Paternalistic View on Treating Mental Disorders

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I'm enrolling to a class in Coursera in regards to social contexts of mental health treatment, and in the first week there was a discussion about the previously prevailing idea of paternalism in psychiatry.

http://culturesociety.vdu.lt/wp-con...he-Mental-Patient-An-Uneasy-Relationship1.pdf

This paper is a good general read for those interested.

First of all, what is paternalism?

Paternalism can be defined as “an action which restricts a person’s liberty justified exclusively by consideration for that person’s own good or welfare and carried out either against his present will or his prior commitment” (Breeze 1998, 260). in this way a paternalistic relationship is similar to a relationship between the parents and the child. it can involve using coercion to achieve the good that is not recognised as such by the recipient (Breeze 1998, 260). the reasons for not disclosing mental illness related information may include a reluctance to distress the patient, particularly if a diagnosis is stigmatizing or has a poor prognosis. as gefenas (2003) notes, the hippocratic oath obliges the doctor to do all the best for a patient and to protect him or her from a harm and offence. This protection is understood not only as inducing no harm to a patient but also as protecting him or her from suffering and anxiety that might be caused by disclosing information about illness. This ethical principle inherent to traditional medicine is called paternalism (gefenas 2003).

in psychiatric and other medical discourses, withdrawing of the information from the patient is often justified as being exercised for the patient’s own sake. gefenas points out, however, that limiting the information that might be decisive in making important life decisions restricts the individual’s free self determination and hence it creates an ethical dilemma

The medical model implies that by drawing on some notion of mental illness, which questions patient’s abilities to apprehend reality, psychiatrists tend to take on a paternalistic stance “the doctor knows best.” in this way, the medical model legitimates and sustains institutionalization of paternalism in the psychiatric care.on the other hand, in some illness situations paternalism might be indispensable and even contribute to the treatment outcomes

Paternalistic relationship by its very nature is a relationship of domination and subordination maintained by the differential access to power and resources and justified by some ideology that emphasizes the caring role of the paternalist (abercrombie et al. 1994). Paternalism is a collective form of social organization in that it exceeds the confines of a single relationship between two individuals and has a tendency to be institutionalized. it is typically a diffuse relationship that covers all aspects of subordinates’ lives (abercrombie et al. 1994, 307). hence, paternalism in the medical encounter both reinforces and is reinforced by the powerless situation of the mental patient in the wider society

Select quotes discussing more about the topic in question:

in the health professional discourses, discussions are still continuing on the credibility of the mentally ill individual’s judgments and views (see, e.g., alexius et al. 2000; Barker and orrell 1999; Shipley et al. 2000). mental patients are often regarded as not capable of making rational choice and as lacking insight (lowry 1998). in lithuania, like in other eastern european countries, mentally ill individuals still remain passive recipients of psychiatric services: their various needs are often defined by the policy makers, health and other professionals, institutions or the family members rather than by themselves (SluÅ¡nys 2000; Pūras 2000).This suggests that some professionals, policy makers and society in general consider mental patients as not capable to define their needs and interests; moreover, the mentally ill individuals do not feel able to change their situation.

This situation might be reinforced by the very psychiatric discourse that tends to portray mental illness as inhibiting an individual’s capacity to appreciate the nature and scope of the health problem and that fosters the belief that the mental patient’s views need to be validated by more “objective” accounts.

The psychiatric conception of an effective treatment raises an important observation: the treatment is considered to be successful not only when symptoms are eliminated but also, and perhaps this is even more important, when the patient complies with it by strictly following a doctor’s advice, taking prescribed medications and attending medical consultations.

Psychiatric literature regards treatment non-adherence as one of the major obstacles to the effectiveness of psychiatric care. colom and Vieta (2002) note that the patient’s failure to adhere leads to chronification, poor psychosocial outcomes and increased suicide rates in case of psychotic and mood disorders. according to them, patient’s non-adherence is often a result of a poor insight (i.e., lack of illness awareness) that is considered to be a common feature in some mental illness (see also Kampman et al. 2001). insight itself is seen as consisting of three overlapping dimensions: recognition that one is mentally ill, the ability to relabel unusual mental events as pathological and adherence to the treatment or recognition of the need for treatment (trauer and Sacks 2000, 211). The mental patient’s failure to demonstrate any of these dimensions is explained as a lack of insight and consequently as a sign of persisting pathology

implicit in the dominant professional worldview is a belief that the role of the professional is to diagnose, prescribe and treat. in its turn, the patient is expected to comply with the diagnosis and treatment. The non-adhering behavior is seen as challenging professionally held beliefs, expectations and norms. according to the authors, this has led to a tendency to view non-adhering patients as both deviant and culpable.

Playle and Keeley maintain that psychiatric discourse fails to take into account what the non-adherence or adherence itself means to the patient. They note that the patient is left with no choice but to comply with the treatment in order to demonstrate insight and competence. it is when patients do comply with treatment the professional may presume that insight has been achieved and that a collaborative and trusting relationship has been developed. if the patient fails to comply, the presumed lack of insight provides both the justification and opportunity for the professional to act paternalistically, diminishing the autonomy of the individual (Playle and Keeley 1998, 309). in other words, non-adherence is often seen as a fault on the part of the patient rather than failure of the psychiatrist to accommodate patient’s needs and expectations to the treatment (lowry 1998; Playle and Keeley 1998).

hence, certain mistrust towards the mental patient becomes characteristic of psychiatric care. Since the patient is seen as potentially lacking insight, it is the professional that has to retain control over the medical encounter and to decide what is best for the patient. This suggests that paternalism in psychiatric care might be legitimated and further sustained by the very conceptualization of mental illness that in turn requires specific behavior towards the patient. also, the psychiatric notion of a mental illness could be seen as lacking a more optimistic scenario. The concept of “remission” used instead of “recovery” has no clear boundaries that would allow separating between health and illness. This locates an individual who has once suffered from a mental illness in a more or less permanent sick role and dependency on the health professionals.

Question :
Do you agree with the paternalistic approach to patients with mental disorders?
Do you think patients should have the (primary) control over their choice of being medicated / treated or not?
The key idea of paternalism in psychiatric seems to be that some people needs to be taken care of, because they can't do it themselves. Is there a line where one may or may not have the sound judgment to do what's best for themselves? Where?
In practice, we can see lots of negative effects in treating and admitting patients within the paternalistic approach. Now with the emerging idea of letting patients choose to be treated, medicated, or not at all; what would be the challenge?

Another related idea is what happened with Britney Spears : Conservatorship. What do you think about this?

 

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And this is what the paper claimed sociologists were thinking:

Sociologists have long been critical towards the psychiatric conceptualization of mental illness and its consequent approach towards mentally ill
individuals. Since the psychiatric diagnosis has been criticized as being based on rather vague criteria that do not allow making clear demarcation between “badness” and “sickness” it was seen as lacking objectiveness. Thus, psychiatry has been largely seen as an institution of social control rather than care

according to navarro (1976) medicine plays an important ideological role in strengthening the capitalist social order since in its emphasis on the physical causes of illness and ignorance of the social ones, it individualizes and de-politicizes the illness. it shifts the focus from the social structure to the physical realm and mutes the potential for action by the patients to change the conditions that trouble them. ingleby (1981, 44) maintains a similar position in claiming that “psychiatry protects the efficient functioning of social institutions by converting the conflict and suffering that arises within them into ‘symptoms’ of essentially individual (or at best familial) ‘malfunctioning’; it thus attempts to provide short-term technological solutions to what are at root political problems.”

Psychiatric claims to value neutrality in diagnostic and treatment practices have been also extensively criticized. Warner (1994), for example, has studied the life-stories of people with schizophrenia in Western societies during the 20th century in order to demonstrate how political and economic factors shaped the course of schizophrenia. according to him, recovery rates for schizophrenia in industrialized societies are closely linked to fluctuations in economy and the requirements of the labor market. Warner concludes that changes in the outcome of schizophrenia reflect changes in the perceived usefulness of the mentally ill individuals for the labor market and are not merely effects of psychiatric treatment.
(Warner also notes that economic climate may affect level of (in)tolerance towards mentally disordered people in the family or in the community: such persons may be more discriminated against and stigmatised during the times of economic hardship)

*) Addition:This is quite unrelated to the paternalistic approach, but it says something about the recently common reliance in mental-alleviating drugs from an interesting perspective.

The introduction of new drug treatments in the 1960s had a particular influence on psychiatric practice. according to Barham, psychiatrists could now style themselves as:


. . . experts in pharmacology rather than experts in human behavior.
abnormal behavior patterns could be controlled: they need not be understood. The psychiatrist could carry out his work as other doctors did –
relieved of the burdens of attempting to follow the processes of disturbed
minds, the trains and complexities of unfamiliar lifestyles, the pressures
of unemployment, squalid housing conditions and poor nutrition. There
was no need to enter the jungle of human emotions – love, hatred, pain,
grief. it was a great deal less wearing and a great deal more respectable in
strictly medical terms (Barham 1992, 14).

 

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In sum....

in sum, the dominant professional conceptions of mental illness, institutionalization of paternalism and patient’s dependency on the health professional might shape the way in which the individual will respond to illness situation and own capabilities to manage it. furthermore, the disempowering medical practices and discourses together with stigmatization, discrimination, exclusion as well as illness-related disability might make it quite difficult for mental patients to challenge their powerless situation in society. also, since empowerment in fact involves acquiring power to challenge the dominant psychiatric discourses and the roles that are ascribed by various professional paradigms and society to the individual suffering from
mental illness, it requires collective action, which in turn implies assuming a collective identity, i.e., identifying and defining oneself as a group – in this case a group of individuals suffering from mental illness. This might be problematic for the mentally ill individuals due to the stigma related to mental illness (which itself is reinforced by the disabling professional conceptualizations of mental disorder), which in turn may result in attempts to conceal illness from the public rather than construct a group identity on the basis of it (Baltrušaitytė 2006).