Perceived coercion in voluntary hospital admission

Abstract

The legal status of service users admitted to psychiatric wards is not synonymous with the level of coercion that they can perceive during the admission. This study aimed to identify and describe the proportion of individuals who were admitted voluntarily but experienced levels of perceived coercion comparable to those admitted involuntarily. Individuals admitted voluntarily and involuntarily to three psychiatric hospitals were interviewed using the MacArthur Admission Experience Interview and the Structured Clinical Interview for DSM-IV diagnoses. One hundered sixty-one individuals were interviewed and 22% of the voluntarily admitted service users had levels of perceived coercion similar to that of the majority of involuntarily admitted service users. Voluntarily admitted service users who experienced high levels of perceived coercion were more likely to have more severe psychotic symptoms, have experienced more negative pressures and less procedural justices on admission. Individuals brought to hospital under mental health legislation but who subsequently agreed to be admitted voluntarily and those treated on a secure ward also reported higher levels of perceived coercion. It needs to be ensured that if any service user, whether voluntary or involuntary, experiences treatment pressures or coercion that there is sufficient oversight of the practice, to ensure that individual's rights are respected.

Introduction

In the last decade, our understanding of individual's perspectives towards the use of involuntary admission and physical coercion has grown substantially (Priebe et al., 2009, Priebe et al., 2010, O’Donoghue et al., 2011). Some individuals admitted involuntarily reflect that the use of coercion can be necessary, while others reflect that it can infringes upon their autonomy and feel that less coercive interventions should be used (Katsakou et al., 2011b). However, less is known about voluntarily admitted service users who experience high levels of perceived coercion on admission to hospital despite it being described nearly half a century ago (Breggin, 1964). It is now well established that an individual's legal status upon admission is not synonymous with the level of coercion they experience upon admission (Monahan et al., 1995). Approximately one quarter of individuals admitted voluntarily to hospital perceive that they were coerced into hospital and half of those individuals continue to feel coerced throughout their admission (Newton-Howes and Stanley, 2012, Katsakou et al., 2011a). In addition to the ethical reasons for reducing perceived coercion, it could actually have benefits in treatment outcome and the perspectives of service users. Voluntarily admitted service users with high levels of perceived coercion are more likely to perceive their treatment as ineffective and conversely, those who experience an improvement in symptoms and functioning are more likely to report a reduction in the level of perceived coercion (Katsakou et al., 2011a, Fiorillo et al., 2012).

Clinicians are at times faced with a dilemma, in that they could use persuasion or pressures to admit a service user voluntarily and prevent an individual having an involuntary admission, which has traditionally been viewed to have a worse outcome, due to the higher risk of readmissions and of suicide (Kallert et al., 2008). Although clinicians may believe that they are acting in the individual's best interest by avoiding an involuntary admission, the ‘coerced voluntary’ service user is not afforded the provisions from mental health legislation, such as a review board or independent legal support and service users could perceive this practice as coercive and an infringement of their autonomy. In addition, voluntary service users who perceive high levels of coercion often think that if they do not agree to a voluntary admission they will be admitted involuntarily anyway (Katsakou et al., 2011a). Worryingly, it is possible that this action by clinicians could actually have the opposite effect to that intended, as more recent evidence suggests that individuals who experience coerced voluntary treatment have worse outcomes compared to involuntarily admitted service users (Kallert et al., 2011). It has been proposed that treatment pressures should be structured within a hierarchy and that as a coercive practice ascends this hierarchy, the justification and oversight of this practice must be stronger (Szmukler and Appelbaum, 2008). There is also a concern that coercive practices may result in service users being ‘pushed away from the service’ (Hoge et al., 1997). In support of this, higher levels of perceived coercion during hospital admission are associated with a poorer therapeutic relationship, which in turn, is also associated with a poorer outcome (Sheehan and Burns, 2011, Theodoridou et al., 2012).

Therefore, in this study we aimed to quantify the proportion of voluntarily admitted service users with levels of perceived coercion equivalent to that of involuntarily admitted service users. Secondly, we aimed to identify demographic and clinical characteristics of voluntarily admitted service users who experienced high levels of perceived coercion.