Charandry only II

History ofPsychiatric Care in the UK

Following centuries of unregulated community care of people with mental illnesses, madhouses and mental asylums/institutions were introduced as means for regulating care provision. Effective psychiatric medication was then developed in the late 1950s, prompting the closure of institutions and the introduction of a new psychiatric care approach called ‘Care in the Community’ whereby the treatment and support of patient with improved symptoms was transferred to outpatient clinics in the community.

Detention and Forced Medical Treatment in NHS Hospitals

This ‘Care in the Community’ approach existed simultaneously with the inpatient care approach designed for detaining treatment-resistant and/or dangerous patients who potentially committed crimes and harmedothers in the community. This triggeredthe introduction of the Mental Health Act (MHA)in 1959 (REF??). The MHA empowered professionals to force patients to take medication against their will,for reasons of protectingthe safety of other people.The NHS, which had been formed in 1948, established specialist psychiatric hospitals to enforce patient detention under the MHA.

Patients detained under the MHA in NHS hospitals were deemed to lack capacity and were resultantlymedicatedforcibly and/or coercively,against their will.Guidance foraddressing ensuing capacity issues in psychiatrywas later provided bythe UK government and the NHS inthe Mental Capacity Act (MCA) of 2005. This laterinformed creation oftheDeprivation of Liberty Safeguards (DoLS) of 2009 statute (Ministry of Justice, 2008).

Scenario

Stakeholders

Stakeholder Interests and Salience

The Stakeholder Salience model

Table ?? contains comprehensive details of salience assessment and prioritisation of the NHS hospital’s stakeholders done using the Stakeholder Salience Model.

According to the assessment, the least important stakeholders for the NHS hospital are:

· Religious organisations

· Public and neighbours

· Non-governmental organisations

These are ‘latent’ stakeholders because they satisfy only one of the three relationship attributes. They are ignored as stakeholders by management, and their effort to influence changeis disregarding by management, with no adverse effects on the organisation.

However, since Competitors and academic institutions satisfy two relational attributes, they occupy the ‘expectant’ stakeholders group and aremoderate in importance.

Finally, the following stakeholders are the most important:

· Patients

· Employees

· Suppliers

· Management

· Government

· Regulators

The ‘high salience’ group status of the above stakeholders is based on satisfying all three attributes of the Stakeholder Salience Model, which enables them toinfluence the organisation in definitive ways.

Source: Stakeholder Salience https://www.stakeholdermap.com/stakeholder-analysis/stakeholder-salience.html#mitchell

Ethical Problems Around CoercingPatients to Accept Psychiatric Medication

The symptoms of serious mental disorder can impair the capacity of people to decide autonomously about taking psychotropic medication, which may cause them to refuse treatment (Sjostrand and Helgesson, 2008). However, when psychotic patients refuse medication, they may pose serious danger to themselves and/or other people around them.

When the dangerously mentally illpatient cited in this report refused psychotropic medication, the psychiatry professionals used a threatto influence him to comply against his will,for reasons of protecting the public. In doing so, the practitioners’ actions were consistent with the ethical principle of utilitarianism, which prioritises doing good for many people over doing good for just one individual in all situations (REF??). Thus, the coercive treatment of thepatient is justified under utilitarianism theory since it allows professionals to do good for many people comprising the society, by usingcoercive treatment to reducethe dangerousness of the patient.

The Royal College of Psychiatrists ((RCP) 2014) and the Nursing And Midwifery Council ((NMC) 2015) codes of ethics and conduct also place rigid accountability obligations on psychiatry professionals to always safeguard and protect patients and other people from harm.These obligations force a duty of care for the public on professionals, making it paramount for their performance of duty to always seek to protect the public with no excerptions.Non-compliance renders them incompetent and liable for disciplinary action.Essentially therefore, failing to treat a psychotic personafter respecting their choice to refuse medication breaches professionals’ ethics of duty around legal responsibility to protect others (Sjostrand and Helgesson, 2008).This means that the practitioners’ obligations of duty of care to society justified the coercive treatment of the patient’s after his refusal of medication.

Analysis of Issue – Patient’s Human Rights

Hem et al (2016) insist that regardless of any prevailing capacity deficits caused by serious mental disorder, influencing and/or forcing another person to accept medical treatment constitutes coercion, which breaches their autonomy. Mendez (2013) further asserts that coercive medicinal treatment of psychiatric patients ‘is tantamount to torture’, a view which validates that, regardless of intensity of potential risk or dangerousness, patients’ freedom and liberty are severely restricted when they are coercively medicated. This means that coercive medication constitutes direct violation of the patient’s human rights.

The Convention for Human Rights (hereby referred to as the convention) dictates that ‘people should not be treated coercively in the interest of others’ (REF??). The convention observes that the coercive and involuntary treatment of persons with serious mental disorders is justified only when serious harm is likely to happen to the affected individual themselves if treatment is not provided. It also clearly specifies that coercive treatment of a psychiatric patient must strictly be exercised only to protect the safety of the patient, and not anyone else.

However according to Sjostrand and Helgesson (2008), coercively medicating a dangerously mentally ill patient may uphold their individual interests and safety since it avoids potential retaliation from other people they may harm, which may harm them in return. For such a perspective to be valid however, it must be the person’s illness that is targeted for treatment, and not the dangerousness of his actions (Sjostrand and Helgesson (2008). The requirement to target the illness and not the dangerousness invalidates the validity of coercively medicating the patient discussed in this report since the professionals clearly identified the dangerousness of his actions asreason for treating him coercively.

Based on the need touphold the human rights of the patient, the coercive treatment of the psychiatric professionals can therefore be argued to be unethical and illegal.This follows it being clear that practitioners forcefully treated him for reasons of treating the dangerousness caused by prevailing mental disorder and protecting others, and not for treating his illness or upholding only his interests.

Strengths and Weaknesses

Coercively treating the patient safeguards the welfare and safety of members of society and renderspractitioners competent and responsible. However, treating another person for the benefit of others and not themselvesinfringes on their Human Rights, whichriskscriminal litigation.

How did the organisation’s management address the situation?

How did the decision affect each of the key stakeholders?

Variety of alternative perspectives from module relating to efficacy of specific management tools and techniques used to encourage ethical conduct in organisations

1.

· Ministry of Justice. (2008). Deprivation of liberty safeguards: Mental capacity act 2005 : Code of practice to supplement the main mental capacity act 2005 code of practice : Issued by the lord chancellor on 26 august 2008 in accordance with sections 42 and 43 of the act. (). London: TSO.

· Royal College of Psychiatrists (2014) CR 186: Good psychiatric practice: code of ethics. (Online) Available from: http://www.rcpsych.ac.uk/files/pdfversion/ CR186.pdf (Accessed: 20 Sept 2017)

· NURSING AND MIDWIFERY COUNCIL (NMC), 2015. The code: professional standards of practice and behaviour for nurses and midwives. London: NMC

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Traditionally and until the 18th century, psychiatric care was provided in the community without government support. This was replaced by madhouses between the industrial revolution and the 1930/40s. The madhouse approach collapsed and was followed by mental asylums in the 1940s and 1950s. Since there was no effective psychiatric medication up to this period, patients’ symptoms stayed constant, resulting in patients never getting discharged, and the institutions getting overcrowded as a result.

The following constitutes a timeline for the provision of psychiatric care in the UK:

In the UK, the period up to the 18th century comprised family members caring for mentally ill relatives and friends in the community on informal basis. Formal structures only emerged during the industrial revolution when madhouses were established as part of an institutional approach. This approach failed, and was replaced in the late 1940s to early 1950s by publicly owned county asylums, which rapidly became overcrowded and underfunded. However advances in psychiatric medication that occurred in the late 1950s facilitated the development of effective psychotropic medication, which made it possible for people with mental illnesses to no longer be admitted into institutions but rather, receive treatment and support in the community through outpatient clinics. The National Health Service formed in 1948 also established hospitals for detaining patients who posed a danger to communities due to challenging symptoms.

Changes in mental health legislation were introduced gradually between the late 1950 and the late 1970s. Theseinitiated and supported the banning of admitting people into asylums, eventually leading to the abolition and closure of asylums and mental institutions in the late 1980s. The UK government had in 1983, introduced the ‘Care in The Community’ approach to mental health care, whereby NHS health teams and local authority social services coordinated mental patient care delivery by providing housing, occupational support, medical treatment, and therapeutic input to support successful reintegration and participation in the community. Thus, the Care in the Community approach also accommodated mentally disordered offenders being treated in the company of their families in the community, a situation thathas sometimes resulted in violent crimes being committed by mental patients against members of the public in the community. Essentially, over the 1987/88 period, around 19000 people were compulsorily detained in mental health hospitals, a number which increased to 50000 within the twelve years that followed (Zigmond, 2011). Also, 4000 community treatment orders were enforced in the 2009/10 period alone.

By the year 2000, 50000 patients were compulsorily detained in NHS hospitals under the MHA, facing forced or coercive treatment with medication against their will. However, to safeguard patients against potential erroneous compulsion and/or unjustified force of patients to comply with medication/treatment, the statutory second opinion system was introduced. 18000 such second opinions were conducted between 2008 and 2010, having increased from 4000 between 1983 and 1985. Of the 18000 second opinions in the 2008/10 period however, 5000 were recorded as refusing medication (REF??).

As time progressed, additional statutory frameworks were introduced, which supported the MHA and the MCA. This enhanced the effectiveness and applicability of efforts in eliminating the unethical and/or coercive medicating of mentally ill people by psychiatry practitioners in the NHS and in private organisations. The Deprivation of Liberties (DOLs), introduced in ??? --- is an example of such --- (REF??). DOLs stipulates the mandatory requirements and actions to ensure when having to legally deprive the liberty of another person in the UK.and the current period when specially trained professionals provide the care of persons with mental illnesses in specialist hospitals. The pathway to the current system involved a period between the This happened prior to the development of effective medication, and treatment of mental illness was ineffective, making it impossible to discharge people from institutions and asylums. Psychiatric medication was then developed in the late 1950s, making it possible for symptoms to be treated successfully, with patients being discharged for treatment in their homes in the community. Legislation was developed by the government to regulate psychiatry. In the institutions, patients were physically and psychologically abused, as well as forced to comply with treatment.

Researchers like --- argued and proved that most practice prevailing and accepted in mental institutions at the time was abusive and unethical, which caused the government to abolish mental institutions in the period between 194?? and 198??. Also, in order to further eliminate the unethical practices in psychiatry and protect psychiatric patients, the UK Government also introduced the first Mental Health Act (MHA) (REF??) in the year ???. The Mental Capacity Act (??) was also introduced in ?? to ensure that persons with impaired capacity due to mental health illness were protected from abuse and exploitation

Each of the thousands of compulsorily detained individuals receives forced or coercedtreatment, regardless of any objections they may have. However, to mitigate erroneous compulsion of patients to comply with treatment unnecessarily, statutory second opinions are used. 4000 second opinions were conducted between 1983 and 1985, and 18000 between 2008 and 2010. Of the 18000 second opinions, 5000 were recorded as refusing medication.

Generally, when the NHS was founded in 1948, psychiatric patients were cared for through detention in mental institutions, and forced to take medication even against their will. Researchers like --- argued and proved that most practice prevailing and accepted in mental institutions at the time was abusive and unethical, which caused the government to abolish mental institutions in the period between 194?? and 198??. Also, in order to further eliminate the unethical practices in psychiatry and protect psychiatric patients, the UK Government also introduced the first Mental Health Act (MHA) (REF??) in the year ???. The Mental Capacity Act (??) was also introduced in ?? to ensure that persons with impaired capacity due to mental health illness were protected from abuse and exploitation.

With continuing evidence of abusive treatment and violation of the rights of mental patients by psychiatry practitioners due to unclear guidance around the capacity of mentally ill people to make own decisions and thus exercise autonomy during periods of distress, the UK government and the NHS produced revised versions of the MHA and developed and introduced new legislation called the Mental Capacity Act (REF??). As time progressed, additional statutory frameworks were introduced, which supported the MHA and the MCA. This enhanced the effectiveness and applicability of efforts in eliminating the unethical treatment of mentally ill people by psychiatry practitioners in the NHS and in private organisations. The Deprivation of Liberties (DOLs), introduced in ??? --- is an example of such --- (REF??). DOLs stipulates the mandatory requirements and actions to ensure when having to legally deprive the liberty of another person in the UK.

By the year 2000, 50000 patients were compulsorily detained in NHS hospitals under the MHA, facing forced or coercivetreatment with medication against their will. However, to safeguard patients againstpotential erroneous compulsion and/or unjustified force of patients to comply with medication/treatment, the statutory second opinion system was introduced. 18000 such second opinions were conducted between 2008 and 2010, having increased from 4000 between 1983 and 1985. Of the 18000 second opinions in the 2008/10 period however, 5000 were recorded as refusing medication (REF??).

Stakeholders

(REF??) defines a stakeholder as ---.

The NHS is one of the largest public sector organisations in the world (REF??). It comprises a various stakeholders concerned with the care of psychiatric patients in its hospitals. The NHS’ mental hospital stakeholders are identified and their respective levels of importance is assessed using three key relationship attributes aligned with the Stakeholder Salience Model by Mitchell et al (1997). The findings are presented in Table ?? below.

The Stakeholder Salience Model is argued by REF?? to be effective for use in identifying stakeholders, define their interests and determining their levels of importance. The model considers three key relational attributes namely power, legitimacy, and urgency for analysing and assessing given stakeholders to highlight their interests and reasons for relevance.

According to (REF??), analysis using Stakeholder Salience Model exposes the behaviour of given stakeholders to justify the level of importance that they are worth.

Table ??: Sal??

Stakeholder mapping of NHS mental health stakeholders

Stakeholder Mapping Grid

Scenario

Whilst working as a mental health nurse (psychiatric nurse), the writer witnessed a psychotic patient being admitted into hospital after being brought in by his family members. He was hearing voices in his head and responding in a dangerous manner, making threats to harm others and attempting to physically assault staff and family. He was also verbalising threats to kill others, but did not threatento harm himself at any point.

The patient had previously been admitted into the current hospital several times before being treated to stabilise his symptoms. This led to his discharge back to live with his family in the community and be treated under Community Treatment Orders. During his treatment at home, the patient had a repeated pattern of believing that he was healed, and then refusing medication from the community psychiatric team members for fear of adverse side effects. However, even the slightest stoppage of treatment caused him to relapse and require readmission into hospital for treatment. In hospital, he was sometimes treated under mental health detention, which he disliked as he felt that it restricted his freedom to live his life the way he wanted.

The patient had historically responded positively to medication within a short period of admission into hospital, regardless of the length of time he would have missed his treatment and medication. On the occasion in question, the patient was offered medication that was proven to best treat his psychosis, based on his history. He refused to take the medication, insisting that he feared its side effects, and a religion that he had recently joined also forbade him to take mind-altering substances like drugs and medication. He said he was convinced that God was going to heal his psychosis at the right time and therefore, psychiatric professionals should never medicate him again. The family members in attendance confirmed that the patient was telling the truth about having recently joined a new religion that shared the beliefs that he was expressing.

Staff and hospital managers then told the patient that if he did not take the medication voluntarily, he would be detained under section on the MHA (1983). He was told that this way, he would be treated compulsorily, which would potentially delay his discharge back to live with his family again. He was told that by sectioning him and forcing treatment on him, professionals would be protecting his family and other members of his community from the potential harm that he was presenting due to psychosis. The patient then accepted the medication. He however kept protesting and accusing the hospital of disregarding his religion and denying him the exercising of his right to live as he chose without interference. He also said that the hospital and the psychiatrists were exposing him to adverse side effects of medication, which compromised his physical health to a high extent.

Coercion in Psychiatry Treatment

What is coercion??

Coercion can either be formal if exercised within regulations of the MHA, or informal if exercised through interventions that lie outside the boundaries of formal coercion (Valenti et al, 2015). The coercion that occurred in the situation informing this report was outside the coverage of the MHA, and therefore informal in nature. Valenti et al (2015) outline that informal coercion can involve persuading, interpersonal leveraging, inducing, or threatening someone as means for influencing their acceptance of medicinal treatment.