1. Preferences of individual mental health service users are essential in determining the least restrictive type of restraint.

    Hempeler, C. Braun, E. Faissner, M. Gather, J. Scholten, M. 2024. Preferences of individual mental health service users are essential in determining the least restrictive type of restraint. AJOB Neuroscience 15 (1): 19-​22. https://doi.org/10.1080/21507740.2023.2292502
    Link to article

  1. Entscheiden unter Zeitdruck. Ethische Entscheidungsfindung in Akutsituationen.

    Hahn, B. Gather, J. Sauter, D. 2024. Entscheiden unter Zeitdruck. Ethische Entscheidungsfindung in Akutsituationen. Psychiatrische Pflege 9(3): 9-​11. https://doi.org/10.1024/2297-​6965/a000568
    Link to article
    Was ist zum Thema bereits bekannt? In Akutsituationen unter Zeitdruck ethische Entscheidungen zu treffen, ist herausfordernd. Wie wird eine neue Perspektive eingebracht? Es stehen verschiedene Ansätze zur Verfügung, die für die ethische Entscheidungsfindung in Akutsituationen hilfreich sein können. Was sind die Auswirkungen auf die Praxis? Psychiatrische Teams sollten sich strukturiert und vorausschauend mit der ethischen Entscheidungsfindung in Akutsituationen befassen und dabei auch das Vorher und das Nachher von Akutsituationen in den Blick nehmen. Dies kann sich sowohl für Nutzende als auch für Mitarbeitende psychiatrischer Institutionen entlastend auswirken und zu einer stärkeren Zufriedenheit führen.

  1. Open-​door policy versus treatment-​as-​usual in urban psychiatric inpatient wards: a pragmatic, randomised controlled, non-​inferiority trial.

    Indregard, A. Nussle, H. M. Vandvik, P. O. Tesli, M. Gather, J. 2024. Open-​door policy versus treatment-​as-​usual in urban psychiatric inpatient wards: a pragmatic, randomised controlled, non-​inferiority trial. Lancet Psychiatry. https://doi.org/10.1016/S2215-​0366(24)00039-​7
    Link to article
    Open-door policy is a recommended framework to reduce coercion in psychiatric wards. However, existing observational data might not fully capture potential increases in harm and use of coercion associated with open-door policies. In this first randomised controlled trial, we compared coercive practices in open-door policy and treatment-as-usual wards in an urban hospital setting. We hypothesised that the open-door policy would be non-inferior to treatment-as-usual on the proportion of patients exposed to coercive measures.

  1. Intersectionality as a tool for clinical ethics consultation in mental healthcare.

    Faissner, M. Gaillard, A.S. Jieman, A.T. Gather, J. Hempeler, C. 2024. Intersectionality as a tool for clinical ethics consultation in mental healthcare. Philosophy, Ethics, and Humanities in Medicine. https://doi.org/10.1186/s13010-​024-​00156-​w
    Link to article
    Bioethics increasingly recognizes the impact of discriminatory practices based on social categories such as race, gender, sexual orientation or ability on clinical practice. Accordingly, major bioethics associations have stressed that identifying and countering structural discrimination in clinical ethics consultations is a professional obligation of clinical ethics consultants. Yet, it is still unclear how clinical ethics consultants can fulfill this obligation. More specifically, clinical ethics needs both theoretical tools to analyze and practical strategies to address structural discrimination within clinical ethics consultations. Intersectionality, a concept developed in Black feminist scholarship, is increasingly considered in bioethical theory. It stresses how social structures and practices determine social positions of privilege and disadvantage in multiple, mutually co-constitutive systems of oppression. This article aims to investigate how intersectionality can contribute to addressing structural discrimination in clinical ethics consultations with a particular focus on mental healthcare. To this end, we critically review existing approaches for clinical ethics consultants to address structural racism in clinical ethics consultations and extend them by intersectional considerations. We argue that intersectionality is a suitable tool to address structural discrimination within clinical ethics consultations and show that it can be practically implemented in two complementary ways: 1) as an analytic approach and 2) as a critical practice.

  1. Electroconvulsive Therapy in Forensic Psychiatry: A systematic review.

    Link to article
    Patients with schizophrenia are the largest population in forensic hospitals, and treatment-resistant psychosis is associated with length of stay. For patients with severe and treatment-resistant psychotic disorders, electroconvulsive therapy (ECT) is a potentially effective treatment. Data regarding the use of ECT in forensic psychiatry are scarce. This systematic review aims to provide an overview of the use of ECT in forensic psychiatry. Three databases (PubMed, Web of Science, and PsycINFO) were searched for publications since 1980. Peer-reviewed articles describing patients who underwent ECT treatment in the context of forensic psychiatry were included when a treatment outcome was reported. We identified 5 case reports and 1 case series comprising 13 patients treated with ECT in forensic settings. The quality of evidence was poor accompanied by a considerable risk of bias. Patients were diagnosed with schizophrenia spectrum disorders (n = 10) or depression with psychotic features (n = 3). Eleven patients (84.6%) were described as responders in terms of symptom improvement associated with a reduction of aggressive behavior and improved functioning. At least 3 patients were able to return to community settings. Despite the very limited evidence base, our review suggests that patients in forensic hospitals may benefit from ECT, but more systematic and higher-quality evidence is urgently needed. In addition to prospective, controlled observational studies, a qualitative view focusing on patients' perspectives in this specific setting is of particular importance.

  1. Strategies to promote treatment compliance: a grounded theory study with relatives of people with a serious mental health condition.

    MC Psychiatry
    Link to article
    This qualitative study supports and conceptually expands prior findings that treatment pressures are not only frequently used within mental healthcare services but also by relatives in the home setting. Mental healthcare professionals should acknowledge the difficulties faced and efforts undertaken by relatives in seeking treatment for their family member. At the same time, they should recognize that a service user’s consent to treatment may be affected and limited by strategies to promote treatment compliance employed by relatives.

  1. Intersectionality as a tool for clinical ethics consultation in mental healthcare

    Link to article
    Bioethics increasingly recognizes the impact of discriminatory practices based on social categories such as race, gender, sexual orientation or ability on clinical practice. Accordingly, major bioethics associations have stressed that identifying and countering structural discrimination in clinical ethics consultations is a professional obligation of clinical ethics consultants. Yet, it is still unclear how clinical ethics consultants can fulfill this obligation. More specifically, clinical ethics needs both theoretical tools to analyze and practical strategies to address structural discrimination within clinical ethics consultations. Intersectionality, a concept developed in Black feminist scholarship, is increasingly considered in bioethical theory. It stresses how social structures and practices determine social positions of privilege and disadvantage in multiple, mutually co-constitutive systems of oppression. This article aims to investigate how intersectionality can contribute to addressing structural discrimination in clinical ethics consultations with a particular focus on mental healthcare. To this end, we critically review existing approaches for clinical ethics consultants to address structural racism in clinical ethics consultations and extend them by intersectional considerations. We argue that intersectionality is a suitable tool to address structural discrimination within clinical ethics consultations and show that it can be practically implemented in two complementary ways: 1) as an analytic approach and 2) as a critical practice.

  1. Open-​door policy versus treatment-​as-​usual in urban psychiatric inpatient wards: a pragmatic, randomised controlled, non-​inferiority trial in Norway

    Link to article
    Open-door policy is a recommended framework to reduce coercion in psychiatric wards. However, existing observational data might not fully capture potential increases in harm and use of coercion associated with open-door policies. In this first randomised controlled trial, we compared coercive practices in open-door policy and treatment-as-usual wards in an urban hospital setting. We hypothesised that the open-door policy would be non-inferior to treatment-as-usual on the proportion of patients exposed to coercive measures.

  1. Ein kollaborativer Bericht über Erfahrungen, Chancen und Herausforderungen in der Zusammenarbeit.

    Link to article
    In diesem Artikel reflektieren die Autor:innen über ihre Erfahrungen der Zusammenarbeit im Betroffenen- und Angehörigenbeirat der Forschungsgruppe SALUS. Die Forschungsgruppe forscht seit 2018 zu ethischen Fragestellungen in der psychischen Gesundheitsversorgung und hat seit 2021 einen Betroffenen- und Angehörigenbeirat. Der Artikel beleuchtet die Chancen und Herausforderungen der Zusammenarbeit zwischen Menschen mit Psychiatrieerfahrung, Angehörigen und Wissenschaftler:innen und fragt nach den Möglichkeiten gemeinsamer Wissenskonstruktion und deren Relevanz für die psychiatrische Praxis. Einen zentralen Diskussionspunkt stellt der Begriff des Wir für die gemeinsame Arbeit dar.

  1. Implementation of self-​binding directives: Recommendations based on expert consensus and input by stakeholders in three European countries.

    Scholten, M. S. Efkemann M. Faissner M. Finke J. Gather T. Gergel Ham, G. Juckel, A. L. Melle, G. Owen, S. Potthoff, L. A. Stephenson, G. Szmukler, A. Vellinga, J. Vollmann, Y. Voskes, A. G. Widdershoven 2023. Implementation of self-​binding directives: Recommendations based on expert consensus and input by stakeholders in three European countries.  World Psychiatry 22 (2):332-​333. doi: 10.1002/wps.21095.
    Link to article
    Self-binding directives (SBDs) are psychiatric advance directives including a clause in which mental health service users give advance consent to involuntary hospital admission and treatment, and grant mental health professionals permission to overrule anticipated treatment refusals during future mental health crises1, 2. They are also known as “Ulysses contracts” or “Ulysses arrangements”. SBDs can enable people with mental disorders which involve fluctuating mental capacity and regular treatment refusals during crises (e.g., psychotic and bipolar disorders) to stay in control of their life and treatment1. During episodes, these people may make decisions that are incompatible with their deeply-held values, convictions and preferences. Such decisions regularly involve refusal of hospital admission or treatment and can have far-reaching consequences. By enabling service users to authorize professionals to overrule such refusals, SBDs are essential to advance care planning in people with psychotic or bipolar disorders. While potential ethical benefits and risks of SBDs have been discussed extensively in the ethics and legal literature, little was known about stakeholders’ views on the opportunities and challenges of SBDs until recently. Recent studies conducted in Germany, The Netherlands and the UK reveal that stakeholders perceive promotion of autonomy, avoidance of harm, possibility of early intervention, improvement of the therapeutic relationship, and involvement of trusted persons as opportunities of SBDs3-9. Perceived challenges include lack of awareness and knowledge of SBDs, lack of formal support for SBD completion, undue influence during the drafting process, inaccessibility of SBDs during crisis, lack of cross-agency coordination, problems of interpretation of SBD content, difficulties in mental capacity assessment, restricted therapeutic flexibility due to narrow SBD instructions, infeasibility of SBDs due to scarce resources, disappointment due to non-compliance with SBD instructions, and outdated SBD content3-9. Stakeholders who participated in these studies tended to see the implementation of SBDs as ethically desirable, provided that the above-mentioned challenges are addressed through the implementation of appropriate safeguards. Based on suggestions made by stakeholders and a structured expert consensus process among authors, we have derived the following recommendations for the legal and clinical implementation of SBDs.

  1. Respect for the will and preferences of people with mental disorders in German law.

    Henking, T. M. Scholten C. Kong J. Coggon P. Cooper A. R. Keene 2023. Respect for the will and preferences of people with mental disorders in German law. In Capacity, Participation, and Values in Comparative Legal Perspective, edited by C. Kong, J. Coggon, P. Cooper, M. Dunn and A. R. Keene. Bristol: Bristol University Press. https://doi.org/10.56687/9781529224474-​015
    Link to article
    This chapter provides an overview of German laws that are particularly relevant to the rights of people with mental disorders. While its focus is on guardianship law, the chapter also briefly discusses Mental Health Assistance Laws, the implications of the United Nations Convention of the Rights of Persons with Disabilities, and the Patients’ Rights Law. Key elements of German guardianship law include respect for autonomy, a prioritisation of supported over substitute decision-making, a prioritisation of the person’s will and preferences over objective categories of well-being, and protection of the deeply held will and preferences of individuals who lack mental capacity and pose a considerable risk of harm to themselves. The primary task of the guardian is to support the person concerned in managing their own legal affairs. Only if the provision of adequate support does not enable the person concerned to make decisions based on their own will and preferences, the guardian can act on their behalf. Substitute decisions made by a guardian must be consistent with the deeply held values and preferences of the person concerned, as derived from the person’s advance directive, preferences they expressed previously, or the person’s ‘presumed will’. Various actions of the guardian are subject to court approval, including financial investments, security deposits, high-stake medical decisions and involuntary interventions. A central element in the court proceedings is an in-person hearing of the person concerned. Involuntary interventions are additionally subject to strict conditions of proportionality. Keywords

  1. Opportunities and challenges of self-​binding directives: An interview study with mental health service users and professionals in the Netherlands.

    Melle, A. L. Ham, Y. Voskes, G. M. Scholten 2023. Opportunities and challenges of self-​binding directives: An interview study with mental health service users and professionals in the Netherlands.  BMC Medical Ethics. https://doi.org/10.1192/j.eurpsy.2023.2421.
    Link to article
    Findings converged on many points. Perceived opportunities of SBDs include promotion of autonomy, avoidance of personally defined harms, early intervention, reduction of admission duration, improvement of the therapeutic relationship, involvement of persons of trust, avoidance of involuntary hospital admission, addressing trauma, destigmatization of involuntary treatment, increase of professionals’ confidence, and relief for proxy decision-makers. Perceived challenges include lack of awareness and knowledge, lack of support, undue influence, inaccessibility during crisis, lack of cross-agency coordination, problems of interpretation, difficulties in capacity assessment, restricted therapeutic flexibility, scarce resources, disappointment due to noncompliance, and outdated content. Stakeholders tended to focus on practical challenges and did not often raise fundamental ethical concerns.  

  1. Research ethics in practice: An analysis of ethical issues encountered in qualitative health research with mental health service users and relatives.

    Potthoff, S. Hempeler, C. Gather, J. Gieselmann, A. Vollmann, J. Scholten, M. 2023. Research ethics in practice: An analysis of ethical issues encountered in qualitative health research with mental health service users and relatives. Medicie, Health Care and Philosophy, https://doi.org/10.1007/s11019-​023-​10169-​5
    Link to article
    The ethics review of qualitative health research poses various challenges that are due to a mismatch between the current practice of ethics review and the nature of qualitative methodology. The process of obtaining ethics approval for a study by a research ethics committee before the start of a research study has been described as “procedural ethics” and the identification and handling of ethical issues by researchers during the research process as “ethics in practice.” While some authors dispute and other authors defend the use of procedural ethics in relation to qualitative health research, there is general agreement that it needs to be supplemented with ethics in practice. This article aims to provide an illustration of research ethics in practice by reflecting on the ways in which we identified and addressed ethical and methodological issues that arose in the context of an interview study with mental health service users and relatives. We describe the challenges we faced and the solutions we found in relation to the potential vulnerability of research participants, the voluntariness of consent, the increase of participant access and the heterogeneity of the sample, the protection of privacy and internal confidentiality, and the consideration of personal and contextual factors.

  1. When treatment pressures become coercive: A context-​sensitive model of informal coercion in mental healthcare.

    Hempeler, C. E. Braun S. Potthoff J. Gather M. Scholten 2023. When treatment pressures become coercive: A context-​sensitive model of informal coercion in mental healthcare. The American Journal of Bioethics. https://doi.org/10.1080/15265161.2023.2232754.
    Link to article
    Treatment pressures are communicative strategies that mental health professionals use to influence the decision-making of mental health service users and improve their adherence to recommended treatment. Szmukler and Appelbaum describe a spectrum of treatment pressures, which encompasses persuasion, interpersonal leverage, offers and threats, arguing that only a particular type of threat amounts to informal coercion. We contend that this account of informal coercion is insufficiently sensitive to context and fails to recognize the fundamental power imbalance in mental healthcare. Based on a set of counterexamples, we argue that what makes a proposal coercive is not whether service users will actually be made worse off if they reject the proposal, but rather whether they have the justified belief that this is the case. Whether this belief is justified depends on the presence of certain contextual factors, such as strong dependency on professionals and the salient possibility of formal coercion.

  1. Situational vulnerability within mental healthcare – a qualitative analysis of ethical challenges during the COVID-​19 pandemic.

    Faissner, M. Werning, A. Foullois, H. Gather, J. 2023. Situational vulnerability within mental healthcare – a qualitative analysis of ethical challenges during the COVID-​19 pandemic. BMC Med Ethics 24, 31. https://doi.org/10.1186/s12910-​023-​00910-​3
    Link to article
    Mental healthcare users and patients were described as a particularly vulnerable group in the debate on the burdens of the COVID-19 pandemic. Just what this means and what normative conclusions can be derived from it depend to a large extent on the underlying concept of vulnerability. While a traditional understanding locates vulnerability in the characteristics of social groups, a situational and dynamic approach considers how social structures produce vulnerable social positions. The situation of users and patients in different psychosocial settings during the COVID-19 pandemic has not yet been comprehensively considered and ethically analyzed under the aspect of situational vulnerability.

  1. When treatment pressures become coercive: A context-​sensitive model of informal coercion in mental healthcare.

    Hempeler, C. Braun, E. Potthoff, S. Gather, J. Scholten, M. 2023. When treatment pressures become coercive: A context-​sensitive model of informal coercion in mental healthcare. The American Journal of Bioethics. https://doi.org/10.1080/15265161.2023.2232754
    Link to article
    Treatment pressures are communicative strategies that mental health professionals use to influence the decision-making of mental health service users and improve their adherence to recommended treatment. Szmukler and Appelbaum describe a spectrum of treatment pressures, which encompasses persuasion, interpersonal leverage, offers and threats, arguing that only a particular type of threat amounts to informal coercion. We contend that this account of informal coercion is insufficiently sensitive to context and fails to recognize the fundamental power imbalance in mental healthcare. Based on a set of counterexamples, we argue that what makes a proposal coercive is not whether service users will actually be made worse off if they reject the proposal, but rather whether they have the justified belief that this is the case. Whether this belief is justified depends on the presence of certain contextual factors, such as strong dependency on professionals and the salient possibility of formal coercion.

  1. Respect for the will and preferences of people with mental disorders in German law.

    Link to article
    This chapter provides an overview of German laws that are particularly relevant to the rights of people with mental disorders. While its focus is on guardianship law, the chapter also briefly discusses Mental Health Assistance Laws, the implications of the United Nations Convention of the Rights of Persons with Disabilities, and the Patients’ Rights Law. Key elements of German guardianship law include respect for autonomy, a prioritisation of supported over substitute decision-making, a prioritisation of the person’s will and preferences over objective categories of well-being, and protection of the deeply held will and preferences of individuals who lack mental capacity and pose a considerable risk of harm to themselves. The primary task of the guardian is to support the person concerned in managing their own legal affairs. Only if the provision of adequate support does not enable the person concerned to make decisions based on their own will and preferences, the guardian can act on their behalf. Substitute decisions made by a guardian must be consistent with the deeply held values and preferences of the person concerned, as derived from the person’s advance directive, preferences they expressed previously, or the person’s ‘presumed will’. Various actions of the guardian are subject to court approval, including financial investments, security deposits, high-stake medical decisions and involuntary interventions. A central element in the court proceedings is an in-person hearing of the person concerned. Involuntary interventions are additionally subject to strict conditions of proportionality.

  1. Research ethics in practice: An analysis of ethical issues encountered in qualitative health research with mental health service users and relatives.

    Potthoff, S. Hempeler, C. Gather, J. Gieselmann, A. Vollmann, J. Scholten, M.
    Link to article
    The ethics review of qualitative health research poses various challenges that are due to a mismatch between the current practice of ethics review and the nature of qualitative methodology. The process of obtaining ethics approval for a study by a research ethics committee before the start of a research study has been described as “procedural ethics” and the identification and handling of ethical issues by researchers during the research process as “ethics in practice.” While some authors dispute and other authors defend the use of procedural ethics in relation to qualitative health research, there is general agreement that it needs to be supplemented with ethics in practice. This article aims to provide an illustration of research ethics in practice by reflecting on the ways in which we identified and addressed ethical and methodological issues that arose in the context of an interview study with mental health service users and relatives. We describe the challenges we faced and the solutions we found in relation to the potential vulnerability of research participants, the voluntariness of consent, the increase of participant access and the heterogeneity of the sample, the protection of privacy and internal confidentiality, and the consideration of personal and contextual factors.

  1. Mental health service users’ perspectives on psychiatric advance directives: a systematic review.

    Link to article
    Psychiatric advance directives (PADs) are documents that allow users of mental health services to express their preferences for treatment in future mental health crises. To increase the use of PADs in psychiatric practice, it is helpful to consider how service users view PADs and the factors that facilitate or hinder PAD creation and implementation. A systematic review of the empirical literature on this topic may help inform evidence-based policy making.  

  1. The content of psychiatric advance directives: a systematic review.

    Gaillard, A.S. Braun, E. Vollmann, J. Gather, J. Scholten, M. 2023. The content of psychiatric advance directives: a systematic review. Psychiatric Services 74: 44-​55.  https://doi.org/10.1176/appi.ps.202200002
    Link to article
    Psychiatric advance directives (PADs) enable users of mental health services to express their treatment preferences for future mental health crises. PAD completion rates remain low despite high rates of interest among service users and empirically confirmed benefits of their use. A systematic review of service users’ preferences regarding the content of PADs could be a valuable resource for clinicians and policy makers and might help reduce barriers to PAD implementation.

  1. Opportunities and challenges of self-​binding directives: An interview study with mental health service users and professionals in the Netherlands.

    Melle, L. Ham, L. Voskes, Y. Widdershoven, G. Scholten, M. 2023. Opportunities and challenges of self-​binding directives: An interview study with mental health service users and professionals in the Netherlands. BMC Medical Ethics 24 (38). https://doi.org/10.1186/s12910-​023-​00915-​y
    Link to article
    Self-binding directives (SBDs) are psychiatric advance directives that include the possibility for service users to consent in advance to compulsory care in future mental health crises. Legal provisions for SBDs exist in the Netherlands since 2008 and were updated in 2020. While ethicists and legal scholars have identified several benefits and risks of SBDs, few data on stakeholder perspectives on SBDs are available.

  1. Implementation of self-​binding directives: Recommendations based on expert consensus and input by stakeholders in three European countries.

    Scholten, M. Efkemann, S.A. Faissner, M. Finke, M. Gather, J. Gergel, T. Ham, L. Juckel, G. Melle, A.L. Owen, G. Potthoff, S. Stephenson, L.A. Szmukler, G. Vellinga, A. Vollmann, J. Voskes, Y. Werning, A. Widdershoven, G. 2023. Implementation of self-​binding directives: Recommendations based on expert consensus and input by stakeholders in three European countries. World Psychiatry 22 (2): 332-​333. https://doi.org/10.1002/wps.21095
    Link to article
    Self-binding directives (SBDs) are psychiatric advance directives including a clause in which mental health service users give advance consent to involuntary hospital admission and treatment, and grant mental health professionals permission to overrule anticipated treatment refusals during future mental health crises1, 2. They are also known as “Ulysses contracts” or “Ulysses arrangements”. SBDs can enable people with mental disorders which involve fluctuating mental capacity and regular treatment refusals during crises (e.g., psychotic and bipolar disorders) to stay in control of their life and treatment1. During episodes, these people may make decisions that are incompatible with their deeply-held values, convictions and preferences. Such decisions regularly involve refusal of hospital admission or treatment and can have far-reaching consequences. By enabling service users to authorize professionals to overrule such refusals, SBDs are essential to advance care planning in people with psychotic or bipolar disorders.

  1. Opportunities and challenges of self-​binding directives: A comparison of empirical research with stakeholders in three European countries.

    Scholten, M. Efkemann, S.A. Faissner, M. Finke, M. Gather, J. Gergel, T. Gieselmann, A. Ham, L. Juckel, G. Melle, L. Owen, G. Potthoff, S. Stephenson, L.A. Szmukler, G. Vellinga, A. Vollmann, J. Voskes, Y. Werning, A. Widdershoven, G. 2023. Opportunities and challenges of self-​binding directives: A comparison of empirical research with stakeholders in three European countries. European Psychiatry 66(1): e48, 1–6. https://doi.org/10.1192/j.eurpsy.2023.2421
    Link to article
    Self-binding directives (SBDs) are psychiatric advance directives that include a clause in which mental health service users consent in advance to involuntary hospital admission and treatment under specified conditions. Medical ethicists and legal scholars identified various potential benefits of SBDs but have also raised ethical concerns. Until recently, little was known about the views of stakeholders on the opportunities and challenges of SBDs.

  1. Self-​binding directives in psychiatric practice: a systematic review of reasons.

    Stephenson, L. Gieselmann, A. Gergel, T. Owen, G. Gather, J. Scholten, M. 2023. Self-​binding directives in psychiatric practice: a systematic review of reasons. Lancet Psychiatry. https://doi.org/10.1016/S2215-​0366(23)00221-​3
    Link to article
    Self-binding directives (SBDs) are an ethically controversial type of advance decision making involving advance requests for involuntary treatment. This study systematically reviewed the academic literature on psychiatric SBDs to elucidate reasons for and against their use in psychiatric practice. Full-text articles were thematically analysed within the international, interdisciplinary authorship team to produce a hierarchy of reasons. We found 50 eligible articles. Reasons for SBD use were promoting service user autonomy, promoting wellbeing and reducing harm, improving relationships, justifying coercion, stakeholder support, and reducing coercion. Reasons against SBD use were diminishing service user autonomy, unmanageable implementation problems, difficulties with assessing mental capacity, challenging personal identity, legislative issues, and causing harm. A secondary finding was a clarified concept of capacity-sensitive SBDs. Future pilot implementation projects that operationalise the clarified definition of capacity-sensitive SBDs with safeguards around informed consent, capacity assessment, support for drafting, and independent review are required.

  1. Situational vulnerability within mental healthcare – a qualitative analysis of ethical challenges during the COVID-​19 pandemic.

    Faissner, M. Werning, A. Foullois, H. Gather, J. 2023. Situational vulnerability within mental healthcare – a qualitative analysis of ethical challenges during the COVID-​19 pandemic. BMC Med Ethics 24, 31.  https://doi.org/10.1186/s12910-​023-​00910-​3
    Link to article
    Mental healthcare users and patients were described as a particularly vulnerable group in the debate on the burdens of the COVID-19 pandemic. Just what this means and what normative conclusions can be derived from it depend to a large extent on the underlying concept of vulnerability. While a traditional understanding locates vulnerability in the characteristics of social groups, a situational and dynamic approach considers how social structures produce vulnerable social positions. The situation of users and patients in different psychosocial settings during the COVID-19 pandemic has not yet been comprehensively considered and ethically analyzed under the aspect of situational vulnerability.

  1. The ethics of coercion in mental healthcare: the role of structural racism.

    Faissner, M. Braun, E. 2023. The ethics of coercion in mental healthcare: the role of structural racism. Journal of Medical Ethics. https://doi.org/10.1136/jme-​2023-​108984
    Link to article
    In mental health ethics, it is generally assumed that coercive measures are sometimes justified when persons with mental illness endanger themselves or others. Coercive measures are regarded as ethically justified only when certain criteria are fulfilled: for example, the intervention must be proportional in relation to the potential harm. In this paper, we demonstrate shortcomings of this established ethical framework in cases where people with mental illness experience structural racism. By drawing on a case example from mental healthcare, we first demonstrate that biases in assessing whether the coercive intervention is proportional are likely, for example, due to an overestimation of dangerousness. We then show that even if proportionality is assessed correctly, and the specific coercive intervention would thus be regarded as ethically justified according to the standard framework, coercion may still be ethically problematic. This is because the standard framework does not consider how situations in which coercive measures are applied arise. If structural racism causally contributes to such situations, the use of coercion can compound the prior injustice of racist discrimination. We conclude that the ethical analysis of coercion in mental healthcare should consider the possibility of discriminatory biases and practices and systematically take the influence of structural discrimination into account.

  1. Ethisches Spannungsfeld – Patientenselbstbestimmung und professionelle Fürsorge

    Gather, J. M. Scholten 2022. Ethisches Spannungsfeld – Patientenselbstbestimmung und professionelle Fürsorge [Ethical conflict – autonomy and beneficence]. In Springer Reference Pflege – Therapie – Gesundheit: Ethik im Gesundheitswesen, edited by A. Riedel & S.Lehmeyer. Springer. https://doi.org/10.1007/978-​3-​662-​58685-​3_48-​1
    Link to article
    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. Das Verständnis von Wohl im Betreuungsrecht – eine Analyse anlässlich der Streichung des Wohlbegriffs aus dem reformierten Gesetz

    E. Braun J. Gather T. Henking J. Vollmann
    Link to article
    The reform of German guardianship law coming into force in 2023 will remove the term “well-being” from the law. This is intended to emphasise that the legal guardian should be guided by the subjective wishes of the person rather than by an objective understanding of well-being. This article analyses the understanding of well-being underlying the reformed guardianship law in comparison to common conceptions of well-being in philosophy and medical ethics, aiming to promote interdisciplinary understanding between ethics and law. The justification for the reform emphasises that the law is based on a subjective understanding of well-being. However, this understanding does not correspond to philosophical subjective theories of well-being, according to which only things that a person desires can contribute to her well-being. In contrast, the guardianship law assumes that the fulfilment of certain wishes can lead to objective harm to the person and thus impair her well-being. Negative consequences for the objective well-being of a person are only relevant insofar as they indicate a limit to following current wishes that are based on a natural will and are not an expression of self-determination. While the term “well-being” is removed from reformed guardianship law, the law implicitly contains an understanding of well-being comparable to a hybrid conception of well-being from a medical ethics perspective. According to this conception, fulfilment of a person’s wishes generally contributes to her well-being, although certain objective criteria are also taken into consideration.

  1. Influence of mental health professionals’ attitudes and personality traits on decision-​making around coercion: Results from an experimental quantitative survey using case vignettes

    Scholten, M. Bottlender, R. Juckel, G. Gather, J.
    Link to article
    Research on coercion in mental healthcare has recently shifted to the investigation of subjective aspects, both on the side of the people with mental disorders affected and the staff members involved. In this context, the role of personality traits and attitudes of staff members in decision-making around coercion is increasingly being assessed. This study aimed to examine the role of staff attitudes towards coercion and staff members’ personality traits in decision-making around coercion in an experimental setting.Methods: We assessed the attitudes towards coercion and (general) personality traits of mental health professionals in psychiatric hospitals with a quantitative survey. Furthermore, we developed case vignettes representing cases in a ‘grey zone’ and included them in the survey to assess staff members’ decisions about coercion in specific situations. Results: A general approving attitude towards coercion significantly influenced decisions around coercion in individual cases—resulting in a more likely approval of applying coercion in the cases described in the vignettes. Personality traits did not seem to be relevant in this regard. Conclusion: Strategies to reduce coercion in mental healthcare institutions should focus more on the role of staff attitudes and encourage staff members to reflect on them critically.

  1. “Voluntary in quotation marks”: a conceptual model of psychological pressure in mental healthcare based on a grounded theory analysis of interviews with service users.

    Potthoff, S. Gather, J. Hempeler, C. Gieselmann, A. Scholten, M.
    Link to article
    The study indicated that psychological pressure is used not only to improve service users’ adherence to recommended treatment but also to improve their adherence to social rules; that it is exerted not only by mental health professionals but also by relatives and friends; and that the extent to which service users perceive communication as involving psychological pressure depends strongly on contextual factors. Relevant contextual factors were the way of communicating, the quality of the personal relationship, the institutional setting, the material surroundings and the level of convergence between the parties’ understanding of mental disorder.

  1. The Content of Psychiatric Advance Directives: A Systematic Review

    Gaillard, A. Braun, E. Vollmann, J. Gather, J. Scholten, M.
    Link to article
    Objective: Psychiatric advance directives (PADs) enable users of mental health services to express their treatment preferences for future mental health crises. PAD completion rates remain low despite high rates of interest among service users and empirically confirmed benefits of their use. A systematic review of service users’ preferences regarding the content of PADs could be a valuable resource for clinicians and policy makers and might help reduce barriers to PAD implementation. Methods: A systematic review concordant with PRISMA guidelines was conducted. CINAHL, Cochrane, EMBASE, PsycINFO, MEDLINE, PubMed, SCOPUS, and Web of Science databases were searched up to July 2, 2021. Included articles contained original empirical data on service users’ preferences regarding the content of PADs or a document analysis of existing PADs. Studies were analyzed thematically, and a narrative synthesis was conducted. The Mixed Methods Appraisal Tool was used to assess the methodological quality and risk of bias of the included studies. Results: The search yielded 4,047 articles, 42 of which were eligible for inclusion. Six themes emerged (most of which included subthemes): signs of crisis, general treatment approach, preferences regarding the treatment setting, treatment preferences, coercion, and social instructions. Conclusions: The concern that PADs may be unclear or incompatible with practice standards was not confirmed. Service users generally included clear, comprehensible, and clinically relevant information in their PADs, often providing underlying reasons for their preferences. These reasons were related to previous adverse effects of medication and personal experiences with hospital admissions.

  1. Das kombinierte Modell der Entscheidungsassistenz: Ein Mittel zur ethisch vertretbaren Umsetzung von Artikel 12 der UN-​Behindertenrechtskonvention in der Psychiatrie

    Scholten, M. J. Gather J. Vollmann 2022. The combined supported decision-​making model: A template for an ethically justifiable implementation of Article 12 of the UN Convention on the Rights of Persons with Disabilities in mental healthcare. Der Nervenarzt. https://doi.org/10.1007/s00115-​022-​01384-​1.
    Link to article
    The interpretation of Article 12 of the United Nations (UN) Convention on the Rights of Persons with Disabilities (CRPD) by the UN Committee on the Rights of Persons with Disabilities led to a controversy over the implementation of the article in psychiatry. Objective How can Article 12 CRPD be implemented in psychiatry in an ethically justifiable way? Material and method An empirically and legally informed conceptual and ethical analysis was carried out. Results The suggested combined supported decision making model ensures the recognition of people with mental disorders as persons before the law, their equal treatment in the informed consent process and the provision of supported decision making. According to this model, coercive treatment can only be carried out in accordance with the will and preferences of the person and is subject to further conditions of proportionality and review by an independent body. Conclusion The combined supported decision making model makes an ethically justifiable implementation of Article 12 CRPD possible in psychiatry.

  1. Compulsory psychopharmacological treatment in forensic psychiatry. An evaluation study on coercive measures in patients with schizophrenia in Westphalia-​Lippe according to Section 17a (2) MRVG NRW

    S. A. Efkemann B. Schiffer 2022. Compulsory psychopharmacological treatment in forensic psychiatry. An evaluation study on coercive measures in patients with schizophrenia in Westphalia-​Lippe according to Section 17a (2) MRVG NRW]. Forens Psychiatry Psychol Kriminol
    Link to article
    Until recently, Section 17a (2) of the North Rhine-Westphalian forensic mental health law regulated the compulsory treatment of patients who lack mental capacity with the goal to “achieve the ability to be discharged”. Little has been discovered so far about the effects of such compulsory treatment. The present study evaluates the effects of compulsory antipsychotic medication in patients with a schizophrenia spectrum disorder who are detained in German forensic hospitals. Therefore, the symptom severity and level of functioning were assessed by mental health professionals directly before the first application of all compulsory medications (n = 16) which were administered in 3 forensic psychiatric hospitals of the Regional Association of Westphalia Lippe in 2019, as well as 4 weeks and 6 months afterwards using Positive and Negative Syndrome Scale (PANSS) and Global Assessment of Functioning (GAF). The achievement of other treatment goals, the assessment of the ability to be discharged and an overall evaluation of the compulsory treatment were also questioned. There was a significant reduction of the PANSS factors “positive symptoms” and “excitable/hostile” and an increase of the level of functioning at the first catamnesis time point, both of which continued slightly weakened. Only two patients showed no or a negative effect. Although the effects on the questioned treatment goals fell short of expectations, the mental health professionals predominantly assessed the compulsory medication positively. Compulsory treatment with antipsychotics can have a favorable effect on the goal of “achieving the ability to be discharged”; however, the limited effect on the insight into the illness and the necessity of taking the medication reveal limitations indicating that this measure is not sufficient to achieve the ability to be discharged.

  1. Ist eine Zwangsbehandlung bei Fremdgefährdung zum Wohl der gefährdenden Person? Eine ethische Analyse von Wohl und Wille im psychiatrischen Behandlungskontext.

    E. Braun M. Faissner
    Link to article
    While psychiatry often has the task of averting danger to third parties, the legitimacy of this task has been controversially discussed and repeatedly questioned. From an ethical perspective, coercive measures or coercive treatment in the context of danger to others must always be well justified. In this article, we first describe how measures against a person’s will can be ethically justified. With reference to the principle of soft paternalism, it is generally assumed that coercive treatment of people who lack decision-making capacity is only justified if it is in the person’s best interests and is in line with their anticipatory or presumed will. We then examine to what extent coercive treatment of people with mental illness who endanger others can be justified on soft paternalistic grounds. We discuss different theories of well-being and propose a hybrid subjective-objective theory of well-being as a suitable standard for assessing the well-being of people with mental illness. A case study is used to discuss in which cases coercive treatment can be in the best interests of a person who endangers others and corresponds to their presumed will, and to clarify when this is not the case, for example when the person’s well-being and will contradict each other.

  1. Opportunities and risks of self-​binding directives: A qualitative study involving stakeholders and scientists in Germany.

    Potthoff, S. Finke, M. Scholten, M. Gieselmann, A. Vollmann, J. Gather, J. 2022.974132">https://doi.org/10.3389/fpsyt.2022.974132
    Link to article
    Purpose: Self-binding directives (SBDs) are a special type of psychiatric advance directive in which mental health service users can consent in advance to involuntary hospital admission and involuntary treatment during future mental health crises. This study presents opportunities and risks of SBDs reported by users with bipolar disorder, family members of people with bipolar disorder, professionals working with people with bipolar disorder and researchers with expertise in mental health ethics and law. Methods: Seventeen semi-structured interviews with users, family members and professionals, and one focus group with five researchers were conducted. The data was analyzed using qualitative content analysis. Results: Six opportunities and five risks of SBDs were identified. The opportunities were promotion of autonomy and self-efficacy of users, relief of responsibility for family members, early intervention, reduction of (perceived) coercion, positive impact on the therapeutic relationship and enhancement of professionals' confidence in decision-making. The risks were problems in the assessment of mental capacity, inaccurate information or misinterpretation, increase of coercion through misuse, negative impact on the therapeutic relationship due to noncompliance with SBDs, and restricted therapeutic flexibility and less reflection on medical decision-making. Stakeholders tended to think that the opportunities of SBDs outweigh their risks, provided that appropriate control and monitoring mechanisms are in place, support is provided during the drafting process and the respective mental healthcare setting is sufficiently prepared to implement SBDs in practice. Conclusions: The fact that stakeholders consider SBDs as an opportunity to improve personalized crisis care for people with bipolar disorder indicates that a debate about the legal and clinical implementation of SBDs in Germany and beyond is necessary.

  1. Shared Decision-​Making for Patients with Mental Disorders or Cognitive Impairments

    Link to article
    Shared Decision-Making (SDM) describes a model of collaborative decision-making that combines the expert knowledge of health professionals and the experiential knowledge of patients. This allows patients to play a more active role in the decision-making process. SDM is also becoming increasingly important in the treatment of persons with mental disorders or cognitive impairments. However, implementation of SDM for this group of patients may face specific challenges, for example, if their decision-making capacity is impaired or if coercion has to be used to prevent acute danger to themselves or others. On the other hand, SDM offers important opportunities in this area. For example, mental health professionals are often more dependent on the patients’ experiential knowledge in clinical decision-making than in somatic care. Furthermore, empowerment and a good therapeutic relationship are central aspects in the treatment of people with mental disorders or cognitive impairments, which can be strengthened by SDM. Against the background of these specific challenges, an overview of opportunities for and experiences with SDM in the care of people with mental disorders or cognitive impairments is given. In addition, different approaches for promoting the implementation of SDM for this patient group will be identified.

  1. Effectiveness of electroconvulsive therapy in patients lacking decision making capacity: A systematic review and meta-​analysis.

    2022.09.001">https://doi.org/10.1016/j.brs.2022.09.001
    Link to article
    Background Electroconvulsive therapy (ECT) is provided for patients with severe and often life-threatening illness, who lack decision making capacity to consent to treatment (DMC-T) in clinical settings. Objective The aim of this study is to summarize previous studies investigating clinical outcomes of ECT in patients lacking DMC-T. Methods A systematic review and meta-analysis of studies reporting clinical outcomes of ECT in patients lacking DMC-T with any psychiatric diagnoses was conducted. The primary outcome was clinical improvement. Secondary outcomes were cognitive outcomes and six month readmission rate. Hedges’ g and odds ratios were calculated using a random-effects model. The protocol was registered in Open Science Framework (https://osf.io/rxjkm). Results Of 3552 identified articles, 41 studies (n = 1299) were included. Approximately 80% of patients lacking DMC-T responded to ECT, and part of the patients regained capacity to consent and consented to further treatment with ECT. A total of seven studies (n = 1081) were included for meta-analysis. Patients without DMC-T showed superior clinical improvement and less cognitive side effects compared with those with DMC-T, whereas the groups did not show any difference in readmission rate. Several clinical characteristics at baseline and ECT techniques were significantly different between the groups. Conclusion ECT is equally, if not superiorly, effective in patients lacking DMC-T compared to patients with DMC-T. ECT can potentially enhance patients’ autonomy, without increasing the risk of cognitive side effects. These results support the clinical and ethical legitimacy of ECT provision for patients with the most severe illness who lack DMC-T at start of treatment.

  1. Psychiatrische Patientenverfügungen in der Praxis.

    2022. Psychiatrische Patientenverfügungen in der Praxis.  PPH 28 (2):77-​81. https://doi.org/10.1055/a-​1687-​7166
    Link to article
    In Deutschland gilt: Eine medizinische Behandlung darf nur durchgeführt werden, wenn sie vom Patientenwillen getragen wird. Doch Menschen mit schweren psychischen Erkrankungen sind in Krisensituationen manchmal nicht mehr in der Lage, diesen zu äußern. Hier erfahren Sie, wie Betroffene ihre Behandlungswünsche schon vorab schriftlich festlegen können und welche Vorteile dies für alle Beteiligten bietet.

  1. Einwilligungsfähigkeit und Freiwilligkeit bei der Einwilligung von Menschen mit psychischen Erkrankungen in pflegerische Maßnahmen.

    Hempeler, C. J. Gather M. Scholten 2022. Einwilligungsfähigkeit und Freiwilligkeit bei der Einwilligung von Menschen mit psychischen Erkrankungen in pflegerische Maßnahmen  Psychiatrische Pflege Heute 28 (6):290-​295. doi: 10.1055/a-​1925-​6213.
    Link to article
    Medizinische Entscheidungen in Situationen zu treffen, in denen Patienten nicht einwilligungsfähig sind, zählt zu den besonders schwierigen und belastenden Aufgaben von Ärzten und Pflegenden. In der Psychiatrie sind Professionelle jedoch besonders häufig in dieser Situation, da psychische Störungen vorübergehend oder dauerhaft mit Einwilligungsunfähigkeit einhergehen können. Wie dennoch Entscheidungen über die Behandlung getroffen werden können, beschreibt unser Autoren-Team.

  1. Zwang im Voraus planen: Die rechtliche Regelung von Odysseus-​Verfügungen in den Niederlanden

    Scholten, M. A. Werning J. Gather 2022. Zwang im Voraus planen: Die rechtliche Regelung von Odysseus-​Verfügungen in den Niederlanden [Planing involuntary treatment in advance: The legal framework for self-​binding directives in The Netherlands]. Psychiatrische Praxis 49 (2): 111-​113. https://doi.org/10.1055/a-​1696-​6976.
    Link to article
    Als ,Odysseus-Verfügung‘ bezeichnet man eine besondere Form einer Vorausverfügung, in der einwilligungsfähige Personen für eine spätere Situation der Einwilligungsunfähigkeit Behandlungspräferenzen verbindlich festlegen können. Der Unterschied zu den in Deutschland etablierten Formen von Vorausverfügungen, wie Patientenverfügungen und Behandlungsvereinbarungen, besteht darin, dass Nutzer in einer Odysseus-Verfügung festlegen, in welchen zukünftigen Situationen sie gegen ihren natürlichen Willen behandelt werden wollen. Dieser Aspekt wird in der Medizinethik und in den Rechtswissenschaften kontrovers diskutiert.

  1. Mental health service users’ perspectives on psychiatric advance directives: a systematic review.

    E. Braun A. S. Gaillard J. Vollmann J. Gather
    Link to article
    Objective: Psychiatric advance directives (PADs) are documents that allow users of mental health services to express their preferences for treatment in future mental health crises. To increase the use of PADs in psychiatric practice, it is helpful to consider how service users view PADs and the factors that facilitate or hinder PAD creation and implementation. A systematic review of the empirical literature on this topic may help inform evidence-based policy making. Methods: A systematic review concordant with PRISMA guidelines was conducted. Relevant electronic databases were searched up to July 2, 2021. Articles containing original empirical data on service users’ perspectives on PADs were included. Data were analyzed thematically, tabulated, and narratively synthesized. Results: Fifty-three articles were identified and included. The following categories were identified: general preferences regarding factors such as legal force and revocability; benefits of PADs at the personal, treatment-related, and social levels; challenges and barriers concerning PAD creation and application; and possible and experienced facilitators of PAD creation. Conclusions: Users of mental health services are highly interested in PADs and regard them as tools to improve their involvement in care. They generally prefer legally binding PADs that can be revoked only when users are competent to consent. Barriers reported by service users were mainly related to the creation and application of PADs, and support in PAD creation was the most important facilitator identified. The involvement of mental health professionals in creating PADs appears essential to realize the benefits of PADs and to reduce barriers to their use.

  1. The influence of mental health professionals‘ attitudes and personality traits on decision-​making around coercion. Results from an experimental quantitative survey using case vignettes.

    Scholten, M. Bottlender, R. Juckel, G. Gather, J.
    Link to article
    Research on coercion in mental healthcare has recently shifted to the investigation of subjective aspects, both on the side of the people with mental disorders affected and the staff members involved. In this context, the role of personality traits and attitudes of staff members in decision-making around coercion is increasingly being assessed. This study aimed to examine the role of staff attitudes towards coercion and staff members’ personality traits in decision-making around coercion in an experimental setting.Methods: We assessed the attitudes towards coercion and (general) personality traits of mental health professionals in psychiatric hospitals with a quantitative survey. Furthermore, we developed case vignettes representing cases in a ‘grey zone’ and included them in the survey to assess staff members’ decisions about coercion in specific situations. Results: A general approving attitude towards coercion significantly influenced decisions around coercion in individual cases—resulting in a more likely approval of applying coercion in the cases described in the vignettes. Personality traits did not seem to be relevant in this regard. Conclusion: Strategies to reduce coercion in mental healthcare institutions should focus more on the role of staff attitudes and encourage staff members to reflect on them critically.

  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). https://doi.org/10.3389/fpsyt.2020.573240
    Link to article
    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.
    Link to article
    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
    Link to article
    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
    Link to article
    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. Combining Supported Decision-​Making with Competence Assessment: A Way to Protect Persons with Impaired Decision-​Making Capacity against Undue Influence

    Scholten, M. E. Braun J. Gather 2021. Combining Supported Decision-​Making with Competence Assessment: A Way to Protect Persons with Impaired Decision-​Making Capacity against Undue Influence The American Journal of Bioethics, 21:11, 45-​47, https://doi.org/10.1080/15265161.2021.1980133

    Link to article
    This is a commentary on an article by Andrew Peterson, Emily Largent and Jason Karlawish on supported decision-making (SDM) in people with dynamic impairments of decision-making capacity (DMC). We argue that Peterson and colleagues fail to address convincingly the concern that supported decision-making may render people with impaired DMC vulnerable to undue influence. We propose our “combined supported decision-making model” as a way to address this concern. The combined SDM model employs a functional and time- and task-indexed DMC assessment as an allocation and success criterion for SDM: SDM is necessary when a person’s level of DMC falls below the threshold at which she can make meaningful treatment decisions, and successful when it raises the person’s level of DMC above this threshold. The model reduces the risk of undue influence by maintaining a clear distribution of responsibility: when SDM is successful, responsibility for the treatment decision is accorded to the person who is supported; and when a person’s DMC remains below the threshold despite SDM, responsibility is accorded to a substitute decision-maker.

  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.
    Link to article
    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

    Gather, J. 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. https://doi.org/10.1016/j.ijlp.2020.101615
    Link to article
    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). https://doi.org/10.3389/fpsyt.2020.538107
    Link to article
    “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. 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
    Link to article
    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

    Link to article
    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

    Link to article
    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

    Link to article
    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. 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
    Link to article
    Menschen mit körperlicher oder geistiger Behinderung haben das gleiche Recht wie alle anderen Menschen auf eine an ihren individuellen Bedürfnissen orientierte, bestmögliche medizinische Diagnostik und Behandlung (Zentrale Ethikkommission bei der Bundesärztekammer 2010). Im hier zu diskutierenden Fall eines 25-jährigen Patienten mit einer in Folge eines frühkindlichen Hirnschadens eingetretenen schweren geistigen und körperlichen Behinderung ist mit einem bösartigen Tumor des Hodens eine schwere und lebensbedrohliche Erkrankung diagnostiziert worden, die zum Zeitpunkt der Diagnosestellung als kurativ behandelbar eingestuft wird. Eine leitliniengerechte und aus medizinischer Sicht indizierte Therapie besteht offenbar zum einen aus einer chirurgischen Tumorentfernung sowie zum anderen – bei im Verlauf eingetretener Metastasierung – aus 4 Zyklen Chemotherapie über 5 Tage für jeweils 24 Stunden.

  1. Anwendung von Zwang im Maßregelvollzug

    Gather, J. S. Gerritsen M. Scholten B. Schiffer
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  1. Das Verhältnis von Polizei und Psychiatrie aus der Sicht von psychiatrischen Professionellen. Ergebnisse aus einer explorativen qualitativ-​empirischen Interviewstudie.

    Efkemann, S. A. Gather, J. Juckel, G. Feltes, T. 2023. Das Verhältnis von Polizei und Psychiatrie aus der Sicht von psychiatrischen Professionellen. Ergebnisse aus einer explorativen qualitativ-​empirischen Interviewstudie. Recht & Psychiatrie 41: 206-​213.  https://doi.org/10.1486/rp-​04-​2023_02
    Link to article
    Hintergrund: Einsätze mit Personen mit psychischen Erkrankungen stellen einen wesentlichen Anteil der polizeilichen Tätigkeit dar. Dabei kommt es auch regelmäßig zur Zusammenarbeit von Polizei und psychiatrischen Kliniken, wobei sich beide Einrichtungen in einem Spannungsfeld aus Gefahrenabwehr einerseits und Hilfeleistung andererseits bewegen. Methodik: Die hier vorgestellten Ergebnisse wurden im Rahmen einer qualitativ-empirischen Interviewstudie zu Polizeieinsätzen im psychiatrischen Kontext erhoben. Hierzu wurden teilstrukturierte Interviews mit n = 10 psychiatrischen Professionellen sowie n = 3 Experteninterviews mit Polizeibeamten geführt. Ergebnisse/Diskussion: Die Zusammenarbeit von Polizei und Psychiatrie ist gekennzeichnet durch ein Hadern der jeweiligen Berufsgruppen mit dem eigenen Rollenverständnis. Es kommt zu einer impliziten Rollenverteilung, in der die Polizei den Aspekt der Sicherheit und die Psychiatrie den Aspekt der Fürsorge übernimmt. Hierdurch kommt es zu einer Distanzierung von Polizei und Psychiatrie, die vor allem in eskalativen Situationen ein zusätzliches Konfliktpotenzial birgt.