Service-user and carer perspectives on compliance and compulsory treatment in community mental health services

When Treatment Pressures Become Coercive: A Context-Sensitive Model of Informal Coercion in Mental Healthcare

Treatment pressures are communicative strategies that mental health professionals use to influence the decision-making of mental health service users and improve their adherence to recommended treatment. Szmukler and Appelbaum describe a spectrum of treatment pressures, which encompasses persuasion, interpersonal leverage, offers and threats, arguing that only a particular type of threat amounts to informal coercion. We contend that this account of informal coercion is insufficiently sensitive to context and fails to recognize the fundamental power imbalance in mental healthcare. Based on a set of counterexamples, we argue that what makes a proposal coercive is not whether service users will actually be made worse off if they reject the proposal, but rather whether they have the justified belief that this is the case. Whether this belief is justified depends on the presence of certain contextual factors, such as strong dependency on professionals and the salient possibility of formal coercion.

Use of compulsory community treatment in mental healthcare: An integrative review of stakeholders' opinions

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.

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

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.

Coercion in psychiatric and mental health nursing: A conceptual analysis

The use of coercion in psychiatric and mental health nursing is a major challenge, which can lead to negative consequences for nurses and patients, including rupture in the therapeutic relationship and risk of injury and trauma. The concept of coercion is complex to define and is used in different ways throughout the nursing literature. This concept is defined broadly, referring to both formal (seclusion, restraint, and forced hospitalization), informal (persuasion, threat, and inducement), and perceived coercion, without fully addressing its evolving conceptualizations and use in nursing practice. We conducted a concept analysis of coercion using Rodgers' evolutionary method to identify its antecedents, attributes, and associated consequences. We identified five main attributes of the concept: different forms of coercion; the contexts in which coercion is exercised; nurses' justification of its use; the ethical issues raised by the presence of coercion; and power dynamics. Our conceptual analysis shows the need for more nursing research in the field of coercion to achieve a better understanding of the power dynamics and ethical issues that arise in the presence of coercion.

'Waiting for the verdict': the experience of being assessed under the Mental Health Act

BACKGROUND

Following the Independent Mental Health Act review, there is increasing focus on this coercive part of mental health services and a call for service user views to be central to proposed changes. Although there are numerous studies into being detained in hospital, there is a lack of data exploring the service user experiences of the assessment process.

AIM

To explore the subjective experience of being assessed under the Mental Health Act (MHA).

METHOD

10 participants were interviewed about their recent assessment experience and the transcribed interviews were analysed using framework approach.

RESULTS

The overarching theme of person centred care emerged from these interviews with interconnecting sub themes: 1) information and options; 2) "the barrage of three"; 3) "sit down and listen"; and 4) service user voice.

CONCLUSION

As one of the first studies into service user experiences of MHA assessments, this exploratory study indicates that there is lack of person centeredness. The Independent Mental Health Act review has set a challenge for treating person as individual and increasing rights and involvement of service users. This study suggests service user's experiences do not yet meet this aspiration and they want to discuss these experiences and have their voices heard.

A "Rapid Best-Fit" model for framework synthesis: Using research objectives to structure analysis within a rapid review of qualitative evidence

The short time frame associated with rapid reviews can be challenging for researchers conducting qualitative evidence synthesis. In these circumstances a Best-Fit Framework Synthesis, drawing upon existing theory and/or research, may be conducted to rapidly make sense of qualitative evidence. This article discusses a "Rapid Best-Fit" approach to conducting Framework Synthesis within an 6-week rapid systematic review of qualitative evidence. In the absence of a suitable theoretical model to inform the synthesis, we drew upon our research objectives to structure a framework, and to identify the studies which contained the most relevant data. Themes from these studies were used to revise the initial framework before inductive thematic synthesis finalized theme content. This "Rapid Best-Fit" approach yielded results aligned with the needs of the commissioners of the review and is a useful addition to qualitative synthesis methods, allowing for the incorporation of diverse views and experiences into fast-paced decision making scenarios.

Experiences with legally mandated treatment in patients with schizophrenia: A systematic review of qualitative studies

Background:

Patients with severe mental illness, including schizophrenia, may be legally mandated to undergo psychiatric treatment. Patients’ experiences in these situations are not well characterized. This systematic review of qualitative studies aims to describe the experiences of patients with schizophrenia and related disorders who have undergone legally mandated treatment.

Methods:

Four bibliographic databases were searched: CINAHL Plus (1981–2019), EMBASE (1947–2019), MEDLINE (1946–2019), and PsycINFO (1806–2019). These databases were searched for keywords, text words, and medical subject headings related to schizophrenia, legally mandated treatment and patient experience. The reference lists of included studies and systematic reviews were also investigated. The identified titles and abstracts were reviewed for study inclusion. A thematic analysis was completed for the synthesis of positive and negative aspects of legally mandated treatment.

Results:

A total of 4,008 citations were identified. Eighteen studies were included in the final synthesis. For the thematic analysis, results were collated under two broad themes; positive patient experiences and negative patient experiences. Patients were satisfied when their autonomy was respected, and dissatisfied when it was not. Patients often retrospectively recognized that their treatment was beneficial. Furthermore, negative aspects of the treatment included deficits in communication and a lack of information.

Conclusions:

Intervention research has historically focused on clinical outcomes and the quantitative aspects of treatment. Thus, this study provides insight into the qualitative aspects of patients’ experiences with legally mandated treatment. Recognizing these opinions and experiences can lead to better attitudes toward treatment for patients with schizophrenia and related psychiatric illnesses.

[Build a bridge to the patient experiences psychosis in a context of coercion]

The nursepatient relationship is particularly challenging when the patient experiences psychosis and when he or she is placed in a context of coercion. Psychosis causes relational problems in the patient, which are further complicated in a context of coercion as this practice implies differences of understanding, status and power between the nurse and the patient. The Tidal Model, a care model focused on recovery, comprises ten principles of commitment for caregivers, which help to build a bridge between them and the person experiencing psychosis.

Mental health patients' experiences of softer coercion and its effects on their interactions with practitioners: A qualitative evidence synthesis

AIMS

To synthesize qualitative evidence of mental health patients' treatment-related experiences of softer coercion and its effect on their interactions with practitioners.

BACKGROUND

Coercion is controversial but global in mental health care. It ranges from softer to harder forms, but less attention is given in the literature to softer coercion.

DESIGN

Qualitative thematic synthesis examining patients' experiences of softer coercion.

DATA SOURCES

Electronic databases searched from inception to September 2015 and further updated January 2018.

REVIEW METHODS

Thematic synthesis of 11 UK/Irish articles, quality appraised using the Critical Appraisal Skills Programme tool.

RESULTS

Three analytic themes were developed: Losing a sense of self, Less than therapeutic relationship, and Journey through treatment.

CONCLUSION

Softer coercion is experienced across mental health care in a context of broader coercion.

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.

Coercion and power in psychiatry: A qualitative study with ex-patients

OBJECTIVE

Coercion is a controversial issue in mental health care. Recent research highlights that coercion is a relational phenomenon, although, it remains unclear how this intersubjective context should be understood. The aim of this study is to propose an interactional model of the relational aspects of coercion that enhances theoretical understanding, based on the assumptions of patients.

METHOD

The research question was studied by means of interpretative phenomenological analysis. Twelve people who had psychiatric hospitalisations were interviewed in-depth, using broad open questions relating to the experience of coercion and power in psychiatry. Data were collected in 2016 and 2017 in Belgium.

RESULTS

Across participants' accounts we observed a specific structure. The relational quality of coercion seemed to be embedded within a process where individuals were one-sidedly approached as a 'sick patient', which led to profound segregation between staff and patients. This segregation caused a form of de-subjectivation: participants felt that important aspects of their subjectivity were neglected and they experienced professionals as de-subjectivated. They felt as if power resides within the (non-) interactions between patients and mental health workers. De-subjectivation arose and was enlarged within relations by broken contact, by silence in coercive acts, and by the necessity of patients to conform to the professionals' treatment regime. Helpful encounters that were not deemed coercive were those where patients and staff were individuated, which altered their relation.

CONCLUSIONS

To understand the relational quality of coercion, interventions like seclusion and house rules should also be understood within this structure of de-subjectivation. We need to tackle this dynamic if we want to reduce coercion in psychiatric care.

Experiences of the ‘Nearest Relative’ provisions in the compulsory detention of people under the Mental Health Act: a rapid systematic review

Background

Service users detained for assessment and/or treatment under the Mental Health Act 1983 (MHA 1983) are allocated a ‘Nearest Relative’ (NR). The NR has access to confidential information about the service user and can make decisions about their care and treatment. Tensions exist regarding the identification, displacement and powers of the NR.

Objectives

To examine the experiences of service users, carers and relevant professionals of the NR provisions of the MHA 1983, and the equivalent Named Person (NP) provisions in Scotland. Five research objectives were defined: understanding the experiences of and issues associated with (1) the identification of the NR, (2) the displacement of the NR, (3) confidentiality and information-sharing, (4) access to support from carers and (5) making decisions about treatment or care.

Data sources

Seven bibliographic databases were searched: MEDLINE (via Ovid), MEDLINE In-Process & Other Non-Indexed Citations (via Ovid), PsycINFO (via Ovid), Social Policy and Practice (via Ovid), Health Management Information Consortium (via Ovid), Cumulative Index to Nursing and Allied Health Literature (via EBSCOhost) and Applied Social Sciences Index and Abstracts (via ProQuest). Citation searching, author contact and grey literature searches were conducted.

Review methods

A rapid systematic review was conducted in 6 weeks. Evidence published after 1998 from the UK pertaining to the experiences of those involved in compulsory detention under the MHA 1983 (or UK variants), including service users, carers, family members, NRs, NPs, mental health professionals, policy-makers and lawyers, was sought. Study selection, data extraction and critical appraisal were completed independently by two reviewers. We looked for data about experiences, which were obtained through qualitative means or surveys. Included studies containing several paragraphs of participant quotations and/or author interpretations were entered into a framework synthesis; the rest were summarised descriptively. The framework synthesis was based on the five research objectives and refined using the findings of key studies from England and Scotland and an inductive thematic analysis.

Results

Twenty studies were included with 12 prioritised for framework synthesis. Four themes emerged: (1) issues regarding the identification of the NR/NP, (2) confidentiality and information-sharing, (3) enabling the use of the NR/NP role and (4) the importance of maintaining relationships. The involvement of service users in choosing their representative and the role of services in supporting the NR/NP was identified as important.

Limitations

There is little recent evidence to inform this important and complex discussion. The review was rigorously conducted despite the short time scale; however, a more in-depth, iterative thematic analysis of all the included studies may have provided additional insights into the mechanisms underpinning the issues.

Conclusions

The NR provisions of the MHA 1983 are complex and of significant importance to individuals detained under the Mental Health Act and their carers. This rapid review provides specific examples of issues that individuals may experience. More research is needed to aid understanding of this complex topic.

Future work

Primary research specifically focused on the perceived and actual use and impact of the NR provisions in England and Scotland.

Study registration

This study is registered as PROSPERO CRD42018088237.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Community treatment orders: exploring the paradox of personalisation under compulsion

The introduction of supervised community treatment, delivered through community treatment orders (CTOs) in England and Wales, contrasts with the policy of personalisation, which aims to provide service users autonomy and choice over services. This article draws upon findings from a primarily qualitative study which included 72 semi-structured interviews (conducted between January and December 2012) with practitioners, service users and nearest relatives situated within a particular NHS Trust. The article also refers to a follow-on study in which 30 Approved Mental Health Practitioners were interviewed. The studies aimed to develop a better understanding of how compulsory powers are being used in the community, within a policy context that emphasises personalisation and person-centred care in service delivery. Findings from the interview data (which were analysed thematically) suggest that service users were often inadequately informed about the CTO and their legal rights. Furthermore, they tended to be offered little, or no, opportunity to make choices and have involvement in the making of the CTO and setting of conditions. Retrospectively, however, restrictions were often felt beneficial to recovery, and service users reported greater involvement in decisions at review stage. Areas of good practice are identified through which person-centred care can be better incorporated into the making of CTOs.

'It's unbelievably humiliating'-Patients' expressions of negative effects of coercion in mental health care

PURPOSE

Some patients criticize coercive mental health treatment using extremely strong words. This may be connected to poor therapeutic relationships and unfavourable treatment outcomes, so a better understanding of this criticism is warranted.

METHODS

Data consisted of detailed notes from 15 all-day dialogue seminars on coercion and voluntariness in Oslo, Norway from 2006 to 2009. Very dissatisfied patients and ex-patients were a central voice through the seminars. To gain a better understanding of their negative experiences of coercion, we conducted a stepwise qualitative thematic analysis of the seminar notes, with a mix of inductive and deductive coding followed by focused coding and analytic induction.

RESULTS

Coercive care was described in strong terms, such as humiliation and Nazism. To explain this, we suggest a model of two pathways towards such strong language: (i) Participants understood their symptoms as mental crises following trauma or spiritual problems, and perceived involuntary medication to harm rather than help. Some found that their complaints were dismissed as lack of insight. (ii) Minor incidents were experienced as coercive, such as being 'defined' by the medical model, receiving repeated negative remarks and feeling one needed to succumb to get care. The accumulated effect could be experienced as eroding self-confidence and trust in their own feelings and thoughts.

CONCLUSION

Involuntary medication and dismissal of patient perspective, combined with the accumulated effects of minor negative incidents, can explain the feelings of humiliation, oppression and the use of metaphors such as imprisonment by totalitarian systems. Our model can help explain such patient reactions seen in clinical practice and the literature.

The experience of involuntary detention in acute psychiatric care. A review and synthesis of qualitative studies

OBJECTIVE

To build on a previous review and updated understanding of how patients experience involuntary detention for their mental health difficulties.

DESIGN

We provide a narrative synthesis review of qualitative studies.

DATA SOURCES

Using pre-defined search terms, the following databases were searched covering the period 2006 to March 2014: Psychinfo, Medline, Medline In-Process, Embase, Web of Knowledge, Scopus, Science Direct, British Nursing Index and Cinahl Plus. Three journals were electronically hand-searched.

REVIEW METHODS

The search resulted in the retrieval of 6230 records which were screened by title. Relevant studies were then screened by abstract and further articles were read for full text. References of articles read for full text were screened using an inclusion and exclusion criteria. A total of fifteen studies were identified and a quality evaluation tool was applied to each study. Themes and constructs from all fifteen studies were coded and synthesised.

RESULTS

Seven overarching themes emerged. 'Sanctuary', 'loss of normality and perceived independence', 'feeling terrified' and 'fluctuating emotions' illustrate the experiences of involuntary detention. The remaining themes reflect the factors that influence these experiences: 'a continuum of person-centred practice', 'disempowerment' and 'intra-psychic coping'.

CONCLUSIONS

Participants varied in how they experienced involuntary detention. Some people experienced a sense of sanctuary, whereas others experienced loss, fear and trauma. People's experiences were influenced by the degree of actual or perceived person-centred and empowering care, which also had an impact on their coping style. Development of a therapeutic bond with clinicians was a key factor which influenced positive experiences of involuntary detention. The implications of the findings are discussed with reference to existing literature and recommendations are made for clinical practice. Ideas for future research are identified.

Examining the use of metaphors to understand the experience of community treatment orders for patients and mental health workers

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.

Consumers and Carer perspectives on poor practice and the use of seclusion and restraint in mental health settings: results from Australian focus groups

BACKGROUND

Seclusion and restraint are interventions currently permitted for use in mental health services to control or manage a person's behaviour. In Australia, serious concerns about the use of such seclusion and restraint have been raised at least since 1993. Consumers and their supporters have also expressed strong views about the harm of these practices. This paper presents the results of ten focus group discussions with people with lived experience of mental health issues and also carers, family members and support persons in relation to the use of seclusion and restraint.

METHODS

The 30 consumers and 36 supporters participating in the focus groups convened in four Australian cities and one regional centre discussed their understandings of the use of seclusion and restraint and its impact on the people involved. Participants also presented their observations about poor practice and what contributes to it as well as providing ideas and recommendations regarding strategies to reduce or eliminate seclusion and restraint. Focus group discussions were recorded and transcribed, then analysed using the NVivo 10 qualitative data analysis software with a general inductive approach used to analyse data. This analysis enabled consideration of the responses to key questions in the focus groups as well as the identification of emerging themes.

RESULTS

Six themes emerged from the analysis, these being: human rights, trauma, control, isolation, dehumanisation and 'othering', and anti-recovery. Examples of poor practice identified by focus groups included the use of excessive force, lack of empathy/paternalistic attitudes, lack of communication and interaction and a lack of alternative strategies to the use of seclusion and restraint. There was a confluence of factors identified by participants as contributing to poor practice, with the main factors being organisational culture, the physical environment, under-resourced mental health services and fear and stigma.

CONCLUSIONS

Focus group participants in the main viewed seclusion and restraint practices in mental health settings as unnecessarily overused, exacerbating problems for individuals, carers, staff and the broader system of care. This study highlights that lived experience of both consumers and their supporters can make an important contribution to mental health services and its ongoing reform.

A qualitative study examining the presence and consequences of moral framings in patients' and mental health workers' experiences of community treatment orders

BACKGROUND

Mental health recovery involves acknowledging the importance of building the person's capacity for agency. This might be particularly important for patients on community treatment orders (CTOs - which involve enforced treatment for their mental illness), given limited international evidence for their effectiveness and underlying concerns about the use of coercion by workers and systems of care towards this population of people with mental illness.

METHODS

This study sought to understand how the meaning of CTOs is constructed and experienced, from the perspective of patients on CTOs and workers directly administering CTOs. Qualitative interviews were conducted with South Australian community mental health patients (n = 8) and mental health workers (n = 10) in 2013-14. During thematic analysis of data, assisted by NVIVO software, the researchers were struck by the language used by both groups of participants and so undertook an examination of the moral framings apparent within the data.

RESULTS

Moral framing was apparent in participants' constructions and evaluations of the CTO experience as positive, negative or justifiable. Most patient participants appeared to use moral framing to: try to understand why they were placed on a CTO; make sense of the experience of being on a CTO; and convey the lessons they have learnt. Worker participants appeared to use moral framing to justify the imposition of care. Empathy was part of this, as was patients' positive right to services and treatment, which they believed would only occur for these patients via a CTO. Workers positioned themselves as trying to put themselves in the patients' shoes as a way of acting virtuously towards them, softening the coercive stick approach. Four themes were identified: explicit moral framing; best interests of the patient; lessons learned by the patient; and, empathy.

CONCLUSIONS

Experiences of CTOs are multi-layered, and depend critically upon empathy and reflection on the relationship between what is done and how it is done. This includes explicit examination of the moral framing present in everyday interactions between mental health workers and their patients in order to overcome the paradox of the moral grey zone between caring and controlling. It suggests a need for workers to receive ongoing empathy training.

Increased influence and collaboration: a qualitative study of patients' experiences of community treatment orders within an assertive community treatment setting

Background

Since 2009, 14 assertive community treatment (ACT) teams have started up in Norway. Over 30 % of the patients treated by the ACT teams were subject to community treatment orders (CTOs) at intake. CTOs are legal mechanisms to secure treatment adherence for patients with severe mental illness. Little is known about patients’ views and experiences of CTOs within an ACT context.

Methods

The study was based on qualitative in depth interviews with 15 patients that were followed up by ACT teams and that were currently subjected to CTOs. The data were analyzed by using a modified grounded theory approach.

Results

While some participants experienced the CTO as a security net and as an important factor for staying well, others described the CTO as a social control mechanism and as a violation of their autonomy. Although experiencing difficulties and tensions, many participants described the ACT team as a different mental health arena from what they had known before, with another frame of interaction. Despite being legally compelled to receive treatment, many participants talked about how the ACT teams focused on addressing unmet needs, the management of future crises, and finding solutions to daily life problems. Assistance with housing and finances, reduced social isolation, and being able to seek help voluntarily were positive outcomes emphasized by many patients.

Discussion

The participants had different views of being on a CTO within an ACT setting. While some remained clearly negative to the CTO, others described a gradual transition toward regarding the CTO as an acceptablesolution as they gained experience of ACT. Many of the participants valued the supportive relationship withthe ACT team, and communication with the care providers and the care providers’ attitudes could make a significant difference. The study shows that the perception of coercion is context dependent, and that the relationship between care providers and patients is of importance to how patients interpret the providers’ behavior and the restrictive interventions.

Conclusions

Although some patients focused on loss of autonomy and being compelled to take medications, other patients emphasised the supportive relationships they had with the ACT teams and that they had received help with housing, finances, and other daily life problems. Thus, being on mandated community treatment could be acceptable in the opinion of several of the patients, provided that they received other services that they found beneficial.

"Life on hold": a qualitative study of patient experiences with outpatient commitment in two norwegian counties

In recent decades, outpatient commitment orders have been increasingly used in the follow-up of persons with serious mental disorders. Most studies on outpatient commitment orders have focused on compliance and consumption of health care services; there is little research on the content of outpatient commitment orders from a patient perspective. The aim of this study is to examine patients' experiences of living with outpatient commitment orders, and is based on qualitative interviews with 16 persons in two Norwegian counties. The data were analysed using a constructivist, interpretive approach to the grounded theory method. The main finding was that patients with outpatient commitment orders felt that their lives were on hold. The feeling of being seen only as patients prevented them from taking responsibility for their own lives. The medical context was perceived as an obstacle to recovery and transition to a more normal life. Patients' daily lives were dominated by the agenda set by health care providers and many said they were subjected to control measures that resulted in a reduced quality of life. However, informants also spoke of positive experiences as outpatient commitment order patients, such as feeling safe and secure and having easy access to health care staff and services.

Subjective experiences of compulsory treatment from a qualitative study of early implementation of the Mental Health (Care & Treatment) (Scotland) Act 2003

Compulsory psychiatric treatment is highly contested, and little research has focused specifically on direct experiences. The Mental Health (Care & Treatment) (Scotland) Act, 2003 introduced new roles and provisions including community treatment orders, and was designed to increase participation, ensure treatment was beneficial and was the 'least restrictive' alternative. This article draws on findings from semi-structured interviews with 49 individuals, who had experienced compulsion under this new legislation during 2007-2008, that were part of a broader cohort study. Interviews with service users were conducted at two stages with 80% agreeing to be interviewed twice. The sample included people on a variety of compulsory orders from four Health Board areas, some of whom had been detained for the first time, while others reported 'revolving door' experiences. Peer researchers who were mental health service users carried out the interviews in partnership with professional researchers. The findings suggest that legislation had a limited impact on participation in the process of compulsion. Consensus was that although service users felt there was increased opportunity for their voices to be heard, this was not matched by having increased influence over professional decision-making, especially in relation to drug treatments. According to people's direct experiences, the passing of the legislation in itself had done little to change the dominant psychiatric paradigm. While providing a foundation for improving the process of compulsion, the findings suggest that as well as legislative reform, fundamental shifts in practice are needed both in terms of the nature of therapeutic relationships, and in embracing more holistic and recovery perspectives.

'I think we're all guinea pigs really': a qualitative study of medication and borderline personality disorder

National Institute for Clinical Excellence recommended the use of medication only in times of crisis for individuals with borderline personality disorder (BPD). Despite this recommendation most service users referred to a specialist personality disorder service were found to be on numerous medications. Although a number of qualitative studies have explored the experience of individuals with a diagnosis of BPD they have failed to discuss their experience of being treated with medication, despite its high prescription with this group (e.g. Sansone et al.). The aim of this study was to explore the experience of service users being treated with medication for the BPD diagnosis. Semi-structured interviews were carried out with seven service users under a specialist service for personality disorder. Interviews were transcribed and analysed using thematic analysis. The main themes to emerge were: staff knowledge and attitudes, lack of resources for BPD and the recovery pathway for BPD. Overall, service users felt that receiving the BPD diagnosis had had a negative impact on the care they received, with staff either refusing treatment or focusing on medication as a treatment option. The introduction of specialist services for this group appears to improve service user satisfaction with their treatment and adherence to the National Institute for Clinical Excellence guidelines.

Is qualitative research second class science? A quantitative longitudinal examination of qualitative research in medical journals

Background

Qualitative research appears to be gaining acceptability in medical journals. Yet, little is actually known about the proportion of qualitative research and factors affecting its publication. This study describes the proportion of qualitative research over a 10 year period and correlates associated with its publication.

Design

A quantitative longitudinal examination of the proportion of original qualitative research in 67 journals of general medicine during a 10 year period (1998–2007). The proportion of qualitative research was determined by dividing original qualitative studies published (numerator) by all original research articles published (denominator). We used a generalized estimating equations approach to assess the longitudinal association between the proportion of qualitative studies and independent variables (i.e. journals' country of publication and impact factor; editorial/methodological papers discussing qualitative research; and specific journal guidelines pertaining to qualitative research).

Findings

A 2.9% absolute increase and 3.4-fold relative increase in qualitative research publications occurred over a 10 year period (1.2% in 1998 vs. 4.1% in 2007). The proportion of original qualitative research was independently and significantly associated with the publication of editorial/methodological papers in the journal (b = 3.688, P = 0.012); and with qualitative research specifically mentioned in guidelines for authors (b = 6.847, P<0.001). Additionally, a higher proportion of qualitative research was associated only with journals published in the UK in comparison to other countries, yet with borderline statistical significance (b = 1.776, P = 0.075). The journals' impact factor was not associated with the publication of qualitative research.

Conclusions

Despite an increase in the proportion of qualitative research in medical journals over a 10 year period, the proportion remains low. Journals' policies pertaining to qualitative research, as expressed by the appearance of specific guidelines and editorials/methodological papers on the subject, are independently associated with the publication of original qualitative research; irrespective of the journals' impact factor.

Self-care and cystic fibrosis: a review of research with adults

The issue of self-care is becoming increasingly central to both policy and practice in health and social care in the community. It is imperative therefore that research in this important area is drawn together and presented coherently so as to ensure that change can be informed by evidence and implemented sensitively. As cystic fibrosis (CF) has until recently been regarded as a paediatric condition, there is relatively little research that focuses on the self-care of adults. Although not entirely uncritical of traditional biomedicine, these studies focus on individual patient deficits and are directed primarily at facilitating their 'compliance'. After discussing some important methodological, evidential and theoretical limitations of this research, other recent CF literature will be considered that suggests the possibility of developing a 'social model' for self-care research. The proposed model is more pluralistic and less prescriptive than its predecessors and the resulting 'types' of self-care indicate that both old and new, mainstream and marginal discourses should co-exist. Indeed, recognising the legitimacy of distinct varieties of self-care not only guards against unwarranted moralising and pathologising but may also enable self-care support to be negotiated and tailored more appropriately.

Coercion and compulsion in community mental health care

There is ongoing debate in the UK as to the place of coercion and compulsion in community mental health care. Recent changes in service provision and amendments to the Mental Health Act in England and Wales have increased the scope for compulsion in the community. This has intensified the debate revealing fault lines in the psychiatric and legal professions. Despite powerful arguments from all sides there is little empirical evidence to inform this debate at a clinical or a theoretical level. This review utilizes evidence from articles in peer reviewed journals. Papers were identified from electronic databases, the authors' databases of relevant literature and personal correspondence with experts in the field. The evidence base is relatively small but is expanding. It has been demonstrated that informal coercion is common in USA mental health services and can be experienced negatively by patients. There is evidence that powers of compulsion in community mental health care are used frequently when available and their availability is generally seen as positive by clinicians when practice becomes embedded. The evidence for the effectiveness of compulsion in community mental health care is patchy and conflicting, with randomized or other trials failing to show significant benefits overall even if secondary analyses may suggest positive outcomes in some subgroups. There are widespread regional and international differences in the use of community compulsion. Research examining treatment pressures (or 'leverage') and the subjective patient experience of them appears to be expanding and is increasing our awareness and understanding of these complex issues. There is an urgent need for evidence regarding the usefulness and acceptability of compulsion in the community now that powers have been made available. Trials of the effectiveness of compulsion are needed as is qualitative work examining the experiences of those involved in the use of such orders. These are needed to help clinicians utilize the powers available to them in an informed and judicious fashion and to ensure adequate training.