Perceptions and Attitudes towards Involuntary Hospital Admissions of Psychiatric Patient

Review Article

Perceptions and Attitudes towards Involuntary Hospital Admissions of Psychiatric Patient

Corresponding author: Dr. Adel Gabriel, Suite 300, 5 Richard Way SW, Calgary AB T3E 7M8, Canada, Tel: 403 291 9122; Fax: 403 291 6631; E mail: gabriel@ucalgary.ca

Abstract

Introduction: Involuntary admissions to acute psychiatric units are one of the most ethically challenging practices in Psychiatry. However, published literature falls back in examining this area that touches patient’s rights and freedom.

Objectives: To examine patients’, physicians’ and relatives’ attitudes towards involuntary hospitalization.

Method: Authors searched PubMed and Medline for articles published in the last 15 years (between January 1999 and January 2014); choosing English-language articles of studies based on samples drawn from inpatients admitted on an involuntary basis.

Results: Out of a total of (198) published papers in refereed journals, there were (n=36) articles, including four reviews and thirty three original research papers which met the inclusion criteria for our review. All (n=36) papers examined patients’, rel- atives’, and professionals’ attitudes towards involuntary admission and perception of coercion. Of the total publications, there were (n=12) research articles which solely examined patients’ perception of coercion. The “European multi-site research project on coercion in psychiatry” (EUNOMIA) research project has provided extensive evidence for the current status on patients’ atti- tudes towards involuntary hospitalization and coercion. Significant proportions of patients regarded that involuntary admission as justified. However, attitudes towards coercion appeared to be more complex, and patients’ attitudes varied between studies. In a number of studies, the diagnosis was the main predictor of the admission status.

Conclusion: There is evidence that the majority of patients who initially perceived that they did not need hospitalization revised their belief after hospital discharge and reported that they had needed hospital treatment.

Keywords: Involuntary; Hospitalization; Attitudes; Coercion; Professionals; Next of Kin

Introduction

Advocating for patients is an important strategic goal of men- tal health. This should include both effective patient day to day care, and defending patients’ rights. Involuntary admission is one of the ethically challenging practices in psychiatry. How- ever, it is crucial to examine in more depth, patients’, psychia- trists’, and relatives’ perspectives.

The frequency of compulsory admissions to psychiatric hos- pitals varies considerably between countries depending on the mental health act legislation that define the criteria and practices of compulsory admissions in these countries [1]. Al- though the criteria for detention of the mentally ill are broad- ly similar in most jurisdictions, to include patients’ at risk to themselves or to others, nearly 20-fold variations in detention rates were found in different parts of Europe. These variations

in detention rates appear to be influenced by professionals’ ethics and attitudes, sociodemographic variables, the public’s perceptions about risks arising from mental illness and by the respective legal framework [2,3]. In a recent large Swiss study examining inpatients (n = 9698), there was an overall of 24.8% involuntary admissions, 6.4% seclusion or restraint and 4.2% coerced medication, and risk factors for involuntary admission were numerous. Results suggested that the type and severity of mental illness are the most important risk factors for be- ing subjected to any form of coercion [4-7]. In a retrospective chart review of a Greek study involving (n=282) admissions, authors reported that involuntary admissions were associat- ed with statistically significant higher levels of restraint and seclusion, with 11.0% of cases subjected to some form of co- ercive physical measures, and lengthy mean duration of seclu- sion and mechanical restraint of 64.9 hours [8].

Risk Factors Associated with Involuntary Hospitalization

European research has provided evidence for the current status on patients’ attitudes towards involuntary hospitaliza- tion and coercion. The most large and prominent study was the “European Multi-Site Research Project, “EUNOMIA” which included a sample consisted of (n =2326) legally coerced pa- tients and 764 voluntarily admitted who also felt coerced. This project shed light in some details on the following issues; the association of patients’ views of involuntary hospital admis- sion, the differences in legislation between different European countries, patient characteristics associated with positive out- comes of coerced hospital admission, and the differences be- tween coercive measures (e.g. mechanical restraint, seclusion and forced medication) used during these hospitalizations. It also provides suggestions for good quality in involuntary ad- mission [9,10]. Involuntary coerced admissions appear to be associated with poorer clinical outcomes than with voluntary admissions. In the “EUNOMIA” Project, Kallert et al, examined a total sample consisted of (n=2326) legally coerced patients and (n=764) patients with voluntary admissions who also felt coerced, from 11 European countries. Authors demonstrated that poor outcome after one month and after three months, was associated with higher baseline symptoms, being unemployed, living alone, repeated hospitalisation, being legally a volun- tary patient, and less satisfied with treatment, [10]. Further, involuntary patients demonstrated lower levels of social func- tioning, had higher suicide rates than voluntary patients, and were more dissatisfied with the treatment and more frequent- ly felt that hospitalization was not justified [10,11]. Other risk factors associated with involuntary admission may include; young age (20 years or less), female gender, a diagnosis of psy- chotic disorder and being hospitalized for the first time [7, 12]. In a review, Katsakou and Priebe, concluded that patients with more marked clinical improvement tend to have more positive retrospective judgements [13]. The qualification of the certify- ing physician, a history of previous hospitalization, presence

of psychotic symptom, lower levels of social functioning, lin- guistic communication problems, all can influence the rate of compulsory versus voluntary admissions [4,7,12,14 -18]. It ap- pears that the complex nature and negative events during the admission process were more common among patients with involuntary admission, but were also observed among those who were voluntarily admitted, where patients were exposed to verbal or physical force [13,15,16-23]. It was emphasized that minimizing patient’s perception of coercion during hos- pital admission may impact positively on the course and ad- herence to treatment [24]. Patients assessed as dangerous and received involuntary treatment were associated with signifi- cantly longer duration of untreated psychosis, were associat- ed with a worse prognosis, increased risk of suicide and were linked to serious violence [25]. Bipolar patients often needed involuntary hospitalization, and some patients become aggres- sive, abuse illicit substances, and have poor insight. This was demonstrated in the European-Mania-in-Bipolar-Longitudi- nal-Evaluation-of-Medication (EMBLEM) study in which (n =

55) out of (n=95) patients needed involuntary hospital admis- sion [26]. Reviewing a Swiss Psychiatric register including (n = 9698) inpatients, It was found that the nature and severity of mental illness were the most important predicting risk factors for being subjected to any form of coercion [27]. Katsakou et al, examined involuntary inpatients (n=778) admissions. Per- ception of coercion was associated with less satisfaction with treatment [28]. Swartz et al, reported that only 36% of con- sumers with chronic psychiatric disorders, reported fear of coerced treatment as a barrier to seeking help [29]. Although compulsory admission was strongly associated with perceived coercion, especially among those with poor insight, other au- thors did not find significant association between perceived coercion and engagement with follow-up or with treatment adherence [30 – 33].

Objectives

If patients’ attitudes towards involuntary hospitalization and coercion are to be understood among patients, then a detailed inquiry about the features and specifications of patients’, phy- sicians’, and relatives’ perceptions to involuntary admission are needed. From reviewing literature on patients’ attitudes to involuntary admission across the globe, there are limited num- bers of published research, and there is no reliable or valid in- strument to examine patients’ attitudes towards involuntary admission.

The objective of this project is to review the recently published research of patients’, relatives’ and professional’ attitudes to- wards involuntary admission.

The objective of the present systematic literature search and review was to examine the recent research and to address the following specific questions:

  1. What are the prevailing attitudes among patients, profes- sionals and the public regarding involuntary admission to psy- chiatry units?
  2. Do patients’ perceptions towards involuntary admission change over time with hospital treatment?
  3. Based on empirical evidence from literature, could a list of specification summarizing patients’ attitudes to involuntary admission be constructed?

Material and Methods

We conducted a Pub Med search during January 2015, cover- ing the period from January 1999 to December 2014 using the following keywords in different combinations: perceptions, attitudes, patients, relatives, next of kin, physicians, profes- sionals, compulsory, formal, involuntary, coercion, admissions, hospital, and psychiatry.

Following the electronic search, hand searches of the literature were undertaken. The search strategy yielded 186 research articles, reviews and commentaries concerning studies exam- ining involuntary hospital admissions and admissions associ- ated with coercion, under mental health acts in different coun- tries. This output constitutes a gross total; including a number of studies that appeared more than once (n= 89), when the dif- ferent keyword combinations were used in the search.

Of the remaining (109) references, 36 met the following in- clusion criteria for our review, about patients’, relatives’, and professionals’ perceptions of coercion and involuntary hospi- talization: 1) articles written in English, 2) studies based on samples drawn from patient populations admitted on an invol- untary basis, 3) articles exploring perceptions and attitudes of patients admitted involuntarily to psychiatry units, 4) articles examining the attitudes of mental health professionals includ- ing physicians’ and other allied mental health workers’, and

  1. articles exploring relatives’ attitudes towards involuntary hospitalization or coercion during hospital admission. The authors excluded articles (n = 27) focusing solely on epide- miological, and demographic aspects, and studies that solely examined clinical outcomes related to involuntary admission such as clinical improvements, and adherence to follow up treatments (n= 14). Also, we excluded research studies or ar- ticles examining legal aspects and legislations related to com- pulsive admissions, and those comparing mental health legis- lation in different countries (n = 32). Figure 1, summarizes the flow of search strategy for this review.

Results

Of the final 36 that met the inclusion criteria, there were only 3 published European reviews [13, 16, 32], two of which ex- amined patients’ attitudes, associated risk factors, and clinical outcomes among the involuntary hospitalized coerced patients

[13,16]. The third Medline review examined the attitude of the general population, mental health professionals, and relatives towards coercive measures in psychiatry, especially those related to involuntary admission and treatments [32].

Of the remaining 33 research papers, there were twenty papers examined patients’ attitudes towards involuntary hospitalization and coercion, two research papers exam- ine patients’ attitude change, over time, six research papers examined professionals’ attitudes (Physicians, Psychiatrists, Psychologists, and Lawyers), and five research papers exam- ined the perceptions of relatives, next of kin, public members, and other stakeholders towards involuntary hospitalization.

The final 36 studies and reviews that met all inclusion crite- ria are listed in the Table1, along with key characteristics of the studies (e. g, author, journal, country of research, sampling, and research method). None of the papers examined in these older reviews [13, 16, 32], is included in our review. In the first review, there were (n =18) studies that were published between 1977- 2004, and examined patients’ attitudes and outcome predictors among involuntary admissions. Authors found, retrospectively that between 33% and 81% of patients regarded the admission as justified, and the treatment as ben- eficial. Also, patients with more marked clinical improvement had more positive retrospective judgments [13]. In the second review, the same authors analyzed (n=5) qualitative studies employing thematic analysis, to explore patients’ attitudes to involuntary admission. Authors reported that patients’ perceptions seemed to vary and had both the positive and neg- ative perceptions towards involuntary hospitalization.

The main areas that appeared to be of concern to patients in- cluded; patients’ perceived autonomy, participation in making decisions for themselves, and about losing their sense of iden- tity [16]. Out of the (n=36) publications that met the selection criteria, there were (n=31) studies which were carried out in European countries, four from USA, and one from China.

Patient’s Attitudes towards Involuntary hospitalization

In a cross-sectional survey conducted among inpatients (n

= 872) of a Swiss psychiatric hospital to assess their subjec- tive view of admission with emphasis on legal status, and perceived coercion, 74% of patients felt that they were under pressure to be hospitalized, whether or not they were invol- untarily admitted. However, seventy percent felt their admis- sion was necessary [34]. Also, using a semi-structured inter- view, (O’Donoghue et al, 2010), examined patients’ (n=81) perception of the involuntary admission and reported that the majority of patients felt that the treatment they received was beneficial. However, some patient perceived a negative impact upon the relationship with their family and on the relationship with their doctors, as a result of the involuntary admission, and about a third felt their chances for employment could be affected [19].

Total yield of PubMed and Medline

n = 198

Selection Criteria

    1. articles in English
    2. Articles examining those admitted on an involuntary basis,
    3. Those studies exploring perceptions of patients, relatives, and mental health professionals towards involuntary admission and coercion.

Selected n = 36

Excluded studies n = 33

  • Mental health

legislations and reforms.

  • Compulsory Community

Treatments (e.g. CTO)

  • Studies examining patients or relatives on issues of capacity or

incompetency

Excluded studies n = 14

  • Examined solely outcomes of involuntary

admission (e.g. clinical symptomatic improvement, or adherence to

treatments)

Excluded studies n = 26

  • epidemiological studies, and
  • demographic studies

Excluded studies n = 89

Studies appeared more than once (when the different keyword combinations were used in the search

Figure 1. The Flow of Search Strategy

Author (year) Country admission type Sample size Outcome measures Objective
1 Johansson and Lundman, 2002 Sweden Involuntary patients 5 Qualitative methods and semi-structured

interview

Patients’ experience of involuntary psychiatric
2 O’Donoghue et al, 2010 Ireland Involuntarily Hospitalization 81 semistructured interview Patients’ perceptions of involuntary hospitalization, and impact on relationships in

family and with doctors

3 Katsakou et al, 2011 UK Involuntarily Hospitalization in 22 hospitals 270 Qualitative study, focus groups interviews, and

thematic analysis

Patients’ perceptions of Involuntarily Hospitalization
4 Rusch et al, 2014 Switzerlan d recent involuntary hospitalization 186 self-report, structured and semi structured

questionnaire

The cognitive appraisal of stigma of involuntary hospitalization
5 Priebe et al, 2009 UK involuntary inpatients’ 1570 semi structured interview Retrospective patients’ views

of involuntary hospitalization, and long term outcomes

6 O’Donoghue et al, 2011 Ireland Patients’ Involuntarily Hospitalization 68 Structured interviews Perceptions of involuntary

admission and risk of subsequent readmission

7 Richardson et al, 2010 UK patients admitted Involuntarily 232 structured questionnaires and

19interviews

Patients’ attitudes and satisfaction of involuntary

admissions

8 Svindseth et al,

2007

Norway. Involuntary and

voluntary patients

102 structured interview Patients’ experience of

humiliation

9 O’Donoghue et al, 2013 Ireland voluntarily and involuntarily 161 MacArthur Admission Experience Client

Satisfaction

Service users perceptions of Coercion
10 Tan, 2010 UK formal compulsory treatment 29 semi structured interview Perception of coercion of

compulsory treatment in anorexia patients

11 Ivar Iversen et al, 2002 Norway. Involuntary and voluntary patients 223 Structured interview visual

analogue scale and the MacArthur

Perceived Coercion Scale (MPCS),

Perceived coercion
12 Fiorillo et al, 2012 Italy Involuntarily or felt coerced 3093 Structured and

semistructured interviews

Perceived coercion
13 Kjellin L, et al 2004 Sweden Voluntary and involuntary 138

involuntary

+144

voluntary

structured interview Perceived coercion
14 Bonsack and

Borgeat, 2005

Switzerlan

d.

Voluntary and

involuntary

87 A cross-sectional

survey

Perceived coercion
15 Poulsen, 1999 Denmark voluntarily and Involuntarily

Hospitalization

143

paticipated

semistructured interview Examining perceived coercion
16 Poulsen et al, 2001 Denmark involuntary commitments 143 Semi structured interviews, and medical files To examine validity of patients’ statements on coercive measures
17 Sheehan and Burns, 2011 UK Voluntary and involuntarily

Hospitalization

164 structured interviews Relationship between perceived coercion and

involuntary hospitalization

18 Katsakou et al, 2010 UK involuntary inpatients’ 778 Semi structured

interview

Coercion and treatment

satisfaction

19 Kallert et al, 2011 Germany Involuntary and voluntary admissions 2326 & 764 Brief Psychiatric Rating

Scale.

Perceptions and outcomes of the coerced patients
20 Sorgaard, 2004 Norway Voluntary and

involuntary

190

admissions

Structured

questionnaire

Changes in perception to

coercion

21 Gardner et al, 1999 USA Voluntarily and involuntarily 433 Semi-structured interview Attitude change of patients to

hospitalization, over time, and perceptions of coercion

22 Priebe et al, 2010 UK involuntarily 2326

(from11 countries)

Semi structured interview Attitude change of patients tohospitalization, over time
23 Katsakou and Priebe, 2006 UK involuntary inpatients 18 studies observer-rated clinical change and

self-rated outcomes

REVIEW:

Retrospective perceptions

24 Katsakou, and Priebe, 2007 UK involuntary admission 5 Qualitative studies Medline-search REVIEW:
25 Jepsen et al, 2010 Denmark General Practitioners 13 Focus group Physicians’ perceptions
26 Shao et al, 2012 China. psychiatrists 314 Survey, using

questionnaire

Psychiatrists’ perceptions
27 Luchins et al, 2004 USA Psychiatrists 432 Survey utilizing a

vignette

Psychiatrists’ perceptions
28 Lepping et al, 2004 Germany & UK Mental health professionals (psychiatrists, nurses, workers 623 in

Germany, 231 in UK

Qualitative study, using 3 vignette scenarios of detainable patients

& questionnaire

Attitudes of mental health professionals and lay people
29 Lauber and Rössler, 2007 Germany involuntary admission survey” 1990-

2006

Medline-search REVIEW

Attitude of the general population, and mental health

professionals

30 Wynn et al, 2007 Norway admit and treat involuntarily 340

psychologists

questionnaire containing three

patients’ Vignettes

Psychologists attitudes Towards coersion
31 Luchins et al, 2006 USA involuntary treatment 89 lawyers vignettes Lawyers attitudes
32 Wallsten et al, 2008 Sweden committed and voluntarily patients over time 84 committed

and 84 voluntary in 1991) &

(118

committed and 117 voluntary in (1997-1999)

semi structured interview Patients and next-of-kin’s’ attitudes
33 Swartz et al, 2003 USA Four groups of stakeholders Patients-104 General public = 59 Family members =49 Clinicians =

85

short vignettes Stakeholders ( patients, families, clinicians and public)
34 Diseth et al, 2011 Norway stakeholders 62

respondents

30 item structured questionnaire stakeholders (former patients, relatives, members of supervisory commissions, psychiatrists, other physicians, and lawyers
35 Jankovic et al, 2011 UK Compulsory admission of a close

relative

29 families semi structured interview,

qualitative study

Family perceptions
36 Borgeat and Zullino

, 2004

Switzerlan d. involuntary treatment of mania 500 patients and their

families

clinical vignette, and visual analogue

scales

Attitudes of self-help organizations

Table 1. Summary of the main characteristics of the 36 published articles, included in this review, on attitudes towards involuntary hospital admission of psychiatric patients

Cite this article: Adel Gabriel. Perceptions and Attitudes towards Involuntary Hospital Admissions of Psychiatric Patients. J J Psych Behav Sci. 2016, 2(1): 013.

by the admission status (involuntary or voluntary) in levels of perceived coercion, perceived pressures, procedural justice, perceived necessity, or satisfaction with services [41].

When patients’ statements on coercive measures were com- pared with medical file information, patients stated to have been subjected to more coercion than was evident from the files, in particular in statements about forced medication [42].

Change of patient’s Attitudes over time, towards involun- tary hospitalization

There is strong empirical evidence to suggest that the nega- tive attitude towards involuntary hospitalization changes over time. In the (EUNOMIA) prospective research project in 11 countries, consecutive involuntary patients (n= 2326) were interviewed within one week, at one month of admission and after three months. Between 39 and 71% considered that their admission was justifiable after one month, and this attitude changed to 86% after three months. Authors found that fe- males, those living alone and those with a diagnosis of schizo- phrenia had more negative views [39 – 45]. Gardner et al, ex- amined (n = 267) patients who were interviewed about their involuntary hospitalization within two days of their admission and were re-interviewed 4-8 weeks following discharge. Au- thors reported that 52% of patients have changed their atti- tude towards involuntary hospitalization, to a more accepting one, and only minority who considered admission as neces- sary, tended to change their attitude to the contrary [46]. Also and others interviewed individuals admitted involuntarily, at one year following discharge to investigate their perception of involuntary admission over time. Authors demonstrated that large proportion (60%), believed that their involuntary admis- sion was necessary [19, 44]. Also found that 40 % of patients considered that their involuntary admission was justifiable one year later. Authors also found that higher initial treatment satisfaction, poorer global functioning, being on benefits, and living alone were associated with more positive retrospective views of the admission [45].

With regards to coercion conducted a study in 67 acute wards in 22 hospitals in England, involving (n =778) patients. Pa- tients who perceived less coercion at admission and during hospital treatment were more satisfied overall, when assessed for satisfaction over time up to one-year follow-ups. Authors found that although patients who perceived less coercion at admission and during hospital treatment were more satisfied overall, whereas coercive measures documented in the med- ical records were not linked to their overall satisfaction with treatment [28].

In conclusion, there is evidence that the majority of patients who initially perceived that they did not need hospitalization revised their belief after hospital discharge and reported that they had needed hospital treatment. However, perceptions of coercion was more complex, and more persistent over time de- pending on the processes perceived from the admission pro-

In a recent large descriptive qualitative study, at the Social & Community Psychiatry Unit, of the institute of psychiatry, to explore involuntary patients’ retrospective views on why in- voluntary hospitalisation was right or wrong, involuntary pa- tients from 22 hospitals in England were interviewed in-depth, utilizing the grounded theory and thematic analysis [19]. Au- thors identified three groups of patients with distinct views on their involuntary hospitalization: those who believed that involuntary hospitalization was acceptable, those who thought it was not acceptable and those who had an ambivalent atti- tude. Those with retrospectively positive views believed that hospitalization ensured that the received treatment, averted further harm and offered them the opportunity to recover in a safe place. Many felt that coercion was necessary, as they could not recognize that they needed help when they were acutely unwell. Substantial minority perceived the involuntary admis- sion negatively and felt that their admission was unfair, could have been handled in less aggressive manner, and experienced hospitalization as violation of their freedom and autonomy. A third group of patients was described by authors as ambiva- lent because they believed that they needed the involuntary hospitalization that averted further harm to them. However, they thought that their admission could have been handled in the community or with shorter voluntary hospitalization [19]. In multiple linear regressions, (Rusch et al, 2014) found that more self-stigma was predicted independently by higher levels of shame, self-contempt and stigma stress, and that a greater sense of empowerment was related to lower levels of stigma stress and self-contempt [35].

In one study, it was noted that the adverse circumstances as- sociated with the forceful involuntary admission may lead to significant perception of humiliation. Commonly, patients re- ported that during admission they were exposed to verbal or physical force [20]. (Tan JO, et al, 2010) examined compulsory treatment among anorexia patients, who seemed to agree with the necessity of compulsory treatment in order to save life. But what mattered most to them was not whether they had expe- rienced restriction of freedom, but the nature of their relation- ships with parents and mental health professionals [36].

Patients’ negative perception about involuntary hospitaliza- tion and coercion is quite complex, and not necessarily related to the degree of restriction of freedom. Most authors reported that, while on one hand significant proportions experienced that their freedom was violated, on the other hand they felt that they were given the opportunity to be taken care of and to recover in a safe place.

Perceived coercion during Hospitalization

In the large “ European multi-site research project on coercion in psychiatry (EUNOMIA), it was reported that high perceived coercion at admission was reported by both the involuntary and voluntary patients. This study included (n=3093) patients who were involuntarily admitted to hospitals, in 11 Europe-

Cite this article: Adel Gabriel. Perceptions and Attitudes towards Involuntary Hospital Admissions of Psychiatric Patients. J J Psych Behav Sci. 2016, 2(1): 013.

an countries. However, coercion was more likely (89% of pa- tients) to be reported by the involuntary patients [10]. In this study, perceived coercion, global functioning, and symptom severity were assessed after admission and at a 3-month fol- low-up. Coercion was found, to be associated with poor global functioning. Authors reported that the improvement in mental state and the global functioning was associated with a reduc- tion in the perception of coercion, and that perception of co- ercion tends to decrease significantly over time [12]. Others reported that the main predictor of felt coercion was seclusion, and that coercion tends to be rather persistent and not amena- ble to interventions that included engaging patients in the for- mulation of the treatment plan [37].

Procedural Justice during the admission process is of crucial importance to the development of positive or negative percep- tion of coercion. This involves the perception of justice, and of being respectfully involved in a fair decision-making process regarding admission [34]. It was demonstrated in several stud- ies that both voluntary and involuntary patients may experi- ence coercion during admission. However, involuntarily ad- mitted patients are more likely to perceive coercion, especially those who have experienced more force due to their uncooper- ative attitudes to the admission process. For this reason, coer- cion is not necessarily associated with the patient’s legal status. Patients who perceived coercion commonly report that they were not heard [12,29,33]. For example, in a recent study ex- amining coercion in both the involuntarily and the voluntarily admitted patients, perceptions of coercion was found to be sig- nificantly more prevalent (89%) among the involuntarily ad- mitted patients, than among the voluntarily admitted patients (48%) [22]. A high perceived coercion score was significantly associated with a poor rating of the therapeutic relationship with treating professionals. Even, among voluntarily hospital- ized patients, more coercion was reported when patients rated their relationship with the admitting clinician negatively [22]. Also, (Ivar Iversen et al, 2002), Investigated perceived coer- cion, among patients (N= 223) admitted both voluntarily and involuntarily to acute wards in Norway. Authors used a visu- al analog scale (CL), the MacArthur Perceived Coercion Scale (MPCS), and a five-item questionnaire, to measure perceived coercion. Patients admitted to acute wards were included and interviewed within five days of admission. Commonly, the in- voluntary group experienced significantly higher levels of per- ceived coercion in the admission process than the voluntary group [38,39]. Coercion was associated with female gender, poorer global functioning, and more positive psychotic symp- toms. It was claimed that these results suggest that the nature and the severity of mental illness were the most important risk factors for being subjected to any form of coercion [12,21,38]. Poulsen et al, found that detention after a voluntary admission results in a statistically significant higher perception of coer- cion [40]. In contrast, O’Donoghue et al, found no differences

cedure to follow-up, and the overall patients’ attitudes toward hospitalization does not seem to change to a more positive one overtime [34,39].

Patients’ perceptions towards involuntary admission from dif- ferent studies which fulfilled our search criteria are summa- rized to form a list of 21 main items.

The list of attitudes toward involuntary admission was devel- oped at four levels of the taxonomy of attitudinal objectives: awareness, willingness to respond, preference and conceptu- alization for a value, and commitment (Appendix A). This was adapted from Hopkins and Krathwohl [47].

Appendix A

Families and next of kin attitudes towards involuntary admissions of their relatives

Compulsory admission of a close relative can be a major source of stress for relatives and caregivers. Interviewed in- depth (n=30) caregivers to investigate their attitudes to the involuntary admission of their relatives who were admitted to 12 hospitals in England [48]. Investigators identified four major themes of perceptions including; relief and conflicting emotions in response to the relative’s admission; frustration with a delay in getting help; being given the burden of care by services; and some relatives had concerns about confidentiali- ty. Authors also reported that although relief was the predom- inant emotion as a response to the relative’s admission, it was accompanied by feelings of guilt, and that caregivers frequent- ly experienced difficulties in obtaining help from services prior to admission. Some relatives thought that services responded to them mainly where there was a crisis, rather than prevented a crisis from taking place, and some family caregivers wanted more information and wanted to have a say in the decisions made about their relatives treatments [40]. In another study to examine and compare the differences in attitudes, before and after the mental health law reform in Sweden among involun- tarily and voluntarily admitted patients and their next-of-kin towards involuntary psychiatric admission, a great majority of the patients and the next-of-kin stated that decisions regard- ing compulsory admission should be taken by doctors. In this study, demonstrated that most patients and next-of-kin con- sidered decisions about involuntary psychiatric care and the decision for coercion, to be a medical decision in the first place which should be made by doctors in order to protect the pa- tient [49].

It could be concluded that, in order for caregivers to be effec- tive partners in care, a balance needs to be struck between valuing their involvement in providing care for a patient and not overburdening them.

APPENDIX A: Table of Specification, Taxonomy of the Attitudinal Objectives

Attitudinal objectives Awareness Willingness to accept or respond Preference & conceptuali-

zation of a value

Commitment Total
The awareness that I received appropriate treatment during my hospitalization P1 1
The conceptualization that being detained as an involuntary patient has averted further harm to me P2 1
Accepting that he / she was offered the opportunity to recover in a safe place. P3 1
Accepting the need for help when was acutely ill P4 1
The perception that I was coerced excessively P5 1
Holding a strong concept that the problem could have been managed through less coercive interventions P6 1
I think that my hospitalization was not necessary at all P7 1
The false perception that hospitalization was unjust P8 1
The false perception that hospitalization constitute an infringement of my rights P9 1
I felt that I was not heard P10 1
The perception that his / her point of view was not seen P11 1
Holding a strong concept that hospitalization posed a permanent threat to my independence P12 1
The preference that the problem might have been managed through a voluntary hospitalization P13 1
The preference that problems might have been managed through a shorter hospitalization P14 1
This admission had a negative impact upon the relationship with my family P15 1
Holding a strong concept that the relationship with doctors / psychiatrist was negatively impacted by this involuntary

admission

P16 1
I felt that the prospects for my employment could be affected P17 1
Committed to hold to his / her legal rights, as an involuntary patient P18 1
Accepting a timely freedom when my doctors allow P19 1
The false perception that hospital was a humiliating experience P20 1
Accepting that I was treated with respect during hospitalization P21 1
Total 6 5 9 1 21

Adapted from Krathwohl et al, 1964

(Diseth et al, 2011), identified three meaningful main attitudes which are entertained by stakeholders. These attitudes includ- ed, emphasis on a balance between protecting the patient ‘s rights, patients’ autonomy, as well as the necessity of using in- voluntary commission for some patients with severe mental disorders. Respondents tended to have differences in attitudes reflecting their respondents’ role in mental health care [50].

(Swartz, 2003) examined four stakeholder group including subjects with schizophrenia disorders, family members, cli- nicians, and members of the general public. The four groups showed remarkably similar views about the preferred out- comes in the treatment of schizophrenia. All groups gave the highest preference to avoiding involuntary hospitalization, followed by avoiding interpersonal violence. It was conclud- ed that stakeholders were willing to accept the coerciveness of outpatient commitment [51].

Attitudes of mental health professionals towards involun- tary hospitalizations

There is empirical evidence to suggest that the attitudes to- wards involuntary treatment also depends on variables such as the medical professional’s profession, age, nationality and ex- periences with mental illness. For example, it was demonstrat- ed that limiting the right to require compulsory admissions to fully certified psychiatrists can reduce the rate of compulsory versus voluntary admissions [14]. Surveyed psychiatrists (n

= 432), to examine their attitudes to involuntary admissions and its relationship to responsibility for mental illnesses. This study examined whether psychiatrists’ responsibility affects their decisions about involuntary hospitalization. A vignette characters were utilized to elicit psychiatrists’ responses and attitudes. Authors found that making decision to involuntarily hospitalize persons with mental illness increased significantly with the level of risk of harm to the patient or to others, and that the decision varied significantly between psychiatric di- agnoses [52]. The same author investigated lawyers’ attitudes toward involuntary hospitalizations and involuntary medi- cation. Authors found that a decisions to hospitalize persons with mental illness involuntarily increased significantly with the level of risk of harm and this was attributed to responsibil- ity to prevent recurrence of mental illness. However, the deci- sions to recommend involuntary medication were not related to attributions of responsibility [53].

Also, when Chinese Psychiatrists (n = 314) were surveyed using a questionnaire to assess their attitudes about the procedure of involuntary admission to mental hospitals, some showed stricter attitudes especially females psychiatrists, those aged under 35, with a low education level and those with a low posi- tion in the institution [54]. When psychologists were surveyed about their views and attitudes about involuntary admissions, coercion and treatments, the majority recommended coercion for violent patients, and if the patient had difficulties in deal-

ing with activities of daily life. However they appeared to be in favor of involuntary admission to involuntary treatment with medication [55].

To examine mental health professionals’ and lay-people’ atti- tudes towards involuntary treatment, and to compare results between England and Germany, (Lepping et al, 2004), devel- oped three scenarios of potentially detainable patients and presented them to professional staff. Overall, authors demon- strated that there were no significant differences in percep- tions towards involuntary hospitalization and involuntary treatment between lay-people and mental health profession- als [56]. Also in a review examining involuntary admission and the attitude of the general population, and mental health professionals by, it was found that the majority of the general public or mental health professionals were in support of invol- untary admissions, and involuntary hospitalization [32].

used a clinical vignette to explore the There were 503 respon- dents who disagreed that patients should decide about their hospitalization and favored some involuntary treatment over treatment refusal. There was an agreement between patients, relatives and caregivers related to acceptance of involuntary hospitalization and coercive treatment. Respondents agreed to trust in the role played by the treatments by professionals, and family members supported decisions for coercive treatment [57].

Discussion

Based on empirical evidence from recent research examining patients’ attitudes to involuntary admission, the majority of patients reflected positively retrospectively on their involun- tary admission. In some studies, retrospectively the propor- tions of patients who viewed their involuntary admissions as justifiable reached 70 %. These positive attitudes should constitute an invaluable opportunity that could be used to examine different perceptions in more depth, and to examine the psychosocial risk factors associated with mental illness. It was demonstrated that efforts to decrease seclusion and re- straint may be accompanied by an increased risk of harm to psychiatric patients. Professional decisions to admit patients involuntarily when necessary, seemed to be supported by the next of kin and the lay person, and there was an agreement between professional’s and the public attitudes towards in- voluntary hospitalization. It appears from current available research, that the nature and severity of mental illness were the most important predicting risk factors for being subjected to any form of coercion (6,7, 14 -17]. As far as the attitudes to coercion is concerned, it was concluded that the nature and the severity of mental illness were the most commonly deter- minant factors for being subjected to any form of coercion, and involuntary coerced admissions appear to be associated with poorer clinical outcomes than with voluntary admissions [12,21,33].

Developing social programs to address negative attitudes and engaging patients in psycho-education are crucial to improv- ing positive perceptions towards admissions in particular, and adherence to treatment in general. Although patients’ percep- tions of involuntary treatment are well described in the liter- ature, future research should explore differences between pa- tient groups, such as diagnostic groups, and high-risk factors groups, which are not extensively examined in present litera- ture. Future research should also examine in more depth and in detail, patients’ perceptions to different coercive measures, such as seclusions and physical or chemical restraints, which are still widely used in acute psychiatry units. Developing re- liable and valid measures of patients’ perceptions of coercion may assist in deeper understanding of patients’ attitudes and may shed light to developing an effective mental health act leg- islations. Studies on patients’ and relatives’ perspectives are scarce and showed that involuntariness and coercion were as- sociated with feelings of being excluded from participation in the treatment. Because of its reflections and repercussions on legal, human rights and ethical issues, there are many patients’ and public questions need to be addressed about Coercion. Fi- nally, the development of a reliable instrument with evidence of validity, to measure patients’ perceptions towards involun- tary admission or coercion may prove useful in examining pa- tients’ attitudes at more depth.

One major strength for conducting this review, was to identify, formulate and construct a list of specifications about the most salient features of patients’ attitudes towards involuntary hos- pitalization. Based on empirical evidence from the review of literature, the list of specifications of patients’ attitudes to- wards involuntary hospitalization ( Appendix A), was con- structed which could be the used as the basis for developing an instrument or a questionnaire with evidence for content validity, to measure patients’ attitudes towards involuntary hospitalization. However this is being examined further in a psychometric study for developing such instrument.

Overall there is paucity in the research of this important area of forensic psychiatry which touches patients’ freedom.

Results from future research among the public, mental health professional, and independent patients’ advocacy agencies, is crucial to better understanding and developing managing strategies for patient with severe mental illness, without vi- olating their rights. It is equally crucial that clinicians under- stand patients’ and relatives’ perceptions to help minimize the negative perceptions of injustice or of coercion among both the voluntarily or the involuntarily admitted patients, by attending more closely to procedural justice issues.

Conclusion

There are widespread high levels of negative attitudes towards involuntary hospitalization among patients admitted involuntarily to psychiatry, including significant perception of hu- miliation, and violation of freedom. However, there is strong evidence to suggest that retrospectively substantial majority of patients considered that their involuntary admission was justifiable over time.

Conflict of Interest

There was no financial assistance received and there is no an- other conflict of interest.

Author’s Contributions

The corresponding author contributed to the review of the lit- erature, and its compilation, drafting the article, interpretation of data, and will be responsible for the final approval of the version to be published.

Acknowledgement

The author would like to thank Dr. Kim Reeves (PhD) for her invaluable contribution to this review by providing helpful editing comments and proof reading of the manuscript.

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