Since 1991, commitment to involuntary psychiatric care has been allowed in Finland for minors in broader terms than for adults. While in adults mental illness has to be diagnosable before involuntary treatment can be imposed, minors can be committed to and detained in involuntary psychiatric treatment if they suffer from “severe mental disorders”, and fulfil the further commitment criteria defined in the Mental Health Act. The first years of the new mental health legislation showed an increase in involuntary treatment of minors in Finland. Concerns were raised about the imprecise nature of the commitment criterion “severe mental illness”. This study set out to find out whether Finnish child and adolescent psychiatrists are in agreement on how to define severe mental illness and whether their interpretations are sufficiently similar to ensure the equality of minors in commitment to psychiatric care as prescribed by the Mental Health Act. Semi-structured, reflexive dyadic interviews were carried out with 44 psychiatrists working with children and adolescents. The data was analysed using qualitative content analysis. There was general agreement about what constitutes a “severe mental disorder” justifying the involuntary psychiatric treatment of minors. The child and adolescent psychiatrists were of the opinion that involuntary treatment of minors should not be tied to specific diagnostic categories. Which disorders are severe enough to justify commitment should rather be considered through developmental and functional impairment and interactions between a minor and her/his environment.
Although self-determination is a highly appreciated value in modern Western health care ethics, involuntary psychiatric treatment is generally allowed in Western countries (Appelbaum, 1997, Salize et al., 2005, Salize and Dressing, 2004a and Salize and Dressing, 2004b), but being a controversial issue juxtaposing the right to self-determination and the right to receive good care, it is carefully controlled in mental health legislation. The mental health acts in various countries vary as to what conditions are considered severe enough to justify compulsory treatment (basic criterion), and as to what additional criteria must be fulfilled before involuntary treatment can be initiated. The additional criteria usually include various combinations of need for treatment, being a danger to self, and being a danger to others (Appelbaum, 1997 and Salize et al., 2005).
In Finland, the Act on the Status and Rights of Patients (1992/785) stipulates a patient's right to decide about her/his own treatment, and a right to refuse recommended treatment, as do Patients' rights acts, for example, in the other Nordic countries (Fallberg, 2000). In specific situations related to mental disorders, mental handicap, substance abuse and certain infectious diseases, involuntary treatment can be imposed, and it is regulated by the respective laws (Kaltiala-Heino & Välimäki, 2001). Of these, involuntary psychiatric treatment is by far the most important, and compulsory care under the other acts is very rare (Kaltiala-Heino & Välimäki, 2001).
The theoretical justification for imposing involuntary treatment in psychiatry is that mental disorders are seen to impair a patient's competence so that s/he is no longer able to make decisions serving her/his own best interests according to her/his own long-standing values (Appelbaum and Grisso, 1988 and Grisso and Appelbaum, 1995). Competency includes the capacity to understand information, to appreciate it as related to oneself, to consider the consequences of different choices, and to communicate a choice. Adults are basically assumed to be competent, but mental disorders are considered to potentially impair an adult's competence so much that it may be justifiable for others to intervene. Children and adolescents are generally deemed not fully competent, which is illustrated in the variety of legal provisions restricting their rights or compelling their compliance in a number of issues including education, economic issues, guardianship, child welfare etc. The Finnish Act on the Status and Rights of Patients states that children and adolescents have a right to participate in decision-making about their health care to the extent it is appropriate given their age and developmental level.
In Finland, the Mental Health Act of 1991 (1990/1116) introduced broader criteria for the involuntary treatment of minors than of adults. While the committed adult has to be mentally ill (psychotic), the basic criterion for the involuntary treatment of minors is “severe mental disorder”. In addition, the legislation requires that the person, due to her/his mental illness (adults) or severe mental disorder (minors) is in need of treatment to the extent that not treating would result in serious deterioration of the condition, or in serious harm to the patient her/himself or to others, and that other treatment options are inadequate. Minors committed to psychiatric care have to be treated separately from adults.
