Attitudes among stakeholders towards compulsory mental health care in Norway

Objectives

The Norwegian Mental Health Care Act allows use of coercion under certain conditions. Even though the current practice has been criticized, little empirical data exist about the attitudes towards compulsory mental health care.

Method

This study used Q-methodology to identify prototypical attitudes and to test possible differences of attitudes between groups of stakeholders towards the use of coercion in mental health care. Sixty-two respondents who represented six groups with different roles in mental health care participated: former patients, relatives of psychiatric patients, members of supervisory commissions, psychiatrists, other physicians, and lawyers.The participants were asked to assess the degree to which they agreed on 30 statements concerning use of coercion for the mentally ill.

Results

Three factors that in a meaningful way express different attitudes towards the question were found. The most widely shared attitude stated that a trusting relationship between patient and therapist is more important than the right to have an attorney. This attitude gives partial support to the present Mental Health Care Act. However, the second most common attitude argues that involuntary hospitalization, if necessary, should be decided in a court and not by the hospital doctor.

Conclusions

Differences in attitude could partly be explained by the respondents' role in mental health care. Both psychiatrists and “somatic” physicians expressed more agreement with the present legislation than the other stakeholders. The findings may have implications for the legal protection of mental health care patients.     

Outpatient commitment and coercion in New Zealand: a matched comparison study

BACKGROUND: It has been hypothesized that a degree of coercion is a necessary component in using outpatient commitment to attain therapeutic outcome for those people subject to mental health law. However, what degree of coercion is required and how it is sustained is poorly understood. There is speculation that patients' recognition of beneficial as well as unwanted aspects of outpatient commitment (ambivalence) maybe an indicator that the necessary level of coercion has been achieved to facilitate a therapeutic outcome. AIM: The aim of this study was to determine the level of coercion perceived by those under outpatient commitment in New Zealand. Emphasis was given to consideration of the presence of ambivalence and the role of interactive processes, including procedural justice, in influencing patients' perceptions of coercion. METHOD: A cross-sectional comparative study was undertaken to compare the perceptions of coercion of patients on outpatient commitment (n = 69) to a matched sample of voluntary outpatients (n = 69), using the Perceived Coercion Scale. The influence of a range of variables, including patients' knowledge of and beliefs concerning outpatient commitment, were considered. RESULTS: Although the level of coercion for involuntary outpatients was relatively low, it was significantly higher than that experienced by voluntary outpatients. Yet involuntary outpatients were more likely to espouse benefits of outpatient commitment. Although there was an inverse correlation between perceptions of procedural justice and perceived coercion, procedural justice did not feature in the linear regression analysis. DISCUSSION: In the New Zealand context, involuntary outpatients hold contrasting views to outpatient commitment. We suggest that this ambivalence is an indicator that the degree of coercion is suffice to achieve therapeutic outcome. Furthermore, this study suggests the impact of procedural justice on patients' perceptions of coercion may be more crucial during admission to hospital than in the context of on-going community care.     

论《精神卫生法》的自愿原则

为了防止正常人"被精神病",更好地保护精神障碍患者的合法权益,《精神卫生法》确立了自愿原则。该原则渊源于私法领域的自愿原则而又与其不同,是在知情的条件下对精神卫生服务的单方接受自愿。它回应了要像人一样保护精神障碍患者,彰显了精神卫生法的福利法本质。它包涵自愿诊断、自愿治疗和自愿出院三个既相互区别又相互联系子原则。非自愿诊断、非自愿治疗、非自愿继续住院治疗只是自愿原则的补充,此种例外旨在寻求患者精神健康权与社会公众安全保护的平衡。     

论强制医疗启动程序决定主体

强制医疗制度是国家医疗保健制度的有机组成部分,强制医疗有广义与狭义之分。狭义的强制医疗,如实施危害行为的精神病患者、甲类传染病患者等;广义的强制医疗,包括预防接种、指定医保单位就医等。强制医疗程序启动的决定主体必须是国家赋予相应权力的机关,其他任何单位不具有这样的权力,因而无权决定强制医疗程序启动。强制医疗主体的确定取决于强制医疗对象的危害程度、广度及时间等因素。     

Severe mental disorder as a basic commitment criterion for minors

Since 1991, commitment to involuntary psychiatric care has been allowed in Finland for minors in broader terms than for adults. While in adults mental illness has to be diagnosable before involuntary treatment can be imposed, minors can be committed to and detained in involuntary psychiatric treatment if they suffer from "severe mental disorders", and fulfil the further commitment criteria defined in the Mental Health Act. The first years of the new mental health legislation showed an increase in involuntary treatment of minors in Finland. Concerns were raised about the imprecise nature of the commitment criterion "severe mental illness". This study set out to find out whether Finnish child and adolescent psychiatrists are in agreement on how to define severe mental illness and whether their interpretations are sufficiently similar to ensure the equality of minors in commitment to psychiatric care as prescribed by the Mental Health Act. Semi-structured, reflexive dyadic interviews were carried out with 44 psychiatrists working with children and adolescents. The data was analysed using qualitative content analysis. There was general agreement about what constitutes a "severe mental disorder" justifying the involuntary psychiatric treatment of minors. The child and adolescent psychiatrists were of the opinion that involuntary treatment of minors should not be tied to specific diagnostic categories. Which disorders are severe enough to justify commitment should rather be considered through developmental and functional impairment and interactions between a minor and her/his environment.     

Reforming the Mental Health Act 1983: an approved social worker perspective

The government green paper, 'Reform of the Mental Health Act 1983', was published in November 1999, for consultation by end of March 2000. This article offers comment on the operation of the Mental Health Act 1983 and the proposals for change, from an approved social worker perspective. Under the Mental Health Act 1983, approved social workers undertake social assessments of mental health crises, deciding upon the need for compulsory admission and treatment. To the debate on legislative change they bring a detailed social perspective on the processes and outcomes of statutory mental health intervention. Approved social workers' main concerns relate to the social context of mental health need, the availability of social resources, civil liberties, protections for people subject to statutory mental health interventions and the effective regulation of practice and services. Current proposals include options that would significantly reduce approved social worker involvement in decisions about compulsory admission and treatment; the implications of this are discussed.     

Perceived coercion and need for hospitalization related to psychiatric admission

Psychiatric hospitalization constitutes a moment of major stress to the point that occurrences of posttraumatic stress disorders have been described. Feelings of coercion are usual, whatever the legal status of admission. Patients may also consider afterwards that they needed hospitalization even if they refused it initially. A cross-sectional survey has been conducted among the inpatients of a Swiss psychiatric hospital to assess their subjective view of admission with emphasis on legal status, perceived coercion and need for hospitalization. Eighty-seven questionnaires were completed and analyzed. Results indicated that 74% of patients felt that they had been under pressure to be hospitalized, whether or not they were involuntarily admitted. Seventy percent felt their admission was necessary. More involuntary patients reported a subjective lack of improvement. Clinicians could decrease feelings of coercion of their patients while discussing need for hospitalization, legal status and subjective feeling of coercion as different dimensions. An argument is presented to favor positive pressure from social environment over legal involuntary commitment in many hospitalizations.     

Invocation of coercion context in compliance communication -- power dynamics in psychiatric care

This article draws on observations from ethnographic fieldwork to develop a theoretical understanding of the power dynamics in psychiatric care. The aim is to analyze how psychiatric clinicians solve compliance problems by invoking "coercion context". It is suggested that clinicians take a rather instrumental approach to laws regulating coercive intervention. Clinicians may invoke a coercion context even with voluntary patients. For example, they may use wordings that connote coercion, or they may make use of how treatment wards are set up to accommodate involuntary patients, thus stalling voluntary patients who cannot exit through locked doors. A coercion context can also be invoked to solve mundane practical problems, e.g. when clinicians talk about "coerced showers". The management of information and maintaining a suitable "awareness context" with regards to coercion is an essential feature in clinical attempts to achieve compliance from patients. In conclusion, the notion of coercion context helps explain the confusing findings from previous research about patients' apparent misconceptions of their formal legal status. Furthermore, it is argued that research that rely on decontextualised, objectifications of "coercion" risk to miss the meaning coercion is assigned in everyday clinical practice.     

精神障碍患者非自愿收治程序设计的若干法律问题研究(上)刘瑞爽

对于精神障碍患者的非自愿收治,应注意保障患者的人身权利,尤其是合理程序保障的权利。比较分析国际上的各国立法,在收治程序各个环节上,均须体现出对人权的保护,其主要问题有：制定强制收治的标准、送治主体、收治主体、初步裁定的步骤和时限、对初步裁定的救济、法律代表人制度、司法审查的介入（或独立第三方的介入）、危险的证明、避免无限期拘留而进行的后续定期审查、患者方获取信息的权利保障、上诉等。我国应坚持程序正义原则,借鉴国际上先进立法经验,弥补我国精神障碍患者非自愿收治程序设计的立法漏洞。     

The mental health service crisis of neoliberalism -- an antipodean perspective

Major transformations in forms of governance of the liberal state have been wrought over the course of the last century, including the rise of neoliberalism and 'new public management.' Mental health too has witnessed change, with pharmacological treatment displacing residential care, a shift to community-based services, mainstreaming with general health care, and greater reliance on civil society institutions such as the family or markets. This article considers whether mental health law, and its court/tribunal 'gatekeepers' have kept pace with those changes. It argues that the focus of the liberal project needs to shift to measures which will better guarantee access to mental health services, and keep a more watchful eye on both 'hidden' coercion of people on community treatment orders, and passive neglect of human need.     

Coercion and patient satisfaction on psychiatric acute wards

Legal-, perceived- and objective coercion were examined both separately and together as a measure of accumulated coercion, to determine how coercion affected patient satisfaction in patients admitted for acute psychiatric care. Accumulated coercive events significantly reduced both overall satisfaction, and satisfaction in four of five subscales evaluating different aspects of treatment. Neither legal status nor perceived coercion affected patient satisfaction, while objective coercion had a significant negative effect on overall satisfaction when these measures were analysed separately. Overall patient satisfaction reported at discharge was low, while satisfaction with different aspects of treatment showed considerable variation. The observation that perceived coercion in the admission process did not affect satisfaction significantly underlines the need to further explore the interaction between subjective and objective measures for coercion. It appears that multiple measures for coercion should be used in future studies.     

The relationship between mandated community treatment and perceived barriers to care in persons with severe mental illness

OBJECTIVE: In recent decades debate has intensified over both the ethics and effectiveness of mandated mental health treatment for persons residing in the community. Perceived barriers to care among persons subjected to mandated community treatment, and the possibility that fear of involuntary treatment may actually create or strengthen such barriers rather than dissolve them, are key issues relevant to this debate but have been little studied. This article explores the link between receipt of mandated (or "leveraged") community treatment and reasons for avoiding or delaying treatment reported by persons with severe mental illness. It also examines the potential moderating effect of social support on the association between mandated treatment experiences and barriers attributable to fear of involuntary commitment or forced treatment. METHOD: Data are presented from a survey of 1011 persons with psychiatric disorders being treated in public-sector mental health service systems in five U.S. cities. Logistic and negative binomial regression analyses were used to examine the association between mandated community treatment and perceptions of barriers to care, controlling for demographic and clinical characteristics. RESULTS: Across sites, 32.4% to 46.3% of respondents reported barriers attributed to fear of forced treatment. Whereas 63.7% to 76.1% reported at least one non-mandate-related barrier to care; the mean number of non-mandated barriers to care ranged from 1.6 to 2.3 (range 0-7). Between 44.1% and 59.0% of participants had experienced at least one type of leveraged treatment. Persons experiencing multiple forms of mandated treatment were more likely to report barriers to care in comparison to those not reporting mandated treatment. Findings also indicated that social support moderates the relationship between multiple leverages (three or four forms) and mandate-related barriers to care. CONCLUSIONS: Perceived barriers to care associated with mandated treatment experience have the potential to adversely affect both treatment adherence and therapeutic alliance. Awareness of potential barriers to care and how they interact with patients' perceived social support may lead to improved outcomes associated with mandated treatment.     

The Effect of Coercion on Aggression and Mental Health Among Reciprocally Violent Couples

Researchers have not investigated mental health outcomes among couples who are reciprocally violent towards each other. The present study investigated differences in partner violence (psychological, physical, and sexual) and mental health symptoms (depression, anxiety, hostility, and somatic) between two types of reciprocally violent couples: situational couple violence (SCV) and mutual control violence (MVC). SCV couples use violence to address stressful family conflicts, while MVC couples use violence as a tool to control each other. Participants (N = 609) completed surveys that contained several instruments that measured past violence, coercive behaviors, physical injuries, and mental health symptoms. Results revealed that MVC reported significantly higher levels of violent perpetration and worse physical and mental health than SCV. These findings have implications for understanding the role of coercion in partner violence and mental health, which can be used for the development of appropriate mental health services for couples who are mutually violent towards each other.     

Therapeutic jurisprudence and mental health tribunals: changing patterns of demand and its impact

For decades the mental health system has been ‘in crisis,’ with too little funding, too much demand and fragmented services. In England and Wales, decisions made concerning the care and treatment of those suffering from a mental disorder is governed by the Mental Health Act 1983 (as amended) (MHA 1983). Detention under the legislation is fraught with conflict; patient and clinical views are often at odds. Mental health tribunals enable patients to seek a review of their case and the legality of their detention. This paper argues that with the increased use of formal detention under the MHA 1983, the caseloads of mental health tribunals have similarly risen. Whether it is possible to advance therapeutic benefit to psychiatric patients attending tribunals is open to question. While mental health tribunals have a role to play in generating a positive psychological impact on an applicant, there is a risk that time and resource pressures may inhibit the adoption of a therapeutic approach. This paper considers the key drivers that are currently pushing detention rates up, the impact this is having on mental health tribunal caseloads and whether it is possible to bring therapeutic jurisprudence to the patient.     

Actions taken in response to mental health screening at reception into prison

Screening for mental health problems on reception into custody has been criticised. However, there have been few studies on care pathways through custody as a result of screening identification. We aimed to identify what actions were taken as a result of screening positive for suicidal ideation and mental health problems. Case records for 2166 prisoners newly received into five prisons in England and documented contact with health care professionals in the following month were examined by hand over a four-month period. Altogether, 3% of prisoners were screened as having current suicidal ideas, of whom 30% had no contact with mental health services or risk assessment documentation. Another 21% of new receptions received psychotropic medication, for whom over 60% received no primary mental health assessment, and only 36% received psychotropic medication in prison. Care pathways need to be defined, and screening needs to be delivered as originally intended by initial screen for life-threatening matters, followed by a later, comprehensive assessment of health needs.     

Voluntary and involuntary care: three-year study of demographic and diagnostic admission statistics at an inner-city adult psychiatry unit

Individuals with mental disorders can, under specific circumstances, be detained and treated against their wishes. In 2009, there were 1633 involuntary admissions in Ireland, accounting for 8.1% of all psychiatric admissions. We examined demographic and diagnostic factors associated with involuntary admission in a general adult psychiatry service in Dublin's north inner-city over a retrospective three-year period. The overall admission rate was 450.5 admissions per 100,000 population per year (deprivation-adjusted rate: 345.7), which is lower than the national rate (476.3). The involuntary admission rate was 67.7 (deprivation-adjusted rate: 51.9), which is higher than the national rate (38.5). Fifteen per cent of admissions were involuntary (for all or part of the admission), which is higher than the national proportion (8.1%) but the same as that reported in another inner-city psychiatry service (15.7%). The proportion of admissions that was involuntary was higher amongst individuals from outside Ireland (33.9%) compared to those from Ireland (12.0%) (p<0.001). Country of origin was, however, related to diagnosis: 53.2% of admissions of individuals from outside Ireland were with schizophrenia, compared to 18.5% of admissions of individuals from Ireland (p<0.001). Diagnosis was, in turn, related to admission status: 37.5% of admissions with schizophrenia were involuntary compared to 15% overall (p<0.001). On multi-variable testing, diagnosis was the only independent predictor of admission status (p=0.01) (R(2)=35.2%); country of origin was not an independent predictor of admission status. Deprivation accounts for part, but not all, of the high rate of involuntary admission in Dublin's inner-city. Diagnosis accounts for one third of the variance in admission status between individuals. Further study is required to determine what factors account for the remaining two thirds (e.g. symptoms, insight) and to clarify better the relationships between admission status, diagnosis and country of origin. There is a strong need for enhanced focus on the mental health needs of individuals from outside of Ireland, especially in Dublin's north inner-city.     

A comparison of mental health legislation from diverse Commonwealth jurisdictions

IntroductionIn the regulation of involuntary treatment, a balance must be found between duties of care and protection and the right to self-determination. Despite its shared common roots, the mental health legislation of Commonwealth countries approaches this balance in different ways. When reform is planned, lessons can be learned from the experiences of other countries.MethodCriteria for involuntary treatment used in a sample of 32 Commonwealth Mental Health Acts were compared using a framework developed from standards derived from the Universal Declaration of Human Rights. Reasons for non-compliance were considered and examples of good practice were noted. Changes in the criteria used over time and across areas with differing levels of economic development were analysed.Results1. Widespread deviation from standards was demonstrated, suggesting that some current legislation may be inadequate for the protection of the human rights of people with mental disorders. 2. Current trends in Commonwealth mental health law reform include a move towards broad diagnostic criteria, use of capacity and treatability tests, treatment in the interests of health rather than safety, and regular reviews of treatment orders. Nevertheless, there are some striking exceptions.DiscussionExplanations for deviation from the standards include differing value perspectives underpinning approaches to balancing conflicting principles, failure to keep pace with changing attitudes to mental disorder, and variations in the resources available for providing treatment and undertaking law reform. Current good practice provides examples of ways of dealing with some of these difficulties.     

反思精神障碍强制医疗的“危险性”原则

很多国家精神卫生立法在强制医疗人院标准方面都适用了“危险性”原则,我国《精神卫生法》也在其列。然而,“危险性”原则是基于三个错误的假设,因此实际上“危险性”原则可能会增加精神疾病对患者的伤害和较大程度增加社区危险的风险。本文呼吁参考Large及Richardson的观点及美国部分州与苏格兰精神卫生立法的实证经验,在“危险性”原则基础上补充“拒绝治疗的能力”评定作为精神障碍者强制医疗入院标准。     

“治疗可能性”要件:遵从抑或摒弃?

精神病人的强制医疗一般以患有精神疾病且对本人或他人具有危险性为条件,"治疗可能性"是否应作为强制医疗的条件,理论和实践均存在较大的分歧。出于公共秩序之维护,摈弃"治疗可能性"要件呼声的日渐高涨,但基于精神病人权利之保护仍有必要将"治疗可能性"作为强制医疗的要件,而对于无治疗可能、具有危险性的精神病人应通过其他社会控制机制予以解决,而不应纳入强制医疗的范围。