Racism, early psychosis, and institutional contact: A qualitative study of Indigenous experiences

BACKGROUND

There is evidence of Indigenous and ethnic minority inequities in the incidence and outcomes of early psychosis. Racism has been implicated as having an important role.

AIM

To use Indigenous experiences to develop a more detailed understanding of how racism operates to impact early psychosis outcomes.

METHODS

Critical Race Theory informed the methodology used. Twenty-three Indigenous participants participated in four family focus group interviews and thirteen individual interviews, comprising of 9 Māori youth with early psychosis, 10 family members and 4 Māori mental health professionals. An analysis of the data was undertaken using deductive structural coding to identify descriptions of racism, followed by inductive descriptive and pattern coding.

RESULTS

Participant experiences revealed how racism operates as a socio-cultural phenomenon that interacts with institutional policy and culture across systems pertaining to social responsiveness, risk discourse, and mental health service structures. This is described across three major themes: 1) selective responses based on racial stereotypes, 2) race related risk assessment bias and 3) institutional racism in the mental health workforce. The impacts of racism were reported as inaction in the face of social need, increased use of coercive practices and an under resourced Indigenous mental health workforce.

CONCLUSION

The study illustrated the inter-related nature of interpersonal, institutional and structural racism with examples of interpersonal racism in the form of negative stereotypes interacting with organizational, socio-cultural and political priorities. These findings indicate that organizational cultures may differentially impact Indigenous and minority people and that social responsiveness, risk discourse and the distribution of workforce expenditure are important targets for anti-racism efforts.

Everyday ethics of suicide care: Survey of mental health care providers' perspectives and support needs

Suicide occurs in people of all ages and backgrounds, which negatively affects families, communities, and the health care providers (HCPs) who care for them. The objective of this study was to better understand HCPs' perspectives of everyday ethical issues related to caring for suicidal patients, and their perceived needs for training and/or support to address these issues. We conducted a mixed methods survey among HCPs working in mental health in Québec, Canada. Survey questions addressed their perspectives and experiences of everyday ethical challenges they encounter in their practice with people who are suicidal, and their perceived needs for training and/or support therein. 477 HCPs completed the survey. Most participants mentioned encountering ethical issues when caring for people who are suicidal. The challenges HCPs encounter in their practice with people who are suicidal are numerous, including issues related to maintaining privacy, confidentiality, freedom and the therapeutic relationship. The lack of time, resources and professional support to address these issues was emphasized. Most HCPs reported that the training or education they have received does not allow them to address everyday ethical issues related to suicide care. In sum, there is a clear reported need for better training and support for HCPs who are offering care to people who are suicidal in relation to everyday ethical issues they encounter. Implications for practice include providing greater access to training, including access to specialists in ethics to address specific issues. This additional support could alleviate morally distressing situations for HCPs.

Telepsychiatry and other cutting-edge technologies in COVID-19 pandemic: Bridging the distance in mental health assistance

BACKGROUND

At the end of 2019, a novel coronavirus (COVID-19) was identified in China. The high potential of human-to-human transmission led to subsequent COVID-19 global pandemic. Public health strategies including reduced social contact and lockdown have been adopted in many countries. Nonetheless, social distancing and isolation could also represent risk factors for mental disorders, resulting in loneliness, reduced social support and under-detection of mental health needs. Along with this, social distancing determines a relevant obstacle for direct access to psychiatric care services. The pandemic generates the urgent need for integrating technology into innovative models of mental healthcare.

AIMS

In this paper, we discuss the potential role of telepsychiatry (TP) and other cutting-edge technologies in the management of mental health assistance. We narratively review the literature to examine the advantages and risks related to the extensive application of these new therapeutic settings, along with the possible limitations and ethical concerns.

RESULTS

Telemental health services may be particularly feasible and appropriate for the support of patients, family members and healthcare providers during this COVID-19 pandemic. The integration of TP with other technological innovations (eg, mobile apps, virtual reality, big data and artificial intelligence (AI)) opens up interesting future perspectives for the improvement of mental health assistance.

CONCLUSION

Telepsychiatry is a promising and growing way to deliver mental health services but is still underused. The COVID-19 pandemic may serve as an opportunity to introduce and promote, among numerous mental health professionals, the knowledge of the possibilities offered by the digital era.

Perspectives of Veterans Affairs mental health providers on working with older adults with dementia and their caregivers

Continuing education directed at building providers' skills and knowledge in geriatrics represents a practical approach to addressing the geriatric mental health (MH) care workforce shortage. To inform the development of professional training curricula, we surveyed MH providers (N = 65) at a Veterans Affairs medical center on working with older persons with dementia (PwD) and informal caregivers. Providers rated service provision to PwD and caregivers as highly important but endorsed modest self-efficacy. Half of respondents were minimally confident in managing risk of harm to self or others in a PwD. Respondents believed PwD can benefit from MH treatments, yet identified several barriers to providing care, including inadequate time and staffing resources. Interest in geriatric training topics was high. Findings demonstrate that MH providers at this site value care provision to PwD and caregivers, and desire additional training to serve this population. System-level barriers to MH care for PwD should also be identified and addressed.

Mental health, mental capacity, ethics, and the law in the context of COVID-19 (coronavirus)

The emergence of the COVID-19 (coronavirus) pandemic in late 2019 and early 2020 presented new and urgent challenges to mental health services and legislators around the world. This special issue of the International Journal of Law and Psychiatry explores mental health law, mental capacity law, and medical and legal ethics in the context of COVID-19. Papers are drawn from India, Australia, the United Kingdom, Ireland, Germany, Portugal, and the United States. Together, these articles demonstrate the complexity of psychiatric and legal issues prompted by COVID-19 in terms of providing mental health care, protecting rights, exercising decision-making capacity, and a range of other topics. While further work is needed in many of these areas, these papers provide a strong framework for addressing key issues and meeting the challenges that COVID-19 and, possibly, other outbreaks are likely to present in the future.

[Appreciating COVID-19 as a child and adolescent psychiatrist on the move]

COVID-19 is a multi-organ disease due to an infection with the SARS-CoV2 virus. It has become a pandemic in early 2020. The disease appears less devastating in children and adolescents. However, stress, quarantine and eventually mourning have major impacts on development. It is difficult to describe what this pandemic implies for a child psychiatrist, other than by giving a first-hand account. I propose to go through the main ethical questions that have arisen; to describe how my hospital team has reorganized itself to meet the new demands and questions, in particular by opening a unit dedicated to people with autism and challenging behaviors affected by COVID-19; and to address, in a context of national discussion, how the discipline has sought to understand the conditions of a certain well-being during quarantine. Finally, I will try to conclude with more speculative reflections on re-opening.

Integrating Genomics into Psychiatric Practice: Ethical and Legal Challenges for Clinicians

Psychiatric genomics is a rapidly growing field that holds much promise for improving risk prediction, prevention, diagnosis, treatment selection, and understanding of the pathogenesis of patients' symptoms. The field of psychiatry (i.e., professional organizations, mental health clinicians, educational institutions), however, needs to address numerous challenges to promote the responsible translation of genomic technologies and knowledge into psychiatric practice. The goal of this article is to review how clinicians currently encounter and use genomics in the clinic, to summarize the existing literature on how clinicians feel about the use of genomics in psychiatry, and to analyze foreseeable ethical and legal challenges for the responsible integration of genomics into psychiatric care at the structural and clinic levels. Structural challenges are defined as aspects of the larger system of psychiatric practice that constitute potential barriers to the responsible integration of genomics for the purposes of psychiatric care and prevention. These structural challenges exist at a level where professional groups can intervene to set standards and regulate the practice of psychiatry and genomics. Clinic-level challenges are day-to-day issues clinicians face when managing genomic tests in the clinic. We discuss the need for action to mitigate these challenges and maximize the clinical and social utility of psychiatric genomics, including the following: expanding genomics training among mental health clinicians; establishing practice guidelines that consider potential clinical, psychological, and social implications of psychiatric genomics; promoting an integrated care model for managing genomics in psychiatry; emphasizing patient engagement and informed consent when managing genomic testing in psychiatric care.

Moral Experiences of Crisis Management in a Child Mental Health Setting: A Participatory Hermeneutic Ethnographic Study

Restraints and seclusion are routinely used in child mental health settings for conflict and crisis management, but raise significant ethical concerns. Using a participatory hermeneutic ethnographic framework, we studied conflict and crisis management in a child mental health setting offering care to children aged 6-12 years old in Quebec, Canada. The use of this framework allowed for an in-depth examination of the local imaginaries, of what is morally meaningful to the people in the setting, in addition to institutional norms, structures and practices. Data collection involved participant observation, interviews, and documentation review, with an interpretive framework for data analysis. We argue that the prevalent view of children shared by staff members as "incomplete human becomings" led to the adoption and legitimization of authoritative norms, structures and practices guided largely by a behavioral approach, which sometimes led to an increased use of control measures for reasons other than imminent harm. Children experienced these controlling practices as abusive and hindering the development of trusting relationships, which impeded the implementation of more collaborative approaches staff members sought to put in place to prevent the use of control measures. Study results are discussed in light of conceptions of children as moral agents.

Psychiatric Advance Directives as an Ethical Communication Tool: An Analysis of Definitions

A psychiatric advance directive (PAD) is a communication tool that promotes patients' autonomy and gives capacitated adults who live with serious mental illnesses the ability to record their preferences for care and designate a proxy decision maker before a healthcare crisis. Despite a high degree of interest by patients and previous studies that recommend that clinicians facilitate the completion of PADs, the rate of implementation of PAD remains low. Research indicates that many clinicians lack the necessary experience to facilitate the completion of PADs and to use them, and, as a consequence, do not effectively engage patients about PADs. This study developed practical recommendations for clinicians to improve their ability to communicate and facilitate PADs. We (1) thematically analyzed definitions of PADs published in 118 articles across disciplines, and (2) presented our recommendations for enhanced communication in clinical practice that emphasizes patient-centeredness, usefulness, and clarity, aligned with evidence-based practices that put patients' autonomy and understanding first. While there is no one-size-fits-all script to engage patients in complex conversations, our recommended strategies include an emphasis on patients' autonomy, the adaptation of word choices, the use of metaphor not simile, and checking for patients' understanding as effective methods of clinical communication.

Reducing coercion in mental healthcare

AIMS

To examine the extent and nature of coercive practices in mental healthcare and to consider the ethical, human rights challenges facing the current clinical practices in this area. We consider the epidemiology of coercion in mental health and appraise the efficacy of attempts to reduce coercion and make specific recommendations for making mental healthcare less coercive and more consensual.

METHODS

We identified references through searches of MEDLINE, EMBASE, PsycINFO and CINAHL Plus. Search was limited to articles published from January 1980 to May 2018. Searches were carried out using the terms mental health (admission or detain* or detention or coercion) and treatment (forcible or involuntary or seclusion or restraint). Articles published during this period were further identified through searches in the authors' personal files and Google Scholar. Articles resulting from searches and relevant references cited in those articles were reviewed. Articles and reviews of non-psychiatric population, children under 16 years, and those pertaining exclusively to people with dementia were excluded.

RESULTS

Coercion in its various guises is embedded in mental healthcare. There is very little research in this area and the absence of systematic and routinely collected data is a major barrier to research as well as understanding the nature of coercion and attempts to address this problem. Examples of good practice in this area are limited and there is hardly any evidence pertaining to the generalisability or sustainability of individual programmes. Based on the review, we make specific recommendations to reduce coercive care. Our contention is that this will require more than legislative tinkering and will necessitate a fundamental change in the culture of psychiatry. In particular, we must ensure that clinical practice never compromises people's human rights. It is ethically, clinically and legally necessary to address the problem of coercion and make mental healthcare more consensual.

CONCLUSION

All forms of coercive practices are inconsistent with human rights-based mental healthcare. This is global challenge that requires urgent action.

Ethical implications of routine outcomes monitoring for patients, psychotherapists, and mental health care systems

Although psychotherapy is generally efficacious, a substantial number of patients fail to improve meaningfully, whereas still others deteriorate. Moreover, psychotherapists have difficulty forecasting which patients are at risk for nonresponse or deterioration, especially when relying predominantly on their judgment. These limitations have implications for the ethical practice of psychotherapy, and they call for remediation strategies. One such strategy involves the use of routine outcomes monitoring (ROM), or the regular collection of core patient progress information that can be fed back to the clinician and patient in real time. ROM-informed analytics outperform clinical judgment in predicting patients who are on or off track for treatment success, which can help psychotherapists plan and responsively adjust their interventions. Additionally, research demonstrates that ROM-generated feedback improves treatment outcomes for the average case who receives versus does not receive it. ROM data can also uncover between-therapist differences in general efficacy, as well as scientifically highlight clinicians' own relative strengths and weaknesses in treating different mental health problems. In light of such evidence, we submit that the research on ROM has matured to the point that it should occupy a central role in discussions of, and guidelines about, the ethical practice of psychotherapy. In this vein, we discuss ROM at patient, psychotherapist, and mental health care systems levels; namely, for each of these stakeholders, we review the extant empirical support before turning to possible ethical implications. Finally, we offer concluding thoughts on the expanding relevance of ROM for helping psychologists fulfill their ethical practice obligations. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Balancing competing interests and obligations in mental health-care practice and policy

It is often challenging for mental health-care providers and health organizations to perform their various roles and to meet their varied obligations. In complex mental health-care circumstances the concurrent application of relevant ethical principles and values often leads to the emergence of completing obligations that need to be carefully weighed and balanced in the making of care-related decisions. Although some clinical circumstances, such as those potentially triggering the duty to warn, are adequately guided by existing rules based on legal precedents, there is a gap in decision-making support in other mental health-care domains. This article proposes that a set of targeted, decision-making approaches be developed to assist in the handling of specific, challenging circumstances. By way of illustration, two novel approaches are introduced; that is, choosing to work within a moral relational space of optimal therapeutic engagement (at the micro level of clinical practice), and the use of a health policy development approach that instantiates deliberative engagement (at the meso and macro levels of health organization).

[Open-door psychiatry and community mental health work]

In connection with the UN Convention on the Rights of Persons with Disabilities, mental healthcare concepts increasingly focus on the prevention of violence and coercion. Hospital care with an open-door policy is linked with a reduction in violence and coercive measures. The authors describe a specific therapeutic milieu aiming to promote social resources and to reduce institutional exclusion. Open-door policies can be extended to and tied in with outreach community mental health work. Model projects according to § 64b of the German Social Code (SGB V) on interdisciplinary care enable flexible needs-based care including home treatment for severe mental illness.

Not just a one-man revolution: the multifaceted anti-asylum watershed in Italy

The Italian psychiatric 'revolution' is the story of a range of flexible, changing formulas, exposed to many 'contaminations'. Historical reconstructions have remained anchored to the lure of a founding myth and an eponymous hero. This essay aims to shed light on the multi-faceted concept of the Italian 'moral management revolution'. We especially focus on: the circumstances which triggered the innovation in its various form; the 'prototypes' available in other countries which have been variously recombined in the different local contexts; the 'special path' of action strategies which has driven the change towards radical closure of the asylums; and the cause-effect relationship between the above 'special path' and several aspects of the current state of deadlock.

Self-admission in psychiatry: The ethics

Self-admission to inpatient treatment is a novel approach that aims to increase agency and autonomy for patients with severe psychiatric illness and a history of high utilization of inpatient care. By focusing on brief, preventive hospital admissions in times of increased risk of relapse, self-admission seeks to reduce the need for prolonged episodes of inpatient treatment. Participants are generally satisfied with the model, which is not surprising given that self-admission programs allocate a scarce resource-hospital beds-to a select group. However, the patients targeted by these programs are not necessarily those in most need of hospital admission, which may compromise the commonly accepted 'principle of need' in allocation of public healthcare resources. In light of the current lack of consistent evidence of the usefulness and cost-effectiveness of the model, several aspects need to be further studied in order to guide any large-scale implementation of self-admission in psychiatry.

Compulsory Admission in Hong Kong: Balance between Paternalism and Patient Liberty

In Hong Kong, compulsory admission is governed by the Mental Health Ordinance Section 31 (detention of a patient under observation), Section 32 (extension of period of detention for such a patient), Section 36 (detention of certified patients), and the sections in Part IV for hospital order, transfer order, and removal order. Mental health professionals adopt both legal criteria and practice criteria for compulsory admission. The present study discusses the harm principle, the patient's decision-making capacity, the multi-axial framework for compulsory admission, and the balance between paternalism and patient liberty.

I nuovi "casi difficili" in psichiatria

In psichiatria, come nelle altre discipline mediche, esistono casi che sono "difficili" per le loro caratteristiche cliniche. Recentemente, sembra tuttavia emergere un nuovo tipo di casi che risultano "difficili" per ragioni non tanto psicopatologiche quanto piuttosto gestionali, di responsabilità e sicurezza. Alcuni di questi casi caratterizzano in particolare la psichiatria italiana, e coinvolgono soprattutto i clinici delle strutture pubbliche. In varie situazioni, essi implicano comportamenti autolesivi ed eterolesivi non prevedibili né prevenibili nonostante l'impegno degli operatori, un problema ancora scarsamente riconosciuto per le responsabilità stesse. La riforma sanitaria del 1978 ha posto l'Italia in una posizione di avanguardia nel mondo riguardo al sistema dell'assistenza territoriale in salute mentale, che ha compiuto negli ultimi quarant'anni grandi passi avanti rispetto al precedente assetto. Ultimamente si sono tuttavia verificati cambiamenti sociali, epidemiologici, psicopatologici e dei bisogni che hanno creato nuovi problemi e difficoltà all'assistenza psichiatrica. Tra questi cambiamenti figurano la crescente complessità delle grandi aree metropolitane; il fenomeno immigratorio; la massiccia crescita nell'utilizzo di sostanze; le modificazioni del profilo di responsabilità del medico; l'introduzione di complesse normative sulla sicurezza, il trattamento dei dati, il consenso alle cure e la competenza a decidere della persona con disturbi mentali. Come conseguenza, gli operatori si trovano oggi ad affrontare nuove difficoltà di tipo organizzativo e gestionale, e questioni problematiche relative alla sicurezza sia del paziente sia del sanitario, con un crescente profilo di responsabilità etica, deontologica e medico legale del sanitario stesso. Auspichiamo che le riflessioni qui proposte possano stimolare un dibattito costruttivo per migliorare le condizioni di lavoro degli operatori impegnati quotidianamente nel migliorare gli esiti clinici dei propri pazienti.

Collaboration, confidentiality, and care

There is an increasing call to attend to the needs of students in distress (Reynolds, 2013). Furthermore, research has begun to highlight links between distress, risky, or dangerous behaviors as well as issues in mental health in the higher education population (Deasy, Coughlan, Pironom, Jourdan, & Mannix-McNamara, 2014). The National Alliance on Mental Health and the Jed Foundation (National Alliance on Mental Illness & the Jed Foundation, 2016) estimate that about 20% of enrolled college students will face some type of mental illness. As such, the work of mental health professionals, which has been increasing with time, will continue to play a pivotal role on today's campus (Kitzrow, 2009). Yet mental health in higher education is too pervasive and significant of a topic for counseling and psychological centers to handle by themselves (Joint Task Force in Student Learning, 1998; Mitchell et al., 2012). Therefore, a collaborative approach is warranted as higher education professionals strive to meet the increasing mental health demands of the student population. Case studies amalgamated from housing and residence life professionals are used to gain a greater understanding of how interdepartmental work is carried out without compromising or breaching ethical or legal regulations as set by the Family Educational Rights and Privacy Act, the Health Insurance Portability and Accountability Act, and/or organizational standards like that of the International Association of Counseling Services Inc. (International Association for Counseling Services Inc., 2014) Specifically, the cases demonstrate ways inter- and intradepartmental staffers can work as a team, safeguard private and confidential information, and concurrently create an environment in which care is nurtured. (PsycINFO Database Record

[Lying in dementia care]

The indiscriminate use of lying, when communicating with patients with dementia, is questioned in terms of ethics and acceptability. In this article we present the concept of "therapeutic lying", to describe those situations where a "non-truth" is used in the patient's interest and not that of the healthcare professional. The debate is still open, so it is necessary to better clarify risks and benefits of lying in the context of care, both to safeguard patients and to allow healthcare professionals to respect ethical and moral standards.

Four Reasons Why Assisted Dying Should Not Be Offered for Depression

Recently, several authors have argued that assisted dying may be ethically appropriate when requested by a person who suffers from serious depression unresponsive to treatment. We here present four arguments to the contrary. First, the arguments made by proponents of assisted dying rely on notions of "treatment-resistant depression" that are problematic. Second, an individual patient suffering from depression may not be justified in believing that chances of recovery are minimal. Third, the therapeutic significance of hope must be acknowledged; when mental healthcare opens up the door to admitting hopelessness, there is a danger of a self-fulfilling prophecy. Finally, proponents of assisted dying in mental healthcare overlook the dangers posed to mental-health services by the institutionalization of assisted dying.

[An ethical reflection on outreaching mental health care]

BACKGROUND

Care providers have a conflicting societal role: on the one hand they must respect the autonomy of individuals with psychiatric problems, but on the other hand they often feel the need to offer these individuals outreaching care.

AIM

To compile an ethical reflection on some of the ways in which outreaching mental health care interventions can be provided in a responsible manner.

METHOD

This ethical reflection is based on an ethical advice by the Ethics committee for Mental Health Care of the Brothers of Charity in Flanders. The method combines ethical discussion and a study of the relevant literature.

RESULTS

A good starting point is a relational view of the human being that emphasises connectedness and involvement. Consequently, the care provider begins to intervene in the care programme by building a trusting relationship with the person with psychiatric problems. This is how these persons, their close family and friends and care providers exercise their responsibility. There is a gradation of responsibility that extends in a continuous line: personal responsibility develops into shared responsibility which can then become vicarious responsibility. On that basis there is also a gradation in the nature of outreaching care; the care providers first make themselves available and give information, then provide advice, negotiate, persuade, increase pressure, and finally take over and force the person with psychiatric problems.

CONCLUSION

The care providers choose in dialogue and in a considered and consistent way for the appropriate form of outreaching care, in line with the degree of responsibility that the person with psychiatric problems can assume.

Malfeasance and Regaining Nursing’s Moral Voice and Integrity

This article discusses some of the most recent developments in US mental health services that follow on the heels of the for-profit hospital scandal that was brought to public attention less than a decade ago. As individuals and as a profession, nurses have a responsibility to uncover, openly discuss and condemn malfeasance when it occurs, yet there has been a collective silence about these developments. The authors explore the reasons for this and make recommendations for regaining nursing’s moral voice and integrity.

Why the professional-Client Ethic is Inadequate in Mental Health Care

Patients who are subject to compulsory care constitute a substantial proportion of the work-load of mental health professionals, particularly psychiatric nurses. This article examines the traditional ‘beneficence-autonomy’ approach to ethics in compulsory psychiatric care and evaluates it against the reality of daily practice. Risk to the public has always been an important but often unacknowledged consideration. Inequalities exist among ethnic and socio-economic groups and there is a lack of agreement on what constitutes mental disorder. Two major changes in compulsory psychiatric care - community orders and care for patients with untreatable severe personality disorders - further challenge the traditional ethical approach. There are also important human rights implications. The simple patient-health professional relationship no longer provides an adequate framework for mental health professionals on which to base their ethical decisions. The public and organizations may have different perspectives and their interests are becoming increasingly important. Mental health professionals, particularly psychiatric nurses, may face ethical dilemmas because of these different perspectives.

Specific Ethical Codes for Mental Health Care Professionals: Do We Need to Annotate?

BACKGROUND

In Israel a general code of ethics exists for physicians, drafted by the Israel Medical Association. The question arises whether psychiatrists require a separate set of ethical guidelines.

OBJECTIVES

To examine the positions of Israeli psychiatrists with regard to ethics in general and professional ethics in particular, and to explore opinions regarding a code of ethics or ethical guidelines for psychiatry.  Methods: A specially designed questionnaire was compiled and completed by psychiatrists recruited for the study.

METHODS

A specially designed questionnaire was compiled and completed by psychiatrists recruited for the study.

RESULTS

Most participants reported low levels of perceived knowledge regarding ethics, professional ethics, and the general code of ethics. Older and more experienced professionals reported a higher level of knowledge. Most psychiatrists agreed or strongly agreed with the need for a distinct code of ethics/ethical guidelines for psychiatrists. This support was significantly higher among both psychiatrists under 50 years and residents.

CONCLUSIONS

Our findings suggest that the existing code of ethics and position papers may not be sufficient, indicating a potential need to develop and implement a process to create the ethical code itself. In addition, the findings highlight the importance of ethics education, suggesting that the need for a code of ethics is more urgent in the early stages of professional training, as younger professionals may be more exposed to advanced media technology. While some may fear that a distinct code of ethics will distance psychiatry from modern medicine, others assert that the profession combines aspects from the humanities and social sciences that require a unique sort of management and thus this profession requires a distinct code of ethics.

Assaults by Mentally Disordered Offenders in Prison: Equity and Equivalence

Managing the violent behaviour of mentally disordered offenders (MDO) is challenging in all jurisdictions. We describe the ethical framework and practical management of MDOs in England and Wales in the context of the move to equivalence of healthcare between hospital and prison. We consider the similarities and differences between prison and hospital management of the violent and challenging behaviours of MDOs. We argue that both types of institution can learn from each other and that equivalence of care should extend to equivalence of criminal proceedings in court and prisons for MDOs. We argue that any adjudication process in prison for MDOs is enhanced by the relevant involvement of mental health professionals and the articulation of the ethical principles underpinning health and criminal justice practices.

[Moral case deliberation: time for ethical reflection in the daily practice of mental health care]

BACKGROUND

Nowadays, reflecting on ethics, which we choose to call moral case deliberation, is occurring more and more frequently in psychiatric institutions. We have personal experience of organising and supervising moral case deliberation in a large psychiatric institute and we can confirm the positive effects of moral case deliberation which have been reported in the literature.

AIM

To describe a structured method for moral case deliberation which enables care-givers in health care and/or addiction care to reflect on moral dilemmas.

METHOD

We refer to the main findings in relevant literature and describe how we developed a structured method for implementing moral case deliberation.

RESULTS

Our studies of the literature indicate that systematic reflection about ethical dilemmas can improve the quality of care and make care-givers more satisfied with their work. This is why we have developed our own method which is applicable particularly to psychiatric and/or addition care and which can be used systematically in discussions of moral dilemmas.

CONCLUSION

Our method for discussing ethical issues works well in clinical practice, particularly when it is embedded in a multidisciplinary context. Of course, to ensure the continuity of the system, deliberation about moral and ethical issues needs to be financially safeguarded and embedded in the organisation. Discussion of moral issues improves the quality of care and increases care-givers' satisfaction with their work.

Correctional mental health in the USA

PURPOSE

The purpose of this paper is to discuss five domains impacted by the transformation of correctional mental health care in the USA: public health, public safety, legal obligations, fiscal responsibility and ethical standards, as well as critical issues such as administrative segregation, suicide prevention and reentry planning.

DESIGN/METHODOLOGY/APPROACH

In the last four decades, the USA has seen a sizable growth in its criminal justice system and corrections population. It has also seen reductions in civil and community-based mental health care. Persons with mental disabilities have come to represent a highly disproportional segment of the corrections population. The paper discusses the implications and underlying causes of these developments as well as recent responses to them.

FINDINGS

This set of circumstances is starting to change the mission of correctional health services from crisis intervention and suicide prevention to include preparation for the inmate's almost inevitable return to the community.

ORIGINALITY/VALUE

Such changes have led to further developments in correctional mental health care, in particular, policy designed to treat mental illness, reduce its destructive outcomes such as suicide, and facilitate successful reentry into the community in attempts to reduce recidivism and improve clinical outcomes. Mental health care professionals working within corrections have likewise faced ethical challenges in effectuating treatment.

Mental health services commissioning and provision: Lessons from the UK?

The commissioning and provision of healthcare, including mental health services, must be consistent with ethical principles - which can be summarised as being "fair", irrespective of the method chosen to deliver care. They must also provide value to both patients and society in general. Value may be defined as the ratio of patient health outcomes to the cost of service across the whole care pathway. Particularly in difficult times, it is essential to keep an open mind as to how this might be best achieved. National and regional policies will necessarily vary as they reflect diverse local histories, cultures, needs and preferences. As systems of commissioning and delivering mental health care vary from country to country, there is the opportunity to learn from others. In the future international comparisons may help identify policies and systems that can work across nations and regions. However a persistent problem is the lack of clear evidence over cost and quality delivered by different local or national models. The best informed economists, when asked about the international evidence do not provide clear answers, stating that it depends how you measure cost and quality, the national governance model and the level of resources. The UK has a centrally managed system funded by general taxation, known as the National Health Service (NHS). Since 2010, the UK's new Coalition* government has responded by further reforming the system of purchasing and providing NHS services - aiming to strengthen choice and competition between providers on the basis of quality and outcomes as well as price. Although the present coalition government's intention is to maintain a tax-funded system, free at the point of delivery, introducing market-style purchasing and provider-side reforms to encompass all of these bring new risks, whilst not pursuing reforms of a system in crisis is also seen to carry risks. Competition might bring efficiency, but may weaken cooperation between providers, and transparency too. On the other hand, it is hard to implement necessary governance and control without worsening bureaucracy and inefficiency. The pursuit of market efficiencies has been particularly contentious in mental health care, where many professionals are defensive about the risks to vulnerable patients and to traditional ways of professional working. Developments and debates in the UK may be instructive for others. We conclude this paper with a set of questions that may help inform debate and evaluation of mental health services internationally.

Conditional shared confidentiality in mental health care

Because of the development towards community care, care providers not only exchange information in a team, but increasingly also in networks. This is a challenge to confidentiality. The ethical question is how care providers can keep information about the care receiver confidential, whilst at the same time exchanging information about that care receiver in a team or network? Can shared confidentiality be extended from a team to a network? To clarify this question, the article refers to the advice of an expert ethics committee in mental health care. The advice regards exchange of information in a network as a further step in enhancing collaboration among care providers. Therefore, the good and evident practice of shared confidentiality in a team can be extended to a network if the same conditions are met. First, the care providers participate in a clearly defined and identifiable team or network. Secondly, they have a shared care responsibility. Thirdly, they have a duty of confidentiality. Fourth, they dialogue with the care receiver and obtain his or her consent. Finally, they apply the filter of relevance. Hence, conditional shared confidentiality is an ethical justification for the exchange of information in a team or network.

People with mental health problems need a hospital bed not a police cell, says CQC

Too many people experiencing a mental health crisis are being sent to police cells because of a shortage of safe healthcare places, the Care Quality Commission (CQC) has warned.

In name only? Mental health parity or illusory reform

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 and the Affordable Care Act mandate significant insurance and patient protection reforms. Despite these safeguards, lax regulatory enforcement and lack of consumer and provider sophistication have failed to remedy ongoing insurer abuses resulting in deprivation of crucial mental health and substance abuse treatment. Even with persistent and informed advocacy, including strategies outlined herein, any potential parity gains are negated by unreasonably low reimbursement benchmarks already used by insurers in many ACA (∗) -exchange plans. The need for legislative remediation is therefore urgent.

Disaster behavioral health: legal and ethical considerations in a rapidly changing field

Disaster behavioral health is increasingly regarded as a central part of disaster preparedness, response and recovery. Legal and ethical issues have received relatively little attention and have sparked divergent opinions. Optimally, understanding and applying legal and ethical considerations requires an understanding of the evolution of the disaster behavioral health field and the context of disaster response and recovery. In addition, there are many legal and ethical questions identified for consideration, and many ways to approach reaching understanding and consensus. Traditionally, discussions of disaster behavioral health, including legal and ethical issues, have not included understanding decision making processes that occur in extreme circumstances. Models which interpret disaster response operations as complex adaptive systems are presented for consideration as useful tools for preparing mental health workers for effectively delivering services in acute disaster response environments.

Preserving the person: The ethical imperative of recovery-oriented practices

For more than a decade the principles of mental health recovery have been promoted as an alternative to traditional models of care. Recovery-oriented practices are those that recognize the strengths of service users and empower them within the mental health system. In contrast to a more hierarchical model of care in which service providers make decisions with a pronounced absence of input from service users, recovery-oriented practices emphasize shared decision-making, respect for service user goals, and the recognition of the full humanity of all persons in care relationships. Recovery-oriented care has yet to be embraced by the majority of service providers, however. There are several reasons for this failure but among them is the lack of attention given to the ethical ground of recovery. This article seeks to bring recovery into conversation with moral philosophy by arguing that recovery-oriented care is essentially linked to fundamental rights and values of personhood within a liberal democracy. By joining together a conception of personhood rooted in essential vulnerability and a Rawlsian perspective on justice, this article argues that recovery is not only a desirable approach to mental health practice but that it is ethically necessary. It argues that recovery practices are not exceptional interventions to be reserved for a few but that a recovery-orientation entails fundamental elements of justice and respect to which all persons are entitled.

Barriers to accessing and receiving mental health care in Eastern Cape, South Africa

The right to the enjoyment of the highest attainable standard of physical and mental health is enshrined in many international human rights treaties. However, studies have shown that people with mental disabilities are often marginalized and discriminated against in the fulfillment of their right to health. The aim of this study is to identify and reach a broader understanding of barriers to the right to mental health in the Eastern Cape Province in South Africa. Eleven semi-structured interviews were carried out with health professionals and administrators. The researchers used the Availability, Accessibility, Acceptability, and Quality (AAAQ) framework from the UN Committee on Economic, Social and Cultural Rights to structure and analyze the material. The framework recognizes these four interrelated and partly overlapping elements as necessary for implementation of the right to health. The study identifies eleven barriers to the enjoyment of the right to health for people with mental disabilities. Three categories of barriers relate to availability: lack of staff, lack of facilities, and lack of community services and preventive care. Four barriers relate to accessibility: lack of transport, lack of information, stigmatization, and traditional cultural beliefs of the community. Two barriers relate to acceptability: lack of cross-cultural understanding among staff and traditional cultural beliefs of staff. Finally, two barriers relate to quality: lack of properly trained staff and lack of organizational capacity. The results, in line with earlier research, indicate that the implementation of the right to health for people with mental disabilities is far from achieved in South Africa. The findings contribute to monitoring the right to mental health in South Africa through the identification of barriers to the right to health and by indicating the importance of building monitoring procedures based on the experiences and knowledge of staff involved in mental health care provision.

[First analysis of the deployment of the ethical approach in the field of mental health in the Nord Pas-de-Calais region]

For 3 years, the Regional Federation of Mental Health Research (F2RSM) has led a space ethics reflexion Department of mental health (ERESM) to federate structures that ethical institutions and mental health services have been creating in the Nord-Pas de Calais. This approach is, in many ways, revealing issues that involve the institutionalisation of ethical reflection in care facilities. In this article, after referring to the major developments in this field, we describe the conditions for the emergence of ethical bodies in the region. Through the choice of development and operation of the ethical reflexion department, we highlight a number of points of attention that illustrate the complex articulation between institutional expectations and concerns of professionals. The trajectory of the ERESM is thus revealed as a process of reflective learning open to all stakeholders, providers and users of mental health.