One of the areas in mental health treatment fraught with the most uncertainty and emotion is the area of involuntary hospital admission.
In most areas of medicine, an adult can choose whether and when to be treated. Of course this is true when it comes to mental illness as well, but there are instances when a person’s right to refuse treatment is over-ruled for their own safety or the safety of others.
For obvious reasons, this subject is governed by some specific criteria in law and we cannot simply admit our loved ones to hospital if they are not behaving the way we would like.
BC’s Mental Health Act covers involuntary hospital admission and sets out some guidelines for when a person can be involuntarily admitted and treated against his or her will.
Four basic criteria must be met in order for an involuntary admission to be warranted. First, the patient must be suffering from a mental disorder impairing his or her ability to react to the environment or associate with others. The patient must also be in need of psychiatric treatment in a hospital. Third, the patient must require care in order to prevent substantial mental or physical deterioration or for the protection of self or others. And of course, the patient must be unwilling to become a voluntary patient.
Most of these criteria are fairly straightforward – but it is the third one that presents the most uncertainty for physicians and family members. Although the criteria is quite broad and cites not only danger to self or others but also risk of physical or mental deterioration, it is usually interpreted quite narrowly.
Most physicians focus almost entirely on whether an individual is a physical danger to self or others. If that imminent danger is not present, they will not admit. In fact, the law leaves more room for interpretation.
By ignoring the clause dealing with substantial deterioration, many people are left to fend for themselves and see their conditions get a lot worse before they get the help they need.
This was arguably a contributing factor in last year’s tragic case of suicide. A 22-year-old man with paranoid delusions slipped away from emergency caregivers and killed himself in a hospital staff washroom after his parents had spent years trying to have his worsening symptoms treated. Although he was finally admitted against his will, his parents believed his condition had deteriorated significantly by that time and he may have benefited from adequate treatment trials much earlier.
As a result of this sad situation, a coroner’s inquest made 43 recommendations surrounding the interpretation of the Mental Health Act and the necessity of it being used in a timely and effective manner.
Civil liberty and choice are important and must be respected. At the same time, there are times when we are very vulnerable and unable to think clearly for ourselves and in those times we may need to be protected from our illness for our own sake.
Our courts have interpreted this protection to include protection of harm to the person’s social, family, work or financial life. As you can imagine, this is much broader than simply protecting someone from doing physical harm to self or others.
It is important for physicians to understand the scope and details of the law surrounding involuntary hospital admission so they can make the most informed decisions when dealing with these situations.
Some health regions have stated plans to provide operational definitions of some of the clauses within this mental health law. This would be worthwhile in all jurisdictions to ensure we are protecting those who truly need it.
If you are interested in learning more about the Mental Health Act, check out the excellent guide online at: http://www.health.gov.bc.ca/library/publications/year/2005/MentalHealthGuide.pdf