I've mentioned evidence-based practice. So, I'll say something here about its influence on treatment options as well. As I've already said, there's much concern at the moment about the kind of research evidence that is available to demonstrate that treatments are effective. It's hard to disagree with this. Surely, there are a few questions more important to answer, than the question of whether we are using treatments that actually benefit people. We certainly have seen that terrible things can happen when there is disregard for evidence that demonstrates treatments are unhelpful or even harmful. Yet there are particular types of treatment that are best able to demonstrate that they are evidence-based. The highest standard evidence-based treatment is that a treatment method must have been demonstrated to be superior to other available treatments in a randomized controlled trial. These RCT trials are experiments where they control the circumstances of the studys so they can say with certainty that they are finding evidence of a treatment effectiveness. But not all treatments can be subjected to this kind of test because they don't produce easily measurable effects or it's not possible to control the circumstances around the experiment to demonstrate their effects. So, they can't be proven to be evidence-based treatments. Without that evidence-based stamp of approval, governments and insurance companies may be unwilling to invest in these treatments, so the treatment options that are available are narrowed down. Another issue with evidence-based treatments is that they are proven to be, they are proven in evidence-based studies that use very specialized samples that may bear very little resemblance to the people who are actually supposed to benefit from the treatment. One issue that always strikes me is that, to get into a treatment trial, you often have to be living in stable conditions, exhibiting no active symptoms, have no issues with substance use, or etc., etc., etc. And the reality is that most of the people that I worked with when I was a social worker, had very complex lives and situations that would have made it impossible for them to be included in one of those samples. So, you have to wonder, how generalizable or transferrable are the findings from those research studies. In other words, does what they find in one of those research studies have much to do with what people out in the real world are dealing with? A final consideration is that the research that is done to establish evidence-based practices is usually focused, focused on determining whether treatments are able to reduce symptoms that people are experiencing. That is undoubtedly an important outcome to measure. But it may not be the outcome or at least the only outcome that is important to people who are actually diagnosed with mental illness. If you remember our discussion about recovery in the first lecture, it is clear that from a recovery perspective, symptom reduction is only one of many things that people hope to gain when they're recovering from mental illness. So, it's not certain that an evidence-based treatment is going to meet the needs of all people who are seeking treatment. Now, this is not to say that we should abandon the whole idea of evidence-based practices. As I've already said, one of the most important questions we need to be asking is, do these treatments help people? I only offer these comments as way to point out that evidence-based treatment are making an important contribution to scope of mental health treatment. But there is a context surrounding them, that we, that means we should not assume that they are the only thing available to help people or the thing available. I want to talk about noncompliance and treatment because it also speaks to the social context of treatment. When we talk about noncompliance in the context of mental health, we are referring to the possibility that clients may stop their medications or not take them as prescribed. Although people may decide to stop psychotherapies or social therapies, I don't think I've ever heard that the term noncompliance used in that context. And although noncompliance is an issue that people deal with across all classes of medications and across mental and physical disorders. It gets a lot of attention in the context of mental healthcare because noncompliance is assumed to demonstrate that someone does not understand their illness and may not be well enough to make decisions about their treatment. Noncompliance, that is not following doctors orders, can be a reason that is given for subjecting someone to involuntary treatment. The fact that someone is refusing to take their medication, opens up a discussion about whether that person is capable of making sound decisions. I want to emphasize that this is an issue that is usually held up to public scrutiny through some kind of process of investigation. In Canada, for example, we have review boards that will meet to evaluate whether a person is well enough to make a sound decision to not take medication. In those review boards, the person who's refusing to take medication has legal representation as well. If you investigate the Mental Health Act that is in effect in your community, you are likely to find that there are similar protections in place to ensure that people get a fair hearing when they decide to oppose a physician's intention to treat them with psychiatric medications. Yet, as I've already mentioned, these issues are taken up quite differently in the mental healthcare system than they are in the general healthcare system. In the mental healthcare system, the refusal to take medication can be interpreted as a symptom of illness. This is not a question that comes up in general medicine, except possibly through the suggestion that someone who refuses to take physician-recommended treatment may be suffering from a mental disorder in addition to the general medical condition. In psychiatry, this intertwining of accepting treatment and being seen as able to understand and make decisions about treatment, gets all tangled up in a concept we call insight. And that failure to fall into line and accept treatment can lead to a lot of other judgments about someone's ability to understand what is going on with them and to make decisions about their own health and welfare. So, this lead us rather logically to the question of involuntary treatment. The mental health, healthcare system has been granted the power to compel people to receive treatment. Involuntary treatment is something that is usually evoked when someone is demonstrated to be a harm to themself or others. You will probably, probably remember that involuntary treatment was the one thing all the people in the anti-psychiatry movement agreed about. Everyone thought that involuntary treatment was an unacceptable violation of people's self-determination and human rights and did more to serve the public or the state, than it did to serve people who were diagnosed with mental illnesses. The counter-narrative to this is presented in an earlier form in the Kelm article. You will recall that psychyatrists at the turn of the century argue that people were reluctant to bring people for care because the committal processes were so cumbersome. As a result, people came to them much later than was prudent and the psychyatrists argue that earlier intervention would serve them better. Similarly, involuntary treatment is available now as something to be used when needed. But there is a definite preference for working with voluntary patients and being able to intervene earlier in illness processes. But there's another parallel that needs to be considered here. In Kelm's article, the research he did indicated that one of the reasons families waited until they had no other option but committal, was because they were reluctant to relinquish control of their family members to the asylum system. We have a contemporary manifestation of this as well. There are certain groups that are more likely to be subjected to involuntary treatment than others. For example, racial and ethnic minority people in the UK have more involuntary treatment than other groups. But when we put this in social context, we have to consider that these are groups who, like the families of the women described in the Kelm's article, may be reluctant to relinquish control to the mental healthcare system. There are many groups that do not see the mental healthcare system as a safe place for them. And therefore, they may be less likely to seek voluntary treatment because they do not see it as in their best interest. In addition, because these are groups that often don't have effective access to healthcare in the first place, they may have more protracted pathways to care that result in them only reaching services when they are more ill and need to be admitted involuntary, involuntarily. So, you see that the social context has a significant effect on achievement options that may be available to socially marginalized groups. So, pulling it all together, you may have once thought that treatment options were just a question of, of what science was able to make available for our use. But hopefully, you now can see that the social contexts affects treatment options in many ways. It affects what treatments are available and favored. It affects what treatments are considered worthwhile investments by the government and insurance companies, etc. It affects whether refusing treatment is an option. And it affects whether involuntary treatment is more or less probable for certain groups. Next, we'll talk about how the social context has an impact on treatment access as well.
