Right of active duty military personnel to refuse psychiatric treatment

Under Federal Court precedents, mentally ill patients have a qualified right to refuse treatment. The amount of due process that may be required to override treatment refusals by active duty military patients is discussed. Due process for these individuals need not be judicial, since medical review satisfies federal requirements. Involuntary administration of medication to active duty military personnel is justified in some circumstances. Specific criteria for overriding treatment refusals are suggested. A sample protocol for overriding the treatment refusals of active duty personnel is offered.     

Provider Conscientious Refusal of Abortion,Obstetrical Emergencies,and Criminal Homicide Law

Catholic doctrine’s strict prohibition on abortion can lead clinicians or institutions to conscientiously refuse to provide abortion, although a legal duty to provide abortion would apply to anyone who refused. Conscientious refusals by clinicians to end a pregnancy can constitute murder or reckless homicide under American law if a woman dies as a result of such a refusal. Such refusals are not immunized from criminal liability by the constitutional right to the free exercise of religion or by statutes that confer immunity from criminal homicide prosecution. Core principles of the rule of law require the state to protect the lives of all persons equally and to place the life and health of persons above any the interests of providers have in moral integrity or in respecting the moral status of prenatal humans. In some states criminal liability related to conscientious objection also applies to corporate hospital officials.     

Time Perception in Boys With Attention-Deficit/Hyperactivity Disorder According to Time Duration,Distraction and Mode of Presentation

The present study describes the incidence of test refusal at neuropsychological assessment, investigates its correlates, and its stability. The participants were 124 children aged 3.5 years whose development has been followed from birth in the Jyväskylä Longitudinal Study of Dyslexia (JLD). The frequency of test refusal on the Finnish version of the NEPSY was analyzed with respect to the children's concurrent and earlier cognitive and language skills, assessed using tests and parental ratings. Refusal during test-taking was found to be relatively common at this age, and high frequency of refusal at an earlier age was associated with similar tendency at a later age. High test refusal was associated with compromised neuropsychological and linguistic test scores. Missing data due to refusal were more common in neuropsychological tasks requiring verbal production. It is concluded that test refusals reflect a child's poor underlying skills and an attempt to avoid failure, rather than noncompliant or oppositional behavior.     

How to justify enforcing a Ulysses contract when Ulysses is competent to refuse

Sometimes the mentally ill have sufficient mental capacity to refuse treatment competently, and others have a moral duty to respect their refusal. However, those with episodic mental disorders may wish to precommit themselves to treatment, using Ulysses contracts known as "mental health advance directives." How can health care providers justify enforcing such contracts over an agent's current, competent refusal? I argue that providers respect an agent's autonomy not retrospectively--by reference to his or her past wishes-and not merely synchronically--so that the agent gets what he or she wants right now-but diachronically and prospectively, acting so that the agent can shape his or her circumstances as the agent wishes over time, for the agent will experience the consequences of providers' actions over time. Mental health directives accomplish this, so they are a way of respecting the agent's autonomy even when providers override the agent's current competent refusal.     

Family Influences on Treatment Refusal in School-linked Mental Health Services

This study analyzed family influences on treatment refusal in school-linked mental health services (SLMHS). Specifically, it assessed whether levels of family cohesion, conflict, and organization were related to whether a family refused to initiate recommended treatment. Children (N = 133) referred for emotional and behavioral problems and their families participated. Results indicated that (1) family environment factors explained a significant amount of variance in treatment refusal after controlling for demographic factors, (2) families of children with predominantly internalizing symptoms were at greater risk for refusing treatment than families of children with predominantly externalizing symptoms, and (3) lower level of family cohesion was an individual risk factor for refusing treatment. Incorporating an evaluation of family environment within SLMHS assessments may aid in the identification of areas wherein intervention may be beneficial in preventing treatment refusal.     

Sensitive Topics,Missing Data,and Refusal in Social Network Studies: An Ethical Examination

We describe our ethics‐driven process of addressing missing data within a social network study about accountability for racism, classism, sexism, heterosexism, cis‐sexism, ableism, and other forms of oppression among social justice union organizers. During data collection, some would‐be participants did not return emails and others explicitly refused to engage in the research. All refusals came from women of color. We faced an ethical dilemma: Should we continue to seek participation from those who had not yet responded, with the hopes of recruiting more women of color from within the network so their perspectives would not be tokenized? Or, should we stop asking those who had been contacted multiple times, which would compromise the social network data and analysis? We delineate ways in which current discussions of the ethics of social network studies fell short, given our framework and our community psychology (CP ) values. We outline literature that was helpful in thinking through this challenge; we looked outside of CP to the decolonization literature on refusal. Lessons learned include listening for the possible meanings of refusals and considering the level of engagement and the labor required of participants when designing research studies.     

Validation of a component model of social skill with outpatient adults

Little social skills research has been generated from applied outpatient settings. The present study examined the relationship of behavioral social skill components to independent judges' social skill judgments. A secondary question was whether nonverbal components would demonstrate a curvilinear relationship to social skill ratings. Forty-two outpatient adults at a community mental health center were videotaped role-playing eight scenes (four commendatory and four refusal). Videotapes were viewed in random order by community members who rated the subject's social skill in the situation. Trained raters scored the videotapes on standard behavioral components. While both nonverbal and verbal components accounted for significant portions of unique variance, the percentage of eye contact was an overwhelmingly large contributor to skill judgments. No curvilinear trend was evidenced for the nonverbal components. The study extended prior findings with psychiatric inpatients into applied outpatient settings and indicated that a component social skills model is equally applicable with outpatient adults. The findings replicated with a second sample of outpatient adults.     

The effects of alcohol intoxication and sexual interest on men's sexual persistence and hostility in a dating simulation

Perpetrators of sexual assault are often intoxicated; however, few experimental studies evaluate alcohol's “in the moment” effects on sexual aggression. This study extends past theory and research by examining the acute effects of alcohol on men's decisions about how to respond to sexual refusals in a dating simulation. Men (N = 62) ages 21–29 were randomly assigned to consume alcohol (target breath alcohol level 0.080%) or no alcohol. Participants were encouraged to talk to a simulated woman and act as they would on an actual date. They made choices from a list which included nonsexual and sexual options. The female agent was programmed to engage in some sexual activities but refuse others. Refusals became more intense if participants persisted. Negative binomial regression analysis was used to test a path analytic model. As predicted, participants' self‐reported desire to have sex was positively associated with choosing more consensual sexual activities during the simulation (i.e., activities in which the woman willingly engaged). Consensual sexual activities were positively associated with the number of times participants persisted after the woman refused. Alcohol moderated this relationship such that it was stronger for intoxicated men than sober men. The more sexual refusals participants received, the more hostile verbal comments they made to the woman. Contrary to our predictions, this relationship was not moderated by alcohol condition. Because participants had multiple opportunities to escalate their aggression or desist, this paradigm provides new insights into the mechanisms through which intoxication enhances the likelihood of sexual aggression in dating situations.

     

On refusal

Traditionally, all efforts to counter psychotherapeutic work have been captured under the umbrella term, "resistance." However, it is useful to distinguish a concept of refusal. Resistance entails therapeutically a gradual elaboration of unconscious, preconscious, and partially conscious experience. Refusal manifests as a willful nonparticipation in offering or responding to material that can be symbolized. All communication has an element of refusal, which occurs at various levels of persistence, intensity, and legitimacy. Clinical examples are provided to discriminate refusal from resistance proper, and to describe three categories of mental and group experience, (a) refusal to perceive external experience; (b) refusal to think about what one knows, and (c) refusal to think about what one does not know. Therapeutic impasses may relate to limitations of the therapist's creativity and flexibility in thinking about and dealing with refusals, including one's own.     

Concurrent treatment of mother and child in resolution of multigenerational separation and individuation difficulties

This case serves as a paradigm of concurrent treatment of a mother and child, where the central problem was one of separation-individuation. The nature of the child's presenting symptom of night terrors, the overinvolvement of the mother and the child, and the tendency of the child to withdraw from the outside world, all pointed to a child at risk for the more symptomatic development of school refusal and greater psychopathology. Since the treatment took place within a full service community mental health clinic, it was possible to provide psychiatric evaluation and consultation of both mother and child and the use of two therapists working collaboratively. With this method of treatment, the unfolding of both mother's and child's separation-individuation processes could be identified and utilized. Since she was an electively mute child who refused to come into the treatment room, another therapeutic tool became the use of the younger brother as a facilitator.     

Preventive intervention strategies with hard-to-reach mothers: A collaboration between midwives and psychotherapists

Maternal refusal of psychiatric services can pose a problem for both the family and mental health practitioners. With a sample of mothers who had refused psychiatric services in the past, the present study examined the effectiveness of initiating and maintaining mental health services when midwives acted as mediators. After the midwives had developed a relationship with the mothers, suggestions for mental health services were made again. For part of the sample, therapists accompanied the midwife on a home visit and scheduled subsequent therapy sessions in the home. For the remaining subjects, referrals were made to the local community mental health center. Results indicated substantially greater success in both the initiation and maintenance of therapy when midwives acted as mediators and therapy continued in the home.     

Clinical significance of test refusal among young children.

The present study describes the incidence of test refusal at neuropsychological assessment, investigates its correlates, and its stability. The participants were 124 children aged 3.5 years whose development has been followed from birth in the Jyv?skyl? Longitudinal Study of Dyslexia (JLD). The frequency of test refusal on the Finnish version of the NEPSY was analyzed with respect to the children's concurrent and earlier cognitive and language skills, assessed using tests and parental ratings. Refusal during test-taking was found to be relatively common at this age, and high frequency of refusal at an earlier age was associated with similar tendency at a later age. High test refusal was associated with compromised neuropsychological and linguistic test scores. Missing data due to refusal were more common in neuropsychological tasks requiring verbal production. It is concluded that test refusals reflect a child's poor underlying skills and an attempt to avoid failure, rather than noncompliant or oppositional behavior.     

Mother–child disputes as arenas for fostering negotiation skills

Valsiner's concepts of the zone of free movement (ZFM) and the zone of promoted actions (ZPA) were applied to mother-child disputes to study how mothers discharge their role as experts in negotiation. Twenty mothers of 3-5-year-olds each reported 20 disputes, 10 in which the mother was making a request and 10 in which she was refusing her child's request. The disputes were analysed sequentially using four models, preservation, copycat, reward/punishment, and provision of a rationale. The results showed that perseveration and copycat models were more likely to apply when there was negative affect. Mother's re-requests fitted the reward/punishment model whereas mother's refusals better fitted the provision of a rationale model. Information from follow-up interviews supported the notion that requests and refusals are being socialized differently. The results imply that, whereas children's requests and refusals are within the ZFM, only their requests are within the ZPA.     

Evaluation of a finger prompt variation in the treatment of pediatric feeding disorders

Children with feeding disorders often engage in refusal behavior to escape or avoid eating. Escape extinction combined with reinforcement is a well-established intervention to treat food refusal. Physical guidance procedures (e.g., jaw prompt, finger prompt) have been shown to increase food acceptance and decrease inappropriate mealtime behavior when more commonly employed escape extinction (e.g., nonremoval of the spoon) procedures are ineffective. The finger prompt, however, has not been extensively evaluated as a treatment adjunct to target food refusal, thus necessitating further examination. The purpose of this prospective study was to assess a variation of a finger prompt procedure to treat food refusal and to assess caregivers' acceptability of the procedure. Three children age 1 to 4 years admitted to an intensive feeding disorders program and their caregivers participated. The finger prompt was effective in increasing bite acceptance across all participants and decreasing or maintaining low levels of inappropriate behavior for 2 participants. The procedure was also acceptable to all caregivers.     

Selective nontreatment and spina bifida: A case study in ethical theory and application

Defective newborn children are to be considered human persons. Thus, primary duty in proxy consent is to act with the infant's best interest in mind. This duty may at times override the otherwise prima facie right to life, but only under restricted circumstances. Refinements of McCormick's “relational potential” criteria and of ordinary-extraordinary means analysis prove useful in such decisions. Utilitarian considerations of social consequences have impact but can be kept subsidiary. The importance for decision making of available child support services is considered. Spina bifida is used throughout as an example of issues discussed.     

THE COSTS OF EATING: A BEHAVIORAL ECONOMIC ANALYSIS OF FOOD REFUSAL

Behavioral economic concepts were applied to the analysis and treatment of pediatric feeding disorders in a clinical setting. In Experiment 1, children who chronically refused food were presented with varying amounts of food on a spoon (empty, dipped, quarter, half, and level). Each child exhibited a different but orderly demand function of response (acceptance, expulsion, and mouth clean) by cost (increasing spoon volume) for a constant pay-off of toys and social interaction. In Experiment 2, physical guidance or nonremoval of the spoon for food refusal was initiated at the smallest spoon volume with low levels of acceptance, and was subsequently introduced at the largest spoon volume with moderate levels of acceptance. Treatment was effective in increasing acceptance, and these effects generalized hierarchically across untargeted spoon volumes. The results of both studies provide preliminary support that increasing spoon volume can be equated conceptually with increasing response effort, and that the change from differential reinforcement to physical guidance or nonremoval of the spoon appears to have altered the elasticity of each child's demand function.     

Hierarchical Vs. Generally Overlapping Models In Psychiatric Classification

This paper illustrates two formal models for psychiatric classification. The first model, called a hierarchical or tree structure, requires patient categories to be disjoint or strictly nested. The second model, called the generally overlapping or network model, allows patient categories to cut across each other in a variety of different ways. Thus, patient groups can be disjoint, strictly nested (as in a hierarchy), or partially overlapping. To derive classification schemes consistent with the structural models, two different clustering techniques were applied to interpatient similarity data collected on 50 psychiatric patients. A hierarchical clustering technique was applied to the similarity data to obtain a hierarchical classification. To obtain a generally overlapping classification, Peay's cliquing procedure was applied to the same data. Two criteria were used to compare the clustering solutions. First, a solution's goodness-of-fit to the original data was examined by calculating the proportion of variance accounted for by cluster categories. Second, the predictive accuracy of a solution was analyzed by looking at the categories' ability to predict treatment assignment. The generally overlapping solution produced the best fit to the original similarity data; however, the hierarchical solution's clusters tended to be more readily interpretable in terms of psychiatric syndromes. Both clustering solutions were relatively poor predictors of treatment assignment. It was concluded that the hierarchical and generally overlapping approaches, although not conclusively demonstrated, represented promising models for psychiatric classification.