Patients’ perception of coercion with respect to antipsychotic treatment of psychotic disorders and its predictors

Purpose The present study investigates perceived coercion in psychiatric inpatients under prescribed antipsychotic medication without a court order. The objective of this study was to investigate whether and to what extent involuntary and voluntary inpatients feel coerced to take their medication and which factors affect perceived coercion. Methods Voluntarily and involuntarily admitted patients (55 and 36, respectively) were interviewed about the extent of perceived coercion. In addition, socio-demographic and clinical data were collected. The Admission Experience Scale (aAES) was used to assess perceived coercion concerning medication. To measure insight into illness, attitude towards medication, and symptom severity, we used a questionnaire on insight into illness (FKE-10), the Drug Attitude Inventory (DAI-10), and the Brief Psychiatric Rating Scale (BPRS-24), respectively. Results Voluntarily treated patients experienced significantly less coercion when taking prescribed medication in inpatient settings than involuntarily treated patients. The experience of coercion was not related to socio-demographic or clinical variables nor to the BPRS-24 score, but to insight into illness and attitude towards medication. Patients who had experienced at least one coercive measure during the index hospital stay showed a higher level of perceived coercion. Conclusion Perceived coercion related to medication is dependent on insight into illness and experience of previous coercive interventions rather than on the severity of psychopathological symptoms. These findings are very similar to a previous study in a forensic psychiatric sample. Having experience of at least one coercive measure seems to be a decisive aspect of the extent of the patients’ perceived coercion.

Behind the screen of voluntary psychiatric hospital admissions: A qualitative exploration of treatment pressures and informal coercion in experiences of patients in Italy, Poland and the United Kingdom

Background: Despite the extensive research and intense debate on coercion in psychiatry we have seen in recent years, little is still known about formally voluntarily admitted patients, who experience high levels of perceived coercion during their admission to a psychiatric hospital. Aims: The purpose of the present research was to explore forms of treatment pressure put on patients, not only by clinicians, but also by patients’ relatives, during admission to psychiatric hospitals in Italy, Poland and the United Kingdom. Methods: Data were obtained via in-depth, semi-structured interviews with patients ( N = 108) diagnosed with various mental disorders (ICD-10: F20–F49) hospitalised in psychiatric inpatient wards. Maximum variation sampling was applied to ensure the inclusion of patients with different socio-demographic and clinical characteristics. The study applied a common methodology to secure comparability and consistency across participating countries. The qualitative data from each country were transcribed verbatim, coded and subjected to theoretical thematic analysis. Results: The results of the analysis confirm that the legal classifications of involuntary and voluntary hospitalisation do not capture the fundamental distinctions between patients who are and are not coerced into treatment. Our findings show that the level of perceived coercion in voluntary patients ranges from ‘persuasion’ and ‘interpersonal leverage’ (categorised as treatment pressures) to ‘threat’, ‘someone else’s decisions’ and ‘violence’ (categorised as informal coercion). Conclusion: We suggest that the term ‘treatment pressures’ be applied to techniques for convincing patients to follow a suggested course of treatment by offering advice and support in getting professional help, as well as using emotional arguments based on the personal relationship with the patient. In turn, we propose to reserve the term ‘informal coercion’ to describe practices for pressuring patients into treatment by threatening them, by making them believe that they have no choice, and by taking away their power to make autonomous decisions.

GABA Boosts Relief from Coercive Power: an fMRI study

Individuals under coercive control frequently suffer from anxiety, with recent research asserting this situation as a catalyst for certain types of violence directed towards those suffering under the most serious and insidious forms of coercive power –such as domestic violence victims. Studies researching this matter have skewed towards dissembling manipulation, or participants' obedience levels, neglecting the fact that agents under coercive power are also victims of coercive violence. In this functional magnetic resonance imaging (fMRI) study, we investigate the effects of the anxiolytic GABAA (gamma-Aminobutyric acid) modulator, lorazepam, on behavioral and neural levels in response to coercive power. We used a virtual obedience to authority paradigm inspired in Milgram's renowned experiments of the same nature. An experimenter ordered a volunteer to press a handheld button to initiate actions that carry different moral consequences, including harming or helping others. Our results showed that lorazepam administration, relative to placebo, slowed down reaction times when initiating harming behaviors, but accelerated reaction times for helping actions, despite comparable subjective ratings regarding perceived coercion. Coercive harming significantly increased activation in the amygdala, hippocampus, orbitofrontal cortex, and dorsolateral prefrontal cortex (dlPFC). After lorazepam administration, activity in the amygdala and hippocampus decreased, but activity in the dlPFC and right temporoparietal junction increased. The lower activity in the hippocampus predicted higher subjective ratings for perceived coercion. Furthermore, lorazepam administration significantly decreased the functional connectivity of the hippocampus with the dlPFC during coercive harming. Our results shed light on the coping strategies against coercion beyond merely examining its effects.

Perceived Coercion of Persons with Mental Illness Living in a Community

Aims: The purpose of this study is to analyze the effect of the perceived coercion of people with mental illness living in a community on their therapeutic satisfaction and life satisfaction, mediated by therapeutic relationships. Methods: We evaluated several clinical variables (symptoms, psychosocial functioning, and insight), levels of perceived coercion, therapeutic relationships, therapeutic satisfaction, and life satisfaction in 185 people with mental illness (Mean age = 47.99, standard deviation (SD) = 12.72, male 53.0%, female 45.9%) who live in the community and use community-based mental health programs. The data collected were analyzed to test the proposed hypotheses using structural equation modeling (SEM). Results: The correlation analysis of all variables showed that clinical variables had statistically significant correlations with therapeutic relationship, therapeutic satisfaction, and life satisfaction, but no significant correlation with perceived coercion. Furthermore, perceived coercion was found to have significant predictive power for treatment satisfaction and life satisfaction mediated by therapeutic relationship. Specifically, the lower the perceived coercion, the better the therapeutic relationship. This, in turn, has a positive effect on the therapeutic satisfaction and life satisfaction of participants. Conclusions: Based on these findings, we suggest strategies to minimize coercion in a community.

COVID-19 welbeing study: a protocol examining perceived coercion and psychological well-being during the COVID-19 pandemic by means of an online survey, asynchronous virtual focus groups and individual interviews

IntroductionThe COVID-19 pandemic has resulted in many countries applying restrictive measures, such as lockdown, to contain and prevent further spread. The psychological impact of lockdown and working as a healthcare worker on the frontline has been chronicled in studies pertaining to previous infectious disease pandemics that have reported the presence of depressive symptoms, anxiety, insomnia, and post-traumatic stress symptoms. Potentially linked to psychological well-being and not yet studied is the possibility that lockdown and working on the frontline of the pandemic are associated with perceptions of coercion.Methods and analysisThe present study aimed to examine perceived coercion in those who have experienced COVID-19-related lockdown and/or worked as a frontline healthcare worker across three European countries. It aimed to describe how such perceptions may impact on psychological well-being, coping and post-traumatic growth. It will employ an explanatory mixed-methods research methodology consisting of an online survey and online asynchronous virtual focus groups (AVFGs) and individual interviews. χ2 tests and analyses of variance will be used to examine whether participants from different countries differ according to demographic factors, whether there are differences between cohorts on perceived coercion, depression, anxiety and post-traumatic growth scores. The relationship between coercion and symptoms of distress will be assessed using multiple regression. Both the AVFGs and the narrative interviews will be analysed using thematic narrative analysis.Ethics and disseminationThe study has been approved by University College London’s Research Ethics Committee under Project ID Number 7335/004. Results will be disseminated by means of peer-reviewed publications and at national and/or international conferences.