The motives and ethical justifiability of treating patients with borderline personality disorder under compulsory care

This thesis aims to investigate what motives psychiatrists have for detaining patients with BPD under compulsory care. Also, to examine hospital staff’s experiences of treating patients with BPD under involuntary care and improve the inpatient mental health care for these patients. Finally, to ethically deliberate on if or when compulsory care is justified for patients with BPD, and thereby provide ethical guidance to psychiatrists when deciding on such care. The thesis consists of five studies. Here are the abstracts:

Study I: A qualitative study based on semi-structured interviews with twelve Swedish psychiatrists to investigate psychiatrists' motives for practising compulsory care of patients with BPD. Results: The qualitative data resulted in three themes: (1) patients with BPD are perceived as difficult, (2) there are medical and non-medical motives for compulsory care of patients with BPD, and (3) patients with BPD have decision competence and sometimes demand to be taken into compulsory care. Conclusion: The interviewed psychiatrists' judgements and values, rather than clinical and legal directives, were decisive in their practice of compulsory care.

Study II: A normative study on the ethical justifiability of treating patients with BPD compulsorily on their demand, as Ulysses contracts. We scrutinize the arguments commonly used in favour of such Ulysses contracts: (1) the patient lacks free will, (2) Ulysses contracts as self-paternalism, (3) the patient lacks decision competence, (4) Ulysses contracts as a defence of the authentic self, and (5) Ulysses contracts as a practical solution in emergencies. Conclusion: Ulysses contracts including compulsory care should not be used for this group of patients.

Study III: A questionnaire study distributed to all psychiatrists and psychiatric residents working in psychiatric emergency units or inpatient care in Sweden. The aim was to investigate their motives for treating patients with BPD under compulsory care. Results: The psychiatrists’ views were divided on when it was justified to treat patients with BPD under compulsory care. Conclusion: The large variations in doctors’ opinions indicate that the care of borderline personality disorder patients is arbitrary. Further, the assessed risk of harm seems to increase the use of compulsory care.

Study IV: A questionnaire study, the respondents being nurses and psychiatric aides employed at psychiatric hospital wards in Sweden. The study aimed to investigate the healthcare staff’s experiences of treating patients with BPD under compulsory care. Results: Most respondents experienced that more than a week’s compulsory admission either increased (68%) or had no effect (26%) on self-harm behaviour. A majority (69%) considered the compulsory admissions to be too long at their wards. Respondents recommended care plans with discharge dates and around three-day-long voluntary admissions to reduce compulsory hospital admissions. Discussion: These findings imply that many patients with BPD are regularly forced to receive psychiatric care that inadvertently can make them self-harm more.

Study V: A normative study on if and when compulsory care is ethically justified for patients with BPD. Analysis of commonly used arguments, which defend the use of compulsory care for patients with BPD: (1) the patients lack decision competence, (2) the patients lack authenticity, (3) compulsory care is suicide-preventive, (4) compulsory care safeguards the doctor against litigation, (5) compulsory care is a practical solution in emergencies, and (6) it is better for the caregiver to ‘err on the safe side’. Conclusion: Compulsory care is rarely ethically justified, save for exceptional situations when the clinician has probable reason to believe that the patient lacks decision capacity, e.g., by suffering from a severe mental co-morbidity, and stands to benefit from such care.

List of scientific papers

I. Lundahl A, Helgesson G, Juth N. Psychiatrists’ motives for practising in-patient compulsory care of patients with borderline personality disorder (BPD). International Journal of Law and Psychiatry. 2018, May-Jun; 58: 63-71.
https://doi.org/10.1016/j.ijlp.2018.03.005

II. Lundahl, A., Helgesson, G. & Juth, N. Against Ulysses contracts for patients with borderline personality disorder. Medicine, Health Care and Philosophy. 2020; 23: 695–703.
https://doi.org/10.1007/s11019-020-09967-y

III. Lundahl A, Hellqvist J, Helgesson G, Juth N. Psychiatrists’ motives for compulsory care of patients with borderline personality disorder – a questionnaire study. Clinical Ethics. 2022, 17(4): 377390.
https://doi.org/10.1177/14777509211040190

IV. Lundahl A, Torenfält M, Helgesson G, Juth N. Patients with borderline personality disorder and the effects of compulsory admissions on self-harm behaviour: a questionnaire study. Nordic Journal of Psychiatry. 2023, Jul; 77(5): 498-505.
https://doi.org/10.1080/08039488.2023.2166106

V. Lundahl A, Helgesson G, Juth N. Is compulsory care ethically justified for patients with borderline personality disorder? Clinical Ethics. 2024; 19(1): 35-46.
https://doi.org/10.1177/14777509231216036