Study on the Medialistic orientation, behavior of hospital and mental health treatment

X RESEARCH x ARTICLE Study on the Medialistic orientation, behavior of hospital and mental health treatment Molissa Farber Professor of Sociology Director of Undergraduate Studies and Co-Director, Center for Research on Inequalities and the Life Course (CIQLE) Maryland University USA Email: Doi Serial Keywords Sociology, social importance, encouragement, behavior of hospital

Farber M. (2025). Study on the Medialistic orientation, behavior of hospital and mental health treatment. Science, Education and Innovations in the Context ofModern Problems, 8(6), 863-879; doi:10.56352/sei/8.5.87. https://imcra-

Ken Kesey’s celebrated novel One Flew Over the Cuckoo’s Nest was published in 1962 at the beginning of an extended period of legal reform aimed at providing mental patients with more rights in and influence over their own psychiatric treatment. Kesey’s novel is set on the ward of an American psychiatric hospital in the 1950’s and follows the involuntary commitment of an energetic Irishman named R.P. McMurphey. While it becomes clear that McMurphey is not actually mentally ill, he is eventually forced into invasive psychiatric procedures including Electroconvulsive Therapy (ECT) and a lobotomy. These “treatments” ultimately cripple and dehumanize Kesey’s hero. The novel not only dramatized the nature of the psychiatric treatment of the previous era, but also indicated the start of a shift toward increasing the power of mental patients to make decisions concerning their own care in a mental health setting.

The patients’ rights movement of this new period represented a change from one conception of mental health treatment to another. The formerly dominant notion of psychiatric care, characterized as a “medicalist orientation,” gave doctors and psychiatrists a large amount of discretionary power to commit patients and treat them as needed, with or without their consent (Fennell 104). This approach has given way to a kind of “new legalism” that not only intends to protect against unjustified commitment or medication, but carries with it an “ideology of entitlement” that bestows patients with positive rights to determine their own care and treatment (Fennell 105).

Much of this legal reform is intended to give patients rights to equalize the power that psychiatrists hold over them. However, simply bestowing rights on committed patients may not be sufficient to correct the imbalance of power in the mental health system. In attempting to equalize the sometimes-coercive interaction between a patient and his or her doctor, the new lawmaking ignores another influential and yet unexamined relationship on the wards of a mental hospital: the relationship between a patient and the ward staff. Ward staff spend a significant amount more time dealing with patients under the constraints of the new legal reforms than do the doctors at the hospital, and they arguably have the most influence over the day-today running of the wards. In the face of reform that overlooks the status and activities of ward staff, it is possible that the practices of ward staff might blunt or directly contradict the impact of patients’ rights reform.

This research utilizes an ethnographic research design to explore whether rights-oriented reform has unintended consequences on the ground for the staff who work with patients on the wards of mental hospitals every day. To investigate this question, research was conducted at a large public psychiatric hospital. The field data gathered included observations of the wards and interviews with a number of professionals in the mental health system. This research uses sociological inquiry to predict and identify the mechanisms by which ward staff carry out (or fail to carry out) liberalizing reform in an institution such as an inpatient psychiatric hospital.

The ward life depicted in One Flew Over the Cuckoo’s Nest dramatized the limited amount of decision-making power afforded to patients in the mental health system in the 1950’s. As the 1960’s approached, the problems of Cuckoo’s era psychiatric care became a matter of public, legal, and academic concern that were eventually addressed through legal reform. A 1967 article from the Columbia Law Review, for example, reports that prior legislation in New York was structured such that psychiatric inpatient admissions often happened hastily, with poor information, and without consulting the patient for additional insight (Columbia 674). In another example, a 1976 report from the Michigan Law Review focused on the use and regulation of ECT (Electroconvulsive Therapy), a form of treatment for some mental disorders that resulted in uncomfortable and sometimes harmful side- effects for patients. The Michigan report on ECT emphasized the need to adopt a review panel that would regulate the administration of electroconvulsive treatments, observing that it is unjust to endow psychiatrists with complete power over a patient’s treatment, as their judgments are often subjective and can risk forcing “intrusive treatments” on unwilling but possibly competent patients (Michigan 390). By 1979, the Yale Law Journal could note that the judicial system had begun to question the amount of unilateral power doctors would be able to hold when it came to the treatment plans of mental patients, and was exploring the amount of protection available to such patients (Yale 850). Such legal reform attempted to provide patients with more rights in their own treatment and focused mainly on the role of doctors and psychiatrists in the treatment of patients on the wards of a hospital. Such reform was aimed at equalizing the doctor-patient relationship, which was seen as coercive and disadvantageous to the patient (Michigan 385). The areas of mental health treatment that were addressed by patients’ rights-oriented reform included requiring informed consent before administering mental health treatment and medication, increasing outpatient care services, and eliminating indefinite periods of hospital commitment. While the rights of patients who had voluntarily sought treatment at a hospital received a significant amount of attention, there has also been a great deal of legal wrangling over the procedure of involuntary commitment, as well as the rights of patients who undergo such a commitment.

Right now, every state in the U.S. as well as the District of Columbia has some form of an involuntary civil commitment law (Stavis). “Involuntary civil commitment” is defined as “a legal procedure used to compel an individual to receive inpatient treatment for a mental health disorder against his or her will” (“Involuntary Hospitalization”). While the exact policies and timetables vary by state, the power of the government to involuntarily detain a person in a mental hospital is most often justified on the grounds that civil commitment procedures prevent the committed person from harming him or herself or others, whether intentionally or unintentionally (Dworkin 294).

Just as previous legal reform increased the rights of voluntary mental patients, a general trend of increasing the rights of involuntary patients has been observed. Unlike laws dealing with voluntarily committed patients, however, the area of involuntary civil commitment has been a particularly sensitive one for patients’ rights advocates. Whereas voluntary patients want to receive some kind of help for their illness, involuntary patients have shown no such initiative and assumedly do not want any kind of medication.

Many of the more recent changes to this legislation have focused on modernizing involuntary civil commitment procedures. One such act is the District of Columbia Mental Health Civil Commitment Modernization Act of 2004, which modified the existing law governing civil commitment of involuntary patients in D.C. This revision is now commonly known as the Ervin Act (Title 21, D.C. Code §501-592). Among the changes made by this reform were an elimination of indeterminate periods of commitment by limiting commitments to one year, and greater emphasis on treating patients in the least restrictive setting possible (Library of Congress). Prior to Ervin Act reform, D.C. also saw mental health legislation that drastically limited the use of involuntary physical and chemical restraints on patients who were involuntarily committed to the hospital.

In a public statement in support of the new legislation, D.C. Delegate Eleanor Holmes Norton argued that these reforms were important in order to “reinvigorate the rights of people with mental illness” and “modernize the way mental health services in the District of Columbia are delivered” (Library of Congress). A house report on the act asserted that the lawmaking was needed in order to “increase the involvement of [patients] in their treatment and recovery process” (THOMAS). Other laws providing increased protection of patients’ rights in D.C. were supported alongside the Department of Mental Health’s promise that these new reforms would “provide patients with the right to complain and be heard” (“DMH Initi- ates…”). Similar legislation in California, the Lanterman-Petris-Short Act, set goals of “protecting mentally disordered persons…from criminal acts” and “safeguarding individual rights” (California Welfare and Institutions Code §5000).

Rights-oriented reform such as this has had a number of positive outcomes for both the patient and for the community. Looking at D.C. in particular, a March 2005 speech by a representative of the Department of Mental Health (DMH)—an entity created by the reform—spoke of a number of the department’s accomplishments in the face of this reform:

[DMH succeeded in] creating Care Coordination and the Access HelpLine, a whole new accountability system, and opportunities for agencies to provide community mental health services. [We also expanded] housing opportunities and services to persons who are homeless, add[ed] new [patients’] rights requirements, moderniz[ed] commitment statutes, creat[ed] a new grievance system and contract[ed] with an external advocacy organization to advocate on behalf of [patients] (“Testimony”).

Additionally, patients’ advocates would tell you that these legal changes have reduced the number of observable rights violations on the wards (Erin, Zoe, Kate, Claire).

Although this sounds positive, the fact remains that the role played by hospital staff on the wards in the successful execution of patients’ rights legislation remains relatively unexamined. Thus far, while reports explore aspects of the conservative social control power held by psychiatrists or the community-based ideals of the reformers (Steadman 263), sociological and legal literature lack a critical look into the role that staff play in the implementation of legal reform within the public mental hospital.