Coercion and the Inpatient Treatment Alliance

A qualitative meta-synthesis of service users' and carers' experiences of assessment and involuntary hospital admissions under mental health legislations: a five-year update

BACKGROUND

Compulsory admissions occur in psychiatric hospitals around the world. They result in coercive and sometimes traumatic experiences for service users and carers. Legal and service reforms in various countries are intended to reduce rates of detention and improve service user experience. We aimed to inform policy and service delivery by providing an up-to-date synthesis of qualitative evidence on service users' and carers' experiences of assessment and detention under mental health legislation, updating previous reviews in which we searched for literature published up to 2018.

METHODS

We searched five bibliographic databases for studies published between January 2018 and March 2023. We identified 24 additional studies reporting qualitative investigations of service users' or carers' experiences of assessment or detention under mental health legislation. A team including researchers with relevant personal experience analysed and synthesised data using a thematic synthesis approach.

RESULTS

Findings suggest that views on compulsory admissions and assessment varied: many reports highlighted its often negative, traumatic impacts on emotional well-being and self-worth, with fewer accounts of it as an opportunity to access help and support, accompanied by feelings of relief. Experiences of racial discrimination, inequality of access, and dissatisfaction with support before and after hospital stay were more prominent than in our previous reviews.

CONCLUSIONS

Increasing service user and carer involvement in treatment decisions, provision of timely information at key stages of the admission process, training of key personnel, addressing the issue of discrimination, and investing in community alternatives of inpatient care may contribute to and lead to better overall treatment experiences.

PROTOCOL REGISTRATION

The study protocol has been registered in the PROSPERO database on 30th May 2023 (CRD42023423439).

Involuntary Psychiatric Hospitalization: How Patient Characteristics Affect Decision-Making

Emergency department (ED) psychiatrists face the consequential decision to pursue involuntary inpatient psychiatric admission. Research on the relationship between patient characteristics and the decision to pursue involuntary psychiatric admission is limited. Using data from 2017 to 2018 at an urban Los Angeles hospital, we used generalized linear mixed effects models to compare patients who were involuntarily admitted to inpatient psychiatry to patients who were discharged from the ED. Of 2,448 patients included in the study, 1,217 (49.7%) were involuntarily admitted to inpatient psychiatry and 1,231 (50.3%) were discharged. After controlling for sociodemographic characteristics, admitted patients were more likely to have been brought in by police, have had an organized suicide plan or recent attempt, physical signs of harm, psychosis, depression or hopelessness, lack social support, have diagnoses of schizophrenia or bipolar disorder, and be administered injectable psychotropic medications. Stimulant use, a diagnosis of anxiety or developmental disorders, and recent medical ED utilization were associated with discharge. Psychiatrists pursued involuntarily psychiatric hospitalization based on factors potentially indicative of dangerousness, leaving patients, particularly those with recent substance use, without immediate access to treatment. Policies should focus on increasing follow up to high quality, voluntary outpatient mental health care.

Psychometric evaluation of the German version of the Opening Minds Stigma Scale for Health Care Providers (OMS-HC)

Background

Healthcare professionals can be a source of stigma and discrimination for people with mental illness, and anti-stigma programs are needed for this target group. However, there is no validated German language scale to assess attitudes of healthcare professionals towards people with mental illness. This study had the aim to validate the German language version of the Opening Minds Stigma Scale for Health Care Providers (OMS-HC), a self-report measure of stigmatizing attitudes.

Methods

Staff (n=392) on general psychiatric inpatient wards (excluding child, forensic and geriatric psychiatry) at five psychiatric hospitals in Switzerland (n=3) and Germany (n=2) participated in the study. The internal consistency of the OMS-HC was examined as well as its factor structure using exploratory and confirmatory factor analyses. To assess the scales concurrent validity, we used the Social Distance Scale.

Results

Internal consistency for the OMS-HC total score was good (=0.74), acceptable for the subscales Attitudes (=0.62) and Social Distance (=0.69), and poor for the Disclosure subscale (=0.55). The original three-factor structure fit our data well. The OMS-HC total score and the Social Distance subscale score were significantly correlated with the Social Distance Scale, supporting concurrent validity.

Conclusion

The German version of the OMS-HC demonstrated satisfactory psychometric properties and can be recommended for future research and intervention evaluation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-021-00592-9.

Patients' perception of coercion with respect to antipsychotic treatment of psychotic disorders and its predictors

PURPOSE

The present study investigates perceived coercion in psychiatric inpatients under prescribed antipsychotic medication without a court order. The objective of this study was to investigate whether and to what extent involuntary and voluntary inpatients feel coerced to take their medication and which factors affect perceived coercion.

METHODS

Voluntarily and involuntarily admitted patients (55 and 36, respectively) were interviewed about the extent of perceived coercion. In addition, socio-demographic and clinical data were collected. The Admission Experience Scale (aAES) was used to assess perceived coercion concerning medication. To measure insight into illness, attitude towards medication, and symptom severity, we used a questionnaire on insight into illness (FKE-10), the Drug Attitude Inventory (DAI-10), and the Brief Psychiatric Rating Scale (BPRS-24), respectively.

RESULTS

Voluntarily treated patients experienced significantly less coercion when taking prescribed medication in inpatient settings than involuntarily treated patients. The experience of coercion was not related to socio-demographic or clinical variables nor to the BPRS-24 score, but to insight into illness and attitude towards medication. Patients who had experienced at least one coercive measure during the index hospital stay showed a higher level of perceived coercion.

CONCLUSION

Perceived coercion related to medication is dependent on insight into illness and experience of previous coercive interventions rather than on the severity of psychopathological symptoms. These findings are very similar to a previous study in a forensic psychiatric sample. Having experience of at least one coercive measure seems to be a decisive aspect of the extent of the patients' perceived coercion.

Negotiating a Medication Treatment Plan

As difficult as it may be for someone to decide to seek mental health care, following up with repeat appointments is more difficult. A common route to that first appointment is discharge from an emergency department or a first hospitalization following a mental health crisis. Best practice in discharge planning is establishing an appointment with an outpatient therapist. Key to establishing care with a mental health professional is building a relationship based on trust and compassion. Establishing that relationship takes time, yet the beginning of that process occurs in the initial appointment and negotiation of a plan of care that the client can commit to. This article focuses on the process of negotiating a plan of care that is collaboratively agreed upon and renegotiated as appropriate. When the plan of care is collaboratively developed, psychotherapy and pharmacotherapy adherence become non-issues because the client and provider have established trust and a clear path to achieve the desired goals. [Journal of Psychosocial Nursing and Mental Health Services, 58(9), 9-12.].