Prevention of involuntary admission through Family Group Conferencing: a qualitative case study in community mental health nursing

The Experiences of Patients Enrolled in Community Mental Health Centers Regarding the Illness Process: A Phenomenological Study

AIMS

The aim of this study is to explore in-depth the experiences of patients enrolled in Community Mental Health Centers regarding the illness process.

DESIGN

This study employed interpretative phenomenological analysis (IPA), one of the phenomenological design approaches within qualitative research methods.

METHODS

The study was conducted between 24 May 2023 and 23 December 2023, at two different Community Mental Health Centers located in the eastern and western regions of Turkey. Maximum variation sampling was employed in the selection of the sample, which consisted of 12 patients registered at the Community Mental Health Centers. Data were collected using a semi-structured interview form. The interviews were conducted face-to-face and audio-recorded. Content analysis was performed using the MAXQDA 2022 software package. The study was written following the COREQ checklist.

FINDINGS

Based on the expressions of the patients, themes, subthemes and codes were identified. Accordingly, three themes were determined: 'emotions felt after diagnosis', 'changes in life with the illness process' and 'coping methods with the process'.

CONCLUSION

This study highlights that patients from diverse geographical backgrounds, served by Community Mental Health Centers, share similar cultural and emotional experiences during their illness. These findings underscore the need for tailored interventions that address universal challenges faced by patients across different regions.

CLINICAL EVIDENCE

This research emphasises the necessity of comprehensive efforts to improve societal understanding, support mechanisms and employment prospects for individuals dealing with mental health issues in Community Mental Health Centers.

Reconsidering the ethics of compulsive treatment in light of clinical psychiatry: A selective review of literature

The ethics of compulsive treatment (CT) is a medical, social and legal discussion that reemerged after the ratification by 181 countries of the 2007 United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD). The optional protocol of the UN-CRPD was ratified by 86 countries aiming to promote, protect and ensure the full and equal enjoyment of all human rights. It also determined the need to review mental health laws as under this light treatment of persons with disabilities, particularly those with mental disorders, cannot accept the use of CT. This selective review of literature aims to clarify inputs from clinical psychiatry adding evidence to the multi-disciplinary discussion. It provides contradictory evidence on how patients experience CT and its impact on their mental health and treatment programs, also which are main reasons for the use of CT and what efforts in psychiatry have been made to reduce, replace and refine it.

Reconsidering the ethics of compulsive treatment under the light of clinical psychiatry

The ethics of compulsive treatment (CT) is a medical, social and legal discussion that reemerged after the ratification by 181 countries of the 2007 United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD). The optional protocol of the UN-CRPD was ratified by 86 countries aiming to promote, protect and ensure the full and equal enjoyment of all human rights. It also determined the need to review mental health laws as under this light treatment of persons with disabilities, particularly those with mental disorders, cannot accept the use of CT. This selective review of literature aims to clarify inputs from clinical psychiatry adding evidence to the multi-disciplinary discussion. It focuses on how patients experience CT and its impact on their mental health and treatment programs, the reasons for the use of CT versus voluntary treatment and what efforts have been made to reduce, replace and refine the presence of CT in psychiatry.

Reconsidering the ethics of compulsive treatment in light of clinical psychiatry: A selective review of literature

The ethics of compulsive treatment (CT) is a medical, social and legal discussion that reemerged after the ratification by 181 countries of the 2007 United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD). The optional protocol of the UN-CRPD was ratified by 86 countries aiming to promote, protect and ensure the full and equal enjoyment of all human rights. It also determined the need to review mental health laws as under this light treatment of persons with disabilities, particularly those with mental disorders, cannot accept the use of CT. This selective review of literature aims to clarify inputs from clinical psychiatry adding evidence to the multi-disciplinary discussion. It provides contradictory evidence on how patients experience CT and its impact on their mental health and treatment programs, also which are main reasons for the use of CT and what efforts in psychiatry have been made to reduce, replace and refine it.

Experiences of involuntary psychiatric admission decision-making: a systematic review and meta-synthesis of the perspectives of service users, informal carers, and professionals

BACKGROUND

In involuntary psychiatric admission, used globally, professionals or caretakers decide upon hospitalization regardless of what the person with psychosocial disabilities decides. This raises clinical, ethical, legal, and human rights concerns, and it goes against Convention on the Rights of Persons with Disabilities (CRPD). CRPD mandates that member states respect the autonomy of people with disabilities. Through Article 12, it recognizes full enjoyment of legal capacity for persons with disabilities. Implementation of Article 12 is challenging in every country, and exploring all the stakeholders' experiences at admission decision-making will help us to understand the challenges that the current psychiatry system poses for service users to exercise their autonomy and identify the areas where service users need support to have their rights, will, and preferences respected.

AIM

To describe the experiences of service users, informal carers, and professionals in involuntary psychiatric admission decision-making and throughout the subsequent involuntary admission. We explored the support that the service users need to have their rights, will, and preferences respected.

METHOD

A search of twelve databases in medicine, sociology, and law in Danish, English, Japanese, Norwegian, Portuguese, Spanish, and Swedish was conducted in 2017 and 2018, limited to the past 10 years, using terms such as "involuntary," "admission," "mental illness," and "experience". The search identified 682 articles. Four researchers independently reviewed the articles to find those that completed original qualitative or mixed method studies exploring experiences of involuntary psychiatric admission among adults. We added seven publications from the articles' references, contacted experts in the field (no publications were added), and excluded two articles that were in German. Three researchers analyzed the articles' results using Thematic Analysis (PROSPERO registration number CRD42019072874).

RESULTS

Overall, 37 articles were included from 11 countries; they involved 731 service users, 100 informal carers, and 291 mental health professionals. We identified a lack of communication and a power imbalance among the stakeholders, which was exacerbated by the professionals' attitudes. At admission decision-making, the service users wanted to be heard and wanted to understand the situation. The families felt responsibility for the service users, they were careful not to ruin relationships, and they struggled to obtain support from the mental health system. Professionals believed that threats or harming others should lead to admission regardless of what the service users or their families felt. Professionals sometimes felt that it was not necessary to explain the information to the service users because they would not understand. Professionals were concerned and frustrated with difficulties in coordinating among themselves. During admission, service users struggled with the ward environment and relationship with staff; they most objected to coercion, such as forced medication. Families were frustrated that they were not involved in the treatment planning, especially as the service users moved toward discharge. The professionals often rationalized that coercion was necessary, and they believed that they knew what was best for the service users.

CONCLUSIONS

A lack of communication and a power imbalance among the stakeholders hindered respect for the service users' rights, will, and preferences. This was exacerbated by professionals rationalizing coercion and assuming that service users were incapable of understanding information. Services that encourage communication and overcome power imbalances (e.g. Crisis Plans, Family Group Conferencing) combined with stronger community mental health support will respect service users' rights, will, and preferences and avoid substituted decision-making on issues such as involuntary admission and forced medication.

Identification of risk factors for involuntary psychiatric hospitalization: using environmental socioeconomic data and methods of machine learning to improve prediction

BACKGROUND

The purpose of this study was to identify factors associated with a high risk of involuntary psychiatric in-patient hospitalization both on the individual level and on the level of mental health services and the socioeconomic environment that patients live in.

METHODS

The present study expands on a previous analysis of the health records of 5764 cases admitted as in-patients in the four psychiatric hospitals of the Metropolitan City of Cologne, Germany, in the year 2011 (1773 cases treated under the Mental Health Act and 3991 cases treated voluntarily). Our previous analysis had included medical, sociodemographic and socioeconomic data of every case and used a machine learning-based prediction model employing chi-squared automatic interaction detection (CHAID). Our current analysis attempts to improve the previous one through (1) optimizing the machine learning procedures (use of a different type of decision-tree prediction model (Classification and Regression Trees (CART) and application of hyperparameter tuning (HT)), and (2) the addition of patients' environmental socioeconomic data (ESED) to the data set.

RESULTS

Compared to our previous analysis, model fit was improved. Main diagnoses of an organic mental or a psychotic disorder (ICD-10 groups F0 and F2), suicidal behavior upon admission, admission outside of regular service hours and absence of outpatient treatment prior to admission were confirmed as powerful predictors of detention. Particularly high risks were shown for (1) patients with an organic mental disorder, specifically if they were retired, admitted outside of regular service hours and lived in assisted housing, (2) patients with suicidal tendencies upon admission who did not suffer from an affective disorder, specifically if it was unclear whether there had been previous suicide attempts, or if the affected person lived in areas with high unemployment rates, and (3) patients with psychosis, specifically those who lived in densely built areas with a large proportion of small or one-person households.

CONCLUSIONS

Certain psychiatric diagnoses and suicidal tendencies are major risk factors for involuntary psychiatric hospitalization. In addition, service-related and environmental socioeconomic factors contribute to the risk for detention. Identifying modifiable risk factors and particularly vulnerable risk groups should help to develop suitable preventive measures.

Invisible population: Understanding recruitment barriers of a nurse-led support programme for families with caregiving children in Austria

Aims

To evaluate why no families could be recruited for a nurse-led and family-centred support programme in Austria which aimed to prevent an age-inappropriate caring role for young carers.

Design

A qualitative study incorporating qualitative e-interviews and telephone interviews.

Method

Twenty-one interviews were conducted with statistically significant project stakeholders (N = 17) and with adult family members of children with caring responsibilities (N = 4). Data collection and analysis were guided by the "Social Marketing Framework." Relevant statements were assigned to the main categories: product; price; promotion; place; and working with partners.

Results

The lack of awareness towards young carers, the unfamiliar, open outcome approach of the intervention, the inappropriate language used in promotional materials and the families' fear of stigma while seeking support were identified as central obstacles for successful recruitment of families and implementation of the support programme.

Interventions delivered by nurses in adult outpatient psychiatric care: An integrative review

WHAT IS KNOWN ON THE SUBJECT?: In many countries, the majority of psychiatric care is being delivered in an outpatient setting and the proportion of outpatients is increasing on a global level. Nurses are the largest workforce in psychiatric care, but their role has been said to be difficult to define. According to our knowledge, there are no previous reviews focusing on nurse-delivered interventions in the adult psychiatric outpatient setting. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This review summarizes nurse-delivered interventions identified in the research literature and describes these systematically. Analysing all the identified interventions using the Nursing Interventions Classification, we conclude that the emphasis of nurse-delivered interventions in psychiatric outpatient care is on interventions aiming at improving the functioning of both patients and their family members by building on their own strengths. These findings differ from those presented in a review on inpatient psychiatric nursing. There are several clinical trials describing nurse-delivered evidence-based treatments, such as psychoeducation for patients and their family members in the case of patients diagnosed with schizophrenia and bipolar disorder. The quality of randomized controlled trials was higher than in earlier reviews describing psychiatric nursing interventions in general or in connection with a specific patient group. Further clinical trials are needed to describe the role of nurses in the care of patients diagnosed with depression and in the use of web-based interventions. Additionally, it would be important to study what supports, and on the other hand hinders, the role of nurses in delivering evidence-based treatments at the clinical level. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses can play a central role in responding to the growing demand for evidence-based practices in adult outpatient psychiatry, by delivering treatments for patients and family members. It is important that both nursing education and clinical practices recognize and support this role. Abstract Introduction According to our knowledge, there are no previous reviews on nurse-delivered interventions in the adult psychiatric outpatient setting. Aim To identify and systematically describe and analyse nurse-delivered interventions based on research literature. Method An integrative review. Results This review included 60 studies, of which 46 were intervention studies, including 40 clinical trials. The most common patient groups were patients diagnosed with schizophrenia and bipolar disorder. The nursing interventions described in the studies resembled a total of 68 interventions from the Nursing Interventions Classification. The treatment delivery methods varied and treatments often lacked a clear theoretical background. Implications for practice The core of nurse-delivered interventions identified in research literature in psychiatric outpatient care is on interventions aiming at improving the functioning of both patients and their family members by building on their own strengths. These findings differ from the interventions identified in a review describing nursing in the inpatient setting. There are high-quality clinical trials describing nurse-delivered treatments for patients diagnosed with schizophrenia and bipolar disorder. These include evidence-based treatments such as psychoeducation. Understanding of how these treatments are transferred in clinical practice is missing. Clinical trials describing nurse-delivered web-based interventions and interventions for patients diagnosed with depression are needed.

A Matter of Trust and Distrust: A Qualitative Investigation of Parents' Perceptions About the Use of Mechanical Restraint on Their Adult Children in a Forensic Psychiatric Setting

INTRODUCTION

Increased knowledge about forensic psychiatric patients' relatives' perceptions in regard to the use of mechanical restraint (MR) is necessary, if clinical practice is to be improved and to achieve a reduction in the use and frequency of MR. However, a specific knowledge deficit about relatives' perspectives on the use of MR limits the evidence base considerably.

AIM

The aim of this study was to investigate the perceptions of MR held by relatives of forensic psychiatric patients' including factors impacting its use and duration.

METHOD

Qualitative interviews were conducted with 15 parents of patients within a forensic psychiatry setting and thematically analyzed.

FINDINGS

Two main themes were identified, namely, "care and protection" and "inclusion and involvement," and one subtheme, "information." These themes revealed the framework used by parents to construct a sense of "trust or distrust" about the ability of staff to provide adequate and safe care for their adult children in the forensic psychiatric setting.

CONCLUSION

Some parents in this study considered that forensic psychiatric staff used MR as a necessary protection. However, most parents held strong negative perceptions regarding the use of MR and the quality and safety of care provision. It is apparent that parents in this study believed they should be included and involved in the care in situations associated with the use of MR, because they considered that this could reduce its use. Further research is required to target interventions to reduce the use and duration of MR episodes and to improve clinical practice in forensic psychiatry.

A retrospective analysis of determinants of involuntary psychiatric in-patient treatment

BACKGROUND

The purpose of our study was to identify predictors of a high risk of involuntary psychiatric in-patient treatment.

METHODS

We carried out a detailed analysis of the 1773 mental health records of all the persons treated as in-patients under the PsychKG NRW (Mental Health Act for the state of North Rhine-Westphalia, Germany) in a metropolitan region of Germany (the City of Cologne) in 2011. 3991 mental health records of voluntary in-patients from the same hospitals served as a control group. We extracted medical, sociodemographic and socioeconomic data from these records. Apart from descriptive statistics, we used a prediction model employing chi-squared automatic interaction detection (CHAID).

RESULTS

Among involuntary patients, organic mental disorders (ICD10: F0) and schizophrenia and other psychotic disorders (ICD10: F2) were overrepresented. Patients treated as in-patients against their will were on average older, they were more often retired and had a migratory background. The Exhaustive CHAID analysis confirmed the main diagnosis to be the strongest predictor of involuntary in-patient psychiatric treatment. Other predictors were the absence of outpatient treatment prior to admission, admission outside of regular service hours and migratory background. The highest risk of involuntary treatment was associated with patients with organic mental disorders (ICD 10: F0) who were married or widowed and patients with non-organic psychotic disorders (ICD10: F2) or mental retardation (ICD10: F7) in combination with a migratory background. Also, referrals from general hospitals were frequently encountered.

CONCLUSIONS

We identified modifiable risk factors for involuntary psychiatric in-patient treatment. This implies that preventive measures may be feasible and should be implemented to reduce the rate of involuntary psychiatric in-patient treatment. This may include efforts to establish crisis resolution teams to improve out-patient treatment, train general hospital staff in deescalation techniques, and develop special programs for patients with a migratory background.

Am I My Brother's 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.

Family group conferencing in dementia care: an exploration of opportunities and challenges

BACKGROUND

The Family Group Conference (FGC) is an approach to partnership working which brings together service users, their support network and care professionals in a family-led decision making forum. Evidence, though limited, indicates that that FGC can enhance outcomes for service providers and their users. This study aimed to evaluate the impact of the pilot FGC service, delivered to people with dementia and their families, in terms of the experience of care provision by families and care professionals involved in the project.

METHODS

Focus group interviews were conducted with families and professionals participating in the pilot intervention.

RESULTS

FGC was perceived as having the potential to positively impact service users, their families, service providers and the wider culture of care. However, despite an overall positive evaluation the participants identified a number of challenges related to service implementation. Both the opportunities and challenges identified in this study are discussed in the context of the existing international evidence base.

CONCLUSIONS

This study contributes to a better understanding of the applicability of FGC as a strategy to support people with dementia and their families. Although promising in terms of potential outcomes for service users and providers, FGC presents challenges which need to be carefully managed in order to secure maximum benefit to all parties.

Flexible ACT & Resource-group ACT: Different Working Procedures Which Can Supplement and Strengthen Each Other. A Response

This article is a response to Nordén and Norlander’s ‘Absence of Positive Results for Flexible Assertive Community Treatment. What is the next approach?’[1], in which they assert that ‘at present [there is] no evidence for Flexible ACT and… that RACT might be able to provide new impulses and new vitality to the treatment mode of ACT’. We question their analyses and conclusions. We clarify Flexible ACT, referring to the Flexible Assertive Community Treatment Manual (van Veldhuizen, 2013) [2] to rectify misconceptions. We discuss Nordén and Norlander’s interpretation of research on Flexible ACT. The fact that too little research has been done and that there are insufficient positive results cannot serve as a reason to propagate RACT. However, the Resource Group method does provide inspiration for working with clients to involve their networks more effectively in Flexible ACT.