Coercion in mental healthcare: time for a change in direction

Abolition of coercion in mental health services - A European survey of feasibility

BACKGROUND

In 2019, the Council of Europe agreed to urge member states to take steps toward total abolition of psychiatric coercive measures.

AIMS

To test if this aspiration is perceived as realistic and what the alternative would be in the event of a total abolition, we surveyed members of the European FOSTREN network of mental health practitioners and researchers, which is specifically dedicated to exchanging knowledge on reducing psychiatric coercion to its minimum.

METHODS

Web-based survey. Categorical responses were analyzed using frequencies, and free text responses were analyzed through thematic analysis.

RESULTS

In total, out of 167 invitations to FOSTREN network members, 76 responded to the survey (Response Rate 45.5%). A minority (31%) of participating experts dedicated to the reduction of psychiatric coercive measures believed a total abolition to be an achievable goal. A commonly held belief was that total abolition is not achievable because mental health disorders are difficult to treat and may cause violence, necessitating coercion, and there is a need to protect the involved persons from harm. Those responding that complete abolition is achievable argued that the consequences of coercion outweigh any gains and indicated that use of advance directives are sufficient as alternatives to coercion.

CONCLUSION

Of a European group of experts specifically dedicated to the reduction of psychiatric coercion who participated in this questionnaire study, a minority believed a total abolition be an achievable goal. The study adds to the empirical evidence of the feasibility of the aspiration to totally abolish involuntary measures in the mental health services from the perspective of experts.

Coercive containment measures for the management of self-cutting versus general disturbed behaviour: Differences in use and attitudes among mental health nursing staff

Self-harm is common in mental health facilities, and coercive containment measures are sometimes used to manage it. Nurses' attitudes towards these measures have been investigated in relation to disturbed behaviour in general, but rarely to self-harm specifically. We therefore investigated mental health nurses' use of and attitudes towards coercive measures (seclusion, restraint, intermittent and constant observations, forced intramuscular medication, and PRN medication) for self-cutting management compared with for disturbed behaviours in general using a cross-sectional, repeated measures survey design. Participants were N = 164 mental health nursing staff. Data collection was via a questionnaire comprising validated attitudinal measures. The study is reported in line with STROBE guidelines. Physical restraint (36.6%), forced intramuscular medication (32.3%) and seclusion (48.2%) had reportedly been used by individuals for self-cutting management. Respondents disapproved of using each coercive measure for self-cutting more than they did for disturbed behaviour in general with the exception of PRN medication. Attitudes to coercive measures differed across target behaviours. Hence, nurses who had used each measure for managing self-cutting disapproved of it less for that purpose than those who had not. Nurses who had used coercive techniques for self-cutting management had less desirable attitudes to their use. We cannot say whether prior use of these techniques led to increased approval or whether greater approval led to an increased willingness to use them. Reducing the use of coercive techniques for self-harm will require attitudes that support its use to be challenged. Less coercive techniques should be encouraged. Harm reduction techniques offer one such alternative.

Gilles Deleuze's societies of control: Implications for mental health nursing and coercive community care

Since the era of deinstitutionalisation, many clinical approaches have emerged to enable the care and treatment of people suffering from mental illness. In recent years, the use of coercive approaches in the community (e.g., outpatient commitment or community treatment orders) has also increased internationally. Although nurses' role regarding these coercive approaches is central and significant, few empirical and theoretical writings have tackled this controversial nursing practice. The purpose of this paper is to analyse coercive nursing care through the lens of French philosopher Gilles Deleuze's concept of 'societies of control'. Taking up Michel Foucault's work on disciplinary power, Deleuze explores how the move from the striated spaces of closed institutions to the smooth spaces of societies of control took place since the middle of the 20th century. According to Deleuze, the overall objective of 'societies of control' is no longer simply to govern deviant behaviour in closed environments (e.g., psychiatric hospitals and prisons) but to ensure a regime of unrelentless surveillance in the open spaces of our communities.

Measuring the level of compulsory hospitalisation in mental health care: The performance of different measures across areas and over time

OBJECTIVE

A variety of measures are used for reporting levels of compulsory psychiatric hospitalisation. This complicates comparisons between studies and makes it hard to establish the extent of geographic variation. We aimed to investigate how measures based on events, individuals and duration portray geographical variation differently and perform over time, how they correlate and how well they predict future ranked levels of compulsory hospitalisation.

METHODS

Small-area analysis, correlation analysis and linear regressions of data from a Norwegian health registry containing whole population data from 2014 to 2018.

RESULTS

The average compulsory hospitalisation rate per 100,000 inhabitant was 5.6 times higher in the highest area, compared to the lowest, while the difference for the compulsory inpatient rate was 3.2. Population rates based on inpatients correlate strongly with rates of compulsory hospitalisations (r = 0.88) and duration (r = 0.78). 68%-81% of ranked compulsory hospitalisation rates could be explained by each area's rank the previous year.

CONCLUSION

There are stable differences in service delivery between catchment areas in Norway. In future research, multiple measures of the level of compulsory hospitalisation should ideally be included when investigating geographical variation. It is important that researchers describe accurately the measure upon which their results are based.

The omnipresence of risk and associated harms in secure and forensic mental health services in England and Wales

Current legislation and policy frameworks regulating the detention and treatment of mentally disordered offenders in England and Wales are predicated on the assumption that a minority of patients have enduring violent tendencies and pose a serious long-term risk to the safety of others. This paper seeks to consider the manner in which notions of risk and the imperative to contain and minimise the potential for harm, present and impact patients in secure and forensic mental health settings. Within this, we consider how mental health stigma and Beck's concept of the Risk Society can affect the thoughts and actions of those who may be held accountable for rare but potentially serious harmful events. We consider what changes may need to be enacted within secure and forensic mental health services to reduce the incidence and severity of consequent risks of harm to patients and their mental health recovery.

Perceived Coercion of Persons with Mental Illness Living in a Community

Aims: The purpose of this study is to analyze the effect of the perceived coercion of people with mental illness living in a community on their therapeutic satisfaction and life satisfaction, mediated by therapeutic relationships. Methods: We evaluated several clinical variables (symptoms, psychosocial functioning, and insight), levels of perceived coercion, therapeutic relationships, therapeutic satisfaction, and life satisfaction in 185 people with mental illness (Mean age = 47.99, standard deviation (SD) = 12.72, male 53.0%, female 45.9%) who live in the community and use community-based mental health programs. The data collected were analyzed to test the proposed hypotheses using structural equation modeling (SEM). Results: The correlation analysis of all variables showed that clinical variables had statistically significant correlations with therapeutic relationship, therapeutic satisfaction, and life satisfaction, but no significant correlation with perceived coercion. Furthermore, perceived coercion was found to have significant predictive power for treatment satisfaction and life satisfaction mediated by therapeutic relationship. Specifically, the lower the perceived coercion, the better the therapeutic relationship. This, in turn, has a positive effect on the therapeutic satisfaction and life satisfaction of participants. Conclusions: Based on these findings, we suggest strategies to minimize coercion in a community.

A Key, Not a Straitjacket: The Case for Interim Mental Health Legislation Pending Complete Prohibition of Psychiatric Coercion in Accordance with the Convention on the Rights of Persons with Disabilities

The practice of coercion on the basis of psychosocial disability is plainly discriminatory. This has resulted in a demand from the Committee on the Rights of Persons with Disabilities (the CRPD Committee) for a paradigm shift away from the traditional biomedical model and a global ban on compulsion in the psychiatric context. However, that has not occurred. This paper considers conflicting pronouncements of the CRPD Committee and other United Nations bodies. Assuming the former's interpretations of the Convention on the Rights of Persons with Disability (CRPD) are accurate, involuntary psychiatric detention and enforced treatment on the basis of psychosocial disability are prima facie discriminatory and unlawful practices. However, dedicated mental health legislation both permits discrimination and protects and enhances rights. This paper proposes a practical way out of the present impasse: the global introduction of interim "holding" legislation lacking full compliance with the CRPD. While imperfect, such a framework would facilitate a move toward a complete ban on psychiatric coercion. The paper outlines four essential ingredients that any interim legislation ought to contain, including clear timebound targets for full CRPD implementation. It concludes by urging the CRPD Committee to take the unprecedented step of issuing a general comment providing reluctant "permission" for the progressive realization of respect for articles 12 and 14 of the CRPD.

Supported decision making for people with mental health disorders in clinical practice: a systematic review

Objectives: The Convention on the Rights of Persons with Disabilities (CRPD) was adopted at the United Nations Assembly in 2006. The main aim of the convention is to ensure equal rights for people with disabilities including the expression of people's own "will and preferences" concerning health treatment. Article 12 demands the respect of a person's "rights, will and preferences" (CRPD) and suggests supported decision making (SDM) when possible. The aim of this review was to gather information regarding the SDM implementation from a clinical perspective for people with mental health disorders.Methods: A systematic literature search was performed on electronic databases MEDLINE, PsycARTICLES, and PsycINFO using the keywords "supported decision making" and "UN convention on the rights of persons with disabilities" in March 2018.Results: Eleven articles were included in the final review, which focussed on three themes: (1) different models of SDM, (2) stakeholder views, and (3) challenges for implementation. A limited number of papers described clinical models that had good theoretical consistency with SDM. The main challenges of implementation related to critical situations when "will and preferences" are poorly understood or appear contradictory. Future studies should assess specific models of SDM implementation, including related outcomes and process measures.

Seclusion versus mechanical restraint in psychiatry - a systematic review

OBJECTIVE

Seclusion and mechanical restraint are coercive interventions used at psychiatric hospitals when patients are at imminent risk of harming themselves and/or others. Although these interventions have been used for decades, it remains unclear whether seclusion or mechanical restraint is superior in terms of efficacy and safety. Therefore, we aimed to systematically review studies comparing the intended and unintended effects of seclusion and mechanical restraint.

METHODS

A systematic search of PubMed and Embase was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Quantitative studies comparing the intended and unintended effects of seclusion and mechanical restraint were included.

RESULTS

The search identified 868 unique records. Fourteen of these (3 reporting on randomized controlled trials and 11 reporting on observational studies) met the predefined inclusion criteria. The study methodology including outcome measures varied significantly across studies. The results of the 11 studies using a subjective outcome measure (patient preference/emotions) were in favour of seclusion, while the 3 studies using an objective outcome measure (duration of coercion/need for transition to other coercive measure) favoured mechanical restraint. There was a high risk of residual confounding by indication and/or bias affecting the reported results.

CONCLUSION

Based on the available literature, it cannot be determined whether seclusion is superior to mechanical restraint or vice versa. Further studies using stringent methodology are required to answer this question. A cautious conclusion based on this review is that the availability of both methods seems necessary - as both have their pros and cons.

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.

Predicting mechanical restraint of psychiatric inpatients by applying machine learning on electronic health data

OBJECTIVE

Mechanical restraint (MR) is used to prevent patients from harming themselves or others during inpatient treatment. The objective of this study was to investigate whether incident MR occurring in the first 3 days following admission could be predicted based on analysis of electronic health data available after the first hour of admission.

METHODS

The dataset consisted of clinical notes from electronic health records from the Central Denmark Region and data from the Danish Health Registers from patients admitted to a psychiatric department in the period from 2011 to 2015. Supervised machine learning algorithms were trained on a randomly selected subset of the data and validated using an independent test dataset.

RESULTS

A total of 5050 patients with 8869 admissions were included in the study. One hundred patients were mechanically restrained in the period between one hour and 3 days after the admission. A Random Forest algorithm predicted MR with an area under the curve of 0.87 (95% CI 0.79-0.93). At 94% specificity, the sensitivity was 56%. Among the ten strongest predictors, nine were derived from the clinical notes.

CONCLUSIONS

These findings open for the development of an early warning system that may guide interventions to reduce the use of MR.

Trends in the use of coercive measures in Finnish psychiatric hospitals: a register analysis of the past two decades

BACKGROUND

Coercive measures is a topic that has long been discussed in the field of psychiatry. Despite global reports of reductions in the use of restraint episodes due to new regulations, it is still questionable if practices have really changed over time. For this study, we examined the rates of coercive measures in the inpatient population of psychiatric care providers across Finland to identify changing trends as well as variations in such trends by region.

METHODS

In this nationwide registry analysis, we extracted patient data from the national database (The Finnish National Care Register for Health Care) over a 20-year period. We included adult patients admitted to psychiatric units (care providers) and focused on patients who had faced coercive measures (seclusion, limb restraints, forced injection and physical restraints) during their hospital stay. Multilevel logistical models (a polynomial model of quadratic form) were used to examine trends in prevalence of any coercive measures as well as the other four specified coercive measures over time, and to investigate variation in such trends among care providers and regions.

RESULTS

Between 1995 and 2014, the dataset contained 226,948 inpatients who had been admitted during the 20-year time frame (505,169 treatment periods). The overall prevalence of coercive treatment on inpatients was 9.8%, with a small decrease during 2011-2014. The overall prevalence of seclusion, limb restraints, forced injection and physical restraints on inpatients was 6.9, 3.8, 2.6 and 0.8%, respectively. Only the use of limb restraints showed a downward trend over time. Geographic and care provider variations in specific coercive measures used were also observed.

CONCLUSIONS

Despite the decreasing national level of coercive measures used in Finnish psychiatric hospitals, the overall reduction has been small during the last two decades. These results have implications on the future development of structured guidelines and interventions for preventing and more effectively managing challenging situations. Clinical guidelines and staff education related to the use of coercive measures should be critically assessed to ensure that the staff members working with vulnerable patient populations in psychiatric hospitals are ethically competent.

Factors associated with use of psychiatric intensive care and seclusion in adult inpatient mental health services

AIMS

Within acute psychiatric inpatient services, patients exhibiting severely disturbed behaviour can be transferred to a psychiatric intensive care unit (PICU) and/or secluded in order to manage the risks posed to the patient and others. However, whether specific patient groups are more likely to be subjected to these coercive measures is unclear. Using robust methodological and statistical techniques, we aimed to determine the demographic, clinical and behavioural predictors of both PICU and seclusion.

METHODS

Data were extracted from an anonymised database comprising the electronic medical records of patients within a large South London mental health trust. Two cohorts were derived, (1) a PICU cohort comprising all patients transferred from general adult acute wards to a non-forensic PICU ward between April 2008 and April 2013 (N = 986) and a randomly selected group of patients admitted to general adult wards within this period who were not transferred to PICU (N = 994), and (2) a seclusion cohort comprising all seclusion episodes occurring in non-forensic PICU wards within the study period (N = 990) and a randomly selected group of patients treated in these wards who were not secluded (N = 1032). Demographic and clinical factors (age, sex, ethnicity, diagnosis, admission status and time since admission) and behavioural precursors (potentially relevant behaviours occurring in the 3 days preceding PICU transfer/seclusion or random sample date) were extracted from electronic medical records. Mixed effects, multivariable logistic regression analyses were performed with all variables included as predictors.

RESULTS

PICU cases were significantly more likely to be younger in age, have a diagnosis of bipolar disorder and to be held on a formal section compared with patients who were not transferred to PICU; female sex and longer time since admission were associated with lower odds of transfer. With regard to behavioural precursors, the strongest predictors of PICU transfer were incidents of physical aggression towards others or objects and absconding or attempts to abscond. Secluded patients were also more likely to be younger and legally detained relative to non-secluded patients; however, female sex increased the odds of seclusion. Likelihood of seclusion also decreased with time since admission. Seclusion was significantly associated with a range of behavioural precursors with the strongest associations observed for incidents involving restraint or shouting.

CONCLUSIONS

Whilst recent behaviour is an important determinant, patient age, sex, admission status and time since admission also contribute to risk of PICU transfer and seclusion. Alternative, less coercive strategies must meet the needs of patients with these characteristics.