Working Group on Ethical Considerations in Science and Scholarship∗

Persons can be subject to involuntary treatment for mental illness or substance abuse in a variety of circumstances. The ability of such persons to give a valid informed consent for research often has been called into question, because the coercive nature of the treatment is thought to impair the voluntariness of their decision making. A careful consideration of the nature of coercion from a “moralized”; perspective focuses attention on two elements that determine the acceptability of consent: the fairness of the proposal to which consent is sought, and the moral baseline from which the proposal is made. Even when coercion is not present, disproportionate rewards offered for participation in research can impair the voluntariness of consent, as can the unintended effects of the social structure of the system in which the research is taking place. When coercion, defined as a moralized concept, is not present, however, and other conditions do not substantially impair voluntariness, consent to research legitimately may be sought from involuntarily treated populations.     

强制结构理论及实验检验

学术界对强制关系的研究较少，尽管它无处不在。本文基于要素论探讨强制结构的含义、分类及模型，重点探讨了间接强制结构的效应。间接强制是涉及至少三个行动者的一类“不给钱就制裁,给钱就‘保护’你”的结构关系。实验研究结果表明，在边界条件内，间接强制结构与直接强制结构一样有效力，即有类似的强制幅度和力度，二者都使强制者获得最大的剥夺率。本文最后讨论了影响强制效果的因素，包括强制者的贪欲与策略、强-强联盟及受制者联盟的效应等。     

An Examination of the Use of Coercion by Assertive Outreach and Community Mental Health Teams in Northern Ireland

In mental health services over recent decades, the positivemove away from hospital-based care to community-based serviceshas entailed that people with higher levels of need are beingsupported by community mental health services. This paper beginsby reviewing the literature on coercion in the field of community-basedmental health care and treatment. It is argued that the lackof a critical understanding of the concept and how it is usedby practitioners and agencies can have serious repercussionsfor the rights of service users. Using a quasi-experimental,longitudinal design, the authors then seek to test some of theideas about coercion by comparing the activities of assertiveoutreach and community mental health teams in Northern Ireland,particularly the key ideas of perceived coercion, workers’strategies and engagement with services. Key findings were thatassertive outreach appeared to be more successful at reducingperceived coercion, minimizing the need for coercive strategies,engaging high-risk clients and reducing inpatient bed use. Thesefindings are compared with other studies in this area. The authorsalso argue that there is a need for greater transparency inthe way that practitioners use coercive measures and more explicitguidance is required in this crucial area of mental health practice.     

Alcohol abuse, compulsory treatment and successive aftercare: a qualitative study of client perspectives

In Sweden, the social welfare boards have a statutory duty to provide aftercare for compulsorily treated substance abusers. However, there are no data on how the aftercare is organised and how clients perceive this phase of the compulsory treatment process. The aim of the study is to analyse how a sample of compulsorily treated alcohol abusers ( n  = 12) characterise the current coercive treatment episode and evaluate previously experienced and forthcoming aftercare interventions. Qualitative interview-data were coded into themes and sub-themes encompassing relevant client perspectives. Results show that the alcohol abusers claimed to want (but be denied) adequate help for their problems, both during primary treatment and after discharge. Their perspectives on coercive care and aftercare interventions appeared related to their views on their own problems and on being incarcerated. For instance, those who recognised their own alcohol problems emphasised the importance of quitting consumption and were dissatisfied with interventions offered during and subsequent to compulsory treatment referrals.     

What difference do different settings in residential care make for young people? A comparison of family‐style homes and institutions in Sweden

Residential care in Sweden has undergone great change in recent decades. With new small family-style institutions, the boundaries between residential care and foster care have been blurred. Almost all residential care used to be run by the public sector. Today about 80 per cent is privately run. This study compares three different settings in residential care: institutions run by the public sector, privately run institutions and family-style homes. Among other things, it is found that the institutions run by the public sector have better educated staff and a higher staff–resident ratio than privately run institutions. Despite this, they are more restrictive in their intake and they have youths with fewer problems, especially delinquency and other antisocial behaviour. The results are discussed in relation to developments in the residential care sector in Sweden and in relation to the balance between care and treatment.     

行政即时强制界说

本文分析了现有行政即时强制的定义,并作了重新界定,即行政即时强制是行政主体在紧急情况下,为了维护公共利益、相对人自身或他人的合法权益,对相对人即时设定权利义务,即时执行的一种实力强制行为。本文认为,行政即时强制应与行政强制执行相区别,这种区别的关键在于行政强制实施前是否先行存在某一具体行政行为。同时,行政即时强制还应当与行政强制措施、行政处罚和强制征收相区别。     

Treatment progress of foster care adolescents with severe behavioural problems: Factors conditioning their performance in the residential treatment centres

Behavioural problems are a recurring issue in the child welfare system population. Normative residential centres do not have the characteristics to address the specific needs of these adolescents, so they are usually treated at therapeutic residential centres. In Catalonia (Spain), these cases are treated in intensive educational residential centres (CREIs), a variant of therapeutic residential care (TRC) facilities. This exploratory study seeks to understand the treatment progress of adolescents with severe behavioural problems who were placed in the CREIs, a variant of TRC facilities. Data from 206 cases, the totality of population under treatment in the CREIs, were collected using a questionnaire administered to the treating team. A cross‐sectional design was used, applying quantitative methods to analyse the incidence and interrelation of a series of variables related to the progress of adolescents in the CREIs. Significant differences among profiles by sex, place of origin, criminal offences, substance abuse and mental health disorders were found. Furthermore, adolescents who performed a positive treatment progress according to the professional staff arrived at the CREI at an earlier age and had longer stays than the group with an unremarkable progress. Logistic regression indicated that duration of stay in the centre and runaways predict the adolescents' treatment progress. This treatment is working well with the milder cases; however, it does not tend to be successful for adolescents with greater difficulties. It is recommended that interventions focus on factors that engage the adolescents in their own rehabilitation process, include substance abuse programmes and consider the gender perspective.     

Kurt Lewin Address: Influence, Power, Religion, and the Mechanisms of Social Control

A power/interaction model of interpersonal influence is applied to the analysis of religions as mechanisms of social control. The original six bases of power presented by French and Raven (1959)—coercion, reward, legitimate position, expert, referent, and informational—are expanded to include variants of these bases: personal reward and coercion and legitimacy of equity, reciprocity, and responsibility (Raven, 1992). Over centuries, certain sages, seers, and chieftains, feeling that they knew what was best for their people individually and collectively, have attempted to utilize these power resources (e.g., to counter tendencies toward murder, theft, adultery, mayhem, or harmful dietary practices). To implement power strategies, various preparatory devices were developed, which include the establishment of a Deity, whose ultimate reward and coercive power is enhanced by omnipotence; whose omnipresence establishes necessary continual surveillance; and whose ultimate expertise follows from omniscience. Much of what has been developed in holy works, and in supportive art and literature, can then be seen as further preparing the bases of power for social control. Tensions result when a populace that is educated to expect informational power is faced with a religion that emphasizes extreme coercion, reward, ultimate legitimate and expert power.     

Compulsory Persuasion: A Problem for Correctional Social Work

Summary Social work risks being misused as a technique for controllingundesirable behaviour, regardless of clients' expectations orchoices. This approach to social work involves certain underlyingassumptions about human nature which raise considerable ethicaland practical difficulties. Recent trends in the probation andafter care service are considered, together with some researchstudies of the effectiveness of social work in reducing offendingbehaviour. From these it is argued that social work servicesfor offenders are more likely to be effective when the emphasisis on helping with perceived problems and difficulties ratherthan on crime prevention.     

Incorporating self‐determination into substance abuse prevention programming for youth transitioning from foster care to adulthood

Youth transitioning from foster care to adulthood are at higher risk for alcohol and substance abuse disorders than general population youth. At the same time, these youths are often recipients of strong clinical intervention, often at levels considered unnecessary, for other mental health or behavioural challenges. Because of this, there is sometimes resistance from providers to offer services such as substance abuse prevention programming as it may be seen as contributing to youths' overclinicalization, stigmatization, or retraumatization. Using thematic content analysis, this qualitative study analysed focus groups with community stakeholders providing recommendations on support services for youth transitioning from foster care to adulthood to derive strategies for delivering substance abuse prevention programming in a way that enhances youth self‐determination. Findings were organized by self‐determination theory's 3 key psychological needs: autonomy, competence, and relatedness. All three needs were represented in stakeholder recommendations, which were translated into strategies for bolstering youths' achievement of each need. Strategies include a mix of those already present in motivational interviewing‐based brief substance abuse prevention interventions as well as more unique strategies that are much less frequently employed but that may better meet the needs of youth with foster care experience.     

Child protection social work and men's abuse of women: an Irish study

This paper reports the findings of an exploratory study of the response of social workers within a community care setting, in a large Dublin suburb, to cases involving men's abuse of women. This research aims to focus on what child protection workers do regarding this abuse, and what they say about what they do, thereby giving readers a sense of the action taking place in this social work team. The data, generated from both qualitative and quantitative methodological research, reflects this aim, as it taps into the working model of responses to men's abuse of women held by social workers, and identifies what influences that, thereby reflecting the realities and constraints of everyday work. At the time the research was carried out (2000), the results confirm that the prevalence of cases involving men's abuse of women on this team was in line with international findings. This research revealed an absence of a team policy, an agreed definition of intimate violence in this context and agency practice guidelines, and illuminated how these gaps act as a deterrent to effective intervention. This paper explores some of the ethical and practical dilemmas that may arise for child protection social workers intervening in cases where the abuse of women by men is present. Recommendations arising from this research identify a need for a clear policy and best practice guidelines for social work staff in relation to this abuse.     

Abscondence and duration of treatment of compulsorily committed alcoholics on a locked ward: effects of changes in the treatment program and the law

The study concerns 124 alcoholics compulsorily committed to a locked ward at Runnagården, a coercive treatment setting in mid-Sweden. Three groups are compared: 57 patients were admitted before and 29 were admitted after the implementation of an introductory Alcoholics Anonymous-oriented program on the ward. Another 38 patients were admitted after the changes in legislation, which resulted in a longer duration of compulsory care. The groups were compared as to the number of days spent on the locked unit and the number of times they absconded. With the implementation of the program, a significant reduction was observed in the time needed on the locked ward, while the number of abscondence incidents showed a weaker tendency to decrease. After the legislative changes were made, the same factors increased. Multivariate regression was used to check confounding background factors. In conclusion, the introduction of an Alcoholics Anonymous-oriented program in a coercive treatment setting reduced the time spent on a locked ward without increasing the number of times patients absconded. Increase in length of coercion increased both the time spent at the locked ward and the number of times absconded.     

Reducing Alcohol Abuse in Gay Men: Clinical Recommendations From Conflicting Research

ABSTRACT

Gay men entering the health care system present with unique needs essential for health care providers to comprehend and address. While data indicate mental health and substance abuse disorders are more prevalent among gay men compared with their heterosexual counterparts, the literature assessing abuse of alcohol by gay men is conflicting. This article explores the conflicting research examining the use and abuse of alcohol by gay men, common findings and themes among studies addressing the issue, the theoretical concepts of internalized homophobia and heterosexism as they relate to alcohol abuse, and clinical strategies providers can implement when encountering this issue among their gay male patients. This comprehensive assessment of the literature will also provide direction for future critical inquiries and outline ways to improve the current methods of inquiry.     

Children living with parental substance misuse: A cross‐sectional profile of children and families referred to children's social care

Parental substance misuse is a significant public health and children's rights issue. In the United Kingdom, social workers frequently work with children and families affected by substance misuse. However, relatively little is known about this population, particularly at point of referral to children's social care. This paper reports on the largest known study of parental substance misuse as a feature of children's social care work in England. The paper provides a cross‐sectional profile of 299 children living with parental substance misuse and referred to children's social care in one local authority in England. Data were collected from social work case files at the point of referral to social care about the child, family, the wider environment, and parental substance misuse. The findings show that children affected by parental substance misuse frequently had other support needs relating to their well‐being and mental health. Children were also likely to be experiencing other parental and environmental risk factors. The significant historical—and in some cases intergenerational—social care involvement for some families indicates potential issues with the capacity of services to meet needs. Recommendations for practice are discussed with a particular focus on the need for early, comprehensive support for children and families.     

Raising the Quality of Home Care: A Study of Service Users' Views

Raising standards is one of the key objectives of the British government's Modernizing Agenda. The quality of life of vulnerable older people who are being maintained at home is fundamentally dependent on the quality of the home‐care services they receive, so raising standards of home care is clearly central to this agenda. This paper draws on a small‐scale study of service users and providers to examine the aspects of quality of home care of importance to older people, their experiences and barriers to improvement. Six key aspects of quality were investigated: reliability, continuity, flexibility, communication, staff attitudes and skills and knowledge. If performance indicators are to have the desired effect, more work needs to be done to ensure they reflect key aspects of quality from the user perspective. We identify potential areas for improvement in commissioning and organization but these all have resource implications that will need to be met if home care is to realize its full potential in maintaining and improving quality of life for older people.     

Negative Aspects of Therapy: Client Perceptions of Therapists' Social Influence, Burnout, and Quality of Care

This study investigated the relationships between client perceptions of therapist use of social influence strategies, therapist burnout, and clients' perceptions of the quality of their therapy. Scales were developed to measure personal coercive power, personal reward power, various forms of expert power, and compromise strategies. A scale was also developed to measure clients' perceptions of their therapists' burnout that contained a combination of modified items from the Maslach Burnout Inventory (Maslach & Jackson, 1986) and original items based on stereotypical burnout behaviors. Research participants were 131 undergraduate students at the University of Pittsburgh who reported their experiences as therapy clients. Therapist use of personal coercive influence strategies and certain types of expert influence strategies were negatively associated with clients' perceptions of the quality of their therapy. Therapist use of personal reward influence strategies, compromise, and the therapist's reputation as an expert were positively related to clients' perceptions of the quality of their therapy. Perceived therapist burnout was positively associated with therapist use of personal coercive influence strategies, direct expert influence strategies, and indirect expert influence strategies. The implications of these findings are discussed.     

Judgements of Solomon: anxieties and defences of social workers involved in care proceedings

Evidence from focus group discussions with social workers in child care and child protection was collected for a research project exploring decision‐making in care proceedings and seeking a better understanding of the causes of delay in the process. Here this material is used to examine social workers' feelings about their work and to explore the anxieties they expressed. Isabel Menzies's work on containing anxiety in institutions is used to provide a conceptual framework for thinking about the ways in which individuals' unconscious defences against anxiety may affect the structure, policies and practices of the organization in which they work. It is suggested that this dimension needs to be taken into account in understanding difficulties which arise in putting policy into practice.     

Maine’s Bold Initiative: Homecare for All

A 2018 ballot initiative in Maine proposed universal home care and improved work conditions for home care workers.Although ultimately defeated, the innovative proposal received considerable support and laid the groundwork for an upcoming legislative campaign.It offers a framework for increasing access to home care and creating quality jobs for home care aides. This commentary reviews the problems addressed by the Homecare for All initiative, what was proposed, the campaign process and anticipated next steps, and implications for gerontological social workers.     

Baby Boomer’s Substance Abuse and Researcher Indifference

The current older adult population is more likely to need and seek treatment for alcohol and drug abuse than previous cohorts of older adults, which necessitates the need for age-appropriate substance use treatment. Building on previous research that examined the lack of attention on substance use among older adults, this study examines articles addressing substance use disorders among older adults in leading gerontological and substance abuse journals and federal funding between 2011 and 2017. Publications were identified from ten leading gerontological and ten leading substance abuse journals using Medical Subject Heading (MeSH) terms. During this time-period, there were 68 and 44 articles published in gerontology and substance abuse journals respectively related to substance use disorders in older adults. Most (59.8%) addressed alcohol abuse and 7% involved intervention studies. In the 7-year period, there were 13 federal grants. A paucity of published or funded work exists in this area despite growing misuse and treatment seeking among older adults with substance use disorders. Effectively addressing substance abuse in older adults will require a coordinated effort between researchers and practitioners to establish and implement best practices for practitioners to rely on when working with substance abusing older adults.