Family, clinician, and patient perceptions of coercion in mental hospital admission. A comparative study

Finding Common Ground for Diverging Policies for Persons with Severe Mental Illness

Two diametrically opposed positions predominate discourse for the care and treatment of persons with severe mental illness: anti-deinstitutionalization and anti-institutionalization. Both share the same goal of ensuring best quality of life for those with severe psychiatric disorders, but pathways to achieving this goal are very different and have resulted in much contention. Supporters of each position espouse a different belief system regarding people with psychiatric disorders and their presumed capabilities, placing varying emphasis on maximizing protection of the community versus protection of individual rights, and result in contrasting mental health policies and practice orientations. The authors delineate the history from which these positions evolved, consequent views, and policies and practices that emerged from these differing attitudes. The article culminates in a proposed practice approach that offers a more balanced approach to serving adults with mental illness -navigating risk management by preserving freedom and opportunities of risk while affording mutually satisfactory "risk control."

How to improve clinical practice on involuntary hospital admissions of psychiatric patients: Suggestions from the EUNOMIA study

Number and procedures of involuntary hospital admissions vary in Europe according to the different socio-cultural contexts. The European Commission has funded the EUNOMIA study in 12 European countries in order to develop European recommendations for good clinical practice in involuntary hospital admissions. The recommendations have been developed with the direct and active involvement of national leaders and key professionals, who worked out national recommendations, subsequently summarized into a European document, through the use of specific categories. The need for standardizing the involuntary hospital admission has been highlighted by all centers. In the final recommendations, it has been stressed the need to: providing information to patients about the reasons for hospitalization and its presumable duration; protecting patients’ rights during hospitalization; encouraging the involvement of family members; improving the communication between community and hospital teams; organizing meetings, seminars and focus-groups with users; developing training courses for involved professionals on the management of aggressive behaviors, clinical aspects of major mental disorders, the legal and administrative aspects of involuntary hospital admissions, on communication skills. The results showed the huge variation of involuntary hospital admissions in Europe and the importance of developing guidelines on this procedure.

Reweighing the Ethical Tradeoffs in the Involuntary Hospitalization of Suicidal Patients

Suicide is the 10th leading cause of death in the United States and the second cause of death among those ages 15-24 years. The current standard of care for suicidality management often involves an involuntary hospitalization deemed necessary by the attending psychiatrist. The purpose of this article is to reexamine the ethical tradeoffs inherent in the current practice of involuntary psychiatric hospitalization for suicidal patients, calling attention to the often-neglected harms inherent in this practice and proposing a path for future research. With accumulating evidence of the harms inherent in civil commitment, we propose that the relative value of this intervention needs to be reevaluated and more efficacious alternatives researched. Three arguments are presented: (1) that inadequate attention has been given to the harms resulting from the use of coercion and the loss of autonomy, (2) that inadequate evidence exists that involuntary hospitalization is an effective method to reduce deaths by suicide, and (3) that some suicidal patients may benefit more from therapeutic interventions that maximize and support autonomy and personal responsibility. Considering this evidence, we argue for a policy that limits the coercive hospitalization of suicidal individuals to those who lack decision-making capacity.

Service users' perspective of their admission: a report of study findings

OBJECTIVES

The 'Service Users' Perspective of their Admission' study examined voluntarily and involuntarily admitted services users' perception of coercion during the admission process and whether this was associated with factors such as the therapeutic alliance, satisfaction with services, functioning and quality of life. This report aims to collate the findings of the study.

METHODS

The study was undertaken across three community mental health services in Ireland. Participants were interviewed before discharge and at 1 year using the MacArthur Admission Experience. Caregivers of participants were interviewed about their perception of coercion during the admission.

RESULTS

A total of 161 service users were interviewed and of those admitted involuntarily, 42% experienced at least one form of physical coercion. Service users admitted involuntarily reported higher levels of perceived coercion and less procedural justice than those admitted voluntarily. A total of 22% of voluntarily admitted service users reported levels of perceived coercion comparable with involuntarily admitted service users and this was associated with treatment in a secure ward or being brought to hospital initially under mental health legislation. In comparison with the service user, caregivers tended to underestimate the level of perceived coercion. The level of procedural justice was moderately associated with the therapeutic relationship and satisfaction with services. After 1 year, 70% experienced an improvement in functioning and this was not associated with the accumulated level of coercive events, when controlled for confounders.

CONCLUSIONS

This study has provided valuable insights into the perceptions of coercion and can help inform future interventional studies aimed at reducing coercion in mental health services.

Denial of Access to Individuals Seeking Inpatient Care: Disposition Determinants and 12 Month Outcomes

OBJECTIVE

This study considers the denial of access to inpatient care to those seeking hospitalization following psychiatric emergency service (PES) evaluation. It evaluates how civil commitment criteria, functional status, institutional constraints, social bias, and procedural justice indicators are likely to impact denial of care decisions, and considers 12 month outcomes.

METHODS

PES evaluations of 583 patients in 9 California county general hospitals were examined via logit modeling to determine those factors contributing to the decision to deny access to inpatient care. Differences in the importance of influences on the decision making process and outcomes at 12 months are examined in two contrasts: first, admitted and released patients seeking care, then, the latter group versus all other patients. Outcome measures include numbers of deaths, violent crimes, and involuntary readmissions to the PES.

RESULTS

Of the patients evaluated, 8.4 % were denied access to inpatient care despite their avowed wish to be hospitalized. When compared to admitted patients seeking hospitalization or to all other patients, analyses show that clinicians relied on civil commitment admission criteria and the availability of a less restrictive alternative to the hospital in making decisions on patient retention. When compared with all other patients, the probability of unwanted release was greater for individuals evaluated in difficult circumstances, for those without insurance, and for those with higher functional status. Fewer deaths were observed in the group denied admission, though no other significant outcome differences were observed.

CONCLUSION

Dangerousness and mental disorder in the absence of a less restrictive alternative to hospitalization, along with an overall assessment of the patient's functional status, are effectively employed as triage criteria in determining who is denied access to inpatient care following PES evaluation. While some higher functioning individuals are subjected to a variant standard of access to inpatient care because of a lack of insurance, and endure the misfortune of being evaluated under difficult clinical circumstances, outcomes seem contingent on clinicians' ability to distinguish between groups on the aforementioned triage criteria.

Perceived coercion in persons with mental disorder in India: A cross-sectional study

BACKGROUND

Little is known about how patients in India perceive coercion in psychiatric care.

AIMS

To assess perceived coercion in persons with mental disorder admitted involuntarily and correlate with sociodemographic factors and illness variables.

MATERIALS AND METHODS

We administered the short MacArthur Admission Experience Interview Questionnaire to all consecutive involuntary psychiatric patients admitted in 2014 in Mysore, India. Multivariate linear regression was used.

RESULTS

Three hundred and one patients participated. "Perceived coercion" subscale scores increased with female gender, nuclear family status, Muslim and Christian religion, lower income, and depressive disorder. It decreased with former coercion, forensic history, and longer illness duration. Drug use increased total scores; the extended family item decreased them. "Negative pressure" increased with male gender, extended family, lower income, forensic history, and longer illness duration.

CONCLUSIONS

The study shows perceived coercion is a reality in India. Levels of perceived coercion and the populations affected are similar to high-income countries.

The Treatment Perspectives of Mentally Ill Offenders in Medium- and High-Secure Forensic Settings in Flanders

There is an increasing interest in mentally ill offenders' (MIOs) treatment experiences in forensic settings. This study focuses on the treatment perspectives of MIOs in treatment as well as in prison settings in Flanders. Seventeen MIOs were interviewed about the treatment they received. Data were analyzed using thematic analysis to derive key themes while acknowledging the individuality of the participants' experiences. Treatment perspectives of MIOs in both settings revolved around similar themes, including "good" staff and privacy. However, their views differed on two themes: MIOs in treatment settings reported on feelings of lacking control and experiencing too much pressure, whereas MIOs in prison settings reported the opposite. The positive experiences in prison settings may complicate the transition from prison to a forensic treatment setting. The study further underscores the major challenge to create more opportunities for MIOs to meet their needs of self-determination in secure forensic treatment settings.

Caregivers' perceptions of coercion in psychiatric hospital admission

While knowledge on service users' perspective on their admissions to psychiatric wards has improved substantially in the last decade, there is a paucity of knowledge of the perspectives of caregivers. This study aimed to determine caregiver's perception of the levels of perceived coercion, perceived pressures and procedural justice experienced by service users during their admission to acute psychiatric in-patient units. The perspective of caregivers were then compared to the perspectives of their related service users, who had been admitted to five psychiatric units in Ireland. Caregivers were interviewed using an adapted version of the MacArthur admission experience interview. Sixty-six caregivers participated in this study and the majority were parents. Seventy one percent of service users were admitted involuntarily and nearly half had a diagnosis of schizophrenia or schizoaffective disorder. Caregivers of involuntarily admitted individuals perceived the service users' admission as less coercive than reported by the service users. Caregivers also perceived a higher level of procedural justice in comparison to the level reported by service users. Reducing the disparity of perceptions between caregivers and service users could result in caregivers having a greater understanding of the admission process and why some service users may be reluctant to be admitted.

Psychiatric Advance Directives in India: What will the future hold?

Psychiatric Advance Directives (PADs) have been incorporated into India's Mental Health Care Bill, 2013. This is the first time any form of Advance Directive stands to receive legal sanction in India. PADs have numerous theoretical and empirically tenable therapeutic and financial advantages. Western experiences have shown high acceptance for the concept among psychiatric patients, and illustrated that most stable patients with severe mental illness retain the capacity to frame PADs consistent with community practice standards. However active psychopathology does impair this capacity, and therein, current subjective assessments of competence performed by Physicians without objective instruments are often inaccurate. Though PADs champion patient autonomy, when applied and studied, they have shown little significant advantage-there is currently not enough data to support evidence-based universal recommendations for PADs. PADs as incorporated into the Mental Health Care Bill model on existing Western statutes, and though many of the strengths of earlier systems have been subsumed, so have several of the shortcomings. The risks, benefits and applicability of PADs in India are complicated by the social re-calibration of patient autonomy, mental-healthcare delivery system weaknesses, and the relatively peripheral role the Psychiatrist is mandated to play in the entire advance directive process. Treating patients within the framework of their pre-stated wishes will be a much more intricate and arduous task than most of modern Psychiatric practice in India, but the difficulties, obstacles and inevitable failures encountered will provide evidence of the delivery system's weaknesses and thereby contribute to its strength.

Coercion in psychiatric care: can paternalism justify coercion?

BACKGROUND

It has long been debated whether coercion can be justified as paternalism in the field of mental health and it is still a continuing issue of controversy today.

AIMS

This study analyses whether coercive intervention in mental health can be justified by the basic assumptions of paternalists: the assumption of incompetence, the assumption of dangerousness and the assumption of impairment.

METHOD

This study involved 248 patients: 158 (63.7%) were diagnosed with schizophrenia and 90 (36.3%) were diagnosed with mood disorder. In this study, experiences of coercion were divided into legal status, subjective (perceived coercion) and objective experiences (experienced coercion).

RESULTS

The assumption of incompetence was justified in all three categories of coercion whereas the assumption of dangerousness was not justified in any. The assumption of impairment was not justified in legal status and perceived coercion, but provided a partial explanation to serve as a basis for justifying experienced coercive measures.

CONCLUSIONS

It can be noted that mental health experts who support paternalism without question must reconsider their previous methods. Above all, the reason why the assumption of dangerousness was not justified in any of the categories of coercion was because coercive intervention used to prevent harm to oneself and others must be very carefully carried out.

Caregivers' appraisals of patients' involuntary hospital treatment: European multicentre study

BACKGROUND

Mental health policies emphasise that caregivers' views of involuntary psychiatric treatment should be taken into account. However, there is little evidence on how caregivers view such treatment.

AIMS

To explore caregivers' satisfaction with the involuntary hospital treatment of patients and what factors are associated with caregivers' appraisals of treatment.

METHOD

A multicentre prospective study was carried out in eight European countries. Involuntarily admitted patients and their caregivers rated their appraisal of treatment using the Client Assessment of Treatment Scale 1 month after admission.

RESULTS

A total of 336 patients and their caregivers participated. Caregivers' appraisals of treatment were positive (mean of 8.5 on a scale from 0 to 10) and moderately correlated with patients' views. More positive caregivers' views were associated with greater patients' symptom improvement.

CONCLUSIONS

Caregivers' appraisals of involuntary in-patient treatment are rather favourable. Their correlation with patients' symptom improvement may underline their relevance in clinical practice.

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.

Are depot antipsychotics more coercive than tablets? The patient's perspective

Some clinicians consider depot antipsychotics to be stigmatising, coercive and unacceptable to patients. This cross-sectional study investigated patients' perspectives of coercion for depot and oral antipsychotics. In all, 72 participants with chronic mental illness on voluntary maintenance antipsychotic medication were interviewed for their views on oral and depot medication and experiences of coercion. The MacArthur Admission Experience (short form) was adapted to explore coercion regarding medication. Mean total coercion levels were higher for those on depot (depot: mean 4.39; oral: 2.80, P = 0.027), as were perceived coercion (2.52 vs 1.73, P = 0.041) and negative pressures subscales (1.17 vs 0.33, P = 0.009). No significant differences were found for the 'voice' subscale and affective reactions. Specifically, more participants on depot felt that people try to force them to take medication (30% vs 2%, P< 0.001). Depots were perceived as more coercive than oral antipsychotics. Greater perceived coercion may explain why some consider depots to be a more stigmatising form of treatment. Although forced medication is sometimes required, the experience of coercion should be minimised by giving patients a fair say in treatment decisions, regardless of formulation.

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.

A comparison of mental health legislation from diverse Commonwealth jurisdictions

INTRODUCTION

In the regulation of involuntary treatment, a balance must be found between duties of care and protection and the right to self-determination. Despite its shared common roots, the mental health legislation of Commonwealth countries approaches this balance in different ways. When reform is planned, lessons can be learned from the experiences of other countries.

METHOD

Criteria for involuntary treatment used in a sample of 32 Commonwealth Mental Health Acts were compared using a framework developed from standards derived from the Universal Declaration of Human Rights. Reasons for non-compliance were considered and examples of good practice were noted. Changes in the criteria used over time and across areas with differing levels of economic development were analysed.

RESULTS

1. Widespread deviation from standards was demonstrated, suggesting that some current legislation may be inadequate for the protection of the human rights of people with mental disorders. 2. Current trends in Commonwealth mental health law reform include a move towards broad diagnostic criteria, use of capacity and treatability tests, treatment in the interests of health rather than safety, and regular reviews of treatment orders. Nevertheless, there are some striking exceptions.

DISCUSSION

Explanations for deviation from the standards include differing value perspectives underpinning approaches to balancing conflicting principles, failure to keep pace with changing attitudes to mental disorder, and variations in the resources available for providing treatment and undertaking law reform. Current good practice provides examples of ways of dealing with some of these difficulties.

Psychiatric advance directives and the right to refuse treatment in Canada

OBJECTIVE

To provide a Canadian perspective on psychiatric advance directives (PADs) and assess whether these documents can be implemented as an adjunct to mental health services to empower people with mental illness.

METHOD

We reviewed Canadian jurisprudence over the past 15 years related to people with mental illness and the right to refuse medical treatment. Provincial mental health legislation is explained to discern PADs' possible effect in Canada.

RESULTS

Evidence is accumulating that legal and mental health professionals see PADs as useful documents to promote patient autonomy. Canadian jurisprudence, mental health legislation, and psychological research suggest that PADs could be implemented by legal and mental health professionals. Mental health legislation has the power to prohibit or facilitate choices regarding the right to refuse medical treatment.

CONCLUSIONS

This review suggests the need for greater empirical research to be conducted in Canada to determine stakeholders' perceptions of whether PADs could successfully be implemented and their interaction with legislation.

Unemployment and civil commitment: a test of the intolerance hypothesis

We theorize that the reported association between economic indicators and the incidence of civil commitment for mental illness may result, at least in part, from reduced tolerance in the community for impaired behavior among minorities. Earlier work suggests that economically induced intolerance will be focused primarily on minority males. Based on this literature, we hypothesize that the median level of functioning among African-American males subjected to civil commitment will vary positively with earlier changes in the unemployment rate. The test applies Box-Jenkins methods to 156 months (August 1985-July 1998) of data from California. Consistent with theory, results support the hypothesis.

Patients' experience of humiliation in the admission process to acute psychiatric wards

The objective of the study was to investigate the experiences of humiliations by patients in the admission process to acute psychiatric wards. One-hundred-and-two patients were interviewed within 48 h after hospitalization about their experiences of the admission process. The structured Admission Experience Survey questionnaire was used to identify negative events of the admission process. Perceived humiliation was defined by a cut-off on the self-reported Cantrill's Ladder Scale. Six qualitative depth interviews of patients with high and low humiliation scores were performed in order to relate interview information on humiliation experiences to the self-report. Negative events during the admission process were significantly more common among patients with involuntary admission, but were also observed among those voluntary admitted. Humiliation in connection with negative events during the admission process was reported by 48 patients, 24 involuntary and 24 voluntary admitted. In univariate analyses, humiliation was significantly associated with events where the patients were exposed to verbal or physical force, as well as with the conviction that "the admission was not right". In multivariate analyses, the latter conviction was the only significant one, although "use of physical force" also showed a trend (P=0.06). Negative events are common among the routines, procedures, and situations of the admission process to acute psychiatric wards. Some of them can hopefully be modified such as the use of verbal and physical force. In contrast, the conviction that "the admission was not right", which showed the strongest association with humiliation, seems less modifiable in the admission process.

Characteristics associated with involuntary versus voluntary legal status at admission and discharge among psychiatric inpatients

BACKGROUND

The objective of this analysis was to determine the ways in which patients' legal statuses at hospital admission and discharge are associated with select sociodemographic and clinical variables. This study specifically investigated differences between patients who were voluntary during both admission and discharge, patients who were involuntary on admission but voluntary on discharge (having converted to voluntary status during hospitalization), and patients who were involuntary during both admission and discharge.

METHOD

Data were collected from the charts and treating clinicians of 227 consecutively discharged patients from two psychiatric units in a large, urban, county hospital in the southeastern United States. Based on results of bivariate tests, sociodemographic and clinical factors were entered into a polytomous logistic regression model to determine effect estimates (adjusted odds ratios).

RESULTS

In the bivariate analyses, 15 variables were significantly associated with the trichotomous legal status. In the model, three factors were independently significantly associated with legal status, while controlling for four potential confounders: (1) whether or not the patient was experiencing psychotic symptoms at discharge, (2) whether or not the patient had documented medical problems requiring medication at discharge, and (3) the number of psychiatric medications.

CONCLUSIONS

A generalized lack of treatment engagement and adherence among involuntary patients likely underlies significant differences between the groups in terms of psychotic symptoms, diagnosed medical problems requiring medications, and number of psychiatric medications at discharge. Studying legal status (and the process of legal status conversion from involuntary to voluntary) and its correlates is an important topic for further research.

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.

Factors in the use of coercive retention in civil commitment evaluations in psychiatric emergency services

OBJECTIVE

The authors examined whether factors other than civil commitment criteria influence the involuntary retention of patients who are evaluated for civil commitment in psychiatric emergency services in California general hospitals.

METHODS

Logistic regression analysis was used to determine whether admission criteria, institutional constraints, social biases, and procedural justice indicators contributed to the use of coercive retention in the evaluations of 583 patients in the psychiatric emergency services of nine California county general hospitals.

RESULTS

Of the 583 patients, 109 (18.7 percent) were retained against their wishes. Clinicians relied primarily on admission criteria in making the decision to retain a patient, which suggests that patients were generally afforded procedural due process during the evaluation in the psychiatric emergency service. Staff workload was a possible factor in violations of due process.

CONCLUSIONS

Psychiatric emergency services need additional resources to ensure procedural due process protection for patients who are being evaluated for civil commitment.

Recovery and serious brain disorders: the central role of families in nurturing roots and wings

Recovery in severe mental illness is a powerful concept for consumers, invoking a journey through understanding and acceptance of illness and disability, along with hope for a quality life, self-empowerment, and responsibility. Although not widely recognized, the journey toward recovery is also important for family members of individuals with severe mental illnesses, who often serve in a care-giving or supportive role for their loved ones. From the family perspective, to make recovery a real possibility, several issues must be confronted. First, progress toward recovery must acknowledge and involve care-giving and supportive family members, recognizing their significant role in the lives of many individuals with severe mental illnesses as well as the journey of family members in understanding and accepting a severe mental illness in a loved one. Second, a real, recovery-oriented system implements treatments and supports shown to be effective. In this day and age, the gap between research findings and ordinary care condemns too many consumers and their families to outcomes far short of what is possible. This includes not only medications, psychotherapy, employment services, dual diagnosis services, housing and other supports for consumers, but also family education, shown to be effective by a large body of research. Third, a recovery-oriented system of care cannot afford to dance around the thorniest and most controversial issues in severe mental illnesses-such as individuals with the most intractable forms of illness or the relatively infrequent but very real situations in which either consumers or family members are assaultive or abusive. All of these elements are essential if recovery is to be more than a slogan, but rather a true goal in a system of care that respects consumers with these disorders and their care-giving family members.

Patients' revisions of their beliefs about the need for hospitalization

OBJECTIVE

An influential rationale for involuntary hospitalization is that prospective patients who refuse hospitalization at the time it is offered are likely to change their belief about the necessity of hospitalization after receiving hospital treatment. The authors examine how patients changed their evaluations of psychiatric hospitalization following hospital treatment.

METHOD

The authors studied 433 patients who were interviewed about their hospitalization within 2 days of their admission to a psychiatric hospital; 267 of these patients were reinterviewed 4-8 weeks following discharge.

RESULTS

When reinterviewed at follow-up, 33 (52%) of 64 patients who said at admission that they did not need hospitalization said that, in retrospect, they believed they had needed it. Only 9 (5%) of 198 patients who said at admission that they needed hospitalization shifted to saying that they had not needed it.

CONCLUSIONS

Many of the patients who initially judged that they did not need hospitalization revised their belief after hospital discharge and reported that they had needed hospital treatment. However, perceptions of coercion were stable from admission to follow-up, and patients' attitudes toward hospitalization did not become more positive. Coerced patients did not appear to be grateful for the experience of hospitalization, even if they later concluded that they had needed it.