Why do some voluntary patients feel coerced into hospitalisation? A mixed-methods study

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Abstract

This study aimed to investigate factors linked to perceived coercion at admission and during treatment among voluntary inpatients. Quantitative and qualitative methods were used. Two hundred seventy patients were screened for perceived coercion at admission. Those who felt coerced into admission rated their perceived coercion during treatment a month after admission. Patient characteristics and experiences were tested as predictors of coercion. In-depth interviews on experiences leading to perceived coercion were conducted with 36 participants and analysed thematically. Thirty-four percent of patients felt coerced into admission and half of those still felt coerced a month later. No patient characteristics were associated with perceived coercion. Those whose satisfaction with treatment increased more markedly between baseline and a month later were less likely to feel coerced a month after admission. In the qualitative interviews three themes leading to perceived coercion were identified: viewing the hospital as ineffective and other treatments as more appropriate, not participating in the admission and treatment and not feeling respected. Involving patients in the decision-making and treating them with respect may reduce perceived coercion.

Introduction

It is commonly assumed that legally voluntary patients willingly participate in their care and do not feel under pressure to comply with hospital treatment. Research in this area, however, has revealed that between 10% and 50% of voluntary patients feel coerced into hospitalisation (Rogers, 1993, Monahan et al., 1995, Hiday et al., 1997). Admissions formally defined as voluntary are often the outcome of a complex process involving advice, persuasion, pressure and threats from patients' families or professionals (Kjellin et al., 2004). Hence, the legal status of admission is only a crude proxy for experienced coercion and many ‘voluntary’ patients feel excluded from treatment decisions and psychologically forced into hospitalisation (Sorgaard, 2007, Bindman et al., 2005).

‘Procedural justice’ (i.e. the perception of being respectfully involved in a fair decision-making process regarding admission) has been identified as predicting lower perceived coercion at admission among involuntary patients or mixed groups of involuntary and voluntary patients (Bennett et al., 1993, Lidz et al., 1995, Hiday et al., 1997, Lidz et al., 1998, McKenna et al., 2001). However, little is known on what patient characteristics or experiences elicit feelings of coercion among voluntary patients.

It is also unclear whether voluntary patients who initially feel coerced into admission continue to feel coerced during treatment and what factors are linked to such perceptions of coercion. It has been suggested that improving patients' satisfaction with their hospital treatment might lead to improved attitudes which might include lower perceived coercion, but this hypothesis has not been tested in previous research (Priebe and Gruyters, 1994, Priebe et al., 2009).

Reducing feelings of coercion is not only an ethical and humane issue, but might also lead to improved treatment outcomes. In effect, perceived coercion might lead to disengagement from services and negative therapeutic relationships (Lidz et al., 1998). Some studies also indicate that perceived coercion during hospitalisation leads to overall negative attitudes towards hospital treatment (Kaltiala-Heino et al., 1997, Gardner et al., 1999, Katsakou et al., 2010), poor clinical outcomes and reduced adherence to treatment after discharge (Luckstead and Coursey, 1995, Kaltiala-Heino et al., 1997).

The present study aimed a) to investigate whether specific socio-demographic and clinical characteristics are associated with perceptions of coercion at admission among legally voluntary patients, b) to examine whether voluntary patients who feel coerced into admission continue to feel coerced during hospital treatment, c) to indentify factors associated with feelings of coercion during treatment, and d) to explore what experiences – in the view of the patients – lead to feelings of coercion both at admission and during treatment.

Section snippets

Methods

We conducted an exploratory study, using both quantitative and qualitative methods. The methods were used concurrently during data collection. The quantitative and qualitative data were first analysed separately and later combined in the interpretation of the study findings. The study design, as described subsequently, was approved by the North East London Health Authority Research Ethics Committee.

Eligible patients and participants in baseline and follow-up interviews

Out of the 446 eligible patients, 270 (61%) agreed to participate in the study and completed the MPCS at baseline. Out of the 91 patients who felt coerced to admission (based on their MPCS scores), 83 (91%) completed additional questionnaires at baseline and 58 (70%) were interviewed at one month follow-ups. From those interviewed at follow-ups, 25 (44%) were still in hospital (for the index admission). The patient flow and reasons for non-participation in the study and missed follow-ups are

Main findings

Approximately one third of legally voluntary patients felt coerced into admission and half of those continued to feel coerced into treatment a month later. No clinical or socio-demographic characteristics were significantly associated with perceived coercion. Patients who became more satisfied with treatment over time were less likely to feel coerced a month after admission. Viewing the hospital care as ineffective and alternative treatments as more appropriate, not participating in the

Acknowledgement

This study was supported by a grant from the European Commission (Quality of life and Management of Living Resources Programme, contract number QLG4-CT-2002-01036). We are grateful to all interviewed patients and staff of the participating hospitals. We also thank all the researchers involved in data collection.

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      Studies have suggested that patients' feeling of being coerced, also named perceived coercion, could negatively influence their prognoses, because it may negatively influence the patient's cooperation during treatment (Pawłowski, Kiejna, & Rymaszewska, 2005). While robust findings are scarce, perceived coercion may or could have long lasting negative effects on patients, such as disengagement from services and negative therapeutic relationships (Katsakou et al., 2011; Lidz et al., 1998; Theodoridou, Schlatter, Ajdacic, Rössler, & Jäger, 2012), reduced satisfaction with care (Nyttingnes, Ruud, & Rugkåsa, 2016) and it may potentially cause trauma (Kinner et al., 2017). The patients' perception of being treated unfairly, coercively and not effectively could have a strong negative impact on treatment adherence and may represent a barrier to mental health service use (Jaeger & Rossler, 2010; Swartz, Swanson, & Hannon, 2003).

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