Opportunities and Risks of Self-Binding Directives: Results from Interview Studies with Stakeholders in Germany and The Netherlands

"Self-binding directives (SBDs) are a special type of psychiatric advance directive in which service users agree in advance to (coercive) treatment they might late refuse during a mental health crisis. SBDs aim to empower and protect service users by enabling them to state their values and to plan their (coercive) treatment in advance in consultation with the treating psychiatrist. SBDs have been widely discussed in the ethics literature. Topics include ethical issues surrounding competence, revocation and the ethical justification of involuntary commitment and treatment based on SBDs. Little empirical research on SBDs has been conducted thus far. The Netherlands is to the best of our knowledge the only country with explicit legal provisions for SBDs. On the 1st of January 2020, the new Dutch Law on Compulsory Mental Health Care (Wvggz) entered into force. The implications of this law for the use of SBDs are still unclear. In this presentation, we will present insights from a qualitative interview study on stakeholders’ experiences with SBDs under the new law and their views on the ethical opportunities and challenges of SBDs. Based on the results, we give recommendations for the implementation of SBDs in other European countries. "

Reopening Selves: Phenomenological Considerations on Psychiatric Spaces and the Therapeutic Stance

Classical and contemporary phenomenological approaches in psychiatry describe schizophrenia as a disorder of common sense and self-affection. Although taking into account intersubjectivity, this conceptualization still puts forward an individualistic view of the disorder, that is, the intersubjective deficit resides within the person. To overcome such individualism, in this article, we first propose that schizophrenic experience might be understood as arising from a dialectic relation between the self’s loss of openness to the world and the world’s loss of openness to the self. To show the relevance of social factors at the onset of schizophrenic experience, we propose a phenomenological analysis of trigger situations. In the second and main part of this article, we then focus on the implications of these phenomenological insights for the clinical practice: we argue that if schizophrenia is understood as a loss of openness between self and social world, psychiatric institutions should be transformed into spaces that enable a reopening of selves. We first describe <i>enclosing</i> phenomena such as coercive treatment to then, in contrast, present particular forms of <i>open psychiatric spaces</i> such as open door approaches and open dialogue. Besides the institutional-structural level, we also highlight aspects of openness at the intersubjective level of the individual agents, thus particularly emphasizing the role of an open therapeutic stance. We thus speak of (re)opening <i>selves</i> as we believe that the reopening of the patients’ self cannot but be related to and fostered by a reopening of the professionals’ self and stance. We thus argue that openness in the therapeutic stance is key to initiating the further process of recovery, which we describe as a reattunement of selves both at the bodily and narrative level. Last but not least, we sketch out possibilities for future phenomenological research on the question of psychiatric space and draw some broader societal implications.

Mandatory treatment for methamphetamine use in Australia

Background In 2016, following a flurry of government inquiries and taskforces including calls for mandatory treatment regimes, the Australian community nominated methamphetamine as the drug most likely to be associated as a problem substance. Mandatory treatment for alcohol and other drug problems in Australia consists of broadly two mechanisms compelling a person into treatment: involuntary treatment or civil commitment regimes; and coercive treatment regimes, usually associated with the criminal justice system. This paper aims to provide a review of the evidence for mandatory treatment regimes for people who use methamphetamines. Methods Using a narrative review methodology, a comprehensive literature and citation search was conducted. Five hundred two search results were obtained resulting in 41 papers that had cited works of interest. Results Small, but robust results were found with coercive treatment programs in the criminal justice system. The evidence of these programs specifically with methamphetamine use disorders is even less promising. Systematic reviews of mandatory drug treatment regimes have consistently demonstrated limited, if any, benefit for civil commitment programs. Despite the growing popular enthusiasm for mandatory drug treatment programs, significant clinical and ethical challenges arise including determining decision making capacity in people with substance use disorders, the impact of self determination and motivation in drug treatment, current treatment effectiveness, cost effectiveness and unintended treatment harms associated with mandatory programs. Conclusion The challenge for legislators, service providers and clinicians when considering mandatory treatment for methamphetamines is to proportionately balance the issue of human rights with effectiveness, safety, range and accessibility of both existing and novel mandatory treatment approaches.

Treatment of Social Anxiety Disorder or Neuroenhancement of Socially Accepted Modesty? The Case of Ms. Suzuki

This chapter presents the case of Ms. Suzuki, a modest Japanese woman who had worked as a clerk for more than 20 years. After she was promoted at age 43, she found herself unable to adapt properly to her management position because it required assertiveness and leadership. She saw a psychiatrist following her supervisor’s advice. She had some of the symptoms of social anxiety disorder (SAD), but it was uncertain whether she met the diagnostic criteria. To elucidate the considerations involved before initiating or refraining from pharmacotherapy, I refer to the ethical debates on neuroenhancement. First, medication would spoil her authenticity, because her modesty is part of her virtue. Second, medicating a person seeing a psychiatrist at her boss’s instigation might constitute a milder form of coercive treatment. Third, diagnosing Ms. Suzuki with SAD seems to endorse her company’s culture, whereas denying her disorder status would affirm Japanese culture’s oppressiveness toward women. When a case lies on the border between normality and pathology, relying on the psychiatric diagnosis for ethical guidance disguises value judgments for matters of fact. Therefore, we should explicitly state the conflicting values and the cultural influences on them to make better clinical decisions.

Coercion, Cooperation, Conflicts and Contempt: Orthodox-Lutheran Relations in Swedish-Occupied Kexholm County, Karelia, in the Seventeenth Century

The article is about the Swedish religious policy towards the Orthodox (a majority at first, a minority after the mid-1650s) and Orthodox-Lutheran relations at the grassroots level. It shows that in official Swedish policy, the highest authorities urged local functionaries to cautious and non-coercive treatment of the Orthodox, while the latter at times proposed, and partly tried to implement, a forced conversion of the Karelians. Grassroots relations between Orthodox and Lutherans varied greatly, depending on which of them made up a majority in each place, who owned the land, and whether the Lutherans were newcomers. When the Orthodox were a majority the Lutherans conformed with their faith, even converting to Orthodoxy, although this was officially forbidden. When the majority consisted of Lutherans, the Orthodox started to convert or to assimilate to the Lutheran way of life. At the county level, religion as such was not a major factor in transforming the region into a Lutheran one. More important was the way in which religious issues were linked to local social encounters and practices and how the state overtly or covertly attempted to change Orthodoxy and encouraged Orthodox emigration from and Lutheran immigration to the county.

Efficacy of interventions to reduce coercive treatment in mental health services: umbrella review of randomised evidence

Background Coercive treatment comprises a broad range of practices, ranging from implicit or explicit pressure to accept certain treatment to the use of forced practices such as involuntary admission, seclusion and restraint. Coercion is common in mental health services. Aims To evaluate the strength and credibility of evidence on the efficacy of interventions to reduce coercive treatment in mental health services. Protocol registration: https://doi.org/10.17605/OSF.IO/S76T3. Method Systematic literature searches were conducted in MEDLINE, Cochrane Central, PsycINFO, CINAHL, Campbell Collaboration, and Epistemonikos from January 2010 to January 2020 for meta-analyses of randomised studies. Summary effects were recalculated using a common metric and random-effects models. We assessed between-study heterogeneity, predictive intervals, publication bias, small-study effects and whether the results of the observed positive studies were more than expected by chance. On the basis of these calculations, strength of associations was classified using quantitative umbrella review criteria, and credibility of evidence was assessed using the GRADE approach. Results A total of 23 primary studies (19 conducted in European countries and 4 in the USA) enrolling 8554 participants were included. The evidence on the efficacy of staff training to reduce use of restraint was supported by the most robust evidence (relative risk RR = 0.74, 95% CI 0.62–0.87; suggestive association, GRADE: moderate), followed by evidence on the efficacy of shared decision-making interventions to reduce involuntary admissions of adults with severe mental illness (RR = 0.75, 95% CI 0.60–0.92; weak association, GRADE: moderate) and by the evidence on integrated care interventions (RR = 0.66, 95% CI 0.46–0.95; weak association, GRADE: low). By contrast, community treatment orders and adherence therapy had no effect on involuntary admission rates. Conclusions Different levels of evidence indicate the benefit of staff training, shared decision-making interventions and integrated care interventions to reduce coercive treatment in mental health services. These different levels of evidence should be considered in the development of policy, clinical and implementation initiatives to reduce coercive practices in mental healthcare, and should lead to further studies in both high- and low-income countries to improve the strength and credibility of the evidence base.