Patients' rights: a cultural challenge to Western psychiatry

To some degree, all psychiatric encounters, by constraining behavioral variation and autonomous decision making, threaten a personhood already impaired by illness. The challenge presented by this and other factors in Western psychiatry is how to resolve the ethical dilemmas of justice, autonomy, and beneficence inherent in contemporary hospitalization and treatment practices for severely mentally ill persons. The author discusses this challenge in terms of the physician-patient contract, clinical standards for limiting autonomy, and the Kantian concept of equality of mutual respect. The legal code in relation to psychiatry has evolved into a contemporary interpreting mechanism for Kantian cultural tradition.     

Patients' rights and psychiatrists' duties: discharging patients against medical advice

Every psychiatrist who treats voluntary inpatients has had or will have patients who leave the hospital against medical advice (AMA). Studies reveal that between 6 and 35 percent of voluntary psychiatric inpatients are discharged AMA. These patients often are acutely ill and have severe symptoms at discharge. They also, as a group, have high rehospitalization rates and worse outcomes than patients who do not leave AMA. When a mentally ill patient demands to leave the hospital AMA, a tension arises between the patient's rights and the psychiatrist's duties. These duties include those to the patient and, in many cases, to third parties. Patients discharged AMA may remain dangerous and can expose health care providers to a heightened liability risk. More importantly, because of such factors, decisions about handling the AMA discharge are more difficult than decisions about admission. This article analyzes the sources of increased liability risk posed by AMA discharges. It includes discussions of patients' rights, including the different types of voluntary admissions, and psychiatrists' duties. Malpractice litigation in this area is reviewed. The article concludes by suggesting risk-management techniques that can aid in protecting the psychiatrist while also respecting patients' rights and delivering good clinical care.     

Multidisciplinary design and implementation of a day program specialized for the frontotemporal dementias

To supervise activities for patients with frontotemporal dementias presents major challenges to day programs typically equipped to care for more elderly, frail patients. In this article, we present the development and immediate outcomes of integrating a day program specialized for patients with frontal lobe disturbances into an already established day program. Planning required new collaborations between the ambulatory memory clinic and the day program staff. Immediate outcomes have included relief of burden for an under-served group of caregivers and behavioral management that more seamlessly combines strategies for medication titration, environmental adjustments, and activity participation.     

A program for continuing care: implementation and outcome.

The authors used the records of the continuing-care program at a large public hospital in Los Angeles to determine the success of referrals for aftercare. A total of 552 patients discharged during an eight-month period were referred for continuing care; 418 of the patients kept their first appointment. Patients were most likely to keep their first appointment if it was set up for within three days of release from the hospital and if it was confirmed before discharge from the hospital. If an appointment could not be arranged within three days, a phone call to the patient improved the referral completion rate.     

Challenging the monologue about silent sterilization: implications for self‐advocacy

• • This is the story of Marie, a woman with ‘learning difficulties’ who lives in Belgium. It is told by Marie and her advocate, Griet. In 2002, Marie was told she had to have a sterilization. This is the story of what happened:
• • The professionals told Marie and her mother the operation was essential.
• • Marie did not know what the operation was because the professionals did not explain what it meant nor did they talk through this difficult issue with her. She discussed it with Griet; Marie did not want it because it was not necessary. They agreed to refuse it.
• • They conclude that sterilization has to be a choice made by the woman concerned and not forced on someone because they are labelled as having ‘learning difficulties’.

     

A system for patients' rights advocacy in state psychiatric inpatient facilities in Maryland.

A patients' rights advocacy system was developed in 1986 by the Maryland Department of Health and Mental Hygiene to serve patients hospitalized in 12 state facilities. The system includes a four-level appeal program that attempts to resolve grievances through mediation between patients and state staff and a legal assistance program operated by attorneys under state contract. Data from fiscal year 1990 indicate that issues related to treatment, to seclusion and restraint, and to admission, discharge, and transfer generated the most complaints. The majority of complaints were resolved without legal intervention at the first stage of the appeal program, usually in a meeting between a rights adviser, the patient, and the patient's primary physician.     

A study of a structured exercise program with members of an ICCD Certified Clubhouse: program design, benefits, and implications for feasibility

Individuals with serious mental illness (SMI) have significantly greater risk of comorbid health problems and premature death, and there is need for interventions that can improve physical fitness and overall health. Accordingly, a study was conducted which evaluated the effectiveness of a structured physical exercise program that was developed as part of a wellness project in an ICCD Certified Clubhouse. Seventeen clubhouse members completed a 16-week program with evidence of significant improvement in aerobic capacity and perceived mental health as well as positive trends in perceived improvements in physical and social functioning. Qualitative data indicated satisfaction with the program by all participants, especially the value of group support, while also highlighting the need for greater attention to nutrition as part of a future program. Moreover, the study found that a structured exercise program can be successfully provided to members of an ICCD Certified Clubhouse.     

Mental health advocacy with black and minority ethnic communities: conceptual and ethical implications

PURPOSE OF REVIEW: Recent policy and legislative developments confirm the right to advocacy for people experiencing mental health problems. Provision of mental health advocacy for black and minority ethnic communities is particularly identified as a key objective for Primary Care Trusts. This review considers the implications for commissioners and practitioners of ensuring access to appropriate advocacy for service users from black and minority ethnic community. RECENT FINDINGS: There is a dearth of literature on mental health advocacy with black and minority ethnic communities. The available research suggests that mainstream conceptualizations of advocacy are not meaningful to these communities and this adversely affects access. Advocacy provided by black community and voluntary sector organizations begins with understanding racism and social disadvantage. It is therefore concerned with addressing these inequalities and resonates strongly with current concepts of recovery. SUMMARY: People from black and minority ethnic communities are not well served by current provision of mental health advocacy, and there is a risk that this will be replicated in the development of independent mental health advocacy, under the amendments to the UK Mental Health Act of 1983. This largely reflects the conceptualization of advocacy and its purpose. The implications for both commissioning and provision of advocacy are explored.     

Patients' comments on psychiatric inpatient treatment experiences: Patient-therapist relationships and their implications for treatment outcome

Only few researchers pay systematic attention to what patients may have to say about their treatment experience during psychiatric hospitalization.This study not only delineates the various therapeutic aspects of an open psychiatric inpatient unit based on the patients' comments, but also attempts to correlate the data with the objective outcome of treatment rated clinically by the therapists and independently by the author. Positive patient-therapist relationship has been found to be the most significant factor correlated closely with the treatment outcome. The correlation may support the relevance of the patients' comments regarding subjectively perceived therapeutic benefits vs. objective actual benefits.The author wishes to thank Dolores Millan, B.A., of the Research Department of the Long Island Jewish-Hillside Medical Center, for her assistance in compiling and evaluating the statistical data.     

A preventive intervention program for bereaved children: problems of implementation

A brief, standardized intervention program to facilitate children's adjustment to the terminal illness and death of a parent posed the following implementation problems: estimation of patient life expectancy; engagement of the family in crisis; adhesion to the parental guidance model; and termination of formal clinical intervention. Resolution of these issues is described, and adaptation of such programs to other high-risk populations is considered.     

Patients' and staff members' attitudes about the rights of hospitalized psychiatric patients.

OBJECTIVE: The goal of this study was to assess and compare patients' and staff members' attitudes about what rights hospitalized psychiatric patients should have. METHODS: A 31-item inventory, developed for the study, for assessing attitudes about what rights hospitalized psychiatric patients should have was used with 122 hospitalized psychiatric patients and 35 staff members in the same hospital. RESULTS: Patients were less likely than staff to express the view that involuntary hospitalization, the use of force or physical restrictions, or the compromise of confidentiality is justified. There were no significant differences in attitudes toward patients' rights to obtain information about their illness and treatment and their right to refuse treatment. CONCLUSIONS: The differences in attitudes found in the study highlight the importance of considering multiple facets of patients' rights and the extent to which attitudes about patients' rights are associated with each facet.     

The patients rights representative program: Design of an ombudsman service for mental patients

The article describes an experimental rights program operating in mental hospitals in one state's department of public welfare. The presentation of the program's internal/external design includes information on goals and objectives, structure, work activities, and reviews of the program to date. The program is linked to the general trend toward developing ombudsman services; several additional research needs are identified.The program design was originally developed with support from Region III of the Department of Health and Human Services Contract No. 130-79-11. The views expressed are solely those of the authors.     

Semantically-bounded anomia: implications for the neural implementation of naming.

We describe a patient whose anomia is disproportionately severe for fruits and vegetables when familiarity and name frequency are taken into account. His fruit and vegetable naming impairment was evident in a variety of different tasks. In contrast, he retained good general knowledge of fruits and vegetables, and he could access their names when given a phonemic cue. We discuss the phenomenon of semantically-bounded anomia in relation to the issues of local vs distributed representation, the existence of semantic "maps" in the brain, and the implementation of arbitrary associations in neural networks.