Coercive Care Research Articles

Reducing coercion in mental healthcare.

To examine the extent and nature of coercive practices in mental healthcare and to consider the ethical, human rights challenges facing the current clinical practices in this area. We consider the epidemiology of coercion in mental health and appraise the efficacy of attempts to reduce coercion and make specific recommendations for making mental healthcare less coercive and more consensual. We identified references through searches of MEDLINE, EMBASE, PsycINFO and CINAHL Plus. Search was limited to articles published from January 1980 to May 2018. Searches were carried out using the terms mental health (admission or detain* or detention or coercion) and treatment (forcible or involuntary or seclusion or restraint). Articles published during this period were further identified through searches in the authors' personal files and Google Scholar. Articles resulting from searches and relevant references cited in those articles were reviewed. Articles and reviews of non-psychiatric population, children under 16 years, and those pertaining exclusively to people with dementia were excluded. Coercion in its various guises is embedded in mental healthcare. There is very little research in this area and the absence of systematic and routinely collected data is a major barrier to research as well as understanding the nature of coercion and attempts to address this problem. Examples of good practice in this area are limited and there is hardly any evidence pertaining to the generalisability or sustainability of individual programmes. Based on the review, we make specific recommendations to reduce coercive care. Our contention is that this will require more than legislative tinkering and will necessitate a fundamental change in the culture of psychiatry. In particular, we must ensure that clinical practice never compromises people's human rights. It is ethically, clinically and legally necessary to address the problem of coercion and make mental healthcare more consensual. All forms of coercive practices are inconsistent with human rights-based mental healthcare. This is global challenge that requires urgent action.

Coercive care and human rights; a complex juxtaposition - part 1.

To explore the clinical implications associated with the United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD), and coercive practice. Both human rights and clinical perspectives are necessary in the management of the mentally ill.

Surveying the Geneva impasse: Coercive care and human rights

The United Nations human rights system has in recent years been divided on the question as to whether coercive care interventions, including coercive psychiatric care, can ever be justified under UN human rights standards. Some within the UN human rights community hold that coercive care can comply with human rights standards, provided that the coercive intervention is a necessary and proportionate means to achieve certain approved aims, and that appropriate legal safeguards are in place. Others have held that coercive care is never justified. Disagreement over this issue has produced an impasse in the UN human rights system. We survey the impasse with particular attention to the legal arguments that inform the divergent positions. In doing so we introduce a distinction among a variety of different ‘abolitionist’ positions regarding coercive care, and draw a distinction between ‘non-consensual’ and ‘coercive’ treatment. We conclude with three proposals for moving beyond the current impasse.

Anti-Refugee Sentiment without Refugees: Human Rights Violations and Social Work in Post-Socialist Countries of Southeastern Europe in their Social Contexts

In the article, the authors pose a question: to what extent can we speak of social work practice in support of refugees in post-socialist Southeastern Europe given that in the region, which was part of the Balkans Humanitarian Corridor in 2015 and 2016, state-supported social work practice is very limited and very prescriptive at the same time? The vocal anti-refugee sentiment in Central and Southeastern Europe that accompanied the migrants can be said to stem from the nineteenth-century primordialism: the one-state, one-nation ideology that also was embedded in the very construction of post-socialist states after 1991. Consequently, refugees are seen as the ultimate danger to everything “ours,” to women, men, and children of purportedly pure-blooded ethnonational origin, threatening “our” transgenerational sense of cultural and pseudobiological homogeneity. The rising post-socialist ethnonational primordialism, intertwined with conservative neopatriarchal ideologies, directly affects human rights observance and social work education and practice. The predominantly government-funded social workers generally are neither trained nor encouraged to work with refugees, while the popular and party politics of hatred is directed toward those who support refugees, social workers included. Anti-refugee sentiment, culturalization, and neopatriarchy are rationalized with arguments of fear and care; protecting the cultural and biological homogeneity of native residents leads to processes that turn care into violence, and ultimately into coercive care.

Co-production and evaluation of an e-learning resource to improve African-Caribbean families\u2019 knowledge about schizophrenia and engagement with services: a pilot randomised controlled trial protocol

BackgroundA higher proportion of African-Caribbean people in the UK are diagnosed with schizophrenia spectrum disorders than other ethnic groups. High levels of shame and stigma at individual and community levels contribute to delayed access to care, potentially increasing the duration of untreated psychosis and so worsening outcomes. Inferior access, more coercive care, and worse outcomes have created a ‘circle of fear’ of mental health services within African-Caribbean communities. This further discourages early engagement with statutory services and increases the burden of care for families living with schizophrenia.Providing tailored and relevant information about psychosis (psychoeducation) has the potential for improving outcomes for patients and families. However, there are no culturally appropriate psychoeducation programmes for African-Caribbeans in the UK. We aim to determine whether an e-learning resource, co-produced with African-Caribbean stakeholders to improve knowledge about psychoses, would be culturally acceptable and accessible to members of this population.MethodsA pilot randomised controlled trial of the feasibility of co-producing and testing a novel e-learning resource to improve knowledge about and attitudes towards schizophrenia in African-Caribbean families. We will seek to recruit 40 participants, aged ≥ 16 years, either to receive the intervention or as controls. They will self-refer or be referred via inpatient and wellbeing services, family and carers’ forums, statutory community mental health teams, and voluntary sector/non-governmental agencies (NGOs). Participants will complete the Ca-KAP, ASMI, and SF-12. Acceptability will be explored qualitatively via focus groups and individual semi-structured interviews.DiscussionThe proposed trial will demonstrate the feasibility of conducting a fully powered RCT to evaluate the efficacy of an e-learning resource about schizophrenia with African-Caribbean families. Qualitative work will explore the intervention’s accessibility and barriers/facilitators to participation, including attitudes to randomisation. These data will facilitate further refinement of the intervention.Trial registrationISRCTN11394005, retrospectively registered 20/03/2018.

Predictors of involuntary patients' satisfaction with care: prospective study.

Involuntary admission can be traumatic and is associated with negative attitudes that persist after the episode of illness has abated. We aimed to prospectively assess satisfaction with care at the points of involuntary admission and symptomatic recovery, and identify their sociodemographic, clinical and service experience predictors. Levels of satisfaction with care, and clinical and sociodemographic variables were obtained from a representative cohort of 263 patients at the point of involuntary admission and from 155 of these patients 3 months after termination of the involuntary admission. Data were analysed with multiple linear regression modelling. Higher baseline awareness of illness (B = 0.19, P < 0.001) and older age (B = 0.05, P = 0.001) were associated with more satisfaction with care at baseline and follow-up. Transition to greater satisfaction with care was associated with improvements in awareness of illness (B = 0.13, P < 0.001) and in symptoms (B = 0.05, P = 0.02), as well as older age (B = 0.04, P = 0.01). Objective coercive experiences were not associated with variation in satisfaction with care. There is wide variation in satisfaction with coercive care. Greater satisfaction with care is positively associated with clinical variables such as increased awareness of illness. None.

New Dutch Legislation and Preventive Coercive Home Health Care for Excessive Alcohol Consumers

Excessive alcohol consumers are in need for effective and targeted thiamine interventions to prevent the development of Korsakoff’s syndrome. Coercive home health care might be a solution to reach excessive alcohol consumers. In many parts of the world, an expansion is seen of more coercive community practices. Due to new legislation in the Netherlands, preventive coercive home health care is permitted. The objective of this article is twofold. Firstly, to describe this new Dutch legislation and secondly, to explore literature to identify themes that might contribute to less-intrusive coercive interventions at the excessive alcohol consumer’s home. Four articles have been identified which concentrate on experiences regarding coercive home health care. Preventive coercive home health care might benefit from a stable and trusting relationship. For healthcare organizations, this means that they need to pay attention to the health and safety of their employees to prevent outflow.

Providing Good Care in the Shadow of Violence – An Interview Study with Nursing Staff and Ward Managers in Psychiatric Inpatient Care in Sweden

The aim was to describe the nursing staff and ward managers' experiences of safety and violence in everyday meetings with the patients. The qualitative content analyses resulted in four themes: the relationship with the patient is the basis of care; the organizational culture affects the care given; knowledge and competence are important for safe care; and the importance of balancing influence and coercion in care. The staff had a varied ability to meet patients in a respectful way. One way of creating a common approach could be to discuss and reflect upon different options in the meeting with the patient.

État des lieux des preuves d'efficacité

Coercive measures in healthcare are frequently used worldwide, and are especially visible and discussed in psychiatry. Ethical, moral and legal questions have become increasingly frequent over past decades, as medical practice has evolved towards more respectful treatment of patients’ autonomy and rights. In parallel, medicine evolved towards evidence-based practice. In this context, the aim of this narrative literature review was to identify scientific evidence for physical coercive measures (seclusion and restraint), with a wider discussion of the results, including ethical aspects. A French and English literature search of PubMed, MEDLINE, Cochrane, Embase, PsycINFO, Google Scholar and CAIRN.INFO was made. Results show variations in coercive care in terms of type, frequency and duration due to differences among countries and hospital practice. Furthermore, its definitions and indications are not clear. We have found no published randomised controlled studies that demonstrate evidence of therapeutic aims and efficiency of coercion. At present, the data are insufficient to assess the clinical or ethical legitimacy of coercion. As a result, a clear consensus for its legitimacy has not yet emerged, despite the fact that the practice of coercive care remains ubiquitous, frequent and limiting of patients’ rights. This article should motivate every healthcare provider to further reflect and implement clear clinical guidelines for adequate treatment, which respect the rights of the patients involved and which follow evidence-based medicine standards.

Patient and Caregiver Perspectives on Ethical Issues in Mental Health Care: an Exploratory Study from India

Ethical viewpoints about the correct course of action in a clinical situation can vary across individuals. The views of patients and their caregivers are also important considerations while exploring solutions to ethical dilemmas. This study aimed to ascertain the perspectives of patients and caregivers on ethical issues in mental health care. This vignette-based study included patients with psychiatric disorders and their caregivers. Patients were included if they were in clinical remission determined by psychiatric rating scales. Caregivers were included if they resided with the patient for the last 1 year. Both patients and caregivers were in the adult age group. The vignettes pertained to confidentiality and coercive care and elicited a yes or no type of responses. Ten short vignettes were presented to the patient caregiver dyad. The types of responses and agreement between the patients and their caregivers were assessed. Responses were available from 160 dyads of patients and their caregivers. The mean age of the patients was 35.6 years while that of the caregivers was 40.5 years. A slight majority of the patients and caregivers were males and were educated above high school. There was considerable variation in the views about correct course in a particular clinical situation. The responses from patients and caregivers endorsing disclosure of confidential information or coercive treatment varied from about 50% to more than 90% depending upon the clinical situation. The responses of patients generally had a fair agreement with responses of the caregivers (kappa values largely between 0.21 and 0.40). Viewpoints of patients and their caregivers provide an important stakeholder insight in approach to resolving ethical dilemmas. In the present cultural context, patients and caregivers were amenable to disclosure of confidential information in for a variety of clinical situations.

Space between the borders? Perceptions of professionals on the participation in decision-making of young people in coercive care

The participation of young people in care and treatment decisions is regarded as an essential element in effective decision-making and care. Although care and treatment in juvenile justice facilities is, in the first instance, based on a coercive placement (i.e. non-participatory decision-making), it is likely that participation is also essential for young offenders during their stay in care. In our study, we interviewed 24 care professionals working in two different juvenile justice facilities in the Netherlands. Professionals understand what participation entails (e.g. informing, listening to, taking views into account), and how and why they can use participation in everyday practice. Typically, they link issues such as safety and existing boundaries when talking about participation in a coercive context. Based on our findings, we present a conceptual model of factors that seem to influence a young person’s participation process. These findings indicate that there is a need for the structural incorporation of youth participation into juvenile justice facilities in such a way as to consider the needs and perspectives of both young people and professionals.

Community treatment orders – what are the views of decision makers?

Background: Community treatment orders (CTOs) are being increasingly used in Western countries. The scheme implies that mental health patients can live outside a hospital, but still be subject to coercive care to ensure compliance with their treatment. There is limited knowledge of how the scheme is practised.Aims: To gain knowledge of how decision makers weigh and evaluate various considerations when making decisions on CTOs.Method: Qualitative in-depth interviews with decision makers responsible for CTOs in Norway.Results: Decision makers viewed CTOs as a useful scheme to ensure control, continuity and follow-up care in the treatment of outpatients with a history of poor treatment motivation. They had varied interest in and knowledge of the patient’s life situation and how the scheme affects the patient’s everyday life. Little attention was devoted to patient experiences of formal and informal coercion.Conclusion: When deciding on CTOs, decision makers should pay more attention to the negative consequences that patients may experience. In many cases, decision makers are probably not aware of these coercive factors.

Are community treatment orders counterproductive?

This article briefly reviews the literature pertaining to community treatment orders (CTOs) specifically how and why they are utilised and how effective mandated community treatment really is. This review discusses the use of CTOs in the context of the recovery model. This article highlights the shortfalls in the current CTO system while also demonstrating the increase in acute coercive care. The literature pertaining to the effectiveness of CTOs is inconsistent with more recent reviews denoting that there is now robust evidence the CTOs are not effective. Further treatment that aligns with the recovery model as oppose to mandated treatment is known to increase treatment compliance.

The use of family group conferences in mental health: Barriers for implementation

Summary The number of compulsory admissions in Dutch psychiatry has increased in the past 25 years. The reduction of coercion with Family Group Conferences in youth care has been successful. How, when and under what conditions can Family Group Conferences reduce coercion in adult psychiatry, is subject of an extensive inquiry. This paper, however, focusses on the reverse question, namely, in what circumstances can Family Group Conferences not be deployed? An answer to this question provides insights regarding situations in which Family Group Conferences may (not) be useful. Barriers in 17 cases were examined using multiple case studies. Findings The following barriers emerged: (1) the acute danger in coercion situations, the limited time available, the fear of liability and the culture of control and risk aversion in mental health care; (2) the severity of the mental state of clients leading to difficulties in decision-making and communication; (3) considering an Family Group Conference and involving familial networks as an added value in crisis situation is not part of the thinking and acting of professionals in mental health care; (4) clients and their network (who) are not open to an Family Group Conference. Applications Awareness of the barriers for Family Group Conferences can help to keep an open mind for its capacity to strengthen the partnership between clients, familial networks and professionals. The application of Family Group Conferences can help to effectuate professional and ethical values of social workers in their quest for the least coercive care.

Coercive Care: Control and Coercion in the Restructured Care Workplace

Coercive Care: Control and Coercion in the Restructured Care Workplace

A two-way process: the client–keyworker relationship and its dynamics in coercive drug treatment

Relationships between client and professional have proved to be an important factor for treatment outcome and for how clients perceive and estimate the help. In this article, we aimed to explore the character and emotional quality of the relationship between client and keyworker, and the conditions for treatment collaboration, in coercive drug treatment. The data was obtained from a larger research project, conducted in Sweden 2005–2009 at four residential treatment centres for coercive care. The article is based on pairwise analyses of qualitative interviews with 16 clients and their keyworkers. By comparing both parties’ perspectives on their on-going relationship we identified three patterns that capture the studied relationships’ character and emotional quality: the ‘friendly and trustful relationship’, the ‘polite and neutral relationship’ and the ‘ambivalent and conflicted relationship’. The findings show that the key dimensions of interaction were (1) the clients and keyworkers expectations, (2) the meaning they ascribe to each other, the actions exchanged and the situation they are in, (3) contextual factors as they appear in everyday life at the centre and (4) how the clients and the keyworkers, individually and together, deal with the tensions and role conflicts embedded in the situation.

Ethical challenges in the use of coercion

The use of coercive measures remains one of the great challenges in psychiatry.Increased focus on patient rights and autonomy, concern from user and relatives organizations as well as from human rights organizations all have contributed to that the use of all kinds of coercion is high on the agenda. And yet, we are still faced with that a number of psychiatric patients will experience that coercive measures are used as part of their treatment.The EPA Ethical Committee carried out a survey comprising the European associations of psychiatry in which a questionnaire was circulated regarding what the different associations found were the major ethical challenges in their respective countries.Among the issues that have given rise to particular concern are the use of physical restraints including why some countries avoid physical restraints while other – e.g. Denmark – use it extensively. Why do we find such large differences? Is this due to different approaches to coercion, different traditions? Shortage of resources?Another concern is that certain groups seem more likely to be subject to coercion compared to others. Thus, it has been demonstrated that patients belonging to ethnic minority groups are more likely to experience this.The paper will focus on ethical problems and issues of concern related to the use of coercion. The focus will be on facets of international relevance with the aim to remain critical towards the use and when needed to strengthen the quality of coercive treatment care. URL:http://www.mariannekastrup.dkDisclosure of interestThe author has not supplied his declaration of competing interest.

Justifications for coercive care in child and adolescent psychiatry, a content analysis of medical documentation in Sweden.

BackgroundThere has been considerable interest in normative ethics regarding how and when coercive care can be justified. However, only a few empirical studies consider how professionals reason about ethical aspects when assessing the need for coercive care for adults, and even less concerning children and adolescents. The aim of this study was to examine and describe how professionals document their value arguments when considering the need for coercive psychiatric care of young people.MethodsAll 16 clinics that admitted children or adolescents to coercive care during one year in Sweden were included in the study. These clinics had a total of 155 admissions of 142 patients over one year. Qualitative content analysis with a deductive approach was used to find different forms of justification for coercive care that was documented in the medical records, including Care Certificates.ResultsThe analysis of medical records revealed two main arguments used to justify coercive care in child and adolescent psychiatry: 1) the protection argument - the patients needed protection, mainly from themselves, and 2) the treatment requirement argument - coercive care was a necessary measure for administering treatment to the patient. Other arguments, namely the caregiver support argument, the clarification argument and the solidarity argument, were used primarily to support the two main arguments. These supportive arguments were mostly used when describing the current situation, not in the explicit argumentation for coercive care. The need for treatment was often only implicitly clarified and the type of care the patient needed was not specified. Few value arguments were used in the decision for coercive care; instead physicians often used their authority to convince others that treatment was necessary.ConclusionsOne clinical implication of the study is that decisions about the use of coercive care should have a much stronger emphasis on ethical aspects. There is a need for an ethical legitimacy founded upon explicit ethical reasoning and after communication with the patient and family, which should be documented together with the decision to use coercive care.

Coercive Care: Rights, Law and Policy

Coercive Care: Rights, Law and Policy

Tensions and Risks in the Blanket Use of Locked Door Policies in Acute Mental Health Inpatient Facilities: Balancing Human Rights, Clinical Utility and Public and Patient Protection

Although there has been a consistent trend away from institutionalised mental health care over the past decades, this has occurred at the same time as increased coercive care measures are employed in mental health inpatient facilities, as these facilities become weighted to more serious cases. Locked wards, which regulate the ability of both voluntary and involuntary patients to leave psychiatric units, are increasingly common in acute mental health inpatient settings. This article focuses on the controversy surrounding a recent initiative to extend locked door policies across all public acute inpatient facilities in Queensland, explores the legal, ethical and clinical issues around the implementation of locked door policies in acute mental health inpatient facilities, and examines the tensions in balancing individual rights and public and personal protections in the treatment of acute mental health disorders.