Perceived coercion in voluntary hospital admission
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.
Section snippets
Setting
This study was undertaken in three psychiatry hospitals attached to three community mental health services in Ireland: the Cluain Mhuire mental health service, Dublin South East mental health service and the Newcastle mental health services, Co. Wicklow. These services cover a combined catchment area population of approximately 390,000. We also included individuals admitted to St. John of God Hospital, an independent psychiatric hospital, which receives referrals on a national basis. Service
Characteristics of participants
The study included 83 voluntarily admitted service users and 78 involuntarily admitted service users. Of the voluntarily admitted cohort, 53% (n=44) were male, 55% (n=46) were unmarried and 35% (n=29) had a diagnosis of a psychotic disorder. The demographic and clinical characteristics of the individuals admitted voluntarily and involuntarily are displayed in Table 1. Individuals admitted involuntarily were more likely to have a diagnosis of a psychotic disorder, have lower functioning and have
Summary of findings
This study shows that a significant minority (22%) of voluntarily admitted service users experience equivalent levels of coercion to those who were admitted involuntarily. These ‘coerced voluntary’ service users report experiencing more negative pressures, lower levels of procedural justice and were more likely to have been treated on secure wards. Of those with a psychotic disorder, higher levels of perceived coercion were associated with more severe positive psychotic symptoms, particularly
Acknowledgements
This study was partially funded by a grant from the Mental Health Commission of Ireland. We would like to thank Karen Cobbe for her administrative work and also her contribution to the discussion. We would also like to thank Veronica Ranieri, Dr. Damian Smith, Dr. Kieran O'Loughlin, Dr. Ciaran Crummey and Darach Murphy for conducting interviews and data collection.
References (37)
- et al.
How to improve clinical practice on involuntary hospital admissions of psychiatric patients: suggestions from the EUNOMIA study
European Psychiatry
(2011) - et al.
Perceptions of coercion in the admission of voluntary and involuntary psychiatric patients
International Journal of Law and Psychiatry
(1997) - et al.
Enhancement of outpatient treatment adherence: patients' perceptions of coercion, fairness and effectiveness
Psychiatry Research
(2010) - et al.
Why do some voluntary patients feel coerced into hospitalisation? A mixed-methods study
Psychiatry Research
(2011) - et al.
Relationship between patients' quality of life and coercion in psychiatric acute wards
Psychiatry Research
(2013) - et al.
Coercion and commitment: understanding involuntary mental hospital admission
International Journal of Law and Psychiatry
(1995) - et al.
Physical coercion, perceived pressures and procedural justice in the involuntary admission and future engagement with the mental health services
European Psychiatry
(2011) - et al.
Therapeutic relationship in the context of perceived coercion in a psychiatric population
Psychiatry Research
(2012) Diagnostic and Statistical Manual of Mental Disorders
(1994)The Scale for the Assessment of Negative Symptoms (SANS)
(1983)
The Scale for the Assessment of Positive Symptoms (SAPS)
Screening depressed patients in family practice. A rapid technique
Postgraduate Medicine
Perceived coercion at admission to psychiatric hospital and engagement with follow-up–a cohort study
Social Psychiatry/Psychiatric Epidemiology
A self-report insight scale for psychosis: reliability, validity and sensitivity to change
Acta Psychiatrica Scandinavica
Coercion of voluntary patients in an open hospital
Archives of General Psychiatry
Pressures to adhere to treatment (‘leverage’) in English mental healthcare
British Journal of Psychiatry
Procedural justice in the context of civil commitment: an analogue study
Behavioral Sciences and the Law
Cited by (53)
The association between perceived coercion on admission and formal coercive practices in an inpatient psychiatric setting
2021, International Journal of Law and PsychiatryCitation Excerpt :Higher levels of positive psychotic symptoms have previously been associated with use of coercive measures (Fiorillo et al., 2012; Kalisova et al., 2014), although there are limited data available linking these with perceived negative pressures. Previous studies have shown that individuals who felt coerced during admission were found to have experienced more negative pressures, and that hallucinations and bizarre behaviour are the symptoms most linked with perceived coercion (O'Donoghue et al., 2014). A significant association between negative pressures and perceived coercion has also been noted (Cascardi & Poythress, 1997; Iversen, Høyer, Sexton, & Grønli, 2002; Lidz et al., 1995).
Feeling coerced during psychiatric hospitalization: Impact of perceived status of admission and perceived usefulness of hospitalization
2019, International Journal of Law and Psychiatry