Patients legal rights be it in relation to coercive measures or research participation should be of great concern not only but most definitely within forensic mental health. Projects aiming at illustrating and investigating these issues will be posted here.. More to come.
Collaboration contacts:
Søren Birkeland: sbirkeland[a]health.sdu.dk
Forensic Mental Health Research Unit Middelfart (RFM),Department of Regional Health Research, Faculty of Health Science, University of Southern Denmark & Psychiatric dept. Middelfart, Mental Health Services in the Region of Southern Denmark.
Abolition of coercion in mental health services – A European survey of feasibility. Birkeland, S., Steinert, T., Whittington, R. & Gildberg, F. A., 1. maj 2024, I: International Journal of Law and Psychiatry.
Background: In 2019, the Council of Europe agreed to urge member states to take steps toward total abolition of psychiatric coercive measures.
Aims: To test if this aspiration is perceived as realistic and what the alternative would be in the event of a total abolition, we surveyed members of the European FOSTREN network of mental health practitioners and researchers, which is specifically dedicated to exchanging knowledge on reducing psychiatric coercion to its minimum.
Methods: Web-based survey. Categorical responses were analyzed using frequencies, and free text responses were analyzed through thematic analysis.
Results: In total, out of 167 invitations to FOSTREN network members, 76 responded to the survey (Response Rate 45.5%). A minority (31%) of participating experts dedicated to the reduction of psychiatric coercive measures believed a total abolition to be an achievable goal. A commonly held belief was that total abolition is not achievable because mental health disorders are difficult to treat and may cause violence, necessitating coercion, and there is a need to protect the involved persons from harm. Those responding that complete abolition is achievable argued that the consequences of coercion outweigh any gains and indicated that use of advance directives are sufficient as alternatives to coercion.
Conclusion: Of a European group of experts specifically dedicated to the reduction of psychiatric coercion who participated in this questionnaire study, a minority believed a total abolition be an achievable goal. The study adds to the empirical evidence of the feasibility of the aspiration to totally abolish involuntary measures in the mental health services from the perspective of experts.
Variation in opinions on coercion use among mental healthcare professionals: a questionnaire study Birkeland, S., Bogh, S. B., Pedersen, M. L., Harder Kerring, J., Morsø, L., Tingleff, E. & Gildberg, F., 2024, (Accepteret/In press) I: Nordic Journal of Psychiatry.
Introduction: Even if coercive measures are widely applied in psychiatry and have numerous well-knowndrawbacks, there is limited known on the agreement among mental healthcare professionals’ opinions on their use. In a questionnaire study using standardized scenarios, we investigated variation in staff opinions on coercion. Methods: In a web-based survey distributed to staff at three psychiatry hospitals, respondents were asked to consider if and what coercion to use by introducing two hypothetical scenarios involving in voluntary psychiatric admission and in-hospital coercion. Results: One hundred thirty-two out of 601 invited staff members responded to the survey (Response Rate = 22%). There was large variation in participating staff members’ opinions on how to best manage critical situations and what coercive measures were warranted. In the first scenario, 57% of respondents(n = 76) believed that the patient should be involuntarily admitted to hospital while the remaining respondents believed that the situation should be managed otherwise. Regarding the second scenario,62% of respondents responded that some in-hospital coercion should be used. The majority of respondents believed that colleagues would behave similarly (60%) or with a tendency towards more coercion use (34%). Male gender, being nursing staff and having less coercion experience predicted being less inclined to choose involuntary hospital admission. Conclusion: There is a high degree of variation in coercion use. This study suggests that this variation persists despite staff members being confronted with the same standardized situations. There is a need for evidence-based further guidance to minimize coercion in critical mental healthcare situations.
The Danish Court Case Database: a data source in forensic mental health? Pedersen, M. L., Gildberg, F. & Birkeland, S., nov. 2022, I: Scandinavian Journal of Forensic Science.
Grey literature complementing evidence from common scientific sources, such as journals, may serve to provide a broader range of evidence, fill in commercial literature gaps and reduce publication bias in research. However, grey literature from legal sources has
been used only to a limited extent in forensic mental health research. In this paper, we presented the newly established Danish Court Case Database in the light of forensic mental health. A systematic review was conducted and 15 cases focusing on forensic mental health issues were identified. The cases contained information about indictment, explanations and testimonies and also the court’s decision and underlying reasoning. The different included case types provided a broad range of information about current issues in forensic mental health regulation and the interpretation of Danish law. The database is thus a relevant grey source in forensic research.
However, this paper also demonstrated that the database may be improved in terms of its current coverage and ease of use.
Birkeland, S., Berzins K., Baker J., Mattson T., Søvig, KH., Gildberg FA., 2020 Prohibition on research involving psychiatric patients subject to coercion. Kritisk Juss. 01(51) Status: Published
This paper compares legislation on clinical research conducted on patients subject to coercion in the Scandinavian countries and the UK, examines it from a human rights perspective, and problematizes the Danish legal model as the only one employing a total ban on this kind of research. Reference is made to the consequences to evidence-based psychiatric care improvements and international ethical principle statements generally entitling psychiatric patients to treatment under similar ethical and scientific conditions as patients with other illnesses, given the absolute premise that the patient does not object to research participation and always retains the right to withdraw.
Birkeland, S. 2019 Coercion and health professional responsibility. Nordisk Sygeplejeforskning. Vol 9. 1 pp. 72-80 Article, peer reviewed, Status: Published.
As is the case in other countries, Danish legislation permits psychiatric coercion in some special situations and health professionals are responsible for only instigating coercive measures when satisfying legal requirements. In this essay, this responsibility is discussed with reference to formal law and case law. It is highligthed that by preventing unlawful utilization, coercion in principle could be considerably reduced. When using coercive measures, nursing staff and other authorized health persons are professionally responsible according to the authorization act’s claim for diligence (Para 17). Nonetheless, contrary to other parts of the healthcare system, patient complaints about application of coercive measures usually are handled as cases about lawfulness only and rarely are managed as malpractice cases about individual health professional responsibility. This suggests a relative gray area. Besides, a great proportion of cases concern documentation issues again drawing attention to the importance of thorough medical records keeping.
Birkeland S. (2017). Threats and Violence in the Lead-up to Psychiatric Mechanical Restraint – a Danish Complaints Audit. Journal of Forensic Psychiatry and Psychology, 1-7. Vol 29, no 1 Article, peer reviewed, Status: Published
Coercive measures like mechanical restraint (MR) are widely used in psychiatry but may collide with bioethical autonomy principles, damage those involved, and harm patient–staff relations. Reductions in usage are desirable and addressing illegitimate MR would be an obvious starting point. As one important reason for instigating MR is dangerous patient behavior this attracts special attention. In this complaints audit the role of threats, violence, and contextual characteristics was examined in decisions concerning MR completed by the Danish Psychiatric Patient Complaint Board system from 2007 to 2014. According to case descriptions, threats and violence were common and sometimes rather serious. Mainly actualized physical violence seemed to justify MR use. However, roughly every sixth patient subject to MR episodes filed a complaint and in one in 25, usage was found unlawful. The interpretation of clinical situations vs. law elements and surrounding coercion legislation needs further investigation as does the impact of, e.g. psychiatry staffing.
Birkeland, S. Gildberg, F.A. 2016 Mental health nursing, mechanical restraint measures and patients’ legal rights. Vol. 2016. No. 10. pp. 8-14. The Open Nursing Journal. Short Communication Article, peer reviewed, Status: Published.
Coercive mechanical restraint (MR) in psychiatry constitutes the perhaps most extensive exception from the common health law requirement for involving patients in health care decisions and achieving their informed consent prior to treatment. Coercive measures and particularly MR seriously collide with patient autonomy principles, pose a particular challenge to psychiatric patients’ legal rights, and put intensified demands on health professional performance. Legal rights principles require rationale for coercive measure use be thoroughly considered and rigorously documented. This article presents an in-principle Danish Psychiatric Complaint Board decision concerning MR use initiated by untrained staff. The case illustrates that, judicially, weight must be put on the patient perspective on course of happenings and especially when health professional documentation is scant, patients’ rights call for taking notice of patient evaluations. Consequently, if it comes out that psychiatric staff failed to pay appropriate consideration for the patient’s mental state, perspective, and expressions, patient response deviations are to be judicially interpreted in this light potentially rendering MR use illegitimated. While specification of law criteria might possibly improve law use and promote patients’ rights, education of psychiatry professionals must address the need for, as far as possible, paying due regard to meeting patient perspectives and participation principles as well as formal law and documentation requirements.