Use and alternatives to coercive measures in inpatient residential care facilities for adults with disabilities: study protocol of a mixed-methods study

BackgroundIn Germany, the use of coercive measures such as physical or chemical restraints in certain settings has been the focus of high court decisions, political debates, and scientific research in areas like psychiatric care. Such encroachments on fundamental rights could easily be overlooked in the case of residents in inpatient residential care facilities for adults with disabilities. However, little data are available on this issue. This study aims to investigate the types, frequencies, and characteristics of the use of coercive measures as well as the reasons and justifications of their use. Possible alternatives to these measures and contextual conditions will also be identified.MethodsThe study is based on an explorative, multi-phase, cross-sectional design, which consists of a mixed-methods approach including several forms of data collection and analysis bringing together forensic, sociological, pedagogical and medical perspectives and expertise. First, the entirety of the approximately n = 880 residential care facilities for adults with disabilities in the study area will be surveyed by an online questionnaire. Participating passive observations will be carried out in n = 5 selected residential care facilities (24 hours per facility), with an approximate total of n = 150 residents. In these facilities, organizational documents such as house rules and residential documents such as medication plans will also be collected and analysed. Focus groups will be conducted in each of the five facilities including residents, staff, and legal guardians of the residents.DiscussionThis study will address important gaps in the current research by providing different forms of empirical data on the use or avoidance, causes, contexts, and alternatives to coercive measures in inpatient residential care facilities for adults with disabilities. This study is the first in Germany to combine a general overview (survey) and detailed insight (observations, document analysis, focus groups) approach to this issue. These findings will provide a basis for further research in the field as well as for the management of coercive measures in practical settings.

Approval of Coercion in Psychiatry in Public Perception and the Role of Stigmatization

Background: Coercion is routinely used in psychiatry. Its benefits and drawbacks are controversially debated. In addition, the majority of persons with mental health problems are exposed to stigmatization and are assumed to be dangerous. Stigmatization is associated with negative consequences for individuals with mental illness such as disapproval, social rejection, exclusion, and discrimination. Being subjected to coercive measures can increase the stigmatization of the affected persons, and stigmatization might lead to higher approval for coercion.Aims of the Study: This study aims to examine the approval for coercive measures in psychiatry by the general public, and to explore its relation with person- and situation-specific factors as well as with stigmatization.Method: We conducted a representative survey of the general population (N = 2,207) in the canton of Basel-Stadt, Switzerland. Participants were asked to read a vignette depicting psychopathological symptoms of a fictitious character and indicate whether they would accept coercive measures for the person in the vignette. Desire for social distance and perceived dangerousness were assessed as measures of stigmatization.Findings: The person in the case vignette exhibiting dangerous behavior, showing symptoms of a psychotic disorder, being perceived as dangerous, and treatment being understood as helpful increased approval of coercion in general, while familiarity of the respondents with mental illness decreased approval.Conclusions: The public attitude regarding the approval of coercion in psychiatry is highly differentiated and largely follows the current legal framework and medical treatment guidelines. Higher approval occurred in situations of self-harm or harm to others and when coercive measures were thought to have a beneficial effect for the affected persons. A considerable part of the approval for coercion is predicted by stigmatization. With the increasing severity of coercive measures, the influence of person- and situation-specific factors and of familiarity with mental illness decreased and generalizing and stigmatizing attitudes became stronger predictors for the approval of more severe measures.

Legal problems of use of compulsory psychiatric treatment in Russia and Belarus

The subject of the research is the problems of legislative regulation of compulsory psychiatric measures in the criminal legislation of the Republic of Belarus and the Russian Federation.The purpose of the article is to confirm or refute the hypothesis that there are defects in legislative regulation that prevent the effective use of compulsory psychiatric treatment. They are not eliminated in the Criminal Codes of the Russian Federation and the Republic of Belarus. Research methodology. On the basis of a system-integrated approach on an interdisciplinary basis, a scientific analysis of special legal and forensic psychiatric scientific literature and interpretation of the criminal legislation of the Republic of Belarus and the Russian Federation were carried out.Main results. An analysis of the Criminal Codes of the Republic of Belarus and the Russian Federation showed that compulsory psychiatric treatment is an independent institution of criminal law, which is regulated in sufficient detail in the national criminal legislation. The article includes a comparative legal analysis of the norms of the criminal legislation of both states (Chapter 14 of the Criminal Code of the Republic of Belarus and Chapter 15 of the Criminal Code of the Russian Federation) that regulate psychiatric coercive measures applied to persons with mental disorders who have committed illegal acts. Based on the results of the study, a number of problems were identified in the legislative regulation of psychiatric compulsory measures in the criminal codes of both states, the authors propose directions for further improvement of the current criminal legislation.Conclusions. The Criminal Codes of the Republic of Belarus and the Russian Federation contain only general criteria for choosing the type of psychiatric measures of a coercive nature, in the most general form, the procedure for their change and termination is provided, they need editorial clarification of their purpose. There is no legislative definition of the concepts of “coercive security measures and treatment” (Chapter 14 of the Criminal Code of the Republic of Belarus) and “compulsory measures of a medical nature” (Chapter 15 of the Criminal Code of the Russian Federation), etc., which causes serious difficulties in law enforcement practice and indicates the need to continue work to improve the current criminal legislation.The terminology used “coercive and security measures and treatment” (Chapter 14 of the Criminal Code of the Republic of Belarus) and “coercive measures of a medical nature” (Chapter 15 of the Criminal Code of the Russian Federation) does not reflect the specifics of these measures, which in their essence and content are exclusively psychiatric measures. The identified problems of legislative regulation of psychiatric compulsory measures in the criminal legislation of both states require their further resolution, and based on the interdisciplinary medico-legal nature of the problems involved, with the obligatory involvement of forensic psychiatrists in their solution.

Collective paternalism and vaccination programmes

One important objection to vaccination programmes involving coercive measures such as re-strictions on unvaccinated people’s access to public space, or even nudging, is that they are paternalistic. We believe this objection is weaker than is often assumed. We defend this belief by: 1) introducing a novel distinction between individual and collective paternalism; 2) showing that, across a range of circumstances, vaccination programmes involve collective, not individu-al, paternalism; and 3) arguing that collective paternalism is not wrong for the reasons that, arguably, individual paternalism is.

Coercive Measures in Psychiatry: A Review of Ethical Arguments

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.

Measuring Staff Attitudes to Coercion in Poland

Introduction: Coercion can be defined as the use of force to limit a person's choices. In Poland, coercive measures may tend to be overused. However, there is limited information regarding the attitudes of nurses toward coercion in psychiatric settings and the factors influencing any decisions to use coercion.Aims: To validate the Staff Attitudes to Coercion Scale (SACS) for a group of psychiatric nurses and psychiatrists, to compare the said with the original Norwegian SACS version, and to compare nurses' attitudes with those displayed by psychiatrists. A second aim was to understand the relationship between self-efficacy and attitudes to coercion.Method: We surveyed 351 psychiatric nurses and psychiatrists rating SACS and GSES (General Self Efficacy Scale). We validated the SACS factor structure using confirmatory principal component factor analysis, calculated the internal consistency of subscales, and analyzed the test-retest reliability and face validity of the subscales themselves. Further, we analyzed the differences in attitudes toward coercion between nurses and psychiatrists, as well as whether there was an association between GSES and the SACS subscales. We compared the means on the SACS items between three countries—Germany, Norway, and Poland.Results: The confirmatory factor analysis of the Polish version of SACS found the same factor structure with three factors as was displayed in the original Norwegian SACS, except that one item was loaded on another factor. Internal consistency was acceptable for the factors on coercion as security and the coercion as offending, and unacceptable for the factor on coercion as treatment. Test-retest reliability was excellent for all the three subscales. Face validity was high for the factor coercion as security, partly present for coercion as offending, and not present for coercion as treatment. The subscale Coercion as Treatment was rated significantly higher by nurses than by psychiatrists, but there was no difference for the two other subscales. There was no significant association between the General Self-Efficacy Scale and any of the SACS subscales. The biggest differences in attitudes toward forms of coercion was noted between Poland and Germany.Discussion: The three-factor structure of SACS was the best solution for the Polish nurses and psychiatrists. The attitudes toward coercion differed between the two groups, but a low correlation was computed for the SACS subscales and self-efficacy. There is a cultural diversity visible amongst the three countries examined. Reduction in the use of coercion is a priority worldwide. More knowledge about the process involved in using coercive measures may contribute to this. The use of coercive interventions may harm patients and threaten patients' rights. Thus, education is needed for pre-service and in-service nurses alike.

Home Quarantine or Home Isolation During the Covid-19 Pandemic as a Deprivation of Liberty under Polish Law

Combating the COVID-19 pandemic requires that States should take many measures, which may also substantially interfere with the rights or freedoms of individuals. One commonly used mechanism to counter the spread of the SARS-CoV-2 virus is home quarantine or home isolation. Bearing in mind the guidelines arising from ECHR case-law, the article assesses whether home quarantine or home isolation applied under Polish law constitutes a deprivation of liberty. Taking into consideration the manner and conditions of these isolation measures and the possibility of using coercive measures, home quarantine or home isolation under Polish law constitutes deprivation of liberty within the meaning of Article 5(1)(e) of the ECHR. Then attention is drawn to selected consequences arising from this classification. In particular, it is emphasized that they cannot be imposed by a decision of the legislator, but only as a result of an act of law enforcement by sanitary authorities or courts.

German Law Reform Does Not Reduce the Prevalence of Coercive Measures in Residential Institutions for Children, Adolescents, and Young Adults With Intellectual and Developmental Disabilities

Background: Approximately 10% of children, adolescents and young adults with an intellectual and developmental disability (IDD) in Bavaria live in residential institutions. 2015 saw media reports raising suspicions about excessive use of coercive measures (cM) in those institutions. Until a law reform at the end of 2017 made permission from family courts mandatory for cM, their use was governed by parental consent. The REDUGIA project conducted a representative survey comparing cM and their relation to challenging behaviour (cB) and employee stress in Bavaria pre and post reform.Methods: We sent questionnaires to 65 residential institutions for children, adolescents and young adults with IDD in 2017 (pre reform, T1) and 2019 (post reform, T2). To assess changes, we analysed data from all available questionnaire pairs (T1 and T2, N = 43). We calculated paired t-test and correlative analyses concerning the relationship between cB, cM, and employee stress.Results: The number of residents overall (T1: N = 1,661; T2: N = 1,673) and per institution (T1: m = 38.6 ± 32.0; T2: m = 38.9 ± 34.5, p = 0.920) remained stable. We did not see any changes in the Index cB (p = 0.508) or the proportion of residents per institution displaying various types of challenging behaviour (all ps>0.220). There was no change in the Index cM (p = 0.089) or any indicator of employee stress, all ps > 0.323. At follow-up, the Index cB correlated positively with the Index cM (r = 0.519 p < 0.001). Regarding employee stress, the Index cB correlated positively with the frequency of sick leave (r = 0.322, p = 0.037) and physical attacks on employees (r = 0.552, p < 0.001). The Index cM also correlated positively with the frequency of sick leave (r = 0.340, p = 0.028) and physical attacks on employees (r = 0.492, p = 0.001).Discussion: Coercive measures are not a general phenomenon, but are focused on specialised institutions. The law reform did not lead to changes in the number of children, adolescents and young adults with IDD affected by coercive measures in residential institutions in Bavaria. There were still large discrepancies between institutions in the prevalence of challenging behaviour and coercive measures. Coercive measures were associated with challenging behaviour and employee stress. Taken together, findings from REDUGIA emphasise the need to prevent challenging behaviour and thus coercive measures.

COERCIVE MEASURESIN PANDEMIC PSYCHIATRIC CARE — RETROSPECTIVE STUDY

Coercion raises serious ethical and legal issues in psychiatric care. Coercive medical measures are applied in psychiatric institutions for protective purposes. Alcoholism is a social and medical problem because it especially affects the behavior of the individual. Alcohol consumption can catalyze exacerbations of mental illness and predispose to behaviors with an increased risk of violence. Aim: The purpose of this study is to illustrate medical and legal issues related to coercive measures in emergency psychiatric care during the pandemic. Methods: The study is retrospective, and the data were taken from the observation sheets of patients in the period between March 1, 2020–March 31, 2021, in acute section II in the Institute of Psychiatry "Socola" Iasi. Results: Of those who required coercive measures during hospitalization, most were restraint for symptoms such as: self-aggression and aggression towards others. Mechanical restraint measures were also necessary in cases with hallucinatory-delusional symptoms, associated with self-aggression and aggression towards others. The share of hospitalized patients for alcohol abuse, who required coercive measures, was significantly higher during the pandemic. Conclusion: Manifestations of violence among patients with major mental disorders are rare. Mechanical restraint was necessary especially in those who had self-aggression and aggression towards others, symptoms secondary to alcohol consumption. Alcohol consumption amplifies the psychological imbalance in the context of the COVID-19 pandemic.