Exploring compulsory admission experiences of adults with psychosis in the UK using Grounded Theory

Feeling coerced during voluntary and involuntary psychiatric hospitalisation: A review and meta-aggregation of qualitative studies

Objective

This review aimed to provide an aggregative synthesis of the qualitative evidence on patients' experienced coercion during voluntary and involuntary psychiatric hospitalisation.

Design

A qualitative review.

Data sources

The search was conducted, in five bibliographic databases: Embase.com, Ovid MEDLINE(R) ALL, APA PsycINFO Ovid, Web of Science Core Collection and the Cochrane Database of Systematic Reviews.

Review methods

Following the Joanna Briggs Institute approach, a systematized procedure was applied throughout the review process, from data search to synthesis of results. The reporting of this review was guided by the standards of the PRISMA 2020 statement. The quality of the included studies was critically appraised by two independent reviewers using the JBI Critical Appraisal Checklist. Included findings were synthesized using meta-aggregation. Confidence in the review findings was assessed following the Confidence in the Output of Qualitative research synthesis (ConQual) approach.

Results

A total of 423 studies were identified through the literature search and 26 were included in the meta-aggregation. Totally, 151 findings were extracted and aggregated into 27 categories and 7 synthesized findings. The synthesized findings focused on: the patients' experience of the hospitalisation and the associated feeling of coercion; the factors affecting this feeling, such as the involvement in the decision-making process, the relationships with the staff and the perception of the hospital treatment as effective and safe; the coping strategies adopted to deal with it and the patients' suggestions for alternatives. All synthesized findings reached an overall confidence score of "moderate". The seven findings were downgraded one level due to dependability limitations of the included studies.

Conclusion

Based on these findings, seven recommendations for clinical practice where developed, such as fostering care ethics, promoting patients' voice and shared decision-making, and enhancing patients' perceived closeness, respect and fairness. Five recommendations for future research were also prompted, for instance improving the methodological quality and cultural variation of future qualitative studies, and exploring the psychosocial impact of experienced coercion on patients. For these recommendations to be effectively implemented, a profound change in the structure and culture of the mental health system should be promoted. The involvement of patients in the design, development and scientific evaluation of this change is strongly recommended.

Involuntary psychiatric admission in Cyprus: A descriptive correlational study

INTRODUCTION

Studies on the clinical and socio-demographic characteristics of those involuntarily admitted to psychiatric settings could help professionals and researchers to develop effective, targeted interventions, alternative to compulsory psychiatric care.

AIM

The association between socio-demographic and clinical characteristics in adults under involuntary hospitalization for psychiatric treatment in the Republic of Cyprus was assessed.

METHOD

This was a descriptive, cross-sectional and correlational study. Data collection was achieved (December 2016 to February 2018) via a census sampling method. Socio-demographic and clinical data of individuals involuntarily admitted to the reference psychiatric hospital of Cyprus with psychotic symptomatology were recorded.

RESULTS

The sample encompassed 144 females and 262 males. The most frequent diagnosis was schizophrenia or a relevant psychotic disorder (72.9%). The most frequent cause of admission was "Disorganized behaviour" along with non-adherence to pharmacotherapy (53.7%). Approximately 42.8% of the participants confirmed positive substance use history, which was more frequently reported in males than in females (88.5% vs. 11.5%, respectively, p < 0.001). Additionally, males were more frequently admitted due to Disorganized behaviour with substance use compared to females (31.3% vs. 4.9%, respectively, p < 0.001), while females were more frequently admitted due to d"Disorganized behaviour with non-adherence to pharmacotherapy (70.1% vs. 44.7%, respectively, p < 0.001). Also, males were more frequently involuntarily hospitalized due to suicidal/self-harming behaviour compared to females (12.2% vs. 5.6%, respectively, p = 0.031).

CONCLUSION

Gender differences were noted in relation to clinical characteristics of the participants, highlighting the need for gender-specific interventions to decrease compulsory psychiatric care, including enhancement of adherence to therapy.

Attachment-based CBT models for psychosis: a PPI-informed approach for acute care settings

People with psychosis often have prolonged in-patient1 admissions at high personal and economic costs. This is due in part to cognitive, affective and behavioural processes that delay recovery and discharge. For many, these processes are affected by enduring insecure attachment styles. People with insecure attachment struggle to manage strong feelings when unwell, and ward staff may struggle to know how best to offer support. Here, we outline the model of interpersonal process in cognitive therapy, and how this may be adapted to capture beliefs and behaviours associated with insecure attachment. Psychological interventions in acute care often fail due to implementation issues. For this reason, and in line with current guidance on developing complex interventions, we report on a series of Patient and Public Involvement (PPI) consultations with people with lived experience of psychosis, family members and ward staff on the potential utility of these attachment-based CBT models. The PPI meetings highlighted three themes: (1) the need to improve staff–patient interactions on wards; (2) continuity in staff–patient relationships is key to recovery; and (3) advantages and barriers to an attachment-based CBT approach. We conclude by describing how the models can be implemented in routine clinical practice, and generalised across services where interpersonal cognitive and behavioural processes may contribute to delays in people’s recovery.

Key learning aims

(1)

Consumers' experiences of rights-based mental health laws: Lessons from Victoria, Australia

Many countries embarked on reforms of mental health law in the wake of the Convention on the Rights of Persons with Disabilities. These reforms have had varying levels of success. This paper considers the experience of consumers in the Victorian mental health system, drawing on an evaluation that asked consumers and clinicians about their knowledge and experience of rights under the Victorian Mental Health Act, 2014. The data show that consumers were not informed of their rights, were not involved in decisions about treatment, were not able to access safeguards, and could not exercise their rights. The explanations for this include limited staff time, unclear delegations of responsibility, a lack of knowledge, training, and support for rights, and a preference for 'best interests' approaches. The paper identifies tangible reforms that would maintain rights for consumers, including competent refusal of treatment, legislative and regulatory reforms, and training and resourcing. Consumers in this study found that the rights-based framework in the Mental Health Act, 2014 had such an insignificant effect on clinical mental health practice in Victoria that their rights appeared to be illusory.

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.

Understanding Implementation of a Digital Self-Monitoring Intervention for Relapse Prevention in Psychosis: Protocol for a Mixed Method Process Evaluation

Background

Relapse is common in people who experience psychosis and is associated with many negative consequences, both societal and personal. People who relapse often exhibit changes (early warning signs [EWS]) in the period before relapse. Successful identification of EWS offers an opportunity for relapse prevention. However, several known barriers impede the use of EWS monitoring approaches. Early signs Monitoring to Prevent relapse in psychosis and prOmote Well-being, Engagement, and Recovery (EMPOWER) is a complex digital intervention that uses a mobile app to enhance the detection and management of self-reported changes in well-being. This is currently being tested in a pilot cluster randomized controlled trial. As digital interventions have not been widely used in relapse prevention, little is known about their implementation. Process evaluation studies run in parallel to clinical trials can provide valuable data on intervention feasibility.

Objective

This study aims to transparently describe the protocol for the process evaluation element of the EMPOWER trial. We will focus on the development of a process evaluation framework sensitive to the worldview of service users, mental health staff, and carers; the aims of the process evaluation itself; the proposed studies to address these aims; and a plan for integration of results from separate process evaluation studies into one overall report.

Methods

The overall process evaluation will utilize mixed methods across 6 substudies. Among them, 4 will use qualitative methodologies, 1 will use a mixed methods approach, and 1 will use quantitative methodologies.

Results

The results of all studies will be triangulated into an overall analysis and interpretation of key implementation lessons. EMPOWER was funded in 2016, recruitment finished in January 2018. Data analysis is currently under way and the first results are expected to be submitted for publication in December 2019.

Conclusions

The findings from this study will help identify implementation facilitators and barriers to EMPOWER. These insights will inform both upscaling decisions and optimization of a definitive trial.

Trial Registration

ISRCTN Registry ISRCTN99559262; http://www.isrctn.com/ISRCTN99559262

International Registered Report Identifier (IRRID)

DERR1-10.2196/15634

Mental health law assessments: interagency cooperation and practice complexities

BACKGROUND

Assessments under mental health law, to determine whether compulsory admission is necessary, tend to be complex, multidisciplinary and inter-agency processes. This article presents the results of a regional audit of assessments under the Mental Health (Northern Ireland) Order 1986.

AIMS

The aims of the audit were to examine routine practice, identify any issues and so inform how policy and practice may be developed.

METHOD

The audit was designed by an inter-agency advisory group and audit team. Data were collected for a sample of 189 assessments. The sample was weighted to ensure all Health and Social Care Trusts and settings were appropriately represented.

RESULTS

These assessments involve high levels of need, risk and complexity. There were no major issues or concerns identified in the majority of assessments. The issues that were identified were mainly due to the difficulties in coordinating professionals and in securing a bed. In 3/189 (2%) of assessments, these issues were identified as contributing to increased distress and risk.

CONCLUSIONS

The results highlight the complexities of these processes and confirm the need for opportunities, such as joint training and inter-agency interface groups, to further promote cooperation and identify when pressures on resources are increasing risk and distress.

Patients' experiences of assessment and detention under mental health legislation: systematic review and qualitative meta-synthesis

BACKGROUND

Understanding patient experiences of detention under mental health legislation is crucial to efforts to reform policy and practice.

AIMS

To synthesise qualitative evidence on patients' experiences of assessment and detention under mental health legislation.

METHOD

Five bibliographic databases were searched, supplemented by reference list screening and citation tracking. Studies were included if they reported on patient experiences of assessment or detention under mental health legislation; reported on patients aged 18 years or older; collected data using qualitative methods; and were reported in peer-reviewed journals. Findings were analysed and synthesised using thematic synthesis.

RESULTS

The review included 56 papers. Themes were generally consistent across studies and related to information and involvement in care, the environment and relationships with staff, as well as the impact of detention on feelings of self-worth and emotional state. The emotional impact of detention and views of its appropriateness varied, but a frequent theme was fear and distress during detention, including in relation to the use of force and restraint. Where staff were perceived as striving to form caring and collaborative relationships with patients despite the coercive nature of treatment, and when clear information was delivered, the negative impact of involuntary care seemed to be reduced.

CONCLUSIONS

Findings suggest that involuntary in-patient care is often frightening and distressing, but certain factors were identified that can help reduce negative experiences. Coproduction models may be fruitful in developing new ways of working on in-patient wards that provide more voice to patients and staff, and physical and social environments that are more conducive to recovery.

DECLARATION OF INTEREST

None.

Individuals' experiences of involuntary admissions and preserving control: qualitative study

BACKGROUND

A theoretical model of individuals' experiences before, during and after involuntary admission has not yet been established.

AIMS

To develop an understanding of individuals' experiences over the course of the involuntary admission process.

METHOD

Fifty individuals were recruited through purposive and theoretical sampling and interviewed 3 months after their involuntary admission. Analyses were conducted using a Straussian grounded theory approach.

RESULTS

The 'theory of preserving control' (ToPC) emerged from individuals' accounts of how they adapted to the experience of involuntary admission. The ToPC explains how individuals manage to reclaim control over their emotional, personal and social lives and consists of three categories: 'losing control', 'regaining control' and 'maintaining control', and a number of related subcategories.

CONCLUSIONS

Involuntary admission triggers a multifaceted process of control preservation. Clinicians need to develop therapeutic approaches that enable individuals to regain and maintain control over the course of their involuntary admission.

DECLARATION OF INTEREST

None.