Reducing Involuntary Psychiatric Admissions in Norway

An interdisciplinary team in Norway, including individuals with lived experience, co-designed an approach to reduce coercive and forced psychiatric interventions.

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A new study published in BMC Health Services Research describes the collaborative process undertaken by an interdisciplinary team of stakeholders to develop the Reducing Coercion in Norway (ReCoN) intervention, a primary care-based mental health care model aimed at reducing involuntary psychiatric admissions amongst adults.

The development of the ReCON intervention comes in response to growing concerns regarding rising rates of involuntary hospitalizations across the globe, with annual percentage increases as high as 4% in the United Kingdom and 5% in the Netherlands. Consumer-led organizations, national governments, and international organizations, including the United Nations, have called for the ban of forced psychiatric hospitalization, labelling the practice a human rights violation that takes autonomy away from persons with psychiatric disabilities. Research has also shown that when individuals feel coerced during a psychiatric hospitalization, they are more likely to experience long-term negative outcomes, including increased risk for suicide.

Illustration depicting a woman lifting a cage to free a sitting man in a suitAlternative interventions based on principles of recovery and shared-decision making have been studied globally in specialty mental health treatment settings and have been found to be effective in preventing and reducing coercion. However, these interventions are lacking within primary care settings, even though it is the only point of contact with healthcare for many individuals with a serious mental illness (SMI).

“For many individuals with an SMI, primary health care provides the majority of services and might thus be in a key position to facilitate less restrictive services and prevent involuntary admissions,” the researchers write.

Researchers at the Norwegian Resource Center for Community Health, led by Irene Wormdahl, set out to develop a primary care-based intervention based on explicit anti-coercion practices as a means of reducing rates of involuntary psychiatric hospitalizations. The research team organized five day-long Dialogue Conferences to facilitate the intervention development process. Dialogue conferences are a participatory action research strategy that aim to promote democratic and collaborative conversations between diverse stakeholders to brainstorm solutions to shared problems.

For the present study, conferences were held between February and March 2020. Each conference included 50 distinct participants, representing multiple relevant stakeholder groups, recruited from five different Norwegian municipalities. Stakeholders included staff and managers of primary and secondary mental health services, primary care service providers, police, individuals with lived experience of serious mental illness or involuntary admission, and family caregivers.

The dialogue conferences each included three small group work sessions and a brief presentation from researchers on intervention components to provide participants with background information. During the first group session, participants were divided by service (e.g., primary care, mental health care) and/or identity category (e.g., individual with lived experience, healthcare professional) to ensure all participants had a comfortable space to openly brainstorm intervention ideas. In subsequent group sessions, stakeholders came together across groups to share and exchange perspectives. Lastly, all attendees participated in a final “star round” during which participants each chose their top three intervention priorities.

Following the conferences, researchers used inductive thematic analysis to categorize the brainstormed intervention components and to identify key strategy areas to include in ReCoN. Strategies were then ranked according to priority. Components chosen by stakeholders from multiple municipalities were maintained, whereas those that were only prioritized by representatives from one municipality, or that were marked as low priority by all participants, were removed. After this primary stage of analysis, researchers created an initial intervention proposal and held eight two-hour long feedback sessions during which stakeholders were presented with the draft intervention. The ReCoN model was iteratively revised based on oral feedback received after each session.

This co-creation process ultimately yielded an intervention with six general principles and strategy areas related to: 1) management, 2) involvement of persons with lived experience, 3) staff competency development, 4) collaboration across primary and specialty care levels, 5) collaboration within primary care, and 6) tailoring services to meet individual needs.

Stakeholders believed that for the intervention to be successful, commitment was needed at the management level. For example, managers should ensure systematic data collection and monitoring related to coercion (e.g., tracking and routinely reviewing data on involuntary admissions). The second strategy area was involvement of persons with lived experience and family caregivers. Participants suggested mandating “post-incident reviews” within organizations, which would require primary care staff to meet with families to review the impact and outcome of any involuntary hospitalization and to engage in joint-crisis planning to prevent future admissions. Employment of peer workers as support staff within primary care for individuals identified as being at risk for an involuntary hospitalization was suggested as another potential strategy.

Intervention components related to “competence development” included the enhancement of training modalities for primary care service providers regarding trauma-informed and recovery-oriented frameworks and risks of coercion. Participants also emphasized the need for training to be flexible and specific to the needs of each site.

Enhanced communication between types of service providers was also deemed a key intervention priority; participants asserted that if primary and specialty care providers had more direct lines of communication, they might be more aware of the options available within an individual’s network and be better equipped to imagine alternatives to involuntary admission.

“Close collaboration between services when assessing the need for involuntary admissions might identify less restrictive alternatives or contribute to finding good solutions if a person is referred but not admitted,” the researchers write.

The last essential strategy area defined by stakeholders was tailoring services to meet the needs of each individual service user. Dialogue participants articulated that implementing this strategy should begin with a provider asking their patient the simple question, “What is important to you?” and then customizing service provision to match an individual’s values and needs (e.g., shelter, food, medication support).

In summary, the co-created ReCoN intervention aims to incorporate multiple new strategies into primary care settings to shift towards a more comprehensive, integrative model of care in which staff and individuals with lived experience of mental illness collaborate to make treatment decisions and tailor services to match individuals’ needs.

The authors suggest that the implementation of the ReCoN intervention has the potential to have a powerful downstream effect.

“Putting prevention of involuntary admissions on the agenda in primary health care settings has the potential to readdress structurally embedded patterns and promote collaborative efforts to decrease the use of involuntary admissions across health care levels,” they write. “For persons with SMI, implementing the ReCoN intervention can contribute to fewer experiences of involuntary admissions and that they receive comprehensive services that are recovery-oriented and individually tailored.”

The effectiveness of ReCoN is currently being tested as part of a large-scale clustered randomized controlled trial in Norway.

 

 

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Wormdahl, I., Hatling, T., Husum, T. L., Kjus, S. H. H., RugkĂĄsa, J., Brodersen, D., … & Rise, M. B. (2022). The ReCoN intervention: a co-created comprehensive intervention for primary mental health care aiming to prevent involuntary admissions. BMC Health Services Research, 22(1), 1-17. (Full text)

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Julia Lejeune
Julia Lejeune is a Clinical Psychology doctoral student at the University of Illinois at Chicago, studying the social and contextual factors that shape youth mental health and pathways to care. She is particularly interested in understanding how various youth-serving institutions, like schools or psychiatric services, approach neurodiversity and suicidality in young people. Julia hopes to use participatory action research and mixed methods to center youth narratives as guides in developing new systems of care.

12 COMMENTS

  1. I, WOLF.

    My nose might all himself diminish,

    high hoisted, horribly finished howls of woundedness.

    I am joined and keeping low,

    I growl in wolfish lurchings.

    I follow huntsmen who running go,
    quickening for speed.

    Their five horses gingerly harp horse fearing withers

    as they look for quivers of hoisted wind.

    Glowing through marble eyes, lightning flashes and holds glimpses,

    hurls slip jawed fistfuls into leaps.

    This

    is how I give nightmares to little children going back to milky sleeps,

    those who know that fugitive siting’s,

    elongated in my nocturnal eyes,

    I might have to eat.

    _________________________

    (Julia have a poem from the channelled pen of a late poet Laureate called Crow. I wrote this his poem with his help. I am a scribe for the famous unseen. Why a poem here? Two reasons. One is that someone should do a book of grim fairy stories about the spell casting antics of old psychiatry, of which involuntary captivity is one beckonning tale. But the other reason is because I read this poem again today and spotted the number “five”. When I jotted it down many years ago I gave no thought to it. Surely four horses would be more traditional, as in four horses of the apocalypse. But since forgetting I had scrawlled this poem I later went on to receive prophecies of pandemics, a change in gender ideology, climate change predictions and all manner of epic landmarks and abrupt scene changes. One prophecy is of “five” meteors. They are going to blitz Earth in such an impactful way that for a long time people will become depressed about even going out for a loaf of bread, lest another meteor smacks the loaf into instant toast. The wreckage from those meteors will cause an enormous global flood, a tsunami. Some countries will not be much affected but other places will be, even though the “five” meteors are not big enough to cause total devastation. The far future is good but humans have messy times to go through yet. As a consequence of the meteors a doomy depressed state will make people become puppets on strings to any loudspeakered idea of utopia. A regime is coming to give people a sense of cushioning but it comes at a cost. Many will be persecuted if they do not fall in line with the regime’s dictates. At its worst some kinds of people will be involunarily held captive in their own home, never mind a hospital.

    I digress. My schizophrenia is diverting me. But I just want to add that there are ONLY those “five” meteors and no more than those. That is why I received the message. After the “five” humanity can breathe a sigh of relief. In the meantime favour inland hilly dwellings.

    When the Hoover Dam becomes broken by explosion, something I was mentioning nine years ago was going to be significant as a turning point, get ready for the biblical flood that shall occur years or so after it.

    A series of natural disasters changes the current human drama into a new epic, with quite different priorities. Simplified priorities.

    The incessant arguing and bickering over free choices bedevilling this era will swill and drain from the barrel like catastrophe took an axe to split the wood.

    What is left behind at the bottom of the barrel is what matters most. Our collective “caring”.

  2. If people refuse to be admitted, and if the people lift any laws which allow for involluntary admission then there won’t be any.

    I am concerned that an article like this legitimates the idea of “mental illness”, like you want to minimize the number of hospital admissions for say motor vehicle accidents.

    There is no such thing as “mental illness”. There are only some people who fallaciously believe that mental illness is real, and there are some people who pass laws to allow involuntary admission.

    Joshua

  3. “Close collaboration between services when assessing the need for involuntary admissions might identify less restrictive alternatives or contribute to finding good solutions if a person is referred but not admitted,” as was I, when I was medically unnecessarily held and force treated by the now FBI convicted, greed only inspired, criminal Dr. V. R. Kuchipudi.

    https://www.justice.gov/usao-ndil/pr/oak-brook-doctor-convicted-kickback-scheme-sacred-heart-hospital

    “Putting prevention of involuntary admissions on the agenda in primary health care settings has the potential to readdress structurally embedded patterns and promote collaborative efforts to decrease the use of involuntary admissions across health care levels,”

    Let’s be real, taking away the right of any doctor to force treat someone is the solution. Merely “Putting prevention of involuntary admissions on the agenda in primary health care settings” isn’t going to help us innocent individuals who had dangerous paranoid PCP’s, whose goal was to cover up her husband’s easily recognized malpractice.

    The incompetent and unethical PCP’s already know how to utilize the psych drugs and psychiatrists against their innocent patients.

  4. Ah yes, I remember the scene when Cool Hand Luke was digging his own grave.

    You know, the ‘collaborative process’ between prisoner and prison guards?

    Our police have only been given ‘shoot to kill’ orders recently, you think they are going to take a step backwards now they have that? Though I think the powers to “edit” legal narratives for the courts, to deny access to effective legal representation, and remove protections afforded by our laws with misrepresentations are much more dangerous.

    There can be no ‘collaboration’ when the provisions of the Mental Health Act are being exploited to enable acts of torture and arbitrary detentions, concealed by making anyone whose human rights they wish to abuse an “Outpatient”.

    I suppose I wouldn’t mind if they had a cure for the reaction to their acts of torture and arbitrary detentions, but the chemical kosh could hardly be called a ‘cure’.

    Collaboration in my State consists of ‘Hi, i’d like to make a complaint regarding being tortured, and I have the proof here in these documents’…. Minister for Health ‘Get treated’.

    Any wonder they can point fingers at other Nations, when there is no effective means to make a complaint DESPITE the provisions of the Convention? All roads lead to Rome, and the torturers make a decision as to what constitutes torture, and have the power to deny access to legal representation and “edit” documents should they not like what they see.

  5. Someone would have to look at the circumstances under which these Involuntary Psychiatric Admissions are occurring.

    Every person on the earth has manic and depressive mood swings. Pamphlets, online materials, and work shops to help people learn to manage them would help. Its really not that big a deal, once people understand that there could be potential consequences.

    And people should be always encourage to refuse chemical mood alterants. Refuse the kind bought in the pharmacy, the liquor store, the back alley, and the kind obtained through a doctor’s prescription. Learning to live in our own skin is the work of a lifetime, and these mood alterants destroy that.

    Then look at what laws cause the involuntary admissions and lift them, then expose the mental health system as falling within Nuremburg precedent for crimes against humanity. Prosecute the practitioners in the International Court, and get these people the sentences they deserve!

    https://en.wikipedia.org/wiki/Doctors%27_trial

    Joshua

    • I agree with you Joshua.

      My own situation has exposed the way the State has been enabling the “editing” of legal narratives to conceal the human rights abuses they are enabling with their negligence. Public Officers being allowed to arbitrarily detain and torture using the mental health facilities no doubt producing valuable information for the State.

      There are of course those who would also recognise an opportunity in that ‘dark place’ created to enable such evil deeds. Political advantage of being able to silence anyone who disagrees with your view of the world.

      And what if those using that place for their own nefarious ends actually exposed the whole kit and caboodle? The State literally caught with their pants down, despite having the resources of police and mental health services to find out “who else has the documents?”

      I know the Shadow Minister for Mental Health found it extremely amusing. Though unable to outright say what it was he found so amusing. I think the statement he made outside of Parliamentary privilege that “the Minister has been derelict in her duty” (ie committed an act of serious misconduct) gave a clue.

      With such power it would be easy to assume that covering up human rights abuses (police and mental health torturing citizens) for a few political favors may be of benefit. I’m sure the ‘opposition’ would have had some concerns though given their vulnerable position in being snatched from their beds and ‘unintentionally negatively outcomed’.

      Particularly given I had sat next to a Politician in the clinic waiting to see the same ‘doctor’. Careful where you step there ‘Minister’, they’re doing ‘remotes’. You might wake up in a cell dribbling from the mouth waiting for your next ‘shock treatment’ until you ‘confess’ your ‘sins’ (any wonder the Treasurer fled the State when Police were looking for him to do a ‘referral’ for ‘treatment’? All got a bit difficult to explain and his ‘confidentiality’ needed to be observed by the media. Don’t ask, or else……)

      Best not expose it though, because once IN power, it’s a valuable tool to have access to. So threaten to expose the ‘little network’ and watch as the government dismantles itself with the paranoia caused by that threat. Nothing like honor among thieves huh? They couldn’t wait to spill the beans on each other once they knew the game was up.

      Worked a treat, and we now have a government which makes the grip on power that the CCP has in China look like a democracy. The now ‘opposition’ holding 2 seats in our lower house (fair enough, they tried the Nazi thing and it failed). The Right side of politics absolutely gutted for years to come.

      “They will take their oaths as a cover” (exploitation of trust and ‘confidentiality’)

      “Do not conceal truth with falsehood, nor conceal the truth when you know what it is” (“editing” of legal narratives to conceal human rights abuses by ‘mental health facilities’ Obviously a knife can be used to cut your meal, or as a weapon. Disguising the real purpose of the weapon as being for good quite an advantage over a trusting community. Especially when they get zero time to respond to being snatched and force drugged, documents being unlawfully held back while they arrange the narrative for the courts. And ‘advocates’ wander aimlessly saying ‘If the Chief Psychiatrist wants to rewrite the law, and remove the protections afforded the community, who are we to complain?’)

      Both ‘sides’ obviously content with the use of these facilities for these purposes. And both wanting to relax the rules around the protections afforded the community, mainly because it seems the only people not getting mentally ill these days are them? There ‘enemies’ are all around them, and only need to be asked for their votes every once in a while. And they do have to vote, to create the illusion of a democracy.

  6. California has Prop 63 2004 which set up this MHSA

    https://dmh.lacounty.gov/about/mhsa/#:~:text=Proposition 63 promised to greatly,for the residents of California

    It has its own tax. Polling told them that the voters would go for a Millionaires Tax. It has already raised $30 billion. And now it is up to $8.3 billion per year.

    So most families that are not rich enough to hire private doctors, will have someone in them who is now believed to be “Mentally Ill”, and is kept medicated. You hear the stories, “Our son can only come home if he takes his meds. Otherwise he has to stay in the homeless shelter.”

    I am sure that this ideology of “Mental Illness” and the drugging causes more voluntary and involuntary hospital admissions.

    This is all clearly within Nuremberg president.

    Joshua

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