Coercive Care Research Articles

Legislation and policy for involuntary mental healthcare across countries in the FOSTREN network: rationale, development of mapping survey and protocol.

Several countries are currently revising or have already revised their mental health laws to align with the global movement to reduce the use of coercive care. No government has yet fully implemented the recommendation of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) to eliminate the use of coercion in mental healthcare. Consequently, the international field of mental health law and policy is in a degree of flux. To describe the rationale, development and protocol for a project that will map and examine how mental health laws, policies and service capacity across European countries relate to the use of coercive measures, including involuntary admissions and treatment, restraints and seclusion. This will help to better understand the current situation and explore future directions of policies regarding coercive care. The project is being carried out under the purview of the European Cooperation in Science and Technology (COST) action network, entitled FOSTREN (Fostering and Strengthening Approaches to Reducing Coercion in European Mental Health Services). A multidisciplinary group of experts developed a comprehensive survey assessing mental health laws, policies and service frameworks, based on World Health Organization and UNCRPD recommendations. The survey was piloted in three countries, revised and disseminated to 30 FOSTREN country representatives. The survey will provide data for three strands of work on legislation, policies and service-level context. A comprehensive evaluation will be conducted, drawing on findings from all work packages. The project could inform the development of strategies, interventions and legislation to address gaps and promote compliance with international standards.

Social Work in Switzerland


 
 
 
 What form does Social Work take in Switzerland, and what are the current discourses? This article aims to trace academic and political developments in the analysis of coercive care in Switzerland. In a spirit of scientific self-observation, it will also reflect critically on the role of Social Work as a force of normalization and of the imposition of norms, as well as contextualizing it within current discourses. Looking back into the past makes it possible to expose arbitrary welfare practices that have violated people’s integrity; at the same time, it can reveal processes of professionalization and, linked with these, the development of work methods. The problems confronting Social Work have to do with the tension self-determination and external control, and interventions in the lives of those affected require a particularly high level of legitimation.
 
 
 

“It’s possible”: reducing the coercion in care for adults living with neurodevelopmental disorders: a mixed-methods study

Adults living with a neurodevelopmental disorder may present episodes of aggression, which may lead to the use of seclusion or restraint. The aim of the study was to assess the effect of an intervention aimed at reducing the use of coercive measures in a long-term care unit for adults suffering from a neurodevelopmental disorder with or without psychiatric co-morbidities. The single-center study used a sequential mixed-methods explanatory design. Retrospective data on periods of seclusion, with and without physical restraint, were collected for the ten-month pre-intervention and post-intervention periods. A qualitative survey was conducted at the end of the intervention period among the health professionals working in the unit to review the implementation and the efficiency of the approach. A significant decrease was observed between the pre- and post-intervention period in the number of seclusion and restraint sequences, the number of patients experiencing seclusion and restraint, and the duration of seclusion and restraint sequences. The efficiency of the approach was confirmed by the health care professionals and was attributed to leadership focused on limiting coercive measures, better adherence to legal obligations, team cohesion, and the implementation of alternative tools and methods. Reducing the use of coercive measures with adults with neurodevelopmental disorders is possible. Further studies are needed to confirm the effectiveness of alternative strategies to seclusion and restraint.

Introducing brief admissions by self-referral in child and adolescent psychiatry: an observational cohort study in Sweden

Brief admission by self-referral, a novel crisis intervention designed to reduce suicide and self-harm in adults, was adopted for adolescents in paediatric psychiatry in Malmö, Sweden, in 2018. We aimed to investigate changes in utilisation of emergency psychiatric care. We did an observational longitudinal cohort study in The University Hospital in Malmö, Sweden, which provides the only psychiatric emergency unit with 24 h psychiatric facilities in Region Skåne. Eligible patients were those aged 13-17 years who were admitted to the psychiatric facility, who had at least one emergency visit or admission during the 6 months before admission, and had prominent features of instability and self-harm, corresponding to at least three of the nine criteria for borderline personality disorder as per the DSM-5 as assessed by a paediatric psychiatrist during the admission. Patients with intellectual disabilities, psychosis, or language barriers were excluded. Patients who signed a brief admissions contract between April 1, 2018, and April 30, 2021, were eligible for inclusion in the study. A brief admissions contract allows patients to admit themselves to psychiatric emergency care for a transitory time. The primary outcome measures were the number of emergency visits, emergency admissions, inpatient days, and episodes of coercive (involuntary) care, compared at individual level before and after signing the brief admissions contract until end of follow-up. The number of visits and days were modelled using random-effects Poisson regression models, and the relative changes in the expected numbers of days per time unit were reported as rate ratios (RRs). Of the 928 patients admitted to the psychiatric facility between April 1, 2018, and April 30, 2021, 60 were excluded, and a further 801 did not meet the inclusion criteria for age, previous emergency visits, or having at least three of the nine criteria of borderline personality disorder. 67 patients were eligible for inclusion, but four patients did not sign a contract. 63 patients were included in the study, including 60 females (95%) and three (5%) males, with a mean age of 14·8 years (SD 1·7). Ethnicity data were not collected. Patients were followed up for a median of 13·5 months (IQR 9·2 -19·6). After signing the contract, there was a decrease in the number of emergency visits (RR 0·22 [95% CI 0·15-0·32]; p<0·0001), emergency admissions (RR 0·26 [0·19-0·35]; p<0·0001), inpatient days (RR 0·29 [0·26-0·32]; p<0·0001), and inpatient days including brief admissions (RR 0·44 [95% CI 0·40-0·48]; p<0·0001). Episodes of coercive care did not change significantly (RR 0·99 [95% CI 0·40-2·43]; p=0·98). Psychiatric evaluation due to persistent suicidal ideations immediately after discharge was required for five patients. Our findings suggest that brief admissions can be successfully implemented in paediatric psychiatry and appear to be an effective crisis management method for adolescents, associated with reduced demand for emergency care. Future randomised controlled trials are warranted. Region Skåne Health Care Authority.

Children in coercive care as ‘Responsibilized Becomings’: On rights and responsibilization in the Swedish welfare state

This study explores the often-ignored relationship between responsibilization and the welfare state, by investigating the translation of UN Convention on the Rights of the Child into Swedish legislation. Through an analysis of official political documents and interviews with Members of Parliament, this article identifies the driving forces behind the responsibilization of children in coercive care and seeks to explain how these forces are used to conceptualize and reconceptualize the rights of children in these settings. By proposing that the responsibilization of these children is closely connected to the internal logic of the welfare state, and that this logic is working in tandem with neoliberalization (rather than against it), this article provides an important contribution to the debate regarding the welfare state and responsibilization in Sweden, and by extension in the Nordic context.

Strong-arm Sobriety: Addressing Precarity through Probation

Over the past half-century, the US welfare and penal systems have become increasingly fused modes of poverty governance. At the center of the welfare-penal continuum sits probation, a form of community supervision that operates as a central hub, directing people to both services and incarceration. Drawing on interviews with 166 adults on probation in Hennepin County, Minnesota, in 2019, we argue that the coercive care of probation is structured by the broader project of controlling alcohol and drug use among the poor. Developing the concept of strong-arm sobriety, we show how the “criminal addict” trope undergirds the central processes of probation: treatment, testing, and revocation. We argue that strong-arm sobriety misreads structural precarity as the result, rather than the cause, of individuals’ choices. In doing so, strong-arm sobriety fails to address the circumstances that engender substance use and produces future subjects for coercive care.

Cannabis criminology: inequality, coercion, and illusions of reform

Cannabis liberalization is a fascinating case study in moral-legal re-negotiation. From broad international examples of decriminalization to specific local legalization models, numerous criminological questions are emerging. This paper describes three significant challenges for cannabis liberalization. These include persistent inequalities associated with policing cannabis, the invisibility of coercive care and control within diversion, and the hazards associated with illusory policy reform. We present Cannabis Criminology as a multidisciplinary effort to understand the prohibition, decriminalization, legalization, and nascent regulation of cannabis in ways that acknowledge but transcend law-based paradigms. Consistent with criminology's multiple and sometimes contradictory dimensions, we outline five thematic areas that can inform the study of cannabis. These include law, society, and social control, police and policing cannabis, race, ethnicity and intrusion, the economics of cannabis use, and cannabis and criminal behavior. Finally, we conclude that privileging the views of people who use cannabis can provoke more inclusive, participatory, and otherwise imaginative efforts.

Autonomy conquers all: a thematic analysis of nurses’ professional judgement encountering resistance to care from home-dwelling persons with dementia

BackgroundAdequate care support from home health care nurses is needed to meet the needs of an increasing number of home-dwelling persons with dementia and those who resist care. The decisions nurses make in home health care when encountering resistance from persons with dementia have an extensive impact on the quality of care and access to care. There is little research on what influences nurse’s encounters with resistance to care from home-dwelling persons with dementia.Research aimTo get insight into how nurses experience resistance to care from home-dwelling persons with dementia.MethodsA qualitative research design using a thematic analysis was conducted following the six steps by Braun and Clarke. Data was gathered from three focus group and three individual interviews, and a total of 18 nurses from home health care participated. The interviews took place over a period of 5 months, from December 2020 to April 2021.Ethical considerationsApproved by the Norwegian Centre for Research, reference number 515138 and by the research advisers and home care managers in each section of the municipality.ResultsTwo main themes were identified: 1) Challenged by complex and inadequate care structures and 2) Adapting care according to circumstances. There were three subthemes within the first main theme: lack of systematic collaboration and understanding, insufficient flexibility to care, and the challenge of privacy. In the second main theme, there were three subthemes: avoid forced treatment and care to protect autonomy, gray-areas of coercive care and reduced care. The two main themes seemed to be interdependent, as challenges and changes in organizational structures influenced how nurses could conduct their care practices.ConclusionOur findings indicate that nurses’ responsibility to decide how to conduct care is downplayed when facing resistance. Further, their professional judgement is influenced by contextual factors and characterized by a strong commitment to avoid forced treatment and care.A continuous challenge is to safeguard shared decision-making at the same time as it is balanced against risks of severe health damage in home-dwelling persons with dementia. A fundamental question to ask is whether autonomy does conquer all, even when severe health damage is at stake.

Strategies for the Prevention of Violence in Institutional Care: A Qualitative Interview Study With Ward Managers.

BackgroundThe presence of violence within psychiatric and residential settings remains a challenge. Research on this problem has often focused on describing violence prevention strategies from either staffs' or service users' perspectives, and the views of ward managers has been largely overlooked. The aim of the present study was therefore to identify ward managers' strategies to prevent violence in institutional care, focusing on safety and values.MethodsData were collected using semi-structured interviews with 12 ward managers who headed four different types of psychiatric wards and two special residential homes for adolescents. Qualitative content analysis was applied, first using a deductive approach, in which quotes were selected within a frame of primary, secondary, and tertiary prevention, then by coding using an inductive approach to create themes and subthemes.ResultsWard managers' strategies were divided into the four following themes: (1) Balancing being an active manager with relying on staff's abilities to carry out their work properly while staying mostly in the background; (2) Promoting value awareness and non-coercive practices in encounters with service users by promoting key values and adopting de-escalation techniques, as well as focusing on staff-service user relationships; (3) Acknowledging and strengthening staff's abilities and competence by viewing and treating staff as a critical resource for good care; and (4) Providing information and support to staff by exchanging information and debriefing them after violent incidents.ConclusionsWard managers described ethical challenges surrounding violence and coercive measures. These were often described as practical problems, so there seems to be a need for a development of higher ethical awareness based on a common understanding regarding central ethical values to be respected in coercive care. The ward managers seem to have a high awareness of de-escalation and the work with secondary prevention, however, there is a need to develop the work with primary and tertiary prevention. The service user group or user organizations were not considered as resources in violence prevention, so there is a need to ensure that all stakeholders are active in the process of creating violence prevention strategies.

A mixed methods study examining perceptions by service-users of their involuntary admission in relation to levels of insight.

Poor insight is associated with negative attitudes to involuntary admission and care in qualitative studies. The current paper aims to examine and compare retrospective qualitative perceptions of service-users in relation to their involuntary admission with their levels of clinical insight, using a mixed methods approach. Forty two participants were assessed 3 months after the revocation of their involuntary admission. Each provided qualitative data relating to their perceptions of the coercive care process, which was analysed using content analysis, along with a quantitative measurement of insight, the Schedule for the Assessment of Insight-Expanded (SAI-E). Employing a mixed methods design and incorporating NVivo matrix coding queries, the datasets were merged to enable qualitative themes to be identified against the quantitative data. Differences were observed between those with high and low insight in terms of their understanding of the need for treatment, their levels of arousal at the time of admission and how they perceived the compassion of health professionals. Certain negative perceptions of care appeared more universal and were common across those with high and low insight. Some negative perceptions of coercive practices appear linked to inherent elements of psychotic illness such as unawareness of illness. Individuals with higher levels of insight tended to perceive their involuntary admission and receiving a diagnosis as beneficial. Negative views that persist amongst service users with high insight levels can highlight areas for successful service improvement, including increased emphasis on non-pharmacotherapy based supports during the coercive care process.

Mental health clinician training and experiences with utilization of advance statements in Victoria, Australia.

Advance statements, advance directives, or psychiatric wills are a key component of a shift to mental healthcare that promotes autonomy and choice and aims to reduce restrictive and coercive care practices in mental health treatment settings. The use of advance statements has gained momentum to provide a means for individuals to detail clear preferences for mental health treatment. This paper uses a qualitative descriptive design to explore the experiences of clinicians (n = 15) implementing advance statements in the state of Victoria, Australia, a region that introduced advance statements as part of an overhaul of mental health legislation in 2014. The study, reported using the COREQ framework, found two key themes after analysis: experiences of advance statement training, with the availability and quality of training and training as a driver of change emerging as sub-themes, and experiences of advance statements in practice, with participants providing narratives of the barriers and facilitators to successful advance statement implementation. We recommend that clinician and service user experiences of advance statement implementation are further explored to identify existing and emerging barriers to implementation of these tools, which are crucial to achieve autonomy and choice for individuals receiving mental healthcare.

Punishment, support, or discipline? Taking stock of recent debates about homeless governance in neoliberal cities

AbstractAn interdisciplinary debate emerged in the 1990s about the nature of homeless governance in neoliberal cities. Contributions to this discussion have interrogated the form, function, and legitimacy of contemporary homeless management. Urban scholars have differentiated three techniques of homeless governance: punishment, support, and discipline. A subset of scholarship has defined punitive governance as an illegitimate act of repression that promotes urban revitalization by excluding the homeless from urban political economies, supportive governance as a legitimate act of voluntary or coercive care that helps the homeless survive a traumatic life experience, and disciplinary governance as an illegitimate act of production that fortifies urban political economies by including rather than excluding homeless individuals into bourgeois institutions. An emerging body of research demonstrates frontline workers coordinate these techniques of governance to pursue the aims of institutional elites. This article outlines the main points of contention in this debate, examines significant empirical findings that scholars have reported, and identifies salient knowledge gaps to be addressed in future research.

Ethics in Public and Community Psychiatry

Public and community psychiatrists who care for patients with serious mental illnesses regularly face ethical challenges. This article summarizes key ethical considerations in the care of a population that can be difficult to engage and may reject treatment, sometimes necessitating coercive care. The digital revolution in medicine, with its promises and perils and accelerated by coronavirus disease 2019 (COVID-19), has added ethical complexity regarding privacy and access to care. Shared decision-making, a process to resolve ethical dilemmas, and commitments to professionalism and reflective practice are emphasized as three ways to practice ethically in public and community psychiatrists' daily work. Additionally, COVID-19 has highlighted that engagement in social justice is a critical element of ethical practice for physicians today. [ Psychiatr Ann . 2021;51(6):272–277.]

Patient confidentiality, theduty to protect, and psychotherapeutic care: perspectives from the philosophy of ubuntu.

This paper demonstrates how ubuntu relational philosophy may be used to ground beneficial coercive care without necessarily violating a patient's dignity. Specifically,it argues that ubuntu philosophy is a useful theory for developing necessary conditions for determining a patient's potential dangerousness; setting reasonable limits to the duty to protect; balancing the long-term good of providing unimpeded therapy for patients who need it with the short-term good of protecting at-risk parties; and advancing a framework for future case law and appropriate regulations in the care of psychotherapy patients. Issues regarding the decision to breach medical confidentiality in psychotherapeutic care are ultimately reserved for the courts. Professional assessment might be an important first step in this process, and court rulings govern most aspects of this assessment. However, current case law, especially in the United States,places an unreasonable expectation on psychotherapists to protect all at-risk parties or foresee that a patient intends to follow through on said threats. It has largely failed to guarantee psychotherapy patients unlimited access to care, while potentially inhibiting future honest communication between patients and health professionals and endangering the safety of others. Of these decisions, the two most prominent are the 1976 Tarasoff decision and the 2016 Volk decision. This paper argues for the possibility of grounding good laws in ubuntu African philosophy in a way that protects others from harm and ensures unimpeded access to care without necessarily breaching medical confidentiality.

Tvingad till autonomi

Utifrån tidigare forskning om öppen psykiatrisk tvångsvård har två paradoxer i förhållande till lagstiftningen identifierats: Öppen psykiatrisk tvångsvård (ÖPT) innebär både mer och mindre autonomi för patienten. ÖPT innebär att autonoma individer tvångsvårdas till autonomi. Syftet med artikeln är att tydliggöra vilka normativa ställningstaganden som ligger till grund för tvångsvårdsformen genom att de två paradoxerna belyses utifrån fyra perspektiv på autonomi. Den första paradoxen förklaras genom att lagstiftaren förhåller sig till både en liberal och en medicinsk-etisk autonomidefinition. I ett liberalt perspektiv är öppen tvångsvård en inskränkning av individens rätt till frihet. I ett medicinsk-etiskt perspektiv kan öppen tvångsvård öka autonomi genom att den ökar eller skyddar patientens autonomi i framtiden. I ett medicinsk-etiskt perspektiv kan andra värden, som hälsa och livskvalitet, också motivera inskränkningar i patientens autonomi. Den andra paradoxen kan förklaras genom att lagstiftaren blandar proceduriella och substantiella rekvisit för autonomi. Patienten förutsätts vara autonom enligt proceduriella rekvisit eftersom patienten inte anses vara beslutsoförmögen. Samtidigt är utfallet av patientens val avgörande för om det respekteras. Om patienten vill avstå vård förutsätts det inte vara patientens autentiska önskan, vilket är ett uttryck för en substantiell syn på autonomi. Vården ska i stället återge patienten dess substantiella autonomi. Vid ÖPT förutsätts patienten i praktiken frivilligt medverka till vården. Det betyder att patienten uppfyller även autenticitetsrekvisiten. Men eftersom syftet med tvångsvården är att återupprätta just den autentiska viljan genom att patienten blir i stånd att frivilligt ta emot tvångsvård är autonomikraven för öppen tvångsvård uppfyllda samtidigt som autonomikraven för vårdens upphörande också är uppfyllda. Om ÖPT ska kunna motiveras utifrån ett medicinsk-etiskt perspektiv krävs att tvångsvården faktiskt ger mer autonomi senare eller andra vinster. I dagsläget finns inget vetenskapligt stöd för att tvångsvårdsformen fungerar. Mot denna bakgrund är det svårt att se vilket värde som tillförs som väger tyngre än patientens autonomi.

‘Rightificating’ Coercion – A Critical Perspective on the Transformation of State-Driven Coercive Care

During the last decade there has been a growing trend to give the child’s rights perspective a prominent role within the Swedish legal system. Simultaneously, one of the most central notions of the Swedish welfare state is the idea of the state having a certain responsibility to protect children. This article explores the tensions and contradictions between the child’s rights perspective and the collectivistic discourse on state protection in the transformation of state-driven coercive care in accordance with the United Nations Convention on the Rights of the Child (UNCRC). Based on a textual analysis on policy documents, it illustrates a complex process, which both endorses and resists the transformation process. Findings show how emphasis on the child’s right to protection is used, not to strengthen the role of the child towards the state, but to legitimise a strengthened position of the state towards the child, decorated in the terminology of a child’s rights perspective. Further, it suggests that an individualisation of problem formulation opens up space for an extended coercion and that children’s access to individual rights is conditional and dependent on an active and capable individual.

“Coercive Care” or “Ur-wir [Great-we]”: Communication and Cooperation in Couples Where One Partner Has Been Diagnosed with Dementia

According to the World Health Organization, dementia is an assembly of conditions with rapidly increasing numbers of afflicted individuals. Whereas the standard medical model focuses on the individual whose brain deteriorates and who therefore needs help, few studies treat dementia as a social phenomenon. This study—part of a larger investigation into the changing nature of the relations within couples where one individual suffers from severe changes in the brain—reports on the irreducibly social dimensions of coping with everyday life activities that involve both partners. We draw on the occasions of shaving and brushing teeth in one couple to exemplify our broader findings of the irreducibly joint work accomplished to successfully complete mundane activities. We draw on the Vygotskian notion of the Ur-wir (Great-we) and on Merleau-Ponty’s notion of the dual sensation touching-touched to discuss issues related to identity, solidarity, and ethics of care.

Barnskyddets innersta kärna

The inner core of child protection – on coercive placement motivated by abuse or neglectThis article is about emergency placement due to child abuse or neglect. Empirical data consists of judgements on coercive care in three administrative courts (n=211). Motives for placements are analysed against the background of the discursive changes that have taken place with regard to definitions of child abuse as well as today’s strong focus on risk and risk assessments. Results show that there were a number of motives to justify the court’s decision in each individual case. However, the broadening of the concept of abuse in research and in general discourse is evident in the judgements. We raise the question whether this matter, in practice, has resulted in more children being cared for because of an expansion of the concept of violence. As for risk assessments, two types of causal reasoning can be identified: situations where the child has been abused or neglected and where the risk assessment is about the probability that the problems will continue, and situations where the child has not been harmed but risks being harmed in the future. However, risk assessments are not that elaborate and systematic as presupposed in legislation. Taken together, the findings call for a discussion both within the justice system and in social work.

PROTECT: Relational safety based suicide prevention training frameworks.

Preventing suicide is a global priority, and staff training is a core prevention strategy. However, frontline pressures make translating training into better care and better outcomes difficult. The aim of the paper was to highlight challenges in suicide risk assessment and management and introduce training frameworks to assist with mindful practice so professionals can strike a balance between risk and recovery. We combined the scientific literature with contemporary practice from two successful initiatives from Cambridgeshire, UK: 333 - a recovery-oriented model of inpatient/community crisis care and PROMISE - a programme to reduce coercion in care by enhancing patient experience. The resulting PROTECT (PROactive deTECTion) frameworks operationalize ongoing practice of relational safety in these programmes. PROTECT is a combination of novel concepts and adaptations of well-established therapeutic approaches. It has four training frameworks: AWARE for reflection on clinical decisions; DESPAIR for assessment; ASPIRE for management; and NOTES for documentation. PROTECT aims to improve self-awareness of mental shortcuts and risk-taking thresholds and increase rigour through time-efficient cross-checks. The training frameworks should support a relational approach to self-harm/suicide risk detection, mitigation, and documentation, making care safer and person-centred. The goal is to enthuse practitioners with recovery-oriented practice that draws on the strengths of the person in distress and their natural circle of support. It will provide the confidence to engage in participatory approaches to seek out unique individualized solutions to the overwhelming psychological pain of suicidal distress. Future collaborative research with people with lived and carer experience is needed for fine-tuning.

Coercive care and human rights; a complex juxtaposition – part 2

To examine capacity assessment, coercive care and principles by which a seemingly reasonable request for the discontinuation of treatment may be considered. A clinical and socio-legal case may be made for 'coercive care'.