Social workers’ perceptions and experiences on the psychiatric disease mandatory assessment review committee: A qualitative study in Taiwan

Abstract

In Taiwan, the decision regarding compulsory detention of patients with severe psychiatric disorders is subject to review by the Psychiatric Disease Mandatory Assessment Review Committee. Approved psychiatric social workers are assigned to this court-like body to ensure the involuntary placement criteria are met. We conducted qualitative research to investigate the dilemmas of social workers on this committee.

Keywords

Psychiatric Disease Mandatory Assessment Review Committee psychiatric patients review body social work Taiwan

The nature of the review committee

In Taiwan, the Mental Health Act of 1990, as recently amended by the Mental Health Act of 2007 (MHA 2007), provided for involuntary psychiatric treatment (Liu et al., 2010). Before the passing of the MHA 2007, compulsory treatment was restricted to in-patient hospital settings (Lyu, 1991; Wu and Song, 2008). According to Article 21 of the Mental Health Act of 1990, when a severely mentally ill patient refused hospitalization, compulsory admission was possible with the medical recommendation of two doctors (Chan et al., 2007; Lyu, 1991; Shen, 1991). In other words, depending on a diagnosis of mental disorder, two responsible clinicians could propose to detain a patient against his or her will. Such a hospitalization was frequently considered a violation of the patient’s rights (Lee and Chou, 2003; Soong et al., 1994; Wang, 2008).

Unlike countries such as Sweden, Spain, Greece, Germany, Bulgaria, and Poland where the judicial authority provides the standard legal procedures for compulsory hospitalization (Kallert et al., 2007), the Psychiatric Disease Mandatory Assessment and Community Care Review Committee (hereinafter the review committee) was introduced by the MHA 2007 to act as a quasi-judicial body to both assess the patient as objectively as possible and ensure the criteria for compulsory admission are met (Wang, 2008; Yang and Wei, 2008). Members of the review committee include seven professionals: a psychiatrist, a professional registered nurse, a legal expert, an occupational therapist, a psychologist, a psychiatric social worker and a caregiver representative advocating for the patient’s rights (Liu et al., 2010). The review committee can also be considered as a kind of expert committee to make treatment decisions (Kallert et al., 2007; Wang, 1997).

The role of the social worker on the review committee

Social workers provide both social and medical perspectives in the decision-making process for compulsory admission (Fawcett, 2007; Furminger and Webber, 2008). As well as performing the functions of the social work profession in the assessment process for compulsory admission in England and Northern Ireland (Hatfield, 2008; Wilson and Daly, 2007), the social workers on the review committee are not only trained to understand the range of clinical psychiatry, but also have the skills to assess relationships from a social context. To explain this further, the ‘people in the environment’ perspective helps us to understand that a social work intervention not only involves the personal psychological aspect, but also the social aspect, especially when medical professionals (such as clinicians or nurses) place more emphasis on the aspects of psychopathology and the cognitive deficits of the patient. The role of social workers in the assessment process of compulsory admission is to consider the biopsychosocial needs of the patient as a whole (Cummings and Cassie, 2008; Hatfield et al., 1997).

Another role the social worker on the review committee must play is risk assessor, since participation in the evaluation process includes the risk of the occurrence of violence and danger. In England, the ultimate decision-making authority for compulsory admission must rely on the evaluations and diagnoses of the approved mental health professionals, including an Approved Social Worker (Bartlett, 2009; Ramon, 2009). In the United States, the clinical social workers in California, Oregon, Washington, Illinois, and Minnesota are all endowed with the legal right to participate in the assessment for the emergency civil commitment of a patient with psychiatric disorders (Newhill, 1992). Bowers et al. (2003) indicated that the mental health social workers in the United Kingdom encountered violent behavior from patients including physical resistance, screaming, aggressiveness, and even threats to personal safety. Such behaviors contribute to unpleasant feelings in the psychiatric social workers, as indicated through their participation in an evaluation regarding compulsory admission. Davidson and Campbell (2009) also found that the approved social workers have felt afraid or at risk. It is conceivable that social workers, in some places, are expected to assess the risk involved in each mental health emergency and make the right judgment as to whether there is a need for compulsory admission (Golightley, 2004).

Normally, social workers in Taiwan encounter a severely mentally ill patient when he or she has been admitted into a hospital. Consequently, their role on the review committee is different than that of the social workers in the countries mentioned above. Although social workers will not join in the psychiatric emergency assessment, the social work committee member participates in the multidisciplinary assessment of the review committee in making a judgment, especially when predicting potential violence could be difficult.

Qualifying for the review committee as a social worker

In order to qualify as a member of the review committee, approved social workers must meet the criteria of having at least seven years’ participation in relevant clinical or practical experience, as well as completing the pre-service and in-service educational training (e.g. consensus camp) required for employment by the Department of Health, Taiwan (Taiwanese Society of Psychiatry, 2009). The term of review committee members is two years, and the decision for compulsory admission is made with the approval of at least two-thirds of the committee members attending the review committee (Legislative Yuan Gazette, 2008). As will become evident, this decision is not always easily reached.

The criteria to be used to make the decision for compulsory admission

Since the pilot project for compulsory community treatment began in January 2010 and the data for this study were collected in 2009, the following discussion will focus on emergency involuntary admission and compulsory admission only.

The duration of an emergency involuntary admission is not to exceed five days (Taiwanese Society of Psychiatry, 2009; Yang and Wei, 2008). The request and medical recommendations for compulsory admission are sent to the review committee and need to be completed within two calendar days of the date of the emergency admission (Yang and Wei, 2008). If the patient does not need to be hospitalized after the assessment, or if the formal admission permit is not obtained within five calendar days, the emergency involuntary admission is immediately terminated.

Two essential criteria should be considered for determining compulsory admission. First, the person should be diagnosed as likely to have ‘severe’ mental disorders. The definition of a ‘severe’ mentally ill patient falls into the following definitions: 1) the person exhibits unrealistic, weird thoughts or behaviors; 2) the person cannot handle his/her own affairs; and 3) the person is regarded as a danger to himself/herself and others (Liu et al., 2010; Taiwanese Society of Psychiatry, 2009).

Once the application submitted by the responsible mental health hospital for compulsory admission is approved, a formal treatment decision leads to an admission period of up to 60 days (Liu et al., 2010; Yang and Wei, 2008). If it is necessary, a request for an extension can be made 14 days before the 60 days expire (Taiwanese Society of Psychiatry, 2009). However, every extended period shall not exceed 60 days.

The controversy

The dilemmas, complications, and problems encountered by the social workers in attempting to make this decision include balancing the needs of the patient with the needs of the caregivers, being present for the decision, and being heard among the other professionals on the committee. Despite the importance of understanding that the purpose of the 2007 Act is to protect a patient’s rights and best interests (Wu et al., in press), limited studies have been done on the role of the social worker in compulsory care and treatment in Taiwan. To properly value the professionalism of the social workers, we need to pay close attention to how the social workers evaluate the human rights, willingness, and autonomy of the severely mentally ill patient (Wilson and Daly, 2007).

Respect for a client’s autonomy has been one of the most important fundamental social work principles underpinning the social worker’s support of a client’s right to self-determination (Beverley and Cheryl, 2003; Biehal and Sainsbury, 1991; Spicker, 1990; Yeung et al., 2010). We understand that an essential definition of autonomy is the capacity to make one’s own deliberated or reasoned decisions and to act on the basis of such decisions (Beauchamp and Childress, 1989; O’Neill, 2009). An individual’s autonomy is apparently undermined and diminished by what Harris (1985) refers to as the four defects: 1) defects in control; 2) defects in reasoning; 3) defects in information; and 4) defects in stability. People whose mental illness affects their ability to control their lives belong in the first category. Thus, ethical questions arise, such as how long should we continue to respect a severely mentally ill patient’s autonomous rights? How long should we advocate a stand of competency when there is a potential for harm to self or others?

Outside agents such as family members, friends, or social support systems in the patient’s life also affect the decision-making as to whether the patient should be compulsorily hospitalized (Hallam, 2007; Pinto, 2006; Rapaport and Manthorpe, 2008; Soong et al., 1994). The improvement of personal health, emphasized by the social worker committee members, refers not only to improving personal functions and abilities, but also to improving access to resources and family support. When social workers attempt to achieve a balance between the patient’s rights and the caregivers’ burden during these reviews on compulsory admission, they usually encounter a conflict with social work ethics (Campbell, 2010; Fawcett, 2007).

Methods

Research purposes

The main purpose of this study was to investigate the difficult questions and dilemmas faced by approved social workers on the review committee. Because qualitative interviewing is a way of understanding and exploring subjective opinions on specific issues (Babbie, 1995; Kvale, 1996; Rubin and Rubin, 1995), four focus groups and three individual interviews were used to explore the clinical and collective experiences of the approved social workers. The duration of the focus groups was maintained at one to two hours due to differences in the number of subjects, while the duration of the individual interviews was approximately 40 minutes to one hour.

An interview guide is useful in these situations because it reminds the researcher of the requisite questions to be asked during the interviews (Arksey and Knight, 1999). To draw up the outline for the semi-structured interview guide, a total of 12 participants, including a severely mentally ill patient, family caregivers, psychiatric social workers, representatives of patients’ rights organizations, and researchers, were invited by the Taiwan Society of Mental Health Social Workers to exchange their views and experiences on compulsory admission. From this dialogue, the outline for the semi-structured interview was drawn up as follows:

Have you ever faced dilemmas in evaluating cases that do not meet the criteria for compulsory admission? (For example, the patient was diagnosed as severely mentally ill, but he/she represented no harm to himself/herself or others. He/she needs to be treated/cured rather than being provided ‘involuntary/compulsory’ treatment.) Please tell us your concrete experience.

What assessments do you, as a social worker, use for hospital admission?

How did you perceive social work as a profession among the professions on the review committee?

Based on your evaluation experience, how did you perceive the rights and interests of the patients in relation to compulsory admission?

Participant recruitment

According to the register list of approved social worker review committee members obtained from the Department of Health, and dated May 2009, there were a total of 47 approved social worker committee members. However, in consideration of their confidentiality, a detailed list of the committee members could not be obtained. Therefore, with the assistance of the Taiwan Society of Mental Health Social Workers, snowball sampling was used to recruit the potential participants. As of October 2009, 23 interviewees participated in focus groups or were interviewed individually according to their time schedule or privacy considerations. Signed informed consent forms were obtained from each participant to comply with research ethics. All of the interviewees agreed that their interviews could be tape-recorded. Participants were assured that their anonymity would be maintained.

Data analysis

The qualitative data were recorded and typed as words. Repeated readings of the transcript in search of similar meanings or casual relationships can be useful to select and reduce complex data. Coding and thematic development were based on four specific themes (compulsory admission criteria, social work assessment, identity of social work, and the protection of patients’ rights).

As to the concern for trustworthiness in qualitative research, the authors were aware of respondent bias that can prevent respondents from revealing information or lying to protect their privacy (Padgett, 2008). Therefore, the respondents were free to choose either being interviewed individually or participating in the focus groups. To enhance the rigor and prevent researcher bias, some members of the focus groups worked as co-researchers alongside the authors to check on the other members, and then shared their feedback on analysis procedures over the course of a year.

Findings

Sample characteristics

Of the total of 23 interviewees, all were female and the average age was 40 years. The average number of years being a psychiatric social worker was 12. Fourteen of the interviewees held master’s degrees and the rest held bachelor degrees.

The dilemma of the criteria for compulsory psychiatric admission

One of the criteria for deciding whether a severe mentally ill patient needs to be hospitalized involuntarily is that the patient may do harm to himself/herself or to others. Our study found that interviewees constantly faced the dilemma that the patient did not meet the criteria for ‘severe mental disorder’ and the ‘dangerous to self or others’ criterion at the same time, especially those who misused alcohol or drugs. Several interviewees shared their experiences and here is an example:

In my opinion, those who are alcohol addicts are more challenging because they actually do harm themselves and other people. However, they are not diagnosed as severely mentally ill patients. So, the review committee usually takes quite a lot of time discussing this kind of case.

On the other hand, interviewees shared their experiences of facing severely mentally ill patients who were not assessed as a danger to themselves or others. At this point, holding a patient against his or her will was clearly placed in the patient’s best interests. Therefore, the meaning of ‘dangerous’ depends on different aspects of past history and presentation:

The patient locked himself up in a room for more than two decades and did no harm to himself or other people. He neither took medicine nor got in touch with his family. He just wanted to be left alone. That was his way to live his life, and his autonomy should not be violated despite the fact that his family is very concerned about him. In my opinion, he is a patient with a severe mental disorder. However, I do not consider that this severity should be regarded as risking either his or others’ safety.

Biopsychosocial analysis model

Those who live with a severely mentally ill patient, especially the family members, are not only the major caregivers for the patient, but also the ones who most frequently face the complex minds of the patient. As we know, daily social work practice not only deals with the patient, but also with the patient’s social system. In the case of compulsory admission, the needs of the patient’s family, especially the need for respite care service accompanied by compulsory admission, should also be considered by the social worker review committee members:

The family had no insight into mental disorder and believed that there was no need to have the patient hospitalized. However, the family had been slashed three times. In our opinion, it is necessary for the patient to be hospitalized. Therefore, this case won one hundred percent approval supporting the decision of compulsory admission, because the patient could have killed his mother. At that time, the opinion of the family was not considered, because such a disorder may risk the life of the patient and his family.

Another interviewee also shared her perspective on the biopsychosocial analysis approach: ‘What is our major concern? Although we do care about the patient’s rights and best interests, we are greatly concerned about their family, since most caregivers are family members.’

In addition, the social worker committee members need to take into account the social dimension of the patient’s needs, conceptualized as a system of biopsychosocial functioning:

One of the main problems we are facing now is the lack of outpatient treatment resources. This fact forces us to make use of compulsory admission to support the family care policy in our country. According to some written documents, family dysfunction is the cause of some mental disorder cases. If there were more community care interviewers or more accessible community resources, there would be no need to detain the patient involuntarily.

Working with other professionals

Every profession has its own limitations because of the restrictions in each field of professional knowledge (Adams, 2009). Because severely mentally ill patients cannot make competent decisions due to their dysfunctional cognition and emotional abilities, the introduction of the review committee forms a critical layer of specialist input in the decision-making process for compulsory care:

Our agreement on this review committee is to respect each person’s opinion. A lawyer’s (committee member) opinion is based on the perspectives of human rights or the legal regulation of mental health care, and he/she can try to influence the other committee members to take these considerations into account. If the committee member is a doctor, he/she will explain the level of existing psychiatric symptoms that justify psychiatric care. A social worker can share what he/she has observed from the patient and the family according to his/her past experience. The review committee enables every committee member to understand the views of the other specialties.

However, this model of multidisciplinary input encountered a variety of complexities and difficulties. Several interviewees shared the inevitable contestability of medical hierarchy and the issue of medical dominance in mental health services they had observed among the specialties (Taylor, 2006):

In Taiwan, the authority of doctors still dominates the decision-making process. Some doctors tried to influence the judgments of other committee members by explaining the serious level of the psychiatric symptoms. I also used to hear complaints from some patients’ rights representatives and lawyer review committee members that the explanation of the doctors affected their judgment and decisions. Such phenomena did happen.

Consideration of a patient’s rights and best interests

Ife (2008) indicated that the social work profession is one of the professions that promote human rights. Undoubtedly, one of the primary training points in the social work profession includes consideration of the patient’s rights and best interests (Biehal and Sainsbury, 1991):

Compulsory admission is a type of stigma to a severely mentally ill patient…. Because society lacks resources, it is undeniable that we sacrifice human rights of the severely mentally ill patient under this type of system. Once the system is reinforced, how many patients will realize that they can file a complaint?

Another interviewee gave a detailed description: ‘The focus of the MHA and review committee should be the patient. However, we cannot hear the voices of the patient on the review committee . . . In addition to a consent form, we can only hear the opinions of the professionals.’

Discussion

To our knowledge, this study is the first of its kind to be conducted with social work review committee members in Taiwan. Our results paint a picture of the approved social workers’ experience on the review committee in assessing the need of severely mentally ill patients for compulsory admission. At the time of writing, the review mechanism has been in practice for two years. As a whole, the review committee is similar to a quasi-judicial administration to assess whether the severely mentally ill patient should receive compulsory care and treatment according to the criteria for compulsory admission.

In legal terms, the distinctiveness of the criteria for compulsory admission is unquestionable. However, the review committee members give strict or thoughtful consideration during the review process according to their professional training and judgment. It was found that the main criteria of ‘a severely mentally ill patient’ and ‘dangerous to self or others’ failed to comply with the difficulties encountered in reality. The definition of ‘a severely mentally ill patient’ is loose and left to the clinicians for interpretation. For instance, an inability to care for the basic needs of food, clothing, or hygiene based on mental illness would be considered for the health and safety of the patient. Meanwhile, alcohol- or drug-addicted patients were not admitted for care under the same consideration. If, after emergency detention, the review committee evaluated that alcohol- or drug-addicted patients did not meet the criteria for compulsory admission, they would be persuaded by the medical staff to agree to be hospitalized for alcohol rehabilitation or drug addiction treatment voluntarily. If the patient was not willing to be hospitalized, he/she would be discharged from the hospital or referred to other settings specifically for such purposes.

In fact, a multitude of constraints may affect the social worker committee members’ decisions on whether or not to approve the compulsory admission. One interviewee indicated that committee members do not like to talk much during the review process because they are afraid of lawsuit threats. If a patient was compulsorily hospitalized, and this subsequently led to a suicide or a homicide in the family, would the review committee be sued? On the other hand, according to the current Taiwanese mental health legal framework, when the commitment is considered inappropriate shortly after the emergency situation or before the commitment commences, patients and their advocates have the right to refuse treatment and apply for a judicial determination to terminate the emergency detention or compulsory admission (under section 42 of the MHA 2007). However, up until the time of this writing, only one application for the termination or opposition to the commitment was successful because the patient had received legal training. The rest were mostly overruled. Despite the different legislative framework in Britain, Northern Ireland, or the United States, the results of the study are similar to findings elsewhere that social workers faced complex dynamics and felt afraid to make the wrong judgment based on the criteria for compulsory care and treatment (Campbell, 2010; Davidson and Campbell, 2009; Manktelow et al., 2002; Ramon, 2009; Taylor, 2006).

The review experiences also reflected the important consideration of the social determinants of mental health in the social work profession. The findings of this study help us understand the crucial role of the social worker in evaluating the existence of a social network and social support, along with the family’s function during the decision-making process for compulsory removal from the community (Manktelow et al., 2002). According to relevant literature, it was found that there was a correlation among the factors of social support, socioeconomic status, and compulsory admission of a severely mentally ill patient (Hallam, 2007; Quirk et al., 2003). Before social workers can act, they need to understand the gender, age, nationality, residential status, and employment status of the severely mentally ill patient involved (Hatfield, 2008; Lorant et al., 2007). In general, social workers tend to include the patients’ families as an important evaluation index in the system for severely mentally ill patients with the need for compulsory admission (Weiss-Gal, 2008). In Taiwan, the majority of the severely mentally ill patients live with their families. The approved social workers with at least seven years of clinical experience understand that the main caregivers of mental health care in Taiwan are the patients’ families. The grim picture of mental health care, such as insufficient outpatient treatment resources and dependence on inpatient care as an alternative resource for temporary relief from the pressure of this family burden, are frequently observed phenomena. Nevertheless, it is hard for severely mentally ill patients to survive in society if they cannot access a certain degree of assistance from others (Grob, 2008). In a society like Taiwan’s, the so-called rights of severely mentally ill patients seem to be equal to the rights of the families. In a case like Taiwan’s, it helps to understand the lack of resources in the community.

Our results also revealed that the shift in the decision-making process for compulsory admission in Taiwan from two clinicians to a review mechanism provides a variety of professional ethical considerations and judgments. Interviewees also found that some clinicians had received both medical and legal training. This fact effectively resulted in two clinicians attending the review committee. As can be imagined, considerations addressed by the review committee were based more on the medical-dominated approach than on the social circumstances of the individual. Therefore, considering the restricted community resources mentioned above and the resulting importance of the review committee, attention should be given to the difficulties with interdisciplinary working on compulsory admission (Davidson and Campbell, 2009; Furminger and Webber, 2008; Manktelow et al., 2002).

With respect to the possible limitations of the study, it should be noted that snowball sampling is a biased sampling method involving some self-selection, favoring those who responded most comfortably to face-to-face interaction in the completion of this research. Arguing that the results of this research can be generalized to apply to all social workers review committee members would be arbitrary. Also, our results may only reflect point-in-time conditions.

Conclusion

This study addressed the fact that the considerations around detaining a severely mentally ill person under the MHA 2007 in Taiwan are evaluated in situations of crisis. Such crises are complicated by both medical and social factors. We need to pay attention not only to the patients’ needs, but also to what kind of mental health care should be provided under the medical system and what necessary resources are available through the social welfare system. In the reform of the MHA 2007, preservation of a social perspective within the review committee is clearly provided. Although social work is still considered, by some, to be a relatively new profession (Farley et al., 2006), one of the contributions of this study is that understanding the role of social workers in the decision-making process of compulsory admission in Taiwan may help demonstrate the professional implications of social work.

Another distinctive contribution of this study is providing an explanatory model of how the decision for compulsory admission is made by a multidisciplinary team. The findings point out that the compulsory admission decision made by seven specialists is considered more comprehensive, and that group discussions provide better consideration of the decision as opposed to taking the recommendations of only two psychiatrists. Finally, we would like to emphasize the importance of working to resolve the difficulties that face the multidisciplinary committee members in reaching a joint decision on compulsory admission.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author biographies

I-Chen Tang, PhD, is at the School of Medical Sociology and Social Work, Chung Shan Medical University, Taichung, Taiwan.

Hui-Ching Wu, PhD, is at the Department of Social Work, National Taiwan University, Taipei, Taiwan.

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