Invocation of coercion context in compliance communication -- power dynamics in psychiatric care

This article draws on observations from ethnographic fieldwork to develop a theoretical understanding of the power dynamics in psychiatric care. The aim is to analyze how psychiatric clinicians solve compliance problems by invoking "coercion context". It is suggested that clinicians take a rather instrumental approach to laws regulating coercive intervention. Clinicians may invoke a coercion context even with voluntary patients. For example, they may use wordings that connote coercion, or they may make use of how treatment wards are set up to accommodate involuntary patients, thus stalling voluntary patients who cannot exit through locked doors. A coercion context can also be invoked to solve mundane practical problems, e.g. when clinicians talk about "coerced showers". The management of information and maintaining a suitable "awareness context" with regards to coercion is an essential feature in clinical attempts to achieve compliance from patients. In conclusion, the notion of coercion context helps explain the confusing findings from previous research about patients' apparent misconceptions of their formal legal status. Furthermore, it is argued that research that rely on decontextualised, objectifications of "coercion" risk to miss the meaning coercion is assigned in everyday clinical practice.     

Perceived coercion and need for hospitalization related to psychiatric admission

Psychiatric hospitalization constitutes a moment of major stress to the point that occurrences of posttraumatic stress disorders have been described. Feelings of coercion are usual, whatever the legal status of admission. Patients may also consider afterwards that they needed hospitalization even if they refused it initially. A cross-sectional survey has been conducted among the inpatients of a Swiss psychiatric hospital to assess their subjective view of admission with emphasis on legal status, perceived coercion and need for hospitalization. Eighty-seven questionnaires were completed and analyzed. Results indicated that 74% of patients felt that they had been under pressure to be hospitalized, whether or not they were involuntarily admitted. Seventy percent felt their admission was necessary. More involuntary patients reported a subjective lack of improvement. Clinicians could decrease feelings of coercion of their patients while discussing need for hospitalization, legal status and subjective feeling of coercion as different dimensions. An argument is presented to favor positive pressure from social environment over legal involuntary commitment in many hospitalizations.     

Dilemmas for clinicians in use of Community Treatment Orders

Clinicians who treat patients using Community Treatment Orders (CTOs) face many potential dilemmas in their relations with involuntary outpatients and the exercise of their powers. We compare the dilemmas identified in the literature with those reported by responsible clinicians in New Zealand (NZ). These clinicians experienced a number of well-known dilemmas, such as determining the right moment for a person's discharge from a CTO, but they seemed less troubled by some other difficulties than might be expected, usually because they considered involuntary outpatient treatment the best option for the patient or the best way to manage the risks involved. Further dilemmas were identified by the NZ clinicians that have not been widely discussed, concerning the proper scope of clinical authority over patients under CTOs and the decision to revoke involuntary outpatient status. In conclusion, some suggestions are made as to how clinicians might best manage the dilemmas involved.     

Outpatient commitment and coercion in New Zealand: a matched comparison study

BACKGROUND: It has been hypothesized that a degree of coercion is a necessary component in using outpatient commitment to attain therapeutic outcome for those people subject to mental health law. However, what degree of coercion is required and how it is sustained is poorly understood. There is speculation that patients' recognition of beneficial as well as unwanted aspects of outpatient commitment (ambivalence) maybe an indicator that the necessary level of coercion has been achieved to facilitate a therapeutic outcome. AIM: The aim of this study was to determine the level of coercion perceived by those under outpatient commitment in New Zealand. Emphasis was given to consideration of the presence of ambivalence and the role of interactive processes, including procedural justice, in influencing patients' perceptions of coercion. METHOD: A cross-sectional comparative study was undertaken to compare the perceptions of coercion of patients on outpatient commitment (n = 69) to a matched sample of voluntary outpatients (n = 69), using the Perceived Coercion Scale. The influence of a range of variables, including patients' knowledge of and beliefs concerning outpatient commitment, were considered. RESULTS: Although the level of coercion for involuntary outpatients was relatively low, it was significantly higher than that experienced by voluntary outpatients. Yet involuntary outpatients were more likely to espouse benefits of outpatient commitment. Although there was an inverse correlation between perceptions of procedural justice and perceived coercion, procedural justice did not feature in the linear regression analysis. DISCUSSION: In the New Zealand context, involuntary outpatients hold contrasting views to outpatient commitment. We suggest that this ambivalence is an indicator that the degree of coercion is suffice to achieve therapeutic outcome. Furthermore, this study suggests the impact of procedural justice on patients' perceptions of coercion may be more crucial during admission to hospital than in the context of on-going community care.     

It's Not You,It's Me: Determinants of Voluntary Legislative Turnover in Canada

The Canadian federal parliament is unique among Westminster parliamentary democracies due to the unusually high level of voluntary and involuntary MP turnover that occurs at each general election. This article builds on existing research to test the hypothesis that the MP career duration is related to MPs' expectations about parliamentary roles, insofar as voluntary turnover is concerned. Data on MPs drawn from historical records collected by the Library of Parliament and from surveys conducted in 1993 and 2001 ¹ are used to develop an event history model which estimates the hazard of voluntary career termination when different parliamentary roles are taken into consideration. Findings suggest that a number of individual factors play a role in voluntary turnover, most notably that MPs who enter Parliament hoping to affect policy are the most likely to move on.     

What medical school did you graduate from? Judicial prescribing of medical treatments

There is much in the literature concerning conflicts between clinicians and the law over who should make decisions in a legal context, such as involuntary hospitalization or patients' competency to make treatment decisions. There is little, however, about judges' trying to impose specific treatment decisions on clinicians. This article addresses that situation and the problems such orders cause.     

论《精神卫生法》的自愿原则

为了防止正常人"被精神病",更好地保护精神障碍患者的合法权益,《精神卫生法》确立了自愿原则。该原则渊源于私法领域的自愿原则而又与其不同,是在知情的条件下对精神卫生服务的单方接受自愿。它回应了要像人一样保护精神障碍患者,彰显了精神卫生法的福利法本质。它包涵自愿诊断、自愿治疗和自愿出院三个既相互区别又相互联系子原则。非自愿诊断、非自愿治疗、非自愿继续住院治疗只是自愿原则的补充,此种例外旨在寻求患者精神健康权与社会公众安全保护的平衡。     

The impact of public policy and publicity on admissions to state mental health hospitals

This paper examines the impact of broadened Washington state civil commitment standards on utilization of the state's mental hospitals. Included in the analysis is an assessment of the impact of a public event (a well-publicized murder case) which was in all likelihood a precursor to the law's revision. We also examine the different ways Washington's two state hospitals managed the dramatic increase in civilly committed patients that occurred after the revision took effect. The findings indicate that the murder case, in which the defendant had been denied voluntary admission to a state hospital prior to the killing, resulted in an increase in involuntary admissions in the county where it occurred a full year before the standards were revised. The law itself had the effect of increasing commitments throughout the state, reducing the levels of voluntary admissions, and increasing the likelihood of involuntary admission for individuals previously admitted voluntarily, thus transforming a principally voluntary system into one which was primarily involuntary. Finally, it was found that the increased demand for services mandated by the broadened commitment standards was managed differently in the two state hospitals: one imposed a cap on admissions; the other phased out voluntary admissions at a rate roughly equal to the increase in commitments. These findings illustrate both the substantive impact of broadened civil commitment law and the importance, when assessing the impact of laws, of examining public events and administrative interventions which may have significant causal links with legal interventions.     

Voluntary and involuntary care: three-year study of demographic and diagnostic admission statistics at an inner-city adult psychiatry unit

Individuals with mental disorders can, under specific circumstances, be detained and treated against their wishes. In 2009, there were 1633 involuntary admissions in Ireland, accounting for 8.1% of all psychiatric admissions. We examined demographic and diagnostic factors associated with involuntary admission in a general adult psychiatry service in Dublin's north inner-city over a retrospective three-year period. The overall admission rate was 450.5 admissions per 100,000 population per year (deprivation-adjusted rate: 345.7), which is lower than the national rate (476.3). The involuntary admission rate was 67.7 (deprivation-adjusted rate: 51.9), which is higher than the national rate (38.5). Fifteen per cent of admissions were involuntary (for all or part of the admission), which is higher than the national proportion (8.1%) but the same as that reported in another inner-city psychiatry service (15.7%). The proportion of admissions that was involuntary was higher amongst individuals from outside Ireland (33.9%) compared to those from Ireland (12.0%) (p<0.001). Country of origin was, however, related to diagnosis: 53.2% of admissions of individuals from outside Ireland were with schizophrenia, compared to 18.5% of admissions of individuals from Ireland (p<0.001). Diagnosis was, in turn, related to admission status: 37.5% of admissions with schizophrenia were involuntary compared to 15% overall (p<0.001). On multi-variable testing, diagnosis was the only independent predictor of admission status (p=0.01) (R(2)=35.2%); country of origin was not an independent predictor of admission status. Deprivation accounts for part, but not all, of the high rate of involuntary admission in Dublin's inner-city. Diagnosis accounts for one third of the variance in admission status between individuals. Further study is required to determine what factors account for the remaining two thirds (e.g. symptoms, insight) and to clarify better the relationships between admission status, diagnosis and country of origin. There is a strong need for enhanced focus on the mental health needs of individuals from outside of Ireland, especially in Dublin's north inner-city.     

Overriding Psychiatric Advance Directives: Factors Associated with Psychiatrists' Decisions to Preempt Patients' Advance Refusal of Hospitalization and Medication

Psychiatric advance directives (PADs) are intended to support patients' treatment decisions during a crisis. However, PAD statutes give clinicians broad discretion over whether to carry out patients' advance instructions. This study uses data from a survey of psychiatrists (N=164) to examine reasons for overriding PADs. In response to a hypothetical vignette, 47% of psychiatrists indicated that they would override a valid, competently-executed PAD that refused hospitalization and medication. PAD override was more likely among psychiatrists who worked in hospital emergency departments; those who were concerned about patients' violence risk and lack of insight; and those who were legally defensive. PAD override was less likely among participants who believed that involuntary treatment is largely unnecessary in a high-quality mental health system.     

The Dutch experience

Euthanasia has been legally sanctioned in the Netherlands by a series of court decisions going back to the 1970s. The author discusses the cultural and historical factors that may have contributed to this development. In the past decade, studies sanctioned by the Dutch government reveal that guidelines established for the regulation of euthanasia--a voluntary, well-considered, persistent request, intolerable suffering that cannot be relieved, consultation with a colleague, and reporting of cases--are consistently violated. Of greatest concern is the number of patients who are put to death without their consent--there are more involuntary than voluntary cases. Euthanasia intended originally for the exceptional case has become an accepted way of dealing with the physical and mental distress of serious or terminal illness. In the process palliative care has become one of the casualties while hospice care lags behind that of other countries. Case examples are given.     

The utility of extended outpatient civil commitment

OBJECTIVE: This study considers three hypotheses regarding the impact of extended involuntary outpatient commitment orders on services utilization. METHOD: Service utilization of Victorian Psychiatric Case Register (VPCR) patients with extended (> or =180 day) outpatient commitment orders was compared to that of a diagnostically-matched treatment compliant group with similarly extended (> or =180 day) periods of outpatient care (N=1182)--the former receiving care during their extended episode on an involuntary basis while the latter participated in care voluntarily. Pre/post first extended episode mental health service utilization was compared via paired t tests with individuals as their own controls. Logistic and OLS regression as well as repeated measures ANOVA via the GLM SPSS program and post hoc t tests were used to evaluate between group and across time differences. RESULTS: Extended episodes of care for both groups were associated with subsequent reduced use of hospitalization and increases in community treatment days. Extended orders did not promote voluntary participation in the period following their termination. Community treatment days during the extended episode for those on orders were raised to the level experienced by the treatment compliant comparison group during their extended episode and maintained at that level via subsequent renewal of orders throughout the patients' careers. Approximately six community treatment days were required for those on orders to achieve a one-day reduction in hospital utilization following the extended episode. CONCLUSION: Outpatient commitment for those on extended orders in the Victorian context enabled a level of community-based treatment provision unexpected in the absence of this delivery system and provided an alternative to hospitalization.     

Unfitness for Detention Among Arrestees with Suspected Mental Disorders in Paris,France

In this retrospective study (11/2013–04/2014), we aimed to identify the factors associated with psychiatric hospitalization among detainees in police custody. We included 137 patients (M/F, 74%/26%; median age, 37 years), and 125 (91%) had a mental disorder. Seventy‐seven patients (56%) had involuntary hospitalization. Sixty patients (44%) were declared fit for detention, and 48 (80%) of these patients had a mental disorder. All patients who required urgent psychiatric care and could not provide valid consent for care were declared as requiring involuntary hospitalization. Forty‐nine of the 62 patients (79%) who required urgent psychiatric care and were suspected to have committed serious crimes were involuntarily admitted. In conclusion, we commonly found that some individuals with mental disorders were considered fit for detention in police cells.     

How research ethics' protections can contribute to public policy: the case of community treatment orders

Though community treatment orders (CTOs) were first used in 1986 in Australia, debate about their clinical and ethical merits continues even today. For some, the benefits of reduced frequency and duration of involuntary hospitalizations are believed to adequately outweigh the harms of restricted liberties in community living. For others, however, such benefits are believed to be achievable by simply arranging integrated, devoted community resources sans any threat of forced re-hospitalization. In response to this enduring controversy, this article examines the ethical merits of community orders using a novel approach. “Novel” because the examination is based on research ethics and its foundational principles.When hospital and community clinicians, family members, consumer/survivors, and advocacy groups discussed the idea of amending Ontario's mental health legislation to permit CTOs in the late 1990s, evidence of their effects and efficacy was very limited. Moreover, an order was characterized much like standard pharmacological or medical therapies because the person or an appropriate substitute decision maker's consent was necessary to authorize the order or make it valid. These two factors prompted this retrospective analysis: if CTOs - as a public policy initiative - had been treated like most other promising therapies, would any different ethics-related concerns have been raised that, in turn, would have benefited the public debate and the legislature's decisions? In other words, if respected safeguards that apply to new drugs and medical devices had applied to CTOs, would anything have changed?     

Compulsory mental health care in Norway: The treatment criterion

The Norwegian government has chosen to retain a treatment criterion in the Mental Health Care Act despite the opposition of several user organizations. From a critical user perspective, the only reason for using coercion to require mental health treatment is that the individuals are in a state where they are an immediate danger to themselves and/or their surroundings. This articles aims, first, to provide an overview of research studies concerning the benefits or harmfulness of involuntary treatment after coerced admission and, second, to evaluate studies that try to compare involuntary with voluntary treatment. A systematic overview of studies of compulsory mental health care with regard to treatment criteria, coercion in mental health, and involuntary admission published over the last decade was examined in detail, along with a secondary manual search of references cited in identified publications. Few studies have been conducted on the effect of compulsory mental health care, and the results have been contradictory. More randomized studies are needed to document the kinds of effects that the use of compulsory treatment has on treatment results. Another issue that needs further examination is whether the use of coercion should be transferred to legal bodies with an adjudicatory process.     

A Foetal Right to Life? The Case of Vo v France

This article examines the scope of application of Article 2of the European Convention on Human Rights, to the unborn foetus.The focus of the articles is on the case of Vo v France, and,in particular, on the jurisprudence of the European Court ofHuman Rights on a state's obligation to protect life in respectof both voluntary and involuntary, negligent terminations ofpregnancies. The last part of the article reviews abortion lawsin Europe and the US and suggests that a gradualist moral perspectiveon the status of the embryo could justify the imposition ofcriminal penalties for foetal death caused by violent conductagainst a pregnant woman without prejudice to the rights ofthe woman.     

Legal,ethical and clinical implications of prescribing involuntary,life-threatening treatment: the case of the Sunshine Kid

Involuntary treatment is a concept often familiar to psychiatrists. In clinical practice, it usually involves the hospitalization and pharmacological management of patients with severe mental disorders. However, the scope of involuntary treatment is not limited to the management of mental illness alone. Psychiatric patients afflicted with medical illnesses may require hospitalization and invasive procedures for optimal management of these disorders. The following case illustrates a dilemma in which a psychotic patient refuses life-saving medical treatment; however, the treatment itself carries significant risk of morbidity and mortality. This article reviews the ethical, legal and clinical implications of making such difficult treatment decisions.     

Attitudes among medical and law students toward decision-making in regard to involuntary psychiatric hospitalization

Background

The management of individuals with mental illnesses sometimes requires involuntary hospitalization. The Israel Mental Health Act requires that cases of involuntary psychiatric hospitalization (IPH) be periodically reviewed by the district psychiatric committee. The discussion in the committee often leads to debate regarding the need for an IPH potentially depriving the patient of his freedom. Little is known about the way in which the psychiatrists and attorneys on these committees arrive at their decisions. The present study was designed to examine the views of future doctors and attorneys concerning cases of possible IPH to determine whether their decisions would be influenced by their respective professional educational backgrounds.

Methods

After compiling demographic data, we asked 170 students from each of the two disciplines what their decision would be in two hypothetical cases that dealt with the question of a prolongation of a psychiatric hospitalization. Questionnaires examining social distance and possible stigmatizing views concerning psychiatric patients were also distributed and collected.

Results

The response rates for the medical and law students were, respectively, 90% and 85%. We found no differences between the medical and law students regarding their views on prolongation of a psychiatric hospitalization. This was consistent regardless of whether the hospitalization was against the patient's will or according to his wish and against the treating physicians' advice. We also found that the medical and law students had similar general views regarding psychiatric patients, but that the latter evidenced greater social distance than the former.

Conclusions

Academic background and socialization were not found to influence the decisions of students regarding IPH. Educational programs and exposure to psychiatric patients during law studies are proposed to lessen psychiatric stigma and promote better understanding between members of the two disciplines.     

Does involuntary outpatient commitment lead to more intensive treatment?

Studies of involuntary outpatient commitment (OPC) among persons with severe mental illness have concluded that OPC is only effective in improving treatment outcomes when it is sustained for 6 months or longer and is combined with frequent outpatient services. This article explores factors that influence the delivery of outpatient services to subjects in a randomized trial of OPC and finds 2 general patterns. Outpatient visits were more frequent among all subjects with apparent clinical need, regardless of study assignment, and among subjects whose OPC was sustained beyond an initial court order. These results suggest that, in practice, sustained OPC represents a consensual agreement between clinicians and the court to more intensively address the complex needs of persons with severe and persistent mental illness.     

The impact of a change in commitment procedures on the character of involuntary psychiatric patients

The statutory requirements for involuntary civil psychiatric confinement have become increasingly restrictive. In the jurisdiction under investigation, patients were originally admitted under an Order to Apprehend (OTA) procedure simply on the petition of two affiants who indicated the patient was in need of care. A newly elected judge instituted changes requiring affiants to claim the subject was "dangerous" to self or others and asking for a clinical assessment and recommendation before signing the petitioned request for involuntary confinement. It might be expected that the more restrictive procedures would have produced a population of more assaultive patients. A study of petitions signed under in the earlier (N = 133) and later, more restrictive (N = 218) procedures indicated that the proportion of assaultive or dangerous patients was virtually identical. Further investigation, using hospital data an OTA patients from this area in both time periods, suggested that while patients were not more assaultive, they appeared to be more seriously ill or psychiatrically impaired. Apparently, movement to a dangerousness standard that allows clinical discretion in interpreting its presence may result in involuntary commitments for more seriously ill, although not necessarily more assaultive, patients.