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Scholten M, Efkemann SA, Faissner M, Finke M, Gather J, Gergel T, Gieselmann A, van der Ham L, Juckel G, van Melle L, Owen G, Potthoff S, Stephenson LA, Szmukler G, Vellinga A, Vollmann J, Voskes Y, Werning A, Widdershoven G. Opportunities and challenges of self-binding directives: A comparison of empirical research with stakeholders in three European countries. Eur Psychiatry 2023; 66:e48. [PMID: 37293987 PMCID: PMC10305757 DOI: 10.1192/j.eurpsy.2023.2421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/29/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Self-binding directives (SBDs) are psychiatric advance directives that include a clause in which mental health service users consent in advance to involuntary hospital admission and treatment under specified conditions. Medical ethicists and legal scholars identified various potential benefits of SBDs but have also raised ethical concerns. Until recently, little was known about the views of stakeholders on the opportunities and challenges of SBDs. AIMS This article aims to foster an international exchange on SBDs by comparing recent empirical findings on stakeholders' views on the opportunities and challenges of SBDs from Germany, the Netherlands, and the United Kingdom. METHOD Comparisons between the empirical findings were drawn using a structured expert consensus process. RESULTS Findings converged on many points. Perceived opportunities of SBDs include promotion of autonomy, avoidance of personally defined harms, early intervention, reduction of admission duration, improvement of the therapeutic relationship, involvement of persons of trust, avoidance of involuntary hospital admission, addressing trauma, destigmatization of involuntary treatment, increase of professionals' confidence, and relief for proxy decision-makers. Perceived challenges include lack of awareness and knowledge, lack of support, undue influence, inaccessibility during crisis, lack of cross-agency coordination, problems of interpretation, difficulties in capacity assessment, restricted therapeutic flexibility, scarce resources, disappointment due to noncompliance, and outdated content. Stakeholders tended to focus on practical challenges and did not often raise fundamental ethical concerns. CONCLUSIONS Stakeholders tend to see the implementation of SBDs as ethically desirable, provided that the associated challenges are addressed.
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Affiliation(s)
- Matthé Scholten
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Simone A. Efkemann
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Mirjam Faissner
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Marleen Finke
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Jakov Gather
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Tania Gergel
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Astrid Gieselmann
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
- Department of Psychiatry and Psychotherapy, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Lia van der Ham
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Georg Juckel
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Laura van Melle
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- GGZ inGeest, Amsterdam, The Netherlands
| | - Gareth Owen
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Sarah Potthoff
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Lucy A. Stephenson
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - George Szmukler
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | | | - Jochen Vollmann
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Yolande Voskes
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Anna Werning
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Guy Widdershoven
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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van Melle L, van der Ham L, Voskes Y, Widdershoven G, Scholten M. Opportunities and challenges of self-binding directives: an interview study with mental health service users and professionals in the Netherlands. BMC Med Ethics 2023; 24:38. [PMID: 37270612 DOI: 10.1186/s12910-023-00915-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/17/2023] [Indexed: 06/05/2023] Open
Abstract
BACKGROUND Self-binding directives (SBDs) are psychiatric advance directives that include the possibility for service users to consent in advance to compulsory care in future mental health crises. Legal provisions for SBDs exist in the Netherlands since 2008 and were updated in 2020. While ethicists and legal scholars have identified several benefits and risks of SBDs, few data on stakeholder perspectives on SBDs are available. AIMS The aim of the study was to identify opportunities and challenges of SBDs perceived by stakeholders who have personal or professional experience with legally enforceable SBDs. METHODS Data collection was carried out in the Netherlands from February 2020 to October 2021 by means of semi-structured interviews. Participants were selected through purposive sampling and snowball methods. Interviews were conducted with mental health service users (n = 7), professionals (n = 13), and an expert on SBD policy (n = 1), resulting in a total number of 21 interviews. The data were analyzed thematically. RESULTS Perceived benefits of SBDs included increased autonomy, improvement of the therapeutic relationship, possibility of early intervention and prevention of harm, prevention of compulsory care, reduction of the duration of compulsory care and recovery, mitigation of negative experiences around compulsory care, and guidance for professionals in providing compulsory care. Perceived risks included infeasibility of SBD instructions, difficulty in decision-making around SBD activation, limited accessibility of SBDs, disappointment of service users due to non-compliance with SBDs, and limited evaluation and updating of SBD content. Barriers to SBD completion included lack of knowledge of SBDs among professionals, lack of motivation or insight among service users, and lack of professional support for SBD completion. Facilitators of SBD completion and activation included support for SBD completion, involvement of relatives and peer experts, specification of SBD content, and evaluation of compulsory care and SBD content. The new legal framework was regarded as having both positive and negative effects on SBD implementation. CONCLUSIONS Stakeholders who have personal or professional experience with legally enforceable SBDs perceive SBDs as having important benefits and tend not to articulate the fundamental ethical concerns about SBDs which can be found in the ethics and legal literature. Instead, they perceive ethical and practical challenges that can be addressed through the implementation of suitable safeguards.
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Affiliation(s)
- Laura van Melle
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Lia van der Ham
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Yolande Voskes
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Guy Widdershoven
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Matthé Scholten
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Markstr. 258a, 44799, Bochum, Germany.
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Scholten M, Efkemann SA, Faissner M, Finke M, Gather J, Gergel T, Gieselmann A, van der Ham L, Juckel G, van Melle L, Owen G, Potthoff S, Stephenson LA, Szmukler G, Vellinga A, Vollmann J, Voskes Y, Werning A, Widdershoven G. Implementation of self-binding directives: recommendations based on expert consensus and input by stakeholders in three European countries. World Psychiatry 2023; 22:332-333. [PMID: 37159359 PMCID: PMC10168143 DOI: 10.1002/wps.21095] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2023] [Indexed: 05/11/2023] Open
Affiliation(s)
- Matthé Scholten
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Simone Agnes Efkemann
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Mirjam Faissner
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Marleen Finke
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Jakov Gather
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Tania Gergel
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Astrid Gieselmann
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
- Department of Psychiatry and Psychotherapy, Campus Benjamin Franklin, Charité, Berlin, Germany
| | - Lia van der Ham
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Georg Juckel
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Laura van Melle
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- GGZ inGeest, Amsterdam, The Netherlands
| | - Gareth Owen
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Sarah Potthoff
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Lucy A Stephenson
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - George Szmukler
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Jochen Vollmann
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Yolande Voskes
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Anna Werning
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Guy Widdershoven
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
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Gerritsen S, Widdershoven G, van der Ham L, van Melle L, Kemper M, Voskes Y. Dealing with care disruption in High and Intensive Care wards: From difficult patients to difficult situations. Int J Ment Health Nurs 2021; 30:317-325. [PMID: 32936986 PMCID: PMC7891438 DOI: 10.1111/inm.12786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 08/07/2020] [Accepted: 08/14/2020] [Indexed: 11/28/2022]
Abstract
High and Intensive Care is a relatively new care model in Dutch mental health care for clinical admissions. One of the goals is to keep the admission short. For some patients, this goal is not realized, which results in a long-term admission. Often, this is experienced as a disruption. Disruptions in care processes are frequently defined in terms of patient characteristics. Yet, it may be that other factors play a role. The aim of this study is to gain better insight into the perceptions of care professionals of what is characteristic for disruptions at High and Intensive Care wards and how professionals can deal with these. Qualitative research was performed by means of semi-structured interviews and a focus group with professionals. Results show that a focus on patient characteristics is too narrow and that other factors also play an important role. These factors include challenges in the relation between professionals and the patient, a divided team, and a lack of collaboration with ambulatory care. In order to deal with these factors, professionals should invest in the relationship with the patient, identify destructive team processes early, and improve communication with ambulatory care. It is recommended to develop a monitoring tool that includes all these factors. Another recommendation is to organize structured reflection on dilemmas experienced in care. In conclusion, this study shows the importance of going beyond patient characteristics in order to better understand, identify, and deal with disruption at High and Intensive Care wards.
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Affiliation(s)
- Sylvia Gerritsen
- Department of Medical HumanitiesAmsterdam University Medical CenterVU University Medical CenterAmsterdamThe Netherlands
| | - Guy Widdershoven
- Department of Medical HumanitiesAmsterdam University Medical CenterVU University Medical CenterAmsterdamThe Netherlands
| | - Lia van der Ham
- Low Vision ResearchOphthalmologyAmsterdam University Medical CenterVU University Medical CenterAmsterdamThe Netherlands
| | - Laura van Melle
- Department of Medical HumanitiesAmsterdam University Medical CenterVU University Medical CenterAmsterdamThe Netherlands
- Institute for Medical Ethics and History of MedicineRuhr University BochumBochumGermany
| | | | - Yolande Voskes
- Department of Medical HumanitiesAmsterdam University Medical CenterVU University Medical CenterAmsterdamThe Netherlands
- GGZ BreburgTilburgThe Netherlands
- Tranzo, Tilburg UniversityTilburgThe Netherlands
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van der Ham L, Wright P, Van TV, Doan VDK, Broerse JEW. Perceptions of mental health and help-seeking behavior in an urban community in Vietnam: an explorative study. Community Ment Health J 2011; 47:574-82. [PMID: 21409418 PMCID: PMC3185226 DOI: 10.1007/s10597-011-9393-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Accepted: 02/28/2011] [Indexed: 01/23/2023]
Abstract
This explorative study assesses perceptions of mental health and help-seeking behavior among adults in Vietnam. Methods included questionnaires (200) and focus group discussions (eight). Respondents were often unable to name specific mental illnesses. Frequently mentioned symptoms of mental illness were talking nonsense, talking/laughing alone and wandering. Pressure/stress and studying/thinking too much were often identified causes. Most respondents showed a preference for medical treatment options, often in combination with family care. The results show that perceptions of mental health and help-seeking behaviour are influenced by a lack of knowledge and a mix of traditional and modern views.
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Affiliation(s)
- Lia van der Ham
- Athena Institute, VU University Amsterdam, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands.
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