Refusing Medication Therapy in Involuntary Inpatient Treatment—A Multiperspective Qualitative Study

Abstract

Objective: Between June 2012 and February 2013, two decisions by the German Federal Constitutional Court restricted the so-far common practice to use involuntary medication in inpatients who were involuntarily hospitalized. Up to then, involuntary medication was justified by a judge’s decision on involuntary hospitalization. It could be applied according to clinical judgment even against the declared will of a patient. Since then, all domestic laws related to involuntary treatment had to be revised. For several months, involuntary medication was allowed only in an emergency. We were interested in the impact of the changed legal framework on the experiences of inpatients, their relatives, and clinical professionals during that time. Methods: Thirty-two interviews were analyzed qualitatively using a grounded theory methodology framework. Results: As a consequence of the restrictions to involuntary medication, special efforts by nursing and medical staff were required concerning de-escalation, ward management, and the promotion of treatment commitment in inpatients who refused medication. Family caregivers were also under strong pressure. They wanted to help and to protect their relatives, but some also welcomed the use of coercion if the patient refused treatment. Most of the interviewed patients had not even noticed that their rights to refuse medication had been strengthened. They complained primarily about the involuntary hospital stay and the associated limitations of their everyday lives. While patients and family members evaluated the refusal of medication from a biographical perspective, the mental health care professionals’ focus was on the patients’ symptoms, and they understood the situation from a professional perspective. It was obvious that, in any of the four perspectives, the problem of feeling restricted was crucial and that all groups strived to gain back their scope of action. Conclusion: The temporary ban on involuntary medication questioned the hitherto common routines in inpatient treatment, in particular when patients refused to take medication. Each of the different groups did not feel good about the situation, for different reasons, however. As a consequence, it might be indispensable to increase awareness of the different perspectives and to focus the efforts on the establishment of nonviolent treatment structures and practices.

Coercion in psychiatric and mental health nursing: A conceptual analysis

“…Lack of insight may lead to the refusal of required psychiatric medication, resulting in an exacerbation of psychotic symptoms (Gustafsson & Salzmann‐Erikson 2016; Jaeger et al . 2019; Jansen et al . 2019).…”

“…Lastly, regarding antecedents, most research supports the need to put in place de‐escalation (or alternative) measures prior to using coercive measures (Hallett & Dickens 2015; Jaeger et al . 2019; McKeown et al . 2019; Salzmann‐Erikson et al .…”

“…Jaeger et al . (2019) stress the need for ongoing critical reflection on the use of coercion and social control in psychiatric care. Such critical reflections, however, need to be supported by organizational policies aimed at reducing and eliminating coercive measures, as well as by peers and managerial support (Green et al .…”

Socio-Demographic and Clinical Characteristics of Adults With Psychotic Symptomatology Under Involuntary Admission and Readmission for Compulsory Treatment in a Referral Psychiatric Hospital in Cyprus

“…Data on the effectiveness of compulsory treatment are insufficient ( 5 , 6 ) while self-stigma in those involuntarily hospitalized for compulsory psychiatric treatment has been well-described in international literature ( 7 ). At the same time, involuntary hospitalization in mental health settings has been described as a severe stressor for family members of those under compulsory treatment, as well as for healthcare professionals providing care to them ( 8 ). Thus, documentation of data which may be applied in policy making, to lessen compulsory hospitalization of people facing mental health problems, may be an important public health issue.…”

Socio-demographic and clinical characteristics of adults under involuntary hospitalization in the acute mental health services of Cyprus

“…Data on the effectiveness of compulsory treatment are insufficient [4][5] while self-stigma in those involuntary hospitalized for compulsory mental health treatment has been well described in the international literature 6 . At the same time, compulsory hospitalization has been described as a severe stressor for family members of those involuntary admitted to psychiatric units for compulsory treatment, as well as for the healthcare professionals providing care to them 7 . Thus, documentation of data which may be applied in policy-making to prevent compulsory hospitalization in people facing mental health problems may be an important public health issue.…”