Intersectional Discrimination in Mental Health Care: A Systematic Review With Qualitative Evidence Synthesis.

OBJECTIVE: Discriminatory practices in mental health care undermine the right to health of marginalized service users. Intersectional approaches enable consideration of multiple forms of discrimination that occur simultaneously and remain invisible in single-axis analyses. The authors reviewed intersectionality-informed qualitative literature on discriminatory practices in mental health care to better understand the experiences of marginalized service users and their evaluation and navigation of mental health care. METHODS: The authors searched EBSCO, PubMed, MEDLINE, and JSTOR for studies published January 1, 1989-December 14, 2022. Qualitative and mixed-methods studies were eligible if they used an intersectional approach to examine discrimination (experiences, mechanisms, and coping strategies) in mental health care settings from the perspective of service users and providers. A qualitative evidence synthesis with thematic analysis was performed. RESULTS: Fifteen studies were included in the qualitative evidence synthesis. These studies represented the experiences of 383 service users and 114 providers. Most studies considered the intersections of mental illness with race, sexual and gender diversity, or both and were performed in the United States or Canada. Four themes were identified: the relevance of social identity in mental health care settings, knowledge-related concerns in mental health care, microaggressions in clinical practice, and service users' responses to discriminatory practices. CONCLUSIONS: Discriminatory practices in mental health care lead to specific barriers to care for multiply marginalized service users. Universities and hospitals may improve care by building competencies in recognizing and preventing discrimination through institutionalized training.

Intersectionality as a tool for clinical ethics consultation in mental healthcare.

Bioethics increasingly recognizes the impact of discriminatory practices based on social categories such as race, gender, sexual orientation or ability on clinical practice. Accordingly, major bioethics associations have stressed that identifying and countering structural discrimination in clinical ethics consultations is a professional obligation of clinical ethics consultants. Yet, it is still unclear how clinical ethics consultants can fulfill this obligation. More specifically, clinical ethics needs both theoretical tools to analyze and practical strategies to address structural discrimination within clinical ethics consultations. Intersectionality, a concept developed in Black feminist scholarship, is increasingly considered in bioethical theory. It stresses how social structures and practices determine social positions of privilege and disadvantage in multiple, mutually co-constitutive systems of oppression. This article aims to investigate how intersectionality can contribute to addressing structural discrimination in clinical ethics consultations with a particular focus on mental healthcare. To this end, we critically review existing approaches for clinical ethics consultants to address structural racism in clinical ethics consultations and extend them by intersectional considerations. We argue that intersectionality is a suitable tool to address structural discrimination within clinical ethics consultations and show that it can be practically implemented in two complementary ways: 1) as an analytic approach and 2) as a critical practice.

Research ethics in practice: An analysis of ethical issues encountered in qualitative health research with mental health service users and relatives.

The ethics review of qualitative health research poses various challenges that are due to a mismatch between the current practice of ethics review and the nature of qualitative methodology. The process of obtaining ethics approval for a study by a research ethics committee before the start of a research study has been described as "procedural ethics" and the identification and handling of ethical issues by researchers during the research process as "ethics in practice." While some authors dispute and other authors defend the use of procedural ethics in relation to qualitative health research, there is general agreement that it needs to be supplemented with ethics in practice. This article aims to provide an illustration of research ethics in practice by reflecting on the ways in which we identified and addressed ethical and methodological issues that arose in the context of an interview study with mental health service users and relatives. We describe the challenges we faced and the solutions we found in relation to the potential vulnerability of research participants, the voluntariness of consent, the increase of participant access and the heterogeneity of the sample, the protection of privacy and internal confidentiality, and the consideration of personal and contextual factors.

When Treatment Pressures Become Coercive: A Context-Sensitive Model of Informal Coercion in Mental Healthcare.

Treatment pressures are communicative strategies that mental health professionals use to influence the decision-making of mental health service users and improve their adherence to recommended treatment. Szmukler and Appelbaum describe a spectrum of treatment pressures, which encompasses persuasion, interpersonal leverage, offers and threats, arguing that only a particular type of threat amounts to informal coercion. We contend that this account of informal coercion is insufficiently sensitive to context and fails to recognize the fundamental power imbalance in mental healthcare. Based on a set of counterexamples, we argue that what makes a proposal coercive is not whether service users will actually be made worse off if they reject the proposal, but rather whether they have the justified belief that this is the case. Whether this belief is justified depends on the presence of certain contextual factors, such as strong dependency on professionals and the salient possibility of formal coercion.

[Shared Decision-Making for Patients with Mental Disorders or Cognitive Impairments]. / Shared Decision-Making bei Patient_innen mit psychischen Störungen oder kognitiven Beeinträchtigungen.

Shared Decision-Making for Patients with Mental Disorders or Cognitive Impairments Abstract. Shared Decision-Making (SDM) describes a model of collaborative decision-making that combines the expert knowledge of health professionals and the experiential knowledge of patients. This allows patients to play a more active role in the decision-making process. SDM is also becoming increasingly important in the treatment of persons with mental disorders or cognitive impairments. However, implementation of SDM for this group of patients may face specific challenges, for example, if their decision-making capacity is impaired or if coercion has to be used to prevent acute danger to themselves or others. On the other hand, SDM offers important opportunities in this area. For example, mental health professionals are often more dependent on the patients' experiential knowledge in clinical decision-making than in somatic care. Furthermore, empowerment and a good therapeutic relationship are central aspects in the treatment of people with mental disorders or cognitive impairments, which can be strengthened by SDM. Against the background of these specific challenges, an overview of opportunities for and experiences with SDM in the care of people with mental disorders or cognitive impairments is given. In addition, different approaches for promoting the implementation of SDM for this patient group will be identified.

"Voluntary in quotation marks": a conceptual model of psychological pressure in mental healthcare based on a grounded theory analysis of interviews with service users.

BACKGROUND: Psychological pressure refers to communicative strategies used by professionals and informal caregivers to influence the decision-making of service users and improve their adherence to recommended treatment or social rules. This phenomenon is also commonly referred to as informal coercion or treatment pressure. Empirical studies indicated that psychological pressure is common in mental healthcare services. No generally accepted definition of psychological pressure is available to date. A first conceptual analysis of psychological pressure focused on staff communication to promote treatment adherence and distinguished between persuasion, interpersonal leverage, inducements and threats. AIM: The aim of this study was to develop a conceptual model of psychological pressure based on the perspectives of service users. METHODS: Data were collected by means of semi-structured interviews. The sample consisted of 14 mental health service users with a self-reported psychiatric diagnosis and prior experience with coercion in mental healthcare. We used theoretical sampling and contacted participants via mental healthcare services and self-help groups to ensure a variety of attitudes toward the mental healthcare system in the sample. The study was conducted in Germany from October 2019 to January 2020. Data were analyzed according to grounded theory methodology. RESULTS: The study indicated that psychological pressure is used not only to improve service users' adherence to recommended treatment but also to improve their adherence to social rules; that it is exerted not only by mental health professionals but also by relatives and friends; and that the extent to which service users perceive communication as involving psychological pressure depends strongly on contextual factors. Relevant contextual factors were the way of communicating, the quality of the personal relationship, the institutional setting, the material surroundings and the level of convergence between the parties' understanding of mental disorder. CONCLUSIONS: The results of the study highlight the importance of staff communication training and organizational changes for reducing the use of psychological pressure in mental healthcare services.