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: firstname.lastname@example.org
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 . 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 .
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, . 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 . 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 . 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 . 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 . 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 . Katsakou et al, examined involuntary inpatients (n=778) admissions. Per- ception of coercion was associated with less satisfaction with treatment . 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 . 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].
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:
- What are the prevailing attitudes among patients, profes- sionals and the public regarding involuntary admission to psy- chiatry units?
- Do patients’ perceptions towards involuntary admission change over time with hospital treatment?
- 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
- 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.
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 .
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 . 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 . 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 . 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 .
Total yield of PubMed and Medline
n = 198
- articles in English
- Articles examining those admitted on an involuntary basis,
- 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
Excluded studies n = 14
- Examined solely outcomes of involuntary
admission (e.g. clinical symptomatic improvement, or adherence to
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
|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
|Patients’ perceptions of Involuntarily Hospitalization|
|4||Rusch et al, 2014||Switzerlan d||recent involuntary hospitalization||186||self-report, structured and semi structured
|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
|Patients’ attitudes and satisfaction of involuntary
|8||Svindseth et al,
|102||structured interview||Patients’ experience of
|9||O’Donoghue et al, 2013||Ireland||voluntarily and involuntarily||161||MacArthur Admission Experience Client
|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),
|12||Fiorillo et al, 2012||Italy||Involuntarily or felt coerced||3093||Structured and
|13||Kjellin L, et al 2004||Sweden||Voluntary and involuntary||138
|structured interview||Perceived coercion|
|15||Poulsen, 1999||Denmark||voluntarily and Involuntarily
|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
|164||structured interviews||Relationship between perceived coercion and
|18||Katsakou et al, 2010||UK||involuntary inpatients’||778||Semi structured
|Coercion and treatment
|19||Kallert et al, 2011||Germany||Involuntary and voluntary admissions||2326 & 764||Brief Psychiatric Rating
|Perceptions and outcomes of the coerced patients|
|20||Sorgaard, 2004||Norway||Voluntary and
|Changes in perception to
|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
|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
|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
|27||Luchins et al, 2004||USA||Psychiatrists||432||Survey utilizing a
|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
|Attitudes of mental health professionals and lay people|
|29||Lauber and Rössler, 2007||Germany||involuntary admission||survey” 1990-
Attitude of the general population, and mental health
|30||Wynn et al, 2007||Norway||admit and treat involuntarily||340
|questionnaire containing three
|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) &
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 =
|short vignettes||Stakeholders ( patients, families, clinicians and public)|
|34||Diseth et al, 2011||Norway||stakeholders||62
|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
|29 families||semi structured interview,
|36||Borgeat and Zullino
|Switzerlan d.||involuntary treatment of mania||500 patients and their
|clinical vignette, and visual analogue
|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 .
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 .
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 . 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 .
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 .
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 . 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 . 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 .
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 . (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 .
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 . 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 . 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 .
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 . 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%) . 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 . 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 . 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 .
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 . 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 . 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 .
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
|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
|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|
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 .
(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 .
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 . 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 . 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 .
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 . 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 .
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 . 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 .
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 .
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.
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.
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.
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.
- Riecher-Rössler A, Rössler W. Compulsory admission of psy- chiatric patients–an international comparison. Acta Psychiatr Scand. 1993, 87(4): 231-236.
- Zinkler M, Priebe S. Detention of the mentally ill in Europe–a review. Acta Psychiatr Scand. 2002, 106(1): 3-8.
- Keown P, Mercer G, Scott J. Retrospective analysis of hospi- tal episode statistics, involuntary admissions under the Mental Health Act 1983, and number of psychiatric beds in England 1996-2006. BMJ. 2008;337:a1837.
- Kallert TW, Glöckner M, Schützwohl M. Involuntary vs. vol- untary hospital admission. A systematic literature review on outcome diversity. Eur Arch Psychiatry Clin Neurosci. 2008, 258(4): 195-209.
- Myklebust LH, Sørgaard K, Røtvold K, Wynn R. Factors of importance to involuntary admission. Nord J Psychiatry. 2012, 66(3): 178-182.
- Ng XT, Kelly BD. Voluntary and involuntary care: Three-year study of demographic and diagnostic admission statistics at an inner-city adult psychiatry unit. Int J Law Psychiatry.2012, 35(4): 317-326.
- Iversen VC, Berg JE, Småvik R, Vaaler AE. Clinical differences between immigrants voluntarily and involuntarily admitted to acute psychiatric units: a 3-year prospective study. J Psychiatr Ment Health Nurs. 2011, 18(8): 671-676.
- Bilanakis N, Kalampokis G, Christou K, Peritogiannis V. Use of coercive physical measures in a psychiatric ward of a general hospital in Greece. Int J Soc Psychiatry. 2010, 56(4): 402-411.
- Jacobsen TB. Involuntary treatment in Europe: different countries, different practices. Curr Opin Psychiatry. 2012,25(): 307-310.
- Kallert TW, Katsakou C, Adamowski T, Dembinskas A, Fioril- lo A et al. Coerced hospital admission and symptom change–a prospective observational multi-centre study. 2011, 6: 28191.
- Kallert TW. Coercion in psychiatry. Curr Opin Psychiatry. 2008, 21(5): 485-489.
- Fiorillo A, Giacco D, De Rosa C, Kallert T, Katsakou C et al. Patient characteristics and symptoms associated with per- ceived coercion during hospital treatment. Acta Psychiatr Scand. 2012, 125(6): 460-467.
- Katsakou C, Priebe S. Outcomes of involuntary hospital admission–a review. Acta Psychiatr Scand 2006, 114(4): 232- 241.
- Eytan A, Chatton A, Safran E, Khazaal Y. Impact of Psychi- atrists’ Qualifications on the Rate of Compulsory Admissions. Psychiatr Q. 2012, 84(1): 78-80.
- Brunner R, Parzer P, Resch F. Involuntary hospitalization of patients with anorexia nervosa: clinical issues and empirical findings. Fortschr Neurol Psychiatr. 2005, 73(1): 9-15.
- Katsakou C, Priebe S. Patient’s experiences of involuntary hospital admission and treatment: a review of qualitative stud- ies. Epidemiol Psichiatr Soc. 2007, 16(2): 172-178.
- Craw J, Compton MT. Characteristics associated with in- voluntary versus voluntary legal status at admission and dis- charge among psychiatric inpatients. Soc Psychiatry Psychiatr Epidemiol. 2006, 41(12): 981-988.
- Künzler N, Garcia-Brand E, Schmauss M, Messer T. German language skills among foreign psychiatric patients: influence on voluntariness and duration of hospital treatment. Psychiatr Prax. 2004, 31(1): 21-23.
- O’Donoghue B1, Lyne J, Hill M, O’Rourke L, Daly S et al. Per- ceptions of involuntary admission and risk of subsequent re- admission at one-year follow-up: the influence of insight and recovery style. J Ment Health. 2011, 20(3): 249-259.
- Katsakou C1, Rose D, Amos T, Bowers L, McCabe R et al. Psychiatric patients’ views on why their involuntary hospital- isation was right or wrong: a qualitative study. Soc Psychiatry Psychiatr Epidemiol. 2012, 47(7): 1169-1179.
- Svindseth MF, Dahl AA, Hatling T. Patients’ experience of humiliation in the admission process to acute psychiatric wards. Nord J Psychiatry. 2007, 61(1): 47-53.
- Sheehan KA, Burns T. Perceived coercion and the therapeu- tic relationship: a neglected association? Psychiatr Serv. 2011, 62(5): 471-476.
- Johansson IM, Lundman B. Patients’ experience of invol- untary psychiatric care: good opportunities and great losses. J Psychiatr Ment Health Nurs. 2002, 9(6): 639-647.
- Pawłowski T, Kiejna A, Rymaszewska J. Involuntary com- mitment as a source of perceived coercion. Psychiatr Pol. 2005, 39(1): 151-159.
- Large MM, Nielssen O, Ryan CJ, Hayes R. Mental health laws that require dangerousness for involuntary admission may de- lay the initial treatment of schizophrenia. Soc Psychiatry Psy- chiatr Epidemiol. 2008, 43(3): 251-256.
- Schuepbach D, Goetz I, Boeker H, Hell D.Voluntary vs invol- untary hospital admission in acute mania of bipolar disorder: results from the Swiss sample of the EMBLEM study. J Affect Disord.2006, 90(1): 57-61.
- Lay B, Nordt C, Rössler W. Variation in use of coercive mea- sures in psychiatric hospitals. Eur Psychiatry. 2011, 26(4): 244-251.
- Katsakou C, Bowers L, Amos T, Morriss R, Rose D et al. Co- ercion and treatment satisfaction among involuntary patients. Psychiatr Serv. 2010, 61(3): 286-292.
- Swartz MS, Swanson JW, Hannon MJ. Does fear of coer- cion keep people away from mental health treatment? Evi- dence from a survey of persons with schizophrenia and men- tal health professionals. Behavioral Sciences & the Law.2003, 21(4): 459-472.
- Bindman J, Reid Y, Szmukler G, Tiller J, Thornicroft et al. Perceived coercion at admission to psychiatric hospital and engagement with follow-up–a cohort study. Soc Psychiatry Psychiatr Epidemiol. 2005, 40(2): 160-166.
- Rain SD,Williams VF, Clark Robbins P, Monahan J, Stead- man H et al. Perceived coercion at hospital admission and ad- herence to mental health treatment after discharge. Psychiatr Serv.2003, 54(1): 103–105.
- Lauber C, Rössler W. Involuntary admission and the atti- tude of the general population, and mental health profession- als. Psychiatr Prax. 2007, 34 (2): 181-185.
- Jaeger S, Pfiffner C, Weiser P, Langle G, Croissant D et al. Long-term effects of involuntary hospitalization on medication adherence, treatment engagement and perception of coercion.Social Psychiatry & Psychiatric Epidemiology. 2013, 48(11): 1787-1796.
- Bonsack C, Borgeat F. Perceived coercion and need for hos- pitalization related to psychiatric admission. Int J Law Psychi- atry. 2005, 28(4): 342-347.
- Rusch N, Muller M, Lay B, Corrigan PW, Zahn R et al. Emo- tional reactions to involuntary psychiatric hospitalization and stigma-related stress among people with mental illness. Eu- ropean Archives of Psychiatry & Clinical Neuroscience.2014, 264: 35-43.
- Tan JO, Stewart A, Fitzpatrick R, Hope T. Attitudes of pa- tients with anorexia nervosa to compulsory treatment and co- ercion. International Journal of Law & Psychiatry.2010, 33(1): 13-19.
- Sorgaard KW. Patients’ perception of coercion in acute psy- chiatric wards. An intervention study. Nordic Journal of Psychi- atry. 2044, 58(4): 299-304.
- Katsakou C, Marougka S, Garabette J, Rost F, Yeeles K et al. Why do some voluntary patients feel coerced into hospitalisa- tion? A mixed-methods study. Psychiatry Res. 2011,187(1-2): 275-282.
- Ivar Iversen K, Høyer G, Sexton H, Grønli OK. Perceived coercion among patients admitted to acute wards in Norway. Nord J Psychiatry. 2002, 56(6): 433-439.
- Poulsen HD. Perceived coercion among committed, de- tained and voluntary patients. Int J Law Psychiatry.1999, 22(2): 167–175.
- O’Donoghue B, Roche E, Ranieri VF, Shannon S, Crummey C et al. Service users’ perceptions about their hospital admission elicited by service user-researchers or by clinicians. Psychiat- ric Services. 2013, 64(5): 416-422.
- Poulsen H D, Engberg M. Validation of psychiatric patients’ statements on coercive measures. Acta Psychiatrica Scandina- vica. 2001,103(1): 60-65.
- Kallert TW. Involuntary psychiatric hospitalization: cur- rent status and future prospects. Srp Arh Celok Lek. 2011,139 (1):14-20.
- Priebe S, Katsakou C, Glöckner M, Dembinskas A, Fiorillo A et al. Patients’ views of involuntary hospital admission after 1 and 3 months: prospective study in 11 European countries. Br J Psychiatry. 2010, 196(3): 179-185.
- Priebe S, Katsakou C, Amos T, Leese M, Morriss R et al. Pa- tients’ views and readmissions 1 year after involuntary hospi- talisation. Br J Psychiatry. 2009, 194(1): 49-54.
- Gardner W, Lidz CW, Hoge SK, Monahan J, Eisenberg et al. Patients’ revisions of their beliefs about the need for hospital- ization. Am J Psychiatry. 1999, 156(9): 1385-1391.
- Krathwohl D, Bloom B, Masia B. Taxonomy of educational objectives: The classification of educational goals. Handbook II: The affective domain. New York David McKay;NY, 1964.
- Jankovic J, Yeeles K, Katsakou C, Amos T, Morriss R et al. Family caregivers’ experiences of involuntary psychiatric hos- pital admissions of their relatives–a qualitative study. PLoS One. 2011, 6(10): e25425.
- Wallsten T, Ostman M, Sjöberg RL, Kjellin L. Patients’ and next-of-kins’ attitudes towards compulsory psychiatric care. Nord J Psychiatry. 2008, 62(6): 444-449.
- Diseth RR, Bogwald KP, Hoglend PA. Attitudes among stake- holders towards compulsory mental health care in Norway. In- ternational Journal of Law & Psychiatry. 2011, 34(1): 1-6.
- Swartz MS, Swanson JW, Wagner HR, Hannon MJ, Burns BJ et al. Assessment of four stakeholder groups’ preferences con- cerning outpatient commitment for persons with schizophre- nia. American Journal of Psychiatry. 2003, 160(6): 1139-1146,
- Luchins DJ, Cooper AE, Hanrahan P, Rasinski K. Psychia- trists’ attitudes toward involuntary hospitalization. Psychiatr Serv. 2004, 55(9): 1058-1060.
- Luchins DJ, Cooper AE, Hanrahan P, Heyrman MJ. Lawyers’ attitudes toward involuntary treatment. Journal of the Ameri- can Academy of Psychiatry & the Law. 2006, 34(4): 492-500.
- Shao Y, Xie B, Wu Z. Psychiatrists’ attitudes towards the procedure of involuntary admission to mental hospitals in Chi- na. Int J Soc Psychiatry. 2012, 58(4): 440-447.
- Wynn R, Myklebust LH, Bratlid T. Psychologists and coer- cion: decisions regarding involuntary psychiatric admission and treatment in a group of Norwegian psychologists. Nordic Journal of Psychiatry. 2007, 61(6): 433-437.
- Lepping P, Steinert T, Gebhardt RP, Röttgers HR. Attitudes of mental health professionals and lay-people towards invol- untary admission and treatment in England and Germany–a questionnaire analysis. Eur Psychiatry. 2004, 19(2): 91-95.
- Borgeat F, Zullino D. Attitudes concerning involuntary treatment of mania: results of a survey within self-help organi- zations. Eur Psychiatry.2004, 19(3): 155-158.