a growing concern about legally incompetent patients being treated under the doctrine of necessity (Eastman & Peav, 1998). The increase in the numbers of detained patients may have come about for a variety of reasons, including a reduction in psychiatric hospital beds, the trend towards community care and the consequent tendency to keep patients at home for longer, the increasing co-morbidity and more severely disturbed behaviour on hospital wards, and the rise in individuals transferred to hospital care from the criminal justice system (Mental Health Act Commission, 1999). For some individuals suffering from certain forms of mental disorder, involuntary detention and compulsory treatment are major and important means of accessing the care that they require (Humphries, Kenney-Herbert & Cope, 2006). The Mental Health Act 1983 bestows upon medical practitioners the power to override the basic autonomy of individuals with mental health disorders in certain circumstances. The onus is bestowed upon the medical practitioner to maintain adequate current knowledge of the relevant legislation, its underlying principles and best practices in its use, and its decided interpretation. Such understanding aids in protecting the rights of those with mental health disorders, as well as, in certain circumstances, increasing the efficacy of medical and/or psychiatric intervention. Only by placing involuntary detention and treatment on a firm and ethical basis will health care professionals and their mentally ill patients be protected from strong societal forces that threaten the very fabric of civil liberty. Psychiatrists have a growing obligation to objectively evaluate the patient's prognosis for behaviour that is dangerous to self or to others before subjecting the patient to involuntary detention and treatment.19 Patients are usually committed under one of the following reasons (Power, 1998; Szmukler & Appelbaum, 2001): as a substitute for hospital admission, to facilitate earlier discharge from hospital or a form of conditional discharge, and to prevent relapse. The use of involuntary detention to prevent relapse in patients with a history of persistent non-compliance and an illness which puts them at risk is particularly difficult. Such orders are likely to be prolonged. Again, a justification in terms of continued incapacity is required. Involuntary treatment should end when the patient stably recovers capacity. Involuntary treatment in the community for patients with capacity for the protection of others is unjustified on any health interest basis (Chamberlin, 1994). In true emergencies, such as the case where a patient's behaviour, due to mental illness, is obviously dangerous to himself or to others, the medical profession has much authority to intervene with therapeutic and preventive measures (Cahn, 2006). In fact, society confers on the physician the obligation to treat the patient until the emergency is over, which may be a matter of minutes, hours, or days, but rarely longer than that. The emergency, of course, may recur, especially if definitive treatment is not instituted. The questions that beg to be asked, however, are: When is the emergency actually over And who, specifically, defines what an 'emergency' is The ethical problem exists, not so much at the beginning of the emergency, but later on: At what point in time is the psychiatrist no longer justified in treating the patient without a valid consent (Cahn, 2006) 20 Since so many psychiatric patients are uncooperative or lack insight, the psychiatrist, in making his decisions, may disregard the patient's present attitude to treatment for the sake of obtaining favorable results later on. One questions, however, whether the end justifies the means. Psychiatrists ought to consider carefully the consequences of involuntary detention and treatment, and help explain to the public the difference between involuntary hospitalization or detention and involuntary treatment (Cahn, 2006). Responsibly, psychiatrists must evaluate the equations of the least intrusive versus the most effective treatment, and effective treatment in exchange for loss of freedom. The attending psychiatrist should attempt to have a continuing dialogue with an objecting patient to try to persuade him to accept treatment on a voluntary basis. In emergencies, the attending psychiatrist may promptly carry out all the necessary treatments, but when the emergency is over, he should carefully review with the patient what was done and what still remains to be done. Mental Health Act reform is a key element in current government plans for modernising mental health services in health care (Department of Health, 1998). Current mental health policy is based on the assumption that community care has failed and that too many patients are walking the streets, at risk to both themselves and others. There seems to be an underlying assumption that having a mental disorder necessarily entails mental incapacity.21 In essence, there is a moral panic about the dangers patients suffering from mental health disorders pose to the community, despite evidence that risks to the public from the mentally ill have been decreasing.22 Furthermore, the American Psychiatric Association (1983) reports that even with individuals in which there is a history of violent acts, predictions of future violence will be inaccurate for two out of every three mentally ill patients. Additionally, although the usual justification for forced treatment is lack of insight and the unwillingness of mentally ill individuals to seek treatment voluntarily, it is important to note that several of the individuals involved in highly publicized incidents of violence committed by former patients had been engaged in fruitless efforts to get treatment in the weeks preceding their criminal acts, visiting emergency rooms and clinics, and were being continually turned away. Rather than lacking insight, these individuals sensed their own emotional deterioration, which was apparently invisible to or ignored by those clinicians that came into contact with them. Under all of these circumstances, it is clear that calls for expanded involuntary detention and compulsory treatment benefit neither those who might be subjected to it, those who are traumatized and driven away from voluntary help, nor the public at large, whose safety is not enhanced, and whose tax dollars will go toward making the mental health system even less able to offer the kinds of voluntary programs that enhance community integration. Chamberlin, in her debate with Torrey on involuntary treatment, (The National Empowerment Center, 2006) raises the question as to whether psychiatrists should be able to define people as 'patients' against their will, making it clear that the issues under discussion are more about legal rights and ethics than about medicine. The typical rationalization for involuntary detention and subsequent forced treatment is violence on the part of the individual with serious mental illness. However, not only is violence rare, but according to the American Psychiatric Association (1983), psychiatrists do not possess special knowledge, nor do they have the ability with which to predict dangerous behavior. Szmukler and Holloway (2001) argue that individuals with mental illness are virtually unique in being liable to detention in hospital because they are assessed as presenting a risk of harm to others, but before they have actually committed an offence. Essentially, 'preventative detention' is created to accommodate society's suspicions, stereotypes, and relative discomfort with mental illness in general. One must conclude that if preventative detention is allowed for patients suffering from mental health disorders solely on account of their danger to others, then so should it be for all of us. Otherwise, we have a case of discrimination against those with mental disorders. How is it that this detrimental situation has evolved, and why is it so infrequently challenged23 Mental health legislation supports the stereotype that individuals with mental health disorders are inherently dangerous and the legislation is thus stigmatizing (Szmukler & Holloway, 2001). In fact, the Mental Disability Advocacy Center (2003) identifies an extremely high level of stigma attached to people with mental disability and advocates that individuals with mental illness are among the most abused and neglected people in society. Special attention needs to converge on the enforcement of the mentally ill individual's protection of rights. Involuntary commitment is the most traumatic experience for individuals suffering from mental health disorders and their families, and that the main problem for involuntary commitment was the lack of community services.24 By increasing preventative services such as crisis stabilization units, mobile crisis and outreach, and access to psychiatrists, many episodes of involuntary commitment and treatment might very well be avoided. The Client Services Committee (1999) acknowledged the importance of expanding programs to prevent crises to aid in the reduction of involuntary detention and advised that the following recommendations would be beneficial in staving off involuntary detention of patients with mental illness: increased access to physicians, during both the emergency/crisis phase and throughout the treatment process; collaborative training efforts among public and private providers, judicial officers, law enforcement officers, attorneys and others involved in the process; increased family support in times of crisis through telephone access to service providers and in-home mobile teams; standardized information-sharing among involved providers, other officials, and with families and significant others; development of a system to train and monitor the practices of special justices, attorneys and independent evaluators in the involuntary commitment process; and more emphasis on patient and family education, including psycho-education for individuals regarding self-management of their condition. Gosden and Beder (2001) argue that the development of political agenda-setting through the use of stylish public relations techniques is threatening to destabilize the delicate balance of delegated democracy. This schema has significant implications for policies intended at providing mental health services and the implementation of mental health laws. The key agenda setters in this arena are pharmaceutical companies with commercial reasons to promote public policies that inflate the sales of their products. Pharmaceutical companies have manufactured highly effective advocacy coalitions that integrate front groups in order to set the policy agenda for mental health (Gosden & Beder, 2001). However, policies tailored to their commercial purpose are not necessarily beneficial to either individuals with mental health disorders or society in general. It has been suggested that there three models of agenda building.25 These models include: an outside-initiative model in which citizen groups gain broad public support and get an issue onto the formal agenda; a second model wherein the issues are initiatives that come directly from government and may need to be placed on the public agenda for successful implementation; and third, an inside-access model where the policy proposals come specifically from policy communities with easy access to government, and usually with support from specialized interest groups, but with little public involvement.26 The use of sophisticated public relations techniques for setting political agendas has become a standard practice in most advanced democracies. The consequences are slowly becoming apparent. The system of representative democracy is being reshaped in such a way that public opinion and government policy are custom-made products that can be shaped, packaged and sold by skilled public relations experts. Policies tailored to this commercial purpose are not necessarily advantageous either for patients or the society at large. Gosden and Beder (2001) note that the acute vulnerability of mental health patients to exploitation, and the existence of mental health laws which provide for involuntary detention and treatment of certain classes of mentally disordered people, ultimately manifests conditions that require cautious fortification of civil liberties and human rights. Much is uncertain about the future of mental health services.27 Community care will depend on the strength of public social supports and community attitudes, feelings of safety, and levels of tolerance. Despite the fact that many more people are now willing to seek treatment and mental health care, mental illness remains stigmatized and discrediting.28 Social policy frequently moves in cycles of advancement and retrogression (Mechanic, 2006; see also Appelbaum, 1997). It, therefore, becomes impossible to foresee how the tensions relating to involuntary detention and the identification and treatment of persons with mental illness might play out in the forthcoming years. Ultimately, effective treatment of mental illness will depend on advances in knowledge and technology, and on the social and political factors that guide social policies in general, and mental health policies in particular. Ideally, the practice of involuntary commitment would evolve as a balance between civil freedom and the need to care for those who could not adequately manage their own safety. Involuntary commitment is still necessary in some instances, but it should be a venue of providing treatment to those who refuse out of the fear, hopelessness, and suspicion that a mental illness can bring, and who might not otherwise survive. References American Psychiatric Association. (1983, March 18). Statement on the prediction of dangerousness. Washington, DC. Amering, M., Denk, E., Griengl, H., Sibitz, I., & Stastny, P. (1999). Psychiatric wills of mental health professionals: A survey of opinions regarding advance directives in psychiatry. Social Psychiatry & Psychiatric Epidemiology, 34(1), 30-34. Appelbaum, P.S. (1997). Almost a revolution: An international perspective on the law of involuntary commitment. Journal of the American Academy of Psychiatry & the Law, 25, 135-147. Bartlett, P., & Sandland, R. (2003). Mental health law: Policy and practice (2nd ed.). Oxford: Oxford University Press. Belkin, Gary. (2004). Perspective on involuntary commitment: Looking toward a global debate. Psychiatric Times Global Watch (2004, April). Retrieved on May 3, 2006 from https://education.cmellc.com/html/involuntarycommitment.html Bluglass, R. (1983). A Guide to the Mental Health Act 1983. Edinburgh: Churchill Livingstone. Bottomley, S. (1987). Mental health law reform and psychiatric deinstitutionalization: The issues in New South Wales. International Journal of Law & Psychiatry, 10, 369-382. Cahn, C. (2006, May 2). The ethics of involuntary treatment. Canadian Psychiatric Association. Retrieved May 2, 2006 from http://www.cpa-apc.org/Publications/Position_Papers/Treatment.asp Chamberlin, J. (1994, June 21). The right to be wrong. Speech presented at the Choice and Responsibility: Legal and Ethical Dilemmas in Serving Persons with Mental Disabilities Conference. Albany, NY. Chodoff, P. (1976). The case for involuntary hospitalisation of the mentally ill. American Journal of Psychiatry, 133, 496-501. Cobb, R., Keith-Ross, J., & Ross, M. (1976). Agenda building as a comparative political process. American Political Science Review, 70(1), 126-38. Cope, R. (1995). Mental health legislation. In D. Chiswick & R. Cope (eds.) Seminars in Practical Forensic Psychiatry (pp. 272-309). London: Gaskell. Crichton, J. (1998). The Bournewood judgement and mental incapacity. Journal of Forensic Psychiatry, 9, 513-517. Curtis, Alicia. (2001, December). Involuntary commitment. Retrieved May 2, 2006 from http://bad.eserver.org/issues/2001/58/curtis.html Dean, C., & Webster, L. (1991). The Mental Health Act 1983: Characteristics of detained patients. Journal of Forensic Psychiatry, 2, 185-192. Department of Health. (1998). Modernising mental health services. Safe, sound, and supportive. London: Department of Health. Diesfeld, K., & Freckleton, I. (Eds.). (2003). Involuntary detention and therapeutic jurisprudence: International perspectives on civil commitment. London: Ashgate. Dunham, A.C. (1985). APA's model law: Protecting the patient's ultimate interests. Hospital & Community Psychiatry, 36, 973-975. Dyer, J. (1998). Treatment in the community in the absence of consent. Psychiatric Bulletin, 22, 73-76. Eastman, N., & Peay, J. (1998). Bournewood: An indefensible gap in mental health law. British Medical Journal, 317, 94-95. Goldbeck, R. and Mackenzie, D. (1997) Detained patients' knowledge of their legal status and rights. Journal of Forensic Psychiatry, 8, 573-582. Gosden, R., & Beder, S. (2001 Fall/Winter). Pharmaceutical industry agenda setting in mental health policies. Ethical Human Sciences and Services, 3(3), 147-159. Gratzer, T.G., & Matas, M. (1994). The right to refuse treatment: Recent Canadian developments. Bulletin of the American Academy of Psychiatry & the Law, 22, 249-256. Hampton-Newport News Community Services. (1999, May 21). Client Services Committee Minutes. Retrieved May 3, 2006 from http://hammond.vipnet.org/Client%20Service%20Minutes%20-%20Newport%20News.html Hiday, V.A., & Goodman, R.R. (1982). The least restrictive alternative to involuntary hospitalisation, outpatient commitment: Its use and effectiveness. Journal of Psychiatry & Law, 10, 81-96. Humphreys, M., Kenney-Herbert, J., & Cope, R. (2006). How to keep up with the Mental Health Act. Advances in Psychiatric Treatment, 6, 407-411. Jones, R. M. (1999). Mental Health Act manual. London: Sweet & Maxwell. Kapp, M.B. (1994). Treatment and refusal rights in mental health: Therapeutic justice and clinical accommodation. American Journal of Orthopsychiatry, 64, 223-233. La Fond, J., & Durham, M. (1992). Back to the asylum: The Future of mental health law and policy in the United States. New York: Oxford University Press. Lawrie, S.M. (1999). Attitudes of the general population to psychiatric and physical illness. Psychiatric Bulletin, 23, 671-674. Lepping, P., Steinert, T., & Gebhardt, R. (2004). A comparison of ethical attitudes of English and German health professionals and lay people towards involuntary admission: Implications for the new Mental Health Act (England & Wales). Journal of Philosophy, Science & Law, 4. Retrieved May 3, 2006 from http://www.miami.edu/ethics/jpsl/archives/papers/mentalHealth.html Mechanic, D. (2006). Status of mental health services at the millennium: Mental health policy at the millennium - Challenges and opportunities. United States Department of Health and Human Services - Substance Abuse and Mental Health Services Administration and Center for Mental Health Services. Retrieved May 3, 2006 from http://www.mentalhealth.samhsa.gov/publications/allpubs/sma01-3537/chapter7.asp Mental Disability Advocacy Center. (2003, March). Quarterly Bulletin, 1, 4. Mental Health Act Commission. (1999). The Mental Health Act Commission Eighth Biennial Report 1997-1999. London: Stationery Office. National Empowerment Center. (2006). Judi Chamberlin debates E. Fuller Torrey, MD on involuntary treatment: Should forced medication be a treatment option in patients with schizophrenia Retrieved on May 3, 2006 from http://www.power2u.org/debate.html Power, P. (1998). Outpatient commitment - Is it effective Doctor of Medicine Thesis, University of Melbourne, Australia. Royal College of Psychiatrists. (1997). Using the Mental Health Act. A training resource for doctors. London: Royal College of Psychiatrists. Schering Healthcare. (1983). A Guide to the Mental Health Act 1983 and allied legislation. Burgess Hill, Sussex: Schering Healthcare. Szmukler, G., & Appelbaum, P. (2001). Treatment pressures, coercion and compulsion. In Thornicroft, G., & Szmukler, G. (Eds.), Textbook of community psychiatry (pp. 529-543). Oxford: Oxford University Press. Szmukler, G., & Holloway, F. (2001). Maudsley discussion paper 10. Mental health law: Discrimination or protection Psychiatric Bulletin, 25, 454. Retrieved May 3, 2006 from http://pb.rcpsych.org/cgi/content/full/25/11/454 Szmukler, G, Thornicroft, G., Holloway, F., & Bowden, P. (1999). Homicides and community care: The evidence. British Journal of Psychiatry, 174, 564-565. Taylor, P., & Gunn, J. (1999). Homicides by people with mental illness: myth and reality. British Journal of Psychiatry, 174, 9-14. Wall, S., Churchill, R., Hotopf, M., & Wessely, S. (1999). A systematic review of research relating to the Mental Health Act (1983). London: Department of Health. Footnotes See Wall, Churchill, Hotopf, and Wessely (1999) for further details. See also Diesfeld and Freckleton (2003). 2 Refer to Gary Belkin's discussion on involuntary commitment. Historically, there has been a continual tension that has advanced or undermined a notion of social reform by appealing to the medical and/or scientific understanding of mental health and the behaviour of individuals suffering from mental health disorders. 3 See Gary Belkin's discussion on involuntary commitment. These government intentions have been criticized, however, for imposing the shared norms of the professional elite and social power interests 4 Gary Belkin notes that from South America to Central Europe, from the Russian Federation to Asia, an explosion of Web sites and non-governmental organisations catalogue and follow practices and the related execution of rules for involuntary commitment in psychiatric hospitals. Inhumane conditions in hospitals in South America, to reports of police-run psychiatric detention centers for so-called political criminals in China, an emergent network of support and oversight organisations relate norms for psychiatric hospital commitment as directly associated outgrowths of the larger cloth of social and political commitments and capacities for human rights in countries around the world. That very work builds on a mounting network of international conventions and new judicial mechanisms that support the notion that State actions toward individuals suffering from mental health disorders are subject to international laws regarding human rights. 5 See Bartlett & Sandland (2003). This transition in care has not been without its problems. 6 For some there are feelings of sinister control with respect to the state's power of social control over seemingly problematic citizens. 7 Curtis (2001) comments that "In any troubled relationship between the powerful and less powerful" the practice of mental health is open to abuse as a form of social control (Abstract section, paragraph 1). 8 For further comments, refer to Cope (1995), Chrichton 1998), Dunham (1985), and Dyer (1998). 9 Curtis (2006) is quick to point out that 'dangerousness' is also a highly convenient standard in that the criminal justice system already confines people who have been determined to be dangerous, and because public fears continue to rage about the alleged dangerousness of those with a mental illness. 10 For further comments, refer to Amering, Denk, Griengl, Sibitz, and Stastny (1999). 11 Cahn (2006) notes that there are still many misconceptions as to the power of psychiatrists to take away the freedom of persons with mental illness. The public at large still grossly overestimates the number and percentage of involuntary patients in psychiatric hospitals. 12 See Cahn (2006). One of the problems with patient care is that relatively few patients are skillful in articulating their stance with respect to involuntary treatment. Many who express negative opinions have impaired judgment or are suffering from delusions. And the majority of patients do not even express an opinion at all. 13 Chamberlin (1994) remarks that locked hospital wards exist so that the outside world can maintain itself. 14 See also Appelbaum (1997), Bluglass (1983), Bottomley (1987), Dean & Webster (1991), and Jones (1991) for further explanation. 15 See Cahn (2006) and Chodoff (1996) for further comments. 16 Those in power seldom cast their own motives in anything but benevolent terms. 17 For such individuals the psychiatric facility serves primarily as a detention centre. 18 See Cahn (2006) for further comments. In the hospital, the patient is taken care of in that he or she receives food, clothing, shelter, nursing care, and a program of structured activities, which for many patients improves the quality of their life as compared to the life they led in the community. 19 See Cahn (2006). In Britain it seems that psychiatrists may still order involuntary treatment to prevent deterioration of the patient's condition, while in the United States, the patients' rights movement seems to make this increasingly difficult, and only behaviour imminently dangerous may justify involuntary treatment 20 See Cahn (2006). The psychiatrist must always establish his own priorities in terms of his ethics, including the reality of the current situation, his relationship with the mentally ill patient, and his responsibility to both the public and patient. 21 See Lepping, Steinert, and Gebhardt (2004). High profile coverage of homicides by the mentally ill in Britain may explain why people were significantly more likely to support involuntary admission than in other countries such as Germany, where such coverage is distinctly less aggressive. 22 See Taylor & Gunn, (1999) and Szmukler, Thornicroft, Holloway, and Bowden (1999) for further comments. 23 The situation presumably reflects deeply entrenched public fears of the mentally ill and typecasts of dangerousness which are so inherent in our stereotypical images of mental illness that their disentanglement is not even deliberately contemplated. 24 Refer to Client Services Committee (1999) for further details. 25 See Cobb, Keith-Ross, and Ross (1976) for further details. 26 Gosden and Beder (2001) suggest that the industry uses all three of the models to set the agenda for mental health. 27 See Mechanic (2006) for further comments. 28 Public perceptions still remain punitive relative to other disabling conditions. Read More