In this series, I dig a little deeper into the meaning of psychological terms. This week’s term is autonomy.
While autonomy falls more under the umbrella of philosophy than psychology, it also has significant implications for mental health care.
The philosopher Immanuel Kant identified several key elements of autonomy, including both the right and the capacity to make one’s own decisions independently, after personal reflection, and without interference. He believed that autonomy is necessary for a meaningful life. So what are we supposed to do when our autonomy is taken away?
Autonomy in medicine
In the field of medicine, informed consent is based upon the principle of autonomy, which runs counter to a paternalistic, doctor-knows-best kind of approach. Complications can arise when a person’s capacity for autonomous decision-making is limited in some way. Other ethical principles may come into conflict with autonomy, such as beneficence (do good) or non-maleficence (do no harm). An article in the Canadian Journal of Psychiatry describes “supported autonomy”, which comes from the belief that “to support autonomy in the long term, it may be necessary to compromise autonomy in the short term.”
The Oxford Handbook of Psychiatric Ethics makes this interesting statement:
The lack of a neat, necessary connection between irrationality and mental disorder calls into question the assumed, straightforward, link between psychiatric diagnosis and decision-making abilities.
It adds that some jurisdictions take the view that mental illness impairs insight, autonomous control, and rationality, and as a result, the presence of a diagnosis “eliminates the need to assess the person’s decision-making ability”. Other areas use a mental capacity approach that requires a separate functional assessment rather than the diagnosis alone to evaluate the individual’s capacity to make decisions.
Implications for mental illness
Autonomy is popular for government and health care organizations to talk about, but how well does this translate into reality? The Australian Department of Health has a non-binding National Framework for Recovery-Oriented Mental Health Services, and it describes “promoting autonomy and self-determination” as an element of recovery-oriented services. It lays out what this might look like in practice, but as a non-binding document, it’s really just a suggestion.
Ireland’s Health Information and Quality Authority has a guidance document for supporting people’s autonomy; again, this is non-binding. It rather euphemistically states that there are a “number of factors potentially affect the extent to which a person’s individual choices can be facilitated”.
My own experience
I’ve had three involuntary hospitalizations, and I really struggled with the loss of autonomy. The power imbalance was huge. While I didn’t necessarily have a problem with the medications or the electroconvulsive therapy (ECT) treatments that were ordered, having the choice of whether or not to be in hospital taken away from me was devastating.
I’ve always been a very independent person. It drove me crazy (crazier?) that these doctors, whose competence I had serious concerns about, were supposedly in a better position than I was to make decisions about what happened to me. The powerlessness brought out some very primitive behavioural responses, and I’ve yelled at doctors when they tried to exercise their power and suppress my own.
From my experience working as a mental health nurse, I know there are times when hospitalization is absolutely necessary to protect someone. However, I believe that when an individual is being treated involuntarily, the treatment team should be bending over backwards to allow the patient to exercise as much autonomy as possible within the confines of what needs to be done to keep them safe. In reality, that is seldom, if ever, the case. Somehow, we need to find a way to convey to those who are not afflicted with mental illness how soul-destroying it can be to have one’s autonomy stripped away.
Autonomy is not just lost because of others, though. The illness itself erodes the ability to freely make choices and then enact those choices. While this effect is perhaps more pervasive in my life, it’s still easier to wrap my head around than externally imposed limitations on the ability to make my own decisions.
Have you experienced a loss of autonomy related to your mental health condition? How have you dealt with it?
References
- Australian Government Department of Health: A National Framework for Recovery-Oriented Mental Health Services
- Craigie, J., & Bortolotti, L. (2014). Rationality, diagnosis, and patient autonomy in psychiatry. In The Oxford Handbook of Psychiatric Ethics, volume 1.
- Health Information and Quality Authority
- Neilson, G., & Chaimowitz, G. (2015). Informed consent to treatment in psychiatry. Canadian Journal of Psychiatry, 60(4), 1-11.
- Wikipedia: Autonomy
The post Cell Phones on Psych Wards—Yea or Nay? is the hub for all psychiatric hospitalization-related content on Mental Health @ Home.
The Psychology Corner has an overview of terms covered in the What Is… series, along with a collection of scientifically validated psychological tests.
Ashley L. Peterson
BScPharm BSN MPN
Ashley is a former mental health nurse and pharmacist and the author of four books.
I was placed on a treatment order once and I HATED being under the threat of court-ordered hospitalization all of the time if I didn’t comply with treatment. I’m always compliant anyway, so it was sort of a ridiculous thing. I was VERY stressed out about it until it expired.
Yeah it can be so mentally damaging.
I’m so sorry you’ve had three involuntary hospitalisations, I would have found that utterly devastating too for the lack of choice and free will. A fascinating post, especially where the definitions and issues around ethics are concerned. I think there’s still a divide between ‘scientific’ journals and ‘in theory’ elements, and the experience of individuals with a power imbalance that can be hugely detrimental. x
Definitely.
Sorry in advance, really long comment.
I think autonomy is waaaay too easily overrriden in mental health care.
In nearly every other area of health care, people are pretty much free to make “bad” choices – ones that might worsen their illness or even result in death (the exception being some situations where these choices would put other people at substantial risk, for example quarantine and compulsory treatment for diseases such as TB). You can decline cancer treatment, refuse blood transfusions, not adhere to your diet in diabetes, continue smoking even as you face progressive amputations because of arterial disease.
You are not given the same freedom in the case of mental illness, and as you say in your article there are times when simply having a diagnosis is automatically equated to incapacity to make a rational decision. Plus, in my state at least, even if you write an advance care directive when you are well and appoint a “substitute decision maker” who is knowledgeable and aware of your preferences for times when you lack capacity, your choices can be completely ignored if you are involuntarily hospitalised under the Mental Health Act, as this also gives the authority for involuntary treatment – basically whatever your treating doctor wants, they can do. So you can’t for example make an advance directive that you don’t ever want ECT or long acting antipsychotics, even if you were well and completely rational when you made that choice and your outpatient psychiatrist agrees with those choices. All it takes is for the inpatient psychiatrist to have a different opinion and you’re screwed. You don’t even have to be involuntarily hospitalised for it to be an issue if the doctor has other forms of power over you, for example making treatment compliance a condition of fitness for employment or professional registration.
This is a huge problem given that diagnosis in psychiatry is not as clear-cut as in other areas of medicine, and what things are considered “illness” has changed dramatically over time. You need look no further than homosexuality and the forced “treatment” of that. But it can also be more subtle, for example in patients who develop minor signs of hypomania on antidepressants, there can be disagreement as to whether this is a “side effect” that might completely resolve and never recur if the antidepressants are simply stopped, or whether it is “unmasking of an underlying bipolar illness” and must be treated long term with mood stabilisers and/or antipsychotics – and the decision as to which of these it is seems to have more to do with peer influence on the psychiatrist than any medical fact.
The sort of power games which can result are not confined to mental health – I have seen them in other areas where uncommon but serious and complex conditions are being treated and where the patient may have more knowledge than a health professional who is not very fmailiar with the condition, and the health professional finds the perceived loss of face in that situation threatening to the point that they will make force incorrect treatment on the patient.
Staffing levels and lack of training also contribute to the problem – it’s easy to overstep and use coercion when you feel you don’t have the time or skills for negotiation.
A lot of this behaviour tends to be overlooked or given a free pass in mental health in a way that it wouldn’t in other areas. For example, if a kid with cancer has a needle phobia, the staff are very open to the concept that the treatment is life-saving and you have to find a way of adminstering it but that if you use force the kid will be traumatised and less co-operative in the long run, so you have to find constructive solutions. This might involve spending time developing a trusting relationship, discussing the treatment in advance, giving the child come element of control. Researchers have gone to the trouble of developing local anesthetic cream to numb the spot where the needle goes, precisely for situations like this. Does this same level of effort go into finding solutions for managing psychiatric patients who for whatever reason are having difficulty accepting their treatment? In a word, no.
I have never completely lost autonomy myself, but that is mainly because I’ve actively avoided situations where I think there is too high a risk, including refusing to see a particular psychiatrist, changing GP’s, and choosing not to go to the ER even when I’ve been highly suicidal. That may seem foolish to other people, but I have made the personal choice that I would prefer the small risk that a lack of insight when I am unwell leads to my death, than the larger risk that unacceptable side effects or retraumatisation from unwanted or coercive treatment leads to a long term worsening of my condition and poorer quality of life.
I wish advance directives were taken more seriously, along the lines of a DNR. It would go a long way in empowering people to be in the driver’s seat when it comes to their own health.
I think it’s particularly problematic when taking some form of treatment is tied into professional registration. That happened to me after my first hospitalization, and for months I was picking up meds on time from the pharmacy to make it look like I was taking them. While that kind of deception felt necessarily, it was pretty counterproductive when it came to my health.
Involuntary hospitalization is probably the time when I felt the biggest loss of autonomy due to my illnesses too. Knowing I had no control over leaving the hospital was terrifying to me.
Yeah that’s a really frightening situation to be in.