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Related Topics
The Right to Refuse Mental Health TreatmentReview - The Right to Refuse Mental Health Treatment
by Bruce J.Winick
American Psychological Association, 1997
Review by Simon Gelsthorpe
Nov 7th 2000 (Volume 4, Issue 45)

I ought to begin by declaring my own interests in this area. As a clinical psychologist in the UK I look to the USA with envy at the amount of research and attention paid to the areas of informed consent, capacity (competence) and legal frameworks for involuntary treatment. The States seems so far ahead of the UK in addressing these fundamentals. As a result I have spent many hours trying to track down research articles from the US. However this also provides a quandary since the actual legislation and case law differs and therefore US research does not always "travel" to the UK because of the different legislative frameworks.

Why is this important to this book? Well, because Bruce Winick's work is massively researched and referenced with case law but this is mostly from the US and is therefore not always directly relevant to those of us who are elsewhere, although it is often indirectly relevant and just requires minor "translation".

That being said, it is still a worthwhile read with much to offer to those people outside the US. It is a dense book, tightly packed with legal argument and information and is clearly the product of a huge amount of reading of the literature. Accordingly (as befits a scholarly work) it is not an easy read but it is a rewarding one. Indeed Winick shares his knowledge of the literature with the reader through very detailed annotated references in the shape of footnotes. Sometimes, however, this process actually renders the footnotes more comprehensive than the text itself and I found myself reading the footnotes rather than the text. Page 114 is the prime example of this with one line of text and 62 lines of footnotes!

A core element of the book is Winick's model of the intrusiveness of a treatment. He discusses this in relation to several classes of mental health treatment and considers their intrusiveness against the degree of consent needed, or alternatively the degree of safeguards needed in the case of involuntary treatment. This is certainly appealing and reflects much of the legislation in the UK while spelling out intrusiveness as the reason behind safeguards. My only reservation about this section of the book, however, was an unexpected lack of criticism toward the claimed effectiveness of treatments and the absence of a more developed method of determining intrusiveness. The latter would have made it more useful as newer treatments are devised in the future.

The book's second section deals with the importance of the US Constitution for involuntary treatment. For those of us outside the US (and in countries with no formal national recognition or statement of human rights) these chapters can still be useful because of the growing importance of the European Convention on Human Rights and the United Nations Declaration. Both of these may well come to have the same kind of legal importance to individuals as the Constitution does in the US, and with this parallel in mind, these chapters become more useful for the non-US worker.

Naturally, the final question is concerned with practice and the right of people to decide for themselves the nature of their own treatment. I was pleased to see in the last section of the book support for the process of Advance Directives (another area where the US appears to be way ahead of the UK) and an analysis of the psychological benefits of helping people to play as large a part as possible in the decision making process.

Simon Gelsthorpe is a Consultant Clinical Psychologist working in Yorkshire,UK for the National Health Service with people with severe and enduring mental health problems. He is also Honorary Visiting Senior Research Fellow at Bradford University. He has a special interest in Human Rights and the legal frameworks in the UK, in particular the areas of informed consent and capacity (competence). He is also currently researching how dissenting professionals are able to continue working in services which they fundamentally disagree with.


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