New Legislation: The Involuntary Psychiatric Treatment Act

By LeRoy Lenethen

This provincial legislation took effect in Nova Scotia on July 3, 2007. The broad general purpose of the Act is to ensure that those who are unable to make treatment decisions, due to severe mental health illness, receive appropriate treatment.

The Act makes significant changes to provisions that used to be included in the Hospital Act. The new Act has Guiding Principles setting out how the Act is to be applied. Among the nine guiding principles are the following:

• Patients are to be treated with dignity and respect
• Patients have the right to make treatment decisions (if the patient has the capacity to do so)
• The patient should be allowed to live in his/her community.
• Promotion of self-reliance by the patient.
• Confirmation that the primary mode of hospital admission is to be voluntary.
• Confirmation that mental health services should be provided as close to a patient’s home as practical.
• Involuntary admission must be based on evidence.
• Lack of capacity to consent to treatment must be determined on the basis of evidence.

The Act deals with “mental disorders” which are defined as:

• any substantial disorder of behaviour, thought, mood, perception, orientation or memory
• that severely impairs judgment, behaviour, capacity to recognize reality or the ability to meet the ordinary demands of life
• in respect of which psychiatric treatment is advisable

Hospital admission to access mental health services can be voluntary in the same way as hospital admission for any physical illness i.e., through your family doctor or the Outpatient process. In addition hospital admission for an involuntary psychiatric assessment can be ordered by any two licensed doctors following an examination of the patient. If the patient refuses the initial examination or to attend for such an initial examination then, in an appropriate case, an order for an initial examination can be obtained from a Family Court Judge (on application by any person) or can be initiated by a police officer (if certain conditions are found to exist). The new Act contains special provisions setting out how the initial medical examination can be obtained through a Family Court Judge or through the police. At the time of the examination by two doctors (not necessarily psychiatrists) any further admission for an involuntary psychiatric assessment must be based on the determination by those doctors that

• the patient has an apparent mental disorder, and
• would benefit from inpatient psychiatric treatment, and
• will not submit voluntarily to a psychiatric assessment, and
• meets the old “dangerousness” criteria (harm or threat or attempt to self or others), or
• is likely to suffer “serious physical impairment” or “serious mental deterioration”.

If the medical examination results in a finding, on the above criteria, by the doctors of a need for an involuntary psychiatric assessment, the patient can be forcibly taken to a facility and held for a maximum of 72 hours to permit an assessment to be done by a psychiatrist.
In order for a patient to be placed in a psychiatric facility on an involuntary basis for a period beyond that psychiatric assessment, the psychiatrist must then conclude that the patient does have a mental disorder, is in need of psychiatric treatment, that the treatment needed can be provided at a psychiatric facility, that the “dangerousness” test is met or that the “serious physical impairment” or “serious mental deterioration” test is be met. In addition, the psychiatrist must conclude that treatment in a psychiatric facility is required (as opposed to in the community) and that the patient will not or is not capable of consenting to such admission.

Finally, the patient will not be admitted unless the psychiatrist concludes that the patient does not have the capacity to make admission and treatment decisions on his or her own. A patient who has the capacity to make his or her own admission and treatment decisions will no longer be “on hold” in a psychiatric facility while refusing treatment. Involuntary admission under the new Act will not occur if the patient has capacity to make his or her own admission/treatment decisions. Unless the psychiatrist can reach all of these conclusions within the 72-hour holding period, the patient must be advised of his/her right to leave the facility. Any declaration by a psychiatrist of involuntary admission beyond the initial 72 hour assessment period must, under the new Act, be reviewed on a stipulated regular basis.

In deliberations to determine whether or not a patient has the capacity to make a specific treatment decision the psychiatrist must consider whether the patient fully understands and appreciates
• The nature of the condition
• The nature and purpose of the treatment
• The risk and benefits involved in taking the treatment
• The risk and benefits involved in not taking the treatment

The new Act also provides for, and sets out a list of those who can act as, a Substitute Decision Maker for an involuntary patient. The Act covers the process for the appointment of such a person and how that person’s authority is exercised on behalf of the patient.

The new Act now specifically provides for “Certificates of Leave” (for a maximum of six months) to permit involuntary patients to live outside the psychiatric facility. The Act spells out how this process works and sets out a process for canceling such certificates.

In addition, the new Act provides for the treatment of an involuntary patient in the community by way of a Community Treatment Order (CTO). The Act spells out the process involved and conditions that must be met for any treatment order that releases the involuntary patient into the community. There is also a process for amending, canceling and renewing a CTO.

Finally, the new Act also provides for a Patient Advisor Service (independent of any hospital or any District Health Authority) and for recognition of patient rights. The Advisor can work with the involuntary patient or the patient’s Substitute Decision Maker. As yet there are no regulations in place under the Act to implement this service.

This has been a brief overview of some of the significant provisions of this new Act. Additional details and facts sheets for patients, police and hospital administrators along with a copy of the Act and the regulations and the various forms involved can be found on the Department of Health website at- http://www.gov.ns.ca/health/mhs. When the page opens on your screen on the right side of the page is a list of patient services, just click on the item entitled “Involuntary Psychiatric Treatment Act”

Stigma In Mental Illness

By: Dr. David Mulhall

There is a high level of stigma associated with mental health problems. Stigma comes from a Greek word meaning “a mark of shame or discredit”. It is an attempt to label a group of people who are less worthy of respect than others. People with mental health problems are often stigmatized due to a lack of knowledge, misinformation and fear. Stigma against people with a mental illness often involves negative labels or inaccurate and offensive representation in the media portraying them as violent, comical or incompetent.

The most common misconceptions about mental health problems are:

1) Fear. Fear of violence and unpredictability. Fear of what mental illness represents and the way it attacks the faculties (emotions, thoughts and behaviors) and the part of us (the brain and mind) that define our very humanity.

2) Blame. It is the view that people with mental illness have brought the problems upon themselves.

3) Poor prognosis. The view that there is little hope for recovery from mental illness.

4) Disruption of social interaction. The view that people with mental illness are not easy to talk to and have poor social skills.

Some people affected by mental illness say the effective stigma can be as distressing as the symptoms. Stigma can be a barrier to individuals in getting the help that they need due to fear of being discriminated against. Recent surveys showed that half the population would not want anyone to know if they developed a mental health problem; likewise, half the respondents in the survey thought that media portrayal of people with mental health problems was more negative than positive. This has negative affects in many ways. People with serious mental illness have the highest rate of unemployment and underemployment of all people with disabilities at a rate of around 85%. When people with mental illness find work, their work tends to be sporadic, poorly paid and lacking employee benefits. They all too often find themselves in the three “F” occupations (food, filing and filth). Also, mental illness is the second leading cause of work-place discrimination complaints. Surveys have found that from one-third to one-half of people with mental illness report being turned down for a job for which they are qualified after their illness was disclosed or of being dismissed from their job and were forced to resign as the result of a mental illness. Contrary to common myths, Schizophrenia is not a split personality, nor does the behavior of people with the diagnosis swing dramatically between “normal” and “dangerous”. People with Schizophrenia are rarely dangerous but are experiencing things that can be extremely unpleasant or frightening to them. Recovery rates for mental health problems are between 70 and 80%.

There have been a number of campaigns overseas to address stigma; i.e. in England, Changing Minds; and in Australia, SANE. Much of the emphasis of these programs is to let the general public know that the myths are not true and that terms like “demented/loony/madman/nutter/schizo” are offensive. The positive messages are that people who have mental illness have the same needs as everyone else; that they can and do recover and lead productive lives; that they make valuable contributions to the society and that discrimination against people who have mental illness keeps them from seeking help. These campaigns have many features in common. They include information leaflets for the public and media about mental illness and are often backed up by monitoring programs that encourage people to report examples of stigmatizing language in the media, supplemented with letter templates for people to write to the perpetrating organization. There are also guides for employers that detail the benefits of hiring people who have mental illness, providing suggestions for recruiting and training people who have mental illness, outlining action plans for educating employees about mental health illness and creating a “healthy environment”.

In Nova Scotia (in 2005), a similar survey was done on the media’s portrayal of mental illness. 2% of all stories showed some inappropriate content with either outdated, negative or inappropriate language. Often, subjects like “suicide” would be sensationalized with reference to celebrities, photograph or description of scene, description of methods, interviews with the bereaved family and with little information on how someone could get help or any contact numbers of appropriate organizations, etc.

Programs that look to change attitudes are hard to evaluate and change comes slowly; however, there is evidence that it is possible to improve attitudes towards illnesses such as Schizophrenia and behavior such as suicide with consistent changes in how the media portrays these issues.

The Department of Health and the Mental Health Program sees this area as an important part of the Mental Health Program playing a role in both mental health promotion and prevention.

For further information, please see the Department of Health website under “Our Peace of Mind” document.