Patients' rights and the psychiatrist's dilemma.

The psychiatrist has traditionally viewed himself as the patient's advocate, friend, and confidant, as well as his physician. Therefore it is no surprise that mental health professionals should feel anger, disappointment, and resentment as a result of the recent flurry of patients' rights litigation and legislation which is so dramatically changing psychiatric practice. Psychiatrists, like other physicians, had grown to expect their clients to accept and follow clinical judgments without question, and were therefore unprepared for recent public requirements of increased accountability for effectiveness and appropriateness of treatment, and unprepared for patients' demands for participation in all treatment decisions. As an outgrowth of the patients' rights and consumer movement of the late '60s and early '70s, the doctor-patient relationship has been significantly altered and expanded. No longer is it acceptable for the physician unilaterally to decide upon treatment with the patient accepting the role of passive recipient of care. Other forces now impinge upon the interactions between doctor and patient, and have created a pentagonal relationship consisting of providers, consumers, third-party insurers, the judiciary, and public regulators and law makers, including Federal and State legislatures, professional licensing and accreditation boards, etc. The interaction among these forces generally affects the availability, quality, and nature of mental health services, and, more specifically, the role the mental health profes~ional has in delivering them. l Psychiatrists, like other health professionals, often have resented the intrusion of government, third-party insurers, and especially the judicial system into the mental health field. Many doctors complain about increased paperwork, limitations on flexibility in treatment decisions, the loss of necessary care for patients in need of help ("dying with their rights on"), etc. Although these complaints may be valid, it must not be forgotten that the conditions which have existed within the mental health system during much of the past one hundred years have warranted the public'S demand for increased accountability and judicial purview. That demand also signals the imperative need for psychiatry to set its own house in order, rather than have changes foisted upon it. Historically, American society has tended to ignore, to mistreat, or to exclude from view the mentally ill citizen. In colonial times, the mentally ill were frequently beaten and were driven from town to town or placed in "poor houses." During the 19th century, care improved somewhat with the establishment of small rural asylums and other institutions where "moral" treatment was provided. The goal was to restore the mentally ill person to normal functioning or, failing that, at least' to isolate him and his deviant behavior from the rest of society. To carry out this mission, government, through its commitment laws, gave a relatively free hand in treating the mentally ill to the only group willing to accept responsibility for their care the earliest mental health professionals.2 This period also marked the beginnings of organized psychiatry. Those early psychiatric physicians, charged by the public with caring for the mentally ill, created in 1844 the