God psychiatry versus
good psychiatry doctor decides and prescribes. Because of his training and experience, he knows what is best for the patient who expects him to do something to put right what has gone wrong in body, brain or mind, and to be responsible for what he does. Some psychiatrists would demur at this point. Many would not, and readily accept their role as experts who apply treatment to relieve distress and correct disorder. Society expects them to bring under control behaviour which is threatening, annoying or disturbing to society or distressing to the patient. They would claim it is right that they should have
A
power to enable them to do Power
so.
conferred
No other branch of medicine accords the doctor the
psychiatry. The Mental Health Act, a psychiatrist as the responsible medical officer (RMO), confers on him the power previously conferred on the medical superintendent by the Lunacy Act, 1890, to detain a patient against same
power
as
1959, in recognising
his wishes once a Section 25 or 26 order has been made out. (Strictly the power to detain is conferred on the managers of the hospital). The Act also confers on
him the power to
patient's wishes, which patient's best interests.
give
treatment
he considers
to
against
Legal sanctions sanctions. There has the issue of treatment administered against the wishes of a de.tained person and any such action is unlikely. There are circumstances, other than detention under the Mental Health Act, in which a patient may be treated without his consent, eg, when he is unconscious. The doctor carrying out such treatment risks action against him for trespass to the person, but would defend himself on the grounds that he had acted in good faith for the benefit of the patient as a matter of necessity. The patient detained under the Mental Health Act may seek redress, like any other patient, on the grounds that the RMO was negligent. If he exercises care, the RMO has little reason to fear such action. The treatments likely to be given against the wishes of the patient are ECT and injection of a phenothiazine or other drug. Both are reasonably safe. Their side-effects, even if occasionally unpleasant or distressing, are short-lived. Nevertheless, the
There never
are
virtually
no
legal
been any court action
on
patient may regard them as an indignity or and in this sense they may do great harm.
an
assault,
the
be in the
This power is usually checked in practice because other people are involved?the patient's relatives, the general practitioner, other doctors in the hospital, nurses, social workers and ward staff and, in theory, but rarely in practice, members of the hospital management committee. The final decision is the RMO's. It is occasionally a lonely one when the patient to be treated is in a thinly staffed 'back' ward, and the only other person involved is a nurse accustomed to act on the doctor's instructions.
Opinions of psychiatrists The NAMH, concerned about the
patients,
wrote
recently to
rights
100 consultant
of detained
psychiatrists
and 34 mental health officers about the treatment of patients detained against their wishes. About threequarters of those written to replied. None doubted the RMO's right to administer treatment if he deems it necessary. The large majority stressed the importance of discussing the medical issues at stake with the relatives. Many said that they would seek a second
Many
people
see
particularly psychiatrists
Derek Russell Davis
doctors -
as
-
remote,
omnipotent figures and invest them with near-mystical powers of healing. Being held in such impossibly high esteem by their patients has 'rubbed off on some psychiatrists over the years. So the profession probably
suffers from inherited traditions and time devoted to 'taking stock' might well be valuable. some
None would carry out an irreversible treatlike leucotomy. None had been involved in any formal complaint.
opinion.
Handicaps of
tradition
ment
Public
disquiet
The replies are reassuring about the ways in which the psychiatrist's power is being used. Yet there is cause for concern. There is public disquiet. That the expression of it has gone to extremes, as in the case of some of the accounts given by Scientologists, should not lead psychiatrists to deny that it exists. The soundness of their judgement on the necessity of treatment is less generally accepted than it used to be. The several ill-founded claims made by psychiatrists about the efficacy of various treatments will not
quickly be forgotten. Many people see their doctors, and particularly their psychiatrists, as remote, omnipotent figures, whom they invest with charismatic powers, and from whom they expect near-miracles. Perhaps mental illness strengthens the tendency to see a helper in this way. A few psychiatrists encourage such a view, rationalising it on the grounds that the true effects of their treatment are then reinforced by suggestion. A few adopt the God-like stance of the surgeon of a generation ago. Most, of course, stay humble. But because psychiatrists are seen in this way there can be serious consequences. Many ordinary members of the public shrink from consulting a psychiatrist because they do not want to be regarded as 'mental', by which they mean, not fully in charge of, and responsible for themselves. They prefer a counsellor, whether medical or lay, with whom they feel they can work
as
equals.
The psychiatrist suffers from the traditions he has inherited. Unlike other doctors of the last generation, the medical superintendent did not live on the fees his patients paid him, but was employed by the local authority, who expected him to keep people who were disturbing to the community under control. Similarly, many of the child psychiatrists of the last generation, and some of this, were appointed to assist courts in deciding how to deal with offenders. Often the patient's family tend to look to the psychiatrist to relieve not so much the patient's problems as their own. It is hardly surprising, therefore, that patients doubt whether the benefit to them is in the forefront of his thoughts, and see him as the agent of society, the institution or the family. The modern psychiatrist in public employ does not readily free himself from his controlling function or escape from the ambiguities of his position. He is under fire from one side for being permissive, and from the other, for belonging to a repressive establishment. Medical model He has also been
handicapped by his disadvantaged within the medical profession. The pressures are on him to become respectable, to be as other physicians are, to do as they do, and adhere to the 'medical' model. This model attributes mental as well as physical illness to a fault in a bodily mechanism? hence the reiteration of the strange view that mental illness is like any other illness. Perhaps it is in some respects, but it should not be looked at in the same way, for the medical model has proved of little help in understanding and relieving mental illness. If he prefers an 'interaction' model, he is liable to be called unscientific (on a topsy-turvy definition of
position
science).
prestige problems are not made any preference for an 'interaction' model separate him from his medical colleagues and His
easier when his tends to
ally him with social workers. The medical model leads the psychiatrist to suppose that the essential treatments lie in such things as ECT or drugs, which give him the power to control and change behaviour. In applying these treatments he is able to maintain a professional detachment. The therapist guided by an 'interaction' model sits with the patient, or with the patient and spouse, and tries to help him define and understand the conflicts in his relationships and to give him courage to do something about them. In order to mediate in this way, he nurtures his relationship with the patient. Since it is the patient who is to act in order to put right what has gone wrong, the therapist divests himself, so far as he can, of the power the patient attributes to him and expects him to use. He may manage to treat the patient against his wishes without doing serious harm if he is aware of the effects such treatment may have on their relationship and if he takes steps to counterto
act them.
A
turning point
is at a turning point. Psychiatrists should take pains to reassure the general public that in the tradition of medicine the patient's benefit is their primary concern, that within medicine their special contribution lies in the field of relationships and, within social work, the bringing together of explanations based on the complementary 'medical' and 'interaction' models, and that they exercise skills and not power. They should give up anything that might be seen as a God-like stance and sit down with the
Psychiatry
patient.
good psychiatry doctor decides and prescribes. Because of his training and experience, he knows what is best for the patient who expects him to do something to put right what has gone wrong in body, brain or mind, and to be responsible for what he does. Some psychiatrists would demur at this point. Many would not, and readily accept their role as experts who apply treatment to relieve distress and correct disorder. Society expects them to bring under control behaviour which is threatening, annoying or disturbing to society or distressing to the patient. They would claim it is right that they should have
A
power to enable them to do Power
so.
conferred
No other branch of medicine accords the doctor the
psychiatry. The Mental Health Act, a psychiatrist as the responsible medical officer (RMO), confers on him the power previously conferred on the medical superintendent by the Lunacy Act, 1890, to detain a patient against same
power
as
1959, in recognising
his wishes once a Section 25 or 26 order has been made out. (Strictly the power to detain is conferred on the managers of the hospital). The Act also confers on
him the power to
patient's wishes, which patient's best interests.
give
treatment
he considers
to
against
Legal sanctions sanctions. There has the issue of treatment administered against the wishes of a de.tained person and any such action is unlikely. There are circumstances, other than detention under the Mental Health Act, in which a patient may be treated without his consent, eg, when he is unconscious. The doctor carrying out such treatment risks action against him for trespass to the person, but would defend himself on the grounds that he had acted in good faith for the benefit of the patient as a matter of necessity. The patient detained under the Mental Health Act may seek redress, like any other patient, on the grounds that the RMO was negligent. If he exercises care, the RMO has little reason to fear such action. The treatments likely to be given against the wishes of the patient are ECT and injection of a phenothiazine or other drug. Both are reasonably safe. Their side-effects, even if occasionally unpleasant or distressing, are short-lived. Nevertheless, the
There never
are
virtually
no
legal
been any court action
on
patient may regard them as an indignity or and in this sense they may do great harm.
an
assault,
the
be in the
This power is usually checked in practice because other people are involved?the patient's relatives, the general practitioner, other doctors in the hospital, nurses, social workers and ward staff and, in theory, but rarely in practice, members of the hospital management committee. The final decision is the RMO's. It is occasionally a lonely one when the patient to be treated is in a thinly staffed 'back' ward, and the only other person involved is a nurse accustomed to act on the doctor's instructions.
Opinions of psychiatrists The NAMH, concerned about the
patients,
wrote
recently to
rights
100 consultant
of detained
psychiatrists
and 34 mental health officers about the treatment of patients detained against their wishes. About threequarters of those written to replied. None doubted the RMO's right to administer treatment if he deems it necessary. The large majority stressed the importance of discussing the medical issues at stake with the relatives. Many said that they would seek a second
Many
people
see
particularly psychiatrists
Derek Russell Davis
doctors -
as
-
remote,
omnipotent figures and invest them with near-mystical powers of healing. Being held in such impossibly high esteem by their patients has 'rubbed off on some psychiatrists over the years. So the profession probably
suffers from inherited traditions and time devoted to 'taking stock' might well be valuable. some
None would carry out an irreversible treatlike leucotomy. None had been involved in any formal complaint.
opinion.
Handicaps of
tradition
ment
Public
disquiet
The replies are reassuring about the ways in which the psychiatrist's power is being used. Yet there is cause for concern. There is public disquiet. That the expression of it has gone to extremes, as in the case of some of the accounts given by Scientologists, should not lead psychiatrists to deny that it exists. The soundness of their judgement on the necessity of treatment is less generally accepted than it used to be. The several ill-founded claims made by psychiatrists about the efficacy of various treatments will not
quickly be forgotten. Many people see their doctors, and particularly their psychiatrists, as remote, omnipotent figures, whom they invest with charismatic powers, and from whom they expect near-miracles. Perhaps mental illness strengthens the tendency to see a helper in this way. A few psychiatrists encourage such a view, rationalising it on the grounds that the true effects of their treatment are then reinforced by suggestion. A few adopt the God-like stance of the surgeon of a generation ago. Most, of course, stay humble. But because psychiatrists are seen in this way there can be serious consequences. Many ordinary members of the public shrink from consulting a psychiatrist because they do not want to be regarded as 'mental', by which they mean, not fully in charge of, and responsible for themselves. They prefer a counsellor, whether medical or lay, with whom they feel they can work
as
equals.
The psychiatrist suffers from the traditions he has inherited. Unlike other doctors of the last generation, the medical superintendent did not live on the fees his patients paid him, but was employed by the local authority, who expected him to keep people who were disturbing to the community under control. Similarly, many of the child psychiatrists of the last generation, and some of this, were appointed to assist courts in deciding how to deal with offenders. Often the patient's family tend to look to the psychiatrist to relieve not so much the patient's problems as their own. It is hardly surprising, therefore, that patients doubt whether the benefit to them is in the forefront of his thoughts, and see him as the agent of society, the institution or the family. The modern psychiatrist in public employ does not readily free himself from his controlling function or escape from the ambiguities of his position. He is under fire from one side for being permissive, and from the other, for belonging to a repressive establishment. Medical model He has also been
handicapped by his disadvantaged within the medical profession. The pressures are on him to become respectable, to be as other physicians are, to do as they do, and adhere to the 'medical' model. This model attributes mental as well as physical illness to a fault in a bodily mechanism? hence the reiteration of the strange view that mental illness is like any other illness. Perhaps it is in some respects, but it should not be looked at in the same way, for the medical model has proved of little help in understanding and relieving mental illness. If he prefers an 'interaction' model, he is liable to be called unscientific (on a topsy-turvy definition of
position
science).
prestige problems are not made any preference for an 'interaction' model separate him from his medical colleagues and His
easier when his tends to
ally him with social workers. The medical model leads the psychiatrist to suppose that the essential treatments lie in such things as ECT or drugs, which give him the power to control and change behaviour. In applying these treatments he is able to maintain a professional detachment. The therapist guided by an 'interaction' model sits with the patient, or with the patient and spouse, and tries to help him define and understand the conflicts in his relationships and to give him courage to do something about them. In order to mediate in this way, he nurtures his relationship with the patient. Since it is the patient who is to act in order to put right what has gone wrong, the therapist divests himself, so far as he can, of the power the patient attributes to him and expects him to use. He may manage to treat the patient against his wishes without doing serious harm if he is aware of the effects such treatment may have on their relationship and if he takes steps to counterto
act them.
A
turning point
is at a turning point. Psychiatrists should take pains to reassure the general public that in the tradition of medicine the patient's benefit is their primary concern, that within medicine their special contribution lies in the field of relationships and, within social work, the bringing together of explanations based on the complementary 'medical' and 'interaction' models, and that they exercise skills and not power. They should give up anything that might be seen as a God-like stance and sit down with the
Psychiatry
patient.
