Implementation of self‐binding directives: recommendations based on expert consensus and input by stakeholders in three European countries

Scholten, Matthé; Efkemann, Simone Agnes; Faissner, Mirjam; Finke, Marleen; Gather, Jakov; Gergel, Tania; Gieselmann, Astrid; Ham, Lia van der; Juckel, Georg; Melle, Anne Laura van; Owen, Gareth; Potthoff, Sarah; Stephenson, Lucy; Szmukler, George; Vellinga, Astrid; Vollmann, Jochen; Voskes, Yolande; Werning, Anna; Widdershoven, Guy

doi:10.1002/wps.21095

Cited by 4 publications

(2 citation statements)

References 8 publications

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“…The implementation issues regarding SBDs thus seem not to go beyond those regarding psychiatric advance directives. This suggests that the implementation of SBDs can be promoted by raising awareness among service users and professionals, creating a technical infrastructure ensuring SBD accessibility, developing training modules for professionals, offering professional support for SBD completion, involving persons of trust in SBD completion and activation, and developing guidance for service users in the form of SBD templates and resource materials [ 22 , 28 , 29 ].…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2023

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Background 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. Aims The aim of the study was to identify opportunities and challenges of SBDs perceived by stakeholders who have personal or professional experience with legally enforceable SBDs. Methods Data collection was carried out in the Netherlands from February 2020 to October 2021 by means of semi-structured interviews. Participants were selected through purposive sampling and snowball methods. Interviews were conducted with mental health service users (n = 7), professionals (n = 13), and an expert on SBD policy (n = 1), resulting in a total number of 21 interviews. The data were analyzed thematically. Results Perceived benefits of SBDs included increased autonomy, improvement of the therapeutic relationship, possibility of early intervention and prevention of harm, prevention of compulsory care, reduction of the duration of compulsory care and recovery, mitigation of negative experiences around compulsory care, and guidance for professionals in providing compulsory care. Perceived risks included infeasibility of SBD instructions, difficulty in decision-making around SBD activation, limited accessibility of SBDs, disappointment of service users due to non-compliance with SBDs, and limited evaluation and updating of SBD content. Barriers to SBD completion included lack of knowledge of SBDs among professionals, lack of motivation or insight among service users, and lack of professional support for SBD completion. Facilitators of SBD completion and activation included support for SBD completion, involvement of relatives and peer experts, specification of SBD content, and evaluation of compulsory care and SBD content. The new legal framework was regarded as having both positive and negative effects on SBD implementation. Conclusions Stakeholders who have personal or professional experience with legally enforceable SBDs perceive SBDs as having important benefits and tend not to articulate the fundamental ethical concerns about SBDs which can be found in the ethics and legal literature. Instead, they perceive ethical and practical challenges that can be addressed through the implementation of suitable safeguards.

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Section: Discussionmentioning

confidence: 99%

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

et al. 2023

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“…The possibility of undue influence during SBD completion, for example, can be addressed by including a person of trust (e.g., a relative) or a neutral party (e.g., a peer support worker) in the drafting process. Recommendations for safeguards and due care criteria to address challenges in SBD implementation have been given in the literature [ 41 ].…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2023

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Background 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. Aims This article aims to foster an international exchange on SBDs by comparing recent empirical findings on stakeholders’ views on the opportunities and challenges of SBDs from Germany, the Netherlands, and the United Kingdom. Method Comparisons between the empirical findings were drawn using a structured expert consensus process. Results 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. Conclusions Stakeholders tend to see the implementation of SBDs as ethically desirable, provided that the associated challenges are addressed.

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What Is Coercion and Can Its Use Be Justified in Mental Healthcare? An Ethical Analysis

Hempeler,

Scholten,

Werning

et al. 2024

Coercion and Violence in Mental Health Settings

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The use of coercion within mental healthcare raises many ethically relevant questions. These include the analytical question about which actions amount to coercion, and the normative question whether and in which situations the use of coercion is justified. This chapter aims to provide an overview of answers to these questions. In answer to the analytical question, we discuss the conceptual distinction between formal and informal coercion. While formal coercion includes interventions that are carried out against the will of service users, informal coercion aims at influencing the will and decision-making of service users to enhance compliance with recommended treatment or social rules. In answer to the normative question, we will differentiate two different argumentative strategies: one based on the harm principle and one based on soft paternalism. We also discuss a third position, which holds that the use of coercion is never justified. The chapter closes by introducing self-binding directives, a type of psychiatric advance directive, as a possible way to reconcile autonomy and coercion.

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Implementation of self‐binding directives: recommendations based on expert consensus and input by stakeholders in three European countries

Cited by 4 publications

References 8 publications

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

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

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

What Is Coercion and Can Its Use Be Justified in Mental Healthcare? An Ethical Analysis

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