Background: In spite of a national strategy for reducing coercion in the mental health services, Norway still has a high rate of involuntary treatment compared to other European countries. It is therefore crucial to study various parties involved in involuntary treatment in order to reduce coercion. Research question: How do patients and staff in a Norwegian locked psychiatric ward experience coercion? Research design: Participant observation and interviews. Participants: A total of 12 patients and 22 employees participated in this study. (...) Ethical considerations: This study is accepted by the National Committee for Medical Health Research Ethics. Findings: The participants experienced coercion in different ways. Patients often felt inferior, while many of the staff felt guilty for violating patients’ dignity, although they ascribed responsibility for their actions to the “system.” The main themes are (1) corrections and house rules, (2) coercion is perceived as necessary, (3) the significance of material surroundings, and (4) being treated as a human being. Discussion: The discussion draws upon the concepts of vulnerability, guilty conscience, and ethical sensitivity, related to the staffs’ divergent views on coercion. Conclusion: Especially among staff, there are divergent views of coercion. Professionals being physically and emotionally close to the patient are more likely to understand him or her as a unique person with individual needs. If patients are kept at a distance, professionals as a group change to understand patients as members of a group with common needs and common restrictions. (shrink)

Background: Nurses working within acute psychiatric settings often face multifaceted moral dilemmas and incompatible demands. Methods: Qualitative individual and focus group interviews were conducted. Ethical considerations: Approval was received from the Norwegian Social Science Data Services. Ethical Research Guidelines were followed. Participants and research context: Thirty nurses working within acute psychiatric wards in two mental health hospitals. Results: Various coping strategies were used: mentally sorting through their ethical dilemmas or bringing them to the leadership, not ‘bringing problems (...) home’ after work or loyally doing as told and trying to make oneself immune. Colleagues and work climate were important for choice of coping strategies. Discussion: Nurses’ coping strategies may influence both their clinical practice and their private life. Not facing their moral distress seemed to come at a high price. Conclusions: It seems essential for nurses working in acute psychiatric settings to come to terms with distressing events and identify and address the moral issues they face. As moral distress to a great extent is an organisational problem experienced at a personal level, it is important that a work climate is developed that is open for ethical discussions and nourishes adaptive coping strategies and moral resilience. (shrink)

On a closed psychiatric ward, conflict and disagreement may exist between patients and psychiatrists on how to interpret the patient’s condition. This forms a complexity for implementing contemporary ideals such as shared decision making, which would require a substantial degree of epistemic flexibility from both psychiatrists and patients. Recently, authors have argued that psychiatrists are pluralistic and pragmatic in their interpretation of the patient’s condition, implying a space for this flexibility in the clinical encounter. In this article we present (...) an empirical study in which we aim to describe, understand, and explain this epistemic space and the dynamics between the psychiatrist’s and patient’s interpretation. We aim to explore and contextualize philosophical discussions through empirical research. We performed a qualitative inquiry on a closed psychiatric ward and found that both patients and psychiatrists were epistemically flexible, but epistemic negotiations were more complex and variegated than often presumed. We constructed an empirically grounded typology of different types of epistemic interaction, which shows that this interaction can only be properly understood if one acknowledges that it is shaped by different professional, societal and personal norms and values. We conclude by discussing the scope and limits of the epistemic space that we found. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 9.1 (2002) 23-26 [Access article in PDF] The Complexity of Evil Behavior David E. Ward I WOULD LIKE TO BEGIN this reply by thanking the commentators. The reports of their clinical experience contained some interesting evidence regarding evil behavior that, I think, supports my thesis and their full frontal criticism has given me a chance to reemphasize how complex the problem of evil behavior is.On (...) the question raised by Steven Sverdlik, as to whether Kant was in possession of the idea of the unconscious: it never occurred to me that Kant's notion of the subreption of the will—the idea that we could somehow be deceived with regard to our true motives (1956, 121)—could be regarded as a reason for assuming that Kant had a concept of the unconscious. Certainly talk of being unsure of one's motives has been common currency in every age that has had the idea of acting out of duty as opposed to desire. This uncertainty allows us to think about unconscious motives and thus of a set of hidden mechanisms that might motivate our actions without our being aware of them. However, I think we would both agree that Kant nowhere articulates this hypothesis. Freud did articulate it. So I agree that I should have said that Kant was not in possession of a concept of unconscious mechanisms that may generate behavior in such a way as to be opaque to the agent involved.Sverdlik has two worries with regard to my thesis. The first concerns my characterization of evil behavior as wrongdoing for wrongdoing's sake. He believes that rather than insisting that all principled behavior must fit this formula, "Ward is really interested in wrongdoing that is non-impulsive and actuated by some principle, but not necessarily the satanic one." This is, indeed, exactly what I was interested in. It is the unconscious adherence to some principle that causes all the trouble for evil people. Sverdlik thinks that my proposal was "to attribute acceptance [of such principles] to the unconscious" and to maintain that though the agent does "not consciously accept it, [it] does do so unconsciously" (my emphasis). What I actually said was: In my account, there is a near-perfect dovetailing of the two different psychological perspectives—that of Kant's moral psychology (which lacks the resources to accommodate the possibility of evil) and that of Peck's psychiatric diagnosis of evil—that explains (on my construal) how an unconscious adherence to unacknowledged principles could be the driving power behind evil behaviour. What is the difference between unconscious acceptance of a principle and unconscious adherence to it? This difference can be illustrated in connection with Sverdlik's continuation of his argument: Ward suggests that the agent does not consciously accept it, but does so unconsciously. But why does the unconscious not see that it is not universalizable? And if it does see this, why does it proceed to act on it? Ward's picture of the unconscious must allow it to be rational enough to understand the narcissistic principle, for example, [protect your self-image at all costs] and to act on it. But if it is that rational, then it is puzzling that it does not draw the same conclusion [End Page 23] that the agent's conscious deliberation can and will draw. Therefore, if consciously acting on a non-universalizable principle is inexplicable, then so is unconsciously acting on it. According to my picture of the unconscious, what the unconscious is rational about are hypothetical principles: it sees the connection between means and ends with perfect rationality. When, in my article, I distinguished between categorical and hypothetical imperatives I pointed out that... it is clear that hypothetical principles like always dress in woolens can only motivate us if we already have a desire to be warm. Strictly speaking, hypothetical principles do not motivate us by themselves. They are only useful in specifying the means to an end that a rational person would follow if she wanted to satisfy a certain desire. (My emphasis.) I was assuming, then... (shrink)

Background: Fear and aggression are often reported among professionals working in locked psychiatric wards and also among the patients in the same wards. Such situations often lead to coercive intervention. In order to prevent coercion, we need to understand what happens in dangerous situations and how patients and professionals interpret them. Research questions: What happens when dangerous situations occur in a ward? How do professionals and patients interpret these situations and what is ethically at stake? Research design: (...) Participant observation and interviews. Participants: A total of 12 patients and 22 professionals participated. Ethical considerations: This study has been accepted by the Regional Committee for Medical and Health Research Ethics in Norway. Findings: (a) Both atmosphere and material surroundings were interweaved within dangerous situations, (b) the professionals applied stereotypes when interpreting dangerous situations and (c) the professionals and the patients had different interpretations of what triggered dangerous situations. Discussion: The discussion centres on how care ethics and a dialogical practice might contribute towards combating difficult situations and the ways in which change is an ongoing ethical process of becoming. Conclusion: The ethics of care and a dialogical approach are suggested as ethical frameworks for preventing fear, danger and aggression in psychiatric wards. Both frameworks can be understood as patient-driven, including the relational and contextual perspectives. It means a shift from professionally driven processes to patient-driven dialogue. (shrink)

In August 2001, the Israeli Ministry of Health issued its Limitation of Smoking in Public Places Order, categorically forbidding smoking in hospitals. This forced the mental health system to cope with the issue of smoking inside psychiatric hospitals. The main problem was smoking by compulsorily hospitalized psychiatric patients in closed wards. An attempt by a psychiatric hospital to implement the tobacco smoking restraint instruction by banning the sale of cigarettes inside the hospital led to the development (...) of a black market and cases of patient exploitation in return for cigarettes. This article surveys the literature dealing with smoking among psychiatric patients, the role of smoking in patients and the moral dilemmas of taking steps to prevent smoking in psychiatric hospitals. It addresses the need for public discussion on professional caregivers’ dilemmas between their commitment to uphold the law and their duty to act as advocates for their patients’ rights and welfare. (shrink)

Between Sickness and Health is about illness rather than disease, and recovery rather than cure. The book argues that illness is an experience, represented by the feeling that 'I am not myself'. From the book's phenomenological point of view, feelings of illness cannot be 'unreal' or 'fake', whatever their biological basis, nor need they be categorised as 'physical', 'psychosomatic' or 'psychiatric'. The book challenges the disease-centred ethos of medicine and medical education. It demonstrates that a clearer conception of illness, (...) as distinct from disease, is therapeutic. The feeling that 'I am once again myself' can return, in some degree, whatever state the body is in. Resilience becomes more available when it is seen as a set of personal skills that can be developed, rather than as an inborn trait. Possibilities of wellness are enhanced by recognising that medical and other therapies can either support or impede recovery, as can human relationships and the socio-political environment. The book's many clinical examples are drawn from the author's broad experience as a neurologist, rehabilitation physician and systemic family therapist. Between Sickness and Health will be useful for students, practitioners and academics, and also for anyone who has been or might one day be ill. (shrink)

Medical doctors arrive at a diagnosis after considering various types of evidence, including the patient's complaints, their outer appearance, talk, and non-verbal behavior. In psychiatry, the role of conversation is more important than in somatic medicine, because it is in the patient's talk that the disease can express itself. Some elements of the conversational machinery have been studied in diagnostic interviews in a psychiatric ward. In the interviews, a recurrent pattern of the doctor’s questions and the patient’s answers was (...) found. Schegloff (2007) showed that “known answer” questions form a distinctive three-part sequence type: question-response-evaluation. In diagnostic interviews in psychiatry, the questions don't address knowledge but the capacity to perform the task. Not all the test questions have a correct answer, and the result of the evaluation is not always announced by the doctor. The doctor consistently repeats the patient’s answer without evaluating it and then adds a follow-up question. At least parts of the repeated cycles in the sequence of doctor-patient interaction exhibit the following pattern: Doctor’s question > Patient’s answer > Doctor’s echo > (optional Doctor's follow-up question). When the doctor's questions seek real information—and do not just test capacity—they sometimes resort to a reformulation of the patient’s answers instead of just repeating it; this reformulation works as a prompt. The questions in the clinical interview appear to follow two lines of accountability: the ordinary conversational order and that which is provided by the professional reasoning aimed at checking diagnostic hypotheses. The second line is not usually accessible to the patient. (shrink)

Background: Informal coercion, that is, situations where caregivers use subtle coercive measures to impose their will on patients, is common in adult psychiatric inpatient care. It has been described as ‘a necessary evil’, confronting nurses with an ethical dilemma where they need to balance between a wish to do good, and the risk of violating patients’ dignity and autonomy. Aim: To describe nurses’ experiences of being involved in informal coercion in adult psychiatric inpatient care. Research design: The study (...) has a qualitative, inductive design. Participants and research context: Semi-structured interviews with 10 Swedish psychiatric nurses were analysed with qualitative content analysis. Ethical considerations: The study was performed in accordance with the Declaration of Helsinki. In line with the Swedish Ethical Review Act, it was also subject to ethical procedures at the university. Findings: Four domains comprise informal coercion as a process over time. These domains contain 11 categories focusing on different experiences involved in the process: Striving to connect, involving others, adjusting to the caring culture, dealing with laws, justifying coercion, waiting for the patient, persuading the patient, negotiating with the patient, using professional power, scrutinizing one’s actions and learning together. Discussion: Informal coercion is associated with moral stress as nurses might find themselves torn between a wish to do good for the patient, general practices and ‘house rules’ in the caring culture. In addition, nurses need to be aware of the asymmetry of the caring relationship, in order to avoid compliance becoming a consequence of patients subordinating to nurse power, rather than a result of mutual understanding. Reflections are thus necessary through the process to promote mutual learning and to avoid violations of patients’ dignity and autonomy. Conclusion: If there is a need for coercion, that is, if the coercion is found to be an ‘unpleasant good’, rather than ‘necessary evil’ considering the consequences for the patient, it should be subject to reflecting and learning together with the patient. (shrink)

The ideal of trust pervades nursing. This article uses empirical material from acute psychiatry that reveals that it is distrust rather than trust that is prevalent in this field. Our data analyses show how distrust is expressed in the therapeutic environment and in the relationship between nurse and patient. We point out how trust can nonetheless be created in an environment that is characterized by distrust. Both trust and distrust are exposed as `fragile' phenomena that can easily `tip over' towards (...) their opposites. Trust is not something that nurses possess or are given; it is rather something that they earn and have to work hard to achieve. Regarding themselves as potential causes of distrust and active wielders of power can contribute to nurses developing a more realistic view of their practice. Assuming a realistic middle-way perspective can help to manoeuvre between the extremities of excellence and resignation, which in turn can lead to processes that create trust between psychotic patients and nurses. (shrink)

Background Research has shown that moral distress negatively impacts nurses, patients, and organizations; however, several scholars have argued that it can be an opportunity for positive outcomes. Thus, factors that may mitigate moral distress and catalyze positive change need to be explored. Research aim The purpose of this study was to explore the relationships among structural and psychological empowerment, psychiatric staff nurses’ experience of moral distress, and strategies for coping with moral distress. Research design A descriptive cross-sectional correlational study. (...) Participants and research context A total of 180 registered nurses working in psychiatric hospitals in Japan participated. This study examined relationships among key variables using four questionnaires to assess structural and psychological empowerment, moral distress for psychiatric nurses, and coping strategies. Statistical analyses of correlations and multiple regressions were conducted. Ethical considerations The study was approved by the institutional review board at the author’s affiliated university. Findings Psychiatric nurses perceived moderate levels of structural and psychological empowerment, and their experiences of moral distress were related to low staffing. Structural empowerment was negatively related to the frequency of moral distress but not the intensity. Contrary to expectations, psychological empowerment was not found to mitigate nurses’ moral distress. Multivariate regression analyses revealed that the significant predictors of moral distress were the leaving issues unresolved coping style, the problem-solving coping style, and a lack of formal power, which explained 35% and 22% of the variance in the frequency and intensity of moral distress, respectively. Conclusions In psychiatric hospitals in Japan, nurses experience moral distress that compromises the quality of care they provide. Therefore, formal support for nurses in voicing and investigating their moral concerns is required to bestow formal power by establishing a ward culture that includes shared governance. (shrink)

Introduction:The concept of mentalizing is nowadays widely used in research as well as in clinical practice. Despite its popularity, the development of an economic assessment is still challenging. The Mentalization Scale appears to be a promising measurement with good psychometric properties but lacking convergent validity with the Reflective Functioning Scale.Objective:This study aims to test the construct validity of the Mentalization Scale through correlations with the gold standard, the Reflective Functioning Scale, within a clinical sample. Furthermore, it was of interest to (...) replicate its internal consistency.Methods:Twenty-six inpatients of an acute psychiatric ward in Vienna were given the Mentalization Scale (MentS). They were interviewed with the Brief Reflective Function Interview, which was coded with the Reflective Functioning Scale. Correlations and internal consistency were calculated.Results:Concerning the primary aim of this study, the validity was satisfactory for the MentS whole-scale mentalizing as well as for the subscales self- and other-oriented mentalizing. Internal consistency was lower to the findings of the developer and close to the 0.70 threshold.Conclusion:Our findings could foster the psychometric properties of the MentS. Furthermore, the MentS seems to be a promising measurement tool for detecting different dimensions of reflective functioning. Limitations and further research are discussed. (shrink)

In the past decade, the Norwegian government has emphasized user participation as an important goal in the care of mentally ill patients, through governmental strategic plans. At the same time, the governmental documents request normalization of psychiatric patients, including the re‐socialization of psychiatric patients back into society outside the psychiatric hospital. Milieu therapy is a therapeutic tool to ensure user participation and re‐socialization. Based on an ethnographic study in a long‐term psychiatric ward in a psychiatric (...) hospital, we identified how staff tried to implement user participation in their milieu‐oriented therapy work. We have identified three major tensions and challenges in implementing user participation in milieu‐therapeutic work. First, it is difficult to implement individual‐based user participation and at the same time take collective house rules and codes of conduct into consideration. Second, user participation proved a difficulty when patients’ viewpoints challenged staff judgements on proper conduct and goals for which patients might aim. Third, user participation becomes a challenge when trying to establish relationships based on equality when using milieu therapy in a biomedical hierarchical hospital structure. These tensions and challenges are seen in light of paradoxical political frames and demands on one side, and milieu therapy as a complex tradition anchored in different ideologies on the other. (shrink)

Police and pastoral power: governmentality and correctional forensic psychiatric nursing Since 1978, the federal inmates of Canada have had access to a full range of psychiatric care within the penitentiary system. Several psychiatric units are now integrated into the correctional services of Canada. This paper presents the results of a grounded theory doctoral study undertaken in a multilevel secured psychiatric ward within the Canadian federal penitentiary system. The author describes and discusses the results of qualitative data (...) that emerged from his fieldwork. The concept of governmentality, as defined by the late French philosopher Michel Foucault, constitutes one of the major theoretical tools that were helpful in analyzing these data. Police and pastoral power, two dimensions of the security apparatus of governmentality, were found to be useful in understanding and characterizing nursing practice caught between the penal and the psychiatric dispositifs. A Foucauldian perspective allows one to understand the manner in which forensic psychiatric nursing is involved in the governance of mentally ill inmates through three forms of power — sovereign, disciplinary and pastoral — which have posited nursing practice as a strategic tool of the correctional services. This research consists of a study of nursing practice in an extreme setting that deserves a radical analysis. (shrink)

Deprivation of liberty in psychiatric hospitals is common world-wide. The aim of this study was to find out whether patients had experienced deprivation of their liberty during psychiatric hospitalization and to explore their views about it. Patients (n = 51) in two acute psychiatric inpatient wards were interviewed in 2001. They were asked to describe in their own words their experiences of being deprived of their liberty. The data were analysed by inductive content analysis. The types (...) of deprivation of liberty in psychiatric hospital care reported by these patients were: restrictions on leaving the ward and on communication, confiscation of property, and various coercive measures. The patients' experiences of being deprived of their liberty were negative, although some saw the rationale for using these interventions, considering them as part of hospital care. (shrink)

The present study aimed at investigating the relationship between environmental and individual factors and Stress of Conscience among nursing staff in psychiatric in-patient care. A questionnaire involving six different instruments measuring Stress of Conscience, the ward atmosphere, the psychosocial work environment, Perceived Stress, Moral Sensitivity, and Mastery was answered by 93 nursing staff at 12 psychiatric in-patient wards in Sweden. The findings showed that Sense of Moral Burden, Mastery, Control at Work and Angry and Aggressive Behavior were (...) related to Stress of Conscience. We conclude that Mastery and Control at Work seemed to work as protective factors, while Sense of Moral Burden and perceptions of Angry and Aggressive Behavior made the nursing staff more vulnerable to Stress of Conscience. Future research should investigate whether measures to increase the level of perceived control and being part of decision making will decrease the level of Stress of Conscience among the staff. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.3 (2003) 227-231 [Access article in PDF] World Traveling as a Clinical Methodology for Psychiatric Care Suzanne M. Jaeger Keywords embodiment, dialogical consciousness, interpersonal communication, epistemic responsibility, self-knowledge, understanding IN HER ARTICLE "Moral Tourists and World Travelers," Nancy Potter suggests a way in which psychiatrists and psychologists could gain a better understanding of their mentally ill patients' experiences. Rather than assuming that hallucinations and (...) incoherent speech and behavior are merely senseless disconnections from reality, Potter argues that mental health care clinicians ought to spend time engaging patients on their own terms. Even when mental illness is a result of brain disease, much can be learned about the patient's experiences of their disease by temporarily setting aside the scientific frameworks of diagnosis and medical treatment. Potter uses Maria Lugones' concept of world traveling and recommends playfully accepting, and even entering into the patient's world (Lugones 1990). She calls world traveling a methodology and explains it in some detail. Moreover, at the close of her essay, Potter suggests that clinicians have a moral obligation to understand the mentally ill patient's world from the patient's perspective. This obligation is based on an appeal to our sense of what it is to be a responsible knower who attends to issues of trust and truth. Relying on arguments made by Lorraine Code (1987), Potter asserts that to try to understand the other's perspective is the responsible thing to do.My discussion focuses on the notion of play to which Potter appeals, as well as on what she sees as the moral obligation of clinicians to communicate with their mentally ill patients in extra-professional ways. This moral obligation arises because (a) the theoretical and professional frameworks of medical science are seen as inadequate, and (b) playfulness opens up mutually respectful, authentic interaction between persons. I generally agree with Potter's claims, and I want to situate them in the wider framework of an epistemological debate about the status of our knowledge of others. A broader context will help to elucidate the strengths of Potter's analysis as well as some points for critical discussion. I begin with the relationship of trust between clinicians and patients.Few people would disagree with the claim that patients need to be able to trust that their physicians are not harming them, but helping them to get better. If patients feel misunderstood, they will not trust their caretakers. This is probably even truer for psychiatric patients, whose conditions and loss of autonomy make establishing trust even more challenging. Psychiatric patients [End Page 227] often have their own ways of compensating for the symptoms of their mental illness. If either their will to survive or their compensatory strategies go unrecognized or misinterpreted, patients may respond by rejecting the well-intentioned efforts of caretakers to restore them to a degree of ease, measured as it must be by the standards of the professionals under whose care the patient remains. 1 Despite the fact that these standards are established through scientific testing procedures for the treatment of diseases, they may be experienced by patients as indifferent to the particular and unique features of their condition. Nestled within the issue of trust is thus a question of truth.Although current scientific knowledge of the human brain, and of human behavior, has made available a range of sophisticated therapies and psychotropic drugs, there are still many mental illnesses that leave families and clinicians wondering whether the treatment plans are providing any help. Alzheimer's disease and schizophrenia are two examples. There is a difference between, on the one hand, containing the patient's behavior by admitting the patient to a psychiatric ward and managing symptoms with psychotropic medications, and, on the other hand, understanding what is happening for the patient, from his or her perspective. Although psychiatric patients may not have a realistic sense of either their abilities or the extent and nature of their disease, there may be much about their experiences that ought to be known and understood by the professionals caring for them... (shrink)

Negotiating clinical knowledge: a field study of psychiatric nurses’ everyday communication Nursing practices at psychiatric hospitals have changed significantly over the last decades. In this paper, everyday nursing practices were interpreted in light of these institutional changes. The objective was to examine how mental health nurses’ production of clinical knowledge was influenced by the particular social relations on hospital wards. Empirical data stemming from an extended fieldwork at two Danish psychiatric hospital wards were interpreted using (...) interactionistic theory and the metaphor: ‘the game of clinical knowledge’. The results indicated that the nurses’ production of clinical knowledge was highly dependent on the individual nurses’ practical ability to participate in the game. Furthermore, the nurses colluded in their mutual communication to enable the collective display and sense of knowing that protected them against explicit signs of uncertainty about the clinic. The game of clinical knowledge influenced processes of clinical decision‐making among the nurses as the game added to a distorted widening of a ‘fictional distance’ between patients and the representations produced by the nurses. (shrink)

Research on nursing ideology and the ethics of child and adolescent psychiatric nursing care is limited. The aim of this study was to describe and explore the ideological approaches guiding psychiatric nursing in child and adolescent psychiatric inpatient wards in Finland, and discuss the ethical, theoretical and practical concerns related to nursing ideologies. Data were collected by means of a national questionnaire survey, which included one open-ended question seeking managers' opinions on the nursing ideology used in (...) their area of practice. Questionnaires were sent to all child and adolescent psychiatric inpatient wards (n = 69) in Finland; 61 ward mangers responded. Data were analysed by qualitative and quantitative content analysis. Six categories - family centred care, individual care, milieu centred care, integrated care, educational care and psychodynamic care - were formed to specify ideological approaches used in inpatient nursing. The majority of the wards were guided by two or more approaches. Nursing models, theories and codes of ethics were almost totally ignored in the ward managers' ideological descriptions. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:A Threat to Selfhood: Moral Distress and the Psychiatric Training CultureEsther NathansonWhile many medical specialties offer to heal, or even cure, psychiatry—uniquely—places the doctor–patient relationship at the center of the therapeutic effort. Psychiatrists must possess a complex and challenging combination of broad medical knowledge, finely honed interpersonal and analytic skills and confidence in their abilities, despite limited understanding of the workings of the brain. Inpatient psychiatry in particular (...) demands a degree of strength to withstand emotional, and sometimes physical, assault from patients who may be suicidal, desperate, paranoid, aggressive or delusional. Beyond these abilities, a good psychiatrist must have robust but ‘therapeutically porous’ emotional boundaries that allow genuine empathy for the patient but, at the same time, limit internalization of the patient’s anguish as the practitioner’s own: the exquisite balance of ‘self–versus–other’ in the therapeutic encounter.Unfortunately, during my psychiatry residency in the UK, development of these intangible but essential boundaries was entirely absent from the curriculum. Early in training I struggled with my tendency to become an emotional chameleon with feelings and energies buffeted around by the prevailing emotions of each patient that walked through the door. I felt that patients expected me to offer tidy explanations for their suffering and provide answers to profound questions of meaning; to make the world a safe and understandable place. Given the complexity of mental illness and its interplay with social circumstances this was naïve and, I now realize, often unnecessary, but the weight of responsibility was unbearable. I was also completely unprepared for the intensity of human suffering I saw, and wholly unready to provide the level of interpersonal engagement required for genuine healing. My own emotional integrity felt threatened by the depth of patients’ needs, and my response—both physical and emotional—was intense and frightening.Much of my distress resulted from the profound and inevitable tension between the empathy necessary to comprehend patients’ experiences, which were often extreme and bewildering, and the need for resilience and self–protection at a time when my grasp of psychological theories and treatment practices was still rudimentary. I felt guilty that patients bore the brunt of my inexperience, and duplicitous purporting to help while burdening them with intolerable drug side–effects and stigmatizing, albeit effective, treatments such as electroconvulsive therapy (ECT). Time constraints and guidance from senior faculty encouraged expediency over treatment efficacy or durability; psychopharmacology was prioritized over the psychotherapeutic techniques and psychosocial interventions I found more effective for many patients. During the phase of our training that took place in a rambling, now defunct, asylum in the U.K, visits to the locked ward, which was reserved for patients considered a danger to others, were usually prompted by nurses’ requests for chemical restraint, the ‘pharmaceutical strait–jacket’. I was deeply uncomfortable with the role of ‘restrainer’ but had insufficient experience or seniority to propose other methods. It was only when, years later, I investigated re–training in the U.S that the senior psychiatry resident at a well–known program told me gently, ‘Oh, we assume that students will have a breakdown in their first year, so we have systems in place to help’. I’ll never forget those words; they are, to this day, the only validation of the emotional toll of my early training years.Adding to my discomfort were various ethically dubious administrative practices, the most troubling being the clinic’s unwillingness to disclose to patients that we were trainees, with little clinical experience. Senior faculty were dismissive when I asked whether my first psychotherapy patient had been told I was a trainee, indeed that I had never conducted psychotherapy before. My question was greeted with amusement and an assurance that, although she had not been told, I (not the patient, interestingly) would do fine.Due to the large number of no–shows in psychiatric outpatient clinics it was also standard practice to triple–book appointment times on the [End Page 115] assumption that one or more patients would fail to attend. Not uncommonly, more than one patient would arrive for the same appointment, leaving others to suffer agonizing waits that were often intensified by the deep discomfort... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 9.1 (2002) 15-18 [Access article in PDF] Through a Glass, Darkly:Commentary on Ward Gwen Adshead Keywords: psychopathy, moral reasoning. Now we see, as through a glass darkly.... (St Paul's first letter to the Corinthians, Chapter 13) JIM DID AN EVIL THING. He deliberately caused another person's suffering in a way that was humiliating, cruel, and persistent. He very nearly killed another man. He knew what (...) he was doing; he knew it was wrong, but somehow, that did not matter to him. After he was caught, he came to a forensic psychiatric facility where he was offered therapy. (What the purpose of therapy is could be the subject of a paper in its own right, although I will say a little more about this at the end of the paper). Several years on, Jim has had many thoughts about his behavior. First, he has no doubt that he was responsible insofar as he chose to do what he did, and he feels guilty on that count. Second, he is also aware that he had consciously carried out such acts many times in his mind before, but had not previously acted out his fantasy; and that therefore the process of crossing the line between fantasy and reality is a crucial one for him to think about further. This metaphor of a line that has to be crossed from one place to another suggests two worlds: one of internal reality and the other of external reality. Jim used the metaphor thus: "I came up to the line, but I drew back." He also said of this moment (when he nearly killed his first victim): "I said to myself... 'This is mad... I can't justify this.'... " I have emphasized these words of Jim's because I want to use his experience to explore some of the arguments raised in David Ward's most interesting paper. I found much to agree with, and some claims that sat less easily. I should say that the context of my response is my work as a psychotherapist with mentally disordered offenders in Broadmoor Hospital, and also a current research project with Jonathan Glover and Christine Brown on moral reasoning in antisocial men. Kant and Won't I have no doubt that most if not all of the men (and women) that I work with do operate according to universalizable principles. As the author suggests, however, these principles are incoherent and contain what Cleckley (1976) called a type of agnosia, or distorted vision. It seems to me that Kant's two forms of principle are really two different levels of intention or choice-making process. Kant's hypothetical level of intention is very much about making choices in the external world: I experience the world as cold, I want to be warm because I need to be warm, I will do what I need to do to make that need happen for me. It is not universalizable because [End Page 15] others may not feel the cold as I do. Notice that this level of intention may be very closely linked to the next level, which Kant calls categorical: I would like the world to be such that everyone who is needy will get their needs met, and I would like to be the sort of person who makes that happen. The categorical level of intention is Kant's take on the Golden Rule: that you should want everyone to be treated as you yourself would wish to be treated. It is an intentional process that is interpersonal, which implies a second order of thinking—thinking about one's thoughts and wishes, and thinking about the sort of person one would wish to be in relation to others.At this point, I think it may be helpful to bring in the other aspect of Kant's vision of moral intentions, which is the injunction to treat others as ends in themselves and not merely as means to ends. Thus every individual is a unique person or self, who claims respect as a person and not... (shrink)

BackgroundAssessment of capacity to consent to treatment is an important legal and ethical issue in daily medical practice. In this study we carefully evaluated the capacity to consent to treatment in patients admitted to an acute medical ward using an assessment by members of the medical team, the specific Silberfeld's score, the MMSE and an assessment by a senior psychiatrist.MethodsOver a 3 month period, 195 consecutive patients of an internal medicine ward in a university hospital were included and their capacity (...) to consent was evaluated within 72 hours of admission.ResultsAmong the 195 patients, 38 were incapable of consenting to treatment (unconscious patients or severe cognitive impairment) and 14 were considered as incapable of consenting by the psychiatrist (prevalence of incapacity to consent of 26.7%). Agreement between the psychiatrist's evaluation and the Silberfeld questionnaire was poor (sensitivity 35.7%, specificity 91.6%). Experienced clinicians showed a higher agreement (sensitivity 57.1%, specificity 96.5%). A decision shared by residents, chief residents and nurses was the best predictor for agreement with the psychiatric assessment (sensitivity 78.6%, specificity 94.3%).ConclusionPrevalence of incapacity to consent to treatment in patients admitted to an acute internal medicine ward is high. While the standardized Silberfeld questionnaire and the MMSE are not appropriate for the evaluation of the capacity to consent in this setting, an assessment by the multidisciplinary medical team concurs with the evaluation by a senior psychiatrist. (shrink)

The power of routine and special observations: producing civility in a public acute psychiatric unit This study directly addresses controlling aspects of psychiatric nursing practice, which are currently marginalised in practice and research. We first consider the discursive tensions surrounding the mandated goal of social control in public acute psychiatric units, particularly referring to those units located within medical hospitals. We attest to the enduring social control mandate in psychiatric nursing and explore ways in which it (...) is enacted.Specific nursing practices of ‘doing the obs’ while scanning the ward and ‘special observations’ are investigated as important activities of social control, based on findings from an ethnographic study in one acute psychiatric unit in Australia. These practices are acknowledged as key modes of nursing surveillance. Contrary to past work, they are regarded as productive for engendering civil conduct among patients in acute psychiatric settings. We reframe these activities of surveillance as liberal therapeutic practices in themselves, to the extent that they assist patients to achieve treatment goals and promote self‐surveillance and self‐control. Instead of effacing practices of control, we encourage nurses to discriminate between more and less liberal modes of control in everyday practice and to build their skills in liberal controlling strategies. (shrink)

This study presents a qualitative description of situations at work that staff members perceive as giving rise to ethical issues. All staff members working with patients across seven wards were given the opportunity to freely describe ethical considerations in an ethical diary over the course of one week. One hundred and five staff members kept a diary. The diaries were analysed with qualitative content analysis where four dominant themes emerged: good care, order and clarity, loyalty, and inadequacy. These results (...) contain statements in which patients are respected and listened to, as well as statements that express a desire for relatively strict, routine-based care. Relatively few statements were of a reflective or discussing nature which highlights the need for clinical ethical support. There is a need of a visible and supportive leadership which encourages ethical reflection. Reflections on real cases could provide an opportunity to challenge existing practices and thereby promote ethical awareness. (shrink)

Background When a patient commits suicide while hospitalized in the psychiatric ward, the mental healthcare professionals (MHCPs) who have had the patient in their care encounter the family members immediately following the suicide. Professionals who encounter the bereaved in this first critical phase may have a significant impact on the grieving process. By providing ethically responsible and professionally competent care, they have the opportunity to influence what can alleviate and reduce suffering and promote health in a longer perspective. Aim (...) The aim of this study is to investigate MHCPs’ experiences in the encounter with family members who has been bereaved by suicide. Methods Data material consists of text from in-depth interviews with six MHCPs belonging to a total of five different psychiatric units in two hospitals. The findings have emerged through analysis using a hermeneutical approach based on Gadamer’s philosophical hermeneutics. Ethical considerations The study was approved by the Ombudsman for Privacy of the Norwegian Social Science Data Services and is based on informed consent and confidentiality. Findings Three themes emerged: Confirming the suffering. Creating encounter through dialogue. Providing consolation and reconciliation. Findings illuminate how MHCPs understand their responsibilities and how they act in the encounter with the bereaved following suicide. Conclusion The participants appear to be led by the responsibility that grows through witnessing the suffering of the bereaved. Encountering the family member’s aggression and threats against staff members is an ethical challenge to the professional’s ability to confirm the bereaved, create dialogue and provide consolation and reconciliation at the start of their grieving process. MHCPs need to be aware of the different reactions and needs of family members following suicide. More research is needed about how to provide sensitive and flexible care in ways that can be perceived as helpful for those left behind. (shrink)

Background: This study is based on the ontological assumption about human interdependence, and also on earlier research, which has shown that patients in psychiatric hospitals and their relatives experience suffering and indignity. Aim: The aim of this study is to explore the experience of patients and relatives regarding respect for dignity following admission to a psychiatric unit. Research design: The methodological approach is a phenomenological hermeneutic method. Participants and research context: This study is based on qualitative interviews conducted (...) with six patients at a psychiatric hospital and five relatives of patients who experienced psychosis. Ethical consideration: Permission was given by the Regional Committee for Medical Research Ethics in Western Norway, the Norwegian Data Protection Agency and all wards within the hospital in which the patients were interviewed. Findings: The analysis revealed one main theme: ‘The significance of small things for experiencing dignity’ and four subthemes described as follows - ‘to be conscious of small things’, ‘being conscious of what one says’, ‘being met’ and ‘to be aware of personal chemistry’. Discussion and conclusion: Staff members seem not to give enough attention to the importance of these small things. Staff members need to explore this phenomenon systematically and expand their own understanding of it. (shrink)

A psychiatrist who has received international recognition for her research on the neural basis of primate social cognition, Leslie Brothers, M.D., offers here a major argument about the social dimension of the human brain, drawing on both her own work and a wealth of information from research laboratories, neurosurgical clinics, and psychiatric wards. Brothers offers the tale of Robinson Crusoe as a metaphor for neuroscience's classic notion of the brain: a starkly isolated figure, working, praying, writing alone. But (...) the famous castaway of literature, she notes, came from society and returned to society. So too with our brains: they have evolved a specialized capacity for exchanging signals with other brains--they are designed to be social. This can be seen in the brain's sensitive attunement to the meanings of facial expressions and physical gestures and the way it assigns mental lives to physical bodies--a feat we too often take for granted. Brothers describes fascinating case studies that show that certain kinds of brain damage can destroy a patient's ability to interpret faces, leaving him or her with the sense that they are surrounded by zombies. She takes us down to the level of the individual neuron, exploring the response of brain cells to social events. Perhaps most important, she connects neuroscience, psychiatry, and sociology as never before, showing how our daily interaction creates an organized social world--a network of brains that generates meaningful behavior and thought. Our emotions and our sense of self have no existence outside of a social context. Brothers conducts her argument with grace and style. By broadening our approach to the brain, this groundbreaking book makes an important contribution to our understanding of the human mind. (shrink)

In a clinic-wide approach to establish liberal policies, a closed psychiatric ward was planned to be opened. The leaders of the multi-professional team of this ward requested continuous ethics support during the first few months after the transition from their previously closed ward into an open one. During the process of accompanying the team through this ethically sensitive period of institutional change, several variations of ethics consultation were developed: the ‘context-adjusted’ clinical ethics support. Some ethics consultations focused on a (...) retrospective evaluation of a patient case, in other ethics consultations consolidation of a previous case discussion was worked out, and/or reflections on fundamental ethical issues were included. Based on our experiences and the feedback of the team, we consider this context-adjusted clinical ethics support as feasible and effective. (shrink)

In her commentary, Kennett helpfully reiterates Pickard’s criticism of Strawsonian theories of blame. Angry forms of blame like resentment are, according to Pickard, characterized by a sense of entitlement and are counterproductive to therapy. Some disagree that entitlement is a necessary condition for emotional blame, but also more permissive understandings of Strawsonian emotional blame have been considered inappropriate and counterproductive in a therapeutic relationship and on a psychiatric ward.We proposed to bracket definitional issues about the meaning of emotional blame (...) and instead looked at the possible therapeutic role of negative affect in clinical settings. Our paper conceptualizes... (shrink)

Background Mental health nurses advocate for patients through a person-centered approach because they care for people experiencing mental distress who tend to be limited to exercising their human rights and autonomy through interpersonal relationships. Therefore, it is necessary to provide high-quality person-centered care for these patients by identifying the influencing factors. Aim This study aims to identify the factors affecting mental health nurses in performing person-centered care for patients. Research design This study had a cross-sectional, descriptive-correlational survey design. Participants and (...) method Nurses ( N = 166) working at psychiatric wards in Korea completed an online questionnaire on moral sensitivity, attitudes toward people with mental illness, and person-centered care. The t-test and stepwise multiple regression analysis were used. Ethical considerations Ethical approval for the study was obtained from the relevant ethics committee. Findings Moral sensitivity was a significant factor correlating with the provision and perception of person-centered care. Attitudes toward patients had no effect on person-centered care. The predictor variables for the provision of person-centered care (R2 = 0.247) were moral sensitivity (β = 0.33), having a professional qualification (β = 0.19), marital status (β = 0.18), and closed ward (β = −0.15). The predictor variables for the perception of person-centered (R2 = 0.150) care were closed ward (β = −0.25), moral sensitivity (β = 0.23), and marital status (β = 0.18). Discussion and conclusion Mental health nurses can strengthen person-centered care by improving moral sensitivity related to the ethical aspect of nursing and professional competence to address the complex needs of patients. Person-centered care needs to be applied more carefully in closed wards where human rights issues may arise. Through these efforts, the dignity of patients can be protected. (shrink)

A murder case that had some features in common with the Tarasoff case occurred in Sasebo City, Japan, in 2014. A 15-year-old high school girl was murdered and her 16-year-old classmate was arrested on suspicion of homicide. One and a half months before the murder, a psychiatrist who had been examining the girl called a prefectural child consultation centre to warn that she might commit murder, but he did not reveal her name, considering it his professional duty to keep it (...) confidential. Article 134 of the Japanese Criminal Law states that doctors should not disclose patient information obtained in clinical practice without a legitimate reason, but the Japanese Supreme Court has not specified what constitutes a legitimate reason. Mass media and commentators suggested that the murder could have been prevented if the psychiatrist had disclosed the girl's name to the authorities or had isolated her coercively in a psychiatric ward. However, the authors disagree with such claims. This article discusses obligations imposed on concerned individuals and third party members in cases involving ethical dilemmas regarding patient confidentiality and information disclosure. It is concluded that everyone should fulfill their obligations to prevent such tragedies and one should judge the appropriateness of others’ actions based not on the consequences of their actions, but on the processes used to decide on a course of action and their commitment. It is necessary for us to establish a society in which concerned parties can do what they think is ethically best without fearing ungrounded charges. (shrink)

Arthur Bispo do Rosário created separate realities inspired by the objects of his surroundings. He intended to summon up everything and report to God. The objects he found or got from other inmates were waste of the Juliano Moreira Colony where he lived in seclusion because the lords of order categorised him as mentally ill. Bispo began by unravelling the uniforms of his seafaring days and Colony clothing and with the threads he wove maps and banners. He collected old shoes, (...) empty milk bags, gears, tools, toys, cutlery, bottles, mugs to shape into powerful amalgams of odd aesthetic narrative. As pieces of the Colony waste were given to Bispo by other inmates and as he turned the scraps into art, his creative strength was offered to the hospital’s population and now to museums and art galleries. The observation of this cycle of stunning wonder between Bispo and his fellow inmates suggests the view of unravelling second-order cybernetic processes. Simple things of the world turned into art got new significance in the eyes of the observers. Their poor world became thrilled in delight. As an inmate of a psychiatric ward in Rio de Janeiro, he never stopped his intense and endless work building an inventory of embroidery, assemblages and objects deemed to present the Lord. His work captured the aesthetic sensibility of the Colony population who started viewing the common things of the world redeemed by Bispo as sacred uncaged tokens with divine destination. A virtuous unending cycle of human sensibility and creativity. As observers, we make the distinction of evolving processes in the realm of second-order cybernetics. (shrink)

In this paper, I explore the concept conduct of everyday life, namely routines and real life, as they are confronted with empirical observations. The observations are from a study of changes in the conduct of everyday life for individuals who attended a patient education course. The course was a part of their treatment after a hospitalisation with depression in a psychiatric ward. I use analysis of the main individual, Steven’s, conduct of everyday life and illustrate my points with models (...) of conduct of everyday life made using beads. The conceptualisation of conduct of everyday life is expanded through three points. Firstly, cyclic routines can matter and fulfill life, which can support the ongoing discussion about the concept conduct of everyday life. Secondly, I show that, from a first person perspective, what matters in conduct of everyday life is more complex than what is possible to grasp analytically through a dualistic opposition between cyclic everyday conduct and the particular meaningful conduct of everyday life. Thirdly, I expand on the notion of timeouts/breaks as solely something that lifts us out of mundane everyday life. I conclude that it makes a more comprehensive analysis to perceive all conduct of everyday life as having profound personal meaning and to analyse the individuals' concerns in relation to their social self-understanding and localisation at a certain time. (shrink)

Background:Suffering in a suicidal crisis includes feelings such as despair, loneliness, anxiety, fear, shame, guilt and hopelessness. This study highlights the experiences of patients in the aftermath of suicide attempts. The research question was, what do suicidal patients see as meaningful help in care and treatment situations?Methodology:The methodology is inspired by Gadamer’s hermeneutics, where the parts are understood in light of the whole, and the whole is understood in light of the parts. Qualitative interviews were employed.Participants and research context:A total (...) of 10 persons, 4 women and 6 men 21–52 years old, were informed and asked to participate by specialists in psychology at two emergency psychiatric wards and by one crisis resolution team. Nine of the participants had experienced one or more suicide attempts using drugs and alcohol. Forced hospitalization prevented one of the 10 participants from attempting suicide.Ethical considerations:Before the participants signed an informed consent form, the interviewer met all participants to provide the written information, talking about the interview. A meeting to terminate contact was arranged after the participants had read their own interviews.Findings:Three themes were generated by the methodology we applied: experiencing hope through encounters, experiencing hope through the atmosphere of wisdom and experiencing a ray of hope from taking back responsibility.Discussion:The findings are discussed in the light of Eriksson’s suffering theory and Lindström’s theory about psychiatric care, as well as earlier research and theories about suicidality.Conclusion:The study reinforces possibilities that hope in suicidal patients can be inspired in encounters with healthcare personnel and within caring cultures. Through dialogue and cooperation, patients’ safety and ability to cope with suffering is created and thereby the hope and will to struggle for life. (shrink)

This essay on choice of law (private international law) appears in the second edition of the Blackwell Companion to Philosophy of Law and Legal Theory, edited by Dennis Patterson. It is a revision of an entry on the same topic in the first edition of the book. The essay focuses on the epic battle over the course of the last century between two very different traditions - classical choice of law, articulated most completely by Joseph Beale in the 1930s, and (...) modernist choice of law, which inspired a massive and still controversial revolution in choice of law thinking. The essay isolates eight distinct jurisprudentially significant premises of classicism, including territorialism, a commitment to a regime of rules, and a conception of law and legal rights that I have called “vestedness.” It then discusses the modernist challenges to most, but significantly not all, of those premises. It also emphasize, however, the degree to which the eight pillars of the classical tradition are actually conceptually independent, and could, at least in principle, be mixed and matched in various combinations and in the service of very different account of choice of law enterprise. Finally, the essay turns to other debates, both within the classical and modernist traditions separately and transcending the differences between them. (shrink)

The use of patient restrictions (e.g. involuntary admission, seclusion, restraint) is a complex ethical dilemma in psychiatric care. The present study explored nurses’ (n = 22) and physicians’ (n = 5) perceptions of what actually happens when an aggressive behaviour episode occurs on the ward and what alternatives to seclusion and restraint are actually in use as normal standard practice in acute psychiatric care. The data were collected by focus group interviews and analysed by inductive content analysis. The (...) participants believed that the decision-making process for managing patients’ aggressive behaviour contains some in-built ethical dilemmas. They thought that patients’ subjective perspective received little attention. Nevertheless, the staff proposed and appeared to use a number of alternatives to minimize or replace the use of seclusion and restraint. Medical and nursing staff need to be encouraged and taught to: (1) tune in more deeply to reasons for patients’ aggressive behaviour; and (2) use alternatives to seclusion and restraint in order to humanize patient care to a greater extent. (shrink)

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. (shrink)

Pseudo-patient studies are studies in which a medical sociologist or anthropologist masquerades as a patient. Medical treatment is sought without revealing that the 'patient' is really a covert research worker. When access has thus been gained to a medical setting--typically a hospital ward--social interaction between medical staff and patients is then observed over a period of days or weeks. Important studies have been carried out in this way of psychiatric treatment and of the care of the terminally-ill. Is the (...) use of the method justified? What ethical problems does its use raise? How do the undoubted advantages of the approach compare with the clear drawbacks and objections which can be made to its use? (shrink)

OBJECTIVE: Questions have been posed about the competence of persons with serious mental illness to consent to participate in clinical research. This study compared competence-related abilities of hospitalized persons with schizophrenia with those of a comparison sample of persons from the community who had never had a psychiatric hospitalization. METHODS: The study participants were administered the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR), a structured instrument designed to aid in the assessment of competence to consent to clinical research. (...) The scores of 27 persons who met DSM-IV criteria for schizophrenia who were long-stay patients on a state hospital research ward were compared with those of 24 individuals from the community who were of similar age, gender, race, and socioeconomic status. RESULTS: Significant differences were found between the patients and the community sample on three measures of competence-related abilities: understanding, reasoning, and appreciation. Degree of psychopathology and cognitive functioning were significantly negatively correlated with understanding and appreciation among the patients with schizophrenia. Length of hospitalization was significantly negatively correlated with all measures of decision-making capacities. CONCLUSIONS: The generally poor performance of the long-stay patients with chronic schizophrenia highlights the difficulties this group is likely to encounter in providing consent to research. However, variation across the sample points to the need for individualized assessment and for validated techniques for facilitating decision making in the face of decisional impairments. (shrink)

Background: Using lies, in dementia care, reveals a common practice far beyond the diagnosis and prognosis, extending to the entire care process. Objectives: In this article, we report results about the attitude and the behaviour of nurses towards the use of lies to patients with dementia. Research design: An epidemiological cross-sectional study was conducted between September 2016 and February 2017 in 12 elderly residential facilities and in the geriatric, psychiatric and neurological wards of six specialised hospitals of Italy’s (...) Campania Region. Participants: In all, 106 nurses compiled an attitude questionnaire (A) where the main question was ‘Do you think it is ethically acceptable to use lies to patients with dementia?’, instead 106 nurses compiled a behaviour questionnaire (B), where the main question was ‘Have you ever used lies to patients with dementia?’ Ethical considerations: Using lies in dementia care, although topic ethically still controversial, reveals a common practice far beyond the diagnosis and prognosis, extending to the entire care process. Findings: Only a small percentage of the interviewed nurses stated that they never used lies/that it is never acceptable to use lies (behaviour 10.4% and attitude 12.3%; p = 0.66). The situation in which nurses were more oriented to use lies was ‘to prevent or reduce aggressive behaviors’. Indeed, only the 6.7% in the attitude group and 3.8% in the behaviour group were against using lies. On the contrary, the case in which the nurses were less oriented to use lies was ‘to avoid wasting time giving explanations’, in this situation were against using lies the 51.0% of the behaviour group and the 44.6% of the attitude group. Conclusion: Our results, according to other studies, support the hypothesis of a low propensity of nurses to ethical reflection about use of lies. In our country, the implementation of guidelines about a correct use of lie in the relationship between health operators and patients would be desirable. (shrink)

BackgroundAn ethics reflection group is one of a number of ethics support services developed to better handle ethical challenges in healthcare. The aim of this article is to evaluate the significance of ERGs in psychiatric and general hospital departments in Denmark.MethodsThis is a qualitative action research study, including systematic text condensation of 28 individual interviews and 4 focus groups with clinicians, ethics facilitators and ward managers. Short written descriptions of the ethical challenges presented in the ERGs also informed the (...) analysis of significance.ResultsA recurring ethical challenge for clinicians, in a total of 63 cases described and assessed in 3 ethical reflection groups, is to strike a balance between respect for patient autonomy, paternalistic responsibility, professional responsibilities and institutional values. Both in psychiatric and general hospital departments, the study participants report a positive impact of ERG, which can be divided into three categories: 1) Significance for patients, 2) Significance for clinicians, and 3) Significance for ward managers. In wards characterized by short-time patient admissions, the cases assessed were retrospective and the beneficiaries of improved dialogue mainly future patients rather than the patients discussed in the specific ethical challenge presented. In wards with longer admissions, the patients concerned also benefitted from the dialogue in the ERG.ConclusionThis study indicates a positive significance and impact of ERGs; constituting an interdisciplinary learning resource for clinicians, creating significance for themselves, the ward managers and the organization. By introducing specific examples, this study indicates that ERGs have significance for the patients discussed in the specific ethical challenge, but mostly indirectly through learning among clinicians and development of clinical practice. More research is needed to further investigate the impact of ERGs seen from the perspectives of patients and relatives. (shrink)

Despite its historical focus on aberrant behavior, sexology barely dealt with sexual deviants in 1950s Czechoslovakia. Rather, sexologists treated only isolated instances of deviance. The rare cases that went to court appeared mostly because they hindered work or harmed the national economy. Two decades later, however, the situation was markedly different. Hundreds of men were labeled as sexual delinquents and sentenced for treatment in special sexological wards at psychiatric hospitals. They endangered society, so it was claimed, by being (...) unwilling or unable to conform to the family norm. The mode of subjection shifted from work to family. I analyse this change by using the tools of Gil Eyal’s sociology of expertise (2013), which focuses on shifts in institutional matrices that bring forth new groups of agents creating new expert networks. I argue that sexology became profoundly institutionalized in the early 1970s, which brought the discipline closer to psychiatry and forensic science. New inpatient facilities were opened that could admit sentenced sexual deviants. Also, demographic changes accelerated in the 1960s, especially skyrocketing divorce rates and plummeting birth rates, which made it imperative for the government to focus on cementing the family. After the failed attempts of the Prague Spring in 1968, the new pro-Soviet government of communist Czechoslovakia did just that. During the time dubbed as ‘normalization’ by the new elites, anyone who strayed from the family norm was suspected of deviance. (shrink)

An ethics reflection group is one of a range of ethics support services developed to better handle ethical challenges in healthcare. The aim of this article is to evaluate the implementation process of interdisciplinary ERGs in psychiatric and general hospital departments in Denmark. To our knowledge, this is the first study of ERG implementation to include both psychiatric and general hospital departments. The implementation and evaluation strategies are inspired by action research, using a qualitative approach and systematic text (...) condensation of 28 individual interviews and 4 focus groups with clinicians, ethics facilitators and ward managers. The implementation process was influenced by both structural factors and factors related to clinicians having different values, interests and experiences. Structural barriers and promotors in the process to implement ERG included the following sub-categories: Organizational factors, recruitment and training of ethics facilitators, the deliberation model, planning and recruitment of participants to the ERGs, the support of the ward managers and the project group. Barriers and promotors found among clinicians included the following sub-categories: Expectations and pre-understandings of ERGs, understandings of a physician’s job, challenges experienced by ethics facilitators. At the end of the study, when it was decided that the ERGs should be continued, the implementation strategies were remodeled by the participants to meet new challenges. The study of ERG implementation identified important structural and professional barriers and promotors that are likely to be relevant to anyone wanting to implement ethics support services across various types of healthcare services. (shrink)

The paper by Szasz is about mental illness and its meaning, and like Procrustes, who altered hapless travellers to fit his bed, Szasz changes the meanings of words and concepts to suit his themes.1 Refuting the existence of “mental illness”, he suggests that the term functions in an apotropaic sense. He submits that in this sense it is used to avert danger, protect society, and hence justify preventive detention of “dangerous” people.But his arguments misrepresent the precise meaning of the term (...) “apotropaic”, which is an adjective, defined in Webster’s, Chambers and the New Shorter Oxford dictionaries as averting or turning aside evil. It is possible that amulets and incantations ward off evil, in the same way as garlic repels vampires, but evil and danger are different concepts. Yet Szasz talks of using phrases like ‘“dangerousness to self and others’ as apotropaics to ward off dangers we fear”, and the word “evil” does not appear in his paper.I will argue that “dangerousness to self and others” and “psychiatric treatment” have a prosaic rather than an apotropaic function.The word “danger” is familiar rather than arcane, and includes many risks. A predatory paedophile is usually both dangerous and evil, but many dangerous people are not evil. For example, a child who plays with a box of matches is dangerous, as is a demented person who drives a car, or a schizophrenic who, acting on delusional beliefs, arms herself with a knife and roams the streets believing she is an avenging angel.Suppose …. (shrink)

This article explores the contribution of the virtue of integrity to the concept of mature care. The virtue of integrity is understood as both a personal and a social virtue. The argument is that the virtue of integrity is a necessary condition for providing mature care. An example from a psychiatric acute ward illustrates that a nurse acting with the virtue of integrity displays clear self‐boundaries and self‐respect as well as respect towards the inherent integrity of the patient. The (...) article also addresses some problems related to lack of the virtue of integrity by discussing the problems connected to detachment and rigidity. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clinical CommentaryTor Phern Chern, Associate ConsultantThe case scenario describes a difficult clinical and ethical challenge of a psychiatric patient refusing treatment in the context of a treatment-resistant condition that may be affecting her capacity to refuse treatment.The patient described in the case scenario displayed partial treatment refusal as evidenced by her refusal of ECT and adherence with medication and her voluntary hospital admission. Partial treatment refusal is generally (...) more common than absolute treatment refusal1 and can be sporadic, time-limited, periodic or continuous. It is important for the medical team to clarify which category of treatment refusal this patient’s refusal falls under. These broad categories include the doctor-patient relationship, religion, secondary gain, treatment- or illness-based refusals.2 The proper identification of category of treatment refusal will guide subsequent management.Refusal of treatments may be in response to reality-based transference issues like fear, distrust or pressure from the patient’s family. In this particular case, there is little data about her relationship with her treating psychiatrist, but the lack of a trusting doctor-patient relationship could be a factor for treatment refusal. The treating psychiatrist at the inpatient setting could be different from the patient’s routine outpatient psychiatrist and this could result in the lack of a trusting doctor-patient relationship. The remedy for this would be to develop a trusting relationship between her treating psychiatrist and the patient via understanding the patient’s needs and concerns. A useful adjunct would be to identify someone with whom the patient has a trusting relationship and recruit that person to help develop trust in the doctor-patient relationship. On this point, it is interesting to note that the patient’s family was noted to be highly supportive and influential in previous treatment decisions, agreed [End Page 235] with the treating psychiatrist’s treatment recommendation and yet both the treating psychiatrist and the patient’s family were unable to convince her to accept ECT. One possibility is that the patient may see her family’s support of the treating psychiatrist’s recommendation as one reason to refuse treatment. This possibility warrants deeper explorations of her premorbid underlying cultural and religious beliefs and attitudes towards her family and her perceived role in her community.Religion-based refusals of treatment (e.g. blood transfusions for Jehovah’s Witnesses) are less prominent in psychiatry than in general medicine but may manifest in treatment refusal due to advice from religious leaders on the need for spiritual solutions to the patient’s challenges. Religion-based refusals need to be distinguished from an illness-based refusal but if truly present will require the support of appropriate religious leaders to allow the patient more management options other than spiritual support for her psychiatric disorder. There is no specific information about the patient’s religion and religion-based refusals of ECT are not particularly common so this is unlikely to be a major reason for treatment refusal in this case.Treatment-based refusals of care are related to the specific treatment modality being offered and are often motivated by concerns about the side effects of treatment or past traumas that the treatment elicits. In this particular case, the patient has demonstrated some degree of treatment resistance as evidenced by the relapse of her bipolar disorder despite adherence to medication, and a change in management is certainly warranted. However, a change in medication management may be possible before proceeding to ECT in view of the patient’s acceptance of medication and no clear evidence of violent or disturbed behaviour in the ward. The occasional refusal of food and water is worrying, but if the patient can be coaxed to continue oral nutrition, there is no absolute indication to have ECT for rapid treatment response. Other options that may be acceptable to the patient are to optimise the dosage of current medications, switch medications or add augmenting pharmacological agents before proceeding to ECT. A change in pharmacotherapy must take into account her past treatment response and side effects to individual medications. Psychotherapy may also be considered to augment treatment response before ECT is considered.3Illness-based refusals are the most challenging category and... (shrink)

In this contribution, I investigate the way in which our understanding of a dementia patient’s self holds relevance to issues of punishment and respon- sibility. This topic is motivated by the fact that some countries with particularly large prison populations—such as the United States—are starting to build special- ized prison tracts for inmates with dementia. In other countries that do not have such specialized facilities, authorities are trying to find the least badly-equipped facility for such patients, and they are turning (...) to ordinary retirement homes, forensic hospitals as well as ordinary psychiatric and geriatric hospital wards. The problem is expected to become increasingly urgent as the population ages and the number of dementia patients increases. I analyse the way in which justifications of legal (or private) punishment for offenders with dementia can depend on an account of relevant psychological features of the self. I argue that especially retributivist and expressivist justifications of punishment require the offender’s ability to comprehend that he or she is being punished for a particular action in the past and that it was him or herself who committed this action. In the second part of my paper, I distinguish between different accounts of responsibility and argue that accounts of relevant features of the self are also needed here to answer the question of whether offenders with dementia are still responsible for past or current inappropriate behavior. In the final part of the paper, I argue that potentially existing private punishment intuitions among care- takers as well as certain puzzles of responsibility interpretation can make it plausible to relieve certain caretakers from primary responsibility for offenders with dementia, especially caretakers who belong to a relevant former victim group of the offender. (shrink)