The psychiatrist's dilemma

This story was first published in The Straits Times on July 12, 2013

KING George III, who ruled Great Britain from 1760 to 1820, suffered from recurrent bouts of mental disturbance. They were part of a rare medical disorder which eventually forced him to retire from public life. The King's experience was depicted in the 1994 movie The Madness Of King George. In one gripping scene, the King was manhandled and restrained to a chair with leather straps. Under the direction of his physician, he was also gagged.

The French philosopher, Michel Foucault, sees in this historical episode a manifestation of the power of the psychiatrist. A monarch was confronted and dethroned by the medical profession. Sovereign power was usurped.

Double agent

TO THIS day, vestiges of such power still reside with psychiatrists, although it is a responsibility and burden that we reluctantly shoulder rather than embrace wholeheartedly.

In our profession, we are sometimes thrust into the role of a double agent. We have a medical and ethical duty to both treat and protect our patients. But because people with mental illness can be dangerous, especially when left untreated, we also have the legal duty to protect those who might be harmed.

Singapore follows other countries in empowering psychiatrists to commit very disturbed patients to psychiatric institutions. In effect, a psychiatrist can incarcerate a person for a stipulated period of time once he or she has been assessed as having a mental illness that might result in self-harm or violence to others.

The practice of medicine, however, is fraught with risk and uncertainty. This is even more so in the case of psychiatry, for it is not an exact science. Society nevertheless expects psychiatrists to be able to predict - and hence prevent - the mentally ill becoming violent.

Such clairvoyance is not something that we possess. Prediction of violent behaviour is difficult. Consistently accurate prediction is impossible.

The danger of stereotyping

RESEARCH has found that the factors most consistently associated with violence are male gender, youth, past antisocial and violent conduct, substance abuse, and aggression as a child. The risk factors present in childhood and adolescence tend to persist well into adulthood.

The mere presence of having a serious mental disorder is a poor predictor of violence. Stereotyping, however, is common. The results of a survey of the American population following the Newtown school shooting published in the New England Journal of Medicine found that half of the respondents believed that people with serious mental illness are more dangerous than the general population.

The reality, however, is that violence is also a product of time, place, and circumstance. It is easy to forget that many people with serious mental illness continue to live with fortitude, including dealing with distressing and frightening thoughts and feelings, without getting violent.

The whole process of risk assessment is anything but simple. It takes time, persistence, and clinical acumen. It also requires curiosity to understand unfolding events in the context of the person's unique life. Added to this is intuition (to sense danger), diligence in gathering all possible information, and the experience and wisdom necessary to make the right call.

That is the ideal situation, of course. But in practice, it rarely happens quite like that. Often, the assessment has to be made in conditions fraught with uncertainty, heightened emotions, and the pressure of time. These pitfalls can have dire consequences, particularly when one underestimates the gravity of the situation.

Involuntary homicide

A RECENT article in a journal published by the Medical Protection Society, a provider of professional indemnity and legal advice to health professionals, featured the case of a psychiatrist in France. She was found guilty of involuntary homicide after her unwell patient killed someone. The court handed her a one-year suspended sentence for the "grave error" of failing to recognise the public danger posed by her patient.

This ruling triggered a frisson of disquiet and unease among psychiatrists. The author of the article noted that the French union of psychiatrists had described the verdict as "worrying", and warned that it might push psychiatrists to practise "defensively". In other words, it could encourage a greater willingness among psychiatrists to use the law to detain a patient who might receive much better care with less restrictive treatment.

Forcible admission

I HAVE on many occasions - in the emergency room and the outpatient clinic of the Institute of Mental Health - made a decision to forcibly admit a severely ill but resisting patient who understandably becomes increasingly more agitated as my intent becomes evident.

Sometimes, I am able to talk them into accepting admission. At other times, a "show of force" is needed. The latter involves getting a number of nursing staff and security people into the room to convince the patient that hospitalisation will be enforced. Sometimes we are even compelled to carry out that intent. Inevitably, the whole encounter becomes adversarial. This is certainly how the patient sees it.

Elyn R. Saks, currently a professor of law, psychology, psychiatry and behavioural sciences at the University of Southern California, wrote of her struggle with schizophrenia in her autobiographical book The Center Cannot Hold. She describes an occasion when as a student in Yale Law School, she had become unwell and believed that people were trying to kill her. As a defence, she armed herself with a six-inch nail. Landing in the Emergency Room of the Yale-New Haven Hospital, she was asked to hand over the nail by the attending doctor. She refused. She writes:

"He (the doctor) immediately called for security. Another attendant came in… with no interest in letting me keep my nail. And once he'd prised it from my fingers, it was all over. Within seconds, the doctor and his whole team of goons swooped down, grabbed me, lifted me out of the chair, and slammed me down on a nearby bed with such force that I saw stars. Then they bound both my legs and arms to the metal bed, with thick leather straps.

"A sound came out of my mouth that I'd never heard before. Half groan, half-scream, barely human, and pure terror."

A hard decision

WE KNOW that such experiences are traumatic for the patient. So it is always a hard decision to make and even harder to carry out. Whenever we do, however, the hope is that, after treatment, such patients will realise that these actions were in their best interests.

This justification is known as the "thank you theory of civil commitment". Unfortunately, studies have shown that only about half of patients who have been hospitalised in this way subsequently admit that they needed treatment. Sadly, many patients continue to see it as an egregious, hostile act.

Once, I had a violent patient in my consultation room in an outpatient clinic who had to be forcibly admitted.

After a tumultuous struggle, we managed to sedate her and wheel her (securely strapped in a gurney) to the inpatient unit. After the commotion had died down, I called for my next patient. As he walked in, he looked at me in a way that he had never done before.

"Dr Chong," he said with unmistakable reproach in his voice, "that was a very evil thing you just did."

The writer is a senior consultant psychiatrist and the vice-chairman, medical board (research) of the Institute of Mental Health.

This story was first published in The Straits Times on July 12, 2013

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