Informed B
Consent
GRACE
B. OLIN.
in Voluntary MA..
AM)
Mental
HARRY
S.
OLIN.
Hospital
Admissions
M.D.
The authors studied the amount ofunderstanding that 100 mental hospital patients had ofa voluntart’ admission application they signed upon entering the hospital. Only 8 patients were rated as being completely informed ofthe terms ofthe contract at the time of admission; 15 of33 patients reinterviewed about 10 days after admission showed increased understanding. Minimal differences werefound between 81 state hospital patients and I 9 private hospitalpatients. Thefinding that few voluntary patients arefully informed to give consent to hospitalization poses a dilemma because ofthe trend to give personal responsibility to the patient.
notice of wanting provisions, Szasz lutely
free
filled with confusion for the already disturbed patient. In Massachusetts, however, all patients not committed by a court are legally required to make an important decision at the time of admission; they must choose between becoming a voluntary patient or an involuntary patient. Voluntary admissions have increased nationwide, and this has been especially true in Massachusetts because of TO A MENTAL
a November
1971
that prospective portunity to
change
HOSPITAL
in the
usually
15
a time
admission
laws
civil patients be presented sign into a mental hospital
requiring
with the opas voluntary
(2)
tary
patients
that
the
and
are
free
hospitals
continued
a major sent (3).
The
debate
vast
to leave
the
hospital
in
on
his voluntary
of the
terms
to the
purpose
status
of
is
to
are
con-
derived
and
discharges,
atti-
opinions
defining
“vol-
patient
can
of our
study
not compremeaning and
be questioned.
was
to examine
hospitalized
admission.
the
patients
We
hospital a patient’s
voluntary
his
coercion
if a patient does the contract’s
that
the
voluntarism
arguments
court
to a mental between
cleared, would
both
or
of voluntary
understanding
and
in court
that
from
admissions
understanding
that on admission inverse relationship
confusion
a hearing
and
moving
contract,
value of
have
since
hend
amount
to
patient
toward treatment, patient.” However,
primary
time
re-
tudes untary
The
of volun-
at any
hardly
hospitalization
is valid,
therapeutic
in jail.
majority
in order
therefore
landmark
statistics
a prisoner
the
He are by
is
mental
like
that
like a prison. a small number of patients who to themselves or others are detained
hospital
garding
the hospital. Because of these that the patient is not abso-
is more
argued
that only dangerous
from
ADMISSION
to leave
McGarry
stated judged
to leave contended
have
hypothesized
there would be an confusion and his
contract.
As
understanding
of
the
his
patient’s
voluntary
increase.
patients.
The voluntary tween been
prospective
patient’s
admission patient given
seems
and to
the
hospital. amount
understanding
of beHowever, little attention has of understanding that the made with the hospital when basic
for
of the terms
a valid
has of the contract he voluntarily admits himself. The meaning of voluntary status Szasz (1) stressed the idea that voluntary ten a “covert form of involuntary patient
contract
is
itself debated. admission is ofmental hospitalization.” Involuntary provisions contained in the conditional voluntary contract may be used by hospital authorities to petition the court for involuntary commitment in the event that a patient who is thought likely to cause serious harm to himself or others gives written
METHOI)
100 newly
A total of domly selected
during
were
interviewed,
their
comprehension
of the patients State Hospital,
conducted ter
a few
AmJ
Psychiatry
132:9, September
1975
patients
period
a questionnaire
oftheir had and
of
designed
voluntary
status.
been recently admitted 19 were in a small private
minutes
after
ran-
the
study
to rate Eighty-one
to
Medfield psychiatric
were between the ages 32. The interviews were
admission
to one
week
af-
admission.
Thirty-three
938
using
voluntary
3-month
hospital. All ofthe patients studied of 16 and 73; the median age was
at Medfield State Hospital were 5 days after admission and again approximately 10 days after admission. The purpose of the second interview was to determine what shift, if any, took place in the individual’s understanding of his voluntary status. The 19 voluntary patients in the private psychiatric hospital were interviewed once to ascertain if interviewed
Ms. Olin is Research Assistant, Medfleld State Hospital, and Dr. Olin was Director of Psychiatry, South Shore Unit, Medfield State Hospital, Medfield, Mass. Dr. Olin is now Acting Chief of Psychiatry, Veterans Administration Hospital, Brockton, Mass. Address reprint requests to Ms. Olin at 55 Windsor Rd., Waban, Mass. 02168.
admitted the
there
patients
twice,
were
any
once
gross
within
differences
in
understanding
be-
GRACE
tween patients hospitalized in a larger state hospital and those in a smaller private hospital. Since there were relatively fewer newly admitted patients in the private psychiatric hospital, the interviewer (G.B.O.) studied all of the available voluntary patients there. When interviewed, these 19 patients had been hospitalized from a few days to nearly 1 year. When the interviewer was present during the admission procedure, she noted the careful manner in which the voluntary contract was explained to the patients in both hospitals. The
Admission
Contract
All 100 ofthe interviewed patients had signed an application for voluntary admission, which is based on Sections 10 and 1 1 of Chapter 123 of the Massachusetts General Laws. The terms of the voluntary admission application are presented in Appendix I. This contract is signed by the patient in the hospital at the time of admission. Approximately 60 percent of all Medfield State 1-lospital patients were brought to the hospital involuntarily in accordance with Section 12 ofChapter 123 ofthe Massachusetts
General
Laws,
by
which
involuntary
admission
for 10 days is requested. This temporary involuntary admission paper is usually made out by a physician outside of the hospital who thinks that hospitalization is urgent and necessary, despite the patient’s refusal. Except for some categories of court-committed patients, all mental hospital patients, including those involuntarily
by law patients The
admitted
be offered at the time
in accordance
an opportunity of admission.
with
to
Section
become
Levels
the
voluntary
a group
S.
of
OLIN
100
pa-
of Understanding
RESULTS
Only 8 of the 100 patients were rated as fully informed concerning the terms of their voluntary admission at the time of the first interview. The number of patients rated at each of the levels of understanding defined above is shown in table 1. Most of the patients in both hospitals were scored at the second, third, and fourth levels. It is of interest to compare the patients rated at level 1
TABLE
contract
to have
HARRY
The patients’ responses to the questionnaire were rated as to the level of understanding shown by the patient. The following five levels of understanding were determined: 1. Irrelevant response: patient answered questions, but answers had no apparent logical meaning. 2. Patient responsive to questions but had no information, e.g., “I don’t know.” 3. Patient responsive to question but had erroneous information, e.g., “I signed myself in for 10 days.” 4. Patient had incomplete information, e.g., the patient was aware that he could write a “3-day letter” but was not aware that the court could be petitioned for involuntary commitment. 5. Patient had complete information.
Lerel.s Pnirate
to
omitted in order identically.
AND
12, must
By personally interviewing each ofthe 100 patients, interviewer minimized ambiguity and misunderstanding of the questionnaire. The interviewer directed attention
were rated
OLIN
voluntary
Questionnaire
patient’s
dom tients
B.
he
1 of L nderstanding of 81 Medfield Psychiatric Hospital Patients
the each
Num
ber
Level
Patient
Group
Medfield Private Total
State Hospital psychiatric hospital
State
Hospital
Patient.c
2 Level
19
Le vel of
of Patients at Each U nderstanding
I Level
and
4 Level
3 Level
5
made
(e.g., “the white paper that you signed in the admission room”). Emphasis was placed on the patient’s answering the questions in his own words. The four following questions comprised the questionnaire: 1 ) What is your understanding of voluntary admission to the hospital? 2) How does a patient get out of the hospital? 3) What could a patient do to initiate his release from the hospital? 4) What are the terms of the agreement for care and treatment in the hospital? The interviewer repeatedly attempted to clarify the patients’ answers in order to rate their levels of understanding. Patients often demonstrated knowledge that spanned two levels; however, we chose the level that most of the responses reflected. Initially, 90 Medfield State Hospital patients were studied; this group plus the 19 private hospital patients totaled 109. The responses of 101 patients were rated identically by both raters; the raters differed on 8 cases. Seven of the 8 dissimilar ratings occurred in the twiceinterviewed group, and 1 occurred with a once-interviewed patient. These 8 cases plus I case chosen at ran-
TABLE
Diagnoses Lnderstanding
II 2 13
16 2 18
18 6 24
28 9 37
8 0 8
2 and
Previous Was Rated
Psychiatric at Level
A dmissions / and at Level
Number Rated
Item
of
Patients
Whose
5
of Patients at Level I
Nu mber R ated
of Patients at Level 5
Diagnosis Organic brain syndrome Schizophrenia Manic-depressive psychosis Personality disorder Neurosis Adjustment reaction Previous psychiatric admissions
AmJ
Psychiatry
3 6 1 I 0 2
0 1 0 2 4 I
6
3
132:9, September
1975
939
INFORMED
TABLE
CONSENT
IN
VOLUNTARY
ADMISSIONS
3
Shi/t.s in Levels tient.s Interviewed
of
Understanding Twice Number
Item
Level
of
of Patients I
Medfield
at Each
Level
4 I
First interview Second intervies
33
2
Level
State
L evel 3
Pa-
of Understanding Level
8 10
7 5
Hospital
4
Level
II 9
5
3 8
to this hospital entered as voluntary patients, a rise to over7l percent. The increasing number of voluntarily admitted patients reflects a steady progress in the treatment of emotional disorders. We concur with the view that the patient’s personal participation in his hospitalization begins with his signing in as a voluntary patient. This study’s major finding, however, is that only 8 out of 100 patients were judged to be fully informed concerning voluntary admission when interviewed shortly after
understanding with those rated at level 5 by diagnosis and previous psychiatric admissions (see table 2). It is apparent that the more seriously disturbed patients, especially those with a thought disorder or an organic impairment, were scored at level I. Thirty-three of the 8 1 Medfield State Hospital patients were interviewed twice. Fifteen demonstrated’a shift toward increased understanding (see table 3). The largest gain was made in level 5; 3 patients showed this level of understanding
scored patients
during
at
this
who
level were
the
first
during
the
scored
at level
interview,
second.
but
The
I decreased
8
from
4 to
some
patients
of their ter
a request
voluntary
voluntary
for
voluntary
admissions
(4).
In
1949,
however,
voluntary admissions constituted only 10 percent of 138,253 admissions to state mental hospitals (4). By 1961, the voluntarily admitted patients had increased to nearly 24 percent of all admissions (4). The mental hospital admission laws of Massachusetts, which were revised in November 1971, heavily favor voluntary admissions. In 1970, there were 83 voluntary patients out of 936 admissions to Medfield State Hospital, nearly 9 percent. Two years later, in 1972, 572 of the 801 patients admitted
940
AmJ
Psychiatry
132:9, September
1975
were
surprised
to leave
to leave;
patients
1.
In 1881, Massachusetts became the first state to provide for voluntary admissions to state mental hospitals (4). Forty-nine of the 50 United States now have leg-
of
demonstrated patients
able
form
voluntary
DISCUSSION
consequences
that
they
minimal
knowledge
by the 92 uninformed are many. For example,
the
there
was
hospital
were
no
assurance
within
unaware
3 days
of the
af-
existence
of a court procedure to detain them if necessary. Some patients felt betrayed when they found this out. Over half of the patients were initially involuntarily admitted to the hospital for 10 days; many of these temporarily inwere
they
unaware
signed
admission.
patients
foronly
that
Confusion
stated
the
supplanted that
they
voluntary
the
ad-
10-day
was
revealed
were
in the
inwhen
hospital
10 days.
The weeks
search for accurate knowledge during the initial of hospitalization seemed to occupy a large part of the patients’ attention. How do I get out of here?” was too often their focus, rather than “What can I get out of being here?” At the private hospital, where most of the patients interviewed were not seen immediately after admission, there seemed to be less concern about discharge. These patients may have expressed concern about dis“
charge with
doned. mental cause
earlier or their families
They might illness and the
surroundings
may and
have friends
have might
maintained and thus
been more have felt of the
private
better contact felt less aban-
sophisticated less stigmatized hospital
were
about bemore
pleasant than those of the state hospital. The massive lack ofcomprehension by patients of their voluntary status is clear, but what can be done? Our original hypothesis that newly admitted confused patients would show a shift toward increased understanding in a relatively
islation
being
of
Three patients shifted backwards; I of these openly wished to remain in the hospital. The level of understanding of I 5 patients was unchanged. An impression gained by the interviewer was that some patients tended to avoid responsible participation in their own care. For instance, a 25-year-old patient rated at 1evel 4 stated, “Ifyou want to leave, you write to the superintendent. You’re supposed to give 3 days’ notice.” When the interviewer asked what would happen when a request for discharge was denied, this patient replied, “The patient would be disappointed, but the doctor knows best.” Other patients emphasized that they had to be “good” in order to “earn” their way out of the hospital. Many patients confused Sections 10 and 1 1 with Section 12 of the admission laws. One voluntarily admitted woman said she would be “free to leave in 3 days to 10.” Here it seemed that the 3-day notice and the 10-day term of involuntary admission were confused with each other.
The
knowledge informed
mission
were
number
admission.
or partial orpartially
short
time
was
proved
by
our
findings.
I-low-
ever, given the current focus on the individual’s rights, it would be regressive to defer voluntary contract decision making until after the patient has been hospitalized. In Massachusetts and in the other 48 states that have provisions for voluntary mental hospital admission there are probably thousands of patients with only partial or no understanding of their voluntary admission status. The dilemmas that these patients confront us with are two: How can a patient participate in his treatment as a voluntary patient without a full understanding of his voluntary admission contract’ The second dilemma concerns current social policies, legal trends, and treatment practices. Social policies, as reflected in mental health legislation and recent court decisions, are increasingly recognizing that autonomy and responsibility reside in the individual’s own decisions, even if the individual is mentally ill.
GRACE
Yet the majority of the individuals in this study did not or could not act on their own behalf in a fully autonomous, responsible manner. In the resolution of these dilemmas lies the practical meaning to our social policies, court decisions, and treatment practices.
REFERENCES
I. Szasz
TS: Voluntary mental hospitalization: an unacknowledged practice of medical fraud. N EngI J Med 287:277-278, 1972 2. McGarry AL, Greenblatt M: Conditional voluntary mental hospital admission. N EngI J Med 287:279-280, 1972 3. McGarry AL: Law-medicine notes. From coercion to consent. N EngI J Med 274:39, 1966 4. Brakel vised
SJ, Rock ed. Chicago,
RS (eds): The Mentally University
of Chicago
Disabled Press,
and the Law, re1971.
pp 15-26
APPENDIX I Items on the Massachusetts tional Voluntary Basis
B.
OLIN
Application
AND
for
HARRY
Care
S.
OLIN
on a Condi-
1. I wish to be admitted in the above facility on a conditional voluntary basis for care and treatment for the following problem: 2. I understand that I am free to leave at any time if I give written notice to the Superintendent, provided, however, that the Superintendent may, in his discretion, delay my departure for at least three days from the time of my notice, and also may petition the district court for my further retention if it appears necessary to him. 3. I understand that during my hospitalization and any aftercare I will be provided with care and treatment which may include the injection of medicines. 4. Identifying data:
Am
I Psychiatry
132:9, September
1975
941
Consent
GRACE
B. OLIN.
in Voluntary MA..
AM)
Mental
HARRY
S.
OLIN.
Hospital
Admissions
M.D.
The authors studied the amount ofunderstanding that 100 mental hospital patients had ofa voluntart’ admission application they signed upon entering the hospital. Only 8 patients were rated as being completely informed ofthe terms ofthe contract at the time of admission; 15 of33 patients reinterviewed about 10 days after admission showed increased understanding. Minimal differences werefound between 81 state hospital patients and I 9 private hospitalpatients. Thefinding that few voluntary patients arefully informed to give consent to hospitalization poses a dilemma because ofthe trend to give personal responsibility to the patient.
notice of wanting provisions, Szasz lutely
free
filled with confusion for the already disturbed patient. In Massachusetts, however, all patients not committed by a court are legally required to make an important decision at the time of admission; they must choose between becoming a voluntary patient or an involuntary patient. Voluntary admissions have increased nationwide, and this has been especially true in Massachusetts because of TO A MENTAL
a November
1971
that prospective portunity to
change
HOSPITAL
in the
usually
15
a time
admission
laws
civil patients be presented sign into a mental hospital
requiring
with the opas voluntary
(2)
tary
patients
that
the
and
are
free
hospitals
continued
a major sent (3).
The
debate
vast
to leave
the
hospital
in
on
his voluntary
of the
terms
to the
purpose
status
of
is
to
are
con-
derived
and
discharges,
atti-
opinions
defining
“vol-
patient
can
of our
study
not compremeaning and
be questioned.
was
to examine
hospitalized
admission.
the
patients
We
hospital a patient’s
voluntary
his
coercion
if a patient does the contract’s
that
the
voluntarism
arguments
court
to a mental between
cleared, would
both
or
of voluntary
understanding
and
in court
that
from
admissions
understanding
that on admission inverse relationship
confusion
a hearing
and
moving
contract,
value of
have
since
hend
amount
to
patient
toward treatment, patient.” However,
primary
time
re-
tudes untary
The
of volun-
at any
hardly
hospitalization
is valid,
therapeutic
in jail.
majority
in order
therefore
landmark
statistics
a prisoner
the
He are by
is
mental
like
that
like a prison. a small number of patients who to themselves or others are detained
hospital
garding
the hospital. Because of these that the patient is not abso-
is more
argued
that only dangerous
from
ADMISSION
to leave
McGarry
stated judged
to leave contended
have
hypothesized
there would be an confusion and his
contract.
As
understanding
of
the
his
patient’s
voluntary
increase.
patients.
The voluntary tween been
prospective
patient’s
admission patient given
seems
and to
the
hospital. amount
understanding
of beHowever, little attention has of understanding that the made with the hospital when basic
for
of the terms
a valid
has of the contract he voluntarily admits himself. The meaning of voluntary status Szasz (1) stressed the idea that voluntary ten a “covert form of involuntary patient
contract
is
itself debated. admission is ofmental hospitalization.” Involuntary provisions contained in the conditional voluntary contract may be used by hospital authorities to petition the court for involuntary commitment in the event that a patient who is thought likely to cause serious harm to himself or others gives written
METHOI)
100 newly
A total of domly selected
during
were
interviewed,
their
comprehension
of the patients State Hospital,
conducted ter
a few
AmJ
Psychiatry
132:9, September
1975
patients
period
a questionnaire
oftheir had and
of
designed
voluntary
status.
been recently admitted 19 were in a small private
minutes
after
ran-
the
study
to rate Eighty-one
to
Medfield psychiatric
were between the ages 32. The interviews were
admission
to one
week
af-
admission.
Thirty-three
938
using
voluntary
3-month
hospital. All ofthe patients studied of 16 and 73; the median age was
at Medfield State Hospital were 5 days after admission and again approximately 10 days after admission. The purpose of the second interview was to determine what shift, if any, took place in the individual’s understanding of his voluntary status. The 19 voluntary patients in the private psychiatric hospital were interviewed once to ascertain if interviewed
Ms. Olin is Research Assistant, Medfleld State Hospital, and Dr. Olin was Director of Psychiatry, South Shore Unit, Medfield State Hospital, Medfield, Mass. Dr. Olin is now Acting Chief of Psychiatry, Veterans Administration Hospital, Brockton, Mass. Address reprint requests to Ms. Olin at 55 Windsor Rd., Waban, Mass. 02168.
admitted the
there
patients
twice,
were
any
once
gross
within
differences
in
understanding
be-
GRACE
tween patients hospitalized in a larger state hospital and those in a smaller private hospital. Since there were relatively fewer newly admitted patients in the private psychiatric hospital, the interviewer (G.B.O.) studied all of the available voluntary patients there. When interviewed, these 19 patients had been hospitalized from a few days to nearly 1 year. When the interviewer was present during the admission procedure, she noted the careful manner in which the voluntary contract was explained to the patients in both hospitals. The
Admission
Contract
All 100 ofthe interviewed patients had signed an application for voluntary admission, which is based on Sections 10 and 1 1 of Chapter 123 of the Massachusetts General Laws. The terms of the voluntary admission application are presented in Appendix I. This contract is signed by the patient in the hospital at the time of admission. Approximately 60 percent of all Medfield State 1-lospital patients were brought to the hospital involuntarily in accordance with Section 12 ofChapter 123 ofthe Massachusetts
General
Laws,
by
which
involuntary
admission
for 10 days is requested. This temporary involuntary admission paper is usually made out by a physician outside of the hospital who thinks that hospitalization is urgent and necessary, despite the patient’s refusal. Except for some categories of court-committed patients, all mental hospital patients, including those involuntarily
by law patients The
admitted
be offered at the time
in accordance
an opportunity of admission.
with
to
Section
become
Levels
the
voluntary
a group
S.
of
OLIN
100
pa-
of Understanding
RESULTS
Only 8 of the 100 patients were rated as fully informed concerning the terms of their voluntary admission at the time of the first interview. The number of patients rated at each of the levels of understanding defined above is shown in table 1. Most of the patients in both hospitals were scored at the second, third, and fourth levels. It is of interest to compare the patients rated at level 1
TABLE
contract
to have
HARRY
The patients’ responses to the questionnaire were rated as to the level of understanding shown by the patient. The following five levels of understanding were determined: 1. Irrelevant response: patient answered questions, but answers had no apparent logical meaning. 2. Patient responsive to questions but had no information, e.g., “I don’t know.” 3. Patient responsive to question but had erroneous information, e.g., “I signed myself in for 10 days.” 4. Patient had incomplete information, e.g., the patient was aware that he could write a “3-day letter” but was not aware that the court could be petitioned for involuntary commitment. 5. Patient had complete information.
Lerel.s Pnirate
to
omitted in order identically.
AND
12, must
By personally interviewing each ofthe 100 patients, interviewer minimized ambiguity and misunderstanding of the questionnaire. The interviewer directed attention
were rated
OLIN
voluntary
Questionnaire
patient’s
dom tients
B.
he
1 of L nderstanding of 81 Medfield Psychiatric Hospital Patients
the each
Num
ber
Level
Patient
Group
Medfield Private Total
State Hospital psychiatric hospital
State
Hospital
Patient.c
2 Level
19
Le vel of
of Patients at Each U nderstanding
I Level
and
4 Level
3 Level
5
made
(e.g., “the white paper that you signed in the admission room”). Emphasis was placed on the patient’s answering the questions in his own words. The four following questions comprised the questionnaire: 1 ) What is your understanding of voluntary admission to the hospital? 2) How does a patient get out of the hospital? 3) What could a patient do to initiate his release from the hospital? 4) What are the terms of the agreement for care and treatment in the hospital? The interviewer repeatedly attempted to clarify the patients’ answers in order to rate their levels of understanding. Patients often demonstrated knowledge that spanned two levels; however, we chose the level that most of the responses reflected. Initially, 90 Medfield State Hospital patients were studied; this group plus the 19 private hospital patients totaled 109. The responses of 101 patients were rated identically by both raters; the raters differed on 8 cases. Seven of the 8 dissimilar ratings occurred in the twiceinterviewed group, and 1 occurred with a once-interviewed patient. These 8 cases plus I case chosen at ran-
TABLE
Diagnoses Lnderstanding
II 2 13
16 2 18
18 6 24
28 9 37
8 0 8
2 and
Previous Was Rated
Psychiatric at Level
A dmissions / and at Level
Number Rated
Item
of
Patients
Whose
5
of Patients at Level I
Nu mber R ated
of Patients at Level 5
Diagnosis Organic brain syndrome Schizophrenia Manic-depressive psychosis Personality disorder Neurosis Adjustment reaction Previous psychiatric admissions
AmJ
Psychiatry
3 6 1 I 0 2
0 1 0 2 4 I
6
3
132:9, September
1975
939
INFORMED
TABLE
CONSENT
IN
VOLUNTARY
ADMISSIONS
3
Shi/t.s in Levels tient.s Interviewed
of
Understanding Twice Number
Item
Level
of
of Patients I
Medfield
at Each
Level
4 I
First interview Second intervies
33
2
Level
State
L evel 3
Pa-
of Understanding Level
8 10
7 5
Hospital
4
Level
II 9
5
3 8
to this hospital entered as voluntary patients, a rise to over7l percent. The increasing number of voluntarily admitted patients reflects a steady progress in the treatment of emotional disorders. We concur with the view that the patient’s personal participation in his hospitalization begins with his signing in as a voluntary patient. This study’s major finding, however, is that only 8 out of 100 patients were judged to be fully informed concerning voluntary admission when interviewed shortly after
understanding with those rated at level 5 by diagnosis and previous psychiatric admissions (see table 2). It is apparent that the more seriously disturbed patients, especially those with a thought disorder or an organic impairment, were scored at level I. Thirty-three of the 8 1 Medfield State Hospital patients were interviewed twice. Fifteen demonstrated’a shift toward increased understanding (see table 3). The largest gain was made in level 5; 3 patients showed this level of understanding
scored patients
during
at
this
who
level were
the
first
during
the
scored
at level
interview,
second.
but
The
I decreased
8
from
4 to
some
patients
of their ter
a request
voluntary
voluntary
for
voluntary
admissions
(4).
In
1949,
however,
voluntary admissions constituted only 10 percent of 138,253 admissions to state mental hospitals (4). By 1961, the voluntarily admitted patients had increased to nearly 24 percent of all admissions (4). The mental hospital admission laws of Massachusetts, which were revised in November 1971, heavily favor voluntary admissions. In 1970, there were 83 voluntary patients out of 936 admissions to Medfield State Hospital, nearly 9 percent. Two years later, in 1972, 572 of the 801 patients admitted
940
AmJ
Psychiatry
132:9, September
1975
were
surprised
to leave
to leave;
patients
1.
In 1881, Massachusetts became the first state to provide for voluntary admissions to state mental hospitals (4). Forty-nine of the 50 United States now have leg-
of
demonstrated patients
able
form
voluntary
DISCUSSION
consequences
that
they
minimal
knowledge
by the 92 uninformed are many. For example,
the
there
was
hospital
were
no
assurance
within
unaware
3 days
of the
af-
existence
of a court procedure to detain them if necessary. Some patients felt betrayed when they found this out. Over half of the patients were initially involuntarily admitted to the hospital for 10 days; many of these temporarily inwere
they
unaware
signed
admission.
patients
foronly
that
Confusion
stated
the
supplanted that
they
voluntary
the
ad-
10-day
was
revealed
were
in the
inwhen
hospital
10 days.
The weeks
search for accurate knowledge during the initial of hospitalization seemed to occupy a large part of the patients’ attention. How do I get out of here?” was too often their focus, rather than “What can I get out of being here?” At the private hospital, where most of the patients interviewed were not seen immediately after admission, there seemed to be less concern about discharge. These patients may have expressed concern about dis“
charge with
doned. mental cause
earlier or their families
They might illness and the
surroundings
may and
have friends
have might
maintained and thus
been more have felt of the
private
better contact felt less aban-
sophisticated less stigmatized hospital
were
about bemore
pleasant than those of the state hospital. The massive lack ofcomprehension by patients of their voluntary status is clear, but what can be done? Our original hypothesis that newly admitted confused patients would show a shift toward increased understanding in a relatively
islation
being
of
Three patients shifted backwards; I of these openly wished to remain in the hospital. The level of understanding of I 5 patients was unchanged. An impression gained by the interviewer was that some patients tended to avoid responsible participation in their own care. For instance, a 25-year-old patient rated at 1evel 4 stated, “Ifyou want to leave, you write to the superintendent. You’re supposed to give 3 days’ notice.” When the interviewer asked what would happen when a request for discharge was denied, this patient replied, “The patient would be disappointed, but the doctor knows best.” Other patients emphasized that they had to be “good” in order to “earn” their way out of the hospital. Many patients confused Sections 10 and 1 1 with Section 12 of the admission laws. One voluntarily admitted woman said she would be “free to leave in 3 days to 10.” Here it seemed that the 3-day notice and the 10-day term of involuntary admission were confused with each other.
The
knowledge informed
mission
were
number
admission.
or partial orpartially
short
time
was
proved
by
our
findings.
I-low-
ever, given the current focus on the individual’s rights, it would be regressive to defer voluntary contract decision making until after the patient has been hospitalized. In Massachusetts and in the other 48 states that have provisions for voluntary mental hospital admission there are probably thousands of patients with only partial or no understanding of their voluntary admission status. The dilemmas that these patients confront us with are two: How can a patient participate in his treatment as a voluntary patient without a full understanding of his voluntary admission contract’ The second dilemma concerns current social policies, legal trends, and treatment practices. Social policies, as reflected in mental health legislation and recent court decisions, are increasingly recognizing that autonomy and responsibility reside in the individual’s own decisions, even if the individual is mentally ill.
GRACE
Yet the majority of the individuals in this study did not or could not act on their own behalf in a fully autonomous, responsible manner. In the resolution of these dilemmas lies the practical meaning to our social policies, court decisions, and treatment practices.
REFERENCES
I. Szasz
TS: Voluntary mental hospitalization: an unacknowledged practice of medical fraud. N EngI J Med 287:277-278, 1972 2. McGarry AL, Greenblatt M: Conditional voluntary mental hospital admission. N EngI J Med 287:279-280, 1972 3. McGarry AL: Law-medicine notes. From coercion to consent. N EngI J Med 274:39, 1966 4. Brakel vised
SJ, Rock ed. Chicago,
RS (eds): The Mentally University
of Chicago
Disabled Press,
and the Law, re1971.
pp 15-26
APPENDIX I Items on the Massachusetts tional Voluntary Basis
B.
OLIN
Application
AND
for
HARRY
Care
S.
OLIN
on a Condi-
1. I wish to be admitted in the above facility on a conditional voluntary basis for care and treatment for the following problem: 2. I understand that I am free to leave at any time if I give written notice to the Superintendent, provided, however, that the Superintendent may, in his discretion, delay my departure for at least three days from the time of my notice, and also may petition the district court for my further retention if it appears necessary to him. 3. I understand that during my hospitalization and any aftercare I will be provided with care and treatment which may include the injection of medicines. 4. Identifying data:
Am
I Psychiatry
132:9, September
1975
941
