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Hempeler C, Potthoff S, Scholten M, Juckel G, Gather J. Strategies to promote treatment compliance: a grounded theory study with relatives of people with a serious mental health condition. BMC Psychiatry 2024; 24:490. [PMID: 38977963 PMCID: PMC11229214 DOI: 10.1186/s12888-024-05907-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 06/10/2024] [Indexed: 07/10/2024] Open
Abstract
BACKGROUND Treatment pressures encompass communicative strategies that influence mental healthcare service users' decision-making to increase their compliance with recommended treatment. Persuasion, interpersonal leverage, inducements, and threats have been described as examples of treatment pressures. Research indicates that treatment pressures are exerted not only by mental healthcare professionals but also by relatives. While relatives play a crucial role in their family member's pathway to care, research on the use of treatment pressures by relatives is still scarce. Likewise, little is known about other strategies relatives may use to promote the treatment compliance of their family member with a serious mental health condition. In particular, no study to date has investigated this from the perspective of relatives of people with a serious mental health condition. AIM The aim of this study was to answer the following research questions: Which types of treatment pressures do relatives use? Which other strategies do relatives use to promote the treatment compliance of their family member with a serious mental health condition? How do treatment pressures relate to these other strategies? METHODS Eleven semi-structured interviews were conducted with relatives of people with a serious mental health condition in Germany. Participants were approached via relatives' self-help groups and flyers in a local psychiatric hospital. Inclusion criteria were having a family member with a psychiatric diagnosis and the family member having experienced formal coercion. The data were analyzed using grounded theory methodology. RESULTS Relatives use a variety of strategies to promote the treatment compliance of their family member with a serious mental health condition. These strategies can be categorized into three general approaches: influencing the decision-making of the family member; not leaving the family member with a choice; and changing the social or legal context of the decision-making process. Our results show that the strategies that relatives use to promote their family member's treatment compliance go beyond the treatment pressures thus far described in the literature. CONCLUSION This qualitative study supports and conceptually expands prior findings that treatment pressures are not only frequently used within mental healthcare services but also by relatives in the home setting. Mental healthcare professionals should acknowledge the difficulties faced and efforts undertaken by relatives in seeking treatment for their family member. At the same time, they should recognize that a service user's consent to treatment may be affected and limited by strategies to promote treatment compliance employed by relatives.
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Affiliation(s)
- Christin Hempeler
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Markstraße 258a, 44799, Bochum, Germany.
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Alexandrinenstraße 1-3, 44791, Bochum, Germany.
| | - Sarah Potthoff
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Markstraße 258a, 44799, Bochum, Germany
- Institute for Experimental Medicine, Department for Medical Ethics, Christian-Albrechts University Kiel, Preusserstraße 1-9, 24105, Kiel, Germany
| | - Matthé Scholten
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Markstraße 258a, 44799, Bochum, Germany
| | - Georg Juckel
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Alexandrinenstraße 1-3, 44791, Bochum, Germany
| | - Jakov Gather
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Markstraße 258a, 44799, Bochum, Germany
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Alexandrinenstraße 1-3, 44791, Bochum, Germany
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Thorvaldsen NO, Husum TL, Sollid SJM. Exploring use of coercion in the Norwegian ambulance service - a qualitative study. Scand J Trauma Resusc Emerg Med 2023; 31:44. [PMID: 37667365 PMCID: PMC10478396 DOI: 10.1186/s13049-023-01104-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 07/21/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND Healthcare laws allow for exceptions from the consent requirement when patients are not competent to consent or pose a danger to themselves or others. In these cases, the use of coercion may be an alternative to voluntary health care. Ambulance personnel are regularly confronted with patients who need healthcare but refuse it and/or refuse to cooperate. This study aimed to explore ambulance personnel`s experience with use of coercion and factors influencing the use of coercion in the ambulance service in Norway. METHOD We conducted two focus group interviews with a total of eight informants, all ambulance personnel from a large Norwegian ambulance service. Digital recordings of the interviews were transcribed verbatim and analysed using systematic text condensation. RESULTS The informants` stories revealed several methods of coercion used by the ambulance personnel; physical coercion, pragmatic coercion, pharmacological coercion and coercion used to ensure the patient is secured during transportation. The main reasons for using coercion were preventing patients from harming themselves or others and to ensure that patients unable to consent receive healthcare considered necessary. Systemic factors as difficulty of applying the law to real-life situations, and organizational factors as fear of breaching guidelines, experienced lack of support from the management, fear of charges of misconduct, and lack of training in assessing patients´ competence to consent seem to influence ambulance personnels use of coercion. CONCLUSION Ethical grey areas in clinical practice emphasize the need for clinical discretion. Despite the fact that regulatory provisions allow for exceptions from the requirement to obtain consent, transferring these regulations to real life prehospital settings can be difficult. Consequently, the decisions made by ambulance personnel in clinical situations are highly influenced by organizational ethos and guidelines. The informants describe the coercive interventions they have employed to manage patients who are deemed to require healthcare but refuse it and/or refuse to cooperate.
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Affiliation(s)
- Nina Oeye Thorvaldsen
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway.
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.
| | - Tonje Lossius Husum
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
- Centre for Medical Ethics, University of Oslo, Oslo, Norway
| | - Stephen J M Sollid
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Prehospital Division, Oslo University Hospital, Oslo, Norway
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Silva B, Bachelard M, Bonsack C, Golay P, Morandi S. Exploring Patients' Feeling of Being Coerced During Psychiatric Hospital Admission: A Qualitative Study. Psychiatr Q 2023; 94:411-434. [PMID: 37452928 PMCID: PMC10460343 DOI: 10.1007/s11126-023-10039-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/18/2023]
Abstract
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.
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Affiliation(s)
- Benedetta Silva
- Community Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
- Cantonal Medical Office, General Directorate for Health, Canton of Vaud Department of Health and Social Action, Lausanne, Switzerland.
| | - Mizué Bachelard
- Community Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Charles Bonsack
- Community Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Philippe Golay
- Community Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- General Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Psychology, Faculty of Social and Political Sciences, University of Lausanne, Lausanne, Switzerland
| | - Stéphane Morandi
- Community Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Cantonal Medical Office, General Directorate for Health, Canton of Vaud Department of Health and Social Action, Lausanne, Switzerland
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Hempeler C, Braun E, Potthoff S, Gather J, Scholten M. When Treatment Pressures Become Coercive: A Context-Sensitive Model of Informal Coercion in Mental Healthcare. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023:1-13. [PMID: 37506325 DOI: 10.1080/15265161.2023.2232754] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
Treatment pressures are communicative strategies that mental health professionals use to influence the decision-making of mental health service users and improve their adherence to recommended treatment. Szmukler and Appelbaum describe a spectrum of treatment pressures, which encompasses persuasion, interpersonal leverage, offers and threats, arguing that only a particular type of threat amounts to informal coercion. We contend that this account of informal coercion is insufficiently sensitive to context and fails to recognize the fundamental power imbalance in mental healthcare. Based on a set of counterexamples, we argue that what makes a proposal coercive is not whether service users will actually be made worse off if they reject the proposal, but rather whether they have the justified belief that this is the case. Whether this belief is justified depends on the presence of certain contextual factors, such as strong dependency on professionals and the salient possibility of formal coercion.
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Affiliation(s)
- Christin Hempeler
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Esther Braun
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Sarah Potthoff
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Jakov Gather
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Matthé Scholten
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
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Valenti E, Giacco D. Persuasion or coercion? An empirical ethics analysis about the use of influence strategies in mental health community care. BMC Health Serv Res 2022; 22:1273. [PMID: 36271380 PMCID: PMC9587610 DOI: 10.1186/s12913-022-08555-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 09/11/2022] [Indexed: 12/04/2022] Open
Abstract
Background Influence strategies such as persuasion and interpersonal leverage are used in mental health care to influence patient behaviour and improve treatment adherence. One ethical concern about using such strategies is that they may constitute coercive behaviour ("informal coercion") and negatively impact patient satisfaction and the quality of care. However, some influence strategies may affect patients' perceptions, so an umbrella definition of “informal coercion” may be unsatisfactory. Furthermore, previous research indicates that professionals also perceive dissonance between theoretical explanations of informal coercion and their behaviours in clinical practice. This study analysed mental health professionals’ (MHPs) views and the perceived ethical implications of influence strategies in community care. Methods Qualitative secondary data analysis of a focus group study was used to explore the conflict between theoretical definitions and MHPs’ experiences concerning the coerciveness of influence strategies. Thirty-six focus groups were conducted in the main study, with 227 MHPs from nine countries participating. Results The findings indicate that not all the influence strategies discussed with participants can be defined as “informal coercion”, but they become coercive when they imply the use of a lever, have the format of a conditional offer and when the therapeutic proposal is not a patient’s free choice but is driven by professionals. MHPs are rarely aware of these tensions within their everyday practice; consequently, it is possible that coercive practices are inadvertently being used, with no standard regarding their application. Our findings suggest that levers and the type of leverage used in communications with the patient are also relevant to differentiating leveraged and non-leveraged influence. Conclusion Our findings may help mental health professionals working in community care to identify and discuss influence strategies that may lead to unintended coercive practices.
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Affiliation(s)
- Emanuele Valenti
- Centre for Ethics in Medicine, Bristol Medical School, Population Health School Sciences, University of Bristol, Canynge Hall, Bristol, BS8 2 PS, UK.
| | - Domenico Giacco
- Department of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, CV 7, AL, UK
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Potthoff S, Gather J, Hempeler C, Gieselmann A, Scholten M. "Voluntary in quotation marks": a conceptual model of psychological pressure in mental healthcare based on a grounded theory analysis of interviews with service users. BMC Psychiatry 2022; 22:186. [PMID: 35296288 PMCID: PMC8928679 DOI: 10.1186/s12888-022-03810-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 02/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Psychological pressure refers to communicative strategies used by professionals and informal caregivers to influence the decision-making of service users and improve their adherence to recommended treatment or social rules. This phenomenon is also commonly referred to as informal coercion or treatment pressure. Empirical studies indicated that psychological pressure is common in mental healthcare services. No generally accepted definition of psychological pressure is available to date. A first conceptual analysis of psychological pressure focused on staff communication to promote treatment adherence and distinguished between persuasion, interpersonal leverage, inducements and threats. AIM The aim of this study was to develop a conceptual model of psychological pressure based on the perspectives of service users. METHODS Data were collected by means of semi-structured interviews. The sample consisted of 14 mental health service users with a self-reported psychiatric diagnosis and prior experience with coercion in mental healthcare. We used theoretical sampling and contacted participants via mental healthcare services and self-help groups to ensure a variety of attitudes toward the mental healthcare system in the sample. The study was conducted in Germany from October 2019 to January 2020. Data were analyzed according to grounded theory methodology. RESULTS The study indicated that psychological pressure is used not only to improve service users' adherence to recommended treatment but also to improve their adherence to social rules; that it is exerted not only by mental health professionals but also by relatives and friends; and that the extent to which service users perceive communication as involving psychological pressure depends strongly on contextual factors. Relevant contextual factors were the way of communicating, the quality of the personal relationship, the institutional setting, the material surroundings and the level of convergence between the parties' understanding of mental disorder. CONCLUSIONS The results of the study highlight the importance of staff communication training and organizational changes for reducing the use of psychological pressure in mental healthcare services.
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Affiliation(s)
- Sarah Potthoff
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Markstraße 258a, 44799, Bochum, Germany.
| | - Jakov Gather
- grid.5570.70000 0004 0490 981XInstitute for Medical Ethics and History of Medicine, Ruhr University Bochum, Markstraße 258a, 44799 Bochum, Germany ,grid.5570.70000 0004 0490 981XDepartment of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Alexandrinenstraße 1-3, 44791 Bochum, Germany
| | - Christin Hempeler
- grid.5570.70000 0004 0490 981XInstitute for Medical Ethics and History of Medicine, Ruhr University Bochum, Markstraße 258a, 44799 Bochum, Germany ,grid.5570.70000 0004 0490 981XDepartment of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Alexandrinenstraße 1-3, 44791 Bochum, Germany
| | - Astrid Gieselmann
- grid.5570.70000 0004 0490 981XInstitute for Medical Ethics and History of Medicine, Ruhr University Bochum, Markstraße 258a, 44799 Bochum, Germany ,grid.6363.00000 0001 2218 4662Department of Psychiatry, Charité_Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Matthé Scholten
- grid.5570.70000 0004 0490 981XInstitute for Medical Ethics and History of Medicine, Ruhr University Bochum, Markstraße 258a, 44799 Bochum, Germany
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Jöbges S, Mouton Dorey C, Porz R, Ricou B, Biller-Andorno N. What does coercion in intensive care mean for patients and their relatives? A thematic qualitative study. BMC Med Ethics 2022; 23:9. [PMID: 35120515 PMCID: PMC8817558 DOI: 10.1186/s12910-022-00748-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 01/21/2022] [Indexed: 01/10/2023] Open
Abstract
Background The need for an ethical debate about the use of coercion in intensive care units (ICU) may not be as obvious as in other areas of medicine, such as psychiatry. Coercive measures are often necessary to treat critically ill patients in the ICU. It is nevertheless important to keep these measures to a minimum in order to respect the dignity of patients and the cohesion of the clinical team. A deeper understanding of what patients and their relatives perceive during their ICU stay will shed different light on intensive care management. Patients' experiences of loss of control, dependency and abandonment may lead to a new approach towards a broader approach to the concept of coercion in intensive care. The aim of our research is to explore the experiences of patients and relatives in the ICU and to determine when it might be possible to reduce feelings and memories of coercion. Methods We conducted and analysed 29 semi-structured interviews with patients and relatives who had been in the ICU a few months previously. Following a coding and categorisation process in MAXQDA™, a rigorous qualitative methodology was used to identify themes relevant to our research. Results Five main themes emerged: memory issues; interviewees’ experiences of restricting measures and coercive treatment; patients’ negative perception of situational and relational dependency with the risk of informal coercion; patients’ perceptions of good care in a context of perceived dependency; progression from perception of coercion and dependency to respect for the person. All patients were grateful to have survived. However, coercion in the form of restraint, restriction of movement, and coercive treatment in the ICU was also acknowledged by patients and relatives. These included elements of informal coercion beyond restraints, such as a perceived negative sense of dependence, surrender, and asymmetrical interaction between the patient and health providers. Conclusions To capture the full range of patients' experiences of coercion, it is necessary to expand the concept of coercion to include less obvious forms of informal coercion that may occur in dependency situations. This will help identify solutions to avoid or reduce negative recollections that may persist long after discharge and negatively affect the patients' quality of life. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-022-00748-1.
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Affiliation(s)
- Susanne Jöbges
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, 8006, Zurich, Switzerland.
| | - Corine Mouton Dorey
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, 8006, Zurich, Switzerland
| | - Rouven Porz
- University Hospital Bern, 3010, FreiburgstrasseBern, Switzerland
| | - Bara Ricou
- Department of Anaesthesiology, Clinical Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, 1211, Geneva, Switzerland
| | - Nicola Biller-Andorno
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, 8006, Zurich, Switzerland
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Becher S, Holzhüter F, Heres S, Hamann J. Barriers and facilitators of shared decision making in acutely ill inpatients with schizophrenia-Qualitative findings from the intervention group of a randomised-controlled trial. Health Expect 2021; 24:1737-1746. [PMID: 34258833 PMCID: PMC8483208 DOI: 10.1111/hex.13313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 06/04/2021] [Accepted: 06/19/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Shared decision making (SDM) is appreciated as a promising model of communication between clinicians and patients. However, in acute mental health settings, its implementation is still unsatisfactory. OBJECTIVE The aim of this study is to examine barriers and facilitators of SDM with acutely ill inpatients with schizophrenia. DESIGN A qualitative interview study was performed. SETTING AND PARTICIPANTS The analysis is based on interviews with participants (patients and staff members) of the intervention group of the randomised-controlled SDMPLUS trial that demonstrated a significant improvement of SDM measures for patients with schizophrenia on acute psychiatric wards. MAIN VARIABLES STUDIED Interviews addressed treatment decisions made during the current inpatient stay. The interviews were analysed using qualitative content analysis. RESULTS A total of 40 interviews were analysed and 131 treatment decisions were identified. According to the interviewees, SDM had taken place in 29% of the decisions, whereas 59% of the decisions were made without SDM. In 16%, a clear judgement could not be made. Barriers and facilitators of SDM were categorised into patient factors, clinician factors, setting factors and others. Clinicians mostly reported patient factors (e.g., symptoms) as barriers towards SDM, which were not mirrored on the patients' side. Facilitators included patient as well as clinician behaviour during consultations. CONCLUSION Even in the context of a successful SDM intervention, the implementation of SDM for patients in the very acute stages of schizophrenia is often not possible. However, strong facilitators for SDM have also been identified, which should be used for further implementation of SDM. PATIENT OR PUBLIC CONTRIBUTION During the development of the study protocol, meetings with user representatives were held.
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Affiliation(s)
- Stefanie Becher
- Klinik und Poliklinik für Psychiatrie und PsychotherapieTechnische Universität MünchenMunichGermany
| | - Fabian Holzhüter
- Klinik und Poliklinik für Psychiatrie und PsychotherapieTechnische Universität MünchenMunichGermany
| | | | - Johannes Hamann
- Klinik und Poliklinik für Psychiatrie und PsychotherapieTechnische Universität MünchenMunichGermany
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Oelhafen S, Trachsel M, Monteverde S, Raio L, Cignacco E. Informal coercion during childbirth: risk factors and prevalence estimates from a nationwide survey of women in Switzerland. BMC Pregnancy Childbirth 2021; 21:369. [PMID: 33971841 PMCID: PMC8112037 DOI: 10.1186/s12884-021-03826-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 04/22/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND In many countries, the increase in facility births is accompanied by a high rate of obstetric interventions. Lower birthrates or elevated risk factors such as women's higher age at childbirth and an increased need for control and security cannot entirely explain this rise in obstetric interventions. Another possible factor is that women are coerced to agree to interventions, but the prevalence of coercive interventions in Switzerland is unknown. METHODS In a nationwide cross-sectional online survey, we assessed the prevalence of informal coercion during childbirth, women's satisfaction with childbirth, and the prevalence of women at risk of postpartum depression. Women aged 18 years or older who had given birth in Switzerland within the previous 12 months were recruited online through Facebook ads or through various offline channels. We used multivariable logistic regression to estimate the risk ratios associated with multiple individual and contextual factors. RESULTS In total, 6054 women completed the questionnaire (a dropout rate of 16.2%). An estimated 26.7% of women experienced some form of informal coercion during childbirth. As compared to vaginal delivery, cesarean section (CS) and instrumental vaginal birth were associated with an increased risk of informal coercion (planned CS risk ratio [RR]: 1.52, 95% confidence interval [1.18,1.96]; unplanned CS RR: 1.92 [1.61,2.28]; emergency CS RR: 2.10 [1.71,2.58]; instrumental vaginal birth RR: 2.17 [1.85,2.55]). Additionally, migrant women (RR: 1.45 [1.26,1.66]) and women for whom a self-determined vaginal birth was more important (RR: 1.15 [1.06,1.24]) more often reported informal coercion. Emergency cesarean section (RR: 1.32 [1.08,1.62]), being transferred to hospital (RR: 1.33 [1.11,1.60]), and experiencing informal coercion (RR: 1.35 [1.19,1.54]) were all associated with a higher risk of postpartum depression. Finally, women who had a non-instrumental vaginal birth reported higher satisfaction with childbirth while women who experienced informal coercion reported lower satisfaction. CONCLUSIONS One in four women experience informal coercion during childbirth, and this experience is associated with a higher risk of postpartum depression and lower satisfaction with childbirth. To prevent traumatic after-effects, health care professionals should make every effort to prevent informal coercion and to ensure sensitive aftercare for all new mothers.
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Affiliation(s)
- Stephan Oelhafen
- Department of Health Professions, Applied Research & Development in Midwifery, Bern University of Applied Sciences, Murtenstrasse 10, 3008, Bern, Switzerland.
| | - Manuel Trachsel
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
- Clinical Ethics Unit, University Hospital of Basel and Psychiatric University Clinics Basel, Basel, Switzerland
| | - Settimio Monteverde
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
- Department of Health Professions, School of Nursing, Bern University of Applied Sciences, Bern, Switzerland
| | - Luigi Raio
- Department of Obstetrics and Gynecology, University Hospital of Bern, Bern, Switzerland
| | - Eva Cignacco
- Department of Health Professions, Applied Research & Development in Midwifery, Bern University of Applied Sciences, Murtenstrasse 10, 3008, Bern, Switzerland
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Abstract
Psychiatry has a contentious history of coercion in the care of patients with mental illness, and legal frameworks often govern use of coercive interventions, such as involuntary hospitalization, physical restraints, and medication over objection. Research also suggests that informal coercion, including subtle inducements, leverage, or threats, is prevalent and influential in psychiatric settings. Digital technologies bring promise for expanding access to psychiatric care and improving delivery of these services; however, use and misuse of digital technologies, such as electronic medical record flags, surveillance cameras, videoconferencing, and risk assessment tools, could lead to unexpected coercion of patients with mental illness. Using several composite case examples, the author proposes that the integration of digital technologies into psychiatric care can influence patients' experiences of coercion and provides recommendations for studying and addressing these effects.
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Affiliation(s)
- Nathaniel P Morris
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco
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Patients' perception of coercion with respect to antipsychotic treatment of psychotic disorders and its predictors. Soc Psychiatry Psychiatr Epidemiol 2021; 56:1381-1388. [PMID: 33904940 PMCID: PMC8316198 DOI: 10.1007/s00127-021-02083-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 04/07/2021] [Indexed: 11/12/2022]
Abstract
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.
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