Elleke Landeweer

Moral margins concerning the use of coercion in psychiatry

In the closed wards of mental health institutions, moral decisions are made concerning the use of forced seclusion. In this article we focus on how these moral decisions are made and can be improved. We present a case study concerning moral deliberations on the use of seclusion and its prevention among nurses of a closed mental health ward. Moral psychology provides an explanation of how moral judgments are developed through processes of interaction. We will make use of the Social Intuitionist Model of Jonathan Haidt that emphasizes the role of emotions, intuitions and the social context in moral judgments and reasoning. We argue that this model can help to explain social dynamics in the context of enforced seclusion. In the discussion we explore how moral psychology can be complemented with the normative perspective of dialogical ethics to develop strategies for improving psychiatric practices. We conclude that social processes play an important role in moral deliberations and that moral development can be fostered by bringing in new perspectives in the dialogue. Moral case deliberation provides a practical tool to systematically organize moral reflections among nurses on the work floor.

The essence of psychiatric nursing: redefining nurses' identity through moral dialogue about reducing the use of coercion and restraint.

In this article, we focus on core values of psychiatric nurses in relation to coercion and constraint. We analyze changes that took place in a project aiming at reducing coercion at a closed inpatient ward of a psychiatric hospital. Using the philosophy of Hans-Georg Gadamer and Margaret Urban Walker, we analyze both the process of moral changes through dialogue and the outcome in terms of new identities and moral responsibilities. We conclude that the project stimulated nurses to redefine their roles and develop a deeper intersubjective understanding of core values of their profession.

Preventing seclusion in psychiatry A care ethics perspective on the first five minutes at admission

In this article, an intervention aimed at improving quality of care to prevent seclusion in psychiatry by focusing on the first five minutes at admission is analyzed from a care ethics perspective. Two cases are presented from an evaluation study in a psychiatric hospital. In both cases, the nurses follow the intervention protocol, but the outcome is different. In the first case, the patient ends up in the seclusion room. In the second case, this does not happen. Analyzing the cases from a care ethics perspective, we conclude that applying the intervention in the right way implies more than following the steps laid down in the protocol. It requires a new way of thinking and acting, resulting in new relationships between nurses and patients. Care ethics theory can help clarify what good care is actually about and keep in mind what is needed to apply the intervention. Thus, care ethics theory can be highly practical and helpful in changing and improving healthcare practice.

Responsive Evaluation in the Interference Zone between System and Lifeworld.

Responsive evaluation honors democratic and participatory values and intends to foster dialogues among stakeholders to include their voices and enhance mutual understandings. The question explored in this article is whether and how responsive evaluation can offer a platform for moral learning (Bildung) in the interference zone between system and lifeworld. A case example from Dutch psychiatry is presented. Policy makers aimed to develop a “monitoring instrument” for closed psychiatric wards to protect patient rights and prevent incidents. Tensions arose between strategic action and system values (accountability, efficiency, control, safety) and the search for meaning and morality. Several dynamics were set in motion. Through the creation of communicative spaces in which there was room for expression of emotions and stories, the “colonization” by system values was countered. Another dynamic called “culturalization” started simultaneously, that is, adoption of lifeworld values in the system world, which resulted in constructive dialogues on the meaning of good care and moral learning.

Psychiatry in the age of neuroscience: the impact on clinical practice and lives of patients

Due to the progress being made in the neurosciences, higher expectations for the use of medication, even against the patient’s will, are arising in mental hospitals. In this article, we will discuss whether the neurosciences and new psychopharmacological solutions really support patients who suffer from mental illnesses. To answer this question, we will focus on the perspective of patients and their experiences with psychiatric (coercive) treatments. The analysis of one person’s story shows that other issues besides appropriate medication are important for recovery from a mental illness. In daily life, issues such as coping, rehabilitation and social support are of major importance for a patient suffering from psychiatric disease. Thus, although progress in the neurosciences is a positive development for clinical practice, it does not mean that (coercive) medication alone will carry a patient into recovery. A patient’s recovery is dependent, not only upon the process of finding the appropriate medication and trust between the psychiatrist and the patient, but also upon relational aspects, such as being recognised as a person, belonging, accepting responsibilities, developing friendships and trusting others. These findings lead to the conclusion that dealing with psychiatric diseases is more complex than what the biomedical model of neuroscience suggests and that one should include the social context of the patient in the recovery process.ZusammenfassungAufgrund des Fortschritts der Neurowissenschaften steigen die Erwartungen an die Anwendung von Arzneimitteln in psychiatrischen Kliniken – auch gegen den Willen der Patienten. Im vorliegenden Artikel gehen wir der Frage nach, ob die Neurowissenschaften und innovative Psychopharmaka Patienten mit psychischen Erkrankungen tatsächlich helfen. Dabei konzentrieren wir uns auf die Sicht der Patienten und deren Erfahrungen mit (zwangsverabreichten) Psychopharmaka. Bei der Analyse einer Patientengeschichte wird deutlich, dass auch noch andere Aspekte als die medikamentöse Behandlung bei der Heilung psychischer Erkrankungen eine Rolle spielen. Im täglichen Leben sind bei der Auseinandersetzung mit einer psychischen Erkrankung Themen wie das Zurechtkommen, Rehabilitation und soziale Unterstützung für die Patienten von großer Bedeutung. Das bedeutet zwar, dass der Fortschritt der Neurowissenschaften für die klinische Praxis als positiv zu bewerten ist, nicht aber, dass allein (zwangsverabreichte) Medikamente zur Genesung des Patienten führen. Allein die richtige Medikation zu finden erfordert ein Vertrauensverhältnis zwischen Psychiater und Patient. Es geht aber auch um soziale Aspekte wie das Gefühl der Anerkennung als Person, Zugehörigkeit, Eigenverantwortung, Freundschaften und Vertrauen gegenüber anderen Menschen. Diese Erkenntnisse lassen die Schlussfolgerung zu, dass der Umgang mit psychischen Erkrankungen sehr viel komplexer ist als das von den biomedizinischen Modellen der Neurowissenschaften suggeriert wird, und dass eine Einbeziehung des sozialen Kontexts der Patienten für den Heilungsprozess unerlässlich ist.RésuméSuite aux progrès des neurosciences, on observe une demande accrue de médication par les hôpitaux psychiatriques, parfois même à l’encontre de la volonté des patients. Dans cet article, nous nous interrogeons sur la pertinence des neurosciences et des nouvelles approches psychopharmacologiques dans le traitement des patients atteints de maladies mentales. À cette fin, nous examinons le point de vue du patient dans son expérience avec les traitements psychiatriques (coercitifs). L’analyse d’une histoire personnelle montre qu’il existe divers facteurs essentiels, autres que la médication, qui entrent en cause dans la guérison d’une maladie mentale. Au quotidien, des aspects tels que l’accompagnement, la réhabilitation et le support social se révèlent d’une importance majeure pour les patients atteints de troubles psychiatriques. Ainsi, même si les progrès en neurosciences s’avèrent positifs pour la pratique clinique, cela ne veut pas dire que la médication (coercitive), seule, mènera le patient à la guérison. En effet, cette guérison ne dépend pas uniquement de la découverte du médicament approprié et de la relation de confiance qui s’établit entre le psychiatre et son patient. Elle est aussi tributaire de la dimension relationnelle de la vie du patient, telle la reconnaissance individuelle, le sentiment d’appartenance, la prise de responsabilité, le développement d’amitiés et la confiance en autrui. Ces révélations nous mènent à la conclusion que la gestion des désordres psychiatriques est beaucoup plus complexe que le modèle des neurosciences le suggère et que le processus de traitement du patient inclus impérativement son contexte social.

Worlds apart? A scoping review addressing different stakeholder perspectives on barriers to family involvement in the care for persons with severe mental illness

BackgroundEmpirical evidence shows that family involvement (FI) can play a pivotal role in the coping and recovery of persons with severe mental illness (SMI). Nevertheless, various studies demonstrate that FI in mental healthcare services is often not (sufficiently) realized. In order to develop more insights, this scoping review gives an overview of how various stakeholders conceptualize, perceive and experience barriers to FI. Central questions are: 1) What are the main barriers to FI reported by the different key stakeholders (i.e. the persons with SMI, their families and the professionals, and 2) What are the differences and similarities between the various stakeholders’ perspectives on these barriers.MethodsA systematic search into primary studies regarding FI was conducted in four databases: Medline/Pubmed, Cinahl, PsychInfo and Web of Knowledge with the use of a PICO scheme. Thematic analysis focused on stakeholder perspectives (i.e. which stakeholder group reports the barrier) and types of barriers (i.e. which types of barriers are addressed).ResultsThirty three studies were included. The main barriers reported by the stakeholder groups reveal important similarities and differences between the stakeholder groups and were related to: 1) the person with SMI, 2) the family, 3) the professionals, 4) the organization of care and 5) the culture-paradigm.DiscussionOur stakeholder approach elicits the different stakeholders’ concepts, presuppositions and experiences of barriers to FI, and gives fundamental insights on how to deal with barriers to FI. The stakeholders differing interpretations and perceptions of the barriers related to FI is closely related to the inherent complexity involved in FI in itself. In order to deal better with these barriers, openly discussing and reflecting upon each other’s normative understandings of barriers is needed.ConclusionsDifferences in perceptions of barriers to FI can itself be a barrier. To deal with barriers to FI, a dialogical approach on how the different stakeholders perceive and value FI and its barriers is required. Methods such as moral case deliberation or systematic ethics reflections can be useful.

The use of family group conferences in mental health: Barriers for implementation

Summary The number of compulsory admissions in Dutch psychiatry has increased in the past 25 years. The reduction of coercion with Family Group Conferences in youth care has been successful. How, when and under what conditions can Family Group Conferences reduce coercion in adult psychiatry, is subject of an extensive inquiry. This paper, however, focusses on the reverse question, namely, in what circumstances can Family Group Conferences not be deployed? An answer to this question provides insights regarding situations in which Family Group Conferences may (not) be useful. Barriers in 17 cases were examined using multiple case studies. Findings The following barriers emerged: (1) the acute danger in coercion situations, the limited time available, the fear of liability and the culture of control and risk aversion in mental health care; (2) the severity of the mental state of clients leading to difficulties in decision-making and communication; (3) considering an Family Group Conference and involving familial networks as an added value in crisis situation is not part of the thinking and acting of professionals in mental health care; (4) clients and their network (who) are not open to an Family Group Conference. Applications Awareness of the barriers for Family Group Conferences can help to keep an open mind for its capacity to strengthen the partnership between clients, familial networks and professionals. The application of Family Group Conferences can help to effectuate professional and ethical values of social workers in their quest for the least coercive care.

Sharing Care Responsibilities Between Professionals and Personal Networks in Mental Healthcare: A Plea for Inclusion

ABSTRACT This positional paper explores the role of personal networks (family and friends) in caring for people with mental health problems. Since the eighties, major changes have been made in the organization and focus of professional mental healthcare. Correspondingly, new expectations and changes in the division of care responsibilities between people with mental health problems, their personal networks and their professional care providers were created. In this paper, I investigate how the transition in mental healthcare changed the allocation of care responsibilities between personal networks, people with mental health problems and professional caregivers. I will consider why care responsibilities of personal networks have been taken for granted in these processes, and discuss whether personal networks should have a more prominent voice in the assignment of care responsibilities, and how this can be done. A theoretical framework of feminist care ethics inspired by scholars such as Margaret Urban Walker, Joan Tronto and Hilde Lindemann is used to reflect on the need for social inclusion.

Living with end-stage renal disease

Background: Living with a renal disease often reduces quality of life because of the stress it entails. No attention has been paid to the moral challenges of living with renal disease. Objectives: To explore the moral challenges of living with a renal disease. Research design: A case study based on qualitative research. We used Walker’s ethical framework combined with narrative ethics to analyse how negotiating care responsibilities lead to a new perspective on moral issues. Participants and research context: One case was chosen from 20 qualitative interviews with renal patients in the Netherlands. Ethical considerations: Several actions have been taken to ensure the informed consent, privacy, anonymity and confidentiality of the patient in this article. More details are offered in this article. The study has been conducted in line with the recommendations of the Medical Ethical Committee of the VU Medical Center. Findings: A renal disease can force people to change their identity, relationships, values and responsibilities. The case study illustrates the moral challenges confronting renal patients. Discussion and conclusion:: Moral issues can be raised by the changes to identities, relationships, values and responsibilities caused by renal disease. Support services for renal patients and their relatives should pay more attention to these issues in order to promote self-management.