In everyday parlance ‘treatment’ has moral as well as medical connotations. Certain medical specialties have been exposed to particular critical attention as far as this non-medical notion of
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treatment is concerned. One of these is gynaecology and the other is psychiatry. This might imply that certain aspects of the person need to be treated with particular sensitivity by medicine.
The final essay in Goffman’s (1961) critique of the mental hospital, Asylums, is subtitled ‘Some notes on the vicissitudes of the tinkering trades’. He analyses the mental hospital, and the medical model of treatment, as if it were a service industry directed towards the repair of damaged parts of society (psychiatric patients). If we accept Goffman’s metaphor of psychiatry as a repair industry then we can examine how its ‘customers’ are treated.
To begin, the scope of psychiatry needs to be restated. At one end of a spectrum of psychiatric service provision is a picture of enforced detention and imposed treatments. In Britain we have the maximum security special hospitals, regional secure units and inpatients detained under ‘mental health law’ in open hospitals or psychiatric units. At the other end of the spectrum are outpatients who attend voluntarily to see a therapist of their choosing in a variety of state-provided and pri- vate therapeutic facilities. In between are patients who hover around a centre-ground of services, which contains a mixture of both voluntary and coercive practices. Depending on their conduct, they may drift or be propelled suddenly towards one or other end of the spectrum.
What separates the two ends of the spectrum is essentially the question of free choice. If the mental health industry does indeed provide a service to its patients then we would expect it to mani- fest certain characteristics. Service industries provide options and opportunities for customers in pursuit of a product of their preference. Rotten products which customers found noxious or aversive would quickly disappear from the range of offers made by the industry. A person experiencing some form of self-defined psychological problem or distress would have the resources (financial and cog- nitive) and the options to freely choose a form of amelioration. How does the mental health industry fare over this issue of free choice? We will explore this question by addressing two more which are raised. Who is psychiatry’s client? And what is the extent of informed consent given to patients?
Who is psychiatry’s client?
One of the ambiguities surrounding psychiatric work is whether or not the identified patient is the actual client of the service. Clearly, some party other than the patient is being served under those sections of the Mental Health Act which empower professionals to remove a person’s liberty and/or impose treatment interventions against the patient’s will. Coulter’s work (described in Chapter 1) on decision-making about madness in the lay area traces such a process. Professionals are sum- moned in order to resolve a distressing drama to those around the patient. Similarly, when mem- bers of the public contact the police about a person acting bizarrely in the street it is clear that the client of the police-psychiatrist ‘disposal’ is not the patient, although quite who psychiatry is serving in this instance is ambiguous. Is it the distressed and perplexed member of public making the first police contact, is it the police themselves, or is it both?
Clearly, if a person is detained without trial, and they are interfered with without consent, then it is difficult to conceptualize them as ‘customers’ or ‘clients’ of psychiatry. Instead, the termi- nology favoured by disaffected psychiatric service users would seem to be more appropriate, of
‘recipients’ or ‘survivors’ (see Chapter 12). On the other hand, if a person chooses freely to make contact with a mental health worker, to seek help with a personal difficulty, in this instance they would seem to have a genuine ‘client’ status. However, even with this voluntary contact there is still a sense in which the client does not enjoy the same rights and privileges as other types of cus- tomers accessing a service industry.
The question of informed choice
This can be examined with reference to five criteria set out by Bean (1986). Bean suggests that to understand whether or not genuinely informed consent takes place in psychiatric services, we must ask the following questions:
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1 Are the patients aware of themselves – are they competent at making judgements on their own behalf?
2 Do those who are assumed to be aware of themselves (relatives and professionals) use that awareness to act morally?
3 Do professionals supply comprehensive and comprehensible information to patients?
4 Are patients subjected to pressure or coercion when they are in receipt of psychiatric treatment?
5 Is consent to specifiable actions offered by professionals to patients?
Answers to these questions, suggested below, point towards psychiatric practice being problem- atic on all five counts.
Insight
Professionals may over-ride the need to seek consent from patients about treatment if they believe that the patient is lacking in insight into their condition. However, three problems with the notion of insight can be noted:
1 Insight tends to be defined in a circular way. That is, insight means that a patient agrees with their psychiatrist. Sanity and madness are socially agreed notions and where agree- ment breaks down in a psychiatric encounter between doctor and patient, then the more powerful party has their view upheld. Consequently, the patient may lose their right to refuse treatment.
2 Even if we take it to be non-problematic, on the first count, then mental illness is con- ceded by professionals often to be episodic in nature. Given this, how do psychiatrists know for sure when a person is aware and when they are not aware?
3 Given that professionals concede that psychotic patients who lack insight may be compe- tent in certain regards (for instance the paranoid patient who can wash, dress and make money on the stock market) how can psychiatrists specify what insight actually means in terms of cognitive and social competence? Clearly, a patient may be aware of some things when they reflect on themselves but not of others; this is probably true of every- body. None of us can be aware of everything relevant to our existence all of the time.
None of us can know our own minds for certain. (Indeed, if we are exposed to the tenet of psychoanalysis we are all encouraged to believe that the bulk of our mind is uncon- scious.) And yet, despite our ubiquitous failure to be fully self-aware, we get by most of the time in most of our lives.
Beck-Sander (1998) deconstructed psychiatric literature referring to insight and found it to have weak construct validity. She found that the concept was used by professionals to indicate four separate patient features:
1 Treatment compliance – when this is a defining feature of insight, then it is assumed that to resist treatment is necessarily irrational. This is a dubious assumption given the iatro- genic effects of psychiatric treatments discussed earlier. Indeed, if all patients were fully informed of these effects, treatment compliance would probably decrease generally.
2 Psychological mindedness – this can be found in the psychiatric literature as another proxy indicator of insight. It refers to insight as a reified defence operating inside patients which purportedly protects them from the pain of their illness. Thus, those with more insight are deemed to be more distressed, whereas those lacking insight are cut off from the pain of the purported disease process they are experiencing.
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3 Prognosis is also used at times by psychiatrists as a circular indicator of insight – those with more insight are deemed to have shorter periods of relapse into psychosis and the inverse is deemed to be true for those with less insight. This professional reasoning is post hoc and tautological. Moreover, given that prognosis is determined by a number of exter- nal as well as patient characteristics, such as socio-economic opportunity and societal discrimination, then how can we ever know whether insight is a defining single feature when prognosis is good or bad for a particular patient?
4 Pathophysiology – this is offered at times by some psychiatrists as a correlate of insight.
That is, purported neuropsychological dysfunction in psychosis is offered as an expla- nation for why psychotic patients lack insight into their condition. This is, of course, a possibility, much as cerebral bleeding accounts for the brain damage which affects the short-term memory and orientation in time and space of some dementing patients.
The problem with this argument is that, by definition, the functional psychoses are not organic conditions, at least they are not demonstrably so at present. They are defined by symptoms alone because biological markers (true signs) are absent, despite substantial bio-medical and neuropsychological research into the psychoses.
Thus, the whole question of competence or self-awareness is problematic. Despite this, profession- als have powers to treat patients without their consent and they do so using the notion of ‘lack of insight’, as if it were non-problematic. Moreover, this purported lack of competence on the part of psychiatric patients is the very rationale for why negotiation about consent is either deemed to be unnecessary or futile. Despite this, there is no evidence that psychiatric patients are actually less able than medical patients to understand what is told to them. Soskis (1978) found that, in fact, psychiatric patients knew more about the adverse effects (‘side effects’) of drugs they were receiving than did medical patients (showing that if they are told they understand). However, the psychiatric patients were less likely than the medical patients to be told why they were receiving the medication. This indicates that psychiatrists are less willing than physicians to discuss diagno- sis and rationale for treatment with their patients.
The morality of others
The discussion above showed that, collectively, psychiatrists have not acted morally in relation to the needs and vulnerabilities of patients. Major tranquillizers are one of the main groups of treat- ments imposed on resistant recipients. Practitioners have also acted immorally in the case of the abuse of patients by psychotherapists. Thus, psychiatric therapists are prone to fail Bean’s second criterion.
Comprehensive and comprehensible information
This question is the one most commonly addressed by disaffected users of services. Whether the disaffection is caused by drugs, ECT or psychotherapy, the recurrent complaint is that patients are not supplied with enough information about the advantages and disadvantages of the treatment offered or imposed. The minor tranquillizer campaign led to litigation against the drug companies and the prescribing doctors, which focused on both iatrogenic effects and the withholding of infor- mation at the time of prescription about these effects. The same has been true of litigation about major tranquillizers in the USA (Brown and Funk 1986). Rogers and colleagues (1993) found that 60 per cent of a sample who had received major tranquillizers reported not being informed of their purpose, and that 70 per cent of this group were unhappy about the amount of information they had been given. Similar findings have been reported in studies in the USA (Soskis 1978; Lidz et al.
1984). These complaints would indicate that psychiatry is found to be lacking according to Bean’s third criterion.
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Coercion
Despite legal safeguards under mental health legislation, detained patients may be injected for- cibly with drugs or given ECT or psychosurgery against their will. They can also be forced into isolation (‘seclusion’) without consent. One of the questions raised is whether informal patients are genuinely in the patient role voluntarily when some do not feel that they are genuinely voluntarily admitted. In the past when admission to hospital for a mental health problem was more readily resorted to, about a fifth of voluntarily admitted patients reported some degree of coercion – this appeared to be the same in the USA as it was in the UK, suggesting that Bean’s fourth criterion was failed by psychiatry. Recently a more significant role has been given over to treatment and management in outpatient contexts and only a small minority of inpatients is admitted on a truly voluntary basis.
Two hypotheses have emerged about the role of coercion in relation to treatment in this new more community-orientated context. The first suggests that the use of coercion might aid engage- ment with treatment through making a contribution to reducing symptoms, which over time can lead to a reduction in stigma. The second suggests the reverse: coercion acts to increase stigma because of associated feelings of low self-esteem and a compromise in the person’s quality of life. Empirical testing of these hypotheses (Link et al. 2008) found that that costs and benefits of coercion are mixed. On the one hand the treatment of symptoms was found to lead to improve- ments in social functioning and assignment to compulsory outpatient treatment was associated with better functioning and improvements in quality of life. On the other hand, self-reported coer- cion increased felt stigma (perceived devaluation and discrimination) and it eroded quality of life and lowered self-esteem.
Consent to specifiable actions
Real informed consent cannot be consent to anything and everything. Instead, it must be consent to a specific action or circumscribed set of actions. If it were consent to anything then this would give arbitrary powers to professionals. Indeed, in secure psychiatric provision, in particular, it is commonplace for patients to be subject to the regime of what Goffman called a ‘total institu- tion’: all activities and interventions are determined by the regime of the hospital. When this is the case, patients have little or no moment-to-moment powers of decision-making. In effect, they abandon their right to agree or disagree to specifiable actions on admission or it is taken away from them.
Even in less coercive surroundings, if professionals do not give a full account, in advance, of what is to happen when a treatment is carried out, then they are not giving patients the right to agree to specifiable actions. For example, biological psychiatrists may be paternalistic about with- holding information on major tranquillizers (in case it may worry the patient). Psychoanalysts may evade questions about their technique as part of their technique (to provide a blank screen for the patient’s projections). Thus, for different reasons, both physical and psychological therapists may evade specifying their intended actions in relation to the patient they treat.
Having now discussed both the problems of identifying psychiatry’s client and informed con- sent, let us return to Goffman’s criteria of a good repair service industry. In essence he argues that such a service would have the following features (with our queries about the gap between principle and practice in brackets):
1 The workshop of the industry would be benign and would prevent a deterioration in the condition that required repair. (Mental health services are clearly not always benign.
Coercion is ever present and treatments can be damaging.)
2 Transporting the part in need of repair to the workshop would not introduce new forms of damage. (Entering services is stigmatizing and can be distressing.)
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3 The damaged part is not linked inextricably to its possessor. That is, the owner can be separated from their damaged part for a defined period of time until it is repaired. (The damaged part and its possessor are one and the same. Mental illness is about a flawed or deviant self. This is why a psychiatric diagnosis has such profound implications, as a patient’s credibility as a social actor or citizen is questioned, possibly for life.)
4 Those providing the service and those using it enter into the repair contract voluntarily and with mutual respect. (Mental health law exists to enforce the relationship between service providers and service recipients.)