Compulsory interventions in mentally ill persons at risk of becoming violent

Abstract

Medical treatments are allowed only with the informed consent of the patient. The German civil commitment laws contain articles, which allow the commitment of mentally ill persons, who are acutely dangerous for themselves and/or for important legal rights of third persons. However, neither a mental illness alone, nor missing insight into the illness and the need for treatment are sufficient for compulsory admission. The most controversial issue is whether persons who are unable to consent have a right to live with their illness, particularly their mental illness, or rather a right for an effective treatment of the illness (implicitly acknowledging the subjective torment and, at times, sheer terror the symptoms cause for the psychotic individual). In Germany, compulsory treatments of patients under custodianship and in confinement can be allowed by courts if certain conditions are fulfilled: The patient is not able to consent to the necessary treatment; the physicians have tried to convince him; the treatment is necessary to avert considerable health detriments; the compulsory treatment is used as a last resort treatment, and its benefit-risk balance is positive. A rather new instrument for avoiding compulsive measures in states of dangerousness is the mental health advance directive. Preliminary results are promising: Patients who have written advance treatment directives committed less violent acts, needed less use of social workers time, showed greater improvement in their working relationship with their clinicians, and were more likely to report satisfaction with their treatment.