Many Faces of the Dual-Role Dilemma in Psychiatric Ethics

Robertson, Michael; Walter, Garry

doi:10.1080/00048670701827291

Cited by 50 publications

(28 citation statements)

References 67 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…This dual role can cause dilemmas for the practitioner who has potentially incompatible duties to the patient, third parties and the wider community [1][2][3]. As Robertson and Walter [4] observed: ''In psychiatric ethics, the dual-role dilemma refers to the tension between psychiatrists' obligations of beneficence towards their patients, and conflicting obligations to the community, third parties, other healthcare workers, or the pursuit of knowledge in the field''. They noted further that these conflicting obligations create a conflict of interest because the expectations of psychiatrists, aside from those related to the best interest of the patients, are quite ''compelling''.…”

Section: Introduction Forensic Psychiatrymentioning

confidence: 99%

Ethical issues of long-term forensic psychiatric care

Völlm

Βartlett

McDonald

2016

Ethics, Medicine and Public Health

View full text Add to dashboard Cite

Summary Forensic psychiatry is a subspecialty of clinical psychiatry that operates at the interface between law and psychiatry. It is concerned with patients who have a mental disorder as well as having committed an offence, often serious. Forensic psychiatric institutions are highcost/low-volume services that impose significant restrictions upon their residents. Patients may be detained in those services against their will for lengthy periods, potentially life-long. The purpose of this detention is seen as two-fold: care and treatment for the patient and protection of the public from harm from the offender. Here we review the ethical issues around such longterm detention. We base our observations on a review of relevant literature and from focus groups with professionals working in forensic psychiatric settings. Additionally, we visited three institutions in the UK where long-stay forensic psychiatric patients receive care. A number of factors have been identified contributing to long-term stay (long-stay) in forensic psychiatric care, including organisational factors (e.g., lack to beds in less secure settings) and patient characteristics (severity of psychopathology and offending). Long-stay in a forensic psychiatric setting -which is often longer than had the patient received a prison sentence for the same offence -poses significant ethical and human rights issues, particularly when it is unclear * Corresponding author. Please cite this article in press as: Völlm B, et al. whether the treatments offered benefit the patient and when risk management considerations may outweigh the best interests of the patient. The main topics of concern identified by our participants included ''system failures'', ''avoidance of warehousing'', ''importance of hope'', ''denial'' and long-stay units and ''quality of life''. Participants were concerned that the system is set up in a way that does not allow patients with complex and long-term needs to move to more appropriate, less restrictive settings and that the issue of ''long-stay'' is met with denial. In order to avoid warehousing and maintain hope, those we spoke to felt it was important to not give up on patients and continue to deliver treatment, almost regardless of its effect. Providing long-stay patients with a good quality of life was seen as important, though we found that the stated ambitions were not always matched by the reality of the units we visited. Despite the stated need to provide something ''different'' for long-stay patients, the units were nevertheless very restrictive in their approach (e.g., prohibition of sexual expression). Professionals seemed to lack a more ambitious and creative vision to create something truly distinct. We discuss possible solutions, including explicitly maximising the quality of life of those detained, limiting the time of detention to equal the sentence length of non-disordered offenders and locating the public protection function of the management of mentally disordered offenders within the criminal justice rather than the he...

show abstract

Section: Introduction Forensic Psychiatrymentioning

confidence: 99%

Ethical issues of long-term forensic psychiatric care

Völlm

Βartlett

McDonald

2016

Ethics, Medicine and Public Health

View full text Add to dashboard Cite

show abstract

“…It refers to psychiatrists' conflicting obligations to their patients and to a powerful third party. Nevertheless, although the moral tensions implicit in a dual role (Austin, 2008;Robertson, 2008) form one important aspect of the present study, in contrast to the more traditional psychiatry within NAA such tensions are not seen as phenomena to be avoided.…”

Section: In a Jungle Of Voicesmentioning

confidence: 79%

“…The interviewees utilized the interviews as a form of clinical supervision, and those who had an ongoing therapeutic relationship with the clients planned changes to the treatments. The diverse barriers to agency resulted partly from the dual-role dilemma (Robertson, 2008), with psychiatrists finding themselves to be servants of several masters. The strength of institutional forces seen in the study was also found in a study by Austin (2008): actions became agent-less, which was experienced as morally disturbing by the psychiatrists.…”

Section: Discussionmentioning

confidence: 99%

Psychosis, Need Adapted treatment, and psychiatrists’ agency

2013

View full text Add to dashboard Cite

Final DraftBackground: In the Need-Adapted approach (NAA) therapy meetings are a deliberate effort to bring all meaningful parties and views to a common discussion prior to decisions; this constitutes a challenge for psychiatrists' agency. Aims:To describe how psychiatrists see their agency in NAA.Methods: Using videos of co-research interviews, stimulated-recall interviews of ten interviewees were conducted and transcribed verbatim. The material was analyzed via an adapted dialogical-narrative analytical method.Results: Institutional forces were experienced as having an enormous impact on psychiatrists' agency, especially in the inpatient setting, reducing professional creativity. In the outpatient setting, psychiatrists who attended also hospital care were the most able to follow the principles of NAA and those who took part only in outpatient treatment had a tendency to adopt the position of medical consultants. Conclusions:The ability of psychiatrists to have agency in the language used with the clients is an underrated issue. The interview methods used in the research could be utilized in practice.

show abstract

“…The expert consensus indicated the importance of an MDT in the performance of the psychiatric examination. Since there may be a risk of a dual-role dilemma between the evaluator and the therapist if the examiner and the physician in charge are the same person [13], the examiner must not be the physician in charge of the subject [8]. However, this principle is not well known to forensic psychiatrists in Japan.…”

Section: Discussionmentioning

confidence: 99%

Expert consensus on hospitalization for assessment: a survey in Japan for a new forensic mental health system

et al. 2011

View full text Add to dashboard Cite

BackgroundIn Japan, hospitalization for the assessment of mentally disordered offenders under the Act on Medical Care and Treatment for the Persons Who Had Caused Serious Cases under the Condition of Insanity (the Medical Treatment and Supervision Act, or the MTS Act) has yet to be standardized.MethodsWe conducted a written survey that included a questionnaire regarding hospitalization for assessment; the questionnaire consisted of 335 options with 9 grades of validity for 60 clinical situations. The survey was mailed to 50 Japanese forensic mental health experts, and 42 responses were received.ResultsAn expert consensus was established for 299 of the options. Regarding subjects requiring hospitalization for assessment, no consensus was reached on the indications for electroconvulsive therapy (ECT) or for confronting the offenders regarding their offensive behaviors.ConclusionsThe consensus regarding hospitalization for assessment and its associated problems were clarified. The consensus should be widely publicized among practitioners to ensure better management during the hospitalization of mentally disordered offenders for assessment.

show abstract

Many Faces of the Dual-Role Dilemma in Psychiatric Ethics

Cited by 50 publications

References 67 publications

Ethical issues of long-term forensic psychiatric care

Ethical issues of long-term forensic psychiatric care

Psychosis, Need Adapted treatment, and psychiatrists’ agency

Expert consensus on hospitalization for assessment: a survey in Japan for a new forensic mental health system

Contact Info

Product

Resources

About