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Brekke E, Clausen H, Brodahl M, Landheim AS. Patients' experiences with coercive mental health treatment in Flexible Assertive Community Treatment: a qualitative study. BMC Psychiatry 2023; 23:764. [PMID: 37853402 PMCID: PMC10585822 DOI: 10.1186/s12888-023-05264-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/08/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Flexible Assertive Community Treatment (FACT) teams have been implemented in Norwegian health and social services over the last years, partly aiming to reduce coercive mental health treatment. We need knowledge about how service users experience coercion within the FACT context. The aim of this paper is to explore service user experiences of coercive mental health treatment in the context of FACT and other treatment contexts they have experienced. Are experiences of coercion different in FACT than in other treatment contexts? If this is the case, which elements of FACT lead to a different experience? METHOD Within a participatory approach, 24 qualitative interviews with service users in five different FACT teams were analyzed with thematic analysis. RESULTS Participants described negative experiences with formal and informal coercion. Three patterns of experiences with coercion in FACT were identified: FACT as clearly a change for the better, making the best of FACT, and finding that coercion is just as bad in FACT as it was before. Safety, improved quality of treatment, and increased participation were described as mechanisms that can prevent coercion. CONCLUSION Results from this study support the argument that coercion is at odds with human rights and therefore should be avoided as far as possible. Results suggest that elements of the FACT model may prevent the use of coercion by promoting safety, improved quality of treatment and increased participation.
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Affiliation(s)
- Eva Brekke
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Inland Hospital Trust, Postbox 104, Brumunddal, 2381, Norway.
| | - Hanne Clausen
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Inland Hospital Trust, Postbox 104, Brumunddal, 2381, Norway
- Department of Research and Development, Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
| | - Morten Brodahl
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Inland Hospital Trust, Postbox 104, Brumunddal, 2381, Norway
| | - Anne S Landheim
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Inland Hospital Trust, Postbox 104, Brumunddal, 2381, Norway
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Nyttingnes O, Benth JŠ, Hofstad T, Rugkåsa J. The relationship between area levels of involuntary psychiatric care and patient outcomes: a longitudinal national register study from Norway. BMC Psychiatry 2023; 23:112. [PMID: 36803444 PMCID: PMC9942375 DOI: 10.1186/s12888-023-04584-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 02/02/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Mental health legislation permits involuntary care of patients with severe mental disorders who meet set legal criteria. The Norwegian Mental Health Act assumes this will improve health and reduce risk of deterioration and death. Professionals have warned against potentially adverse effects of recent initiatives to heighten involuntary care thresholds, but no studies have investigated whether high thresholds have adverse effects. AIM To test the hypothesis that areas with lower levels of involuntary care show higher levels of morbidity and mortality in their severe mental disorder populations over time compared to areas with higher levels. Data availability precluded analyses of the effect on health and safety of others. METHODS Using national data, we calculated standardized (by age, sex, and urbanicity) involuntary care ratios across Community Mental Health Center areas in Norway. For patients diagnosed with severe mental disorders (ICD10 F20-31), we tested whether lower area ratios in 2015 was associated with 1) case fatality over four years, 2) an increase in inpatient days, and 3) time to first episode of involuntary care over the following two years. We also assessed 4) whether area ratios in 2015 predicted an increase in the number of patients diagnosed with F20-31 in the subsequent two years and whether 5) standardized involuntary care area ratios in 2014-2017 predicted an increase in the standardized suicide ratios in 2014-2018. Analyses were prespecified (ClinicalTrials.gov NCT04655287). RESULTS We found no adverse effects on patients' health in areas with lower standardized involuntary care ratios. The standardization variables age, sex, and urbanicity explained 70.5% of the variance in raw rates of involuntary care. CONCLUSIONS Lower standardized involuntary care ratios are not associated with adverse effects for patients with severe mental disorders in Norway. This finding merits further research of the way involuntary care works.
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Affiliation(s)
- Olav Nyttingnes
- Health Services Research Unit, Akershus University Hospital, Nordbyhagen, Norway. .,Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway.
| | - Jūratė Šaltytė Benth
- grid.411279.80000 0000 9637 455XHealth Services Research Unit, Akershus University Hospital, Nordbyhagen, Norway ,grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tore Hofstad
- grid.412008.f0000 0000 9753 1393Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway ,grid.5510.10000 0004 1936 8921Centre for Medical Ethics, University of Oslo, Oslo, Norway
| | - Jorun Rugkåsa
- grid.411279.80000 0000 9637 455XHealth Services Research Unit, Akershus University Hospital, Nordbyhagen, Norway ,grid.463530.70000 0004 7417 509XCentre for Care Research, University of South-Eastern Norway, Notodden, Norway
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Chen LY. Social security net for the mentally ill. TAIWANESE JOURNAL OF PSYCHIATRY 2023. [DOI: 10.4103/tpsy.tpsy_11_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
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Costigan CL, Woodin EM, Duerksen KN, Ferguson R. Benefits and Drawbacks of Police Integration Into Assertive Community Treatment Teams. Psychiatr Serv 2022; 73:447-455. [PMID: 34615367 DOI: 10.1176/appi.ps.201900549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Assertive community treatment (ACT) teams provide outreach services to individuals coping with severe mental illness. Because such individuals are at increased risk for involvement with law enforcement, a model that integrates police officers into ACT teams (ACT-PI) was developed for ACT teams serving clients with or without forensic involvement. The goal of this study, conducted in British Columbia, was to evaluate the benefits and drawbacks of the ACT-PI model. METHODS Qualitative semistructured interviews were conducted with 21 ACT-PI clients (in 2017) and 22 ACT-PI staff (in 2018). Thematic analyses identified key themes related to the benefits and drawbacks of officer integration into the ACT-PI model. RESULTS Perceived benefits of police integration were opportunities for relationship building between officers and clients, improved safety, more holistic care due to embeddedness (i.e., effective interagency collaboration between police and health care providers), the prevention of future problems, and police officers' authority enhancing compliance. Perceived drawbacks included risk for legal consequences, stigma from police interaction, escalating distress of clients, low officer availability, and the risk for changing the nature of ACT teams. CONCLUSIONS Participants reported that the model of officer integration into ACT-PI teams may improve both client and staff well-being. In some communities, and with certain precautions, ACT-PI may be a viable model for ACT teams serving clients with and clients without a history of forensic involvement.
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de Waardt DA, van Melle AL, Widdershoven GAM, Bramer WM, van der Heijden FMMA, Rugkåsa J, Mulder CL. Use of compulsory community treatment in mental healthcare: An integrative review of stakeholders' opinions. Front Psychiatry 2022; 13:1011961. [PMID: 36405930 PMCID: PMC9669570 DOI: 10.3389/fpsyt.2022.1011961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Multiple studies have examined the effects of compulsory community treatment (CCT), amongst them there were three randomized controlled trials (RCT). Overall, they do not find that CCT affects clinical outcomes or reduces the number or duration of hospital admissions more than voluntary care does. Despite these negative findings, in many countries CCT is still used. One of the reasons may be that stakeholders favor a mental health system including CCT. AIM This integrative review investigated the opinions of stakeholders (patients, significant others, mental health workers, and policy makers) about the use of CCT. METHODS We performed an integrative review; to include all qualitative and quantitative manuscripts on the views of patients, significant others, clinicians and policy makers regarding the use of CCT, we searched MEDLINE, EMBASE, PsycINFO, CINAHL, Web of Science Core Collection, Cochrane CENTRAL Register of Controlled Trials (via Wiley), and Google Scholar. RESULTS We found 142 studies investigating the opinion of stakeholders (patients, significant others, and mental health workers) of which 55 were included. Of these 55 studies, 29 included opinions of patients, 14 included significant others, and 31 included mental health care workers. We found no studies that included policy makers. The majority in two of the three stakeholder groups (relatives and mental health workers) seemed to support a system that used CCT. Patients were more hesitant, but they generally preferred CCT over admission. All stakeholder groups expressed ambivalence. Their opinions did not differ clearly between those who did and did not have experience with CCT. Advantages mentioned most regarded accessibility of care and a way to remain in contact with patients, especially during times of crisis or deterioration. The most mentioned disadvantage by all stakeholder groups was that CCT restricted autonomy and was coercive. Other disadvantages mentioned were that CCT was stigmatizing and that it focused too much on medication. CONCLUSION Stakeholders had mixed opinions regarding CCT. While a majority seemed to support the use of CCT, they also had concerns, especially regarding the restrictions CCT imposed on patients' freedom and autonomy, stigmatization, and the focus on medication.
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Affiliation(s)
| | | | - Guy Antoine Marie Widdershoven
- Department of Ethics, Law, and Humanities, Amsterdam University Medical Centers (Location VUmc), Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | | | - Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway.,Centre for Care Research, University of South-Eastern Norway, Porsgrunn, Norway
| | - Cornelis Lambert Mulder
- Parnassia Psychiatric Institute, Rotterdam, Netherlands.,Department of Psychiatry, Epidemiological and Social Psychiatric Research institute (ESPRi), Erasmus MC, Erasmus University Medical Center, Rotterdam, Netherlands
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Paradis-Gagné E, Holmes D. Gilles Deleuze's societies of control: Implications for mental health nursing and coercive community care. Nurs Philos 2021; 23:e12375. [PMID: 34724314 DOI: 10.1111/nup.12375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/14/2021] [Accepted: 10/17/2021] [Indexed: 10/19/2022]
Abstract
Since the era of deinstitutionalisation, many clinical approaches have emerged to enable the care and treatment of people suffering from mental illness. In recent years, the use of coercive approaches in the community (e.g., outpatient commitment or community treatment orders) has also increased internationally. Although nurses' role regarding these coercive approaches is central and significant, few empirical and theoretical writings have tackled this controversial nursing practice. The purpose of this paper is to analyse coercive nursing care through the lens of French philosopher Gilles Deleuze's concept of 'societies of control'. Taking up Michel Foucault's work on disciplinary power, Deleuze explores how the move from the striated spaces of closed institutions to the smooth spaces of societies of control took place since the middle of the 20th century. According to Deleuze, the overall objective of 'societies of control' is no longer simply to govern deviant behaviour in closed environments (e.g., psychiatric hospitals and prisons) but to ensure a regime of unrelentless surveillance in the open spaces of our communities.
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Affiliation(s)
| | - Dave Holmes
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, Ontario, Canada
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Brekke E, Clausen HK, Brodahl M, Lexén A, Keet R, Mulder CL, Landheim AS. Service User Experiences of How Flexible Assertive Community Treatment May Support or Inhibit Citizenship: A Qualitative Study. Front Psychol 2021; 12:727013. [PMID: 34566813 PMCID: PMC8457351 DOI: 10.3389/fpsyg.2021.727013] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/13/2021] [Indexed: 11/25/2022] Open
Abstract
The aim of this study was to explore and describe service user experiences of how receiving services from a Flexible Assertive Community Treatment (FACT) team may support or inhibit citizenship. Within a participatory design, individual interviews with 32 service users from five Norwegian FACT teams were analyzed using thematic, cross-sectional analysis. The findings showed that FACT may support citizenship by relating to service users as whole people, facilitating empowerment and involvement, and providing practical and accessible help. Experiences of coercion, limited involvement and authoritarian aspects of the system surrounding FACT had inhibited citizenship for participants in this study.
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Affiliation(s)
- Eva Brekke
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Inland Hospital Trust, Brumunddal, Norway
| | - Hanne K. Clausen
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Inland Hospital Trust, Brumunddal, Norway
- Department of Research and Development, Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
| | - Morten Brodahl
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Inland Hospital Trust, Brumunddal, Norway
| | - Annika Lexén
- Department of Health Sciences, Medical Faculty, Lund University, Lund, Sweden
| | - Rene Keet
- Flexible, Innovative Top-ambulatory Academy of Community Mental Health Service, Geestelijke Gezondheidszorg Noord-Holland-Noord, Heerhugowaard, Netherlands
| | - Cornelis L. Mulder
- Department of Psychiatry, Erasmus Medical Center (MC), University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Anne S. Landheim
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Inland Hospital Trust, Brumunddal, Norway
- Department of Health and Nursing Sciences, Faculty of Social and Health Sciences, Inland Norway University of Applied Sciences, Elverum, Norway
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Seaward H, Wangmo T, Vogel T, Graf M, Egli-Alge M, Liebrenz M, Elger BS. What characterizes a good mental health professional in court-mandated treatment settings?: Findings from a qualitative study with older patients and mental health care professionals. BMC Psychol 2021; 9:121. [PMID: 34404482 PMCID: PMC8371872 DOI: 10.1186/s40359-021-00624-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 07/24/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Therapist-related activities and characteristics such as empathy and genuineness are factors that significantly contribute to psychotherapy outcome. As they play a role in psychotherapy more generally, it can be expected that they are equally important in the treatment of court-mandated patients more specifically. At the same time, these treatment settings come with specific challenges-e.g. due to coercion and control-and it could thus be that some therapist-related characteristics might have a different empathy on the therapy. This interview study sought to investigate service providers' and users' perspectives on therapist-related characteristics in the context of detention. METHODS We conducted a qualitative interview study with 41 older incarcerated persons mandated to treatment, and 63 mental health professionals (MHP). The data analysis followed thematic analysis. RESULTS Patients and experts both emphasized the importance of treating patients with respect by taking a humanistic approach, that is, condemn the deeds but embrace the person and display genuine interest in supporting patients with any issue or concern that is of relevance to them. Furthermore, interviewees underscored that the coerciveness of the therapy context required to incorporate patients' wishes into treatment planning, recognize and respond to the patients' needs, and allow some choice within the given framework. Such inclusive attitude was deemed critical to engage and motivate patients to participate in treatment. In addition, it was emphasized that feedback and advice by the therapists need to be concrete, detailed and applied to each person's current situation. Lastly, patients questioned MHP's qualification when they did not progress in therapy. DISCUSSION Our findings indicate that some therapist-related activities and characteristics are of particular importance in court-mandated settings. These include genuine interest in the patient, a respectful and positive attitude, as well as the capacity to target sensitive issues in a directive but non-confrontational manner. Further research needs to identify specific expressions and behaviors that are linked to the aforementioned characteristics in the forensic context. Our study therefore contributes to much-needed empirical research on clinician and patient perspectives on therapist characteristics and activities in the treatment of court-mandated patients.
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Affiliation(s)
- Helene Seaward
- Institute for Biomedical Ethics, University Basel, Bernoullistrasse 28, 4056, Basel, Switzerland.
| | - Tenzin Wangmo
- Institute for Biomedical Ethics, University Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
| | - Tobias Vogel
- Psychiatric Hospital of the University of Basel, Forensic Psychiatric Hospital, Basel, Switzerland
| | - Marc Graf
- Psychiatric Hospital of the University of Basel, Forensic Psychiatric Hospital, Basel, Switzerland
| | | | - Michael Liebrenz
- Department of Forensic Psychiatry, Institute of Forensic Medicine, University of Bern, Bern, Switzerland
| | - Bernice S Elger
- Institute for Biomedical Ethics, University Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
- Center for Legal Medicine (CURML), Medical Faculty, University of Geneva, Geneva, Switzerland
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Neijmeijer L, Kuiper C, Kroon H, Didden R. Experiences of service users with a mild intellectual disability or borderline intellectual functioning with Flexible Assertive Community Treatment: A qualitative study. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2020; 33:1005-1015. [PMID: 32141154 PMCID: PMC7496458 DOI: 10.1111/jar.12723] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 02/14/2020] [Accepted: 02/17/2020] [Indexed: 11/27/2022]
Abstract
Background In the Netherlands, Flexible Assertive Community Treatment (FACT) teams have been established for people with mild intellectual disability (MID) or borderline intellectual functioning (BIF) and mental health problems or challenging behaviour. Little is known yet about service users’ experiences with FACT. Method An inductive grounded theory approach was used to explore how service users valued the treatment and their own functioning, and which factors were perceived as supportive. Semi‐structured interviews were held with 15 service users. Results Most service users highly appreciated the contact with the staff and the practical and emotional support. Persistent involvement, availability and humanity, and respect for autonomy were distinguished as core values in the relationship with the staff. Most service users experienced improvement in time and attributed this to intrapersonal changes and/or less stress in life. Conclusions From the perspective of service users with MID/BIF, FACT appears to have an added value.
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Affiliation(s)
- Laura Neijmeijer
- Behavioural Science Institute, Radboud University Nijmegen, Nijmegen, The Netherlands.,Trajectum, Zwolle, The Netherlands
| | - Chris Kuiper
- University of Applied Sciences Leiden, Leiden, The Netherlands
| | - Hans Kroon
- Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands.,Tranzo, School of Social and Behavioural Sciences, Tilburg University, Tilburg, The Netherlands
| | - Robert Didden
- Behavioural Science Institute, Radboud University Nijmegen, Nijmegen, The Netherlands.,Trajectum, Zwolle, The Netherlands
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Beentjes TAA, van Gaal BGI, van Achterberg T, Goossens PJJ. Self-Management Support Needs From the Perspectives of Persons With Severe Mental Illness: A Systematic Review and Thematic Synthesis of Qualitative Research. J Am Psychiatr Nurses Assoc 2020; 26:464-482. [PMID: 31578904 DOI: 10.1177/1078390319877953] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND: The development of de-hospitalization policies in mental health has resulted in a growing emphasis on self-management. In the chronic care model, self-management support is an essential element. Because of the episodic nature of severe mental illness (SMI) and its high relapse rates, we assume that the extent of self-management support needs of individuals with an SMI is considerable. However, a clear overview of the nature of the self-management support needs of persons with SMI is missing. AIMS: This study aimed to identify self-management support needs from the perspective of individuals with SMI. METHOD: A systematic review was conducted using the method of thematic synthesis of qualitative studies. After searching the databases MEDLINE, PsycINFO, CINAHL, and EMBASE, we screened the papers for the eligibility criteria: individuals with an SMI, adequately representing the voice of persons with SMI and describing their self-management support needs. Thirty-one papers were included. RESULTS: The main findings showed that participants in the studies described the need for informational support, emotional support, acknowledgment, encouragement, and guidance to make sense of their illness experiences, ease suffering, obtain validation and recognition, execute self-management tasks, and be led through unfamiliar territory. CONCLUSION: The perspectives of persons with SMI can provide a road map for constructing a self-management support intervention for persons with SMI. Important others have an essential role in fulfilling support needs. Independently managing an SMI is difficult. Therefore, it is preferable to let important others participate in self-management interventions and to introduce peer support.
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Affiliation(s)
- Titus A A Beentjes
- Titus A. A. Beentjes, MScN, APRN, RN, Radboud university medical center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, the Netherlands; Dimence Group Mental Health Care Centre, Deventer, the Netherlands; Centre for Nursing Research, Saxion University of Applied Science, Deventer, the Netherlands
| | - Betsie G I van Gaal
- Betsie G. I. van Gaal, PhD, FEANS, Radboud university medical center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, the Netherlands; HAN University of Applied Sciences, Faculty of Health and Social Studies, Nijmegen, the Netherlands
| | - Theo van Achterberg
- Theo van Achterberg, PhD, FEANS, KU Leuven, Academic Centre for Nursing and Midwifery, Leuven, Belgium
| | - Peter J J Goossens
- Peter J. J. Goossens, PhD, APRN, RN, FEANS, Dimence Group Mental Health Care Centre, Deventer, the Netherlands; University Centre for Nursing and Midwifery, Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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Lawrence RE, Perez-Coste MM, Bailey JL, DeSilva RB, Dixon LB. Coercion and the Inpatient Treatment Alliance. Psychiatr Serv 2019; 70:1110-1115. [PMID: 31480927 DOI: 10.1176/appi.ps.201900132] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The importance of building a strong treatment alliance is widely accepted and uncontroversial. Quantitative research suggests that coercive experiences during psychiatric treatment negatively affect the treatment alliance, but reveals little about how this happens or how patients navigate treatment relationships while experiencing coercion during psychiatric treatment. METHODS Fifty psychiatric inpatients were interviewed at two hospitals. Patients were asked open-ended questions about the relationship between the treatment alliance and a set of coercive treatment experiences (court-mandated treatment, involuntary hospitalization, locked facilities) and whether such hospital experiences affected the patients' plans for future adherence. Interviews were audio-recorded, transcribed, and qualitatively analyzed. RESULTS Many participants reported events where coercion made it difficult to form a treatment alliance. An imbalance of power, lack of control, and insufficient participation in treatment planning were described as experiences that interfered with the treatment alliance. Other participants felt the treatment alliance was maintained despite coercive experiences and spoke of good communication with the psychiatrist, understanding the rationale behind interventions, and feeling the psychiatrist was trying to keep the patient's best interests in mind. CONCLUSIONS Coercive experiences remain undesirable and are frequently detrimental to the treatment alliance. Nevertheless, patients and clinicians should continue to seek a strong treatment alliance even when treatment plans include coercive elements. Efforts to improve communication, to explain the rationale for treatment plans, and to show that clinicians are trying to act in the patient's best interests may help to preserve a therapeutic alliance.
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Affiliation(s)
- Ryan E Lawrence
- Department of Psychiatry, New York-Presbyterian Hospital, New York (Lawrence, Perez-Coste, DeSilva); Mount Sinai Icahn School of Medicine, New York (Bailey); Department of Psychiatry, New York State Psychiatric Institute, New York (Dixon)
| | - Maria M Perez-Coste
- Department of Psychiatry, New York-Presbyterian Hospital, New York (Lawrence, Perez-Coste, DeSilva); Mount Sinai Icahn School of Medicine, New York (Bailey); Department of Psychiatry, New York State Psychiatric Institute, New York (Dixon)
| | - Jennifer L Bailey
- Department of Psychiatry, New York-Presbyterian Hospital, New York (Lawrence, Perez-Coste, DeSilva); Mount Sinai Icahn School of Medicine, New York (Bailey); Department of Psychiatry, New York State Psychiatric Institute, New York (Dixon)
| | - Ravi B DeSilva
- Department of Psychiatry, New York-Presbyterian Hospital, New York (Lawrence, Perez-Coste, DeSilva); Mount Sinai Icahn School of Medicine, New York (Bailey); Department of Psychiatry, New York State Psychiatric Institute, New York (Dixon)
| | - Lisa B Dixon
- Department of Psychiatry, New York-Presbyterian Hospital, New York (Lawrence, Perez-Coste, DeSilva); Mount Sinai Icahn School of Medicine, New York (Bailey); Department of Psychiatry, New York State Psychiatric Institute, New York (Dixon)
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12
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Rugkåsa J, Nyttingnes O, Simonsen TB, Benth JŠ, Lau B, Riley H, Løvsletten M, Christensen TB, Austegard ATA, Høyer G. The use of outpatient commitment in Norway: Who are the patients and what does it involve? INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2019; 62:7-15. [PMID: 30616856 DOI: 10.1016/j.ijlp.2018.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/04/2018] [Accepted: 11/01/2018] [Indexed: 06/09/2023]
Abstract
PURPOSE Despite one of the longest histories of using Outpatient Commitment (OC), little is known about the use in the Norwegian context. Reporting from the Norwegian Outpatient Commitment Study, this article aims to: establish the profile of the OC population in Norway; ascertain the legal justification for the use of OC and what OC involves for patients; investigate possible associations between selected patient and service characteristics and duration of OC, and; explore potential differences based on gender or rurality. METHODS A retrospective multi-site study, extracting data from the medical records of all patients on OC in six large regional hospitals in 2008-12, with detailed investigation over 36 months of the subsample of patients on first ever OC-order in 2008-09. We use descriptive statistics to establish the profile of the OC population and the legal justification for and the content of OC, and logistic regression to examine factors associated with duration of OC over 36 months. RESULTS 1414 patients were on OC over the 5 years, and 274 had their first OC in 2008-09. The sample included more men than woman, and three-quarters were diagnosed with schizophrenia. They had long service histories, including involuntary admissions. The legal justification for all OC-orders was the need for treatment, and 18% were additionally justified by dangerousness. The option to initiate OC directly from the community was not used in any of the 274 first ever OC-orders. While 98% of patients were prescribed psychotropic medication, under half had an Involuntary Treatment Order, which under the Norwegian OC regime is required in addition to the OC-order to oblige patients to accept treatment (usually medication). 60% of patients had ≥2 clinical contacts monthly. There were some gender differences in descriptive analyses with men generally being worse off, but no clear pattern in terms of rurality. Patients in the sample had been on OC between one week and 20 years. The median duration of OC over 36 months was 365 days. Three factors contributed to longer duration: the use of the dangerousness criterion; a diagnosis of schizophrenia disorder, and; considerable problems with substance abuse. CONCLUSION The characteristics of the OC population in Norway are very similar to that reported in other jurisdictions. Medication seems to be the central focus of OC, yet additional Involuntary Treatment Orders are imposed for less than half of patients. While all OC-orders were justified by the need to ensure treatment, risk seems to be a concern for a subgroup of patients who are kept on for longer. How the 2017 amendment to the mental health act, which precludes compulsion for competent patients unless danger is present, will affect OC use, remains to be seen. Further studies should specifically focus on variation in the use of OC, including at the level of individual clinicians.
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Affiliation(s)
- Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, 1478 Lørenskog, Norway; Centre for Care Research, University of South-Eastern Norway, 3900 Porsgrunn, Norway.
| | - Olav Nyttingnes
- Health Services Research Unit, Akershus University Hospital, 1478 Lørenskog, Norway; R&D Department Mental Health, Akershus University Hospital, 1478 Lørenskog, Norway.
| | - Tone Breines Simonsen
- Health Services Research Unit, Akershus University Hospital, 1478 Lørenskog, Norway.
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, 0318 Blindern, Norway; Health Services Research Unit, Akershus University Hospital, 1478 Lørenskog, Norway
| | - Bjørn Lau
- Lovisenberg Diaconal Hospital, Norway
| | - Henriette Riley
- Division of Mental Health and Substance Abuse, University Hospital of North Norway, Tromsø, Norway
| | - Maria Løvsletten
- Division of Mental Health Care, Innlandet Hospital Trust, Postboks 104, NO-2381 Brumunddal, Norway
| | | | | | - Georg Høyer
- Institute of Community Medicine, UiT-Norway's Arctic University, 9037 Tromsø, Norway
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Stuen HK, Landheim A, Rugkåsa J, Wynn R. How clinicians make decisions about CTOs in ACT: a qualitative study. Int J Ment Health Syst 2018; 12:51. [PMID: 30258490 PMCID: PMC6151000 DOI: 10.1186/s13033-018-0230-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 09/16/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The first 12 Norwegian assertive community treatment (ACT) teams were piloted from 2009 to 2011. Of the 338 patients included during the teams' first year of operation, 38% were subject to community treatment orders (CTOs). In Norway as in many other Western countries, the use of CTOs is relatively high despite lack of robust evidence for their effectiveness. The purpose of the present study was to explore how responsible clinicians reason and make decisions about the continued use of CTOs, recall to hospital and the discontinuation of CTOs within an ACT setting. METHODS Semi-structured interviews with eight responsible clinicians combined with patient case files and observations of treatment planning meetings. The data were analysed using a modified grounded theory approach. RESULTS The participants emphasized that being part of a multidisciplinary team with shared caseload responsibility that provides intensive services over long periods of time allowed for more nuanced assessments and more flexible treatment solutions on CTOs. The treatment criterion was typically used to justify the need for CTO. There was substantial variation in the responsible clinicians' legal interpretation of dangerousness, and some clinicians applied the dangerousness criterion more than others. CONCLUSIONS According to the clinicians, many patients subject to CTOs were referred from hospitals and high security facilities, and decisions regarding the continuation of CTOs typically involved multiple and interacting risk factors. While patients' need for treatment was most often applied to justify the need for CTOs, in some cases the use of CTOs was described as a tool to contain dangerousness and prevent harm.
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Affiliation(s)
- Hanne Kilen Stuen
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brummundal, Norway
- Department of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Anne Landheim
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brummundal, Norway
- Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway
| | - Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
- Centre for Care Research, University of South-Eastern Norway, Porsgrunn, Norway
| | - Rolf Wynn
- Department of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
- Divison of Mental Health and Addictions, University Hospital of North Norway, Tromsø, Norway
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Lofthus AM, Weimand BM, Ruud T, Rose D, Heiervang KS. "This is not a Life Anyone would want"-A Qualitative Study of Norwegian ACT Service users' Experience with Mental Health Treatment. Issues Ment Health Nurs 2018; 39:519-526. [PMID: 29370562 DOI: 10.1080/01612840.2017.1413459] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We discuss Norwegian service users' experiences with community mental health treatment in general, and the interprofessional Assertive Community Treatment (ACT) model in particular. To gain the right to treatment, service users have to accept certain limitations, such as medication and community treatment orders (CTOs). Seventy participants responded to five open-ended questions. In addition, eight of them participated in either focus group or interviews. A collaborative approach, using Stepwise-Deductive Induction (SDI) method was used to analyze the participants' experiences. The results showed that the treatment contributes to an experience of autonomy but also one of restriction. It provides service users with enhanced normalcy, but simultaneously a feeling of deviance. There needs to be an ongoing reflection and discussion about those paradoxes in treatment, and service users have to be involved.
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Affiliation(s)
- Ann-Mari Lofthus
- a Akershus Universitetssykehus HF , Department of Research and Development, Division of Mental Health Services , Lorenskog , Norway.,b National Centre for knowledge through experience in mental health , Skien , Norway.,c University of Oslo, Institute of Clinical Medicine , Oslo , Norway
| | - Bente M Weimand
- a Akershus Universitetssykehus HF , Department of Research and Development, Division of Mental Health Services , Lorenskog , Norway
| | - Torleif Ruud
- a Akershus Universitetssykehus HF , Department of Research and Development, Division of Mental Health Services , Lorenskog , Norway.,c University of Oslo, Institute of Clinical Medicine , Oslo , Norway
| | - Diana Rose
- d King's College London, Institute of Psychiatry, Psychology & Neuroscience , London , United Kingdom of Great Britain and Northern Ireland
| | - Kristin S Heiervang
- a Akershus Universitetssykehus HF , Department of Research and Development, Division of Mental Health Services , Lorenskog , Norway
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Stuen HK, Landheim A, Rugkåsa J, Wynn R. Responsibilities with conflicting priorities: a qualitative study of ACT providers' experiences with community treatment orders. BMC Health Serv Res 2018; 18:290. [PMID: 29669558 PMCID: PMC5907185 DOI: 10.1186/s12913-018-3097-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 04/05/2018] [Indexed: 11/21/2022] Open
Abstract
Background Patients with severe mental illness may be subjected to Community Treatment Orders (CTOs) in order to secure that the patients adhere to treatment. Few studies have investigated the use of CTOs within an Assertive Community Treatment (ACT) setting, and little is known about how the tension between the patients’ autonomy and the clinicians’ responsibility to act in the patients’ best interest are resolved in practice. The aim of this study was to explore the service providers’ experiences with CTOs within an ACT setting. Methods The study was based on reviews of case files of 15 patients, eight individual qualitative in depth interviews and four focus group interviews with service providers involved in ACT and decisions related to CTOs. A modified grounded theory approach was used to analyze the data. Results The main theme ‘responsibility with conflicting priorities’ emerged from data analysis (case file reviews, individual interviews and focus group interviews). The balance between coercive approaches and the emphasis on promoting patient autonomy was seen as problematic. The participants saw few alternatives to CTOs as long-term measures to secure ongoing treatment for some of the patients. However, participants perceived the ACT model’s comprehensive scope as an opportunity to build rapport with patients and thereby better meet their needs. The team approach, the ACT providers’ commitment to establish supportive relationships and the frequent meetings with patients in their home environment were highlighted. The ACT approach gave them insight into patients’ everyday lives and, in some cases a greater sense of security when considering whether to take patients off CTOs. Conclusions Many of the participants viewed CTOs as helpful in securing long-term treatment for patients. CTO decision-making was described as challenging and complex and presented the providers with many dilemmas. The ACT approach was considered as helpful in that it afforded comprehensive, patient-centered support and opportunities to build rapport. Electronic supplementary material The online version of this article (10.1186/s12913-018-3097-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hanne Kilen Stuen
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brummundal, Norway.,Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Anne Landheim
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brummundal, Norway.,Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway
| | - Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway.,Centre for Care Research, University College of Southeast Norway, Porsgrunn, Norway
| | - Rolf Wynn
- Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway. .,Divison of Mental Health and Addictions, University Hospital of North Norway, Tromsø, Norway.
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16
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Wynn R. Involuntary admission in Norwegian adult psychiatric hospitals: a systematic review. Int J Ment Health Syst 2018; 12:10. [PMID: 29588656 PMCID: PMC5865388 DOI: 10.1186/s13033-018-0189-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 03/15/2018] [Indexed: 11/15/2022] Open
Abstract
Background It is an important objective of the psychiatric services to keep the use of involuntary procedures to a minimum, as the use of coercion involves clinical, ethical, and legal issues. It has been claimed that Norway has a relatively high rate of involuntary admissions. We reviewed the peer-reviewed literature on the use of involuntary admission in Norway, with the purpose of identifying the current state of knowledge and areas in need of further research. Methods A systematic review following the PRISMA statement was conducted. We searched the electronic databases PsycInfo, PubMed, Web of Science, CINAHL, and Embase for studies relating to involuntary admission to Norwegian adult psychiatric hospitals published in the period 1 January 2001 to 8 August 2016. The database searches were supplemented with manual searches of relevant journals, reference lists, and websites. Results Seventy-four articles were included and grouped into six categories based on their main topics: Patients’ experiences, satisfaction and perceived coercion (21 articles), the Referral and admission process (11 articles), Rates of admission (8 articles), Characteristics of the patients (17 articles), Staff attitudes (9 articles), and Outcomes (8 articles). Four of the included articles described intervention studies. Fifty-seven of the articles had a quantitative design, 16 had a qualitative design, and one a mixed-method design. There was a broad range of topics that were studied and considerable variation in study designs. The findings were largely in line with the international literature, but the particularities of Norwegian legislation and the Norwegian health services were reflected in the literature. The four intervention studies explored interventions for reducing rates of involuntary admission, such as modifying referring routines, improving patient information procedures, and increasing patients’ say in the admission process, and represent an important avenue for future research on involuntary admission in Norway. Conclusions The review suggests that Norway has a relatively high rate of involuntary admissions. The identified studies represent a broad mix of topics and designs. Four intervention studies were identified. More studies with strong designs are needed to bring research on involuntary admission in Norway to a next level. Electronic supplementary material The online version of this article (10.1186/s13033-018-0189-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rolf Wynn
- 1Department of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, 9037 Tromsø, Norway.,2Division of Mental Health and Addictions, University Hospital of North Norway, Tromsø, Norway
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Lofthus AM, Westerlund H, Bjørgen D, Lindstrøm JC, Lauveng A, Rose D, Ruud T, Heiervang K. Recovery concept in a Norwegian setting to be examined by the assertive community treatment model and mixed methods. Int J Ment Health Nurs 2018; 27:147-157. [PMID: 28026106 DOI: 10.1111/inm.12304] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2016] [Indexed: 11/26/2022]
Abstract
Recovery is a crucial concept in the mental health field. The research of recovery is split into the categories of personal, social and clinical recovery. The purpose of this study was to explore the fragmented concept of recovery in light of assertive community treatment (ACT) in Norway. The study has a mixed methods design with a pragmatic approach. The Questionnaire about the Process of Recovery and open-ended questions posed to 70 participants from 12 ACT teams in Norway, gathered by the "Users interview users" method, are combined with interviews or focus groups with eight of these participants. Surprisingly those under a community treatment order (CTO) report the highest degree of personal recovery. The qualitative material shows that the service users interpreted the concept of recovery differently than researchers and professionals. The ACT service users highlighted three important elements: flexible treatment, medication and access to a car. They emphasized the necessity for basic needs to be met in order to experience a meaningful recovery process, and these basic needs may be of even greater importance to those under CTOs. Their experiences should imply a greater emphasis on securing basic needs such as secure housing, sounder finances and access to the normal benefits offered by society.
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Affiliation(s)
- Ann-Mari Lofthus
- Division Mental Health Services, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, Regional Research Network in Psychotic Disorders, University of Oslo, Oslo, Norway
| | - Heidi Westerlund
- National Centre for Knowledge Through Experience in Mental Health, Skien, Norway
| | - Dagfinn Bjørgen
- National Centre for Knowledge Through Experience in Mental Health, Skien, Norway
| | | | - Arnhild Lauveng
- Division Mental Health Services, Akershus University Hospital, Lørenskog, Norway
| | - Diana Rose
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Torleif Ruud
- Division Mental Health Services, Akershus University Hospital, Lørenskog, Norway
| | - Kristin Heiervang
- Division Mental Health Services, Akershus University Hospital, Lørenskog, Norway
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Corring D, O'Reilly R, Sommerdyk C. A systematic review of the views and experiences of subjects of community treatment orders. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2017; 52:74-80. [PMID: 28325533 DOI: 10.1016/j.ijlp.2017.03.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 01/17/2017] [Accepted: 03/02/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVE CTOS have been the subject of many qualitative and quantitative research studies. Both research approaches add value to our understanding of CTOs. Qualitative studies provide an understanding of CTOs and the experience of being on a CTO that quantitative studies cannot provide. Many qualitative studies that have examined the views of subjects of CTOs have been published. However, authors of these studies continue to note that views and experiences of the subjects of these orders are not well known. This paper provides the results of a systematic review of qualitative studies focused on understanding the experiences of individuals who have been the subjects of CTOs. METHOD Relevant databases and grey literature were searched. To be included, a study had to have used a qualitative methodology for data collection and analysis, and focus on examining stakeholder perspectives on the lived experience of CTOs. RESULTS After a rigorous review of the abstracts, we identified 22 papers that met the criteria. These papers were analysed in detail in order to examine the existence of common themes. The 22 papers represented the views of 581 participants from 7 countries around the world. Ten themes were found to be common among the research findings of the 22 papers. Three themes in particular were highlighted: feelings of coercion and control, medication seen as the main reason for a CTO and that the perception of CTOs as a safety net. Findings also highlight the ambivalence that subjects of CTOs experience, the importance of the therapeutic relationship for successful engagement of the subject of the CTO and the complex role of coercion. RECOMMENDATIONS We have made a number of recommendations about how clinicians might use the views of the subjects of CTOs achieve a more positive experience of a CTO.
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Affiliation(s)
- Deborah Corring
- Department of Psychiatry, Faculty of Medicine and Dentistry, Clinical Skills Building, Rm. 3700, Western University, London, ON, Canada.
| | - Richard O'Reilly
- Department of Psychiatry, Faculty of Medicine and Dentistry, Clinical Skills Building, Rm. 3700, Western University, London, ON, Canada
| | - Christina Sommerdyk
- Department of Psychiatry, Faculty of Medicine and Dentistry, Clinical Skills Building, Rm. 3700, Western University, London, ON, Canada
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Dawson S, Lawn S, Simpson A, Muir-Cochrane E. Care planning for consumers on community treatment orders: an integrative literature review. BMC Psychiatry 2016; 16:394. [PMID: 27832769 PMCID: PMC5105250 DOI: 10.1186/s12888-016-1107-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 11/01/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Case management is the established model for care provision in mental health and is delivered within current care philosophies of person-centred and recovery-oriented care. The fact that people with a mental illness may be forced to receive care and treatment in the community poses challenges for clinicians aiming to engage in approaches that promote shared decision-making and self-determination. This review sought to gain an in-depth understanding of stakeholders' perspectives and experiences of care planning for consumers' on CTOs. METHODS An integrative review method allowed for inclusion of a broad range of studies from diverse empirical sources. Systematic searches were conducted across six databases. Following appraisal, findings from included papers were coded into groups and presented against a framework of case management. RESULTS Forty-eight papers were included in the review. Empirical studies came from seven countries, with the majority reporting on qualitative methods. Many similarities were reported across studies. Positive gains from CTOs were usually associated with the nature of support received, highlighting the importance of the therapeutic relationship in care planning. Key gaps in care planning included a lack of connection between CTO, treatment and consumer goals and lack of implementation of focussed interventions. CONCLUSIONS Current case management processes could be better utilised for consumers on CTOs, with exploration of how this could be achieved warranted. Workers need to be sensitive to the 'control and care' dynamic in the care planning relationship, with person-centred approaches requiring core and advanced practitioner and communication skills, including empathy and trust.
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Affiliation(s)
- Suzanne Dawson
- School of Nursing & Midwifery, Flinders University, GPO Box 2100, Adelaide, 5001, Australia.
| | - Sharon Lawn
- School of Medicine, Flinders University, Adelaide, Australia
| | - Alan Simpson
- School of Health Sciences, Nursing, City University London, London, UK
| | - Eimear Muir-Cochrane
- School of Nursing & Midwifery, Flinders University, GPO Box 2100, Adelaide, 5001, Australia
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Lawn S, Delany T, Pulvirenti M, Smith A, McMillan J. Examining the use of metaphors to understand the experience of community treatment orders for patients and mental health workers. BMC Psychiatry 2016; 16:82. [PMID: 27030136 PMCID: PMC4815077 DOI: 10.1186/s12888-016-0791-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 03/22/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community Treatment Orders (CTOs) are often complex because of the ethical tensions created by an intervention that aims at promoting the patient's good through an inherently coercive process. There is limited research that examines the complexity of CTOs and how patients on CTOs and workers administering CTOs make sense of their experiences. METHODS The study involved in-depth interviews with 8 patients on CTOs and 10 community mental health workers in South Australia, to explore how they constructed their experiences of CTOs. Critical discourse analysis (CDA) was used to analyse the data, supported by NVIVO software. RESULTS Analysis of the interviews revealed that patients and workers experienced the CTO process as multi-dimensional, including some positive as well as more negative constructions. The positive metaphor of CTOs as a safety net is described, followed by a more detailed description of the metaphors of power and control as the dominant themes, with five sub-themes of the CTO as control, wake-up, punishment, surveillance, and tranquiliser. DISCUSSION Metaphors are a way that mental health patients and mental health workers articulate the nature of CTOs. The language used to construct these metaphors was quite different, with patients overwhelmingly experiencing and perceiving CTOs as coercive (that is, punishing, controlling and scrutinizing), whereas workers tended to perceive them as necessary, beneficial and supportive, despite their coerciveness. CONCLUSIONS By acknowledging the role of metaphors in these patients' lives, workers could enhance opportunities to engage these patients in more meaningful dialogue about their personal experiences as an alternative to practice predominantly focused on risk. Such a dialogue could enhance workers' reflection on their work and promote recovery-based practice. More understanding of how to promote autonomy, capacity and supported decision-making, and how to address the impacts of coercion within care, is needed.
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Affiliation(s)
- Sharon Lawn
- Flinders Human Behaviour and Health Research Unit, Department of Psychiatry, Flinders University, Room 4 T306 Margaret Tobin Centre, PO Box 2100, Adelaide, South Australia, 5001, Australia.
| | - Toni Delany
- Southgate Institute for Health, Society and Equity, Flinders University, Adelaide, South Australia, Australia
| | | | - Ann Smith
- C/o Flinders Human Behaviour and Health Research Unit, Flinders University, Adelaide, Australia
| | - John McMillan
- The Bioethics Centre, University of Otago, Dunedin, New Zealand
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Røtvold K, Wynn R. Involuntary psychiatric admission: how the patients are detected and the general practitioners' expectations for hospitalization. An interview-based study. Int J Ment Health Syst 2016; 10:20. [PMID: 26958076 PMCID: PMC4782338 DOI: 10.1186/s13033-016-0048-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 02/16/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Norway, it is usually GPs that refer patients to involuntary admission. A high proportion of such referrals come from out-of-hours clinics. Little is known about who first initiate the contact between the patients and the referring doctors and which expectations the referring doctors have with respect to the involuntary admissions. The aim of the study was to examine who first detected the patients who were subsequently involuntarily admitted, and to examine the referring doctors' expectations for the admissions. METHODS Semi-structured interviews with 74 doctors that had referred patients for involuntary admission at a psychiatric hospital. RESULTS Patients who were involuntarily admitted were detected by other branches of the health service (52 %, n = 39), family (25 %, n = 19), and the police (17 %, n = 13). The doctors mentioned these expectations for the admission (more than one expectation could be given): start treatment with neuroleptics: 58 % (n = 43), take care of the patient: 45 % (n = 34), extensive changes to the treatment regime: 37 % (n = 28), solve an acute situation: 35 % (n = 26), and clarify the diagnosis: 22 % (n = 17). Female doctors significantly more often expected that the patients would be examined and treated, while the male doctors significantly more often expected that the patients would be cared for. CONCLUSIONS Involuntary admissions are typically complex processes involving different people and services and patients with various needs. More knowledge about the events preceding hospitalization is needed in order to develop alternatives to involuntary admissions.
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Affiliation(s)
- Ketil Røtvold
- Department of Clinical Medicine, UiT - The Arctic University of Norway, 9037 Tromsø, Norway ; Division of Mental Health and Addictions, University Hospital of North Norway, Tromsø, Norway
| | - Rolf Wynn
- Department of Clinical Medicine, UiT - The Arctic University of Norway, 9037 Tromsø, Norway ; Division of Mental Health and Addictions, University Hospital of North Norway, Tromsø, Norway
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