Restraints and seclusion in psychiatry: striking a balance between protection and coercion. Critical overview of international regulations and rulings.

Restraint and seclusion (R&S) measures in psychiatric settings are applied worldwide, despite poor scientific evidence to back up their effectiveness. The medical, ethical and medico-legal implications of coercive interventions are broad-ranging and multifaceted. The review aims to shed a light on the most relevant and meaningful standards that have been laid out by international treaties, supranational institutions (United Nations, Council of Europe, World Health Organization), scientific institutions (American Medical Association, Australian Department of Health), legislative bodies and courts of law. Several court cases are herein expounded upon, with a close focus on meaningful analysis, decisions and conclusions that have laid the groundwork for a different, more restrictive and more clearly defined approach towards R&S imposed upon psychiatric patients. It is reasonable to assume that changing norms, civil rights enforcement, court rulings and new therapeutic options have influenced the use of R&S to such an extent that such measures are among the most strictly regulated in psychiatric practice; health care providers should abide by a strict set of cautionary rules when making the decision to resort to R&S, which must never be put in place as a substitute for patient-centered therapeutic planning. Case law shows that R&S should only be weighed in terms of their effectiveness towards therapeutic goals. Being able to prove that R&S was employed as part of a therapeutic path rather than used to maintain order or to exact punishment may go a long way towards shielding operators against negligence lawsuits and litigation.

A survey of national trends in psychiatric patients found incompetent to stand trial: reasons for the reinstitutionalization of people with serious mental illness in the United States.

OBJECTIVE: Recent information indicates that the number of forensic patients in state hospitals has been increasing, largely driven by an increase in patients referred to state hospitals as incompetent to stand trial (IST). This survey was intended to broaden the understanding of IST population trends on a national level. METHODS: The authors developed a 30-question survey to gather specific information on IST commitments in each state and the District of Columbia. The survey was administered to all 50 states and the District of Columbia via email. Specific individuals identified as primary administrators responsible for the care and evaluation of IST admissions in each state were contacted. RESULTS: A total of 50 out of the 51 jurisdictions contacted completed the survey. Fully 82% of states indicated that referrals for competency evaluation were increasing. Additionally, 78% of respondents thought referrals for competency restoration were increasing. When asked to rank factors that led to an increase, the highest ranked response was inadequate general mental health services in the community. Inadequate crisis services were the second ranked reason. Inadequate number of inpatient psychiatric beds in the community was the third highest, with inadequate assertive community treatment services ranking fourth. CONCLUSIONS: Understanding the national trend and causes behind the recent surge in referrals for IST admissions will benefit states searching for ways to remedy this crisis. Our survey indicates most states are facing this issue, and that it is largely related to insufficient services in the community.

Therapeutic Jurisprudence and Restorative Justice in the United States: The Process of Institutionalization and the Roles of Judges.

The legal systems and the judiciary in many countries have been changed and reformed, with the aim of dispensing justice quicker and more effectively. Some reforms have tried a less adversarial approach to resolving legal disputes, for example, Therapeutic Jurisprudence (TJ) and Restorative Justice (RJ). The objective of this article is to describe how institutionalized these movements are in the United States and the roles played by judges in this process. The data collection involved document analysis, observation of court-hearings, and interviews with 13 judges from several judicial areas involved in TJ and/or RJ judicial proceedings in the United States. Data analysis was undertaken using content analysis and the software NVivo. The results provide evidence that (a) these movements are in a process of divergent change implementation; (b) judges who engage with these approaches act as institutional entrepreneurs; and (c) the judges interviewed can be classified into four roles that are complementary in the promotion of TJ/RJ: promoter, author, convener, and maintainer.

Legal Regulation of Psychosurgery: A Fifty-State Survey.

Following the rise and fall of lobotomy, a majority of U.S. states took legislative aim at psychosurgical procedures. This article canvasses, organizes, and analyzes the existing body of United States statutes and regulations mentioning psychosurgery. Many states regulate psychosurgery without defining the term; existing definitions are imprecise, but many would arguably apply to contemporary procedures like deep brain stimulation. Common to many states are restrictions on surrogate consent to psychosurgery, codifications of patients' consent or refusal rights, and situation-specific bans on the practice targeting certain contexts of vulnerability. Many states have only a handful of scattered laws bearing on psychosurgery, but a few have wide-ranging and well-integrated regulatory regimes. In reviewing these laws we perceive much room for harmonization and modernization. Greater consistency in protecting vulnerable persons from troubling uses of psychosurgery is achievable even alongside an effort to remove undue legal obstacles impeding patient access to potentially therapeutic procedures. Our hope in surveying current psychosurgery law is to inaugurate a conversation on how best to shape its future.

Deviancy, Dependency, and Disability: the Forgotten History of Eugenics and Mass Incarceration.

Three widely discussed explanations of the punitive carceral state are racism, harsh drug laws, and prosecutorial overreach. These three narratives, however, only partially explain how our correctional system expanded to its current overcrowded state. Neglected in our discussion of mass incarceration is our largely forgotten history of the long-term, wholesale institutionalization of the disabled. This form of mass detention, motivated by a continuing application of eugenics and persistent class-based discrimination, is an important part of our history of imprisonment, one that has shaped key contours of our current supersized correctional system. Only by fully exploring this forgotten narrative of long-term detention and isolation will policy makers be able to understand, diagnose, and solve the crisis of mass incarceration.

Views on the Effects of the Spanish Dependency Law on Caregivers' Quality of Life Using Concept Mapping.

In 2006 the Spanish Dependency Law established new rights for people in situation of dependency. The impact of the Law could have also affected the quality of life of their carers. This study aims to understand how the Law may have influenced caregivers' quality of life through their own perceptions and those of Primary Health Care professionals, and to compare both perspectives. The study used Concept Mapping, a mixed methods technique. In total, 16 caregivers and 21 professionals participated. Both groups identified a mix of positive and negative effects. Uncertainties and delays in granting benefits were reported. However, several advantages were identified, such as the possibility of sharing the burden of care, thus reducing its physical, mental and social consequences, while at the same time being able to maintain responsibility. Most of the mechanisms identified were common to both caregivers and professionals; the most notable differences were that the latter attached more importance to economic support and less to the negative effects of implementation of the Law. This study reveals positive effects of the Law on caregivers' quality of life and the potential for improvement of some negative aspects in its implementation related with the context of austerity.

[ELDERLY ADULTS IN NURSING HOMES IN THE PROVINCE OF CORDOBA: OBJECTS OF CARE OR LEGAL SUBJECTS?]. / Adultos mayores en establecimientos geriátricos en la provincia de Córdoba: objeto de cuidado o sujetos de derecho?

Argentina is among the Ibero-American countries with the greatest old age population, and is going through a process of advanced demographic transition. Elderly adults have long been considered a vulnerable group in need of care. The purpose of this work was to problematize the conceptions underlying the care given to the elderly in nursing homes, and the possible slides this involves from a human rights stance. An approach to this problem was built up by resorting to secondary documentary sources and interviews with key informants located in institutions for the elderly in the Province of Cordoba. This approach revealed a predominantly asylum-oriented conception centered on caring for others as objects, and a noticeable lack of consideration for the elderly as legal subjects, visible in numerous serious infringements of human rights, mostly silenced and rendered invisible. It seems that to overcome these situations it will be necessary not merely to review legal loopholes and current programs but also to reconsider the place given to the elderly in society. Regardless of their age and other social differences, the elderly require the same opportunities to claim full respect and exercise their human rights and fundamental freedoms.

'A disease that makes criminals': encephalitis lethargica (EL) in children, mental deficiency, and the 1927 Mental Deficiency Act.

Encephalitis lethargica (EL) was an epidemic that spread throughout Europe and North America during the 1920s. Although it could affect both children and adults alike, there were a strange series of chronic symptoms that exclusively affected its younger victims: behavioural disorders which could include criminal propensities. In Britain, which had passed the Mental Deficiency Act in 1913, the concept of mental deficiency was well understood when EL appeared. However, EL defied some of the basic precepts of mental deficiency to such an extent that amendments were made to the Mental Deficiency Act in 1927. I examine how clinicians approached the sequelae of EL in children during the 1920s, and how their work and the social problem that these children posed eventually led to changes in the legal definition of mental deficiency. EL serves as an example of how diseases are not only framed by the society they emerge in, but can also help to frame and change existing concepts within that same society.

United States Department of Justice findings letters in psychiatric hospital CRIPA cases: an aid or a distraction?

The Civil Rights of Institutionalized Persons Act (CRIPA) of 1980 allows the United States Department of Justice (DOJ) to investigate and file lawsuits against certain institutions, including state and county psychiatric hospitals, where individuals within may face unconstitutional conditions. Subsequent to an investigation and before negotiations or litigation, the state is provided a Findings Letter generated by the DOJ that generally contains recommended remedial measures. It has never been determined to what extent a Findings Letter provides a state with a recommendation specific to the institution for corrective action before the state enters into negotiations with the DOJ. Three study groups were derived from a sample of 15 Findings Letters written to states concerning their psychiatric hospitals between 2003 and 2009. The individual recommended remedial measures, labeled texts of interest (TOI), were identified, and the degree of overlap among the Findings Letters was determined. To a surprising degree, TOIs overlapped to various extents, from exact copies of text to paraphrased versions, in Findings Letters written between 2003 and 2009 to different states and for multiple state hospitals in the same state. The recommended remedial measures provided in the DOJ's Findings Letters are not specific to each state hospital's deficiencies. The Findings Letters offer limited guidance to the state on how to remedy the deficiencies before negotiating with the DOJ. This lack of specificity causes inefficient and delayed remediation of unconstitutional conditions and other deficiencies in care and treatment in psychiatric hospitals. While the current process most often leads to improvements in state hospitals, it is a costly, inefficient remedy, despite the possibility of alternative remedial processes of less expensive and equal or greater effectiveness.

Commentary: Evaluations of DOJ investigations of state psychiatric hospitals.

Geller and Lee use their study of Findings Letters, sent by the United States Department of Justice (DOJ) to the states after investigations of state psychiatric hospitals, as a way to study the investigation process itself. Their article serves as a useful program evaluation for DOJ and suggests important ways in which the investigations could be improved.

Perceptions of institutional elder neglect in civil court.

Perception of institutional elder neglect (IEN) in civil court was investigated. Experiment 1 participants (N = 162) read an IEN trial summary in which alleged victim testimony was presented or not. Victim testimony increased the likelihood of ruling for the plaintiff, partially mediated by credibility of witnesses for each side. Experiment 2 (N = 68) included a condition with testimony from the victim's floor-mate. Likelihood of ruling for the victim: victim = floor-mate > no testimony, was mediated by perceived credibility of the plaintiff's case. Results are discussed in terms of the importance of alleged victim testimony in IEN cases.

North Carolina's institutional bias: enforcing the ADA's integration mandate.

Last year, the US Department of Justice determined that the state of North Carolina was violating the Americans with Disabilities Act by inappropriately institutionalizing people in adult care homes rather than providing them with housing and appropriate supports in the community. The state's long-standing institutional bias must now be corrected.