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Subjective experience of coercion in psychiatric care: a study comparing the attitudes of patients and healthy volunteers towards coercive methods and their justification

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Abstract

Under certain conditions, coercive interventions in psychotic patients can help to regain insight and alleviate symptoms, but can also traumatize subjects. This study explored attitudes towards psychiatric coercive interventions in healthy individuals and persons suffering from schizophrenia, schizoaffective or bipolar disorder. The impact of personal history of coercive treatment on preferences concerning clinical management of patients unable to consent was investigated. Six case vignettes depicting scenarios of ethical dilemmas and demanding decisions in favour of or against coercive interventions were presented to 60 healthy volunteers and 90 patients. Structured interviews focusing on experienced coercion were performed in conjunction with the Coercion Experience Scale and the Admission Experience Survey. Symptom severity, psychosocial functioning and insight into illness were assessed as influencing variables. Student’s t tests compared patients’ and controls’ judgments, followed by regression analyses to define the predictive value of symptoms and measures of coercion on judgments regarding the total patient sample and patients with experience of fixation. Patients and non-psychiatric controls showed no significant difference in their attitudes towards involuntary admission and forced medication. Conversely, patients more than controls significantly disapproved of mechanical restraint. Subjective experience of coercive interventions played an important role for the justification of treatment against an individual’s “natural will”. Factors influencing judgments on coercion were overall functioning and personal experience of treatment effectiveness and fairness. Qualitative and quantitative aspects of perceived coercion, in addition to insight into illness, predicted judgments of previously fixated patients. Results underline the importance of the quality of practical implementation and care, if coercive interventions cannot be avoided.

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Conflict of interest

The authors declare that they have no competing interest.

Ethical statement

Approval for this study has been obtained from the Ethics Committee of the Charité—Universitätsmedizin Berlin, Germany.

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Authors and Affiliations

  1. Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin, Campus Mitte (PUK Charité im SHK), Charitéplatz 1, 10117, Berlin, Germany

    J. Mielau, J. Altunbay, A. Heinz, F. Bermpohl, A. Lehmann & C. Montag

  2. Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

    J. Gallinat

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  1. J. Mielau
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  2. J. Altunbay
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  3. J. Gallinat
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Correspondence to J. Mielau.

Appendix: Case vignettes

Appendix: Case vignettes

Case vignette 1

Mrs. L (42 years), a former teacher, has been living homelessly for an extensive period of time. She believed that her neighbors were responsible for the supply of toxic gas to her former flat, and flew from one place to another. She has been admitted to hospital for the first time due to severe squalor and homelessness. In the clinic she refuses any kind of diagnostics because she is convinced that she will be poisoned. She prefers to live homeless and wants to be discharged.

Case vignette 2

Since Miss U stopped taking her medication, she has terminated her job and remained silent for several weeks. “Mentally communicating with angels”, she sits and just smiles for enduring periods. She does not wish to be treated. Her work colleagues are understandably concerned, as prior to this she had been a reliable work colleague. All of her family members want to see Miss U return to her former self. She does not agree to pharmacological treatment.

Case vignette 3

Mrs. W has suffered from psychosis for a considerable period of time. Now she has a confirmed diagnosis of early stage breast cancer, and appears to blame her divorced husband directly for this. She fails to understand the benefit of surgical intervention. She participates in all non-drug therapies but strictly refuses medical treatment. Since living in therapeutic shared accommodation she has felt no need for taking antipsychotics.

Case vignette 4

Mr. A having previously loved his father suddenly saw him as the devil and was immensely fearful. He felt controlled by “higher powers”. Having felt the need to defend himself, he actually committed an assault against his father (by hitting him with a dumbbell). The father was seriously hurt. Legal consequences may arise.

Case vignette 5

Mr. N wished to end his life and for this reason jumped out of a third floor window. As a result he broke both legs. Whilst on the trauma ward he states that he still wants to die and does not wish to receive any treatment. He is severely depressed. It is evident that he feels guilty for something that he has not actually done yet believes he does not deserve to live. Seven years ago Mr. N had a depressive episode which was successfully treated by medication and psychotherapy.

Case vignette 6

The young student Miss K (23 years) developed her first psychotic episode just after giving birth to her child. Having neglected her newborn, the youth welfare office was called by her friends and the baby was temporarily accommodated at a child care home. Miss K’s language is highly incoherent and she appears to hear voices. Nevertheless she claims her child back and does not see a problem in caring for it. She disagrees with the need of any medical treatment.

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Mielau, J., Altunbay, J., Gallinat, J. et al. Subjective experience of coercion in psychiatric care: a study comparing the attitudes of patients and healthy volunteers towards coercive methods and their justification. Eur Arch Psychiatry Clin Neurosci 266, 337–347 (2016). https://doi.org/10.1007/s00406-015-0598-9

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