Involuntary admission or involuntary treatment？

JoséM.BERTOLOTE

Involuntary admission or involuntary treatment？

JoséM.BERTOLOTE

The interesting forum on involuntary treatment that appeared in the previous issue of the Shanghai Archives of Psychiatry［1,2］touches upon two closely related issues that have important and distinct implications both for forensic and clinical psychiatry: involuntary（or forced？）admission and involuntary（or forced？）treatment.

Involuntary psychiatric treatment is one of several methods society uses to deprive individuals of their freedom；the more commonly used methods are incarceration in jails,prisons and penitentiaries. The first"psychiatric hospitals"in 15thcentury Europe（in Spain,Italy and England）were built under the aegis of the Catholic Church to provide housing for people with strange behavior who were unable to care for them selves.But these asylums subsequently became another type of government-run institution where society could confine people with deviant or unwanted behavior.Involuntary treatment in its statutory form has been with us for more than two centuries,since the Bapoleonic Code included it as a legal practice in 1803［3］.Over this long period involuntary treatment has become an integral,albeit not always esteemed,part of clinical psychiatry.The declared good intentions；the pseudo justifications of‘protection of self’,‘protection of others’,and‘protection of society’；and the unproven assumption that involuntary treatment is‘therapeutic’have all been used to justify seclusion of the mentally and deprivation of their liberty.

More recently some locations have moved away from this repressive approach by introducing law s that make a distinction between involuntary admission and involuntary treatment.An international systematic review of mental health law s conducted between 1992 and 1995 by Poitras and Bertolote［4］found that about 30%of reviewed mental health law s made this important distinction.The jurisdictions with law s that clearly separate involuntary admission from involuntary treatment include Victoria State in Australia,Quebec and Ontario（provinces in Canada）,Bavaria State in Germany, Italy,Japan,Bew Zealand,Borway,Romania,England,W ales,and Massachusetts and Indiana（states in the USA）.In most of these location the legislation makes a distinction between persons who have the authority to involuntary lock someone in a psychiatric institution（hospital,clinic or ward）and persons with the authority to treat someone from a mental disorder,even against that person’s will.In several of these jurisdictions the legal requirements for involuntary admission have remained the same but there is a further specification that treatment（usually involving the administration of medications）cannot be imposed on someone who refuses it.

The law in Italy is considered one of the most advanced and"libertarian".Involuntary hospitalization in Italy is limited to cases where:1）urgent intervention is required,2）the patient refuses necessary treatment on an outpatient basis,and 3）alternative community-based treatment is not available or is not feasible［5］.In other words,hospitalization is authorized against a person’s will only after a psychiatrist（not a judge nor a policeman）has certified that that person needs urgent treatment and that treatment cannot be provided outside the hospital.This is very different from the criteria used in most other jurisdictions that sanction involuntary hospitalization on the grounds of"dangerousness to the patient or others",a decision that is often made by judicial officials,not mental health professionals.

For many clinical psychiatrists treatment requires a collaborative relationship betw een doctor and patient,so the very idea of involuntary（or forced）treatment is hard to accept.But the mental health law s that psychiatrists must implement are developed and promulgated by government agencies,not by psychiatrists（though psychiatrists may be consulted during the drafting of these law s）.In their daily practice clinicians should notuncritically accept the role of guardian of society；their application of the law s needs to take into consideration the best interests of the individual they are treating. Psychiatric treatment is already a complex and sometimes arduous task that should not be contaminated with functions alien to its core m ission.

1. Young D.Com pulsory treatment and diagnostic errors.Shanghai Arch Psychiatry,2011,23（1）:46-47.

2. x ie B.Balancing patients’rights and public safety:rethinking‘deinstitutionalization’and‘reinstitutionalization’Shanghai Arch Psychiatry,2011,23（1）:48-50.

3. How ells JG.World History of Psychiatry.Bew York:Brunner/ Mazel,1975:119-135.

4. Poitras S,Bertolote JM.Mental health legislation:international trends.In:Henn,Sartorius,Helm chen&Lauter（eds.）,Contemporary Psychiatry（Vol 1,Foundations of Psychiatry）.Berlin: Springer,2001:269-285.

5. Law 180（Italy）.International Digestof Health Legislation.1979, 30（1）:75-79.

（JoséM.Bertolote,MD,Professor,AlSRAP,Griffith University.Brisbane,Australia；Associate Professor,Botucatu Medical School,UNESP.Botucatu,Brazil.E-mail bertolote@gmail.com）

10.3969/j.issn.1002-0829.2011.02.010