Abstract
I have recently been involved in a number of discussions regarding the steps that mental health services should be taking to minimize risk for patients. Such discussions have caused me to reflect on this issue.
Frequently, inquiry findings and media reports force me to ponder on the assignment of responsibility. We are all familiar with headlines such as ‘ex-mental health patient rapes’. We do not see ‘ex-taxi driver rapes’ or ‘ex-cardiac patient rapes’. If you are stupid enough to read the article you are likely to find that someone, be it the judge, the local member of parliament or mother-of-three-from-Gresham, holds the mental health services accountable for this tragic event. I had a conversation with a surgeon colleague about this issue and he was greatly relieved that he is not held accountable for the behaviours of the patients he has operated on in the past!
Why, I ask myself, are we in this apparently ridiculous situation where psychiatrists are seen as responsible for the actions of patients and even ex-patients? Surely this is both absurd and opposes any principles of recovery and self-determination.
The wholesale use of compulsion in the treatment of those with mental illness obviously plays a part in this creation. Another contribution must come from the laws that allow an individual to be ‘not guilty by virtue of insanity’ (or whatever your local equivalent is). Members of the public have understandably said: ‘How can a person who did the murder be not guilty?’ I know there is a moral and ethical explanation that has to do with the individual's capacity to form intent, etc. These arguments are beyond the average woman or man in the street, though.
I suspect that a more important contribution to this undesirable state comes from the years of institutional care for the mentally ill. The ‘bins’ provided large walls that kept the patients in and also kept the public out. The hospital was the community for the patient and absorbed the patient's activities.
The major contributor, however, are the remnants of paternalism. I shudder when I hear the expression ‘my patient’. While I appreciate that it is great to have a doctor who has a personal commitment to the delivery of best possible care, there are overtures of ownership of the person which are distinctly unhealthy.
It is crucial that modern psychiatry spells out a set of expectations that ensure consumers get the best possible support to take their own path to recovery. In New Zealand, the Health and Disability Commissioner has generated a code of consumers’ rights. This code is helpful in
informing us regarding decisions in the responsibility arena. The right to respect, to freedom from discrimination, coercion, harassment and exploitation and the right to dignity and independence are obvious drivers of treatment. The right to appropriate services includes services that are provided in a manner that minimizes the potential harm to, and optimizes the quality of life of, the consumer. Optimizing the quality of life means taking a holistic view of the needs of the consumer in order to achieve the best possible outcome in the circumstances. This right sits hand in glove with the right to make an informed choice and give informed consent.
The position previously referred to, namely that which holds the psychiatrist as accountable for the behaviour of the patient, is far from respectful, is coercive and is discriminatory. If we allow treatment choices and treatment environments to be dictated because of the perceived behaviours of the patient we run a strong risk of falling foul of respecting the right to informed choice and even to the right to provision of services of an appropriate standard.
I have so far quite deliberately avoided the ‘r’ word. Risk is an alternative expression of the behaviour of the patient. I can now feel the thin ice beneath me cracking! There is considerable debate both within the profession and in wider circles about this whole issue of the risk imposed by the mentally ill and how we should deal to it. I am not advocating a psychiatric service that ignores the fact that a mental illness might make a person more vulnerable to certain acts that will be damaging to themselves or to others. Indeed if we follow the rights paradigm then we are again well informed in what we should do. If we are to meet the right of the consumer to be fully informed then we must properly evaluate the propensity of unwanted actions as a result of their illness. We should also fully advise about what would be reasonable steps to protect themselves from these undesirable events.
If we follow the code of rights the use of the Mental Health Act for those people who require compulsory treatment is easily understood and mandated. Importantly, however, what is not mandated is the use of an Act, which is supposed to be about the treatment of a mental illness, for the preventative detention of people who are seen as ‘a risk’. There was a recent mental health tribunal decision that pointed strongly to the fact that the mental health act may not be used to detain someone where they did not have a mental disorder that had a treatment likely to make a difference.
To those of you who have been tolerant enough to follow my musings I have a final suggestion, well really a request. I believe that in large part the solution to this aberrant world position that holds the psychiatrist accountable for the behaviour of the patient is for us as psychiatrists to display a total commitment to accountability for our own actions. If we strive to meet the rights of consumers and display a keenness to deliver quality care that reaches best evidential standards maybe we can affect the current climate that wants to hold the psychiatrist responsible, that wants heads to roll. There appears to be a misguided view that the way to get quality clinical care is to seriously threaten any practitioner who delivers errant care. The more we are overtly taking the responsibility for quality care the less excuse there can be to blame and shame, and to hold the psychiatrist responsible for the patient's behaviour.
A word of caution is required. I am all too familiar with the fact that often we are not able to deliver to the best practice level because of resource limitations. We know all too clearly what best practice would look like. We might even use the College's guidelines to design what would be in the consumer's best interests. There will be times when we cannot deliver to that required level. I believe we need, in such circumstances, to fully inform patients and their families/carers of the limitations and of what they can expect from us. Such dialogue should not be of a type that engenders negativity to any treatment possibility, but realistically explains constraints. As a College we then need to put the effects of these constraints on health outcomes before the funders and planners of health services.
All this is about creating a very transparent image of a psychiatry where we will look after the behaviour of psychiatrists and by so doing contribute to an environment where the person with a mental illness is best equipped to take responsibility for themselves.