Strengthening Self-Determination of Persons with Mental Illness

Abstract

“Self-determination” is taken to mean a freedom from forms of control or coercion deriving from external limitations imposed through common treatment practices and social institutions. The relationship between self-determination and discrimination is noted.

Four domains of mental health practice are considered in which patient self-determination can be enhanced. First, treatment at the individual level, how, in everyday practice, patient self-determination may be respected and enhanced in the relationships between the patient and members of the clinical team. The “recovery movement” and “advance statements” are examples. Second, how service user involvement may shape the services offered to patients at a local institutional level, a national level, and even an international level. Third is a recent development, the involvement of patients as collaborators in the conduct of research, as distinct from participating as research “subjects.” Here there is the opportunity to influence the research agenda, including the questions that should be asked and thus what knowledge is deemed important in mental health care. Fourth, constraints that limit patient self-determination are examined. These include the range of “treatment pressures” exercised on patients reluctant to accept a proffered treatment, including those that can be termed “coercive.” Powerful sociopolitical pressures, generated to a large degree by stereotypes of mental illness, act against patient self-determination. The way in which mental health law is constructed reflects these sociopolitical influences. Conventional mental health legislation discriminates against persons with “mental illness” and fails to respect their autonomy to the same degree as persons with “physical illness.” Proposals for mental health law reform are discussed.