By Dr David Laing Dawson
An old friend and colleague, now retired, sits on a panel reviewing Involuntary admissions, along with a lawyer and a lay person. At lunch one day a couple of years ago he commented that he has had to learn to think like a lawyer. I chuckled but didn’t think seriously about this offhand remark at the time.
This might be part of the explanation for the deterioration of mental illness treatment over the last three decades: The presence and influence of lawyers. When I think about it, I can remember many discussions with psychiatrists when I could hear them thinking like lawyers, weighing the words of the mental health act, the questions the lawyers might ask, the likelihood of the panel, hearing the lawyer’s arguments, voting to “convict” (uphold the Involuntary admission), or not. And then increasingly not filling out that form for involuntary admission even when they knew, as I did, that this person would be back in emergency within a week, now more Ill, more damaged mentally, socially, financially, and physically.
An unforeseen consequence of the mental health act and the legal structures and hurdles in place.
Lawyers and doctors function within very different social contracts – the set of expectations and privileges that govern our relationship with our communities and our patients or clients. These two very different words, client and patient, carry the embodiment of this difference. It is expected that the doctor will do his or her utmost to do (prescribe) whatever will alleviate suffering and increase health and welfare.
The lawyer is expected to do his or her best to ensure their client’s wishes are achieved or realized.
We have all watched how these two different social contracts play out in numerous legal and medical TV dramas.
For the lawyer’s contract to work he or she must receive instructions from the client. The client must be capable of offering instruction. Thus, in legal proceedings, a client can be found to be incompetent to instruct counsel.
But not within the mental health act. He or she may be flagrantly delusional and still have their day in “court”.
Privately many lawyers dealing with the mental health act will acknowledge that they are not acting in what they know is the best interest of their client, but they are following the client’s instruction.
And the psychiatrist who has been working hard for a couple of weeks to gain this patient’s trust, now has to tell a panel of strangers, while his patient sits there and listens, just how sick, ill, confused, and delusional his patient really is. And while he or she is doing this he knows (in Ontario) that even if the Review Board upholds the Involuntary admission, his patient can still refuse treatment, leading to a set of entirely predictable consequences.
In the application of any act, system, rule, statute, or law, we humans can (and will) make two types of errors: Type 1 and Type 2. In the case of a mental health act governing Involuntary admission and Involuntary treatment a Type 1 error is applying Involuntary treatment and Involuntary admission when neither was necessary or helpful. Clearly this could constitute a violation of a person’s civil rights. A Type 2 error is the opposite: not using Involuntary admission and Involuntary treatment when doing so would have alleviated suffering, prevented a deterioration of health and welfare, and/or saved a life.
The architects of our mental health act and its processes and safeguards have definitely ensured there would be no Type 1 errors, but they have also definitely ensured Type 2 errors would occur every day.
Message to the Psychiatry Resident in the form of an anecdote:
Some years ago a family brought an angry, hypomanic, paranoid woman to my office in a community hospital. She steamed, and ranted and accused others for an hour or more while I tried to find a way of reaching her, calming her, and getting her to accept treatment.
In the end, reluctantly (always reluctantly), I filled out and signed a form, and organized an escort to the nearby Psychiatric Hospital. She left my office with a few choice words for me and my future.
Six weeks later I was walking the long main corridor of that same community hospital when I saw this same woman coming from the other direction. I hoped she might pass by without recognizing me.
But as we passed one another she made brief eye contact with me, and then simply said, “Thank you for saving my life.”