International Journal of Law and Psychiatry 38 (2015) 44–50

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International Journal of Law and Psychiatry

The experiences of the legal processes of involuntary treatment orders: Tension between the legal and medical frameworks Marianne Wyder a,⁎, Robert Bland a, Ann Herriot b, David Crompton c a b c

School of Social Work and Human Services, University of Queensland, Brisbane 4072, Australia Queensland Public Interest Law Clearing House Incorporated, Brisbane 4101, Australia Metro South Hospital and Health Service, Brisbane, Australia

a r t i c l e

i n f o

Available online 21 March 2015 Keywords: Involuntary treatment orders Recovery oriented practice Therapeutic jurisprudence

a b s t r a c t 3An involuntary treatment order (ITO) allows a person to be treated for a mental illness without consent under some circumstances. While the treatment and assessment of mental illness are essentially clinical decisions, involuntary mental health admissions are governed by a framework of legal principles, safeguards and procedures. The underlying philosophy of these laws is based on therapeutic jurisprudence. This approach focuses on the importance of the legal process as a social force and suggests that this can either protect or empower people. The legal processes can however adversely impact upon people's states of mind. This study reports on 25 qualitative interviews with involuntary inpatients of a major teaching hospital. The interviews were analysed thematically using a general inductive approach. The analysis focused on the patients' general experience of being placed under an ITO and their understanding of the ITO process. Generally, those who described the experience of an ITO in more positive terms, also experienced the ITO as a positive right. In addition to providing them with the treatment needed, they also felt that the ITO gave them protection and guidance. Conversely, those who experienced being placed under an ITO in more negative or mixed ways, described feeling powerless in the process, as they felt that the ITO took away their rights. By and large the ITO process was experienced as arbitrary when patients did not understand the reasons for their admission. In addition, these patients had limited or no information about their involuntary treatment order and they did not know what was expected of them to have the ITO revoked. Most importantly, they did not feel that there were any meaningful legal protections in place. These experiences highlight the importance of the legal processes and how these can be used as clinical tools. © 2015 Published by Elsevier Ltd.

1. Introduction The experience of a serious mental illness can be a profoundly life changing event. While most people who develop a mental illness recover without the need for hospitalisation, some will require an involuntary admission to a psychiatric hospital where they receive treatment against their will (Morgan et al., 2010). While most involuntary patients are treated in the community, a significant minority is treated as inpatients in a hospital. Some of these may remain on an involuntary order and receive treatment in the community. This paper concentrates on the experience of one group of in-patients who are on involuntary treatment orders. From a human rights perspective, taking away a person's rights to refuse treatment is one of the most serious actions that can be taken against an individual and represents a serious intrusion into a person's liberty and physical integrity (Bland, Renouf, & Tullgren, 2009; McSherry, 2008). Yet a person with a serious mental illness may also

⁎ Corresponding author. E-mail address: [email protected] (M. Wyder).

http://dx.doi.org/10.1016/j.ijlp.2015.01.006 0160-2527/© 2015 Published by Elsevier Ltd.

need involuntary treatment or admission to protect the patient or the community from harm to themselves or others (Campbell, 2008; Fawcett, 2007; Hatfield & Antcliff, 2001). For individuals whose psychotic illness substantially impairs their decision-making, mandatory treatment may offer the best hope of becoming well enough for them to actively participate in their recovery (Hatfield & Lefley, 1987; Wallsten, Ostman, Sjoberg, & Kjellin, 2008). Mental health laws in Australia are a state or territory responsibility. Each state and territory in Australia has legislation that, under certain circumstances, enables people with a mental illness to be detained and treated without their consent. Although there is no national human rights charter or bill of rights mental health legislation has been drafted to varying degrees with regard to various international human rights instruments including: the International Covenant on Civil and Political Rights (ICCPR), International Covenant on Economic, Social and Cultural Rights (ICESCR), United Nations Principles for the Protections of Persons (the MI Principles) with Mental illness and the International Convention on the Rights of Persons with Disabilities (CRPD) to which Australia is a signatory. The CRPD is the most recent international instrument and supersedes the MI Principles to the extent of any inconsistency between them.

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The degree of compliance of state and territory legislation with international human rights obligations, and the CRPD and the MI Principles in particular, varies between jurisdictions. Victoria and ACT are the only states or territories that have adopted specific domestic human rights legislation (Charters of Human Rights and Responsibilities). In both Victoria and ACT, the Charters incorporate civil rights obligations and require agencies and legislation to consider international obligations (Carney & Beaupert, 2008). Mental health legislation in all Australian states and territories, aims to balance the many conflicting individual and community interests by providing statutory safeguards to allow for the lawful detention and treatment of patients while ensuring that the patient's rights are respected. The fundamental aim of mental health legislation is to protect, promote and improve the lives and wellbeing of citizens. Mental health legislation aims to strike a balance between clinical concerns that promote individual wellbeing, public safety and legal rectitude (Carney, 2003; McKenna, Simpson, Coverdale, & Laidlaw, 2001). Australian mental health legislation is founded on the following principles: 1) the promotion of autonomy; 2) accessibility of mental health services; 3) establishment of a clear set of objective criteria for involuntary mental health admissions; 4) the provision of structural protections for involuntary committed persons, including the right to review and appeal compulsory treatment or hospital admission; and, 5) the prevention of inappropriate restrictions on autonomy and liberty such as rights to freedom of association, confidentiality and having a say in their treatment plans (Carney, 2003; McSherry & Weller, 2010). Autonomy and access to services are not only key principles from a human rights perspective but are also cornerstones of recovery oriented practice. Over the past ten years, there has been a major shift in mental health care delivery and recovery oriented care is now a central organising concept for mental health services internationally and in Australia (Meadows et al., 2012). A recovery philosophy emphasises the importance of hope, empowerment, choice, connectedness, identity, responsibility and exercising citizenship (Davidson, O'Connell, Tondora, & Lawless, 2005; Leamy, Bird, Le Boutillier, Williams, & Slade, 2011). Recovery does not mean cure, and beginning the journey of recovery does not depend on getting effective treatment first. While the principles of self-sufficiency, self-advocacy, control and having input into their own treatment, may appear to have limited relevance to involuntary treatments, qualitative studies have suggested that the concepts of hope, relationships but also control remain particularly relevant to involuntary settings (Wyder, Bland, & Crompton, 2012). The evolving legislative framework in Australian jurisdictions has implicitly incorporated an underlying philosophy of therapeutic jurisprudence which seeks to recognise the therapeutic and antitherapeutic impact of the law and legal institutions in the broader context of a person's life. This approach recognises that legal processes can protect and empower people but can also have an adverse impact upon a person's states of mind (Freckelton, 2003). Therapeutic jurisprudence in the context of mental health treatment aims to balance the protection of individual liberties with the clinical agendas and tries to incorporate the values and considerations of both for the benefit of the patient. It does this by ensuring clinical objectives, appropriate legal safeguards and procedural rights and broader social considerations are taken into account in involuntary mental health decisions (Carney, Tait, Perry, Vernon, & Beaupert, 2011). It has been suggested that the most important component is a person's sense of satisfaction with decision-making processes and their perception of fairness rather than the actual outcome (Wales, Hiday, & Ray, 2010). In this sense it is important for a person not only to understand the legal processes involved but also to have a sense of procedural justice or “fairness”. In the Australian context, unlike that in North America, legal oversight of the decision to place a person on

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an involuntary treatment order is conducted by a specialist multidisciplinary mental health review tribunal (MHRT) rather than a court. In Queensland, where the study was conducted, the MHRT is composed of a lawyer, a psychiatrist and a community member (Carney, Tait, & Beaupert, 2008). Australian MHRTs are generally bound by the rules of natural justice (procedural fairness) and are inquisitorial rather than adversarial and are conducted in a relatively informal manner. These features are best understood through the therapeutic jurisprudence lens in that they aim to produce both a clinically correct and legally justifiable decision that neither a purely medical or purely legal approach could achieve alone. Procedural fairness is a well understood legal concept which involves three elements: the right to a fair hearing, the right to an unbiased decision-maker and the right for any decision affecting a person's interest to be made on rational evidence. The fair hearing rule requires that a person be given notice of the hearing, the opportunity to contribute and participate in the hearing and that he or she knows what is being alleged against them. The bias rule requires that the decision maker is independent and that there is no actual or perceived bias. In the context of mental health reviews, this means ensuring that patients understand that the tribunal is not part of the health system and that it is not “on the doctor's side”. Finally, there must be rational evidence on which the decision is based and that the person should have the opportunity to provide explanatory or contradictory evidence. The vast majority of ITOs are confirmed at review hearings which makes it more difficult but even more important to assure patients of the independence of the MHRT through information and structure. In summary, while the assessment and treatment of mental illness are essentially clinical decisions, involuntary mental health admissions are governed by a framework of legal principles, safeguards and procedures. Medical practitioners are given the legal authority to make the decision about who should be committed and treated involuntarily. These decisions however are made in a legal framework with various safeguards, which determine whether the treatment criteria have been satisfied. For the purposes of involuntary treatment then, medical practitioners are statutory decision-makers and must conform to the legal principles of natural justice and reviewability in making their clinical decisions. Clinical factors undoubtedly influence how involuntary treatments are experienced. Patients who viewed themselves as being ill, had fewer illness symptoms and agreed that they needed treatment also had a greater perception of effectiveness as well as fairness of involuntary treatment (Richardson & Machin, 2000; Swartz, Wagner, Swanson, & Elbogen, 2004). It is also possible that the perception of being treated fairly, of clear legal processes, and “procedural justice”, has the potential to influence clinical outcomes. It has been shown that the way commitment or review hearings are conducted influences clinical treatment outcomes (Galon & Wineman, 2010; Tyler, 1992) and involuntary patients may perceive the ITO as less coercive if they are treated with respect and are afforded procedural justice (Swartz et al., 2004). These findings demonstrate that the legal process governing involuntary admissions plays an important role in people's perceptions of care and treatment. Despite the potential serious consequences of an involuntary mental health admission on human rights, the importance of procedural justice and the long term recovery journey, there is limited information around how the legal processes are experienced and understood by people who are placed under an ITO. This article reports on the experiences of twenty-five patients who have been admitted to an inpatient unit of a major teaching hospital under an endorsed ITO. The analysis focuses on the experiences and understandings of the legal process involved in an ITO and (when relevant) their experiences with the Mental Health Tribunal (MHT).

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2. Methods 2.1. Recruitment and interviews As we were interested in the lived experience of being placed under an ITO we adopted a qualitative research methodology. Twenty-five people who were admitted under an endorsed involuntary treatment order to a large metropolitan based hospital were interviewed about their experiences of being under an ITO in hospital. Only patients close to being discharged from hospital were interviewed. Daily referrals were obtained from the multidisciplinary treatment team. Patients were first approached by a member of the hospital staff and asked if they would agree to be approached by the research team. Only if the patient agreed would they be approached by the researcher who would then outline the study and seek informed consent to participate. The interviews followed a semi-guided interview outline with topic areas to be covered. This format allowed us to pursue interesting leads and unanticipated topics. The topic guide included pathways to hospital, understanding and experiences of being under an ITO, experience of involuntary treatment and MHT. All interviews started with the question: “Tell me what happened leading up to your admission”. With their permission these interviews were taped. When participants felt uncomfortable with having their interviews taped, copious notes were taken throughout the interview. The interviews lasted between 20 min and 2h and were conducted by MW. Throughout the interview we adopted a stance of ‘conscious partiality’ where we deliberately focused on the participants' version of events (Miess, 1983). Furthermore, as we focused on perceptions of care and wanted to understand their experiences we did not check their version of events with the health care professionals or their files. As part of the study we also interviewed health care professionals and families about their experiences with ITOs. The results of these interviews will be reported elsewhere. 2.2. Data analysis An interpretivist approach underpins this research. In this approach interpretations of the social world are culturally derived and historically situated. A general inductive approach was used for the analysis. This approach enables varied raw text data to be condensed into a brief summary format. It then establishes clear links between the research objectives and the summary findings derived from the raw data. This then allows the development of a model or theory about the underlying structure of experiences, which are evident in the raw data (Mason, 2002). The data was analysed in different stages. In the first stage we undertook a narrative restructuring of the data. This stage involved the transcription of the tapes that were then written up into case summaries. In these files the data was structured into overarching themes such as experience of the ITO or illness history. To ensure that the case summary reports remained as close as possible to what the participants experienced, the transcripts on which the summaries were based were also included in these files. All parts of the transcripts – even when the participants digress from their story – were included at the end of these summary files. These case summaries were then cross checked. Where the interpretations differed the authors had detailed discussion and reached a consensus. The next stage involved the coding of these summary files. In this stage overarching and subthemes were developed inductively. The summary files and transcripts were thematically coded. The data was managed in NVIVO 9.2. 2.3. Ethical concerns The decisional capacity of people with severe mental illness has been the focus of much debate. While in the past it was thought that people with a mental illness on involuntary treatment orders could not give

informed consent, recent research suggests that when psychiatric symptoms improve, patients can consent (Kallert, Glöckner, & Schützwohl, 2008) and that a functional approach is ethically better than a categorical approach (Appelbaum & Grisso, 1995; Van Staden, 2010). In this approach, a patient's capacity to give informed consent is not assumed on the basis of his/her belonging to a legal category, but is clinically assessed on the basis of the following: 1) understanding the research proposal; 2) choosing decisively for or against participation; and, 3) communicating his or her choice (Van Staden, 2010). In this study we viewed informed consent as a process where, when necessary, participants were reminded throughout the interview of the purpose of the study. During the informed consent procedure the researcher made sure that the research participants were aware of their rights as research participants, the limits of the confidentiality and understood that the researcher was not part of the treatment team. The consent and participant information forms were also written in a language that was easy to understand. In addition, prior to each interview the main interviewer would take participants through the main points and make sure that they understood the content, that they did not have to participate if they did not want to, that they did not have to answer any of the questions and that they could withdraw or stop the interview at any time. This research project has received ethics approval by the University of Queensland and Queensland Health. 3. Results 3.1. Sample description Thirty-two patients were approached, 6 did not want to participate. One person was excluded as the researcher did not think that he was able to give informed consent. Twenty-five patients participated in the study. From anecdotal reports from the nurses, those who did not want to participate felt that the experiences were too difficult to talk about or they just wanted to put it all behind them. Thirteen patients agreed to be taped. Copious notes were taken throughout the other interviews. Fourteen females and eleven males participated in the study. The age range was from 24 to 65 (average age 36). Our sample includes a wide variety of experiences and diagnoses. These ranged from schizophrenia (11) to bi-polar (6) and borderline personality disorder (2) to anxiety (1) and anorexia (1). Seven participants did not identify with their diagnosis. Six participants did not believe that they needed to be in hospital. Of the 19 that believed that they needed to be in hospital, two felt that they had been there too long and one wanted to be admitted to a private hospital. Table 1 summarises these characteristics. 3.2. Experiences of the ITO Ten participants felt that the ITO had protected them from harm and had greatly benefited from the experience. Twelve participants experienced the ITO as an intrusion into their liberty and physical integrity, and felt that the hospital experience had not been beneficial to their recovery. Three participants had a more mixed experience. Two of these felt that while being in hospital had been beneficial, the ITO was still experienced as too intrusive and the last participant felt that the hospital experience had been negative but was not concerned with having been placed under an ITO. Below we will describe the characteristics of each of these groups. 3.2.1. The ITO protects from harm All the participants in this group, at the time of the interview, agreed that they had needed treatment and that their hospitalisation had been necessary. All the participants also agreed with their diagnosis. While some in this group initially had a more negative experience, once their symptoms improved and they believed that the treatment they received

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Interviewer: And what was it like to be on an ITO?

Table 1 Characteristics of sample. Gender Males Females Age range Diagnosis Schizophrenia Bi-polar Borderline personality disorder Anxiety Anorexia Agreed needed hospitalization Agreement with their diagnosis

11 14 24 to 65 (average age 36) 11 6 2 1 1 19 18

had been beneficial, they changed their mind. For some participants the ITO was seen as providing them with safety and security, others described the ITO as being cared for. Henry,1 Hannah and Isabella expressed this as follows: Henry: I was feeling a medium depression. The ITO was put on me then. It was for ECT. It is not too bad, it really benefits you. It gets your brain going. The ITO is alright, it does not bother me (58-year-old male). Hannah: It does make a difference that I am on an ITO. It is like God is putting his foot down. And I needed it. I got sick because I had too much faith in God. I need strictness in my life. […] The involuntary order was for my safety and I agree with it (35-year-old female). Isabella: Again, knowing that I couldn't go out, really, really, really saved me. I didn't know the door was open all the time though. I didn't know that it was an open wing. I thought it was closed. Yeah, It made me feel safe. […] I already felt worthless. If anything, it made me feel more important and recognised, if you know what I mean. I knew I'd misbehaved, but, being recognised that, hey, this girl is ill, she needs help, and we're going to do this for her. I know it's like tough love, but I needed that. If I didn't have that and I wasn't put under an ITO after I'd misbehaved, who knows where I would have ended up. I just felt like they looked out for me more. Even though it was annoying. […] I think that's what kept me sane, knowing that they cared enough to put me under an ITO (24-year-old female). In addition to feeling safe, secure and cared for, the ITO was described as providing guidelines for dealing with their illness. They felt that the ITO was in place for their own good and had allowed them to consider what they needed to do to get better. For some, almost paradoxically, the ITO was viewed as giving them more freedom as it provided clear boundaries with other patients as to what they could or could not do. Ryan and Audrey expressed this as follows: Interviewer: How do you feel about being under an ITO? Ryan: Not happy about it, but it's for my own good, so. Sometimes you get a bit mixed up […] There are a lot of people that don't like being on an ITO but they don't understand that it is really good. Interviewer: So did you realise that at first [when you became ill]? Ryan: No, it probably took me like four years to realise what was going on. Like, I didn't really realise I had a mental illness and didn't want to take my medication, and just took more drugs and it took me a good few years to work out was really going on.

1

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To help protect the participants' identity pseudonyms are used in this study.

Ryan It was actually pretty good, because I realised what it was all about. Medication was coming good (25-year-old male). Audrey: Voluntary give you lots of options, but also bring you lots of trouble, because people will ask you to buy stuff [for them]. So being involuntary gives me more freedom to do whatever I want (31-yearold female). For those in this group that went through a MHRT review their experiences had been positive as they agreed with the Mental Health Review Tribunal they needed to stay on the ITO. Others felt that the MHRT had given them a space to talk about their experiences and had given them some insight into what had been happening to them. When they did not attend the hearing, this was because they had wanted to be on the ITO. Amelia, Anna and Ryan described these themes as follows: Amelia: They [MHRT] had everything I said written down […] when they showed me the evidence it really helped. It was softened by the fact that it was written down on paper. It was really scary and it gave me a real insight. My psychiatrist was at the hearing and he was just very objective (24-year-old female). Anna: And I was talking to them [MHRT members]. I felt that they appreciated me [being there]. They thanked me and said: “You speak well. You present well. You do well. We understand you well”. This is the first time I felt listen to and it is something that made me proud. (33-yearold female). Ryan: I did not need to attend as I wanted to be on the ITO (25-year-old male). 3.2.2. ITO was experienced as an intrusion into their liberty and physical integrity In contrast to this group, were those that felt that the ITO had been an intrusion into their liberty and physical integrity. The participants in this group described their experiences in very negative terms. Half of the participants did not believe that they needed to be in hospital and four of these did not agree that they needed treatment. These four also did not agree with their diagnosis. Three did not believe that they had a mental illness at all. Of the five who agreed that they needed to be in hospital and treatment, two felt that they had been in hospital for too long and one wanted to be admitted to a private hospital. Nine participants felt that the ITO restrictions/ involuntary treatment had made their illness experience worse. All of the participants in this group felt that the ITO process had been arbitrary. They also described their experience of being under an ITO as having no rights or that their rights had not been respected. They also stated that they did not know what needed to happen to have their ITO revoked. Many in this group felt that the ITO process had been arbitrary. They had a very limited understanding of the legal processes behind the ITO and some did not understand why they had to be in hospital at all. Beverly and Mia exemplify this theme as follows: Beverly: The ambulance officer then did the same as that funny doctor in 2009, he put me under the Mental Health Act. My opinion was I had this heavy heart feeling, a heavy feeling in the chest, and my breathing wasn't normal, and I was panicking. He thought that I was acting erratic — how about that? […] And why go on the word of an ambulance man? (64-year-old female). Emily: I just don't understand why I have to be here, that's all. I have done nothing wrong, why do I have to be on the frickin order? (31year-old female).

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All the participants in this group equated being involuntary either as either having no rights or that their rights had not been respected. They were often unaware that there were legal protections in place and felt that the hospital could do whatever they wanted. Seven participants in this group equated being under an ITO with being in prison without having committed a crime. Lucas, Mia, Beverly's and Chloe's accounts are examples of this theme. Lucas: You got no rights. You go to bed when they say. If you don't go to bed, they'll give you drugs. You wake up when they say. You see a doctor when they say. And you don't have any rights (53-year-old man). Mia: I know the ITO is there to protect me but it impacts on the way I feel. It is scary, you have no rights. […] Being involuntary means that I have no rights to say or do anything nor to make any legal decisions. […] I am part of the government now and they look after me. My parents won't get any information if I abscond, as it is between the hospital and me (36-year-old female). Interviewer: What was it like to be on an ITO? Beverly: Threatening. That's how I felt, and that's how I feel right now; threatened. They have the right to do anything with you. If they consider that you're not taking all this medication or whatever, they can do anything with you (64-year-old female). Interviewer: I just wanted to come back to you being in here involuntarily, what is that like? Can you describe it to me? Chloe: I guess, just like what I imagine that jail wouldn't be too much different to this. Interviewer: Why do you say that? Chloe: Well, just because everything is controlled. Your meal times are controlled, your food is controlled, your medication is controlled, your actions are controlled, and your behaviour is, in a way controlled (25year-old female). Some in this group while they understood that they had rights under the Mental Health Act, described how they did not believe that they could challenge the treatment team or that, when when they tried to assert they rights, they were labelled as difficult. For example, Alexander while he was in hospital googled involuntary care and realised that he had the right to see his care plan. However, when he asked for his plan, the nurses told him that his behaviour was unacceptable. You have no rights they can do whatever they want. I understand I have to be in here, but the way they do it is wrong. […] If they put me here against my will, I need to know what is going on (30-year-old). Furthermore, the arbitrary nature of the ITO was often reinforced by a sense that participants did not know what they needed to do, to have the ITO revoked. For example Lucas, And I've done everything since I've been here. I've taken my pills, been a good boy, and they're still not letting me out (53-year-old male). Those who attended their MHRT hearing described this experience in negative terms. They did not believe that they had been able to put their point of view forward and that the outcome of the hearing had been a foregone conclusion. Others believed that the MHRT only saw them as a mental patient. One participants did not understand the information that was given to him. Lucy, James and Evelyn expressed these themes as follows:

Lucy: It felt OK going in, but that they had already talked to the doctors. It felt like they had taken the doctors side. It felt like they did not listen. In the tribunal it was not just the ITO review it was also about the shock treatment. If they had listened to me, they would not have given it to me (28-year-old female). Interviewer: And what was it like going to the tribunal? James: Vague. Interviewer: What do you mean by vague? James: Don't you know what vague means? Interviewer: Well, they didn't give you any information; is that what it is? James: The information that was hard to understand. Interviewer: Did they use words you didn't understand, or was it just the way they were talking? James: It was the way they were talking (53-year-old male). Evelyn: You are just a number and it does not matter where I come from and I am not a bad person. They don't care who you are. They don't know who I am, they don't know me, they don't know if I am stable or what the heck I am. You are a stranger, you can be very capable but they do not know this (52-year-old women). 3.2.3. The mixed group This group had very ambiguous feelings about being in hospital under an ITO. Two people said that even though being in hospital had been beneficial; they still had very ambiguous feelings about the restrictions imposed by the ITO. Joshua expressed this as follows Interviewer: And so when you first came in was it a relief for you or did you find it difficult? Joshua: Yes and no. It was good in a sense that I was able to get help when I needed it, but it was bad in a sense that I was under an ITO, which means they're monitoring. I couldn't just go So you know that part was the bad part. I did end up getting the help I needed, which was good (29-year-old male). Jack, had been admitted for suicidal feelings and depression, felt very ambivalent about his hospital admission and did not believe that being in hospital had helped him. For him it was the hospital experience rather than the ITO that was difficult to deal with. He did not believe that the ITO had made a difference. 4. Limitations We were interested in the subjective experiences of the participants as these perceptions are likely to influence future behaviour. For these reasons we did not cross check their stories with their medical files or with their health care professionals. We however believe that this is strength rather than a weakness as it provided insight into what it was like for those people who are admitted to hospital under an ITO. It was also recognition that the perceptions of people with a mental illness are as valid as the perceptions of health care professionals and families. It is important to note that we have captured the experiences of health care professionals and families in a similar way and that these will be reported elsewhere. Furthermore our analysis is descriptive rather than causal and from these experiences we are not able to draw causal conclusions about if it was the lack of perceived procedural justice influenced their illness or treatment experience or the other way around.

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5. Discussion The analysis of participants' experiences of being placed under an ITO showed that people had diverse and differentiated perspectives about the involuntary admission. There were those who felt that the ITO provided them with safety, those who felt that the ITO took away their liberty and those who had a more mixed experience of being placed under an ITO. Participants either felt that they did were not in need of treatment or that the treatment they had received had not been appropriate. These different perspectives on involuntary hospital admission and treatment have also been noted in the literature (Katsakou et al., 2012). The different accounts highlight the complex interplay between legal and therapeutic/clinical factors. For those who had a more positive experience the ITO was experienced as a positive right and provided them with the treatment, protection and guidance they needed. Those who experienced being treated under an ITO in more negative or mixed way, described feeling powerless and believed that the ITO had taken away most of their rights. Many did not understand why they were still receiving treatment under an ITO, had limited or no information about the conditions attached to their ITO, and did not know what was expected of them to have the ITO revoked. They also did not believe that there were any meaningful legal protections in place. This was particularly the case for patients whose problems were formulated by mental health staff as being psychiatric issues which were contrary to the ways patients perceived their problems and what was needed to solve them. It has often been argued that the way involuntary treatment is experienced depends on the clinical outcomes of a person's treatment and that once people regain their capacity and an understanding of their illness, they will come to accept the involuntary nature of their experiences. In a large European study it was found that at one month after discharge between 39 and 71% of patients thought that their admission was justified. This number increased to between 46 and 86% at three months. The authors also found that gender, living situation and diagnosis were significantly associated with patients' views and patients with a diagnosis of schizophrenia had more negative views when compared to those with other diagnoses (Priebe et al., 2010). This suggests that for some when their illness symptoms improved and they developed a greater understanding of the nature of their illness they also accepted their treatment. And while in the current study, some did not agree with the diagnosis of their illness, many in the positive and negative groups did agree with their diagnosis and need for treatment and some, even when their illness symptoms improved, still viewed their involuntary mental health admission as unjustified and an infringement on their rights. While it is possible that they may change their minds once they are discharged, it is also possible that the feelings of having their rights abused stay with them after discharge and impacts on their long term recovery. The experiences of those in the negative group highlight that there is still a gap between the rights and principles enshrined in the mental health legislation and the experience of it by individuals. Different mental health legislation allow for the assessment, detention and compulsory treatment of people with severe mental illness in defined circumstances. They also include checks and balances to ensure that compulsory treatment is only used where necessary (Carney, 2003). It is designed to ensure that compulsory treatment is given in the least possible restrictive manner and to minimise limitations on rights. While these mechanisms are in place, many in this study did not feel that their rights were protected. Participants in the negative and mixed group felt coerced into treatment and did not believe that they were given any procedural justice. It has consistently been reported that the perception of procedural justice and coercion are inversely related (Galon & Wineman, 2010; Monahan et al., 1995; Wales et al., 2010). While it is likely that the illness experience may have played a part in this perception, it is also likely that the lack of information and

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knowledge about how a person can be placed under the Mental Health Act and what happens once they receive treatment while under an ITO also contributed to their increased feelings of anxiety. It appeared to be a two way process where their illness and treatment experience influenced their perceptions of the legal process, and in return their understanding (or misunderstandings) of the legal framework influenced the way the illness and the treatment were experienced. Fig. 1 illustrates this concept. While the mental health professionals in this study may have talked to the participants about the ITO process and the legal protections, it is clear that many patients did not understand this information. This may be because the information was not conveyed in appropriate language or the information was not provided at the appropriate time (for example, the person may have been too unwell). This suggests that the health professionals may not be prepared or know how to talk about the legal processes of an ITO. This conclusion is consistent with the literature, where it has been found that some professionals were not sufficiently prepared, or were resistant to giving information about patients' rights (Campbell, 2008; Marriott, Audini, Lelliott, Webb, & Duffett, 2001). The need for accurate and timely information appears to be crucial for most of the participants in this study. The experiences of the negative and mixed group suggest that information provision is an ongoing process in which patients need to have easy and consistent access about their legal rights. It is important for patients to have access to reliable information about their rights and describe how they can have their voices heard during periods of hospitalisation (Rapaport & Manthorpe, 2008; Rose, 2001; Victorian Government, 2012). This has important implications not only for respect to patients' rights but for recovery principles. Recovery oriented care principles require that patients are informed and treatment preferences respected and that patients are involved and supported to make treatment decisions. They also require that patients are informed about their rights and are given the opportunity and support to exercise these. This suggest that there can still be an uneasy fit between legal principles and processes and clinical values. There can be tension points between the legal and medical frameworks and between clinical goals and protection of rights. In addition, health care professionals and lawyers have different professional duties to their clients. Health care professionals have a duty to act in their clients' best medical interest and to ensure clients receive the best medical treatment whereas lawyers have a duty to act on instructions and ensure that their clients' rights are respected. This tension and its resolution have been considered in the review of the Mental Health Act in the Australian state of Victoria. It is proposed that patients will be able to request advocates to visit mental health services or provide telephone advice to assist people to participate in decisions about their assessment, treatment and recovery. These advocates will provide information and assist people to understand and exercise their rights. The advocates may also make representations on behalf of people receiving mental health services. Advocates will talk with people receiving mental health services about any concerns around their treatment, and support them to find solutions and to make decisions. These supports will empower patients to self-advocate as well as make choices about their treatment and recovery (Victorian Government, 2012). And while this may not apply to everybody, an understanding of the legal basis for the ITO and what is required for it to be removed is likely to increase the acceptance of the order. Respect given by the health care professionals, an opportunity for a person to have a voice or to state their case, regardless of the outcome, are key process elements that influence fairness perceptions (Cascardi, Poythress, & Hall, 2000). Involuntary patients may perceive less coercion if treated with respect and afforded procedural justice (Swartz et al., 2004). 6. Conclusions This research suggests that the promotion of clinical goals and of legal rights protections can operate in tandem and support each other.

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Illness experience Treatment factors

Understanding of the legal framework Procedural justice

Fig. 1. Interaction between illness experience and treatment factors with the understanding of the legal framework and procedural justices.

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