www.psljournal.com/archives/papers/mentalHeath.cfm
A comparison of ethical
attitudes of English and German
health professionals and lay
people towards involuntary admission:
Implications for the new Mental Health Act (England & Wales)
Peter Lepping, M.D.,* Tilman Steinert, M.D.,** and
Ralf-Peter Gebhardt, Ph.D.***
* Specialist Registrar in Psychiatry, Cheshire
and Wirral Partnership NHS Mental Health Trust and the University
of Liverpool (England)
** Senior Lecturer and Consultant Psychiatrist, University
of Ulm (Germany)
*** Statistician, University
of Ulm (Germany)
ABSTRACT:
Objectives:
To identify ethical attitudes about involuntary admission (known in Great
Britain as formal admission) in
mental health professionals and lay-people in England and Germany, especially
looking at possible differences between Mental Health Professionals who are
directly involved in the involuntary admission process and those who are not.
Method:
Three scenarios of potentially certifiable patients (known in Great Britain as sectionable
patients) were presented to identify attitudes. A questionnaire asked about
attitudes towards involuntary admission as well as treatment. A questionnaire
analysis was then performed.
Results:
There were similar attitudes towards involuntary admission between lay-people
and mental health professionals involved in the involuntary admission process
with the exception of professionals not actively involved in the involuntary
admission process. Neither personal or professional experience with mental
illness nor the different legal frameworks between Germany and England influenced attitudes much. Support for
involuntary admission broadly increased with age.
Conclusions:
Psychiatrists and other mental health workers are in tune with society with
regards to attitudes to involuntary admission. People involved with mentally
ill patients but not in the involuntary admission process have negative
attitudes towards involuntary admission. This may influence Mental Health
Tribunals suggested in the new draft Mental Health Bill (2002) for England and Wales, because these Tribunals will
potentially lack any involvement of professionals involved in the involuntary
admission process.
BACKGROUND: Involuntary admission to hospital is seen as
an ethical as well as medical and legal challenge all over the world (HELMCHEN,
1998). This is exemplified by patients
with symptoms of schizophrenia; an illness, which is commonly associated with a
lack of insight by patients into their illness. The ethical dimension of
involuntary admission has become increasingly important over the last few years
in a fast changing climate (COUNCIL REPORT 83, 2000). In England and Wales the
new Draft Mental Health Act (2002) suggests that Mental Health Tribunals take
place within seven days of involuntary admission in order to comply with
article 5 of the European Human Rights Act (1998) (EHPA, 1998), guaranteeing
the right to liberty and security and thus requiring quick legal reviews of any
involuntary detention. Currently the Tribunals consist of lawyers,
psychiatrists and physicians with mental health experience and general members,
but have to have medical and legal
representation. The general members are people from associated professions such
as nurses, social workers or psychologists who have experience with mental
illness. The Royal College of Psychiatrists has rightly been concerned about the
resource implications of this measure (RCPsych, 2002), which the draft bill
intends to solve by allowing more general members onto the Mental Health
Tribunal panels. This can frequently lead to panels being made up entirely by
non-medical members (DRAFT MENTAL HEALTH BILL, 2002). The Royal College has warned that this may lead to
undesirable decisions, because of a lack of medical involvement on the panel
(RCPsych, 2002). Mental Health Professionals likely to become general members
are to a large extent those not directly involved in the involuntary admission
process. There would be serious cause for alarm, however, if it were found that
Mental Health Professionals not involved in the involuntary admission process
have significantly different attitudes towards involuntary admission than other
Mental Health Professionals or indeed society as a whole, because it may skew
the panel’s decisions.
In a wider
context it is interesting to note that different legal systems – case law in
Anglo-American countries compared to coded law in Germany and other Continental
European countries (RÖTTGERS, 1999) – are not resulting in different numbers of
involuntary admissions in those two countries (RÖTTGERS, 1999). In all parts of
the United
Kingdom doctors - including a psychiatrist - and social workers are
involved in the admission process; in Germany, however, it is a judge acting on the
application by a public health physician who makes the decision regarding
involuntary detention. In Britain social workers and doctors are
therefore actively involved in the involuntary admission process, whereas this
is not the case in Germany. There, doctors only advise the courts
as to whether a patient should be involuntarily admitted and social workers
play no role in the involuntary admission process at all (RUDOLF, 2000). It is,
however, unclear whether different legal systems and historical experiences
with psychiatry have resulted in different ethical attitudes in the societies
as a whole and amongst mental health professionals in particular in England and Germany. This is important considering the
English experience with asylums and the German experience of abuse of
psychiatry by totalitarian regimes (RÖTTGERS, 1999). Until now any research has
focused on predicting factors and attitudes amongst service users (SANGUINETI,
1996; STEINERT, 2001; LIDZ, 1995) rather than mental health professionals and
lay-people where data has been conspicuously lacking. Furthermore, nothing is
known about whether personal or professional experience with mental illness
influences attitudes about involuntary admissions or whether possibly different
professions consistently have different views on this issue.
OBJECTIVES: To analyse attitudes of mental health
professionals and lay-people towards involuntary admission of people who suffer
from symptoms of schizophrenia.
METHOD:
Three case reports (scenarios) of patients with schizophrenia were presented to
a sample of n=641 in Germany and n=289 in England. The scenarios were translated from
German into English and back into German. There was very high correspondence
between the original and the retranslated text. Simple yes/no decisions were
asked about involuntary and treatment. The participants were coded to guarantee
anonymity and were asked to give details about their sex, age, profession and
whether they had been mentally ill themselves or experienced mental illness in
their family and whether they regularly work with mentally ill patients. We did
not specifically ask whether they had been personally or professionally
involved in involuntary admission procedures.
The German
sample consisted of 22.3% psychiatrists, 14.0% nurses, 9.7% social workers, and
5.0% other doctors, 3.4 % psychologists and 42.3% lay-people. Furthermore there
were 3% lawyers in the German sample, which are not part of the lay-people
category. We disregarded them, because we did not have an English sample of
lawyers. There were, however, no differences between the German sample of
lawyers and German lay-people with regards to the variables examined. They were
recruited from all over Germany by placing advertisement in the German
equivalent of the BMJ asking for assistance. Participants were then sent the
questionnaires and asked to distribute them further. The English sample consisted of 15.2%
psychiatrists, 13.1% nurses, 8.0% other doctors, 10.7% psychologists working in
mental health, 8.0% social workers and 45.0% lay-people. The health
professionals were recruited by direct distribution of the questionnaires at
medical meetings and on wards; the lay-people were recruited via GP practices.
The English sample was recruited only in the Northwest of England.
The first
scenario describes a 19-year old man with a first episode of delusions and
marked social withdrawal. The second case describes a 33-year old woman with a
first relapse of schizophrenia presenting disorganised, thought disordered,
delusional and posing a moderate threat to her elderly mother whom she lives
with. The third scenario describes a 38-year old man with multiple relapses of
schizophrenia, now presenting with self-neglect, delusions and social
withdrawal.
The
statistical analysis was done using Chi-square and logistic regression.
RESULTS: The two samples (Germany and England) are broadly comparable. There are, however,
some statistically significant differences: a) the English sample is older
(Mean: 42.0 compared to Mean German sample: 38.7: p=0.0006). (Table 1)
Furthermore the English sample has less personal experience with psychotic
mentally ill people (p<0.001) with the exception of the group of
psychiatrists where there is no significant difference.
The first scenario (young man, delusions,
social withdrawal) showed the following results: Table 2 + 3, references to
admission and treatment refer to involuntary admission and treatment against
the patient’s will, differences refer to statistically significant differences
only.
There was no
difference between German and English psychiatrists in agreement over
admission, but English psychiatrists were significantly more likely to treat
once the patient was involuntarily admitted
(93.2% v. 62.9%, p<0.001). There was no difference between other
doctors in the English and German samples. English psychologists
were significantly less likely to support admission or treatment than their
German counterparts or any other profession in the English sample (32.3% v.
77.3% for admission: 35.5% v. 59.1% for treatment, p<0.01 for both). There
was no difference between English and German social workers (this is due
to the relatively small number in the English sample), but German social
workers are significantly less likely to support admission than any other
profession in the German sample (p<0.01). There are no differences between
the English and the German nurses sample for involuntary admission, but English
nurses support treatment more often (86.8% v. 61.1%, p<0.05). English lay-people
support admission, but not treatment more than the German sample (85.4 v. 73.3%
for admission, p<0.08; 71.5% v. 67.0% for treatment, p<0.5). In both
samples increasing age was positively correlated with increasing support for
admission and treatment (p<0.001 in both samples).
The second scenario (33-year old woman,
first relapse, thought disordered, possible threat to mother) showed the
following results: Table 2 + 3:
There were no
differences between the English and the German sample for psychiatrists,
other doctors, psychologists, nurses and lay-people.
German social workers were less likely to support admission or treatment
(p<0.001 for admission, p<0.01 for treatment). Women were more likely
than men to support admission in the German sample (p<0.05). In the English
sample people who had suffered from a mental illness themselves were less
likely to support treatment in the English sample only (p<0.01). Age was no
important factor in this scenario.
The third scenario (38-year old, multiple
relapses, self-neglect, delusions, and social withdrawal) showed the following
results: Table 2 + 3:
English psychiatrists
were more likely to support admission and treatment than German psychiatrists
(79.5% v. 61.5%, p<0.05 for admission; 79.1% v. 58.7%, p<0.02 for
treatment). There were no differences amongst other doctors. English psychologists
were less likely to support admission and treatment (16.1% v. 54.5%, p<0.005
for admission; 10.0% v. 50.0%, p<0.002 for treatment). German social
workers were less likely to support admission or treatment than other
professions in the German sample (p<0.001). There were no differences with
the English social workers’ sample. Between the nurses’ samples there were no
differences with regards to admission or treatment. The English nurses,
however, were more likely to agree to admission if there was a history of
previous successful treatment or if there was a chance to re-establish contact
with relatives (p<001 for both). English lay-people were by far more
likely to support admission and treatment than German lay-people (82.3% v.
59.3%, p<0.001 for admission; 68.5% v. 57.9%, p<0.05 for treatment).
Surprisingly,
personal or professional knowledge of mentally ill people as well as personal
mental illness was not a predictor of attitude in either country. When we
examined these findings in more detail we saw that in the German sample people
who regularly deal with the mentally ill were less likely to support admission
than those who do not (p<0.05). In the German sample increasing age
positively correlated with increased support for admission and treatment
(p<0.001). In the English sample this age related correlation was weaker and
only significant for admission (p<0.05), but not treatment. In the English
sample the whole sample was more likely to change their mind and agree to
involuntary admission if there was a chance to re-establish contact with
relatives compared with the German sample (p<0.01).
DISCUSSION:
The results show that, against our predictions, personal knowledge of mentally
ill people as well as personal mental illness was not a predictor of attitude in either country, profession
however was. The results would suggest
that psychiatrists and other physicians are remarkably in tune with society as
a whole regarding attitudes on to involuntary admission in both countries
examined. Significant differences, however, were observed amongst those Mental
Health Professionals not actively involved in decision-making about involuntary
admission, regardless of whether they had personal or professional experience
with mental illness or not. What we termed the “Social work scepticism effect” in Germany, equalled to some extent by a “psychology scepticism effect” in England may logically be explained by the fact
that these professions are not involved in the involuntary admission process at
all in their respective country. On the other hand, it is possible that there
are significant inter-professional differences such as training or recruitment
issues, which we did not examine in this study, but might account for these
findings. Given the amount of potential co-founding factors that may explain
the observed differences between professions, we feel that caution should be
observed before generalising our results. However, in a recent study using the
same questionnaire in Hungary and Switzerland, Steinert et al showed similar
scepticism amongst social workers regarding involuntary admission in those two
countries, where only doctors and judges are involved in the involuntary
admission process (STEINERT T, 2003), which confirms our findings. The lack of
this involvement absolves these professionals to some extent from
responsibility for any outcome, which in turn makes criticism easier. Given the
proposed changes in the Draft Mental Health Act, there is a real danger that in
the future panels for the Mental Health Tribunals may consist of members who
are generally more opposed to involuntary admission as a concept than the
treating psychiatrists and society as a whole. This is particularly worrying
when one considers that frequently there will be no medical member on these
panels and that not all detained patients will be required to have an RMO
(RCPsych, 2002). Decisions may be in danger of being skewed towards a more
sceptical approach to involuntary admission beyond the point that is deemed
acceptable by the treating psychiatrists and society as a whole. While some
people may welcome a voice on the panel that is likely to be overly critical of
involuntary admission, the results of this work show that the Royal College of
Psychiatrists is right to be concerned about the absence of medical members on
future tribunal panels.
It is
remarkable how little overall difference exists between the English and the
German sample. The tendency of the German sample to support involuntary
admission less may be caused by negative experiences with abuse of psychiatry
in Germany by the National Socialists (RÖTTGERS,
1999). Although this was to some extent countered by the positive experiences
in Germany with care in the community,
anti-psychiatric scepticism and the anti-psychiatry movement in the 1970s had a
wider basis in German society than in Britain. Care in the community was introduced
in Germany after a parliamentary commission in
1975 on the state of psychiatric services heralded the end of asylums and it
was very well funded. High profile coverage of homicides by the mentally ill in
Britain may explain why the English lay-people
sample was significantly more likely to support involuntary admission than
lay-people in Germany where such coverage is distinctly less
aggressive.
Furthermore,
the differences in the involuntary admission process may also be explained to
some degree by the greater scepticism towards psychiatric services amongst the
whole of society in Germany, where doctors are confined to an
advisory role in the involuntary admission process (RUDOLF, 2000). In England, however, there is an “assumption of benevolence” towards the
patients by mental health professionals (RÖTTGERS, 1999). Comparing the two
health services it is interesting that, despite higher levels of funding,
recent surveys show that Germans are less content with their health service
than Britons (41.3% satisfaction rate v. 49.3% in Britain) (DER SPIEGEL, 2001).
This is corresponding with a higher degree of scepticism towards the services
in Germany.
In the German
sample there seemed to be more difference between support for involuntary
admission and treatment than in the English sample. It appears that in England a more pragmatic approach is taken
where it is felt that once somebody is admitted one might as well “get on with
it and treat”.
In Germany and to a slightly lesser extent also
in England increasing age was a positive predictor
for involuntary admission. This might be happening in
correspondence with somewhat more conservative values
of the older generations, although any generalisation
in this respect would be misplaced. It is also remarkable
that the opinions of lay-people, psychiatrists, other
doctors and nurses were very similar supporting the conclusion
that psychiatry is in tune with society as a whole in
both countries.
In the wider
European context differences in the type of legal systems used and differences
in the people involved in the involuntary admission process seem to influence
society’s opinion about involuntary admission very little. In contrast to this,
direct involvement in the involuntary admission process seems to increase
support rather than diminish it.
LIMITATIONS:
Limitations include the fact that participants were not asked whether they
specifically had personal or professional experience with the involuntary
admission process. It is assumed that professionals who work in Mental Health
Services have such experience, but it is not specifically enquired. Limitations
also include the differences in sample size and age between the two samples.
Furthermore, the sample size of psychologists and social workers in both
countries (but especially in the English sample) was limited and conclusions
should be drawn with caution. The English sample size was limited to the
Northwest of England and attitudes may be different in other parts of the
country.
ACKNOWLEDGEMENTS: We would like to thank Ann Gould, Department of Psychiatry,
Royal Liverpool Hospital as well as Northgate Village Surgery
in Chester for their support in distributing the
questionnaires and the Department for Child and Adolescent Psychiatry in Runcorn, England, for their support. We would also like
to thank Dr. V. Sharma for his comments on the draft paper. In Germany the University of Ulm funded the study. There are no other
financial interests.
REFERENCES:
- COUNCIL REPORT 83, 2000: Good psychiatric practice, Royal
College of Psychiatrists
- DER SPIEGEL Magazine, 13/26.03.2001, p.54-7
- DRAFT MENTAL HEALTH BILL, 2002, schedule 1, page 120 - 1
- EHRA: http://www.hmso.gov.uk/acts/acts1998/80042--d.htm#sch1
-Helmchen H, 1998:
Die Deklaration von Madrid 1996. (World
Psychiatric
Association:
The Madrid declaration 1996), Nervenarzt 69, p.
454-5
- Lidz CW, Hoge SK, Gardner W et al., 1995: Perceived
coercion in mental hospital admissions, Arch Gen Psychiatry, 52, p.1034-1039
- Royal College of Psychiatrists:
http://www.rcpsych.ac.uk/college/parliament/responses/mhbMhlsc2002a.htm
- Röttgers HR, Lepping P, 1999: Zwangsunterbringung und –behandlung
psychisch Kranker in Großbritannien und Deutschland (Involuntary admission and
treatment of the mentally ill in Great Britain and Germany), Psychiat Prax, 26,
p.139-142
- Röttgers HR,
Lepping P, 1999: Treatment of the mentally ill in the Federal Republic of
Germany, Psychiatr Bull Vol.23, No.10, p.601-3
- Rudolf GAE, Röttgers HR, 2000: Rechtsfragen in Psychiatrie und
Neurologie, 2. Auflage (Law Issues in psychiatry and neurology, 2nd
edition), Wiesbaden, Deutscher Universitätsverlag
- Sanguineti
VR, Samuel SE, Schwartz SL, 1996: Retrospective study of 2200 involuntary
psychiatric admissions and readmissions, Am J Psychiatry, 153, p. 392-6
- Steinert T, Hinüber W, Arenz D, Röttgers HR, Biller N, Gebhardt RP, 2001:
Ethische Konflikte bei der Zwangsbehandlung schizophrener Patienten (Ethical
conflicts in the involuntary treatment of schizophrenic patients): Nervenarzt 72, p. 700-8
- Steinert T, LeppingP,
Baranyai R, Hoffmann M, Leherr H, 2003: “Formal admission and
treatment in schizophrenia: A study of ethical attitudes in four European
Countries”, submitted 2003
TABLE 1
A: (German sample)
Age
n = 623
Mean = 38.7
Median = 38.0
Min = 17
Max = 87
Standard deviation = 12.7
Male = 272 (42.4%)
Female = 359 (56.0%)
Missing = 10 (1.6%)
B: (English sample)
Age
N = 289
Mean = 42.0
Median = 39.0
Min = 15
Max = 82
Standard deviation = 14.9
Male = 105 (44.7%)
Female = 130 (55.3%)
Missing = 0 (0%)
TABLE 2
|
English sample
|
Psychiatrists
|
Other
doctors
|
Psychologists
|
Social
workers
|
Nurses
|
Lay people
|
Total
|
|
Scenario 1
Admission
|
88.9%
|
78.3%
|
32.3%
|
61.5%
|
80.0%
|
85.4%
|
79.2%
|
|
Scenario 1
Treatment
|
96.3%
|
87.0%
|
35.5 %
|
61.5%
|
83.3%
|
71.5%
|
73.2%
|
|
Scenario 2
Admission
|
96.3%
|
95.7%
|
80.7%
|
76.9%
|
93.3%
|
88.5%
|
90.2%
|
|
Scenario 2
Treatment
|
92.6%
|
95.7%
|
58.1%
|
76.9%
|
90.0%
|
76.2%
|
80.4%
|
|
Scenario 3
Admission
|
88.9%
|
47.8%
|
16.1%
|
53.9%
|
56.7%
|
82.3%
|
70.6%
|
|
Scenario 3
Treatment
|
92.6%
|
52.2%
|
10.0%
|
53.9%
|
53.3%
|
68.5%
|
63.0%
|
TABLE 3
|
German
sample
|
Psychiatrists
|
Other
doctors
|
Psychologists
|
Social
workers
|
Nurses
|
Lay people
|
Total
|
|
Scenario1
Admission
|
75.5%
|
78.1%
|
77.3%
|
54.8%
|
70.0%
|
73.3%
|
72.2%
|
|
Scenario 1
Treatment
|
62.9%
|
84.4%
|
59.1%
|
48.4%
|
61.1%
|
67.0%
|
63.8%
|
|
Scenario 2
Admission
|
92.3%
|
90.6%
|
68.2%
|
69.4%
|
90.0%
|
83.9%
|
85.2%
|
|
Scenario 2
Treatment
|
84.6%
|
84.4%
|
77.3%
|
92.9%
|
83.3%
|
81.0%
|
80.3%
|
|
Scenario 3
Admission
|
61.5%
|
59.4%
|
54.5%
|
38.7%
|
54.4%
|
59.3%
|
56.6%
|
|
Scenario 3
Treatment
|
58.7%
|
65.6%
|
50.0%
|
30.7%
|
50.0%
|
57.9%
|
54.1%
|
