Patients' perceptions of coercion on admission to forensic psychiatric hospital: a comparison study

Procedural justice and forensic mental health: An introduction and future directions

This article advocates for integrating procedural justice principles into forensic mental health services to enhance patient engagement and autonomy. Procedural justice, broadly defined as fair decision-making processes, is introduced and key principles including voice, neutrality, respect and trustworthiness are described. Evidence suggestive of positive outcomes following procedural justice experiences, such as improved satisfaction, collaboration and reduced perceptions of coercion is outlined. Practical applications are suggested, including staff training and reflective practices using procedural justice principles. The article then calls for further research to explore patients' and staff members' experiences of procedural justice in forensic settings, develop measurement tools, undertake intervention studies and establish causal links between procedural justice and outcomes important for forensic patients.

Perceptions of procedural justice and coercion among forensic psychiatric patients: a study protocol for a prospective, mixed-methods investigation

BACKGROUND

The risk and recovery paradigms are the dominant frameworks informing forensic mental health services and have been the focus of increasing research interest. Despite this, there are significant gaps in our understanding of the nature of mental health recovery in forensic settings (i.e., 'secure recovery'), and specifically, the key elements of recovery as perceived by forensic patients and their treatment providers. Importantly, we know little about how patients perceive the forensic mental health system, to what extent they see it as fair and legitimate, and how these perceptions impact upon treatment engagement, risk for adversity, and progress in recovery.

METHODS

In this prospective, mixed-methods study, we investigate patient perceptions of procedural justice and coercion within the context of the forensic mental health system in Ontario, Canada (final N = 120 forensic patients and their primary care providers). We elicit patient self-assessments of risk and progress in recovery, and assess the degree of concordance with clinician-rated estimates of these constructs. Both qualitative and quantitative methods are used to assess the degree to which patient perceptions of coercion, fairness and legitimacy impact upon their level of treatment engagement, risk for adversity and progress in recovery. A prospective, two-year follow-up will investigate the impact of patient and clinician perspectives on outcomes in the domains of forensic hospital readmission, criminal reoffending, and rate of progress through the forensic system.

DISCUSSION

Results from this mixed-methods study will yield a rich and detailed account of patient perceptions of the forensic mental health system, and specifically whether perceptions of procedural fairness, justice and legitimacy, as well as perceived coercion, systematically influence patients' risk for adversity, their ability to progress in their recovery, and ultimately, advance through the forensic system towards successful community living. Findings will provide conceptual clarity to the key elements of secure recovery, and illuminate areas of similarity and divergence with respect to how patients and clinicians assess risk and recovery needs. In doing so, knowledge from this study will provide a deep understanding of factors that promote patient safety and recovery, and provide a foundation for optimizing the forensic mental health system to improve patient outcomes.

An exploration of perceived coercion into psychological assessment and treatment within a low secure forensic mental health service

Psychologists working within forensic mental health (FMH) services face challenges around supporting clients' informed consent when engaging in psychological assessment and treatment. Given that there is little research in this area, this qualitative study interviewed ten forensic inpatients from a low secure FMH service, to determine the impact of any perceived coercion to engage with psychologists. Interviews were transcribed and subject to Thematic Analysis. Three over-arching themes emerged from the analysis: 'Awareness of Coercive Power', 'Experiencing and Responding to Coercion' and 'Psychological Treatment is Helpful, But…'. Participants perceived coercion to engage with psychologists. Perceived coercion led to psychological distress, wanting to resist, and superficial engagement. Despite this, therapeutic alliance was established with the psychologist but the quality of the therapeutic alliance was compromised. The findings have implications for psychologists working in FMH services. Suggestions for reducing perceived coercion and future directions for research are discussed.

Crushed by the Belgian system: Lived experiences of forensic care trajectories by persons labelled as not criminally responsible

BACKGROUND

Care trajectories of Persons labelled Not Criminally Responsible (PNCR) are often characterized by multiple transitions from one (forensic) mental health service to another and by long periods of admission. So far, little research has been conducted on forensic care trajectories, in particular on how PNCR perceive the trajectories they are subjected to.

METHOD

Data were obtained via semi-structured interviews (N = 23) with PNCR in various (forensic) mental health services in Belgium. A maximum variation sampling strategy was applied to recruit a heterogeneous group of PNCR and inductive thematic analysis adopted to analyse the data.

RESULTS

PNCR's experiences about care trajectories in Belgium are marked by an absent voice and passive position in the decision-making process in addition to a lack of support during transitions. Barriers for admission in (forensic) mental health services and the indeterminate duration of care trajectories contribute to overall negative lived experiences.

CONCLUSION

Although some findings are interchangeable with general mental health care, PNCR's care trajectories differ by their undetermined nature, barriers for accessing care and power dynamics in compulsory forensic care. As concepts from prison sociology, such as tightness, power holders and pain of indeterminacy, seem to be equally relevant for the situation of PNCR, the balance between a criminal justice and mental health approach in forensic mental health care is questioned.

Coercion in psychiatric care: where are we now, what do we know, where do we go?

Coercion is a subjective response to a particular intervention and has been considered an unfortunate but necessary part of the care of people with psychiatric illness. Its ethical underpinnings, evidence base and clinical implications are not commonly considered in day-to-day care; however, this requires reconsideration as the potential for an increase in coercion stretches beyond the boundaries of the hospital into the community. Much of the research that has been undertaken highlights the prevalence of coercion, the ‘grey zone’ between compulsory interventions and the experience of patients and patient outcomes in the light of coercion. Policy makers need to consider the evidence for interventions that increase the experience of coercion in order to reduce its impact. Clinicians need to understand the principles of procedural justice, minimise the use of legal detention and be mindful that implied consent for one intervention may lead to experiences of coercion involving linked management strategies.

Coercion or Caring: The Fundamental Paradox for Adherence Interventions for HIV+ People with Mental Illness

To determine if an escalating HIV treatment adherence intervention would be considered by participants from a caring or coercive perspective, perceived coercion was examined in 238 community-based dually diagnosed individuals (HIV+ and a serious mental illness) randomized to a treatment-as-usual (TAU) control group or preventing AIDS through health for HIV+ persons (PATH+) Intervention that increased intervention intensity when adherence fell below 80 %. Minor differences were observed in perceived coercion between the PATH+ Intervention and Control groups with perceived coercion marginally higher in the PATH+ group. Latent growth curve analyses indicate that perceived coercion was not related to duration of the intervention for either the PATH+ or Control group. The experience of coercion by HIV+ individuals receiving community-based mental health services was not related to the intensity or duration of delivered services.

The impact of coercion on treatment outcome: one-year follow-up survey

OBJECTIVE

This study examined whether coercive measures or perceived coercion experienced by mentally disabled patients in the hospitalization process could be justified under paternalism. To find out whether coercion can be justified by paternalism, a year of follow-up research was conducted to examine the impact of coercive measures and perceived coercion experienced during hospitalization on the patients' therapeutic benefit.

METHODS

A 6-month period and a 1-year period of follow-up research was conducted with 266 patients to assess whether the coercion they experienced during hospitalization (coercive measures and perceived coercion) had an effect on changing the patients' mental symptoms and insight.

RESULTS

The results showed a decrease in both mental symptoms and insight over time. However, it was found that neither coercive measures nor perceived coercion had a significant effect on the change of mental symptoms and that, thus, coercion had little contribution to the declining of symptoms. Coercive measures had no effect on the change of insight but perceived coercion was shown to have a positive effect on a change in insight. Patient insight was shown to improve with increased perceived coercion.

CONCLUSIONS

Paternalism provides a partial explanation to serve as a basis for justifying perceived coercion. Limitations and suggestions for further study are discussed.

Examining attitudes about and influences on research participation among forensic psychiatric inpatients

Although a growing body of research has examined various types of coercive practices that may occur among psychiatric patients over the years, almost no attention has been given to coercive influences that may occur specifically in the context of recruitment into research projects. Particularly for those who are institutionalized (e.g., in-patient insanity acquittees), there are significant concerns that their autonomous decision-making to consent or not may be significantly impaired due to the highly restrictive and controlled environment in which they live. This exploratory study sought to examine patients' perceptions of coercive influences by presenting them with hypothetical research vignettes regarding possible recruitment into either a biomedical or social-behavioral research project. Among 148 multi-ethnic male and female participants across two facilities, participants reported relatively minimal perceptions that their autonomous decision-making would be impacted or that various potentially coercive factors (e.g., pressures from staff) would impair their free choice to participate (or not) in such research. To the extent that such perceptions of coercion did occur, they were moderately associated with patients' more general personality traits and attitudinal variables, such as alienation and external locus of control. Limitations of this study and their implications for future research are discussed.

Quasi-experimental comparison of coercive interventions on client outcomes in individuals with severe and persistent mental illness

This study compares outpatient commitment (OPC) and Assertive Community Treatment (ACT) as forms of coercive treatment interventions to evaluate the influence of each individually and in combination on clients' perception of procedural justice and coercion, as well as clinical outcomes that include treatment compliance, quality of life, symptom distress, empowerment, and violence/victimization. Findings support that the perception of procedural justice and coercion are inversely related; persons subject to OPC experience higher levels of perceived coercion, and higher levels of perceived coercion do not influence treatment compliance. ACT alone does not increase the perception of coercion nor is there any interaction effect.

The meaning of care on a locked acute psychiatric ward: Patients' experiences

BACKGROUND

The deinstitutionalization of psychiatric care has led to a concentration of patients to fewer wards. This leads to difficulties in separating voluntarily and involuntarily admitted patients, and there is a risk that the interest in safeguarding patients' autonomy will decrease.

AIMS

The aim of this study was to elucidate the meaning care has to patients on a locked acute psychiatric ward. The study was performed on a ward for patients with affective and eating disorders who were admitted both voluntarily and involuntarily.

METHODS

Interviews were conducted and analysed using qualitative content analysis.

RESULTS

The results show that to the patients, care had contradictory qualities some alleviated their suffering while others contributed to stress. The alleviation from suffering originated from the experiences of strengthened integrity and self-determination, from being supported, and having a place of refuge on the ward. In contrast to this, there were experiences of being dependent and trapped because of lack of influence and choice, and being controlled.

CONCLUSIONS

In conclusion, this qualitative study shows that to the patients, care can mean being disciplined in a way that risks undermining the alleviation of suffering that care can provide. It is thus important to be observant when it comes to manifestations of control in care. The study also shows that the support of fellow patients has a value as a complement to the care given by staff members and next of kin, something that needs to be further investigated.

Outpatient commitment and coercion in New Zealand: a matched comparison study

BACKGROUND

It has been hypothesized that a degree of coercion is a necessary component in using outpatient commitment to attain therapeutic outcome for those people subject to mental health law. However, what degree of coercion is required and how it is sustained is poorly understood. There is speculation that patients' recognition of beneficial as well as unwanted aspects of outpatient commitment (ambivalence) maybe an indicator that the necessary level of coercion has been achieved to facilitate a therapeutic outcome.

AIM

The aim of this study was to determine the level of coercion perceived by those under outpatient commitment in New Zealand. Emphasis was given to consideration of the presence of ambivalence and the role of interactive processes, including procedural justice, in influencing patients' perceptions of coercion.

METHOD

A cross-sectional comparative study was undertaken to compare the perceptions of coercion of patients on outpatient commitment (n = 69) to a matched sample of voluntary outpatients (n = 69), using the Perceived Coercion Scale. The influence of a range of variables, including patients' knowledge of and beliefs concerning outpatient commitment, were considered.

RESULTS

Although the level of coercion for involuntary outpatients was relatively low, it was significantly higher than that experienced by voluntary outpatients. Yet involuntary outpatients were more likely to espouse benefits of outpatient commitment. Although there was an inverse correlation between perceptions of procedural justice and perceived coercion, procedural justice did not feature in the linear regression analysis.

DISCUSSION

In the New Zealand context, involuntary outpatients hold contrasting views to outpatient commitment. We suggest that this ambivalence is an indicator that the degree of coercion is suffice to achieve therapeutic outcome. Furthermore, this study suggests the impact of procedural justice on patients' perceptions of coercion may be more crucial during admission to hospital than in the context of on-going community care.

Coercion, involuntary treatment and quality of mental health care: is there any link?

PURPOSE OF REVIEW

This paper summarizes major results and debates in the field of coercive or involuntary treatment of the mentally ill and how these relate to the quality of care, as published in literature during 2002 and 2003.

RECENT FINDINGS

Studies focus on four major issues: involuntary hospital placement and treatment of mentally ill patients, compulsory outpatient treatment, attitudes towards or perceived coercion, and ethics of coercive measures in mental health care. Studies suggest a complex correlation between the involuntary placement of mentally ill patients, coercive measures, and outcomes. Outcome indicators for the quality of mental health care are not standardized, but vary with the point of view of the individual or collective assessor. None of the results question the necessity or the legality of involuntary treatments or conclude to refrain from employing coercive measures in mental health care if these cannot be avoided. Many results of research on attitudes towards involuntary treatments or perceived coercion suggest an acceptance of the application of coercive measures, even by the persons concerned, if the legal conditions are clearly defined. Research standards or study designs may benefit from some improvement. Study samples usually are small and only in rare cases has their selection been representative.

SUMMARY

Research activities are remarkably few in number, especially considering the frequency of involuntary measures and the controversial perception or discussion of these measures among the persons concerned, professionals, or a wider public. Many basic research questions still remain to be adequately addressed, such as the long-term effects of involuntary treatment.

Integrating the criminal justice system into mental health service delivery: the worcester diversion experience

The substantial number of persons with mental illness encountered in many sectors of the criminal justice system has spurred actors from various agencies within that system to take actions aimed at reducing the growth of this population. These actions have included the development of specialty police units, jail diversion programs, and other mechanisms for channeling persons with mental illness out of the criminal justice system and into mental health treatment. The courts, too, have become involved in this effort with the recent development of the "mental health court," the latest of the "specialty" or "problem solving courts." These courts have not been without their critics, however, nor are they the only feasible approach to court-based diversion. This paper identifies and explores a range of options for structuring the relationship between criminal courts and local mental health systems. Beginning with a discussion of the rationale motivating the development of mental health courts, two alternatives to this specialty court model are discussed. One involves judges dealing with defendants having mental illness and substance abuse on a case-by-case basis. The other takes advantages of linkages that may already exist between most courts and the mental health providers who conduct their forensic assessments, expanding the role of these providers to serve as boundary spanners between courts and the components of local mental health systems. Regardless of the model adopted, however, appropriate linkages must exist between the courts and relevant providers. A case study is provided that demonstrates how the status of a locale's linkages can be evaluated and how the information derived from such evaluation can be used to improve the linkages between police, courts, and health and human services agencies.