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Chapter 20: the Therapeutic Relationship: Treatment and Confidentiality Chapter 21: Powers of Restraint, and the Protection of Staff

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Chapter 20: the Therapeutic Relationship: Treatment and Confidentiality Chapter 21: Powers of Restraint, and the Protection of Staff PART VI ^ TREATMENT AND RESTRAINT Chapter 20: The Therapeutic Relationship: Treatment and Confidentiality Chapter 21: Powers of Restraint, and the Protection of Staff 20.01 Chapter 20 THE THERAPEUTIC RELATIONSHIP: TREATMENT AND CONFIDENTIALITY 20.01 Introduction 20.19 What forms of Treatment are A. TREATMENT FOR MENTAL governed by Part TV? DISORDER 20.20 Treatment requiring Consent and 20.02 Definition of Medical Treatment a Second Opinion (Section 57) 20.03 MilieM Therapy 20.21 Treatment requiring Consent or a Second Opinion (Section 58) 20.04 Psychotherapy 20.22 Appointment of Doctors and 20.05 Drug Treatment (Chemotherapy) others to Certify Consent and 20.06 Electroconvulsive Therapy (ECT) give Second Opinions 20.07 Psychosurgery 20.23 Visiting Patients and Inspection of 20.08 Behaviour Modification Records 20.08A Seclusion 20.24 Plans of Treatment 20.09 Sterilisation 20.25 Withdrawal of Consent 20.09A Treatment Plans 20.26 Review of Treatment B. CONSENT TO TREATMENT 20.27 Urgent Treatment UNDER THE COMMON LAW 20.28 Treatment Not Requiring Consent 20.10 Applicability of Common Law D. RIGHT TO TREATMENT Principles to Mentally UNDER THE EUROPEAN Disordered Persons CONVENTION ON HUMAN 20.11 Trespass to the Person: The Basic RIGHTS Principles 20.29 Article 5(1) Protects Only the 20.12 Information Right to Liberty and Not the 20.13 Voluntariness Right to Treatment 20.14 Specificity E. CONFIDENTIALITY 20.15 Competency 20.30 Professional Responsibility 20.15A Competency of Minors 20.31 Ownership of Medical Records 20.15B Substituted of Proxy Consent of 20.32 The Law of Confidence Incompetent Minors 20.33 Proposal for Reform of the Law 20.16 Necessity: Treatment in the of Confidence Absence of Consent 20.34 Access to Medical Records C. CONSENT TO TREATMENT 20.35 Access to Social Services Records UNDER PART IV OF THE MENTAL HEALTH ACT 20.17 Background 20.18 Patients to whom Part IV applies ISSUE No. 13 20.01 THE THERAPEUTIC RELATIONSHIP 20.01 Introduction A personal therapeutic relationship is the most important aspect of the care and treatment of mentally disordered people. This chapter describes the most common forms of treatment; it examines the common law and the Mental Health Act to determine when treatment can be imposed with or without the consent of the patient; and it discusses the principle of confidentiality both from a professional and a legal perspective. A. TREATMENT FOR MENTAL DISORDER 20.02 Definition of ^ ^Medical Treatment" "Medical treatment", under section 145(1) of the Act, "includes nursing, and also includes care, habilitation and rehabilitation under medical supervision".^ The term is, therefore, used to refer to a wide range of professional activities undertaken by doctors, nurses, clinical psychologists, occupational therapists and other mental health professionals. Apart from nursing, all such activities must be under medical supervision if they are to be legally classified as medical treat ment. Arguably, any activity approved and supervised by the respons ible medical officer or doctor in charge of treatment (see para. 6.17 ante) could qualify as medical treatment irrespective of its objective, for example, seclusion or restraint. Often there is a fine line between "medical treatment", "restraint" and "management". It is suggested that the courts would be likely to limit the use of the term "medical treatment" to activities with the objective of alleviating or preventing a deterioration in the patient's mental disorder, and which are within the range of treatments recognised and practised within the profession. The courts would probably look at the primary objective of the treat ment in cases where it was said to have a number of purposes. (Not every activity supervised by a doctor can reasonably be deeiped to be medical treatment). Contemporary psychiatry is noted for its eclectic approach to the treatment of mental illness. Conventional medical treatments range from changing the social circumstances of the patient to causing physio- logical changes. It is intended here to provide only a brief description of the nature and objects of the most conventional forms of psychiatric treatment. For a more definitive examination the reader should refer to medical texts. ^ The terms "habilitation" and "rehabilitation" in the 1983 Act replaced "training" in the 1959 Act. This was intended to broaden the scope of "medical treatment" particularly for mentally handicapped people. Rehabilitation may be described as a process of restor ing the patient to his previous better state of mental health and social functioning. Habilitation is the raising of the patient to a level of mental health and social functioning he has never before attained. ISSUE No. 13 TREATMENT FOR MENTAL DISORDER 20.03 20.03 Milieu Therapy Milieu therapy refers to the possible beneficial effects on the well-being of the patient of the environment and social surroundings in the hospital. Milieu therapy is a scientifically imprecise term because it can refer to widely ranging and diverse hospital environments, making it difficult to conduct any properly controlled study of the effects on the individual. 20.04 Psychotherapy Psychotherapy refers to psychological (as opposed to physical) methods for the treatment of mental disorders and psychological prob lems. It gives the patient the opportunity to talk about his problems and experiences with a doctor, psychologist, social worker or other therapist who is experienced in mental health. There are many different approaches including psychoanalysis, client-centred therapy, group therapy and counselling. Most share the views that the relationship between therapist and client is of prime importance, that the primary goal is to help personal development and self-understanding, rather than remove symptoms as such, and that the therapist does not direct the client's decisions. 20.05 Drug Treatment (Chemotherapy) Psychotropic drugs are those used to affect mental functions, particularly mood: antidepressants, sedatives and tranquillisers are psychotropic. The administration of medicine for mental disorder to a patient to whom Part IV of the Mental Health Act applies is subject to the safeguards in section 58, if three months or more have elapsed since the first occasion when the medication was administered to him in a relevant period. (See further para. 20.21 below). 20.05.1 Phenothiazines Phenothiazines are a group of chemically related compounds with various pharmacological actions. Some (including chlorproma- zine—trade name LargactiP) are major tranquillisers and are used to treat symptoms associated with such psychoses as schizophrenia and mania. Phenothiazines are usually given orally but can be administered intramuscularly (by injection). Long-acting phenothiazihes (including fluphenazine—trade name Modecate) are usually administered intramu scularly and may have an effect ranging from 14-40 days. There is increasing evidence that, with prolonged use, the side effects can be serious and lasting, sometimes irreversible producing a condition known 'There are many trade names for each of the forms of medication given in the text. Some of the more commonly used trade names are indicated for the use of lay readers, t>ut there is no significance in any trade name mentioned. ISSUE No. 8 20.05 THE THERAPEUTIC RELATIONSHIP as tardive dyskinesia—i.e. difficulty in performing and controlling movements, particularly in the tongue, lips, jaw and extremities. 20.05.2 Minor tranquillisers Minor tranquillisers, such as benzodiazepines (which include chlordiazepoxide—trade name Librium—and diazepam—trade name Valiiim) produce a calming effect and are used to treat neuroses and to relieve anxiety and tension due to various causes. Some drowsiness and dizziness are side effects, and prolonged use can cause dependence. 20.05.3 Antidepressants Antidepressants are used to alleviate the symptoms of depression. They are characteristically slow to act, sometimes taking up to two or three weeks to take effect. The most widely prescribed antidepressants are a group of drugs called tricyclic antidepressants. These include amitriptyline—trade names Tryptizol, Saroten and Elatrol—and imipramine—trade name Tofranil. Side effects commonly include dry mouth, blurred vision, constipation, drowsiness, and diffi culty in urination. Monamine oxidase inhibitors (MAOI) are another main group of antidepressants. These prevent the activity of the enzyme monoamine oxidase in the brain tissue and therefore affect mood. They include phenelzine—trade name Nardil. Their use is restricted because of the severity of their side effects. These include interactions with other drugs (e.g. amphetamine) and foods containing tyramine (e.g. some cheeses) to produce a sudden increase in blood pressure. Other commonly prescribed medications for depression are Lithium and Fluoxetine Hydrochloride—trade name Prozac. 20.06 Electroconvulsive Therapy(ECT) In electroconvulsive therapy an electric current is passed through the front part of the brain in order to produce a convulsion. The convulsion is almost always modified by giving a muscle relaxant drug and an anaesthetic to minimise the risk of physical damage during the convulsion; failure to modify the convulsion in this way is ethically controversial, and could only rarely be justified.' ECT is often given in a course of 6-12 sessions and is administered once or twice weekly. i , The means by which ECT acts is not yet known. However, it has been demonstrated to be a successful empirical treatment for
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