Patient perceptions of coercion in mental hospital admission

Pathways to experienced coercion during psychiatric admission: a network analysis

BACKGROUND

In mental health care, experienced coercion, also known as perceived coercion, is defined as the patient's subjective experience of being submitted to coercion. Besides formal coercion, many other factors have been identified as potentially affecting the experience of being coerced. This study aimed to explore the interplay between these factors and to provide new insights into how they lead to experienced coercion.

METHODS

Cross-sectional network analysis was performed on data collected from 225 patients admitted to six psychiatric hospitals. Thirteen variables were selected and included in the analyses. A Gaussian Graphical Model (GGM) using Spearman's rank-correlation method and EBICglasso regularisation was estimated. Centrality indices of strength and expected influence were computed. To evaluate the robustness of the estimated parameters, both edge-weight accuracy and centrality stability were investigated.

RESULTS

The estimated network was densely connected. Formal coercion was only weakly associated with both experienced coercion at admission and during hospital stay. Experienced coercion at admission was most strongly associated with the patients' perceived level of implication in the decision-making process. Experienced humiliation and coercion during hospital stay, the most central node in the network, was found to be most strongly related to the interpersonal separation that patients perceived from staff, the level of coercion perceived upon admission and their satisfaction with the decision taken and the level of information received.

CONCLUSIONS

Reducing formal coercion may not be sufficient to effectively reduce patients' feeling of being coerced. Different factors seemed indeed to come into play and affect experienced coercion at different stages of the hospitalisation process. Interventions aimed at reducing experienced coercion and its negative effects should take these stage-specific elements into account and propose tailored strategies to address them.

Exploring Patients' Feeling of Being Coerced During Psychiatric Hospital Admission: A Qualitative Study

Various coercive measures can be used to legally compel a person suffering from psychiatric disorder to undergo treatment. However, evidence suggests that patients' feeling of being coerced is not determined solely by their being submitted to formal coercion. This study aimed to explore voluntary and involuntary patients' experience of coercion during psychiatric hospitalisation and to identify which factors, from their perspective, most affected it. We chose a qualitative design inspired by a hermeneutic-phenomenological approach. Participants were purposively selected from six psychiatric hospitals in Switzerland. Maximum variation sampling was used to ensure the inclusion of patients with different levels of perceived coercion and different admission statuses. In-depth, semi-structured interviews were co-conducted by a research psychologist and a service-user researcher. The transcribed data underwent thematic analysis. All twelve interviewed patients described the hospitalisation as an experience of loss of control over their life due to either external or internal pressures. During the process, perceptions of these pressures varied and sometimes overlapped, leading some patients to describe their admission as a form of simultaneous protection and violation. The balance between these two contradictory feelings was affected by a variety of contextual and relational factors, as well as by the meaningfulness of the experience and the patient's subsequent satisfaction with it. Increasing policy-makers' and clinicians' awareness about the main factors influencing patients' experience of loss of control is of paramount importance in order to develop skills and strategies able to address them, reinforcing patients' empowerment, reducing their feeling of coercion and improving their well-being.

Feeling coerced during voluntary and involuntary psychiatric hospitalisation: A review and meta-aggregation of qualitative studies

Objective

This review aimed to provide an aggregative synthesis of the qualitative evidence on patients' experienced coercion during voluntary and involuntary psychiatric hospitalisation.

Design

A qualitative review.

Data sources

The search was conducted, in five bibliographic databases: Embase.com, Ovid MEDLINE(R) ALL, APA PsycINFO Ovid, Web of Science Core Collection and the Cochrane Database of Systematic Reviews.

Review methods

Following the Joanna Briggs Institute approach, a systematized procedure was applied throughout the review process, from data search to synthesis of results. The reporting of this review was guided by the standards of the PRISMA 2020 statement. The quality of the included studies was critically appraised by two independent reviewers using the JBI Critical Appraisal Checklist. Included findings were synthesized using meta-aggregation. Confidence in the review findings was assessed following the Confidence in the Output of Qualitative research synthesis (ConQual) approach.

Results

A total of 423 studies were identified through the literature search and 26 were included in the meta-aggregation. Totally, 151 findings were extracted and aggregated into 27 categories and 7 synthesized findings. The synthesized findings focused on: the patients' experience of the hospitalisation and the associated feeling of coercion; the factors affecting this feeling, such as the involvement in the decision-making process, the relationships with the staff and the perception of the hospital treatment as effective and safe; the coping strategies adopted to deal with it and the patients' suggestions for alternatives. All synthesized findings reached an overall confidence score of "moderate". The seven findings were downgraded one level due to dependability limitations of the included studies.

Conclusion

Based on these findings, seven recommendations for clinical practice where developed, such as fostering care ethics, promoting patients' voice and shared decision-making, and enhancing patients' perceived closeness, respect and fairness. Five recommendations for future research were also prompted, for instance improving the methodological quality and cultural variation of future qualitative studies, and exploring the psychosocial impact of experienced coercion on patients. For these recommendations to be effectively implemented, a profound change in the structure and culture of the mental health system should be promoted. The involvement of patients in the design, development and scientific evaluation of this change is strongly recommended.

Examining Perceived Coercion in Drug Treatment Courts

While perceptions of voluntary consent have been studied among participants in Mental Health Courts (MHC), little is known about coercion among participants in Drug Treatment Courts (DTC), the most common type of specialty court. The purpose of the present study was to examine perceptions of coercion at enrollment among participants (N = 85) in two Massachusetts DTCs. Results indicated that, on average, participants reported low levels of perceived coercion (M = 1.67, SD = 1.23), which suggests that most individuals did not perceive their decision to enroll in DTC to be coercive. However, further research is needed to delineate whether clinical or procedural variations exist within DTCs, if levels of perceived coercion predict DTC participant outcomes, and if subpopulations experience higher or lower levels of coercion.

Perceived fairness as main determinant of patients' satisfaction with care during psychiatric hospitalisation: An observational study

INTRODUCTION

Patient satisfaction with care is widely recognized as one of the most important indicator of quality in mental health care. It can impact several treatment outcomes, such as treatment adherence and engagement with services. At the same time, as an outcome in itself, satisfaction with care is also affected by several factors, first and foremost by being coerced. The main aim of this study was to test if perceiving treatment pressures as fair and effective could positively impact patient satisfaction, even more than formal coercive measures.

METHODS

Globally, 133 voluntary and involuntary inpatients were interviewed. Socio-demographic and clinical characteristics, including history of previous experiences of formal coercion and legal status of the hospitalisation, were collected through a structured questionnaire and medical charts. The participants were also asked to complete the Index of Fairness and Index of Effectiveness tools as well as a structured questionnaire on satisfaction with care. Simple and multiple linear regressions were performed.

RESULTS

Although several factors were found to affect satisfaction with care when taken independently, perceived fairness was the stronger predictor of both satisfaction with treatment (β =.234; p = .022) and satisfaction with decision-making involvement (β =.360; p < .001) when controlling for confounders.

CONCLUSIONS

Our results point to the paramount importance of developing and implementing interventions that promote procedural fairness in psychiatric treatment and thereby improve patient satisfaction while reducing the risk of disengagement with care.

COVID-19 welbeing study: a protocol examining perceived coercion and psychological well-being during the COVID-19 pandemic by means of an online survey, asynchronous virtual focus groups and individual interviews

INTRODUCTION

The COVID-19 pandemic has resulted in many countries applying restrictive measures, such as lockdown, to contain and prevent further spread. The psychological impact of lockdown and working as a healthcare worker on the frontline has been chronicled in studies pertaining to previous infectious disease pandemics that have reported the presence of depressive symptoms, anxiety, insomnia, and post-traumatic stress symptoms. Potentially linked to psychological well-being and not yet studied is the possibility that lockdown and working on the frontline of the pandemic are associated with perceptions of coercion.

METHODS AND ANALYSIS

The present study aimed to examine perceived coercion in those who have experienced COVID-19-related lockdown and/or worked as a frontline healthcare worker across three European countries. It aimed to describe how such perceptions may impact on psychological well-being, coping and post-traumatic growth. It will employ an explanatory mixed-methods research methodology consisting of an online survey and online asynchronous virtual focus groups (AVFGs) and individual interviews. χ² tests and analyses of variance will be used to examine whether participants from different countries differ according to demographic factors, whether there are differences between cohorts on perceived coercion, depression, anxiety and post-traumatic growth scores. The relationship between coercion and symptoms of distress will be assessed using multiple regression. Both the AVFGs and the narrative interviews will be analysed using thematic narrative analysis.

ETHICS AND DISSEMINATION

The study has been approved by University College London's Research Ethics Committee under Project ID Number 7335/004. Results will be disseminated by means of peer-reviewed publications and at national and/or international conferences.

Prevalence of the use of chemical restraint in the management of challenging behaviours associated with adult mental health conditions: A meta-synthesis

WHAT IS KNOWN ON THE SUBJECT?: The use of chemical restraint in emergency situations is to control aggression or violence to protect consumers and staff and is to be used as a last resort when all other behavioural control alternatives have been exhausted. Chemical restraint involves the use of medication. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first paper to systematically review the prevalence of the use of chemical restraint. The use of chemical restraint is common across emergency departments and acute psychiatric inpatient units worldwide. Consumers who are restrained are also likely to receive chemical restraint. The studies reviewed demonstrate that there is a need for more standardized data collection so that clearer comparisons can be made between healthcare settings and countries. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Implications of practice include the need to report adverse events post-chemical restraint as these can deleteriously affect a person's physical health. Identification of and staff education about first-line management techniques before chemical restraint is administered are significant to reduce its use. ABSTRACT: Introduction Chemical restraint is used to manage uncontrolled aggression, agitation or violent behaviours of consumers with mental health disorders admitted to acute psychiatric or emergency settings. Aim This systematic review aimed to synthesize the international prevalence of chemical restraint for non-consenting adults. Method PsycINFO, CINAHL, MEDLINE/PubMed and Google Scholar databases were searched for peer-reviewed literature published between January 1996 and July 2018. This paper reports on data extracted from retrospective audits of chemical restraint practice. Results Forty-eight papers were included. The median prevalence of use of any restraint was 21.2% (25th% 8.0 to 75th% 36.3). Median prevalence of people who were chemically restrained, of all people restrained in any manner, was 43.1% (25th% 22.9% to 75th% 70.7%). Of all people admitted to facility(ies), the median prevalence of chemical restraint was 7.4% (25th% 2.7 to 75th% 17.6). There was no statistically significant difference in any prevalence measure considering healthcare setting or country. There was a significant decrease over the review period in the use of any restraint, including chemical restraint. Discussion and implications for practice This is the first known comprehensive meta-view of chemical restraint use worldwide, highlighting the need for standardized data collection to enable comparisons between healthcare settings and countries. Relevance statement There is an international imperative to reduce or eliminate the use of coercive practices, such as physical and chemical restraint, in mental health care. This study provides important information for mental health nursing by synthesizing the international prevalence of chemical restraint for non-consenting adults. This meta-view of the worldwide use of chemical restraint can inform ongoing efforts to reduce its use.

International research into 22 years of use of chemical restraint: An evidence overview

BACKGROUND

Chemical restraint (CR) (also known as rapid tranquilisation) is the forced (non-consenting) administration of medications to manage uncontrolled aggression, anxiety, or violence in people who are likely to cause harm to themselves or others. Our population of interest was adults with mental health disorders (with/without substance abuse). There has been a growing international movement over the past 22 years towards reducing/eliminating restrictive practices such as CR. It is appropriate to summarise the research that has been published over this time, identify trends and gaps in knowledge, and highlight areas for new research to inform practice.

AIMS

To undertake a comprehensive systematic search to identify, and describe, the volume and nature of primary international research into CR published since 1995.

METHODS

This paper reports the processes and overall findings of a systematic search for all available primary research on CR published between 1 January 1996 and 31 July 2018. It describes the current evidence base by hierarchy of evidence, country (ies) producing the research, CR definitions, study purpose, and outcome measures.

RESULTS

This review identified 311 relevant primary studies (21 RCTs; 46 non-controlled experimental or prospective observational studies; 77 cross-sectional studies; 69 retrospective studies; 67 opinion pieces, position or policy statements; and 31 qualitative studies). The USA, UK, and Australia contributed over half the research, whilst cross-country collaborations comprised 6% of it. The most common research settings comprised acute psychiatric wards (23.3%), general psychiatric wards (21.6%), and general hospital emergency departments (19.0%).

DISCUSSION

A key lesson learnt whilst compiling this database of research into CR was to ensure that all papers described non-consenting administration of medications to manage adults with uncontrolled aggression, anxiety, or violence. There were tensions in the literature between using effective CR without producing adverse events, and how to decide when CR was needed (compared with choosing non-chemical intervention for behavioural emergencies), respecting patients' dignity whilst safeguarding their safety, and preserving safe workplaces for staff, and care environments for other patients. The range of outcome measures suggests opportunities to standardise future research.

"Voluntarily Admitted Against My Will": Patient Perspectives on Effects of, and Alternatives to, Coercion in Psychiatric Care for Self-Injury

Introduction:

Various forms of coercion are used in the psychiatric care of patients with self-injurious behaviors, but there is little research on how these are perceived by the patients. The aim of this study was to investigate how 6 patients, who had received care for self-injurious behavior, perceived coercion and how they think coercion could be avoided.

Methods:

This study employed a qualitative design with 6 semistructured interviews and interpretative phenomenological analysis.

Results:

Three main themes were identified: keep voluntary care voluntary, apportioning control and responsibility, and dialogue and participation. Constant supervision was described as the most destructive form of coercion. To enable self-responsibility, a reduction of control and supervision was advocated. Calls were made for a treatment based on the assumption that there is a desire, on behalf of the patients, to get better.

Conclusions:

The use of coercion in the psychiatric care of patients with self-injurious behavior can be reduced by increasing predictability, by listening to the patient with genuine interest, and by involving the patient in decisions regarding their treatment.

The Admission Experience Survey Italian Version (I-AES): A factor analytic study on a sample of 156 acute psychiatric in-patients

Coercive treatments are often regarded as an inevitable and yet highly debated feature of psychiatric care. Perceived coercion is often reported by patients involuntarily committed as well as their voluntary counterparts. The Admission Experience Survey (AES) is a reliable tool for measuring perceived coercion in mental hospital admission. We developed the Italian AES (I-AES) through translation back-translation and administered it to 156 acutely hospitalized patients (48% women, 69% voluntarily committed) in two university hospitals in Rome (Policlinico Umberto I, Sant'Andrea Hospital). A principal component analysis (PCA) with equamax rotation was conducted. The I-AES showed good internal consistency (Cronbach's alpha = 0.90); Guttmann split-half reliability coefficient was 0.90. AES total score significantly differed between voluntary and involuntary committed patients (5.08 ± 4.1 vs. 8.1 ± 4.9, p < .05). PCA disclosed a three-factor solution explaining 59.3 of the variance. Some discrepancies were found between the factor structure of the I-AES and the original version. I-AES total score was positively associated with numbers of previous involuntarily hospitalization (r = 0.20, p < .05) and psychiatric symptoms' severity (r = 0.22, p < .02). I-AES and its proposed new factor structure proved to be reliable to assess perceived coercion in mental hospital admission. Consequently, it may represent a helpful instrument for the study and reduction of patients' levels of perceived coercion.

Coercion in Outpatients under Community Treatment Orders: A Matched Comparison Study

OBJECTIVE

Since the deinstitutionalization of psychiatric services around the world, the scope of outpatient psychiatric care has also increased to better support treatment access and adherence. For those with serious mental illness who may lack insight into their own illness, available interventions include coercive community practices such as mandated community treatment orders (CTOs). This paper examines the perceptions of coercion among service users treated with a CTO.

METHOD

We used a cross-sectional comparative design where service users treated under a CTO were matched to a comparison group of voluntary psychiatric outpatients. Both groups were receiving intensive community mental health services (n = 69 in each group). Participants were interviewed using a series of questionnaires aimed at evaluating their perceptions of coercion and other aspects of the psychiatric treatment.

RESULTS

The level of coercion reported by service users treated under a CTO was significantly higher than that in the comparison group. However, in adjusted analyses, service users' perception of coercion, irrespective of their CTO status, was directly correlated with their previous experience with probation and inversely correlated with the sense of procedural justice in their treatment.

CONCLUSIONS

Evaluation of psychiatric service users' experiences of coercion should consider their past and current involvement with other types of coercive measures, particularly history of probation. Clinicians may be able to minimize these experiences of coercion by incorporating procedural justice principles into their practice.

Assessment of global law and psychiatry research in the period of 1993-2012

Purpose

The purpose of the present study is to analyze highly cited articles and global research emphases and trends of law and psychiatry (L&P) research during the period of 1993 to 2012 from the Web of Science (WOS) database. Besides the analysis of highly cited articles to learn about the classic articles and intellectual base of the L&P research domain, an attempt is made to detect research emphases and trends of the study field.

Design/methodology/approach

The present study applies quantitative analyses of citations of scientific publications to find highly cited articles and summarizes research hotspots and trends on L&P research articles from WOS during 1993-2012 using statistical analysis of words in titles, KeyWords Plus, author keywords and co-keywords.

Findings

The top 21 highly cited articles of research on L&P were found; most of the highly cited papers used survey research to measure patterns of violence of psychiatric patients. This present study identified forensic psychiatry, mental health and criminal offenders were the continuing mainstream topics in the L&P field and risk assessment, risk factors and risk management of violent behavior, legislation for sexual offences, mental health courts, recidivism and expert testimony were recent research emphases and trends of the study field. On the contrary, psychiatric hospitalization, psychiatrist-patient, community and services were not mainstream topics in the study field and were of decreasing importance and popularity in L&P research. Additionally, the topics of violent behavior and risk assessment have developed to a significant subgroup of L&P research. Finally, research emphases and trends in the L&P field were found based on the co-keywords cluster map and density map.

Originality/value

This is the first study to quantify and detect research emphases and trends in L&P from the WOS during 1993-2012, which may provide the groundwork for future studies of the L&P research domain, and offer some important suggestions and implications for professional researchers, specialists, publications’ editors and public policy makers concerned with the domain.

Perceptions of voluntary consent among jail diverted veterans with co-occurring disorders

This study assessed perceptions of voluntary consent among 69 veterans who enrolled in a "jail diversion" program for co-occurring disorders. Perceptions were measured using modified items from the MacArthur Perceived Coercion and Negative Pressure Scales. A majority reported that they "chose to" (88.4%) or "felt free to" (85.5%) enroll. Most reported having "control over" (69.6%) and "more influence than anyone else" regarding (60.9%) their participation. About half reported that enrollment was "their idea" (49.3%). Fewer reported perceptions of negative pressure, including the feeling that someone "talked them into" enrolling (24.6%), "threatened them with the maximum criminal punishment" (13.0%), "offered or promised them something" (5.8%), or "forced" them to enroll (5.8%). Nobody felt "tricked, lied to, or fooled into" participating. Total negative pressure scores were higher in those with combat experience, U = 406.50, p = .016. Although potentially inappropriate pressures were reported, these data suggest that the majority perceived enrollment as voluntary.

Applying Ethical Guidelines in Nursing Research on People with mental illness

This article describes how ethical guidelines have been applied while interviewing psychiatric patients who were recovering from mental illness, especially from psychosis, to allow nurses to understand these patients’ experiences. Because psychiatric patients are vulnerable, their participation in research involves ethical dilemmas, such as voluntary consent, legal capacity to consent, freedom of choice, and sufficient knowledge and comprehension. The first part of this article describes the most important ethical guidelines concerning human research. These have been published by different organizations, departments, committees and commissions for the purpose of protecting human rights and dignity whenever research participants are vulnerable persons or their capacity to consent is limited. At present, however, no special regulations govern research involving adults who have been diagnosed with a condition characterized by mental impairment. Furthermore, a relatively small body of research has documented the effects of various disorders (e.g. psychiatric conditions) on decision-making capacity per se. One basic moral and policy question is whether these individuals should ever be involved in research. The second part of this article concentrates on how the investigator made sure that participating patients had understood their role in this particular piece of nursing research. During the interviews the investigator noticed that some ethical dilemmas required further study and debate because of the lack of consensus on the proposed regulatory provisions on research involving institutionalized persons and their ability to make an informed and voluntary decision.

Racial disparities during admission to an academic psychiatric hospital in a large urban area

Multiple studies confirm that African Americans are less likely than non-Hispanic whites to receive needed mental health services. Research has consistently shown that African Americans are under-represented in outpatient mental health treatment settings and are over-represented in inpatient psychiatric settings. Further, African Americans are more likely to receive a diagnosis of schizophrenia and are less likely receive an affective disorder diagnosis during inpatient psychiatric hospitalization compared to non-Hispanic white patients, pointing to a need for examining factors contributing to mental health disparities. Using Andersen's Behavioral Model of Health Service Use, this study examined predisposing, enabling and need factors differentially associated with health service utilization among African American and non-Hispanic white patients (n=5183) during psychiatric admission. We conducted univariate and multivariate logistic regression analyses to examine both main effects and interactions. In the multivariate model, African American race at admission was predicted by multiple factors including younger age, female gender, multiple psychiatric hospitalizations, elevated positive and negative symptoms of psychosis, a diagnosis of schizophrenia and substance use, as well as having housing and commercial insurance. Additionally, screening positive for cannabis use at intake was found to moderate the relationship between being female and African American. Our study findings highlight the importance of examining mental health disparities using a conceptual framework developed for vulnerable populations (such as racial minorities and patients with co-occurring substance use).

Preventing Compulsory Admission to Psychiatric Inpatient Care: Perceived Coercion, Empowerment, and Self-Reported Mental Health Functioning after 12 Months of Preventive Monitoring

OBJECTIVE

To evaluate the effects of a preventive monitoring program targeted to reduce compulsory rehospitalization and perceived coercion in patients with severe mental disorder. We analyze patient outcomes in terms of perceived coercion, empowerment, and self-reported mental health functioning at 12 months.

METHODS

The program consists of individualized psychoeducation, crisis cards and, after discharge from the psychiatric hospital, a 24-month preventive monitoring. In total, 238 psychiatric inpatients who had had compulsory admission(s) during the past 24 months were included in the trial. T1-assessment 12 months after baseline was achieved for 182 patients.

RESULTS

Study participants reported lower levels of perceived coercion, negative pressures, and process exclusion, a higher level of optimism, and a lesser degree of distress due to symptoms, interpersonal relations, and social role functioning (significant time effects). However, improvements were not confined to the intervention group, but seen also in the treatment-as-usual group (no significant group or interaction effects). Altered perceptions were linked to older age, shorter illness duration, female sex, non-psychotic disorder, and compulsory hospitalization not due to risk of harm to others.

CONCLUSION

Our findings suggest that changes in the subjective perspective were fueled primarily by participation in this study rather than by having received the specific intervention. The study contributes to a better understanding of the interaction between "objective" measures (compulsory readmissions) and patients' perceptions and highlights the need for treatment approaches promoting empowerment in individuals with a history of involuntary psychiatric hospitalizations.

Sociodemographic and Clinical Characteristics of Victimized Versus Non-Victimized Patients with Schizophrenia: An Egyptian Study

Persons with mental disorders living in the community are liable for victimization and are considered as a high-risk group. Objective of this study was to explore the sociodemographic variables and clinical characteristics related to victimization of patients with schizophrenia in comparison to their nonvictimized counterparts. One hundred patients were recruited from the inpatient wards and outpatient clinics of the Institute of Psychiatry, Ain Shams University. They were subjected to Structured Clinical Interview for DSM-IV Axis I diagnosis (Clinical Version); Positive and Negative Syndrome Scale (PANSS); Global Assessment of Functioning (GAF); Clinical Global Impression (CGI); designed extensive questionnaire to elicit demographic data; inquiry about drug compliance and Victimization Questionnaire. Results show that 70 patients of the studied sample were non-victimized and 30 patients were victimized. Victimized patients were significantly younger, living mainly in urban areas, had less frequent history of bullying at school. There were exposed significantly to higher frequency of family domestic violence and childhood abuse. They scored higher for all subscales and in total PANSS scores and they were less compliant on medication than did their non-victimized counterparts. Until now studies of victimization of mentally ill did not draw the attention of researchers and clinicians in Arab world. This study proves that victimization is not uncommon among patients with schizophrenia; Clinicians should include assessment for victimization of their patients as a routine work. The current study provides preliminary data for clinicians and policy makers to consider strategies to protect patients with various mental illnesses from being victimized.

What influences perceptions of procedural justice among people with mental illness regarding their interactions with the police?

According to procedural justice theory, a central factor shaping perceptions about authority figures and dispute resolution processes is whether an individual believes they were treated justly and fairly during personal encounters with agents of authority. This paper describes findings from a community-based participatory research study examining perceptions of procedural justice among sixty people with mental illness regarding their interactions with police. The degree to which these perceptions were associated with selected individual (e.g., socio-demographic characteristics), contextual (e.g., neighborhood, past experiences), and interactional (e.g., actions of the officer) factors was explored. The results of regression analyses indicate that the behavior of police officers during the interactions appears to be the key to whether or not these interactions are perceived by people with mental illness as being procedurally just. Implications of these findings for improving interactions between the police and people with mental illness are discussed.

Perceived humiliation during admission to a psychiatric emergency service and its relation to socio-demography and psychopathology

BACKGROUND

There is a lack of empirical studies of patients' level of humiliation during the hospital admission process and its implications for the clinical setting. We wanted to explore associations between self-rated humiliation and socio-demography and psychopathology in relation to admission to a psychiatric emergency unit.

METHODS

Consecutively admitted patients (N = 186) were interviewed with several validated instruments. The patients self-rated humiliation by The Cantril Ladder, and 35% of the sample was defined as the high humiliation group.

RESULTS

Final multivariate analysis found significant associations between compulsory admission, not being in paid work, high scores on hostility, and on entitlement, and high levels of humiliation. No significant interactions were observed between these variables, and the narcissism score was not a confounder concerning humiliation.

CONCLUSIONS

High level of humiliation during the admission process was mainly related to patient factors, but also to compulsory admission which should be avoided as much as possible protecting the self-esteem of the patients.

Adverse impact of coercive treatments on psychiatric inpatients' satisfaction with care

Consumers' satisfaction with inpatient mental health care is recognized as a key quality indicator that prospectively predicts functional and clinical outcomes. Coercive treatment experience is a frequently cited source of dissatisfaction with inpatient care, yet more research is needed to understand the factors that influence consumers' perceptions of coercion and its effects on satisfaction, including potential "downstream" effects of past coercive events on current treatment satisfaction. The current study examined associations between objective and subjective indices of coercive treatments and patients' satisfaction with care in a psychiatric inpatient sample (N = 240). Lower satisfaction ratings were independently associated with three coercive treatment variables: current involuntary admission, perceived coercion during current admission, and self-reported history of being refused a requested medication. Albeit preliminary, these results document associations between patients' satisfaction ratings and their subjective experiences of coercion during both current and prior hospitalizations.

Therapeutic relationship in the context of perceived coercion in a psychiatric population

The relationship between patient and therapist in mental health care is one of the most important treatment factors. It is a reliable predictor of treatment outcome, regardless of diagnosis, setting or of the type of therapy used. On the other hand, influence and coercion occur in patient-physician relationships in psychiatry. We investigated the associations between patients' perceived coercion and the therapeutic relationship. A total of 116 psychiatric patients, who have been admitted to the Psychiatric University Hospital Zurich, were interviewed using a structured interview. Data were collected by using Scale To Assess the Therapeutic Relationship (STAR) (therapeutic relationship) and Mac Arthur Admission Experience Survey (AES) (perceived coercion). Associations were investigated using bivariate and multivariate methods. Perceived coercion predicts the patients' appraisal of the therapeutic relationship. We found a moderate relation between the patients' and the clinicians' view of their relationship. Perceived coercion is related to a higher symptom level and a lower level of global functioning at admission, and higher perceived coercion is related to a more negative patient-therapist relationship rated by the patient. Perceived loss of autonomy goes hand in hand with a more negative relationship between the patient and the clinician. This phenomenon has to be impeded, regarding the unambiguous impact relationship quality has on treatment outcome.

Psychiatric patients' views on why their involuntary hospitalisation was right or wrong: a qualitative study

PURPOSE

To explore involuntary patients' retrospective views on why their hospitalisation was right or wrong.

METHODS

Involuntary patients were recruited from 22 hospitals in England and interviewed in-depth. The study drew on grounded theory and thematic analysis.

RESULTS

Most of the patients felt mentally unwell before admission and out of control during their treatment. Despite these common experiences, three groups of patients with distinct views on their involuntary hospitalisation were identified: those who believed that it was right, those who thought it was wrong and those with ambivalent views. Those with retrospectively positive views believed that hospitalisation ensured that they received treatment, averted further harm and offered them the opportunity to recover in a safe place. They felt that coercion was necessary, as they could not recognise that they needed help when acutely unwell. Those who believed that involuntary admission was wrong thought that their problems could have been managed through less coercive interventions, and experienced hospitalisation as an unjust infringement of their autonomy, posing a permanent threat to their independence. Patients with ambivalent views believed that they needed acute treatment and that hospitalisation averted further harm. Nonetheless, they thought that their problems might have been managed through less coercive community interventions or a shorter voluntary hospitalisation.

CONCLUSIONS

The study illustrates why some patients view their involuntary hospitalisation positively, whereas others believe it was wrong. This knowledge could inform the development of interventions to improve patients' views and treatment experiences.

Patient characteristics and symptoms associated with perceived coercion during hospital treatment

OBJECTIVE

Large numbers of psychiatric patients either are involuntarily admitted to hospital treatment or feel coerced despite a legally voluntary admission. For ethical and clinical reasons, their perceived coercion should be reduced as far as possible. There is however limited evidence on patient characteristics associated with perceived coercion during hospital treatment. This study aimed to identify i) sociodemographic and clinical characteristics associated with perceived coercion at admission and ii) changes in symptoms and global functioning associated with changes in perceived coercion over time.

METHOD

Three thousand and ninety three in-patients who were involuntarily admitted or felt coerced to hospital treatment despite a legally voluntary admission were recruited in the European evaluation of coercion in psychiatry and harmonization of best clinical practice - EUNOMIA project in 11 European countries. Perceived coercion, global functioning and symptoms were assessed after admission and at a 3-month follow-up.

RESULTS

Involuntary admission, female gender, poorer global functioning and more positive symptoms were associated with higher levels of perceived coercion at admission. Perceived coercion significantly decreased over time, and the improvements in global functioning and positive symptoms were associated with reduction in perceived coercion.

CONCLUSION

Female patients perceive more coercion in psychiatric hospital treatment. Effective treatment for positive symptoms and improving patients' global functioning may lead to a reduction in perceived coercion.

Potential legal protection problems in the use of compulsory commitment in mental health care in Norway

Compulsory commitment in mental health care represents a dramatic infringement on an individual's life. In Norway, this deprivation of liberty is based on a professional medical assessment that does not require a court verdict. This article presents possible changes that may increase legal protection for the mentally ill. The concept of legal protection has at least two definitions: the state's protection of the individual's legal rights (including the right to health care) and the protection afforded to citizens from abuse and arbitrary actions by the state. Infringements on personal liberty without consent require such legal authority as is found in the Human Rights Conventions. These Conventions have precedence over national laws. Norwegian legislation is based on confidence in psychiatry as a profession. This confidence allows professionals to treat patients against their will. In some countries, initial court action is necessary before compulsory mental health care can be implemented. This should also be possible in Norway in most cases, with the exception of life-threatening situations.

Why do some voluntary patients feel coerced into hospitalisation? A mixed-methods study

This study aimed to investigate factors linked to perceived coercion at admission and during treatment among voluntary inpatients. Quantitative and qualitative methods were used. Two hundred seventy patients were screened for perceived coercion at admission. Those who felt coerced into admission rated their perceived coercion during treatment a month after admission. Patient characteristics and experiences were tested as predictors of coercion. In-depth interviews on experiences leading to perceived coercion were conducted with 36 participants and analysed thematically. Thirty-four percent of patients felt coerced into admission and half of those still felt coerced a month later. No patient characteristics were associated with perceived coercion. Those whose satisfaction with treatment increased more markedly between baseline and a month later were less likely to feel coerced a month after admission. In the qualitative interviews three themes leading to perceived coercion were identified: viewing the hospital as ineffective and other treatments as more appropriate, not participating in the admission and treatment and not feeling respected. Involving patients in the decision-making and treating them with respect may reduce perceived coercion.

Perceived coercion and need for hospital admission among psychiatric in-patients: figures from a Pakistani tertiary care hospital

In Pakistan, an increasing proportion of psychiatric patients present to community health services as crisis admissions, with their relatives as the main decision makers. Patients are bound to perceive this process as coercive. Farnham & James (2000) report that elements of coercion are found even in voluntary hospital admission, in the form of verbal persuasion, physical force and threats of commitment. Few patients consider hospitalisation justified and most view the process of admission negatively (Swartz et al, 2003; Katsakou & Priebe, 2006; Priebe et al, 2009).

Perceived coercion among jail diversion participants in a multisite study

OBJECTIVE

Although jail diversion is considered an appropriate and humane response to the disproportionately high volume of people with mental illness who are incarcerated, little is known regarding the perceptions of jail diversion participants, the extent to which they feel coerced into participating, and whether perceived coercion reduces involvement in mental health services. This study addressed perceived coercion among participants in postbooking jail diversion programs in a multisite study and examined characteristics associated with the perception of coercion.

METHODS

Data collected in interviews with 905 jail diversion participants from 2003 to 2005 were analyzed with random-effects proportional odds models.

RESULTS

Ten percent of participants reported a high level of coercion, and another 26% reported a moderate level of coercion. Having a drug charge was associated with lower perceived coercion to enter the program. In addition, an interaction between sexual abuse and substance abuse indicated that recent sexual abuse was associated with higher levels of perceived coercion, but only among those without current substance abuse. At the 12-month follow-up (N=398), variables associated with higher perceived coercion to receive behavioral health services included spending more time in jail and higher perceived coercion at baseline. The amount of behavioral health service use was not predicted by perceived coercion at baseline. Rather, being older, having greater symptom severity, and having a history of sexual abuse but no substance abuse and no history of physical abuse were associated with higher levels of outpatient service use.

CONCLUSIONS

Overall, one-third of jail diversion participants reported some level of perceived coercion. Important determinants of perceived coercion included charge type, length of time in jail, and sexual abuse history. Engagement in treatment was not affected by perceived coercion.

An Empirical Ethics Agenda for Psychiatric Research Involving Prisoners

In the past 30 years, the incarcerated population in the United States has more than quadrupled to 2.3 million adults. With an alarmingly high prevalence of mental illness, substance use, and other serious health conditions compounding their curtailed autonomy, prisoners constitute perhaps the nation's most disadvantaged group. Scientifically rigorous research involving prisoners holds the potential to inform and enlighten correctional policy and to improve their treatment. At the same time, prisoner research presents significant ethical challenges to investigators and institutional review boards (IRBs) alike, by subjecting participants to conditions that potentially undermine the validity of their informed consent. In 2006, the Institute of Medicine Committee on Ethical Considerations for Revisions to the Department of Health and Human Services (DHHS) Regulations for Protection of Prisoners Involved in Research recommended both further protections and a more permissive approach to research review that would allow inmates greater access to potentially beneficial research. These recommendations have sparked renewed debate about the ethical trade-offs inherent to prisoner research. In this article, the authors review the major justifications for research with prisoner subjects and the associated ethical concerns, and argue that the field of empirical ethics has much to offer to the debate. They then propose a framework for prioritizing future empirical ethics inquiry on this understudied topic.

Attitudes among stakeholders towards compulsory mental health care in Norway

OBJECTIVES

The Norwegian Mental Health Care Act allows use of coercion under certain conditions. Even though the current practice has been criticized, little empirical data exist about the attitudes towards compulsory mental health care.

METHOD

This study used Q-methodology to identify prototypical attitudes and to test possible differences of attitudes between groups of stakeholders towards the use of coercion in mental health care. Sixty-two respondents who represented six groups with different roles in mental health care participated: former patients, relatives of psychiatric patients, members of supervisory commissions, psychiatrists, other physicians, and lawyers. The participants were asked to assess the degree to which they agreed on 30 statements concerning use of coercion for the mentally ill.

RESULTS

Three factors that in a meaningful way express different attitudes towards the question were found. The most widely shared attitude stated that a trusting relationship between patient and therapist is more important than the right to have an attorney. This attitude gives partial support to the present Mental Health Care Act. However, the second most common attitude argues that involuntary hospitalization, if necessary, should be decided in a court and not by the hospital doctor.

CONCLUSIONS

Differences in attitude could partly be explained by the respondents' role in mental health care. Both psychiatrists and "somatic" physicians expressed more agreement with the present legislation than the other stakeholders. The findings may have implications for the legal protection of mental health care patients.

Enhancement of outpatient treatment adherence: Patients' perceptions of coercion, fairness and effectiveness

Interventions aimed at enhancing psychiatric patients' outpatient treatment adherence frequently include informal coercion such as inducements, and threats of negative sanctions. Little is known about patients' subjective perspective concerning these practices. This study examined the perceived coercion, and also the appraisal of the fairness and effectiveness of the treatment. A total of 187 psychiatric patients with different diagnoses were interviewed using a structured questionnaire that included socio-demographic and clinical data, insight into illness (ITAQ), psychopathology (BPRS), functioning (GAF) and a modified version of the MacArthur Admission Experience Survey (AES) as a measure of perceived coercion, fairness and effectiveness. Bivariate correlations and logistic regression analyses were used to identify the influencing factors on the outcome variables. Perceived coercion was associated with experience with informal coercive treatment pressures (OR 2.5-2.9; P<0.05), and a main diagnosis of a schizophrenic disorder (OR 3.8; P<0.001). Experience with informal coercion was inversely associated with fairness (OR 0.3-0.4; P<0.05), but not with effectiveness. Patients with more insight into their illness indicated higher fairness and effectiveness concerning the procedures for enhancing their treatment adherence (OR 3.1; P<0.01). Insight into illness was not associated with perceived coercion. This might indicate that enhancing insight using psycho-educational approaches and high transparency when applying informal coercive practices could improve patients' appreciation for these procedures. They could probably cope better with perceived coercion when understanding its purpose, and when they perceive they are being treated fairly.

Perceived coercion among jail diversion participants in a multisite study

OBJECTIVE

Although jail diversion is considered an appropriate and humane response to the disproportionately high volume of people with mental illness who are incarcerated, little is known regarding the perceptions of jail diversion participants, the extent to which they feel coerced into participating, and whether perceived coercion reduces involvement in mental health services. This study addressed perceived coercion among participants in postbooking jail diversion programs in a multisite study and examined characteristics associated with the perception of coercion.

METHODS

Data collected in interviews with 905 jail diversion participants from 2003 to 2005 were analyzed with random-effects proportional odds models.

RESULTS

Ten percent of participants reported a high level of coercion, and another 26% reported a moderate level of coercion. Having a drug charge was associated with lower perceived coercion to enter the program. In addition, an interaction between sexual abuse and substance abuse indicated that recent sexual abuse was associated with higher levels of perceived coercion, but only among those without current substance abuse. At the 12-month follow-up (N=398), variables associated with higher perceived coercion to receive behavioral health services included spending more time in jail and higher perceived coercion at baseline. The amount of behavioral health service use was not predicted by perceived coercion at baseline. Rather, being older, having greater symptom severity, and having a history of sexual abuse but no substance abuse and no history of physical abuse were associated with higher levels of outpatient service use.

CONCLUSIONS

Overall, one-third of jail diversion participants reported some level of perceived coercion. Important determinants of perceived coercion included charge type, length of time in jail, and sexual abuse history. Engagement in treatment was not affected by perceived coercion.

Procedural justice and the mental health court judge's role in reducing recidivism

Based on qualitative observation and quantitative data from eight mental health courts (MHCs), this article argues that observed reductions in recidivism from participation in MHC are caused in part by the role of the judge in conveying elements of procedural justice. Specifically, the judge provides: (1) a heightened level of interpersonal treatment of participants that accords them dignity, respect, and voice; (2) accountability for participants and service providers alike; and (3) transparency for decisions reached through an open negotiation process. Procedural justice theory predicts that participants will thereby be more likely to see legal decisions as legitimate and incorporate the court's values and goals as their own. Preliminary qualitative and quantitative data are presented from interviews of a sample of participants in the Superior Court of the District of Columbia's Mental Health Diversion Court (DCMHDC) that support these hypotheses. DCMHDC participants hold strongly positive views about the procedural justice they receive from their court experience and of the judge's role in providing justice.

Accumulated coercion and short-term outcome of inpatient psychiatric care

BACKGROUND

The knowledge of the impact of coercion on psychiatric treatment outcome is limited. Multiple measures of coercion have been recommended. The aim of the study was to examine the impact of accumulated coercive incidents on short-term outcome of inpatient psychiatric care

METHODS

233 involuntarily and voluntarily admitted patients were interviewed within five days of admission and at discharge or after maximum three weeks of care. Coercion was measured as number of coercive incidents, i.e. subjectively reported and in the medical files recorded coercive incidents, including legal status and perceived coercion at admission, and recorded and reported coercive measures during treatment. Outcome was measured both as subjective improvement of mental health and as improvement in professionally assessed functioning according to GAF. Logistic regression analyses were performed with patient characteristics and coercive incidents as independent and the two outcome measures as dependent variables

RESULTS

Number of coercive incidents did not predict subjective or assessed improvement. Patients having other diagnoses than psychoses or mood disorders were less likely to be subjectively improved, while a low GAF at admission predicted an improvement in GAF scores

CONCLUSION

The results indicate that subjectively and professionally assessed mental health short-term outcome of acute psychiatric hospitalisation are not predicted by the amount of subjectively and recorded coercive incidents. Further studies are needed to examine the short- and long-term effects of coercive interventions in psychiatric care.

Psychiatric advance directives and reduction of coercive crisis interventions

BACKGROUND: Psychiatric advance directives are intended to enable self-determined treatment for patients who lose decisional capacity, and thus reduce the need for coercive interventions such as police transport, involuntary commitment, seclusion and restraints, and involuntary medications during mental health crises; whether PADs can help prevent the use of these interventions in practice is unknown. AIMS: This study examined whether completion of a Facilitated Psychiatric Advance Directive (F-PAD) was associated with reduced frequency of coercive crisis interventions. METHOD: The study prospectively compared a sample of PAD completers (n=147) to non-completers (n=92) on the frequency of any coercive interventions, with follow-up assessments at 6, 12, and 24 months. Repeated-measures multiple regression analysis was used to estimate the effect of PADs. Models controlled for relevant covariates including a propensity score for initial selection to PADs, baseline history of coercive interventions, concurrent global functioning and crisis episodes with decisional incapacity. RESULTS: F-PAD completion was associated with lower odds of coercive interventions (adjusted OR=0.50; 95% CI=0.26-0.96; p < 0.05). CONCLUSIONS: PADs may be an effective tool for reducing coercive interventions around incapacitating mental health crises. Less coercion should lead to greater autonomy and self-determination for people with severe mental illness.

Making sense of 'consent' in a constrained environment

BACKGROUND

This project investigates patients' and practitioners' experiences and understandings of the consent process, as it is governed by the Mental Health Act in Great Britain.

AIMS

We aim to illuminate our respondents' experiences of the consent process, and to explore their attempts to make sense of that process.

METHOD

Semi-structured interviews with 5 Responsible Medical Officers, and 7 of their consenting adult patients, were conducted at a medium-secure psychiatric hospital. We approached the analysis from the perspective of Interpretative Phenomenological Analysis.

RESULTS

Our analysis begins with an account of some of the common phenomenological consequences of the consent process as our participants understand them, but then moves on to discuss some of the contextual constraints which are evident from their negotiation of these understandings.

CONCLUSIONS

We conclude by outlining a number of emergent issues relevant to the current development of new Mental Health legislation. These include: mechanisms to allow collaboration with user groups; a more consultative role for users in their own treatment decisions; formal training and support for those conducting competency assessments; and more flexible and transparent legislative frameworks.

The experience of admission to psychiatric hospital among Chinese adult patients in Hong Kong

BACKGROUND

The paper reports on a study to evaluate the psychometric properties and cultural appropriateness of the Chinese translation of the Admission Experience Survey (AES).

METHODS

The AES was translated into Chinese and back-translated. Content validity was established by focus groups and expert panel review. The Chinese version of the Admission Experience Survey (C-AES) was administered to 135 consecutively recruited adult psychiatric patients in the Castle Peak Hospital (Hong Kong SAR, China) within 48 hours of admission. Construct validity was assessed by comparing the scores from patients admitted voluntarily versus patients committed involuntarily, and those received physical or chemical restraint versus those who did not. The relationship between admission experience and psychopathology was examined by correlating C-AES scores with the Brief Psychiatric Rating Scale (BPRS) scores.

RESULTS

Spearman's item-to-total correlations of the C-AES ranged from 0.50 to 0.74. Three factors from the C-AES were extracted using factor analysis. Item 12 was omitted because of poor internal consistency and factor loading. The factor structure of the Process Exclusion Scale (C-PES) corresponded to the English version, while some discrepancies were noted in the Perceived Coercion Scale (C-PCS) and the Negative Pressure Scale (C-NPS). All subscales had good internal consistencies. Scores were significantly higher for patients either committed involuntarily or subjected to chemical or physical restrain, independent on severity of psychotic symptoms.

CONCLUSION

The Chinese AES is a psychometrically sound instrument assessing the three different aspects of the experience of admission, namely "negative pressure, "process exclusion" and "perceived coercion". The potential of C-AES in exploring subjective experience of psychiatric admission and effects on treatment adherence should be further explored.

Coercion and patient satisfaction on psychiatric acute wards

Legal-, perceived- and objective coercion were examined both separately and together as a measure of accumulated coercion, to determine how coercion affected patient satisfaction in patients admitted for acute psychiatric care. Accumulated coercive events significantly reduced both overall satisfaction, and satisfaction in four of five subscales evaluating different aspects of treatment. Neither legal status nor perceived coercion affected patient satisfaction, while objective coercion had a significant negative effect on overall satisfaction when these measures were analysed separately. Overall patient satisfaction reported at discharge was low, while satisfaction with different aspects of treatment showed considerable variation. The observation that perceived coercion in the admission process did not affect satisfaction significantly underlines the need to further explore the interaction between subjective and objective measures for coercion. It appears that multiple measures for coercion should be used in future studies.

Satisfaction and coercion among voluntary, persuaded/pressured and committed patients in acute psychiatric treatment

RATIONALE

Whereas the distinction between committed and voluntary admissions in mental health is clear from a legal point of view, this clarity is not always present in the patients' experiences. Voluntary patients may be pressured or persuaded and committed patients may want admission.

AIMS

To compare three groups of patients--committed, voluntary and persuaded--admitted to acute psychiatric inpatient care as regards different aspects of satisfaction, treatment and experienced coercion.

METHOD

The Sjukvårdens Planerings- och Rationaliseringsinstitut form and the Coercion Ladder were administered to all admitted patients on two acute wards. A total of 189 patients participated (86%). Data were analysed with nonparametric (Kruskal-Wallis, chi-square) and parametric tests (multinominal regression).

RESULTS

A substantial proportion of the patients did not know of their legal status. Many reported restrictions on movement, forced medication and patronising communication. Satisfaction with the treatment was generally high. Compared to the voluntary patients, the two other groups were characterized by lack of influence, forced medication and high satisfaction with the key worker.

CONCLUSION

Involuntariness was associated with increased likelihood of feeling excluded from participation in the treatment. The key worker seems to have an important position with regard to committed and pressured patients.

LIMITATIONS

The data were limited to the patients' subjective reports.

Involuntary outpatient treatment as "desintitutionalized coercion": the net-widening concerns

In American jurisprudence, two justifications have traditionally been put forth to support the government's social control of persons with mental illness: police power and parens patriae. As public mental hospitals became less available as loci in which to exercise these functions, governments sought alternative means to achieve the same ends. One prominent but quite controversial means is involuntary outpatient treatment (IOT). While the concerns about IOT have been myriad, one often alluded to but never documented is that of "net-widening." That is, once IOT became available, it would be applied to an ever greater number of individuals, progressively expanding the margins of the designated population to whom it is applied, despite the formal standard for its application remaining constant. We tested the net-widening belief in a naturalistic experiment in Massachusetts. We found that net-widening did not occur, despite an environment strongly conducive to that expansion. At this time, whatever the arguments against IOT might be, net-widening should not be one of them.

On conflict, containment and the relationship between them

A programme of research into conflict (e.g. violence, absconding, medication refusal) and containment (e.g. seclusion, special observation, physical restraint) in inpatient psychiatry has been under way at City University, London, UK, for the past 10 years. Recent research findings, plus the challenges posed by ongoing projects, have made apparent the need for greater clarity about the overarching concepts of 'conflict' and 'containment'. This paper pulls together research findings pertaining to this issue, and conducts a reasoned analysis of what common characteristics might underlie 'conflict' and 'containment'. It is concluded that these are patient threats to safety, and the staff maintenance of safety. Details are presented on the inclusions and exclusions that follow from taking such a position, and potential definitions offered. On the grounds of this conceptual analysis, plus evidence for moderate degrees of statistical association between behaviours and events in each domain, it is concluded that it is legitimate to conduct analyses at the level of total conflict and containment rates, as well as at the level of individual types of behaviours and events (e.g. verbal abuse, sedation). Some of the mathematical difficulties in the analysis of total conflict and containment are addressed, and results of a weighting exercise presented. This exercise challenges our perception of the severity of some containment measures that are becoming more commonly used in acute psychiatry.

Outpatient commitment: the state of empirical research on its outcomes

This article briefly describes the historical conditions in the origin and development of outpatient commitment that framed the discourse on its merits and the empirical studies on its outcomes. It divides those empirical studies into two sets on the basis of the questions addressed and critically reviews them. The review pays particular attention to the latest studies that were able to randomize subjects to experimental and control conditions and that were able to offer enhanced services. Finally, this article presents issues not addressed by the empirical studies on outpatient commitment but that need to be addressed in order to understand the choice of using the law to force persons with mental illness to comply with treatment and receive services in the community.

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.

Differences in perceived coercion at admission to psychiatric hospitals in the Nordic countries

BACKGROUND

International variation in compulsory admissions to psychiatric care has mainly been studied in terms of civil commitment rates. The objectives of this study were to compare and analyse the levels of perceived coercion at admission to psychiatric in-patient care among the Nordic countries and between centres within these countries, in relation to legal prerequisites and clinical practice.

METHOD

From one to four centres each in Denmark, Iceland, Norway, Finland and Sweden, a total of 426 legally committed and 494 formally voluntarily admitted patients were interviewed within 5 days from admission.

RESULTS

The proportion of committed patients reporting high levels of perceived coercion varied among countries (from 49% in Norway to 100% in Iceland), and in Sweden, only, among centres (from 29 to 90%). No clear variations in this respect were found among voluntary patients. A wide concept of coercion in the Civil Commitment Act and no legal possibility of detention of voluntary patients were associated to low levels of perceived coercion at admission among committed patients.

CONCLUSION

For committed patients, differences in national legal prerequisites among countries were reflected in differences in perceived coercion. The results from Sweden also indicate that local care traditions may account for variation among centres within countries.

Experiences of coercion during investigation and treatment

According to Swedish legislation (LVM) compulsory treatment shall be decided on if someone, due to ongoing abuse of alcohol, drugs or volatile solvents, is in need of care to overcome abuse and if a voluntary intervention is not possible. Very little research has been conducted in Sweden on this particular legislation with regard to the clients' experiences of entire process from assessment to aftercare. We interviewed 74 subjects who were being assessed prior to the court's decision on involuntary care (n=39), or with previous experience of assessment and involuntary care (n=35). The assessment group more often reported having the opportunity to express their opinions to the social worker during the assessment period (55% vs. 21%, p<.05) and they were more positive towards the final decision (60% vs. 24%, p<.05). In spite of the law, 18% were not contacted by the social services while in coercive treatment. The clients who did meet with a social worker, often described the conferences as more of a perfunctory nature with a lack of focus on the actual situation and aftercare planning. This study points at a need of studying the subjects' experiences of the whole continuum of the coercive process: from the investigation, to treatment and to aftercare. It also points at the need for new instruments to be developed covering all aspects of the coercive process and in particular the period of investigation prior to the decision on involuntary care.