Experiences of involuntary psychiatric admission decision-making: a systematic review and meta-synthesis of the perspectives of service users, informal carers, and professionals
Introduction
Involuntary admission is used globally in psychiatry (Zhang, Mellsop, Brink, & Wang, 2015). Although it has a wide range of applications (Walker et al., 2019), the most common rationales are diagnosed mental illnesses, imminent danger to oneself or others, a manifest link between illness and danger, and a need for treatment (Davidson et al., 2016; Zhang et al., 2015). The assessments are usually conducted by doctors in clinical settings and the involuntary admission is often decided by doctors and family members regardless of what the person with psychosocial disabilities may prefer. These attitudes and practices have been criticized for overly skewing to the medical model and emphasizing a paternalistic approach (United Nations Human Rights Council, 2017). Involuntary admission raises human rights concerns, especially in the light of Convention on the Rights of Persons with Disabilities (CRPD).
CRPD, ratified by 182 countries, informs laws, services, and clinical protocols governing mental health practices (United Nations Department of Economic and Social Affairs, 2020; United Nations General Assembly, 2006). CRPD asks member states to view people with disabilities from the perspective of a bearer of human rights, and asserts that their rights, will, and preferences should always be respected (United Nations, 2007). Article 12 of CRPD recognizes that “persons with disabilities enjoy legal capacity on an equal basis with others in all aspects of life.” It also asks state parties to take appropriate measures to provide access by persons with disabilities to the support they may require in exercising this legal capacity. The General Comment 1 under Article 12 interprets this further to affirm everyone should be treated as having equal decision-making competency at all times. Its mandate calls for seeking and ascertaining the person's will and preferences; the Comment states that this requires “both the abolition of substitute decision-making regimes and the development of supported decision-making alternatives” (United Nations General Assembly, 2006, para. 24). When a person, even with all available support, is unable to make a decision, the clinician or the supporters need to apply “best interpretation of the individual's will and preference” instead of traditional “best interests.” This former standard requires communication of the individual's choices, including via nonverbal communication, while the latter relies on judgment by an external person (United Nations General Assembly, 2006, para. 24). Article 12 and General Comment 1 are heavily contested among service users, clinicians, and policy makers (Freeman et al., 2015; Mahomed, Stein, & Patel, 2018). Many member states that ratified CRPD issued reservations and limited its application to allow substituted decision-making (McSherry & Wilson, 2015). The major controversy has been around its impact on emergency psychiatry, including involuntary psychiatric hospitalization and medication. For example, clinicians are concerned that they will no longer be able to protect service users (Scholten & Gather, 2018). Others raise difficulties in considering every service user's preferences (Dawson, 2015). These attitudes may come from paternalism, based on the assumption that people with psychosocial disabilities are helpless and dangerous, and reluctance around giving power to mental health service users (Spandler, Anderson, & Sapey, 2015), which is nurtured through the current medical approach and the idea of protection. Mahomed et al. (2018) interviewed stakeholders to explore tensions regarding implementation of universal legal capacity, especially in mental health services. The results showed that political and epistemological differences among stakeholders had impact on opinions on legal capacity and its practical applications. There was a broad agreement that involuntary mental health treatment is overutilized and that more participatory dialogues are needed (Mahomed et al., 2018).
CRPD asks member states to move away from the current medical approach to adopt the social approach. The CRPD training guide encourages the social approach and states that “This model puts the person at the center, not his/her impairment, recognizing the values and rights of persons with disabilities as part of society” (Pillay, 2014, p. 9). The social approach views disability as the interaction between a person's individual makeup and their social environment, and it emphasizes addressing barriers and social adaptations (Oliver, 2004). The social approach developed as the social model of disability, which has many variations; for example, the US literature focuses more on issues of “psychology, identity, personal affirmation and moral development” while the UK literature focuses on issues of “equality in political and material participation” (Meekosha, 2004). Any form of the social model of disability takes participation in everyday life, in mental health services, or in policies as a key aspect (Owens, 2015). People are socially embedded and form their identity through social relationships and intersecting social determinants such as gender and class (Mackenzie & Stoljar, 2000). The social approach asks us to reconsider how we understand autonomy. The current model of autonomy is called “individual autonomy,” and it is based on the assumption that individuals are rational, independent, and individualistic and that when they have enough information they can make a decision (informed consent) (Walter & Ross, 2014). Anyone who cannot make decisions in this model is considered not to be autonomous and to need guardianship; thus, the involuntary admission systems were created. Instead, we can ground our understanding of autonomy in the social approach and refer to relational autonomy, which situates autonomy within the relational and social nature of an individual's life (Arstein-Kerslake, 2017; Christman, 2004). Within a relational understanding of autonomy, decisional capacities are dynamic in nature, changing with the meanings and structures of an individual's relationships (Ells, Hunt, Chambers-Evans, & Care, 2011). With the social approach and relational autonomy, we can attend to rights, such as the right to health and the right to live independently, to realize legal capacity of the person. By combining rights and legal capacity to provide a range of care options and formal and informal decision-making supports, we can reform mental health services to move away from substituted decision-making for the person with psychosocial disabilities (Arstein-Kerslake, 2017; McSherry & Wilson, 2015).
Reviews have looked into experiences during involuntary admission and reduction of involuntary admissions. Regarding service users' experiences during involuntary admission, an existing systematic review shows that participation in decisions, the feeling of being cared for, and having a sense of identity led to positive experiences (Katsakou & Priebe, 2007). Another review (Seed, Fox, & Berry, 2016b) found that social circumstances, certain mental health treatment practices, and the clinician–patient relationship influenced the service users' involuntary admissions experiences, which were categorized as a relief, loss, or trauma. Those who received person-centered and individualized treatments experienced involuntary admission as a sanctuary, and they were more comfortable with clinicians taking control (Seed et al., 2016b). A review of informal carers' (e.g. families') perspectives on mental health services indicates that family members want to be acknowledged and respected as official partners in care. The review also suggests that recognizing them as partners in care can lead to effective care, but it can also lead to disagreement or human rights oppression of service users (Rowe, 2012). A review looked into measures to prevent and reduce coercion in mental health services and identified the following categories: “legal change,” “government policy change,” and “hospital- and community-based changes to practice.” The study also identified prominent measures such as “Six Core Strategies for Restraint Minimization,” “No Force First” initiatives, advance planning for crises, open door policies in hospitals and other facilities, crisis respite houses, family-based interventions, measures to release people from communal settings and family homes in which they were deprived of liberty, and the use of non-legal advocacy (Gooding, McSherry, & Roper, 2020).
Exploring context and relationship between service users, informal carers, and professionals in involuntary admission decision-making and exploring service users' will and preference is necessary to recognize and implement relational autonomy and develop supported decision-making models. It is also important to provide global and layered perspectives via qualitative literature in many disciplines and languages through reflexive analysis.
The objectives of this review are to
- 1.
Describe the context and relationship in which service users, informal carers, and professionals decided upon involuntary psychiatric admission.
- 2.
Describe their experiences during the subsequent involuntary admission.
- 3.
Explore the kind of supports that service users require to stay autonomous during situations 1 and 2.
Section snippets
Study design
This review included articles that performed original qualitative or mixed methods (focusing on the qualitative results) studies, which explored experiences of involuntary psychiatric admission among adults. This review excluded articles that: a) did not relate to inpatient psychiatric involuntary admissions (such as palliative care, physical conditions, forensic psychiatry, or nursing homes); b) targeted both involuntary and voluntary patients without separating their analysis; and c) focused
Included studies
Overall, 37 articles (33 studies) from 11 countries (Australia, Austria, Brazil, Denmark, Ireland, Japan, the Netherlands, Norway, Sweden, Taiwan, and the United Kingdom) were included in this review. There were 24 articles focusing on service users (involving 731 service users), five articles focusing on informal carers (involving 100 family members such as parents, children and siblings, partners, and relatives), 11 articles focusing on professionals (involving 291 professionals, including
Discussion
This study qualitatively reviewed the context and relationships within which involuntary psychiatric admission was decided and the experiences throughout the involuntary admission from the perspectives of service users, informal carers, and professionals. All the stakeholders had their own reasoning; however, professionals tended to dominate the communication in decision-making, which belittled service users and made families bystanders. Professionals often assumed that the service users were
Conclusions
At involuntary psychiatric admission decision-making and throughout the involuntary admission, lack of communication and a power imbalance marginalized service users, which was exacerbated by the professionals who rationalized coercion and family who relied heavily on hospital admission. Any support service users can obtain to overcome these challenges, combined with a variety of community services, will respect service users' autonomy. Service users need to speak, be informed, participate, and
Declaration of Competing Interest
The authors do not have any conflicting interests to declare.
Acknowledgements
We would like to thank Dr. Vikram Patel and Dr. Toshiaki Baba for their advice on the study protocol. We are also grateful for Ms. Miki Kuwabara for sifting the literatures.
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