Paper
The past thirty years have seen great changes in the treatments available for people with
mental illness. Advances in neuroleptic medications, better understanding of the neurobiological
aspects of mental illness and more effective styles of psychosocial intervention have all improved
the services available for the mentally ill. However, the last three decades have also been a period
in which several obstacles to the access of care have made the treatment of persons with mental
illness more difficult. Although designed to protect those who suffer from mental illness, changes
in policy and law have created difficulties in delivering services to involuntary clients and assisting
them to control their illnesses.
People with severe mental illness require a variety of interventions in order to successfully
manage their conditions. Basic needs such as housing, vocational training, and financial assistance
are all areas which, although perhaps taken for granted by many, can be of great difficulty for
someone with a mental illness. People may require varying degrees of assistance in these areas as
well as with managing interpersonal relations and other spheres of social and emotional
functioning (Hershberg & Posner, 1992). Most people with mental illness can benefit greatly
from the use of antipsychotic medications. In the past, many of the drugs offered to mentally ill
people to control their psychoses, such as haldol and stelazine, would sometimes produce side
effects almost as debilitating as the illness itself. However, in recent years, advances in the field of
neuroleptic medications have produced new drugs which are far more effective than their
predecessors and which cause far fewer negative side effects. It can be argued that without a
medical control of severe mental illness through medication, assisting clients to function
adequately for extended periods of time can be an almost impossible task (Isaac & Armat, 1992;
Torrey, 1995).
Although established to protect the people s rights and put a stop to past abuses, current laws
and policy can prove to be difficult hurdles to overcome when working with persons with mental
illness. Since the 1960s, deinstitutionalisation and changes in rights protection have greatly
altered the face of psychiatric care. Before these changes, many people were unnecessarily
hospitalised for lengthy periods and subject to poor treatment, over medication and in some cases
to questionable medical procedures (Torrey, 1995). In response to the situation, survivors of the
previous institutional system, their families and civil rights groups fought for the protection of
patients and succeeded in having laws and medical practices changed. These protections are
crucial in order to avoid a return to past abusive practices. They do, however, necessitate that
professionals working with people with metal illness be creative in working within the constraints
of the existing laws.
Under normal circumstances, people are not required to accept any form of treatment for their
illness. It is common for psychiatric patients to refuse medical and psychosocial intervention.
The very nature of many mental illnesses may lead the person to believe that they are not actually
ill but in fact well and living in a sick world. In many cases, after a short hospitalisations, patients
are discharged into the community and have the choice as to whether or not to continue
treatment. Sometimes, when people are under the effects of medication and feeling relatively
well, they believe that they are no longer are sick and cease following their medication programs
and other aspects of their follow up. Sometimes the effects are devastating. The fact that a
surprisingly large portion of the homeless population are in fact people who have dropped out
of treatment programs for mental illness and their being homeless is a consequence, direct or
otherwise, of their dropping out is a frightening and concrete example of the possible outcome of
treatment refusal. (Torrey, 1997; Torrey, 1988).
With such clients, it is often necessary to be creative in order to convince them to follow their
treatments. Abramson (1989) uses the term paternalistic beneficence to describe actions taken to
serve the best interests on the client while depriving the person to some degree of their right of
choice. While this may take the form of outright decision making for the client, other more subtle
forms of paternalistic beneficence are possible. Some clients may seek certain services while
refusing others. In some cases, withholding desired services and only providing them if the client
complies to certain conditions may be justifiable. In the case of people who are mentally ill and
homeless, material assistance such as budgeting or assistance in finding housing might be given on
the condition that the client agrees to be followed by a physician. Although it may sound
unethical to suggest refusing services, it may be justifiable if the end result is that the client gets
the treatment they need. Also, in the case of the mentally ill, certain services may be useless if not
accompanied by medical follow up. For example, assisting a person to find an apartment when
they accept no other support and are incapable of maintaining the living arrangement for any
length of time due to their untreated illness might not be productive and turn out to be only a
temporary arrangement and a frustrating, confusing failure for the client.
A number of other strategies can also be used. If necessary, legal procedure is available to
oblige clients to follow treatment plans and for forced hospitalisation. However, although a court
order may bring about the care a person needs, it is a last resort and is often only enough to have
a person evaluated by a psychiatrist or hospitalised for a short period but can not force people to
take their medication. In some cases, people with metal illness are required to do so but usually
only when the criminal justice system is involved and following a treatment plan is part of the
person s probation or parole terms. Torrey (1995) suggests the implication of family members
whenever possible. By using the family s influence, as well as having them present throughout the
helping process to reassure their loved one of the positive outcomes of treatment, convincing the
client to accept the help needed may be facilitated. When the family is involved, time must be
taken to educate them on aspects of the illness and possible outcomes.
However, Isaac and Armat (1992) suggest that without some sort of mandatory adherence to
taking medication for clients, treatment plans can not be truly successful. They describe a number
of successful programs which use public legal authority in a system similar to a public curatorship
of a person s treatment plan. The authors note that without such measures to keep clients on
their medication, community services can not be entirely successful. Torrey (1997) suggests that
similar programs might be needed to reach the hard to treat clients who are presently not
receiving any sort of treatment. This refers to those who have been hospitalised several times,
usually by way of court order, then released only to again stop taking their medication and retreat
from view until the next court order. Simply hospitalising and re-hospitalising these people is not
necessarily beneficial and is extremely costly. Although mandatory adherence to treatment is not
the answer for all clients, it may be an effective response for some who have a tendency to drop
out of treatment. While some regions of the USA have such programs, Quebec only forces
adherence to treatment through its legal system as a condition of probation or parole when the
person s untreated illness has lead to criminal acts.
It is sometimes suggested that the current laws do too much to protect clients rights and
impede assisting them (Torrey, 1997). Although treatment is sometimes made difficult, the
protection is essential. Without it, clients would be disempowered and possibly rendered unable
to play an active part in their treatment plan. Whenever possible, clients should be able to have at
least some choice in what services they do or do not receive. Having the choice bestows a sense
of responsibility upon the client and improves chances of long term adherence to a plan of service
(Torrey, 1995). By providing incentives and assistance to make those choices, clients may have
their needs met while at the same time playing an active part in determining the outcome of their
illness. For those clients who can not be reached in this way, a more flexible and creative legal
tool is needed as suggested by Isaac and Armat (1992). However, there is no one response to
dealing with clients who might not adhere to treatment plans and the legal system is not the
answer for all. What is needed and can assist in almost all cases is a general flexibility as well as
creativity and tolerance, all of which are at times lacking in our system. Not only must health and
social services be less rigid but also the legal system. If all players can adopt a mentality suited to
this population, treatment might be better provided to more people without threatening the
protections of human rights as they presently exist.
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