Sugiura Kanna, Morita Yasuko, Kawakami Norito, Kayama Mami
Department of Mental Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyoku, Tokyo, Japan.
National College of Nursing, Tokyo, Japan.
Community Ment Health J. 2023 May;59(4):654-663. doi: 10.1007/s10597-022-01046-1. Epub 2022 Nov 3.
To include people with disabilities as equal citizens, CRPD (Convention on the Rights of Persons with Disabilities) promotes direct or supported decision-making by people with disabilities. However, involuntary psychiatry admission is considered in many countries to be necessary for people with psychosocial disabilities. To overcome the tension and implement CRPD, it is essential to understand the experiences and concerns of service users, family members, and medical professionals in each country. To understand the process and the factors that make psychiatrists decide involuntary psychiatric admission in Japan, and explore their attitudes toward direct or supported decision-making by people with psychosocial disabilities. Psychiatrists who had authorized involuntary admission and who were in charge of the service users were recruited at hospitals in Japan. The interviews were individual, peer to peer, and semi-structured. The interviews were audio-recorded, transcribed verbatim, and the analysis followed reflexive thematic analysis using NVIVO 12. Six psychiatrists (five designated psychiatrists and one psychiatric resident) participated in the study at two hospitals in urban Japan. The study found that the psychiatrists assessed symptoms, behaviors, and perceptions of the service users together with supports and wishes of their families. The psychiatrists decided on involuntary admission when they saw self-harm or violence, weak insights and judgment abilities, family's wishes, or when they wanted to avoid the service users leaving the hospital with incomplete treatment. The psychiatrists felt that the service users would not understand any explanations, which made their communications minimal. The psychiatrists thought it was hard to imagine a system other than the current involuntary admission mechanism. If it was to change, they felt the essential things were to avoid abuse, clarify who is responsible, make plans medically valid and feasible, and assess and plan through everyday life, not just in crisis. During a crisis, the psychiatrists were most careful about complying with the Mental Health Act and responded to the family's wish. The psychiatrists justified involuntary admission as they believed that people in a psychiatric crisis cannot decide or understand and need protection. Related protocols, laws, and expectations from family members shapes the values and practices of psychiatrists in Japan. The paper concludes with several recommendations to regard people with psychosocial disabilities as equal citizens, and promoting the aim of reducing or ending involuntary admission.
为了将残疾人纳入平等公民的范畴，《残疾人权利公约》（CRPD）倡导残疾人进行直接决策或在他人支持下进行决策。然而，许多国家认为，对患有心理社会障碍的人进行非自愿精神科住院治疗是必要的。为了化解这种矛盾并实施《残疾人权利公约》，了解每个国家服务使用者、家庭成员和医疗专业人员的经历与担忧至关重要。为了了解在日本精神科医生决定非自愿精神科住院治疗的过程及因素，并探究他们对心理社会障碍者直接决策或在他人支持下进行决策的态度。在日本的医院招募了批准非自愿住院治疗且负责服务使用者的精神科医生。访谈采用一对一、同行间的半结构化形式。访谈进行了录音，并逐字转录，分析采用NVIVO 12软件进行反思性主题分析。六位精神科医生（五位指定精神科医生和一位精神科住院医生）参与了在日本城市两家医院开展的研究。研究发现，精神科医生会综合评估服务使用者的症状、行为和认知，以及其家人的支持和意愿。当精神科医生看到自我伤害或暴力行为、洞察力和判断力薄弱、家人的意愿，或者当他们想要避免服务使用者未完成治疗就出院时，就会决定非自愿住院治疗。精神科医生觉得服务使用者无法理解任何解释，这使得他们之间的沟通极少。精神科医生认为很难想象除了当前的非自愿住院机制之外的其他系统。如果要改变，他们觉得关键是要避免滥用、明确责任主体、制定合理可行的医疗计划，并通过日常生活而非仅在危机时刻进行评估和规划。在危机期间，精神科医生最谨慎地遵守《精神健康法》并回应家人的意愿。精神科医生为非自愿住院治疗进行辩护，因为他们认为处于精神危机中的人无法做出决定或理解情况，需要保护。相关的协议、法律以及家人的期望塑造了日本精神科医生的价值观和行为方式。本文最后提出了若干建议，以将心理社会障碍者视为平等公民，并推动减少或停止非自愿住院治疗的目标。
