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This book explores the moral lives of mental health clinicians serving the most marginalized individuals in the US healthcare system. Drawing on years of fieldwork in a community psychiatry outreach team, Brodwin traces the ethical dilemmas and everyday struggles of front line providers. On the street, in staff room debates, or in private confessions, these psychiatrists and social workers confront ongoing challenges to their self-image as competent and compassionate advocates. At times they openly question the coercion and forced-dependency built into the current system of care. At other times they justify their use of extreme power in the face of loud opposition from clients. This in-depth study exposes the fault lines in today's community psychiatry. It shows how people working deep inside the system struggle to maintain their ideals and manage a chronic sense of futility. Their commentaries about the obligatory and the forbidden also suggest ways to bridge formal bioethics and the realities of mental health practice. The experiences of these clinicians pose a single overarching question: how should we bear responsibility for the most vulnerable among us?

Psychiatry Under the Influence investigates the actions and practices of the American Psychiatric Association and academic psychiatry in the United States, and presents it as a case study of institutional corruption.

Codes of ethics in medicine have an ancient tradition, extending back to the Oath of Hippocrates. Yet it was only in the early 1970s that the speciality of psychiatry developed a specific code to address the unique ethical dilemmas and complexities arising in psychiatric practice. As the 50th anniversary of the publication of psychiatry's first code of ethics approaches, it is timely to reflect on the progress, role, and impact of such codes.Our aim is to provide a historically informed review of codes of ethics in psychiatry - their origins and evolution, the current picture, and the possibilities for future development. We conducted a selective review of relevant literature (including all codes of ethics accessible on the websites of World Psychiatric Association members states), analysis of the form and content of codes and related documents in psychiatry, and interviews of psychiatrists who have played central roles in their evolution. Of the 143 WPA member states, only 15 codes of ethics for psychiatrists were identified, and few of these were associated with professional disciplinary processes. We found that these codes are rarely revised and sometimes supplemented with other statements and guidelines. While there are difficulties in measuring the direct effectiveness of codes of ethics on the practice of psychiatrists, we conclude that these codes help to (1) promote professional solidarity and autonomy, (2) enhance moral sensitivity, and (3) aid in psychiatric education and training.

Criminal sanctions including court orders, prosecution and imprisonment persist as responses to suicidality in the UK even where there is no public danger. Their prevalence, the level of clinical involvement and outcomes are unclear. There is an urgent need to examine the national picture of harms, benefits and the responsibilities of mental health professionals.

Once common, therapeutic privilege—the practice whereby a physician withholds diagnostic or prognostic information from a patient intending to protect the patient—is now generally seen as unethical. However, instances of therapeutic privilege are common in some areas of clinical psychiatry. We describe therapeutic privilege in the context of borderline personality disorder, discuss the implications of diagnostic non-disclosure on integrated care and offer recommendations to promote diagnostic disclosure for this patient population.

The integrity of the patient–physician relationship depends on maintaining professional boundaries. While ethicists and professional organisations have devoted significant consideration to the subject of sexual boundary transgressions, the subject of non-sexual boundaries, especially outside the mental health setting, has been largely neglected. While professional organisations may offer guidance on specific subjects, such as accepting gifts or treating relatives, as well as general guidance on transparency and conflict of interest, what is missing is a principle-based method that providers can use to assess non-sexual interactions with patients that transcend norms of practice. This paper attempts to offer an operational model for such assessment that considers not only the traditional emphasis on beneficence, but also incorporates concerns over entanglement and concordance.

Background Members of the transgender community have identified healthcare access barriers, yet a corresponding inquiry into healthcare provider perspectives has lagged. Our aim was to examine physician perceptions of barriers to healthcare provision for transgender patients. Methods This was a qualitative study with physician participants from Ontario, Canada. Semi-structured interviews were used to capture a progression of ideas related to barriers faced by physicians when caring for trans patients. Qualitative data were then transcribed verbatim and analysed with an emergent grounded theory approach. Results A total of thirteen (13) physician participants were interviewed. Analysis revealed healthcare barriers that grouped into five themes: Accessing resources, medical knowledge deficits, ethics of transition-related medical care, diagnosing vs. pathologising trans patients, and health system determinants. A centralising theme of “not knowing where to go or who to talk to” was also identified. Conclusions The findings of this study show that physicians perceive barriers to the care of trans patients, and that these barriers are multifactorial. Access barriers impede physicians when referring patients to specialists or searching for reliable treatment information. Clinical management of trans patients is complicated by a lack of knowledge, and by ethical considerations regarding treatments—which can be unfamiliar or challenging to physicians. The disciplinary division of responsibilities within medicine further complicates care; few practitioners identify trans healthcare as an interest area, and there is a tendency to overemphasise trans status in mental health evaluations. Failure to recognise and accommodate trans patients within sex-segregated healthcare systems leads to deficient health policy. The findings of this study suggest potential solutions to trans healthcare barriers at the informational level—with increased awareness of clinical guidelines and by including trans health issues in medical education—and at the institutional level, with support for both trans-focused and trans-friendly primary care models.

Background Restrictive practices, such as seclusion and restraint, in psychiatric inpatient settings carry significant risks of harm and raise critical ethical concerns, which has prompted efforts to minimize their use. Models like Safewards, with its ten interventions, have shown promise in reducing conflict and containment but require active engagement from all healthcare professionals. Despite their leadership roles, psychiatrists’ engagement in implementing Safewards remains underexplored, even though their involvement is likely critical for the model’s success. This study aimed to identify key facilitators and barriers to psychiatrists’ engagement in implementing Safewards and other quality improvement work. Methods In this qualitative exploratory study, semi-structured interviews and inductive content analysis were utilized. Ten psychiatrists from nine psychiatric clinics in Sweden, providing both voluntary and involuntary care and implementing Safewards to varying extents, were recruited via convenience sampling. Participants, equally distributed by gender, had an average of 12 years of experience in their roles. Interviews were conducted in person or digitally, lasting 30–90 min, and transcribed verbatim. Data were analyzed using qualitative content analysis, with coding and categorization conducted collaboratively to ensure consistency. Reflexive practice and the COREQ checklist were applied to enhance trustworthiness. Results Psychiatrists’ engagement in Safewards and quality improvement efforts was influenced by factors tied to their professional role and the clinical work environment. Positive influences included leadership aspects, professional training, and visible benefits for patient care, such as improved communication with patients and staff. Barriers included a narrow care perspective, feelings of detachment from holistic patient care, and the unpredictable nature of psychiatrists’ work. Time allocation, prioritization, and support from local management also played crucial roles in shaping engagement. Conclusions This study identifies key facilitators and barriers to psychiatrists’ engagement in implementing Safewards, offering guidance for enhancing their participation. Strengthening leadership, broadening perspectives, and ensuring protected time for quality improvement initiatives may optimize multidisciplinary collaboration. Future research should examine whether increased psychiatrist participation positively affects Safewards outcomes. Trial registration Clinical trial number: not applicable.

There is a place for the use of benzodiazepines/z-hypnotics on adult mental health wards, but they are often continued beyond a length of time where they are beneficial. This can result in dependence and withdrawal effects if stopped. Timely deprescribing of these medicines is encouraged, but there is limited evidence available as to what can be a facilitator or barrier to deprescribing benzodiazepines/z-hypnotics on these wards. Semi-structured interviews, with twenty-nine NHS healthcare professionals from eleven different NHS organisations, involved in the use of benzodiazepines/z-hypnotics on adult mental health wards, were conducted and recorded on Microsoft Teams and transcribed. Themes were generated via thematic analysis on NVIVO software, informed by a grounded, inductive approach, to identify similarities and differences in participants perceptions. The four main themes identified from participants’ experiences were: Culture (shared values, beliefs and practices). Patient factors. Practical measures to facilitate deprescribing of benzodiazepines/z-hypnotics on adult mental health wards. Primary/secondary care interface. Deprescribing culture, rather than being led nationally, is more influenced by local factors. Some patient behaviour patterns can be a barrier to deprescribing but many of these can be overcome by promoting patient-centred care, allowing patients to feel involved and enabled to make informed decisions around their care. Access to non-pharmacological methods to de-escalate behaviour, promote wellbeing and improve sleep on adult mental health wards can support deprescribing. Cohesive multi-disciplinary team working aids deprescribing, but staff pressures can hinder this by reducing access to appropriately trained staff. Effective discharge planning is important but not always achieved. Good communication post discharge can facilitate continued deprescribing. Overcoming the barriers and developing the facilitators identified could improve benzodiazepine/z-hypnotic deprescribing on adult mental health wards. Changes to national NHS culture and priorities are required to influence local culture. Otherwise, deprescribing practices will remain greatly influenced by local factors on individual wards. Good practice exists but further research and funding is needed to disseminate this throughout the NHS.

Introduction Recognition of the value of involving relatives in mental health care is growing. This study explores the ambivalence surrounding their role, including formalisation, instrumental use, burden, and potential benefits. Collaboration between relatives, patients, and professionals is essential to recovery-based approaches. Thus, despite challenges, the involvement of relatives remains crucial. This study aims to understand perspectives on involving relatives in mental health care, within the larger context of collaboration across the triad of relatives, patients, and professionals. Methods We conducted a qualitative study using semi-structured interviews with relatives ( n  = 7), patients ( n  = 7), and professionals ( n  = 10) connected to various mental health care organizations. The study took place in The Netherlands. Data were analysed using thematic analysis. Results For collaboration in the triad, we found five aspects to be of importance: the significance of involving relatives, changing roles from relative to caregiver, relatives’ intermediary role in patient-professional relationship, negative experiences of relatives in the triad, and ambivalence about patient’s autonomy. Notably, because collaboration between professionals and relatives is often challenging, it often leads to tensions. Conclusion Our study uncovers varying perspectives both on involving relatives and on collaboration within the triad. Recovery-oriented approaches do not always align with patients’ and relatives’ intentions and values. Although relatives want to be involved, they often feel unheard and unseen by professionals. Relatives’ roles -especially the intermediary role- are surprisingly underrepresented in the recovery-oriented literature. This study reveals several tensions between the three perspectives, culminating in a so-called uneven triad. We conclude that although the concept of involving relatives is highly advocated in recovery-based approaches, actual practice is lagging behind.