A mixed methods study examining perceptions by service-users of their involuntary admission in relation to levels of insight

Background: Poor insight is associated with negative attitudes to involuntary admission and care in qualitative studies. Aims: The current paper aims to examine and compare retrospective qualitative perceptions of service-users in relation to their involuntary admission with their levels of clinical insight, using a mixed methods approach. Methods: Forty two participants were assessed 3 months after the revocation of their involuntary admission. Each provided qualitative data relating to their perceptions of the coercive care process, which was analysed using content analysis, along with a quantitative measurement of insight, the Schedule for the Assessment of Insight-Expanded (SAI-E). Employing a mixed methods design and incorporating NVivo matrix coding queries, the datasets were merged to enable qualitative themes to be identified against the quantitative data. Results: Differences were observed between those with high and low insight in terms of their understanding of the need for treatment, their levels of arousal at the time of admission and how they perceived the compassion of health professionals. Certain negative perceptions of care appeared more universal and were common across those with high and low insight. Conclusion: Some negative perceptions of coercive practices appear linked to inherent elements of psychotic illness such as unawareness of illness. Individuals with higher levels of insight tended to perceive their involuntary admission and receiving a diagnosis as beneficial. Negative views that persist amongst service users with high insight levels can highlight areas for successful service improvement, including increased emphasis on non-pharmacotherapy based supports during the coercive care process.

‘Rightificating’ Coercion – A Critical Perspective on the Transformation of State-Driven Coercive Care

During the last decade there has been a growing trend to give the child’s rights perspective a prominent role within the Swedish legal system. Simultaneously, one of the most central notions of the Swedish welfare state is the idea of the state having a certain responsibility to protect children. This article explores the tensions and contradictions between the child’s rights perspective and the collectivistic discourse on state protection in the transformation of state-driven coercive care in accordance with the United Nations Convention on the Rights of the Child (UNCRC). Based on a textual analysis on policy documents, it illustrates a complex process, which both endorses and resists the transformation process. Findings show how emphasis on the child’s right to protection is used, not to strengthen the role of the child towards the state, but to legitimise a strengthened position of the state towards the child, decorated in the terminology of a child’s rights perspective. Further, it suggests that an individualisation of problem formulation opens up space for an extended coercion and that children’s access to individual rights is conditional and dependent on an active and capable individual.

Barnskyddets innersta kärna

The inner core of child protection – on coercive placement motivated by abuse or neglectThis article is about emergency placement due to child abuse or neglect. Empirical data consists of judgements on coercive care in three administrative courts (n=211). Motives for placements are analysed against the background of the discursive changes that have taken place with regard to definitions of child abuse as well as today’s strong focus on risk and risk assessments. Results show that there were a number of motives to justify the court’s decision in each individual case. However, the broadening of the concept of abuse in research and in general discourse is evident in the judgements. We raise the question whether this matter, in practice, has resulted in more children being cared for because of an expansion of the concept of violence. As for risk assessments, two types of causal reasoning can be identified: situations where the child has been abused or neglected and where the risk assessment is about the probability that the problems will continue, and situations where the child has not been harmed but risks being harmed in the future. However, risk assessments are not that elaborate and systematic as presupposed in legislation. Taken together, the findings call for a discussion both within the justice system and in social work.

Coercive care and human rights; a complex juxtaposition – part 2

Objective: To examine capacity assessment, coercive care and principles by which a seemingly reasonable request for the discontinuation of treatment may be considered. Conclusions: A clinical and socio-legal case may be made for ‘coercive care’.

Reducing coercion in mental healthcare

AimsTo examine the extent and nature of coercive practices in mental healthcare and to consider the ethical, human rights challenges facing the current clinical practices in this area. We consider the epidemiology of coercion in mental health and appraise the efficacy of attempts to reduce coercion and make specific recommendations for making mental healthcare less coercive and more consensual.MethodsWe identified references through searches of MEDLINE, EMBASE, PsycINFO and CINAHL Plus. Search was limited to articles published from January 1980 to May 2018. Searches were carried out using the terms mental health (admission or detain* or detention or coercion) and treatment (forcible or involuntary or seclusion or restraint). Articles published during this period were further identified through searches in the authors' personal files and Google Scholar. Articles resulting from searches and relevant references cited in those articles were reviewed. Articles and reviews of non-psychiatric population, children under 16 years, and those pertaining exclusively to people with dementia were excluded.ResultsCoercion in its various guises is embedded in mental healthcare. There is very little research in this area and the absence of systematic and routinely collected data is a major barrier to research as well as understanding the nature of coercion and attempts to address this problem. Examples of good practice in this area are limited and there is hardly any evidence pertaining to the generalisability or sustainability of individual programmes. Based on the review, we make specific recommendations to reduce coercive care. Our contention is that this will require more than legislative tinkering and will necessitate a fundamental change in the culture of psychiatry. In particular, we must ensure that clinical practice never compromises people's human rights. It is ethically, clinically and legally necessary to address the problem of coercion and make mental healthcare more consensual.ConclusionAll forms of coercive practices are inconsistent with human rights-based mental healthcare. This is global challenge that requires urgent action.

Coercive care and human rights; a complex juxtaposition – part 1

Objective: To explore the clinical implications associated with the United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD), and coercive practice. Conclusions: Both human rights and clinical perspectives are necessary in the management of the mentally ill.

Predictors of involuntary patients’ satisfaction with care: prospective study

BackgroundInvoluntary admission can be traumatic and is associated with negative attitudes that persist after the episode of illness has abated.AimsWe aimed to prospectively assess satisfaction with care at the points of involuntary admission and symptomatic recovery, and identify their sociodemographic, clinical and service experience predictors.MethodLevels of satisfaction with care, and clinical and sociodemographic variables were obtained from a representative cohort of 263 patients at the point of involuntary admission and from 155 of these patients 3 months after termination of the involuntary admission. Data were analysed with multiple linear regression modelling.ResultsHigher baseline awareness of illness (B = 0.19, P < 0.001) and older age (B = 0.05, P = 0.001) were associated with more satisfaction with care at baseline and follow-up. Transition to greater satisfaction with care was associated with improvements in awareness of illness (B = 0.13, P < 0.001) and in symptoms (B = 0.05, P = 0.02), as well as older age (B = 0.04, P = 0.01). Objective coercive experiences were not associated with variation in satisfaction with care.ConclusionsThere is wide variation in satisfaction with coercive care. Greater satisfaction with care is positively associated with clinical variables such as increased awareness of illness.Declaration of interestNone.