Moral dilemmas in contact-based care:The relevance of Moral Case Deliberation for forensic psychiatry

Currently, forensic psychiatry shows a shift from a control-based to a contact-based approach. Working from contact may, however, entail new moral questions and dilemmas. How to secure safety when focusing on contact? Does contact imply being physically close to the patient, or should one refrain from intimate relations? In order to help care professionals to deal with these moral issues, clinical ethics support can be useful. A specific approach in clinical ethics support is moral case deliberation (MCD). An MCD is a structured dialogue between professionals on a moral issue they experience in practice, structured by a conversation method and guided by a facilitator. In this article, we describe the background and procedures of MCD. Furthermore, we present a case example in which care professionals reflect on the moral question of whether provision of care in forensic psychiatry may entail physical closeness. The MCD shows that an open conversation results in a better understanding of different perspectives and creates the basis for finding a joint way to proceed in the case. We conclude that MCD can enable professionals to reflect on moral issues and develop shared values in forensic psychiatry

Symptomatic and Functional recovery: Does symptom severity affect the recovery of executive functioning in people with a psychotic disorder?

Background:Recovery in psychotic disorder patients is a multidimensional concept that can include personal, symptomatic, societal and functional recovery. Here we define Functional Recovery (FR) as recovery or compensation after the loss or impairment of skills in different cognitive functions. Some of the most impaired cognitive functions in psychosis are the executive functions, whose impairment in people with a psychotic disorder can produce problems that are difficult to overcome, partly because treatment often focuses only on Symptomatic Recovery (SR). Although symptom severity may be a risk factor for longstanding impairments of executive functioning, the association is not always found. To date, there has been little research on the association between the 2.MethodThis study is part of the UP’S study, a longitudinal cohort study of patients with a psychotic disorder. The Behaviour Rating Inventory of Executive Functioning Adult version (BRIEF-A) was used to measure FR at baseline and after 1 year. SR was measured using the Positive and Negative Symptom Scale-Remission (PANSS-R), also at baseline and 1 year? At both time points, correlations were computed as cross-sectional analyses. For the longitudinal analysis, the difference scores were used to calculate generalized linear models. Model selection was based on the Wald-Chi square test.Results323 people were included for the baseline assessment of the UP’S study, 163 of whom had completed the T1 follow-up measurement at the time of this study. We found a moderate association between PANSS-R baseline scores and BRIEF-A baseline scores (β=3.76). While there was also an association between the PANSS-R score at baseline and the BRIEF-A difference scores (β=1.67), we found no association between the PANSS-R difference scores and the BRIEF-A differences scores.ConclusionOur finding that less overall symptom severity was associated with 1 year improvement in executive functioning suggests that symptom severity could be a way of improving executive functioning over a year. However, as no link was found within the year between changes in symptoms and changes in executive functioning, it is possible that symptom severity does not have an immediate effect on executive functioning, but that its effect is delayed. This leaves scope for targeted interventions to improve executive functioning, and thus functional recovery

The Active Recovery Triad monitor:Evaluation of a model fidelity scale for recovery-oriented care in long-term mental health care settings

Objective The Active Recovery Triad (ART) model is a recently developed care model for people who are admitted to an institutional setting for several years and receive 24-h mental health care and support. This study focuses on the ART monitor, a model fidelity scale that measures the degree of compliance with the ART model. Our aim is to evaluate the psychometric properties of the ART monitor and to further improve the instrument. Methods Fifteen teams at the start (n = 7, group 1) or in the process (6 months to three years) of implementing care according to the ART model (n = 8, group 2) were audited using the ART monitor. Auditors were trained care workers, peer workers, and family peer workers. Auditors and team members provided feedback on the instrument. The content validity, construct validity and inter-rater reliability of the ART monitor were investigated. Based on the outcomes of these psychometric properties, the ART monitor was finalized. Results Regarding content validity, auditors and teams indicated that they perceived the ART monitor to be a useful instrument. In terms of construct validity, a significant difference (t(13) = 2.53, p < 0.05) was found between teams at the start of the implementation process (group 1, average score of 2.42 (SD = 0.44)) and teams with a longer duration of implementation (group 2, average score of 2.95 (SD = 0.37)). When allowing for a one-point difference in scores, 88% of the items had an inter-rater agreement over 65%. Items with a relatively low inter-rater reliability, in combination with feedback from auditors and teams regarding content validity, provided direction for further improvement and revision of the instrument. Conclusions We concluded that the revised ART monitor is feasible and useful in mental health care practice. However, further evaluation of its psychometric properties will be needed

UP's: A cohort study on recovery in psychotic disorder patients : Design protocol

Recovery is a multidimensional concept, including symptomatic, functional, social, as well as personal recovery. The present study aims at exploring psychosocial and biological determinants of personal recovery, and disentangling time-dependent relationships between personal recovery and the other domains of recovery in a sample of people with a psychotic disorder. A cohort study is conducted with a 10-year follow-up. Personal recovery is assessed using the Recovering Quality of Life Questionnaire (ReQoL) and the Individual Recovery Outcomes Counter (I.ROC). Other domains of recovery are assessed by the Positive and Negative Symptom Scale Remission (PANSS-R), the BRIEF-A and the Social Role Participation Questionnaire—Short version (SRPQ) to assess symptomatic, functional and societal recovery, respectively. In addition, multiple biological, psychological, and social determinants are assessed. This study aims to assess the course of personal recovery, and to find determinants and time-dependent relationships with symptomatic, functional and societal recovery in people with a psychotic disorder. Strengths of the study are the large number of participants, long duration of follow-up, multiple assessments over time, extending beyond the treatment trajectory, and the use of a broad range of biological, psychological, and social determinants

Participatory bioethics research and its social impact: The case of coercion reduction in psychiatry

In this article we address the social value of bioethics research and show how a participatory approach can achieve social impact for a wide audience of stakeholders, involving them in a process of joint moral learning. Participatory bioethics recognizes that research co-produced with stakeholders is more likely to have impact on healthcare practice. These approaches aim to engage multiple stakeholders and interested partners throughout the whole research process, including the framing of ideas and research questions, so that outcomes are tailored to the interests and context, and the type of impact stakeholders envisage. There is an emphasis on realizing social change through the conduct (not merely the results) of the research, and it is believed that the engagement of stakeholders in the research process will promote their intrinsic motivation to change their practice. Another distinctive feature of participatory bioethics research is that its central normative commitment is to reflection and dialogue, not to a particular substantive ethical approach. In reflection and dialogue there is an emphasis on inclusion and the co-production of knowledge. Furthermore, empirical and normative research are combined, and there is a deliberate attempt to give voice to otherwise marginalized positions. This provides a model of social impact which is relevant not only for bioethics research, but also for other areas of health care research. We will show the merits of a participatory approach to bioethics research with a case example. It concerns the reduction of coercion and in particular seclusion in Dutch mental healthcare