اعمال فشار رسمی در محیط بیماران حاد بستری - دانش و نگرش برگزار شده توسط متخصصان بهداشت روانی

This pilot study aimed at investigating how mental health professionals on acute psychiatric wards recognize different levels of formal and informal coercions and treatment pressures as well as their attitude towards these interventions. An explorative cross-sectional survey among mental health professionals (N=39) was conducted using a questionnaire that consisted of 15 vignettes describing typical clinical situations on five different stages of the continuum of coercion. Low levels of coercion are recognized adequately while higher levels are grossly underestimated. The degree of coercion inherent to interventions comprising persuasion and leverage was underestimated by professionals with a positive attitude and overestimated by those with a negative attitude towards the respective interventions. No associations of the ability to recognize different levels of coercion with ward or staff related variables were found. Higher knowledge on ambiguous variations of coercive interventions seems to foster more balanced reflections about their ethical implications. Advanced understanding of influencing factors of professionals׳ attitudes towards coercion could lead to improved training of professionals in utilizing interventions to enhance treatment adherence in an informed and ethical way.

Informal coercion and treatment pressures (for definitions, see Table 1) are frequently used in community mental health care and have gained increasing clinical and scientific attention recently (Jaeger and Rossler, 2010, Molodynski et al., 2010 and Burns et al., 2011). In inpatient setting informal coercion is also existent but in the light of formal coercion practices it is prone to be clinically and scientifically ignored (Gaskin et al., 2007 and Scanlan, 2010). If applied uncritically informal coercion such as persuasion, leverage, offers and threats hold the risk of increasing patients׳ perceived coercion thereby interfering with the therapeutic relationship (Sheehan and Burns, 2011 and Theodoridou et al., 2012). From an ethical perspective it is obligatory to consider carefully if a treatment pressure can be justified in the light of the caring therapeutic relationship and the professional duties (Dunn et al., 2012). If consequently reflected, those interventions can be embedded in the person-centered care of choice (Geller, 2012). Staffs׳ attitudes on and knowledge about formal and informal coercion are fundamental to these considerations but to date there is only limited evidence available. Attitudes towards formal coercive measures depend amongst others on external factors such as individually experienced treatment practices and internal factors such as emotional exhaustion and therapeutic optimism (Happell and Koehn, 2011). With respect to patient-related factors, staff is most likely to accept highly restrictive formal interventions when patients are physically violent (Wynn et al., 2011). Attitudes of patients towards informally coercion interventions strongly depend on contextual factors (Jaeger and Rossler, 2009). To date there is no data on attitudes of professionals towards informal coercion available.

This study identifies a clear deficit in knowledge and the ability to identify informal coercion in acute inpatient setting where formal coercion is prevalent. There is also an association with attitudes towards interventions that include informal coercion. Interactions with higher degrees of informal coercion are underestimated and less accepted than interventions with lower levels of coercion. Education and training about the factual and ethical dimensions of informal coercion would be a prerequisite to help mental health professionals if necessary to employ interventions including persuasion, leverage and offers in an adequate way according to ethical pathways (Dunn et al., 2012), and to reduce unconscious or uncritical application that might damage the therapeutic relationship.