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The Royal College of Psychiatrists Improving the lives of people with mental illness

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


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