1
|
El-Alti L. Shared Decision Making in Psychiatry: Dissolving the Responsibility Problem. HEALTH CARE ANALYSIS 2022; 31:65-80. [PMID: 36462103 PMCID: PMC10126083 DOI: 10.1007/s10728-022-00451-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2022] [Indexed: 12/04/2022]
Abstract
AbstractPerson centered care (PCC) invites ideas of shared responsibility as a direct result of its shared decision making (SDM) process. The intersection of PCC and psychiatric contexts brings about what I refer to as the responsibility problem, which seemingly arises when SDM is applied in psychiatric settings due to (1) patients’ potentially diminished capacities for responsibility, (2) tension prompted by professional reasons for and against sharing responsibility with patients, as well as (3) the responsibility/blame dilemma. This paper aims to do away with the responsibility problem through arguing for a functional approach to mental illness, a blameless responsibility ascription to the person with mental illness, as well as a nuanced understanding of SDM as part of an emancipation-oriented PCC model.
Collapse
Affiliation(s)
- Leila El-Alti
- School of Health and Social Care, Edinburgh Napier University, Sighthill Court, EH11 4BN, Edinburgh, UK.
- Department of Philosophy, Linguistics, and Theory of Science, University of Gothenburg, Box 200, 405 30, Gothenburg, Sweden.
| |
Collapse
|
2
|
Dawson S, Muir-Cochrane E, Simpson A, Lawn S. Risk versus recovery: Care planning with individuals on community treatment orders. Int J Ment Health Nurs 2021; 30:1248-1262. [PMID: 33960100 DOI: 10.1111/inm.12877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/28/2021] [Accepted: 04/06/2021] [Indexed: 11/29/2022]
Abstract
Community treatment orders (CTOs) require individuals with a mental illness to accept treatment from mental health services. CTO legislation in South Australia states that treatment and care should be recovery-focused, although justification for use is predominantly risk-based, and care often coercive. Although CTOs are contested, individuals, families, and clinicians frequently engage in care planning within this context. This paper examines how the concepts of risk and risk management impact care planning from the perspectives of individuals on CTOs, their families, and clinicians. Ethnographic methods of observation and interview provided a detailed account of the perspectives of each group over an 18-month period from two community mental health teams in South Australia. Findings show that care planning occurred within a culture of practice dominated by risk. Risk, however, was understood differently by each participant group, with the dominant narrative informed by biogenetic understandings of mental illness. This dominance impacted on the positioning of participant groups in care planning, focus of care contacts, and care options available. To improve care experiences and outcomes for individuals on CTOs, narrow conceptualizations of risk and recovery need to broaden to include an understanding of personal and social adversities individuals face. A broader understanding should reposition participants in the care planning context and rebalance care discussions, from a focus on clinical recovery to recovering citizenship.
Collapse
Affiliation(s)
- Suzanne Dawson
- School of Allied Health Science and Practice, University of Adelaide, Adelaide, SA, Australia.,College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia.,Mental Health Directorate, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Eimear Muir-Cochrane
- College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia
| | - Alan Simpson
- Health Service and Population Research, Institute of Psychiatry, Psychology & Neuroscience and Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Sharon Lawn
- College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| |
Collapse
|
3
|
Martin W, Brown M, Hartvigsson T, Lyons D, MacLeod C, Morgan G, Schölin L, Taylor K, Chopra A. SIDMA as a criterion for psychiatric compulsion: An analysis of compulsory treatment orders in Scotland. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2021; 78:101736. [PMID: 34450485 PMCID: PMC8527859 DOI: 10.1016/j.ijlp.2021.101736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/12/2021] [Accepted: 08/13/2021] [Indexed: 06/13/2023]
Abstract
Scottish mental health legislation includes a unique criterion for the use of compulsion in the delivery of mental health care and treatment. Under the Mental Health (Care and Treatment) (Scotland) Act, 2003, patients must exhibit 'significantly impaired decision-making ability' (SIDMA) in order to be eligible for psychiatric detention or involuntary psychiatric treatment outside the forensic context. The SIDMA requirement represents a distinctive strategy in ongoing international efforts to rethink the conditions under which psychiatric compulsion is permissible. We reconstruct the history of the Scottish SIDMA requirement, analyse its differences from so-called 'fusion law,' and then examine how the SIDMA standard actually functions in practice. We analyse 100 reports that accompany applications for Compulsory Treatment Orders (CTOs). Based on this analysis, we provide a profile of the patient population that is found to exhibit SIDMA, identify the grounds upon which SIDMA is attributed to individual patients, and offer an assessment of the quality of the documentation of SIDMA. We demonstrate that there are systemic areas of poor practice in the reporting of SIDMA, with only 12% of CTOs satisfying the minimum standard of formal completeness endorsed by the Mental Welfare Commission. We consider what lessons might be drawn both for the ongoing review of mental health legislation in Scotland, and for law reform initiatives in other jurisdictions.
Collapse
Affiliation(s)
- Wayne Martin
- Essex Autonomy Project, School of Philosophy and Art History, University of Essex, Wivenhoe Park, Colchester, Essex CO4 3SQ, UK
| | - Miriam Brown
- Mental Welfare Commission for Scotland, 91 Haymarket Terrace, EH12 5HE Edinburgh, UK
| | - Thomas Hartvigsson
- Essex Autonomy Project, School of Philosophy and Art History, University of Essex, Wivenhoe Park, Colchester, Essex CO4 3SQ, UK
| | - Donny Lyons
- Mental Welfare Commission for Scotland, 91 Haymarket Terrace, EH12 5HE Edinburgh, UK
| | - Callum MacLeod
- Mental Welfare Commission for Scotland, 91 Haymarket Terrace, EH12 5HE Edinburgh, UK
| | - Graham Morgan
- Mental Welfare Commission for Scotland, 91 Haymarket Terrace, EH12 5HE Edinburgh, UK
| | - Lisa Schölin
- Mental Welfare Commission for Scotland, 91 Haymarket Terrace, EH12 5HE Edinburgh, UK.
| | - Kathleen Taylor
- Mental Welfare Commission for Scotland, 91 Haymarket Terrace, EH12 5HE Edinburgh, UK
| | - Arun Chopra
- Mental Welfare Commission for Scotland, 91 Haymarket Terrace, EH12 5HE Edinburgh, UK
| |
Collapse
|
4
|
Rees H. Identifying people with deteriorating mental health using a mental state assessment. Nurs Stand 2021; 36:62-69. [PMID: 33843167 DOI: 10.7748/ns.2021.e11612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2020] [Indexed: 11/09/2022]
Abstract
Research indicates that approximately one in six people will experience a common mental health condition such as depression or anxiety, while people with severe mental illness commonly experience significant health inequalities. Nurses will come into frequent contact with people experiencing mental health issues in hospitals and in the community. Mental state assessment is a tool that enables nurses to develop an understanding of an individual's mental health that will be universally recognised across healthcare services. This article provides an outline of the various elements involved in a mental state assessment, so that clinicians such as non-mental health nurses can identify people experiencing deteriorating mental health.
Collapse
Affiliation(s)
- Helen Rees
- Nottingham Trent University, Nottingham, England
| |
Collapse
|
5
|
Curk P, Gurbai S, Freyenhagen F. Removing Compliance: Interpersonal and Social Factors Affecting Insight Assessments. Front Psychiatry 2020; 11:560039. [PMID: 33192677 PMCID: PMC7533568 DOI: 10.3389/fpsyt.2020.560039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/17/2020] [Indexed: 11/13/2022] Open
Abstract
This paper probes the format and underlying assumptions of insight conceptualizations and assessment procedures in psychiatry. It does so with reference to the often-neglected perspective of the assessed person. It delineates what the mental steps involved in an insight assessment are for the assessed person, and how they become affected by the context and dynamics of the clinical setting. The paper examines how expectations of compliance in insight assessment tools and procedures extend far beyond treatment adherence, to compliance with diagnostic language and the assessment relationship. Such compliance can be ethically problematic and not in line with human rights standards, notably the Convention on the Rights of Persons with Disabilities. Most importantly, it can be counterproductive in supporting an individual to gain better insight in the sense of self-knowledge. The paper concludes with guidelines for a new approach to insight. This new approach requires taking into account currently neglected components of insight, in particular its relational and social dimensions, through which a person's insight operates and develops, and through which it could be supported. Concretely, this would mean removing the condition of compliance and reflecting on the influence of the clinician-patient relationship and assessment situation on insight.
Collapse
Affiliation(s)
- Polona Curk
- Independent Researcher, London, United Kingdom
| | - Sándor Gurbai
- Human Rights Centre, School of Law, University of Essex, Colchester, United Kingdom
- Essex Autonomy Project, School of Philosophy and Art History, University of Essex, Colchester, United Kingdom
- Faculty of Special Needs Education, Institute for Disability and Social Participation, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Fabian Freyenhagen
- Human Rights Centre, School of Law, University of Essex, Colchester, United Kingdom
- School of Philosophy and Art History, University of Essex, Colchester, United Kingdom
| |
Collapse
|
6
|
David A, Ariyo K. Insight is a useful construct in clinical assessments if used wisely. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2020-106128. [PMID: 32273295 DOI: 10.1136/medethics-2020-106128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 02/21/2020] [Indexed: 06/11/2023]
Abstract
Medical ethicist, Guidry-Grimes has critically reviewed the concept of insight, voicing concerns that it lacks consensus as to its components and that it undermines patient perspectives. We respond by briefly summarising research over the last 30 years that she overlooks which has helped establish the clinical validity of the construct. This includes the adoption of standardised assessment tools-at least in research-and longitudinal and cross-sectional studies quantifying associations with psychopathological, clinical and cognitive measures. We also make the distinction between the current standards for assessing decision-making capacity leading to, where appropriate, involuntary treatment in clinical and medico-legal settings which in most legislations do not include insight assessments, and anecdotal reports of the use and misuse of 'lack of insight' as a proxy for more comprehensive evaluation. We conclude by encouraging a broader view of insight akin to self-knowledge.
Collapse
Affiliation(s)
- Anthony David
- Department of Psychiatry, UCL Institute of Mental Health, London, UK
| | - Kevin Ariyo
- Department of Psychological Medicine, Institute of Psychiatry Psychology and Neuroscience, London, UK
| |
Collapse
|