Coercive Measures In Psychiatry Research Articles

Coercive Measures in Psychiatry Can Hardly Be Justified in Principle Any Longer-Ethico-Legal Requirements Versus Empirical Research Data and Conceptual Issues.

To review the scientific and empirical evidence that is usually accepted for the ethical and legal justification of coercion in psychiatry. Five key criteria are examined as follows: (1) the demonstrable existence of a mental disorder; (2) the effectiveness of psychiatric measures; (3) the use of coercion as last resort and as least possible restriction; (4) the benefit of the person affected by the coercive measure and (5) the restoration of the affected person's autonomy. (1) The existence of a demarcation between a mentally ill and a mentally healthy state cannot be confirmed; (2) Pharmacological and psychotherapeutic interventions in psychiatry are not even moderately effective; (3) Coercive measures are usually not used as last resort and as least restrictive measure; (4) Most people affected by psychiatric coercion do not benefit from the measures; (5) It is at least unclear whether autonomy is affected by a mental illness and whether it can be restored through a coercive psychiatric measure. None of the central ethical and legal criteria for the use of coercion in psychiatry are clearly and unambiguously fulfilled according to current research. Psychiatric coercion can hardly be justified any longer.

Protecting the Autonomy of Patients with Severe Mental Illness Through Psychiatric Advance Directive Peer-Facilitation

Protecting the Autonomy of Patients with Severe Mental Illness Through Psychiatric Advance Directive Peer-Facilitation

Coercive measures in psychiatry – When do they occur and who is at risk?

Coercive measures (CM) in psychiatry adversely affect patients and efforts to minimize CM are steadily increasing. One area that has not been a strong focus of preventative efforts to date is the time of use of CM during hospitalization although previous research indicates that the admission situation and early hospitalization are times of increased risk for CM. This study therefore aims to contribute to the body of research in this field by analyzing in detail the times of use of CM and identifying patient characteristics serving as predictors for CM during early hospitalization. Using a large sample (N = 1556) of all cases admitted in 2019 via the emergency room at the Charité Department of Psychiatry at St. Hedwig Hospital in Berlin, this study supports previous research showing that the risk of CM is highest within the first 24 h h of hospitalization. Of 261 cases who experienced CM, 71.6% (n = 187) experienced a CM within the first 24 h of hospitalization and 54.4% (n = 142) of cases only experienced CM within the first 24 h of hospitalization and did not receive any CM after. Furthermore, this study identified significant predictors for the early use of CM during hospitalization including acute intoxication (p < .01), aggression (p < .01), male gender (p < .001) and limited communication ability (p < .001). The results highlight the importance of directing preventative efforts to minimize the use of CM not only to psychiatric units but also to mental health crisis response and to develop interventions specifically tailored to this time and patient groups at highest risk.

The Attitude of the Public Concerning Coercive Measures in Psychiatric Patients

To examine the attitude of the general public in Basel concerning the use of coercive measures while dealing with psychiatric patients. The common population indirectly governs the use of coercive measures in psychiatry by its stigmatization of people with psychiatric illnesses, and its attitude towards treatment in psychiatry and by local opinion leaders and reactions of social networks. The answers of 1,112 persons from a representative population survey were evaluated. Participants were mailed case vignettes and questionnaires, and asked if they considered involuntary admission, coercive medication, and/or seclusion as acceptable measures in dealing with psychiatric patients. When symptoms of a psychotic disorder were present, 31.5% approved of at least one coercive measure, with 22% approval in the case of a borderline personality disorder, and 20.7% in the case of alcohol dependency. However, the overall rejection of coercive measures by the general public in Basel was high. The differential approval of the examined coercive measures depending on psychiatric symptoms was in line with professional medical and ethical guidelines. Public attitudes have an indirect influence on the local use of coercive measures and should be included in the specialist psychiatric discourse.

General and Case-Specific Approval of Coercion in Psychiatry in the Public Opinion.

Psychiatric patients are subjected to considerable stigmatization, in particular, because they are considered aggressive, uncontrollable, and dangerous. This stigmatization might influence the approval of coercive measures in psychiatry by the public and healthcare professionals and might have an influence on the clinical practice of coercive measures. We examined whether the general approval of coercive measures for psychiatric patients with dangerous behaviors differs from case-specific approval. We conducted a representative survey of the general population (n = 2207) in the canton of Basel-Stadt, Switzerland. In total, 1107 participants assessed a case vignette depicting a fictitious character with a mental illness and indicated whether they would accept coercive measures (involuntary hospitalization, involuntary medication, and seclusion) for the person in the vignette. It was explicitly stated that within the last month, the fictitious character displayed no dangerous behavior (Vignette ND) or dangerous behavior (Vignette D). Another 1100 participants were asked whether they would approve coercive measures (involuntary hospitalization, involuntary medication, and seclusion) for psychiatric patients with dangerous behavior in general (General D), i.e., without having received or referring to a specific case vignette. The logistic regression model containing all variables explained 45% of the variance in approval of any type of coercive measures. Assessment of case vignettes without dangerous behavior (Vignette ND) was associated with significantly reduced approval of coercive measures compared to assessment of a case vignette with dangerousness (Vignette D), while approval for coercive measures in a person with mental health disorder with dangerous behavior in general (General D) was significantly higher than for the case vignette with dangerousness. The general approval of coercive measures for people with mental disorders seems to differ depending on if the respondents are asked to give a general assessment or to examine a specific and detailed clinical case vignette, indicating an increased role of stigmatization when asking about generalized assessments. This may contribute to diverging findings on the acceptance of coercive measures in the literature and should be considered when designing future studies.

National Strategies to Reduce the Use of Coercive Measures in Psychiatry in Denmark – A Review of Two Decades of Initiatives

Coercive measures are a major infringement of the autonomy of psychiatric patients and no medical justification exists for applying mechanical restraint (MR) to these patients currently. Knowledge regarding how preventive strategies affect the use of MR is limited. This paper aimed to understand the link between the initiatives taken by national authorities and the practical implications to MR reduction. Policy texts and the number of coercive measures used in two decades were reviewed. Trends were discussed with five experts with real-life experience and suggestions were obtained regarding how to end the use of mechanical restraint in mental health care settings.

A two-center pilot study on the effects of clinical ethics support on coercive measures in psychiatry

BackgroundThe use of formal coercion such as seclusion, mechanical restraint, and forced medication is one of the most challenging and complex issues in mental health care, on the clinical, the legal, and the ethical level. Clinical ethics support aims at assisting healthcare practitioners in determining the morally most justifiable course of action in these situations. However, the effectiveness of clinical ethics support has hardly been studied so far.MethodsMonthly moral case deliberation (MCD) was implemented in two acute wards of two different psychiatric hospitals in Switzerland. Frequency and intensity of coercion was measured on ward level (npatients = 405), and the Moral Attentiveness Scale, Knowledge on Coercion Scale, and Staff Attitudes towards Coercion Scale were applied on healthcare practitioner level (nHP = 46). Pre-post-comparisons were conducted using multi-level modeling where appropriate.ResultsAfter implementation of MCD, formal coercion was less frequent (particularly seclusion, small effect size; 9.6 vs. 16.7%, p = .034, Cramér’s V = .105) and less intense (particularly mechanical restraint, large effect size; 86.8 ± 45.3 vs. 14.5 ± 12.1 h, exact p = .019, r = -.74), and approval for coercive measures among healthcare practitioners was lower when controlling for the number of MCD sessions attended.ConclusionsClinical ethics support such as MCD may be a hitherto underutilized service for the reduction of coercion, complementing existing strategies and programs. Implementing clinical ethics support may help improve quality of care for persons suffering from severe mental illness.

Approval of Coercion in Psychiatry in Public Perception and the Role of Stigmatization.

Background: Coercion is routinely used in psychiatry. Its benefits and drawbacks are controversially debated. In addition, the majority of persons with mental health problems are exposed to stigmatization and are assumed to be dangerous. Stigmatization is associated with negative consequences for individuals with mental illness such as disapproval, social rejection, exclusion, and discrimination. Being subjected to coercive measures can increase the stigmatization of the affected persons, and stigmatization might lead to higher approval for coercion.Aims of the Study: This study aims to examine the approval for coercive measures in psychiatry by the general public, and to explore its relation with person- and situation-specific factors as well as with stigmatization.Method: We conducted a representative survey of the general population (N = 2,207) in the canton of Basel-Stadt, Switzerland. Participants were asked to read a vignette depicting psychopathological symptoms of a fictitious character and indicate whether they would accept coercive measures for the person in the vignette. Desire for social distance and perceived dangerousness were assessed as measures of stigmatization.Findings: The person in the case vignette exhibiting dangerous behavior, showing symptoms of a psychotic disorder, being perceived as dangerous, and treatment being understood as helpful increased approval of coercion in general, while familiarity of the respondents with mental illness decreased approval.Conclusions: The public attitude regarding the approval of coercion in psychiatry is highly differentiated and largely follows the current legal framework and medical treatment guidelines. Higher approval occurred in situations of self-harm or harm to others and when coercive measures were thought to have a beneficial effect for the affected persons. A considerable part of the approval for coercion is predicted by stigmatization. With the increasing severity of coercive measures, the influence of person- and situation-specific factors and of familiarity with mental illness decreased and generalizing and stigmatizing attitudes became stronger predictors for the approval of more severe measures.

Coercive Measures in Psychiatry: A Review of Ethical Arguments.

Introduction: Coercion is frequent in clinical practice, particularly in psychiatry. Since it overrides some fundamental rights of patients (notably their liberty of movement and decision-making), adequate use of coercion requires legal and ethical justifications. In this article, we map out the ethical elements used in the literature to justify or reject the use of coercive measures limiting freedom of movement (seclusion, restraint, involuntary hospitalization) and highlight some important issues.Methods: We conducted a narrative review of the literature by searching the PubMed, Embase, PsycINFO, Google Scholar and Cairn.info databases with the keywords “coercive/compulsory measures/care/treatment, coercion, seclusion, restraint, mental health, psychiatry, involuntary/compulsory hospitalization/admission, ethics, legitimacy.” We collected all ethically relevant elements used in the author's justifications for or against coercive measures limiting freedom of movement (e.g., values, rights, practical considerations, relevant feelings, expected attitudes, risks of side effects), and coded, and ordered them into categories.Results: Some reasons provided in the literature are presented as justifying an absolute prohibition on coercion; they rely on the view that some fundamental rights, such as autonomy, are non-negotiable. Most ethically relevant elements, however, can be used in a balanced weighting of reasons to favor or reject coercive measures in certain circumstances. Professionals mostly agree that coercion is only legitimate in exceptional circumstances, when the infringement of some values (e.g., freedom of movement, short-term autonomy) is the only means to fulfill other, more important values and goals (e.g., patient's safety, the long-term rebuilding of patient's identity and autonomy). The results of evaluations vary according to which moral elements are prioritized over others. Moreover, we found numerous considerations (e.g., conditions, procedural values) for how to ensure that clinicians apply fair decision-making procedures related to coercion. Based on this analysis, we highlight vital topics that need further development.Conclusion: Before using coercive measures limiting freedom of movement, clinicians should consider and weigh all ethically pertinent elements in the situation and actively search for alternatives that are more respectful of patient's well-being and rights. Coercive measures decided upon after a transparent, carefully balanced evaluation process are more likely to be adequate, understood, and accepted by patients and caregivers.

The Role of Implicit and Explicit Staff Attitudes in the Use of Coercive Measures in Psychiatry.

Many determinants leading to the use of different coercive measures in psychiatry have been widely studied and it seems that staff attitudes play a crucial role when it comes to the decision-making process about using coercion. However, research results about staff attitudes and their role in the use of coercive measures are inconsistent. This might be due to a focus on self-report studies asking for explicit answers, which involves the risk of bias. This study aimed to expand research on this topic by examining the impact of explicit and implicit staff attitudes on the use of coercive measures in clinical practice. In addition, the influence of gender, profession (nurses, psychiatrists), and years of professional experience as well as their influence on staff attitudes were examined. An adaption of the implicit association measure, the Go/No-Go Association Task (GNAT), with the target category coercion and distracter stimuli describing work load, as well as the explicit questionnaire Staff Attitudes to Coercion Scale (SACS) was completed by staff (N = 149) on 13 acute psychiatric units in 6 hospitals. Data on coercive measures as well as the total number of treated cases for each unit was collected. Results showed that there was no association between staff's implicit and explicit attitudes toward coercion, and neither measure was correlated with the local frequency of coercive measures. ANOVAs showed a significant difference of the GNAT result for the factor gender (F = 9.32, p = 0.003), demonstrating a higher tendency to justify coercion among female staff members (M = −0.23, SD = ±0.35) compared to their male colleagues (M = −0.41, SD = ±0.31). For the SACS, a significant difference was found for the factor profession (F = 7.58, p = 0.007), with nurses (M = 2.79, SD = ±1.40) showing a more positive attitude to the use of coercion than psychiatrists (M = 2.15, SD = ±1.11). No significant associations were found regarding the extent of professional experience. Results indicate a complex interaction between implicit and explicit decision-making processes dependent on specific contexts. We propose future research to include primers for more context-related outcomes. Furthermore, differences in gender suggest a need to direct attention toward occupational safety and possible feelings of anxiety in the workplace, especially for female staff members.

Correlates of seclusion and restraint of patients admitted to psychiatric inpatient treatment via a German emergency room

Coercive measures in psychiatry are associated with negative consequences for both patients and staff. When it comes to preventing coercive measures, innovative models of care like the Weddinger Modell focusing on recovery, participation and supported decision-making have proven successful. However, observations from clinical practice show that emergency admissions to psychiatric facilities pose a great challenge in this regard and that most coercive measures take place during or shortly after emergency admission. This study retrospectively examined all cases (N = 1477) admitted to inpatient treatment at the Department of Psychiatry of the Charité at St. Hedwig Hospital in Berlin via the emergency room in 2018 aiming to identify patient characteristics that serve as predictors for coercive measures. Physical aggression, involuntary admission, police referral and younger age were found to be significant predictors (p < .001). Of 218 cases who experienced coercive measures, 81.2% (n = 177) were subjected to seclusion or restraint within the first 24 h of their hospital stay and 56.9% (n = 124) of cases only experienced coercive measures within these first 24 h and were not subjected to any coercive measures after. These results show that certain patient characteristics put individuals at higher risk of being secluded or restrained and that the risk of experiencing coercive measures is highest at the time during and shortly after emergency admission. To prevent coercive measures, it is crucial to target more resources and put in place measures specifically tailored to these emergency situations and the most vulnerable patient groups.

Six years of open-door policy at the University Psychiatric Hospital Basel

Coercive measures in psychiatry have well-known negative consequences for the patients and their treatment. They are considered ethically problematic and must only be used as a last resort. Locked wards may promote athreatening atmosphere leading to more aggression and a subsequent higher use of coercive measures. The aim of this was to investigate the frequency of seclusion and forced medication during clinic-wide implementation of an open-door policy. In this 6‑year longitudinal observational study (2010-2015) the frequencies of seclusion and forced medication were investigated on the basis of 17,359 cases treated in the University Psychiatric Hospital Basel. During the observational period, six formerly permanently locked wards were opened. The examined data showed aclinically relevant decrease in the frequency of seclusion (from 8.2% to 3.5%) and forced medication (from 2.4% to 1.2%) during the observational period. These results underline the potential of aless restrictive policy in psychiatry to reduce the frequency of coercive measures.

A Communication Model of Instrumental Power in Jeopardizing Situations in Psychiatry - Part V: "Simulation and Reduction of Coercive Measures in Psychiatry"

Results of PART II to IV are analyzed under the perspective of power theory of the German sociologist Heinrich Popitz. A communication process model - based on enforcement, instrumental and action power - is derived, which could empirically be revised, enhanced and criticized by means of the introduced speech act methods (PART I). From the theoretical point of view all basic features (from PART II to V) structuring communication in jeopardizing situations using alert systems are listed in a schedule.

Mixed-Methods Design for Analyzing Jeopardizing Situations by Means of Communication Profiles - Part I: "Simulation and Reduction of Coercive Measures in Psychiatry"

Psychiatric research needs more information about what happens in times using coercive measures. In their structure jeopardizing situations are fundamental different from allday-life situations (e. g. school lesson) or even other environmental crisis situations (e. g. airplane cockpit). Results of communication analysis of jeopardizing situations in psychiatry ward within mixed-methods design are presented for the first time. Data basis comprises videos of psychodramatical rearranged standard conflict situations. By means of deductive identification (N = 2338) of observed utterances and followed by statistical evaluation, quantitative and qualitative procedures are able to distinguish different scenes (in school education vs. psychiatry) and actor communication patterns (therapists vs. inpatients). Using declaratives (determining, regulating) and commissives (promising, threatening) the actor communication profiles are totally different. The methods enrich the psychiatric process- and conflict research. More results are given in SRZP-PART II to PART VI.

Semiotics and Social Psychiatry: Cooperation, Benefit, Outlook - PART VI: "Simulation and Reduction of Coercive Measures in Psychiatry"

Giving appointments to semiotics and social psychiatry the framework of semiotics is characterized with regard to fields of application in social psychiatry. From that point an interdisciplinary cooperation could be achieved with benefit for both sides. By means of the theory of semiosis (sign process) it could be shown, in which way the communicative meaning of all speech acts (illocutionary forces) could be formally represented. Against this background the SRZP-research concepts of structure (PART II), dynamics (PART III) and modelling (PART V) of jeopardizing situations could be unfolded retrospectively.

Machine Learning: An Approach in Identifying Risk Factors for Coercion Compared to Binary Logistic Regression.

Introduction: Although knowledge about negative effects of coercive measures in psychiatry exists, its prevalence is still high in clinical routine. This study aimed at define risk factors and test machine learning algorithms for their accuracy in the prediction of the risk to being subjected to coercive measures.Methods: In a sample of involuntarily hospitalized patients (n = 393) at the University Hospital of Psychiatry Zurich, we analyzed risk factors for the experience of coercion (n = 170 patients) using chi-square tests and Mann Whitney U tests. We trained machine learning algorithms [logistic regression, Supported Vector Machine (SVM), and decision trees] with these risk factors and tested obtained models for their accuracy via five-fold cross validation. To verify the results we compared them to binary logistic regression.Results: In a model with 8 risk-factors which were available at admission, the SVM algorithm identified 102 out of 170 patients, which had experienced coercion and 174 out of 223 patients without coercion (69% accuracy with 60% sensitivity and 78% specificity, AUC 0.74). In a model with 18 risk-factors, available after discharge, the logistic regression algorithm identified 121 out of 170 with and 176 out of 223 without coercion (75% accuracy, 71% sensitivity, and 79% specificity, AUC 0.82).Discussion: Incorporating both clinical and demographic variables can help to estimate the risk of experiencing coercion for psychiatric patients. This study could show that trained machine learning algorithms are comparable to binary logistic regression and can reach a good or even excellent area under the curve (AUC) in the prediction of the outcome coercion/no coercion when cross validation is used. Due to the better generalizability machine learning is a promising approach for further studies, especially when more variables are analyzed. More detailed knowledge about individual risk factors may help to prevent the occurrence of situations involving coercion.

Cross-sectional study on nurses\u2019 attitudes regarding coercive measures: the importance of socio-demographic characteristics, job satisfaction, and strategies for coping with stress

BackgroundCoercive measures are containment methods used in psychiatry to curb patients’ disruptive and aggressive behaviours towards themselves, others or objects. The prevalence of the practice of coercive measures in psychiatry is directly related to the attitudes of the staff. When discussing these attitudes, nurses are often particularly singled out. The purpose of the study is to research the impact of individual factors on nurses’ attitudes in the decision-making process for the use of coercive measures.MethodsA cross-sectional study among all psychiatric nursing staff in Slovenia (n = 367, 79%) was conducted over the years 2013/2014. Standardized questionnaires were used, including a survey of nurses’ attitudes to the use of seclusion, the Job Descriptive Index, and the Folkman-Lazarus test.ResultsNurses’ attitudes towards special coercive measures are predominantly negative ( overline{x} = 11.312, SD = 2.641). The factors that explain a positive attitude are as follows: female gender (β = − 0.236, p < 0.001), fewer years of service (β = − 0.149, p = 0.023), emotion-focused strategies of coping with stress (β = 0.139, p = 0.020), and less-threatening patient behaviour (β = 0.157, p = 0.012).ConclusionsThe effects of some known factors did not prove important in the model. Newly recognized factors are “less-threatening patient behaviour” and “emotion-focused strategies of coping with stress”. Therefore, attitudes towards special coercive measures in psychiatry must be regarded as contextualized, interactive, and multidimensional phenomena that cannot be explained merely through a defined set of factors.

Am I My Brother\u2019s Keeper? Moral Dimensions of Informal Caregiving in a Neoliberal Society

Within the current Dutch policy context the role of informal care is revalued. Formal care activities are reduced and family and friends are expected to fill this gap. Yet, there is little research on the moral ambivalences that informal care for loved ones who have severe and ongoing mental health problems entails, especially against the backdrop of neoliberal policies. Giving priority to one’s own life project or caring for a loved one with severe problems is not reconciled easily. Using a case study we illustrate the moral ambivalences that persons may experience when they try to shape their involvement and commitment when a relative is in need. The case comes from a research project which explores whether it is possible to reduce coercive measures in psychiatry by organizing a Family Group Conference. The purpose of the article is to explore what theoretical concepts such as ‘communities of fate’, ‘communities of choice’ and ‘personal communities’ add in understanding how persons shape their involvement and commitment when a family member experiences recurrent psychiatric crises.

Bitte macht (irgend)was! Eine bundesweite Online-Befragung Psychiatrieerfahrener zum Einsatz milderer Maßnahmen zur Vermeidung von Zwangsmaßnahmen

Aim In recent years the legal basis in Germany for the use of coercive measures in psychiatry has changed. Now, coercive measures are permitted only as last resort after milder measures failed. However, there is no regulation of the type or amount of milder measures. In this study, we investigated which and how many milder measures were experienced by service users before coercion was used and which measures they value as potentially helpful to avoid it. Methods A sample of 83 service users was recruited. In an online survey the experience with 21 milder measures and their evaluation as helpful were assessed by self-report. Results On average, participants reported 5.4 experienced milder measures. The most frequent reason provided for why measures failed were structural factors, followed by staff behavior, and reasons caused by the participants themselves. The only milder measure rated by less than 50 % as potentially helpful in avoiding coercive measures was being persuaded to take medication.Conclusion Although many milder measures are perceived as potentially helpful, only few seem to be made use of in routine clinical practice. In order to prevent coercion staff members should apply a wider range of milder measures.

Where there's a Will, there's a Way? A nationwide Online-Survey of Psychiatrists about the Use of Alternatives to Coercive Measures

A series of legal regulations on the use of coercive measures in psychiatry initiated a vivid medico-ethical debate during the last year. The changed legal bases now require the use of alternatives before applying coercion as a "last resort". In this study we investigated whether and which alternatives are applied by psychiatrists in order to prevent coercive measures in general psychiatric hospitals and which factors are associated with their application. A sample of 343 psychiatrists was recruited by contacting psychiatric hospitals throughout Germany. In an online-survey attitudes to coercive measures and the use of alternatives to coercion were assessed by self-report. Before initiating their most recent coercive measures almost half (46%) of the participants employed only 2 or less alternatives. Patient related, individual and structural factors were reported as reasons for the failure of such measures. The use of alternatives was associated with a more positive assessment of their effectiveness as well as a more negative attitude towards coercive measures. Alternative measures are applied by many psychiatrists, but are not standard practice. Thus, there is a considerable room for improved practice.