Removing Compliance: Interpersonal and Social Factors Affecting Insight Assessments

Curk, Polona; Gurbai, Sándor; Freyenhagen, Fabian

doi:10.3389/fpsyt.2020.560039

Cited by 2 publications

(2 citation statements)

References 46 publications

(102 reference statements)

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“…In this model, appreciating and reasoning (Grisso and Appelbaum) are replaced by using or weighing ( 51 , 63 – 66 ), but it is not obvious that these terms are equivalent ( 51 ). Independent of the particular definition of DMC, a common controversy surrounds its evaluation for people suffering from mental disorders, whether they are decompensated or not ( 14 – 16 , 31 , 67 ).…”

Section: Introductionmentioning

confidence: 99%

Coercive Measures in Psychiatry: A Review of Ethical Arguments

et al. 2021

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Introduction: Coercion is frequent in clinical practice, particularly in psychiatry. Since it overrides some fundamental rights of patients (notably their liberty of movement and decision-making), adequate use of coercion requires legal and ethical justifications. In this article, we map out the ethical elements used in the literature to justify or reject the use of coercive measures limiting freedom of movement (seclusion, restraint, involuntary hospitalization) and highlight some important issues.Methods: We conducted a narrative review of the literature by searching the PubMed, Embase, PsycINFO, Google Scholar and Cairn.info databases with the keywords “coercive/compulsory measures/care/treatment, coercion, seclusion, restraint, mental health, psychiatry, involuntary/compulsory hospitalization/admission, ethics, legitimacy.” We collected all ethically relevant elements used in the author's justifications for or against coercive measures limiting freedom of movement (e.g., values, rights, practical considerations, relevant feelings, expected attitudes, risks of side effects), and coded, and ordered them into categories.Results: Some reasons provided in the literature are presented as justifying an absolute prohibition on coercion; they rely on the view that some fundamental rights, such as autonomy, are non-negotiable. Most ethically relevant elements, however, can be used in a balanced weighting of reasons to favor or reject coercive measures in certain circumstances. Professionals mostly agree that coercion is only legitimate in exceptional circumstances, when the infringement of some values (e.g., freedom of movement, short-term autonomy) is the only means to fulfill other, more important values and goals (e.g., patient's safety, the long-term rebuilding of patient's identity and autonomy). The results of evaluations vary according to which moral elements are prioritized over others. Moreover, we found numerous considerations (e.g., conditions, procedural values) for how to ensure that clinicians apply fair decision-making procedures related to coercion. Based on this analysis, we highlight vital topics that need further development.Conclusion: Before using coercive measures limiting freedom of movement, clinicians should consider and weigh all ethically pertinent elements in the situation and actively search for alternatives that are more respectful of patient's well-being and rights. Coercive measures decided upon after a transparent, carefully balanced evaluation process are more likely to be adequate, understood, and accepted by patients and caregivers.

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Section: Introductionmentioning

confidence: 99%

Coercive Measures in Psychiatry: A Review of Ethical Arguments

et al. 2021

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“…Their approaches to resolution, including considering how overwhelming the emotional state was or whether it caused the patient to make a decision out of keeping with their usual preferences, reflect procedural approaches in the literature (19). In contrast, hard cases involving insight did not reflect conceptual difficulty with insight in capacity assessment (40,41) but rather practical difficulties in establishing whether an apparent lack of insight was real or not.…”

Section: Ethical Skillsmentioning

confidence: 99%

Difficult Capacity Cases—The Experience of Liaison Psychiatrists. An Interview Study Across Three Jurisdictions

et al. 2022

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BackgroundAssessment of capacity for treatment and discharge decisions is common in the general hospital. Liaison psychiatrists are often asked to support the treating medical or surgical team in difficult capacity assessments. However, empirical research on identification and resolution of difficult capacity cases is limited. Some studies have identified certain patient, decisional, and interpersonal factors which cause difficulty, but no study has explored how these issues are resolved in practice. Our study therefore aimed to describe how experienced liaison psychiatrists identify and resolve difficult capacity cases in a general hospital setting.MethodsWe carried out semi-structured interviews with 26 liaison psychiatrists from England, Scotland, and New Zealand, on their most difficult capacity cases. Thematic analysis was used to examine types of difficulty and how these were resolved in practice. Summaries were prepared and example quotes extracted to illustrate phenomena described.ResultsWe identified four types of difficulty in capacity assessment, spanning both clinical and ethical domains: 1) Difficulty determining whether the decision is the patient's own or driven by illness, 2) Difficulty in applying ethical principles, 3) Difficulty in avoiding personal bias, and 4) Procedural difficulties. The liaison psychiatrists presented as self-reflective and aware of challenges and pitfalls in hard cases. We summarized their creative strategies to resolve difficulty in assessment.ConclusionPractitioners approaching difficult capacity cases require both clinical skills, e.g., to uncover subtle illness impairing decision-making and to consider interpersonal dynamics, and ethical skills, e.g., to negotiate the role of values and risks in capacity assessment. Education and training programmes should incorporate both aspects and could include the resolution strategies identified in our study. Practitioners, supported by health and social care systems, should work to develop self-aware and reflective capacity assessment practice.

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Removing Compliance: Interpersonal and Social Factors Affecting Insight Assessments

Cited by 2 publications

References 46 publications

Coercive Measures in Psychiatry: A Review of Ethical Arguments

Coercive Measures in Psychiatry: A Review of Ethical Arguments

Difficult Capacity Cases—The Experience of Liaison Psychiatrists. An Interview Study Across Three Jurisdictions

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