Treatment over objection: minds, bodies and beneficence

“The only freedom which deserves the name is that of pursuing our own good in our own way, so long as we do not attempt to deprive others of theirs or impede their efforts to obtain it. Each is the proper guardian of his own health, whether bodily or mental and spiritual”John Stuart Mill – On Liberty1This quote from Mill highlights an important distinction for medical ethics: a distinction between bodily and mental health. In this paper, we want to look at the ways that ethics and law have addressed this distinction, especially in relation to involuntary treatment. We will claim that both philosophy and case law appear to address involuntary treatment for physical disorders in very different ways to involuntary treatment for mental disorders; and will relate these differences in analysis to different approaches to understanding the capacity to make autonomous decisions

Locks, Keys, and Security of Mind: Psychodynamic Approaches to Forensic Psychiatry

In this article, we discuss psychological approaches to the understanding of acts of violence and, specifically, psychodynamic approaches to both formulation and treatment. We suggest that the key theoretical paradigm of a psychodynamic approach involves the exploration and elaboration of the meaning of a violent act for the offender and describe the relevance of this approach for both legal assessments and clinical services in secure residential care. We argue that a psychodynamic approach can improve the quality of assessments of both psychopathology and risk and inform effective therapeutic interventions in hard-to-treat patients. J Am Acad Psychiatry Law 41:38 -45, 2013 The principal model of mind that is utilized in AngloEuropean mental health care systems is the cognitive model, which emphasizes conscious cognitions and their influence on feeling, choices, and behavior. In forensic clinical practice, the cognitive model has been helpful in the development of programs aimed at the reduction of offending, mainly for use in prisons. 1 In this article, we discuss the theory and practice of the psychodynamic model in forensic practice, or forensic psychotherapy. Psychodynamic models of therapy assume the following: Healthy psychological function includes both conscious and unconscious processes and their meaning for the individual. Psychological function is relational and includes interpersonal, intersubjective, and embodied experience of both the social world and the internal world. Representations of the world are built up over time and reflect dispositions that arise from innate vulnerability and early childhood experience. These representations of both the internal and external world are dynamic; they shift and change in the context of the social relationships and group settings experienced over a lifetime. Therapists are affected by these processes as much as patients. In addition to these elements, we believe that understanding is fundamental to the practice of forensic psychotherapy: understanding the reasons that the offender committed his index offense; understanding why some individuals relate to others by predominantly violent means; understanding the workings of the criminal mind and how it has been shaped by early, often adverse, experience; understanding the unconscious meaning of a person's current antisocial behavior and how it may represent a repetition of such early experience; and understanding how this behavior may be the manifestation of a mind in which negative emotions such as anxiety, humiliation, and shame become impossible to tolerate and are expressed instead by violent action toward others. This process of understanding includes attention to both conscious and unconscious processes and motivations, especially those negative emotions that in particular are often less consciously experienced as thoughts or feelings and so are less verbally accessible

Domains of Need in a High Secure Hospital Setting:A Model for Streamlining Care and Reducing Length of Stay

There are financial and humanitarian consequences to unmet need amongst service users of high secure hospital care, not least in terms of length of stay. This article presents two reviews of high secure service user needs. They provide support for the sequencing of interventions to meet service user needs and the utility of a structured framework for their review. Through analyses of these reviews, eight domains of need were identified: Therapeutic Engagement, Risk Reduction, Education, Occupational, Mental Health Recovery, Physical Health Restoration, Cultural and Spiritual Needs, Care Pathway Management. A model is presented, within which logically sequenced, timely and relevant interventions could be framed in order to provide a comprehensive and streamlined pathway through a high secure hospital

COVID-19 Vaccination in those with mental health difficulties: A guide to assist decision-making in England, Scotland, and Wales

There is currently no specific guidance addressing vaccine hesitancy in those with mental health difficulties in the United Kingdom. This is particularly problematic when one considers that individuals with serious mental illnesses are at greater risk of infection and have poorer health outcomes for a range of reasons. There are also many individual and system level barriers to vaccination in this group. When an affected adult lacks the capacity to make a decision for themselves, it often falls to healthcare professionals to make a decision on that person's behalf and in their best interests. This article explores this matter with regard to the law in practice in the English and Welsh, and Scottish, jurisdictions and consider this with relevance to the safest approach that doctors and other healthcare professionals should take in working with patients for whom mental disorder may impact on decision-making capacity. The article focuses on psychiatric inpatients, including those who are detained involuntarily, to consider whether, and in what circumstances, COVID-19 vaccination should be given to individuals who cannot or do not consent