Patients’ attitudes towards and acceptance of coercion in psychiatry

Highlights

• The level of acceptance of coercive measures differed widely from patient to patient.

• “Noninvasive measures” (e.g., a “soft room”) were more accepted than “invasive measures” (e.g., mechanical restraint).

• The retrospective understanding of coercive interventions increased over the course of treatment.

• Psychiatric wards should offer flexible and milder options to reduce coercion.

• Involving patients in their treatment plan, such as through the creation of a crisis plan, is recommended.

Abstract

Coercive interventions for psychiatric patients are controversial. Research on different preventive measures has increased over the last years. The present study examined patients’ attitudes towards and understanding of previously experienced coercive measures as well as their preferences related to coercive measures and possible alternatives. In total, 213 patients who had experienced coercion and 51 patient controls (patients staying voluntarily on a closed ward with no coercive treatment) from three acute wards were examined via expert interviews and questionnaires in the framework of a naturalistic trial. Assessments included a new self-developed questionnaire as well as instruments measuring psychopathology. Patients who had experienced coercion differed from controls in both symptoms and insight into their illness. As expected, “noninvasive measures” (e.g., the use of a “soft room,” observation in seclusion) were better accepted by patients than “invasive measures” (e.g., mechanical restraint, forced medication). Forced medication and mechanical restraint were less well accepted than involuntary hospitalization, seclusion, or video surveillance. The retrospective understanding of coercive measures increased over the course of treatment. In addition, patients rated a number of options for reducing coercion on the wards, particularly music or exercises. A large subgroup indicated they would like to discuss future admissions with the staff.

Introduction

Coercive interventions (CI) in psychiatry, such as mechanical restraint, seclusion, or forced medication, are increasingly seen as controversial by both patients and clinicians and are considered as ultima ratio, to be only used when standard procedures have failed and patients are a danger to themselves or others. Psychiatrists often find themselves caught in an ethical dilemma between protecting their patient's autonomy and fulfilling their obligation to provide medical care (Simon, 2014).

A literature review revealed a dearth of empirical data about the prevalence of restraint and seclusion (Steinert et al., 2010). Coercion differs greatly in terms of frequency and type of measures used, depending on the institution (Martin et al., 2007b) and country (Raboch et al., 2010, Steinert et al., 2010; Martin et al., 2007a). The widely inconsistent application of CI emphasizes that more research is needed to better understand the relationships between different person-related as well as contextual factors (e.g., patient, staff, or institutional factors) and the use of CI. More insight may foster consensus (Raboch et al., 2010). Since there is insufficient evidence for the safety or effectiveness of CI (Nelstrop et al., 2006), research about the prevention or reduction of coercion in psychiatry is increasing (de Jong et al., 2016, Gaskin et al., 2007, Scanlan, 2010). Nevertheless, there is still a knowledge gap concerning patient and staff attitudes towards compulsory interventions. The use of coercion is emotionally stressful for many patients (Armgart et al., 2013) as well as for staff members (Wynn, 2003). However, Duxbury and Whittington (2005) showed that there are strong differences in the way patients and staff perceive aggression and its management. Several studies with different research aims have assessed patients’ experiences of coercive measures or involuntary admissions (Armgart et al., 2013, Fugger et al., 2016, Haw et al., 2011, Iversen et al., 2011, Katsakou et al., 2012, Katsakou et al., 2010, Katsakou and Priebe, 2006, Keski-Valkama et al., 2010, Kontio et al., 2012, Larue et al., 2013, Mayers et al., 2010, McLaughlin et al., 2016, Mellow et al., 2017, Mielau et al., 2016a, O’Donoghue et al., 2010a, Priebe et al., 2010, Priebe et al., 2009, Soininen et al., 2013, Valenti et al., 2014, Vishnivetsky et al., 2013). A number of studies focused on involuntary admissions. O’Donoghue et al. (2010) found that as many as 72% of patients believed that their involuntary hospitalization had been necessary. This statement was moderated by patients’ insight into their illness. Furthermore, the authors found a significant change in perspectives of one third of the participants to a rather neutral or negative view. A literature review on the outcomes of involuntary hospital admissions shows that between 33% and 81% of patients rated their coercive treatment as beneficial and the admission as justified. The positive views increased over time. Nevertheless, a large subgroup of patients did not feel that the treatment was helpful (Katsakou and Priebe, 2006). In a large sample, 2326 involuntarily admitted patients’ views on their admission were assessed in 11 countries. After one month, 55% thought that their involuntary admission was justified; after 3 months, the agreement had increased to 63% (Priebe et al., 2010). In a different study, the same authors found that after one year, only 40% of the formerly admitted patients considered their admission justified (Priebe et al., 2009). A secondary analysis from the EUNOMIA study with 2030 participants across ten countries identified forced medication as the only CI that was significantly associated with patient disapproval of treatment (McLaughlin et al., 2016). According to a recent American study (Paksarian et al., 2014), more than two thirds of psychotic patients perceived at least one of their hospitalizations as traumatic. Other studies have assessed the experiences evoked by different coercive measures, mostly seclusion and/or restraint (Armgart et al., 2013, Iversen et al., 2011, Keski-Valkama et al., 2010, Kontio et al., 2012, Larue et al., 2013, Mellow et al., 2017, Soininen et al., 2013). Patients’ predominant emotions related to CI are usually rage, anger, and desperation (Armgart et al., 2013, Haw et al., 2011). In retrospect, however, one third of the patients reported understanding the need for coercion (Armgart et al., 2013). All but one study (Iversen et al., 2011) found a rather negative appraisal of the treatment (Keski-Valkama et al., 2010, Kontio et al., 2012, Soininen et al., 2013) or great variance in their perceptions of their seclusion or restraint experiences (Larue et al., 2013). Future research should further focus on why the patients’ views regarding their treatment differ so widely. Fugger et al. (2016) investigated patients’ subjective perceptions during and after belt fixation. Contrary to the researchers’ hypothesis, patient's attitudes towards the measure remained unchanged over time. Symptoms of post-traumatic stress disorder (PTSD) were noted in one quarter of the patients. Studies on patient's attitudes towards forced medication are rare, based on a literature review (Jarrett et al., 2008). Most available research has focused on only one or two CI but has not included the more common measures.

Few studies have investigated patients’ preferences for specific types of coercive measures, and, again, conclusions vary widely (Georgieva et al., 2012, Haw et al., 2011, Veltkamp et al., 2008, Vishnivetsky et al., 2013, Whittington et al., 2009). Whittington et al. (2009) examined the approval ratings for 11 coercive interventions among 1361 patients and 1226 staff members in England via the Attitudes to Containment Measures Questionnaire (ACMQ). Patients strongly disapproved of net beds, mechanical restraint, and intramuscular medication, whereas intermittent observation, time-outs, and PRN medication (medication taken as needed) represented preferred methods. However, Haw et al. (2011), who investigated forensic patients, found that a majority of patients preferred intramuscular medication over seclusion. A similar result was presented by Georgieva et al. (2012), who asked 161 patients before their discharge from closed wards for their preferred coercive measures if required in the future; the majority (57%) preferred the use of forced medication in future emergencies. Their choices were strongly influenced by their prior experiences with coercion: patients who had experienced no coercion, or seclusion and forced medication preferred forced medication for future stays; those who had experienced only seclusion also favored seclusion for the future. Veltkamp and colleagues (Veltkamp et al., 2008) came to a different conclusion when comparing seclusion and forced medication. They found no difference in the effectiveness or aversiveness of these two forms of coercion, and an equal number of patients preferred both measures. A study from Israel investigated adolescent patients’ attitudes towards seclusion versus restraint (Vishnivetsky et al., 2013). Seventy percent preferred seclusion over restraint, and more than 80% experienced seclusion as less threatening than restraint. Emotions such as shame, discomfort, or anger appeared significantly less during seclusion. In contrast, Bergk et al. (2011) found no difference between the subjective restrictiveness of mechanical restraint and seclusion, as measured with the Coercion Experience Scale (Bergk et al., 2010). In fact, no coercive measure was deemed superior with respect to safety or from an ethical perspective. In conclusion, results from the literature differ widely with respect to patients’ attitudes and preferences regarding CI.

According to Bergk et al. (2011), patients’ preferences and former experiences should be integrated into future clinical decisions. Valenti et al. (2014) come to a similar conclusion: considering patients’ views and involving them in the treatment process is an important factor in protecting patients’ autonomy. As preventive measures against coercion, patients called for more one-on-one conversations and better communication with staff members (Mielau et al., 2016b). Similarly, another recent study (Heumann et al., 2015) found that patients perceived most milder noncoercive interventions as helpful in preventing coercion, especially physical activity, adressing their fears and needs, and shared decision-making. Kontio et al. (2012) gave recommendations for nursing practice based on interviews with patients to improve the situation during seclusion or restraint, such as a more comfortable environment or patient-staff agreements.

For the present study, a new questionnaire was developed to examine patients’ attitudes towards coercion. The study examined whether patients experiencing CI differ from those who stay voluntarily on a closed ward (i.e., no coercive measures adopted) with respect to demographic and psychopathological parameters. The control group was examined to distinguish between coercion-related and other (e.g., ward-specific) factors. Another aim was to assess patients’ emotional strain in response to CI using established scales for depression. Furthermore, patients’ understanding of a variety of ongoing methods of CI (involuntary admission, mechanical restraint, seclusion, forced medication, video surveillance) was evaluated at two points in time. Video surveillance on psychiatric wards is only allowed temporarily and under specific circumstances by law (e.g., the patient agrees to the surveillance). As there is no consensus on how to classify surveillance, the current study added video surveillance as one method of CI. The study also investigated which forms of CI patients with a history of CI would prefer if CI were considered inevitable in the future. Patients were asked for their perspective on possible means of reducing coercion. To the best of our knowledge, this is the first study to assess patients’ preferences regarding prevalent specific forms of CI, their accompanying emotions, and their understanding of the experience as measured at different sites and different points in time using both interviews and self-assessments.