Beneficial Coercion in Psychiatric Care: Insights from African Ethico‐Cultural System

There is a ‘catch 22’ situation about applying coercion in psychiatric care. Autonomous choices undeniably are rights of patients. However, emphasizing rights for a mentally‐ill patient could jeopardize the chances of the patient receiving care or endanger the public. Conversely, the beneficial effects of coercion are difficult to predict. Thus, applying coercion in psychiatric care requires delicate balancing of individual‐rights, individual well‐being and public safety, which has not been achieved by current frameworks. Two current frameworks may be distinguished: the civil liberty approach and the Stone model. Both frameworks are restrictive, and not respectful of human dignity. In a civil liberty approach, individuals who are severely mentally‐ill but not dangerous would be denied care because they do not meet the dangerousness threshold or because the use of coercion will not lead to rebirthing of autonomy. This is unsatisfactory. Albeit involuntary interventions such as talk therapies, peer‐support etc., may not always lead to rebirthing of autonomy or free patients from mental illness; they can however help to maintain the dignity of each mentally ill patient. In place of these frameworks, this study proposes a new ethical framework for applying coercion in psychiatric care that is respectful of human dignity. Specifically, it draws on insights from the African ethico‐cultural system by using the Yoruba concept Omo‐olu‐iwabi to develop this new framework. This way, the study shows that only a more respectful approach for applying coercion in psychiatric care can lead to the careful balancing of the competing interests of individual's rights, individual's well‐being and public safety.     

Violence and psychosis. II--Effect of psychiatric diagnosis on conviction and sentencing of offenders.

An examination of the records of all sick and violent men remanded to a large English prison suggested a tendency among police to consider men to be exceptionally dangerous simply because of their mental illness. On further study, however, there was no evidence that the mentally ill were more vulnerable to detention without subsequent conviction than their normal peers. Remand was rarely followed by help for the mentally abnormal men studied; this is disturbing as requests for psychiatric help constitute an important reason for custodial remand. Less than a third of the men with active symptoms went to hospital, although some of the less disturbed received supervision (including probation) orders, occasionally with treatment. As there is evidence that most of the few mentally abnormal offenders who subsequently receive treatment benefit from it, psychiatrists should do more for offender patients.     

Ought We to Sentence People to Psychiatric Treatment?

In principle, there seem to be three main ways in which society can react when people commit crimes under influence of mental illness.
(1) The standard model. We excuse them. If they are dangerous they are detained in the interest of safety of the rest of the citizens.
(2) The Swedish model. We hold them responsible for their criminal offence, we convict them, but we do not sentence them to jail. Instead, we sentence them to psychiatric treatment.
(3) My model. We sentence them to jail, but offer them (voluntary) psychiatric treatment.
The advantages of my model are obvious. We get a clear delineation of roles. We allow the psychiatrist to be just a doctor, not a warden. We liberate psychiatry of the objective of deciding whether people who were mentally ill when they committed criminal offences 'could have acted otherwise'— a hopeless task. We allow that psychiatrists live up to their professional ethical code (the Hawaii Declaration). We treat psychically ill persons as 'normal', we allow them to repent their crimes, which renders easier their recovery.
However, two objections to my model come to mind. First of all, is it not unfair to sentence people to jail who could not help doing what they did? And, secondly, the question of fairness set to one side, is it not inhumane to sentence mentally ill persons to jail? Is it not inhumane to the mentally ill persons themselves, and does it not mean that they will be a burden to other prisoners?
In my paper I show that, if our system of criminal punishment takes a civilised form, neither of these objections carries any weight.     

Ought we to sentence people to psychiatric treatment?

In principle, there seem to be three main ways in which society can react when people commit crimes under influence of mental illness. (1) The standard model. We excuse them. If they are dangerous they are detained in the interest of safety of the rest of the citizens. (2) The Swedish model. We hold them responsible for their criminal offence, we convict them, but we do not sentence them to jail. Instead, we sentence them to psychiatric treatment. (3) My model. We sentence them to jail, but offer them (voluntary) psychiatric treatment. The advantages of my model are obvious. We get a clear delineation of roles. We allow the psychiatrist to be just a doctor, not a warden. We liberate psychiatry of the objective of deciding whether people who were mentally ill when they committed criminal offences 'could have acted otherwise' -- a hopeless task. We allow that psychiatrists live up to their professional ethical code (The Hawaii Declaration). We treat psychically ill persons as 'normal', we allow them to repent their crimes, which renders easier their recovery. However, two objections to my model come to mind. First of all, is it not unfair to sentence people to jail who could not help doing what they did? And, secondly, the question of fairness set to one side, is it not inhumane to sentence mentally ill persons to jail? Is it not inhumane to the mentally ill persons themselves, and does it not mean that they will be a burden to other prisoners? In my paper I show that, if our system of criminal punishment takes a civilised form, neither of these objections carries any weight.     

Attitudes and sterotypes of supporting fields towards the persons with disabilities

The aim of this research was to establish the attitudes, the views and reactions of the helping fields (which include social workers and medical nurses) and those who aren't the part of that cathegory, towards the mentally ill people. One hundred and twenty persons questioned have taken part in this research where in the group of supporting fields consisted of social workers and medical nurses (N = 40). The questionnaire was used in examining the attitudes of those questioned persons, the questionnaire that was used in Joki?-Begi?'s research (2005) and it turned out to be a really good one in defining the attitudes and stereotypes towards the mentally ill persons. The questionnaire consisted of several parts in which different things have been examined such as stereotypes, knowledge, attitudes, level of acceptance and social- demographic information. The research has shown the differences among the attitudes and the level of acceptance of the mentally ill as well as the level of knowledge which the examinees had. All the examinees that have been the part of this research mentioned "ill" as a dominant trait of the mentally disturbed person. Furthermore, the characteristics such as instability, insecurity, nervousness and inclination to suicide, indicate that all of these three groups of examinees have sterotypes about unstable emotional condition and state of mind of the sick. The examinees that don't belong to this group of supporting fields have enough knowledge neither about the emergence of the disease nor about its development and preventive measures. However, the social workers have a bit more negative attitude towards the mentally ill if compared to medical nurses which could be explained by insufficient working experience with the mentioned group of patients. It's important to say that all of the three groups of examinees don't have extremely negative attitudes towards the people with mental disorder. We shouldn't ignore the fact that these three groups have noticable social restraint towards the mentally ill and they cannot easily accept them in their own environment. Considering the fact there is a low number of researches that deal with this problem of labelling or in other words- stigmatization of the mentally ill, this research gives a great stimulus for writeup this very important problem area, especially if we take into consideration that the attitude of the community may help to bring about the feeling of marginalization and unacceptability with the mentally ill.     

Mentally abnormal prisoners on remand: I—Rejected or accepted by the NHS?

Increasing numbers of mentally abnormal offenders are sentenced to prison. The decision to treat or imprison them is influenced by the attitudes of consultant psychiatrists and their staff. The process whereby those decisions were made and the willingness of consultants to offer treatment were investigated. A retrospective survey of all (362) mentally abnormal men remanded to Winchester prison for psychiatric reports over the five years 1979-83 showed that one in five were rejected for treatment by the NHS consultant psychiatrist responsible for their care. Those with mental handicaps, organic brain damage, or a chronic psychotic illness rendering them unable to cope independently in the community were the most likely to be rejected. They posed the least threat to the community in terms of their criminal behaviour yet were more likely to be sentenced to imprisonment. Such subjects were commonly described by consultants as too disturbed or potentially dangerous to be admitted to hospital or as criminals and unsuitable for treatment. Consultants in mental hospitals were most likely and those in district general hospitals and academic units least likely to accept prisoners.The fact that many mentally ill and mentally handicapped patients can receive adequate care and treatment only on reception into prison raises serious questions about the adequacy of current management policies and the range of facilities provided by regional health authorities.     

A proposal for the use of advance directives in the treatment of incompetent mentally ill persons

[M]y question is how these patients while competent might be able to give their own informed consent to treatment, despite being both unwilling and incompetent to do so when treatment is to be begun, thereby reducing the need to relax the dangerousness criteria for involuntary commitment. It is uncontroversial that the dangerousness requirement would be too restrictive for all treatment of mental illness. When competent patients voluntarily seek and/or accept treatment for their mental illness, neither public policy nor medical practice restricts treatment to those patients judged to be dangerous. Instead, criteria should be and generally are comparable to those for the treatment of physical illness -- whether the patient is ill, in this case mentally ill, and likely to benefit from treatment. Through use of advance directives, it would be possible for mentally ill persons who are currently refusing treatment to give prior consent, while competent and with their disease in remission, to treatment at a later time when they are incompetent, have become noncompliant, and are refusing treatment. My proposal is certainly not entirely novel, since others have made similar proposals under the heading of Ulysses contracts and voluntary commitment contracts. Addressing briefly some of the criticisms of these earlier proposals will bring out one fundamental difference between them and my proposal here for a new use of advance directives -- whether the patient must then be incompetent when the contract or directive made earlier is later invoked -- a difference I shall argue strongly favors my proposal.     

PSYCHOPHARMACOLOGY OF DRUGS

Seventeen states provide for admission of patients to mental hospitals by medical certification without judicial procedure. The aim is to avoid the police aspects of dealing with mentally ill persons without depriving them of constitutional rights. The California law, passed in 1947, has now had ten years'' trial. In Orange County, 888 patients were examined under this act between 1947 and 1957. Of these, 486 were admitted to state mental institutions while 402 did not currently require hospitalization. Local modifications have provided additional safeguards to the patient, have made it more acceptable professionally, and have resulted in wider use of the act in Orange County.A comparison of costs between the medical certification procedure and court commitments indicated that, in 1957, court commitments were seven times more expensive than admissions by medical certification.The greater humanity of the procedure and the economy of it lead to the conclusion that, with a few changes, medical certification of mentally ill patients should be more widely used.     

A cross sectional study of somatic complaints of Nigerian females using the Enugu Somatization Scale

Among Nigerian mentally ill a constant male-female ratio of 2:1, over-representation of single males and married females and the tendency for the females who seek psychiatric aid to be psychotic with schizoaffective disturbances have been observed. The question arose as to why this is so. To answer this, the Enugu Somatization Scale, developed in an effort to avoid the difficulty encountered in using Western diagnostic illness categories and scales for assessing mental illness in Nigeria was administered to 51 mentally ill females, 60 adolescent secondary school girls, 67 post secondary school females, 149 pregnant females, and 60 women who were once able to bear children but now no longer can. It was found that somatization is used by Nigerian females to contain their stress. The pregnant females scored lowest while those women who can no longer deliver scored highest. Pregancy is seen as a state of rest from societal stress for the females, who otherwise are not allowed by the society to be so mentally ill as to seek a psychiatrist and who have to be psychotic to be able to do so. Various tentative, dynamic explanations of the items in the scale answered in the affirmative by a wide cross section of the women, based on the clinical experience of the author, are offered.     

Adaptation of children to a chronically ill or mentally handicapped sibling.

The presence of a chronically ill or mentally handicapped child in a family can be a stress for the child''s siblings, who often are ill informed about the nature and prognosis of the illness, may be uncertain what is expected of them in the caregiving role, may feel their own identities threatened, and may experience ostracism by their friends and misunderstanding at school. Although individual reactions vary widely, feelings of anger, guilt, resentment and shame are commonly reported. Excessive responsibility and concern about one''s identity may add to these feelings and culminate in psychologic problems in the sibling. The physician caring for the family must be alert for symptoms of emotional disturbance or social maladjustment among the siblings of chronically ill or mentally handicapped children and should be prepared to counsel the family or refer them to a counsellor experienced in this area. In general, the first step is to be sure that the sibling is fully informed about the condition and to encourage frank discussion between the parents and the handicapped child''s siblings.     

Psychogeriatric Ward for Mentally Disturbed Elderly Patients

The operation is described of a special psychogeriatric ward of 23 beds set up in 1967 to provide treatment for mentally disturbed elderly patients who could not be kept in a general ward or at home. The unit is in a predominantly geriatric hospital which serves a population of 340,000 and in the four and a half years reviewed 600 patients were admitted. Half of the admissions were emergencies. A consultant geriatrician was in charge and the nursing staff were general trained. The number of beds was found to be adequate for the demand. Few patients had to be transferred to a psychiatric hospital, but, since the mental disturbance was often associated with severe illness and the patients were old, the death rate was high. The nursing staff have found the work interesting and stimulating.     

‘I need help’: caregivers' experiences of caring for their relatives with mental illness in Jamaica

The findings reported here form part of a larger research project that examined non-compliance with medication among the mentally ill patients attending public clinics in a specific parish in Jamaica. The aim of the research was to explore the perceptions of caregivers about caring for the mentally ill at two outpatient psychiatric clinics. Caregivers involved in looking after their relatives with mental illness played a vital role in mental health promotion. This study sought to examine the caregivers'' perception of mental illness, including how they thought the illness was best controlled, the reasons why their relatives found it difficult to take their medication as instructed, and the coping skills that they employed when caring for their relatives. There were two focus groups, consisting of four individuals each, at two psychiatric clinics.The results revealed the following about the majority of the caregivers. First, it was recognised that caregivers have a good knowledge (and awareness) of medication usage inferred by either the absence or the presence of their relatives'' symptoms. Secondly, they sometimes felt sad and hopeless as a result of being the victims of violent attacks by those for whom they provided care. Thirdly, they highlighted issues of cost, accessibility and availability of medications as being problematic. Fourthly, in some cases they received little or no assistance from other family members.     

Sociocultural background of the mental health system in Japan

Japan is not among the countries with a high ratio of beds and admissions into psychiatric hospitals to total population, but the average length of hospitalization in Japan is among the longest in the world.The ie characteristic of Japanese culture has taken care of the elderly and the mentally disturbed even though it regarded them as a nuisance, thus serving to keep the number of beds and admissions in Japan lower than in Western countries. But those treated as a nuisance who sever all face-to-face ties upon being admitted to hospitals tend to be expected culturally to regard the hospitals as their homes, thus prolonging the length of their hospitalization.     

OxDONS syndrome: the inevitable disease of the NHS reforms.

The financial demise of Oxford''s department of neurosurgery (OxDONS) was precipitated by the financial rules of the reformed NHS. In particular it was produced by the failure of "resources to follow patients"; the requirement that "prices have to follow costs"; and the use of private income for revenue expenditure, not capital expenditure. This process will eventually affect all hospital departments, but it affected the unit in Oxford sooner as it started as "efficient"--that is, underresourced--and has depended on income from extracontractual referrals and private work. Current NHS accounting rules act as a disincentive to private income being generated in NHS hospitals, and consultants should be aware of this.     

Management of septic shock.

There have been important advances in the resuscitation of patients in septic shock in recent years. Survival can be improved by earlier recognition and therefore eradication of the sepsis combined with logical supportive measures. As with any acutely ill patient consultation with intensive care unit staff may be useful. Consultation with the intensive care unit does not necessarily imply the need for admission and mechanical ventilation; helpful advice may be forthcoming. Equally, referral to the intensive care unit does not mean an admission of failure but merely a recognition that additional skills and technical facilities are necessary for the patient''s survival.     

The outcome of targeting community mental health services: evidence from the West Lambeth schizophrenia cohort.

OBJECTIVES--To report outcome of targeting community mental health services to people with schizophrenia in an inner London district who had been shown, one year after discharge, to have high levels of psychotic symptomatology and social disability but very low levels of supported housing and structured day activity. DESIGN--Repeat interview survey of symptoms, disability, and receipt of care four years after index discharge. SETTING--Inner London health district with considerable social deprivation and a mental hospital in the process of closure. SUBJECTS--51 patients originally aged 20-65 years who satisfied the research diagnostic criteria for schizophrenia. MAIN OUTCOME MEASURES--Contact with services during the three months before interview, levels of symptoms (from present state examination), global social disability rating. RESULTS--65% (33/51) of the study group had been readmitted at least once in the three years between surveys. Recent contacts with community psychiatric nurses and rates of hospital admission increased (8 at one year v 24 at four years, p < 0.01; 5 v 13, p < 0.06). Conversely, fewer patients were in contact with social workers (17 v 7, p < 0.03). Proportions in supported housing, day care, or sheltered work did not change. Unemployment rates remained very high. A considerable reduction (almost a halving) in psychiatric symptoms was observed, but there was no significant change in mean levels of social disability. CONCLUSIONS--The policy of targeting the long term mentally ill resulted in significant increases in professional psychiatric input to the cohort but failed to improve access to social workers or suitable accommodation. Improvements in social functioning did not follow from reductions in the proportions of patients with psychotic mental states. Social interventions are likely to be crucial to achieving the Health of the Nation target of improving social functioning for the seriously mentally ill, as improving mental state seems in itself to be insufficient.     

Investigation of Hepatitis B Virus and Human Immunodeficiency Virus Transmission among Severely Mentally Ill Residents at a Long Term Care Facility

Background

A high prevalence of hepatitis B virus (HBV) and human immunodeficiency virus (HIV) infections have been reported among persons with severe mental illness. In October, 2009, the Cook County Department of Public Health (CCDPH) initiated an investigation following notification of a cluster of HBV infections among mentally ill residents at a long term care facility (LTCF).

Methods

LTCF staff were interviewed and resident medical records were reviewed. Residents were offered testing for HBV, HCV, and HIV. Serum specimens from residents diagnosed with HBV or HIV infection were sent to the Centers for Disease Control and Prevention (CDC) for analysis.

Results

Eleven newly diagnosed HBV infections were identified among mentally ill residents at the LTCF. Of these 11 infections, 4 serum specimens were available for complete HBV genome sequencing; all 4 genomes were found to be closely related. Four newly diagnosed HIV infections were identified within this same population. Upon molecular analysis, 2 of 4 HIV sequences from these new infections were found to be nearly identical and formed a tight phylogenetic cluster.

Conclusions

HBV and HIV transmission was identified among mentally ill residents of this LTCF. Continued efforts are needed to prevent bloodborne pathogen transmission among mentally ill residents in LTCFs.     

The new Israeli law on the care of the terminally ill: conceptual innovations waiting for implementation

Israel has recently enacted a law on the care of terminally ill patients. This law, the Patient Nearing Death Act, is the first of its kind in the world. The law divides terminally ill patients--upon their own wishes--into two separate groups: "those who wish their lives be prolonged," and those who do not. Doctors will have to abide by elaborate advanced directives and take into account various sources of information on the presumed wishes of the patient. The law sanctions discontinuation of mechanical ventilation should it become a "cyclical" rather than "continuous" therapy, a provision that has implications for the use of the already available paraPAC ventilators. The law exposes gaps in modern Judaism between the religious law and the attitudes of the observant population with regard to medical ethics.     

Shuttle case records: link between general practice and the specialist unit.

General practitioners have participated in the long term follow up of 367 patients who have undergone treatment with potent antirheumatic drugs at this hospital. Over the past two and a half years we have used the "shuttle case record" system, whereby patients'' records are mailed back and forth between our department and general practitioners. This seems to work well. It is safe for the patients, and they save time and money in travel. The general practitioners like it, it improves communication between them and the specialist unit, and it enables the specialist unit to use its resources and manpower more effectively. The system may also be used to monitor patients with other chronic disorders, and it may be a valuable tool for doing research in general practice.     

Mirror agnosia.

Normal people rarely confuse the mirror image of an object with a real object so long as they realize they are looking into a mirror. We report a new neurological sign, ''mirror agnosia'', following right parietal lesions in which this ability is severely compromised. We studied four right hemisphere stroke patients who had left visual field ''neglect''. i.e. they were indifferent to objects in their left visual field even though they were not blind. We then placed a vertical parasagittal mirror on each patients'' right so that they could clearly see the reflection of objects placed in the (neglected) visual field. When shown a candy or pen on their left, the patients kept banging their hand into the mirror or groped behind it attempting to grab the reflection; they did not reach for the real object on the left, even though they were mentally quite lucid and knew they were looking into a mirror. Remarkably, all four patients kept complaining that the object was ''in the mirror'', ''outside my reach'' or ''behind the mirror''. Thus, even the patients'' ability to make simple logical inferences about mirrors has been selectively warped to accommodate the strange new sensory world that they now inhabit. The finding may have implications for understanding how the brain creates representations of mirror reflections.