1. A German version of the Staff Attitudes to Coercion Scale (SACS). Development and empirical validation

    Efkemann, S. A. M. Scholten R. Bottlender G. Juckel J. Gather 2021. A German version of the Staff Attitudes to Coercion Scale (SACS). Development and empirical validation. Frontiers in Psychiatry 11 (1458).
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    Individual staff factors, such as personality traits and attitudes, are increasingly seen as an important factor in the reduction of coercion in mental health services. At the same time, only a few validated instruments exist to measure those factors and examine their influence on the use of coercion. The present study aimed to develop and validate a German version of the Staff Attitude to Coercion Scale (SACS). The original English version of the SACS published was translated into German. Subsequently, it was empirically validated on a sample of N = 209 mental health professionals by conducting an exploratory factor analysis. The three-factor structure in the original version of the SACS, consisting of critical, pragmatic and positive attitudes toward the use of coercion, could not be replicated. Instead, the German version revealed one factor ranging from rejecting to approving the use of coercion. The SACS is one of the first instruments created to assess staff attitudes toward coercion in a validated way. The version of the instrument developed in this study allows for a validated assessment of those attitudes in German. Our results highlight the ethical importance of using validated measurements in studies on the role of staff factors in the reduction of coercion.

  1. Self-​binding directives under the new Dutch Law on Compulsory Mental Health Care: An analysis of the legal framework and a proposal for reform

    Scholten, M. L. V. Melle G. Widdershoven 2021. Self-​binding directives under the new Dutch Law on Compulsory Mental Health Care: An analysis of the legal framework and a proposal for reform. International Journal of Law and Psychiatry. https://doi.org/10.1016/j.ijlp.2021.101699.
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    Self-binding directives (SBDs) are a special type of psychiatric advance directive by means of which mental health service users can give advance consent to compulsory hospital admission or treatment during a future mental health crisis. SBDs are legally binding in the Netherlands since 2008. On the 1st of January 2020, the Dutch Law on Special Admissions to Psychiatric Hospitals (Wet bijzondere opnemingen in psychiatrische ziekenhuizen; Bopz) was replaced by the new Law on Compulsory Mental Health Care (Wet verplichte geestelijke gezondheidszorg; Wvggz). This replacement brought with it various changes in the legal arrangement for SBDs. In this article, we expound the changes in the legal arrangement and assess the implications of these changes for the practical feasibility of SBDs. We argue that the procedures for arranging compulsory care based on an SBD in the new law are too complex and time-intensive for SBDs to yield their potential benefits. We close by proposing a workable mechanism of legal authorisation of compulsory care on the basis of an SBD.

  1. Changes in the practice of involuntary hospitalization during the COVID-​19 pandemic: Experiences and opinions of chief psychiatrists

    Gather, J. S. A. Efkemann T. Henking M. Scholten C. Chrysanthou K. Hofmann G. Juckel 2021. Changes in the practice of involuntary hospitalization during the COVID-​19 pandemic: Experiences and opinions of chief psychiatrists. Psychiat Prax. https://doi.org/10.1055/a-​1406-​7265
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    Objective: To collect experiences and opinions of chief psychiatrists in relation to changes in the practice of involuntary hospitalization during the COVID-19 pandemic. Methods: Online survey among members of the Association of Chief Physicians for Psychiatry and Psychotherapy in North Rhine-Westphalia (LLPP) and analysis of protocols of LLPP board meetings. Results: Changes in the practice of involuntary hospitalization have been perceived in contexts with and without direct reference to COVID-19. These changes have affected, among other things, judicial hearings as well as decisions about the use of coercive measures. Conclusion: Procedural standards for involuntary hospitalization must be maintained and coercive measures may only be used if they meet the applicable ethical and legal requirements. It must be ensured that people with mental disorders are not treated unequally both when taking and withdrawing restrictive measures to contain the pandemic.

  1. Types of Ethical Problems and Expertise in Clinical Ethics Consultation in Psychiatry – Insights From a Qualitative Empirical Ethics Study

    Haltaufderheide, J. J. Gather G. Juckel J. Schildmann 2021. Types of Ethical Problems and Expertise in Clinical Ethics Consultation in Psychiatry – Insights From a Qualitative Empirical Ethics Study. Front. Psychiatry 12:558795. https://doi.org/10.3389/fpsyt.2021.558795
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    Background: Ethics consultation has been advocated as a valuable tool in ethically challenging clinical situations in healthcare. It is paramount for the development and implementation of clinical ethics support services (CESS) in psychiatry that interventions can address the moral needs of mental health professionals adequately and communicate the nature of the services clearly. This study explores types of ethical problems and concepts of ethical expertise as core elements of CESS in mental healthcare with the aim of contributing to the further development of ethical support in psychiatry. Methods: We conducted 13 semi-structured interviews with mental health professionals and CESS members and triangulated them with four non-participant observations of ethical case consultations in psychiatry. Data were analyzed according to principles of grounded theory and are discussed from a normative perspective. Results: The analysis of the empirical data reveals a typology of three different ethical problems professionals want to refer to CESS: (1) Dyadic problems based on the relationship between patients and professionals, (2) triangular problems, where a third party is involved and affected as a side effect, and (3) problems on a systemic level. However, CESS members focus largely on types (1) and (2), while the third remains unrecognized or members do not feel responsible for these problems. Furthermore, they reflect a strong inner tension connected to their role as ethical experts which can be depicted as a dilemma. On the one hand, as ethically trained people, they reject the idea that their judgments have expert status. On the other hand, they feel that mental health professionals reach out for them to obtain guidance and that it is their responsibility to offer it. Conclusion: CESS members and professionals in mental healthcare have different ideas of the scope of responsibility of CESS. This contains the risk of misunderstandings and misconceptions and may affect the quality of consultations. It is necessary to adapt concepts of problem solving to practitioners' needs to overcome these problems. Secondly, CESS members struggle with their role as ethical experts. CESS members in psychiatry need to develop a stable professional identity. Theoretical clarification and practical training are needed.

  1. Nieuwe ggz-​wet tast privésfeer van patiënten ernstig aan

    Scholten, M. 2020. Nieuwe ggz-​wet tast privésfeer van patiënten ernstig aan [The new Dutch law on compulsory mental healthcare violates service users’ right to privacy]. NRC Handelsblad.
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    The new Dutch law on compulsory mental healthcare allows for ambulatory coercion. It grants mental health professionals not only permission to apply involuntary medication and physical restraint in people's homes, but also to do body and home searches and to keep people under surveillance. This opinion piece criticizes the new law. 

  1. Under which conditions are changes in the treatment of persons under involuntary commitment justified during the COVID-​19 pandemic? An ethical evaluation of current developments in Germany

    G. Juckel T. Henking S. A. Efkemann J. Vollmann M. Scholten 2020. Under which conditions are changes in the treatment of persons under involuntary commitment justified during the COVID-​19 pandemic? An ethical evaluation of current developments in Germany. International Journal of Law and Psychiatry 73: 101615. .
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    The COVID-19 pandemic poses significant challenges in psychiatric hospitals, particularly in the context of the treatment of people under involuntary commitment. The question arises at various points in the procedure for and process of involuntary commitment whether procedural modifications or further restrictive measures are necessary to minimise the spread of COVID-19 and protect all people involved from infection.In the light of current developments in Germany, this article examines under which conditions changes in the treatment of people under involuntary commitment are ethically justified in view of the COVID-19 pandemic. Among others, we discuss ethical arguments for and against involuntary commitments with reference to COVID-19, the use of different coercive interventions, the introduction of video hearings, an increased use of video surveillance and interventions based on the German Infection Protection Act.We argue that strict hygiene concepts, the provision of sufficient personal protective equipment and frequent testing for COVID-19 should be the central strategies to ensure the best possible protection against infection. Any further restrictions of the liberty of people under involuntary commitment require a sound ethical justification based on the criteria of suitability, necessity and proportionality. A strict compliance with these criteria and the continued oversight by external and independent control mechanisms are important to prevent ethically unjustified restrictions and discrimination against people with the diagnosis of a mental disorder during the COVID-19 pandemic.

  1. Advance decision making in bipolar: A systematic review

    Stephenson, L. A. T. Gergel A. Gieselmann M. Scholten Keene, L. G. Owen 2020. Advance decision making in bipolar: A systematic review. Frontiers in Psychiatry 11 (1020).
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    “Advance decision making” (ADM) refers to people planning for a future when they may lose the capacity to make decisions about treatment (decision making capacity for treatment or DMC-T). This can occur in a variety of physical and mental health scenarios. Statutory provision for ADM is likely to be introduced to mental health legislation in England and Wales, which will support planning for mental health crises. Conceptually, it may have particular utility for people with Bipolar Affective Disorder (bipolar) due to the pattern of rapid loss and then recovery of DMC-T during episodes of illness. Furthermore, ADM is recommended by clinical experts in bipolar. However, the empirical evidence base for ADM in bipolar is unclear. Therefore, a systematic review is required to collate available evidence and define future research directions. A PRISMA concordant systematic review of empirical literature on the use of ADM in bipolar. We found 13 eligible articles which reported on 11 studies. Of the eligible studies 2 used a mixed methods design, 8 were quantitative descriptive studies and 1 was a randomised controlled trial. Outcomes of included studies fell into 4 categories: Interest in ADM, type of ADM preferred, barriers to completing ADM and impact of ADM. The available evidence suggests that people with bipolar are interested in engaging with ADM which is supported, collaborative and allows them to state treatment requests and refusals. Evidence in this area is limited. Clinicians should be aware that service users with bipolar are likely to value their support in creating ADM documents. In addition, it seems that people with bipolar may face fewer barriers and achieve greater success with ADM compared to those with other severe mental illnesses. Given the greater focus and likely demand for ADM following upcoming legal reform, further research is urgently needed to ensure available resources are most effectively targeted to achieve the best outcomes from ADM activities. This research should focus on clarifying: causal assumptions around ADM, the outcomes which are valued by key stakeholders, barriers to achieving these outcomes, stakeholder opinions on supporting ‘self-binding’ and the development and evaluation of models of ADM which are tailored for fluctuating DMC-T.

  1. Ethisches Spannungsfeld – Patientenselbstbestimmung und professionelle Fürsorge

    Gather, J. M. Scholten A. Riedel S. Lehmeyer 2020. Ethisches Spannungsfeld – Patientenselbstbestimmung und professionelle Fürsorge [Ethical conflict – autonomy and beneficence]. In Springer Reference Pflege – Therapie – Gesundheit: Ethik im Gesundheitswesen, edited by A. Riedel, and S. Lehmeyer. Springer.
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    In der medizinischen Praxis können Situationen eintreten, in denen die ethischen Prinzipien des Respekts vor der Patientenselbstbestimmung und der professionellen Fürsorge miteinander in Konflikt geraten. In solchen Situationen stellt sich für Professionelle im Gesundheitswesen die Frage, ob sie die Entscheidung der Patient*innen respektieren oder unter Umständen eine Maßnahme gegen den Patientenwillen durchführen sollen. Im vorliegenden Beitrag werden zunächst die medizinethischen Prinzipien der Patientenselbstbestimmung und der professionellen Fürsorge vorgestellt. Im Anschluss daran wird vom ethischen Prinzip des Respekts vor der Patientenselbstbestimmung das Konzept der informierten Einwilligung bzw. Ablehnung abgeleitet. Dabei werden die Voraussetzungen einer gültigen Einwilligung, nämlich Informationsvermittlung, Selbstbestimmungsfähigkeit und Freiwilligkeit, unter Einbezug von Strategien der Entscheidungsassistenz erläutert. Auf der Grundlage der normativen Differenzierung zwischen selbstbestimmungsfähigen und selbstbestimmungsunfähigen Patient*innen werden danach unterschiedliche Stufen der stellvertretenden Entscheidungsfindung diskutiert. Abschließend werden Konfliktsituationen zwischen Patientenselbstbestimmung und professioneller Fürsorge ethisch analysiert und es werden Kriterien formuliert, unter denen eine Maßnahme gegen den Willen einer selbstbestimmungsunfähigen Person ethisch gerechtfertigt sein kann.

  1. Psychiatric advance directives under the Convention on the Rights of Persons with Disabilities: Why advance instructions should be able to override current preferences

    Scholten, M. A. Gieselmann J. Gather J. Vollmann 2019. Psychiatric advance directives under the Convention on the Rights of Persons with Disabilities: Why advance instructions should be able to override current preferences. Frontiers in Psychiatry 10 (631). https://doi.org/10.3389/fpsyt.2019.00631
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    Psychiatric advance directives (PADs) are documents by means of which mental health service users can make known their preferences regarding treatment in a future mental health crisis. Many states with explicit legal provisions for PADs have ratified the United Nations (UN) Convention on the Rights of Persons with Disabilities (CRPD). While important UN bodies consider PADs a useful tool to promote the autonomy of service users, we show that an authoritative interpretation of the CRPD by the Committee on the Rights of Persons with Disabilities has the adverse consequence of rendering PADs ineffective in situations where they could be of most use to service users. Based on two clinical vignettes, we demonstrate that reasonable clinical recommendations can be derived from a more realistic and flexible CRPD model. Concerns remain about the accountability of support persons who give effect to PADs. A model that combines supported decision making with competence assessment is able to address these concerns.

  1. Wodurch wird die geschlossene Tür ersetzt? Konzeptionelle und ethische Überlegungen zu offenen Unterbringungsformen und psychologischem Druck

    Gather, J. M. Scholten T. Henking J. Vollmann G. Juckel 2019. Wodurch wird die geschlossene Tür ersetzt? Konzeptionelle und ethische Überlegungen zu offenen Unterbringungsformen und psychologischem Druck [What replaces the locked door? Conceptual and ethical considerations regarding open door policies, formal coercion, and treatment pressures]. Der Nervenarzt 90 (7): 690-​694. https://doi.org/10.1007/s00115-​019-​0717-​3

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    Mental health professionals use various strategies to prevent involuntarily committed persons from absconding under an open door policy. To provide an ethical framework for the evaluation of the replacement of locked ward doors by formal coercion or treatment pressures. The replacement of locked ward doors by formal coercive measures applied to individual persons, such as mechanical restraint or seclusion, is ethically problematic. The use of treatment pressures, for example in the context of intensified observational measures, requires a differentiated ethical evaluation and does not necessarily constitute the milder means in comparison to locked ward doors. Unexplored conceptual, empirical and ethical issues surrounding open door policies and treatment pressures should be clarified by means of psychiatric and ethical research. In clinical practice, the choice of the least burdensome and least restrictive measures for involuntarily committed persons should be facilitated by appropriate ethical support services.

  1. Qualitative research with vulnerable persons: How to ensure that burdens and benefits are proportional and fairly distributed

    Gieselmann, A. S. Efkemann M. Scholten 2019. Qualitative research with vulnerable persons: How to ensure that burdens and benefits are proportional and fairly distributed. Journal of Empirical Research on Human Research Ethics. https://doi.org/10.1177/1556264619847322b

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    This case commentary investigates whether the risks and benefits of an interview study with persons under involuntary commitment on open-door policies in psychiatry were proportional and fairly distributed. Given that there is little data available on the views of service users on open-door policies, the study had significant social value. Because the individual benefits are limited in studies like this, we recommend that special measures be taken to forestall what has been called the “therapeutic misconception.” The study imposed burdens on individual research participants, as evidenced by the distress that a woman with bipolar disorder experienced during the interview. Risks and burdens must be actively monitored in qualitative studies with persons under involuntary commitment. If the actual burdens are disproportional, interviews must be interrupted and risks must be reassessed. A common principle for the fair distribution of the risks and burdens of research participation says that a research study may be carried out with vulnerable persons only if the research aims cannot be attained by including only persons who are not vulnerable. In the study under discussion, both persons who were still involuntarily committed and persons who were no longer committed were included. This indicates that either the aforementioned principle is not fully satisfied or the validity of the study is somewhat compromised. Judging that the latter option is more likely, we contend that this compromise is ethically defensible.

  1. Interviewing a Person With Bipolar Disorder Under Involuntary Commitment: A Case Report

    Gather, J. J. Kalagi I. Otte G. Juckel 2019. Interviewing a Person With Bipolar Disorder Under Involuntary Commitment: A Case Report. Journal of Empirical Research on Human Research Ethics. https://doi.org/10.1177/1556264619847322

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    In this case report, we report an ethical problem that we faced in the course of an interview study on open-door policies in psychiatry with persons under involuntary commitment. One of the interviewees was a young woman with bipolar disorder who was under involuntary commitment at the time of the interview. While the woman had been assessed as competent and gave informed consent to research participation, her manic symptoms increased when the interview became increasingly distressing for her. Because of this, we decided to break off the interview and resume it at a later point of time. Within the research team, we raised the following ethical questions: (1) Was the participant, contrary to the initial assessment, unable to give consent for the study? (2) Was the voluntariness of her research participation compromised by her manic symptoms and involuntary commitment? (3) Should the participant have been excluded from the study against her expressed wish? (4) Should we have refrained from interviewing persons who were still under involuntary commitment?

  1. Ist Forschung in der forensischen Psychiatrie ethisch zulässig?

    Gather, J. K. Radenbach K. Jakovljevic 2019. Ist Forschung in der forensischen Psychiatrie ethisch zulässig? Ethik in der Medizin 31: 201-​205. https://doi.org/10.1007/s00481-​019-​00540-​7
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  1. Kommentar I zum Fall: Ethisch vertretbare Anwendung freiheitsentziehender Maßnahmen zur Durchführung einer Chemotherapie?

    Gather, J. K. Hoffmann 2018. Kommentar I zum Fall: Ethisch vertretbare Anwendung freiheitsentziehender Maßnahmen zur Durchführung einer Chemotherapie? Ethik in der Medizin 30 (4): 367-​369. https://doi.org/10.1007/s00481-​018-​0504-​x
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