|Year : 2020 | Volume
| Issue : 3 | Page : 110-116
Knowledge of mental health law and attitude toward mental illness among attorneys in Nigeria
Oluyemi O Akanni1, Nosa G Igbinomwanhia2, Adegboyega Ogunwale3, Adeagbo F Osundina4
1 Clinical Services, Forensic Unit, Federal Neuropsychiatric Hospital, Uselu, Benin City, Nigeria
2 Mental Health In-reach Team, HMP Elmey and Burgess Ward, Bracton Centre, Oxleas NHS Foundation Trust, Dartford Kent, England, United Kingdom
3 Clinical Services, Forensic Unit, Neuropsychiatric Hospital, Aro, Abeokuta, Nigeria
4 Older People's Health and Ageing, Northwick Park Hospital, Central and Northwest London NHS Foundation Trust, London, England, United Kingdom
|Date of Submission||29-Mar-2020|
|Date of Decision||11-May-2020|
|Date of Acceptance||13-May-2020|
|Date of Web Publication||27-Jul-2020|
Oluyemi O Akanni
Federal Neuropsychiatric Hospital, Benin City, Edo State
Source of Support: None, Conflict of Interest: None
Introduction: There are legal provisions for the protection of those who are mentally ill, and law officers may have a role in this regard. Few, if any studies have attempted to investigate the knowledge about and attitude towards mental illness among the members of the legal profession. Methods: This was a cross-sectional descriptive survey conducted among attorneys in Benin-City, Edo State, South-South, Nigeria, using a 21-item knowledge/attitude questionnaire. Results: Seventy-five attorneys who filled the questionnaire were in the age range of 23 and 65 years, with more males (69.3%), more married (60.8%), and more private defense attorneys (79.2%) participating. A greater proportion (64.8%) had not adjudicated for persons with mental illness, and a few (22.2%) would not agree to solicit for them. Only a few were accurate about when the Nigerian mental health law was enacted (9.3%), what it says about the treatment of the mentally ill persons (3.0%), and the handling of the property of the same (3.1%). Although only a minority (7.1%) were familiar with the provisions of the insanity defense under section 28 of the criminal code, most (85.9%) identified correctly the disposal of a mentally ill person found unfit to plead according to the criminal procedure act. Conclusion: Lawyers in the study appeared to have very little experiential knowledge about mental illness, demonstrated a poor level of knowledge regarding mental health laws as well as criminal provisions regarding mentally abnormal offenders. There is a need to improve training content in Legal education in Nigeria with regard to legislation affecting both civil and criminal aspects of mental disorder.
Keywords: Attitude, attorney, knowledge, mental health law
|How to cite this article:|
Akanni OO, Igbinomwanhia NG, Ogunwale A, Osundina AF. Knowledge of mental health law and attitude toward mental illness among attorneys in Nigeria. Soc Health Behav 2020;3:110-6
|How to cite this URL:|
Akanni OO, Igbinomwanhia NG, Ogunwale A, Osundina AF. Knowledge of mental health law and attitude toward mental illness among attorneys in Nigeria. Soc Health Behav [serial online] 2020 [cited 2020 Aug 8];3:110-6. Available from: http://www.shbonweb.com/text.asp?2020/3/3/110/290974
| Introduction|| |
Mental illness places a significant burden on affected individuals and their families, and society at large. In developing countries and in some western parts of the world, mental disorders still attract a lot of stigmas which may be largely driven by a lack of knowledge., This dearth of knowledge and accompanying negative attitude not only affect the general public but also affects professionals as well. While there are existing studies that have examined knowledge about and attitude toward mental illness among various health-related professionals such as doctors, nurses, health-care students and primary health-care workers,,,,, few, if any studies, have attempted to investigate this among the members of the legal profession.
Furthermore, the depth of knowledge about mental illnesses among attorneys, as well as the adequacy of their training in mental health-related legislation is not clear. Inadequate knowledge and training of lawyers on the operation of the mental health laws may be doing a great disservice to the mentally ill who are a vulnerable group of individuals. It is possible that some offenders who may have committed crimes in the context of untreated mental disorders may be punished without recourse to treatment largely because the quality of their legal defense is poor or because judicial officers adjudicating them are quite unfamiliar with the intricacies of the insanity defense.
Therefore, the role of the legal professionals in understanding what constitutes mental illnesses and their knowledge of the mental health legislations are important in determining how the laws can be applied for the benefit of the mentally ill. Studies evaluating the knowledge of lawyers about mental health laws in the United States tend to suggest that attorneys were just fairly knowledgeable about mental illness. A study by Frierson et al. reported that majority of attorneys preferred to work with clients without mental illnesses but that as they become more experienced interacting with defendants who are affected by mental illness, they become more willing to defend them. In our environment, there is currently no known study that has researched in this direction. This study was conducted to bridge this gap in literature and also to make recommendations that will improve the care and adjudication of mentally ill individuals who come into contact with the law either in a civil or criminal sense.
| Methods|| |
Study setting and population
It was a cross-sectional descriptive survey conducted among attorneys in Benin-City, Edo State, South-South, Nigeria. In Nigeria, attorneys must have completed 5 years of law study in a university and 1 year in a Law School which provides practical training. Basically, after the Law school, majority enter into practise while few go into academics. For those practising, some can secure employment in the public service while others operate within the private sector. In general, in legal practice, a period of apprenticeship is desirable before independent professional practice. Most lawyers in Nigeria work as a barrister-solicitors. In select cases, lawyers who have practised in the profession for a variable period of time may be invited to serve as judges. Our study population comprised a good mix of most categories of lawyers.
This was a convenience sample of all available participants at an annual conference of lawyers, which lasted for 5 days. The conference affords the lawyers in the state the opportunity to update their knowledge on the ethics and practice of their profession and also to network with colleagues. There are over 35,000 registered lawyers in Nigeria and close to a thousand in the city of study, however, about 300 of them attended the conference. The conference is opened to associate members; however, the questionnaire was only administered to attorneys. The respondents were informed that they were not to consult texts, statutes, or colleagues before completing the survey to ensure that their responses represented their personal level of knowledge at the time of the study. Out of the 200 questionnaires distributed at the conference, 35 (17.5%) were returned before the conference ended.
Following this rather low response rate, additional questionnaires were distributed to attorneys through their association's administrative office as well as approaching them at their law offices where possible. Furthermore, a snowballing technique was adopted to reach other attorneys. Finally, an additional 40 questionnaires were collected, resulting in a total of 75.
It consisted of a 21-item survey questionnaire; some of the items were extracted from a 32-item written survey used by previous researchers, and the rest were designed by the authors to fit the objectives of the study. Seventeen of the items were structured in a way for respondents to pick the most appropriate option while one was a multiple-choice format. The remaining 3 items which were self-designed were open-ended, in which respondents were to write their opinions in less than 3 sentences.
The demographic characteristics in the questionnaire included: age, gender, marital status, attorney type (prosecutor, public defender, private defense attorney, or judge), and experience (i.e., years of practising law). Other questions explored the perception of respondents about mental illness, level of training in recognizing mental illness, and degree of understanding of the Nigerian mental health law. The questions whose items were open-ended formats included opinions on the role of the judiciary in a mental health law, the role of an attorney in the adequate protection of the rights of the mentally ill and how to handle mentally ill clients who wish to sue a doctor who has treated them for mental illness against their will.
Items included from questionnaires used in previous studies included questions related to the level of training in law school about mental illness and mental health laws. The items designed by the authors focused on questions about knowledge of the Nigerian mental health laws and criminal proceedings involving the mentally ill.
Ethical approval was obtained from the Ethics and Review Board of the Federal Neuropsychiatric Hospital, Benin-City. Informed consent was duly obtained from the attorneys who took part in the survey and anonymity was observed in questionnaire administration.
Data were processed and analyzed using IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. Descriptive statistics such as frequencies were used, and data presented in tables.
Twenty-five persons did not fill in one of the items of the semi-structured questionnaire (the role the judiciary sub-serve in the current mental health law); hence it was expunged from the analysis, thus leaving the items to 20. Less than two-thirds of the participants did not respond to the three open-ended questions, and among those who did, some gave multiple responses. However, because of the qualitative nature of the responses, the items were preserved for analysis. Recurring or similar responses were regrouped, and outcomes were constructed into a table.
| Results|| |
The 75 respondents' ages ranged between 23 and 65 years, and the median age was 37 years. There were more males (69.3%), more married (60.8%) and more private defense attorney (79.2%). Other demographic variables are summarized in [Table 1].
Concerning their knowledge about and experience with mental illness [Table 2], 2.7% admitted to having a major mental illness, and 18.7% indicated that they knew a friend or family member with a mental illness. A greater proportion (64.8%) had not adjudicated for persons with mental illness, and a few (22.2%) do not agree to solicit for them. Twenty-nine of the attorney's (43.4%) correctly identified the definition of delusion.
[Table 3] shows the perception and knowledge of the attorneys with regard to mental health laws. Thirty-one percent revealed that they received instruction in Law School on mental health laws, whereas only 14.1% indicated that their education on mental health laws was adequate. Only a few were accurate about when the Nigerian mental health law was enacted (9.3%), what it says about the treatment of the insane (3.0%) and the handling of the property of the same (3.1%). Also, a minority (7.1%) were correct in choosing what the insanity defense is about according to section 28 of the criminal code, but most (85.9%) identified correctly the disposal of a mentally ill person found unfit to plead according to the criminal procedure act.
The summary of the results of the qualitative assessment revealed varied responses, which have been tabulated [Table 4].
Fourteen persons thought that the role of the judiciary in the mental health law is restricted to maintaining, interpreting, and implementing the law. Some (11 persons) believed in referring mentally ill for treatment while 6 attorneys felt their role was in reviewing the laws.
In the role of an attorney to adequately protect the rights of a mentally ill persons, many (15) maintained that they will do same without stating how, however, 10 respondents opined that they will ensure treatment while 6 viewed upholding justice and ethics as the role of an attorney in the adequate protection of the rights of a mentally ill persons?
In the scenario where a client who is mentally ill wishes to sue a doctor who treated him for mental illness against his will, eleven of the participants stated that they will counsel their client against such action or seek for alternative resolution dispute. Five persons each opted to reject the brief and refer for treatment. Fourteen persons agreed that legal proceedings can be taken against the doctors, however for varying reasons.
| Discussion|| |
To the knowledge of the researchers, this is the first study in Nigeria to survey lawyers' knowledge and experience of mental illness, their knowledge of the Nigerian mental health laws, and their perceived role in the care of mentally ill persons. The only related study found was carried out among magistrates and judges in which their opinion was sought regarding the usefulness of psychiatric reports written by psychiatrists to the court.
This study revealed stigmatizing attitudes towards mentally ill persons as have been reported in earlier studies among laypersons and professional groups, including doctors, teachers, and clergy.,,, This stigmatizing attitude among lawyers may not be unconnected with social distance as only a small number of respondents reported personal experience with mentally ill persons among family or friends, or in professional situations; as almost 95% of those surveyed in this study were defence attorneys, the observed stigmatizing attitude may also not be unconnected with the likelihood of lawyers encountering the mentally ill more frequently in situ ations where they have offended, in which case lawyers' stereotype of offenders and criminality may be brought to bear on the mentally ill. It is uncertain if stigmatising attitudes among the respondents is reflected in the observation that almost two-thirds of those surveyed had never handled cases involving a mentally ill person.
This study also sought to assess lawyers' knowledge of mental illness by using the definition of a delusion, a core psychotic feature, as a screening test. Over half of respondents did not correctly identify what a delusion is, despite its importance in law with regard to criminal responsibility. This is unsurprising considering that over 85% of respondents perceived their law school instruction in mental illness and offending as inadequate, while almost 40% had never received instruction on mental illness. There is therefore poor understanding of mental illness and its interface with offending among lawyers; they may as such lack confidence to take up cases in defense of mentally ill persons, a situation that could be responsible for the low number of respondents who reported ever handling a case involving a mentally ill person. Successfully arguing a case in court is predicated on adequate knowledge, among other factors; therefore, for lawyers who do take up cases on behalf of mentally ill persons, their success in such cases may be hampered by inadequacy of knowledge as pertains to mental illness and the law. This highlights a need for uniformity and enhancement of law school curriculum in Nigeria as it pertains to mental illness and offending since lawyers are likely to hold brief/adjudicate for the mentally ill at some point in their career.
Overall, lawyers' knowledge of Nigerian mental health laws was poor in this study, which was in keeping with the reported inadequate instruction received in law school about the law and mentally ill persons; it may also reflect a lack of interest in handling cases involving mentally ill persons or a paucity of such cases within the population. The mental health laws form part of the framework within which lawyers are expected to serve mentally ill persons. Going forward, therefore, improved curriculum bearing on mental health laws both at undergraduate law faculties and the Nigerian law school is key to improving lawyers' knowledge of mental health laws and how lawyers fit in the operationalization of these laws. Joint training and improved collaboration between psychiatrists and other mental health workers and lawyers would likely enhance lawyers' knowledge of these laws and harness the benefits that could accrue from improved participation of lawyers in the mental health care delivery system.
Lawyers are by their professional calling, in vantage position to advocate for the rights of mentally ill persons. Unfortunately, they may not get round to doing so if they are ignorant of the obsolete nature of Nigeria's mental health laws and its numerous inadequacies that can lead to infringements of the rights of mentally ill persons., With <10% of respondents correctly identifying the period of enactment of Nigerian mental health laws, it is doubtful if lawyers even know the deficiencies in these laws or what roles lawyers could possibly play in advocating for the rights and privileges of mentally ill persons or in ensuring that such rights are not infringed upon or that the mentally ill can seek redress when they perceive that their rights have been abused. Contemporary mental health laws are the product of composite contribution by stakeholders with the mentally ill as the focus. Lawyers are significant stakeholders and as such should be clearly aware of what role lawyers and the judiciary play in enacting and interpreting mental health laws.
Fortunately, a majority of respondents correctly identified the disposal for persons with unsound mind unfit to plead according to the Nigerian. This may be helpful in engaging lawyers to signpost or recommend the mentally ill for appropriate treatment or hospital disposal from the point of knowledge. On the other hand, however, their poor knowledge of the reference period of the insanity defense as stipulated in s28 of the CC implies that the majority of lawyers may not be able to utilize this leeway in assisting the mentally ill obtain appropriate disposal when they stand accused for crimes committed in the context of an unsound mind, thus leading to inadvertent denial or perversion of justice.
Regarding property of the mentally ill, lawyers showed quite an uncomfortable level of knowledge. Their role in supporting the mentally ill to safeguard their right to property is, therefore in jeopardy.
Respondents' perceived role of lawyers in protecting the rights of mentally ill persons spanned advocacy, adjudication, signposting and safe-guarding. More lawyers appear to be confident of the judgment of doctors who care for mentally ill persons and would rather tow a more cautious path when deciding what action to take in suspected infringement of the rights of mentally ill persons by doctors. This may again be reflective of lack of confidence deriving from poor knowledge of mental health laws or a stigmatizing perception of mentally ill persons as lacking the ability to make good judgments, or else lawyers simply preferring to defer to doctors' professionalism.
There are some important limitations to this study which we wish to highlight. Firstly, the small sample size limits the generalizability of the study as well as further statistical analyses, which could have been informative. Secondly, the fact that questionnaires were taken home by some of the lawyers could have compromised the validity of the knowledge measure since it was possible that some of them consulted other sources in answering those questions. However, it was expressly stated in the questionnaires that texts or other persons were not to be so consulted. Another limitation is the validity of the questionnaire used in the present study, which has not been validated before. Also, questions aimed at identifying knowledge and attitudes were rather restrictive and could at best, pass for screening for stigma and knowledge of psychotic disorders. Finally, the predominance of private practitioners and defense attorneys in the sample surveyed may have inevitably introduced some bias since we do not have information about the actual population distribution of the lawyers in the city in which the survey was conducted.
| Conclusion|| |
The study revealed that a small percentage of lawyers have adjudicated for the mentally ill, possessed adequate knowledge about mental illness and showed a positive attitude towards the mentally ill. They also demonstrated a poor level of knowledge regarding mental health laws as well as criminal provisions regarding mentally abnormal offenders. The need to improve training content in Legal education in Nigeria, and encourage collaboration between psychiatrists and other mental health workers and lawyers were recommended.
The authors wish to thank late Barister K Ohahuna for his invaluable assistance in facilitating data collection and guidance in the course of writing the manuscript.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]