Treating people who don’t want to be treated
One of the unique challenges of
working as a psychiatrist is that you will frequently encounter
patients who do not want any contact with psychiatry and do not
recognise their difficulties as being due to any kind of health
problem. This dilemma challenges the clinical and ethical
skills of all psychiatrists. You will have to consider a number of
issues. Firstly, and most importantly, patients have a right
to autonomous decision making with regard to their health. The
following rights are enshrined in the European Convention on Human
Rights:-
1. The obligation to respect Human Rights
5. The right to liberty and security
8. The right to respect for private life
9. The right to freedom of thought, conscience and
religion
10. The right to freedom of expression
14. The right to prevention of discrimination
They are also protected by the Mental Capacity Act 2005 and the
Mental Health Act 1983 (amended 2007).
As a psychiatrist, you will be
expected to weigh these rights against the risks that a patient may
pose to himself or other people. In order to make a risk
assessment, you will be required to use your own clinical skills
and judgement, but also communicate with individuals and agencies
involved in the patient’s care in addition to informants, such as
family members and informal carers.
The Mental Health Act allows for
the lawful detention and treatment of patients suffering from a
mental disorder, and for them to be treated and detained in
hospital and assessed and treated against their wishes. One of
the most difficult decisions psychiatrists have to make is whether
to recommend detention to hospital for treatment of mental
disorder, knowing that this may have serious repercussions for the
individual, not least the long term relationship with the
psychiatrist and his team.
Patients with mental health
problems present a special problem. As a result of their
illness they may cause harm to themselves or other people. Their
condition may be a cause for concern for their family, carers and
society in general. The patient, however, lacks the ability to
understand they are unwell and seek help
appropriately. Appropriate help may take the form of
in-patient or out-patient treatment and pharmacological or
psychological treatment. The powers of the Mental Health Act
aim to ensure that such people may be admitted to hospital against
their will. The Mental Health Act contains very detailed
safeguards regarding the circumstances in which patients may be
detained, the conditions on treatment, and rights for patients who
are detained.
When a patient is detained to
hospital, the psychiatrist will have the challenge of establishing
a relationship with the patient who does not believe that they have
a health problem of any kind, does not wish to remain in hospital,
and may reject the treatment offered to them. Establishing
relationships in circumstances such as these are some of the
greatest challenges to your personal and communication skills you
are likely to encounter in any branch of medicine. You are likely
to experience difficult interviews and will need to draw on the
skills of the team around you for help for the patient and support
of your own management plans. Patients with mental health
problems severe enough to warrant detention may be in hospital for
quite some time and the rewards in treating these patients may
be slow in coming and subtle. However, the reward of restoring
a patient to a degree of independence and autonomy from the
distress and chaos encountered during a period of mental ill
health, is one of the most satisfying therapeutic rewards you are
likely to experience in medicine.
Dr Tim Branton
Consultant psychiatrist, The Mount