Compulsory admission.
Journal: BMJ (1976)

Compulsory admissionFor half a century the use of compulsory admission for the mentally ill has steadily declined.In this decline the Mental Health Act of 1959 stands out as a landmark.Its main purpose was to enable as many of the mentally ill as possible to be admitted to hospital as informally as other patients and to ensure that the few who needed treatment but refused it were dealt with quickly, easily, and humanely.This Act in its turn has now come under criticism.Some reformists take the view that civil liberty should be paramount and that no one should be admitted to hospital against his or her will.More cautiously, the Department of Health and Social Security has put out a consultative document,' based mainly on a comparison of suggestions from the Royal College of Psychiatrists2 and from MIND (the National Association for Mental Health),3 on how the Act should best be amended.The Department held an all-day conference on the document on 25 October.If the more extreme views (including one or two of those put forward by MIND) were adopted there would be more difficulty and delay in getting patients admitted to hospital, and their sufferingincluding that of their relatives-would be intensified.Extra force would then be given to the gibe4 that the proponents of these views are content to see patients "dying with their rights on."In a challenging article in the American3Journal of Psychiatry, Paul Chodoff5 has not been content with defending orthodox psychiatry against such views: he has gone over to the attack.He believes that the rights of the mentally ill to be treated and protected are as important as their civil rights, if not more so, but that the right to treatment is being perilously set aside in favour of freedom.Despite variations in the legal process his analysis-essentially a study of points of view-is wholly transplantable to this side of the Atlantic.Chodoff distinguishes three viewpoints.The first, the abolitionist, includes those who believe with almost religious fervour that compulsion is never warranted in any circum- stance, that liberty is always to be valued above mental health, and that when voluntary compliance with treatment is not forthcoming psychiatrists should withdraw and, if an offence is committed, allow the law to take its course.The abolitionists have included Thomas Szasz, R D Laing, and the several groups of antipsychiatrists.None of the patients described in Chodoff's paper-a severe depressive, a catatonic, a manic, a deluded schizophrenic, and a patient with delirium tremens- would, if unwilling, have received treatment from any of them.On the other hand all would probably be treated by Chodoff's second group, the medical-model psychiatrists, who would regard such people as ill and would recognise an obligation to treat them with compulsion if necessary.That obligation would not, however, apply to individuals not suffering from mental illness but having instead personality disorders, neurotic reactions, or being dependent on alcohol or other drugs of dependence.The third viewpoint, that of civil liberties lawyers, does not reject the need on occasion for compulsory admission to hospital.But it does reject the medical model, the notion of psychiatric illness, and the expertise that psychiatrists claim in diagnosis.In rejecting medical criteria this group of lawyers exalt the supposedly more objective estimate of dangerousness "to self or others" as the sole or almost sole ground for using compulsion.Chodoff argues-with clinical evidence on his side-that to concentrate on dangerousness (especially to others) as the sole criterion for involuntary admission to