[Coercion and urge from a care ethics perspective]. / Dwang en drang vanuit zorgethisch perspectief.

BACKGROUND: Coercion is much discussed topic in psychiatry. AIM: Presentation of an ethics of care perspective on coercion, focusing on the moral aspects of the relationship between care recipient and caregiver, and the prevention and reduction of coercion. METHOD: Clarification of the care-ethical aspects of the high and intensive care (HIC) model and discussion of the Compulsory Mental Health Care Act (Wvggz). RESULTS: In the HIC model, ethics of care underlies three cultural changes: from control to contact, from reactive to proactive, from individuality to solidarity. More than the older Bopz Act, the Wvggz pays attention to relational aspects of coercion, but the procedures endanger care contact. CONCLUSION: Ethics of care - in which the care relationship is the starting point - offers a perspective that is of great value to psychiatry. The development of HIC is a concrete example of this. The Wvggz emphasizes collaboration in care, but care contact is hindered in practice by a multitude of procedures.

[Towards a proactive psychiatric ethics: a care ethics perspective]. / Naar een proactieve psychiatrische ethiek: een zorgethisch perspectief.

Background Proactive psychiatry requires proactive psychiatric ethics. Aim To describe ethical considerations with regard to proactive psychiatry. Method Discussion of care ethics aimed at proactive psychiatric care. Results In this contribution, we plea for a proactive psychiatric ethics, stimulating and supporting healthcare professionals in working from a developmental and contextual perspective. We describe care ethics, and show that it is in line with the principles of proactive psychiatry. We address three issues related to the development of proactive psychiatry: the goals of care; identifying risk factors; and the division of responsibilities in mental healthcare. Conclusion Proactive psychiatric ethics can be useful in identifying and discussing ethical issues associated with proactive psychiatry and thus contribute to improving practice. Tijdschrift voor Psychiatrie 63(2021)2, 150-153.

[High and intensive care as a next step in the reduction of coercion]. / High en intensive care als een volgende stap in dwangreductie.

BACKGROUND: The high and intensive care (HIC) model provides a framework for acute admission wards and is being implemented since 2013 by all mental healthcare institutions in the Netherlands. AIM: To investigate how the HIC model has been implemented between 2014 and 2018 and how the implementation of the HIC model is associated to coercive measures. METHOD: Between 2014 and 2018, 79 audits were organized in two phases within 25 institutions to measure the degree of implementation of HIC using a model fidelity scale, the HIC monitor. HIC monitor scores were compared to data on coercion to determine the relationship between implementation of the HIC model and coercive measures. RESULTS: Scores on the HIC monitor increased over time, especially in terms of vision, hospitality and facilities. However, a third of wards scored lower on the HIC monitor in the second audit compared to the first audit. Institutions that score higher use less seclusion and use less forced medication. CONCLUSION: Progress in the implementation of the HIC model is visible and institutions that are further in the implementation of the HIC model apply less coercion. Securing implementation proves difficult. Attention should be paid to the national staff shortage and systematic evaluation of coercion.

Does high and intensive care reduce coercion? Association of HIC model fidelity to seclusion use in the Netherlands.

BACKGROUND: A new inpatient care model has been developed in the Netherlands: High and Intensive Care (HIC). The purpose of HIC is to improve quality of inpatient mental healthcare and to reduce coercion. METHODS: In 2014, audits were held at 32 closed acute admission wards for adult patients throughout the Netherlands. The audits were done by trained auditors, who were professionals of the participating institutes, using the HIC monitor, a model fidelity scale to assess implementation of the HIC model. The HIC model fidelity scale (67 items) encompasses 11 domains including for example team structure, team processes, diagnostics and treatment, and building environment. Data on seclusion and forced medication was collected using the Argus rating scale. The association between HIC monitor scores and the use of seclusion and forced medication was analyzed, corrected for patient characteristics. RESULTS: Results showed that wards having a relatively high HIC monitor total score, indicating a high level of implementation of the model as compared to wards scoring lower on the monitor, had lower seclusion hours per admission hours (2.58 versus 4.20) and less forced medication events per admission days (0.0162 versus 0.0207). The HIC model fidelity scores explained 27% of the variance in seclusion rates (p < 0.001). Adding patient characteristics to HIC items in the regression model showed an increase of the explained variance to 40%. CONCLUSIONS: This study showed that higher HIC model fidelity was associated with less seclusion and less forced medication at acute closed psychiatric wards in the Netherlands.

High and Intensive Care in Psychiatry: Validating the HIC Monitor as a Tool for Assessing the Quality of Psychiatric Intensive Care Units.

This study aims to validate the HIC monitor as a model-fidelity scale to the High and Intensive Care (HIC) model, a recently developed model for acute psychiatric wards. To assess the psychometric properties of the HIC monitor, 37 audits were held on closed inpatient wards at 20 psychiatric hospitals in the Netherlands. Interrater reliability, construct validity and content validity were examined. Our results suggest that the HIC monitor has good psychometric properties. It can be used as a tool for assessing the implementation of the HIC model on acute psychiatric wards in the Netherlands, and for quality assessment and improvement.

[High and intensive care in long-term inpatient psychiatric services]. / High en intensive care in de langdurige klinische psychiatrie.

BACKGROUND: The increase in ambulant healthcare has also led to (simultaneously gained) insights that possibilities for temporary hospitalisation/admittance should be available for patients who experience a serious mental crisis. Based on experiences gained from the projects 'Reducing Coercion', high and intensive care (hic) has been developed. hic aims to improve care for psychiatric patients who are in need of crisis admission in a psychiatric hospital.
AIM: To investigate whether the hic model is applicable to patients staying at a long-term psychiatric unit in hospital who, due to a severe psychiatric crisis, need to be hospitalised short-term in an emergency department of long-term inpatient care.
METHOD: A responsive process evaluation in which three emergency departments with inpatient healthcare (from three different psychiatric institutions) participated. Starting point was application of the hic evaluator, followed by semi-structured interviews and focus groups.
RESULTS: The items as described in the hic manual could be implemented within this setting. Stimulating and impeding factors were found, as well as adjustments needed to remove barriers to successful implementation.
CONCLUSION: Although the hic model can be applied to the crisis departments of long-term inpatient psychiatric services, adjustments are indicated.

Self-report versus performance based executive functioning in people with psychotic disorders.

Background: Although executive functioning is often measured using performance-based measures, these measures have their limits, and self-report measures may provide added value. Especially since these two types of measures often do not correlate with one another. It thus has been proposed they might measure different aspects of the same construct. To explore the differences between a performance-based measure of executive functioning and a self-report measure, we examined their associations in patients with a psychotic disorder with the following: other neurocognitive measures; psychotic symptoms; anxiety and depression symptoms, and daily-life outcome measures. Method: This cross-sectional study consisted of baseline measures collected as part of a cohort study of people with a psychotic disorder (the UP'S study; n = 301). The Behavioral Rating Inventory of Executive Functioning Adult version (BRIEF-A) was used to assess self-rated executive functioning, and the Tower of London (TOL) to assess performance-based executive functioning. Generalized linear models (GLM) were used with the appropriate distribution and link function to study the associations between TOL and BRIEF-A, and the other variables, including the Brief Assessment of Cognition in Schizophrenia (BACS), the Positive and Negative Symptoms Scale-Remission (PANSS-R), the General Anxiety Disorder - 7 (GAD-7), the Patient Health Questionnaire - 9 (PHQ-9) and the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0). Model selection was based on the Wald test. Results: The TOL was associated with other neurocognitive measures, such as verbal list learning (ß = 0.24), digit sequencing (ß = 0.35); token motor task (ß = 0.20); verbal fluency (ß = 0.24); symbol coding (ß = 0.43); and a screener for intelligence (ß = 2.02). It was not associated with PANNS-R or WHO-DAS scores. In contrast, the BRIEF-A was associated not with other neurocognitive measures, but with the PANSS-R (ß = 0.32); PHQ-9 (ß = 0.52); and GAD-7 (ß = 0.55); and with all the WHODAS domains: cognition domain (ß = 0.54), mobility domain (ß = 0.30) and selfcare domain (ß = 0.22). Conclusion: Performance-based and self-report measures of executive functioning measure different aspects of executive functioning. Both have different associations with neurocognition, symptomatology and daily functioning measures. The difference between the two instruments is probably due to differences in the underlying construct assessed.

A Descriptive Mixed-Methods Analysis of Sexual Behavior and Knowledge in Very Young Children Assessed for Sexual Abuse: The ASAC Study.

Child sexual abuse (CSA) is a worldwide problem with serious consequences. We hypothesized that worrisome sexual behavior and knowledge would frequently be reported in children assessed after CSA. We therefore investigated (A) what types of sexual behaviors and knowledge were reported by parents of young children assessed for CSA; (B) in what cases such behaviors and knowledge were worrisome; and (C) how such children responded verbally and non-verbally during child interviews. We conducted a mixed-methods study, including qualitative inductive content analysis and quantitative analysis. It included 125 children (76 boys, 60.8%; median age 3.3 years, age range 0-11), all involved in the Amsterdam sexual abuse case (ASAC) and examined for highly suspected (n = 71) or confirmed CSA (n = 54). We identified themes from (1) the parent reports: sexual behavior (e.g., self-stimulation, touching others, imitation of sexual acts), fears and anxiety with regard to sexuality, and sexual utterances (sexual slang, references to sexual acts); and (2) the child interviews: behavioral reactions (avoidance, distractive behaviors), emotional reactions (anger, aggression), and verbal reactions (conspicuous utterances, refusal to talk about specific subjects). In 37% of the children the sexual behavior was deemed worrisome or very worrisome. Clinicians who assess children for CSA are advised to focus in particular on sexual behavior problems and inappropriate sexual knowledge.

Psychosocial symptoms in very young children assessed for sexual abuse: A qualitative analysis from the ASAC study.

Child sexual abuse (CSA) is a worldwide problem with serious consequences. No recognizable symptom pattern for suspected CSA has yet been identified in very young children. We aim to investigate psychosocial symptoms in a sample of children with confirmed or strongly suspected CSA and the interpretations given to such symptoms by independent clinical experts. Secondly we examined whether experts were able to identify confirmed victims of severe CSA. A qualitative study including inductive content analysis of medical files and focus group discussions with independent experts on the interpretation of psychosocial symptoms was conducted. We included 125 children (76 boys, 60.8%, and 49 girls, 39.2%; median age 3.3 years; age range 0-11) who were involved in the Amsterdam sexual abuse case (ASAC) and had been examined for strongly suspected CSA. We identified four themes among the psychosocial symptoms: problems concerning emotions, behavior, toilet training, and development, whether or not associated with the daycare center or the perpetrator. Clinical experts identified signs of posttraumatic stress disorder (PTSD), regression in continence skills (not otherwise explained), and problems triggered by exposure to the perpetrator or the abuse location as concerning symptoms for CSA. Less concerning symptoms were designated as worrisome if they were numerous and there was no clear explanation for these symptoms. A clear symptom pattern was lacking and about half of the confirmed severe victims of CSA did not display any psychosocial problems. Therefore, it is difficult for experts to identify confirmed CSA victims. Thus, the assessment of suspected CSA should be over time and multidisciplinary.