Ethics in community psychiatry

HUMAN RIGHTS OF MENTALLY ILL PATIENTS

Introduction: Mental health is the development of a person's healthy view ofthemselves and the environment in which they live, so that they can achieve thehighest degree of self-fulfillment. Purpose: The purpose of the present work is toinvestigate and highlight the rights of the mentally ill and to promote and promotethe health of these patients. Methodology: The study material consisted of articleson the topic found in Greek and international databases such as: Google Scholar,Mednet, Pubmed, Medline and the Hellenic Academic Libraries Association(HEAL-Link), using keywords: mental illness, patient rights, health professionals. Results: The rights of mental patients and their exercise in a meaningful andeffective manner is a dynamic process that encompasses the corresponding rightsand obligations of mental health professionals. An important legal effort to protectthe rights of the mentally ill is Resolution 46/119 of the United Nations GeneralAssembly on the Protection of Persons with Mental Illness and Improving MentalHealth Care, adopted on 17 December 1991. Conclusions: The exercise of therights of the mentally ill requires their encouragement from mental healthprofessionals, who are essentially obliged to refrain from restrictive practices.

Professional perspectives on service user and carer involvement in mental health care planning: a qualitative study

BACKGROUND

Involving users/carers in mental health care-planning is central to international policy initiatives yet users frequently report feeling excluded from the care planning process. Rigorous explorations of mental health professionals' experiences of care planning are lacking, limiting our understanding of this important translational gap.

OBJECTIVES

To explore professional perceptions of delivering collaborative mental health care-planning and involving service users and carers in their care.

DESIGN

Qualitative interviews and focus groups with data combined and subjected to framework analysis.

SETTING

UK secondary care mental health services.

PARTICIPANTS

51 multi-disciplinary professionals involved in care planning and recruited via study advertisements.

RESULTS

Emergent themes identified care-planning as a meaningful platform for user/carer involvement but revealed philosophical tensions between user involvement and professional accountability. Professionals emphasised their individual, relational skills as a core facilitator of involvement, highlighting some important deficiencies in conventional staff training programmes.

CONCLUSIONS

Although internationally accepted on philosophical grounds, user-involved care-planning is poorly defined and lacks effective implementation support. Its full realisation demands greater recognition of both the historical and contemporary contexts in which statutory mental healthcare occurs.

Consultant psychiatrists' experiences of and attitudes towards shared decision making in antipsychotic prescribing, a qualitative study

BACKGROUND

Shared decision making represents a clinical consultation model where both clinician and service user are conceptualised as experts; information is shared bilaterally and joint treatment decisions are reached. Little previous research has been conducted to assess experience of this model in psychiatric practice. The current project therefore sought to explore the attitudes and experiences of consultant psychiatrists relating to shared decision making in the prescribing of antipsychotic medications.

METHODS

A qualitative research design allowed the experiences and beliefs of participants in relation to shared decision making to be elicited. Purposive sampling was used to recruit participants from a range of clinical backgrounds and with varying length of clinical experience. A semi-structured interview schedule was utilised and was adapted in subsequent interviews to reflect emergent themes.Data analysis was completed in parallel with interviews in order to guide interview topics and to inform recruitment. A directed analysis method was utilised for interview analysis with themes identified being fitted to a framework identified from the research literature as applicable to the practice of shared decision making. Examples of themes contradictory to, or not adequately explained by, the framework were sought.

RESULTS

A total of 26 consultant psychiatrists were interviewed. Participants expressed support for the shared decision making model, but also acknowledged that it was necessary to be flexible as the clinical situation dictated. A number of potential barriers to the process were perceived however: The commonest barrier was the clinician's beliefs regarding the service users' insight into their mental disorder, presented in some cases as an absolute barrier to shared decision making. In addition factors external to the clinician - service user relationship were identified as impacting on the decision making process, including; environmental factors, financial constraints as well as societal perceptions of mental disorder in general and antipsychotic medication in particular.

CONCLUSIONS

This project has allowed identification of potential barriers to shared decision making in psychiatric practice. Further work is necessary to observe the decision making process in clinical practice and also to identify means in which the identified barriers, in particular 'lack of insight', may be more effectively managed.

[New parameters in community treatment practices: the contribution of community and alternative mental health groups in Québec]

This article examines the origin and the context of the implementation project of community treatment according to the perspective of community and alternative mental health groups in Québec. The author presents results of a research on practices of these groups through a specific array that integrates the essential components of the community treatment model. The author examines six parameters characterizing devices, approaches and practices: 1) approach in supportive care and attention; 2) voluntary relation with the organization 3) the place of biomedical treatment; 4) flexibility in length and intensity of treatment; 5) the individual and collective dimension of supportive care; 6) and, participation as an active citizen.

Quasi-experimental comparison of coercive interventions on client outcomes in individuals with severe and persistent mental illness

This study compares outpatient commitment (OPC) and Assertive Community Treatment (ACT) as forms of coercive treatment interventions to evaluate the influence of each individually and in combination on clients' perception of procedural justice and coercion, as well as clinical outcomes that include treatment compliance, quality of life, symptom distress, empowerment, and violence/victimization. Findings support that the perception of procedural justice and coercion are inversely related; persons subject to OPC experience higher levels of perceived coercion, and higher levels of perceived coercion do not influence treatment compliance. ACT alone does not increase the perception of coercion nor is there any interaction effect.

Perceptions of coercion in the community: a qualitative study of patients in a Danish assertive community treatment team

Assertive community treatment (ACT) has been claimed to be paternalistic and coercive, yet little is known about how patients experience the assertive aspects of ACT. To explore views on--and perceptions of--coercion of patients in Danish assertive community teams. In-depth interviews were conducted with six purposefully selected patients and analysed using thematic analysis. Patients reported lack of influence on treatment process and a poor alliance with case-mangers, not being recognised as an autonomous person, and experiences of staff crossing the line and intruding privacy, as most central to perceptions of coercion. A collaborative and mutually trusting relationship, commitment, persistence and availability of staff, and recognition of the need for social support and help with everyday activities, were most important for counteracting such experiences. Perceptions of coercion were not emphasised in patients' account of their engagement with ACT, and generally only related to patients' initial contact with ACT staff. The study suggests that developing mental health practices that enhance the formation of a therapeutic relationship with patients will minimize circumstances that induce perceptions of coercion. ACT, with its engaged and committed staff with sufficient time, focusing on social and practical issues, is successful in facilitating such a contact, as experienced by patients.

Techniques used by assertive community treatment (ACT) teams to encourage adherence: patient and staff perceptions

Assertive community treatment (ACT) has become a cornerstone of care for people with serious mental illnesses. But it has also been suggested that ACT is an inherently coercive approach, with a variety of techniques, including leverage, frequently employed to encourage treatment adherence. Staff and patients of 4 ACT teams participated in focus groups exploring their experiences with and opinions about the use of these techniques in ACT. Little evidence was found of significant use of leverage or perceptions of coercion. Instead both groups reported that supporting patients and building relationships were the preferred mechanisms for promoting treatment goals. This study suggests that ACT need not appear to either staff or patients as an intrinsically coercive model for the delivery of mental health services.

'I'm not an outsider, I'm his mother!' A phenomenological enquiry into carer experiences of exclusion from acute psychiatric settings

Contemporary standards and policies advocate carer involvement in planning, implementing, and evaluating mental health services. Critics have questioned why such standards and policies fail to move from rhetoric to reality, this particularly being applicable to carer involvement within acute psychiatric settings. As there is only limited UK research on this topic, this interpretive phenomenological study was undertaken to explore the perceived level of involvement from the perspective of carers of service users who were admitted to acute inpatient settings within the previous 2 years. Interviews were conducted with four individuals who cared for a loved one with a mental illness. The interview analysis was influenced by Van Manen, whose interpretive approach seeks to generate a deeper understanding of the phenomenon under study. Four main themes emerged: powerlessness, feeling isolated, needing to be recognized and valued, and a desire for partnership. The findings reflect the views expressed by carers in other studies, identifying that while carers seek to work in partnership with health-care professionals, at a clinical level they often feel excluded. The study concludes by discussing ways of improving and promoting carer involvement and advocating a partnership in care approach within acute psychiatry.

The experience of caring for a person with a mental illness: a grounded theory study

A substantive theory that explained the experience of caring for a person with a mental illness was developed using grounded theory methodology. When participants began caring, they were overwhelmed by the role and consumed by what was happening to the ill family member, to themselves, and to their family. This state was conceptualized as a social psychological problem called being consumed. In managing the experience of being consumed, all carers engaged in a social psychological process, call seeking balance. During this process, carers moved to a state where their commitment to the ill family member was more balanced and proportionate to other areas of their lives. The implications of this research include the need for increased collaboration between health professionals, policy makers, and carers along with the recognition that mental illness impacts on the individual, their family, and the community at many levels. The findings also provide health professionals with a valuable insight into caring. The need to decrease the stigma directed towards people with a mental illness is important to facilitate the person's integration into the community and sustain a cohesive level of family life. To support this, the general population requires increased education to be better prepared at a community level to effectively support the ill person and their family.

Sharing decisions in consultations involving anti-psychotic medication: a qualitative study of psychiatrists' experiences

In psychiatry, and in treating people with a diagnosis of schizophrenia in particular, there are obstacles to achieving concordant, shared decision making and in building a co-operative therapeutic alliance where mutual honesty is the norm. Studies of people with a diagnosis of schizophrenia have revealed critical views of medical authority, particularly over the issue of enforced compliance with antipsychotic medication. Psychiatrists are known to place particular value on such medication. This qualitative study reports the views of 21 general adult psychiatrists working in UK about their experiences of consultations involving discussion of antipsychotic medication. Interviewees reported a general commitment to achieving concordant relationships with patients and described a number of strategies they used to promote this. In this respect, their self-perception differs from the picture of authoritarian practice painted by critics of psychiatry, and by some studies reporting patients' views. Interviewees also described obstacles to achieving concordance, including adverse judgements of patients' competence and honesty about their medication use. Explaining the adverse effects of medication was perceived to discourage some patients from accepting this treatment. Moments of strategic dishonesty were reported. Psychiatrists perceived that trust could be damaged by episodes of coercion, or by patients' perception of coercive powers. We conclude that a self-perception of patient-centredness may not preclude psychiatrists from fulfilling a social control function.

Impact of patient confidentiality on carers of people who have a mental disorder

This paper discusses how patient confidentiality issues impact on carers of people with mental disorders. Data obtained from interviews with 27 primary carers were analysed using the grounded theory method. Despite the emphasis that Australian mental health policy documents place on collaboration with carers, the findings of this Western Australian study showed that carers were expected to undertake the caring role with little support, education or understanding. The lack of collaboration with health professionals increased carers' level of distress and left them feeling frustrated and resentful. Carers have identified that patient confidentiality was one reason why health professionals were unwilling to collaborate with them. To ensure carers' continued commitment to caring, negotiation about patient confidentiality issues must occur at the onset of the caregiving process. Carers have the right to certain information in order to maintain their level of well-being and their personal safety. Moreover, in certain circumstances, patient confidentiality may need to be breached if the life of the ill family member or others is in danger. A greater carer involvement in and understanding of the ill family member's illness will facilitate better treatment outcomes in the community for the ill family member.

Making the case for ethics consults in community mental health centers

Practitioners in community mental health center (CMHC) settings face an environment of vast and ever-increasing ethical complexities, in which there are both emergent dilemmas and ongoing ethical tensions created through competing treatment paradigms. CMHCs clients are a highly vulnerable population due to lower socio-economic status, possibly compromised mental functioning, and societal stigmatization. While many healthcare institutions serving vulnerable individuals offer access to clinical ethics consultations, consults are not routinely available at CMHCs. In this article, we explore the need for ethics consults in CMHCs, propose possible benefits and costs of ethics consultations, and offer suggestions for incorporating consults at CMHCs.

Ulysses directives in The Netherlands: opinions of psychiatrists and clients

In this article we present a study on the opinions of Dutch psychiatrists and clients on Ulysses directives. In-depth interviews were conducted with 18 clients and 17 psychiatrists. Most respondents were proponents of Ulysses directives. The most frequently mentioned objective of these directives was to secure timely admission to hospital, although a large minority was mainly interested in giving patients influence on treatment decisions. Psychiatrists differed on how much autonomy they preferred with regard to decisions about the moment of admission and kind of treatment. Clients also differed in this respect. Pressure from others to execute a Ulysses directive, and premature admission to the hospital were mentioned as risks of Ulysses directives. Crisis cards were seen as an alternative by many psychiatrists and some clients. Recommendations are made for a good functioning of Ulysses directives, and the appropriateness of crisis cards as an alternative for a number of patients is discussed.

How mental health clinicians view community treatment orders: a national New Zealand survey

OBJECTIVE

To determine New Zealand mental health clinicians' views about community treatment orders, indications for their use, their benefits, problems and impact on patients and therapeutic relationships.

METHOD

A national survey of New Zealand psychiatrists and a regional survey of non-psychiatric community mental health professionals for comparison.

RESULTS

The great majority of NZ psychiatrists prefer to work with community treatment orders as an option. They consider they are used properly in most cases, can enhance patients' priority for care, provide a structure for treatment, support continuing contact and produce a period of stability for patients during which other therapeutic changes can occur. They consider these orders can harm therapeutic relationships, especially in the short term, but when used appropriately their overall benefits outweigh their coercive impact. The other mental health professionals surveyed have similar views. A minority of clinicians do not support their use.

CONCLUSIONS

The precise impact of community treatment orders on patients' quality of life remains an open question. Until that matter is more clearly resolved, New Zealand law should continue to authorise compulsory outpatient care, provided it is carefully targeted and adequate community services are available.

Coercion in mental healthcare: the principle of least coercive care

Coercive practices are relatively common in mental healthcare, but coercion is ethically problematic because it involves acting against an individual's autonomy. However, coercion is often poorly defined in mental health literature, resulting in problems in considering coercion from an ethical perspective. This paper challenges the traditional paternalistic justification for coercive practices in mental healthcare, and argues that the failure to make a conceptual distinction between what counts as coercive practice and what justifies coercive practice results in instances of unjustified use of coercion. It also results in the failure to recognize other justifications for coercive practice. We propose a broad definition of coercion that recognizes the prevalence of coercion in mental healthcare. In particular, we wish to recognize the potential for persuasion and manipulation of clients' wishes to be coercive. We argue that there should be a prima facie ban on coercion in mental healthcare, and that the use of coercive practices needs to be justified in the specific circumstances of each case. The presupposition that mental illness involves limited autonomy cannot be taken to justify use of coercion. We outline a principle of least coercive intervention that we think has the potential to lessen the prevalence and extent of coercion in mental healthcare.