No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Civil commitment: A range of patient attitudes
Abstract
The authors interviewed adult civil commitment excandidates about their perceptions of commitment six months after discharge. Scales were developed for the following constructs: perceived need of commitment, perceived personal consequences of commitment, view of medication, view of primary hospital physician, and view of hospital experience. Excandidates had a mixed view of commitment. The majority reported positive views, but a substantial minority endorsed negative descriptors.
... Researchers have given more attention to patients' experience of involuntary hospital care. Contrary to what might be expected, some studies have found that compulsory inpatients subsequently hold generally favourable views of their hospitalization and treatment (Gove & Fain, 1977;Edelsohn & Hiday, 1990;Kaltiala-Heino, 1996), and many will later agree it was required (Spence, Goldney, & Costain, 1988;Conlon, Merskey, Zilli, & Fromhold, 1990;Edelsohn & Hiday, 1990;Kaltiala-Heino, 1996;Gardner et al., 1999). ...
... Researchers have given more attention to patients' experience of involuntary hospital care. Contrary to what might be expected, some studies have found that compulsory inpatients subsequently hold generally favourable views of their hospitalization and treatment (Gove & Fain, 1977;Edelsohn & Hiday, 1990;Kaltiala-Heino, 1996), and many will later agree it was required (Spence, Goldney, & Costain, 1988;Conlon, Merskey, Zilli, & Fromhold, 1990;Edelsohn & Hiday, 1990;Kaltiala-Heino, 1996;Gardner et al., 1999). ...
Background:
New Zealand operates a well-embedded community treatment order scheme for patients with serious mental disorders. A similar scheme may be enacted for England and Wales.
Aim:
To explore the views of patients with recent experience of community treatment orders.
Method:
All patients in one region under an order in the last 2 years, not readmitted to hospital for at least 6 months, were included, subject to their capacity and consent. Forty-two patients out of 84 potential participants were interviewed.
Results:
The majority of patients were generally supportive of the community treatment order, especially if the alternative was hospital. Many valued the access to services and sense of security obtained, and attributed improvements in their health to treatment under the order. They also experienced reduced choice about medication and restrictions on residence and travel. For a minority this meant they were strongly opposed to the order, but for most the restrictions did not unduly hinder them. The majority of patients viewed the order as a helpful step towards community stability.
Conclusions:
The usefulness of community treatment orders is accepted by most patients under them in NZ, as well as by most psychiatrists. Critical factors include the quality of therapeutic relationships and the structure provided for community mental health care.
... There is some support for this argument. Several studies have found that a minority of persons who were coerced into mental hospitals hold strongly negative feelings and no desire for future psychiatric treatment (Edelsohn & Hiday, 1990;Rogers, 1993;Shannon, 1976), and one survey reported that a large majority of persons with mental illness did not seek treatment at least once for fear of involuntary commitment (Campbell & Schraiber, 1989). On the other hand, a significant proportion of committed patients do not report negative feelings or even perceive much coercion in their involuntary treatment (Cascardi & Poythress, 1997;Cascardi, Poythress, & Ritterbard, 1998;Hiday et al., 1997;Hoge et al., 1993;, McKenna, Simpson, & Laidlaw, 1999. ...
... It seems that mandatory treatment in the community permits development of stability and a trusting clinical relationship that persist beyond the active time of court orders (Geller, 1986;Pinfold et al., 2001;Stein & Diamond, 2000). The experience of being legally ordered to involuntary treatment, thus, varies across those ordered to it (Cascardi et al., 1998;Edelsohn & Hiday, 1990;Gardner et al., 1993;Hiday et al., 1997;McKenna et al., 1999;Monahan et al., 1996;Scheid, 1993). Perceived coercion and negative feelings do not necessarily accompany court orders, and treatment deterrence does not necessarily follow from court orders. ...
This article briefly describes the historical conditions in the origin and development of outpatient commitment that framed the discourse on its merits and the empirical studies on its outcomes. It divides those empirical studies into two sets on the basis of the questions addressed and critically reviews them. The review pays particular attention to the latest studies that were able to randomize subjects to experimental and control conditions and that were able to offer enhanced services. Finally, this article presents issues not addressed by the empirical studies on outpatient commitment but that need to be addressed in order to understand the choice of using the law to force persons with mental illness to comply with treatment and receive services in the community.
... This is the largest national prospective study of involuntary hospitalization to date. Although patients' views on whether their commitment was appropriate or beneficial have been sought in earlier, smaller studies, using mostly single items (7,11,12,24), satisfaction with treatment on an established scale has rarely been assessed among involuntary patients. The scale used in this study is likely to provide more reliable scores than single items and reflects a relatively wide concept of satisfaction. ...
Objective:
This study aimed to assess involuntary inpatients' satisfaction with treatment and explore how coercion and other factors are associated with satisfaction.
Methods:
An observational prospective study was conducted in 67 acute wards in 22 hospitals in England. A total of 778 involuntary inpatients were recruited, and their satisfaction with treatment was assessed a week after admission and at the one-month, three-month, and one-year follow-ups. Perceived and documented coercion at admission and during hospital treatment, sociodemographic and clinical characteristics, and clinical improvement were tested as potential predictors of satisfaction.
Results:
Mean scores on the Client's Assessment of Treatment Scale measuring satisfaction with treatment ranged from 5.5 to 6.0 (on a scale with possible scores ranging from 0 to 10) at different time points and improved significantly from admission to the follow-ups. Patients who perceived less coercion at admission and during hospital treatment were more satisfied overall, whereas coercive measures documented in the medical records were not linked to satisfaction. Patients with more symptom improvement expressed higher levels of treatment satisfaction.
Conclusions:
Satisfaction with treatment among involuntary patients was associated with perceptions of coercion during admission and treatment, rather than with the documented extent of coercive measures. Interventions to reduce patients' perceived coercion might increase overall treatment satisfaction.
... Gardner et al. (1999) found they are mainly negative. Edelsohn and Hiday (1990) found that the majority of patients reported positive experiences, while patients interviewed by Luckstedt and Coursey (1995) and Westrin and Nilstun (2000) had mixed opinions. The systematic over-focusing of the media on violence committed by mental patients (Blumenthal & Lavender, 2001), contributes to the public's perception of the mentally ill patient as dangerous. ...
Since the 1950s, changes in mental health care and the activities of human rights movements have changed the focus of treatment from a prescriptive type to one that takes into consideration the patients' views and the rights of the mentally ill individual. With this change, the legal framework for involuntary admission and treatment of the mentally ill has been reformed in many European countries (Salize, Dreâing, &Peitz, 2002). It is undisputed that treating the mentally ill without paying attention to their views has led to serious abuses that tarnished the status of psychiatry. Various asylum scandals that took place in western European countries made it evident that safeguards, for the people admitted and treated against their wishes, needed to be firmly in place (Blom-Cooper, 1992). The abuses of psychiatry and the application of various treatments that were directed against individuals opposed to the state, and the fact that in Eastern Europe political dissidents could be branded mentally ill and kept in asylums against their wishes, further underlined the need for respect of the basic human rights of people as well as the need for firm safeguards and a standard procedure that allows for appeal and a second opinion.
... Patient perceptions of having been kept properly informed and treated in a respectful manner was furthermore associated with a more positive attitude towards psychiatric coercion in general. In another study Edelsohn and Hiday found that a majority of patients interviewed six months after discharge found their commitment as helpful and necessary and even wanted to be committed again if they would become sick and dangerous in the future 83 . However 46% described the treatment episode as definitely depressing and 41% as unpleasant. ...
... Based on interview data, Beck and Golowka (1988) concluded that nearly a quarter of involuntary patients' admission was "largely a voluntary choice." Other studies have found that as many as half of committed patients may be unaware of their involuntary status and that two thirds of those committed report they were not offered the opportunity to enter the hospital voluntarily, about half of whom would have signed in willingly (Cavadino, 1989;Edelsohn & Hiday, 1990;Toews, el-Guebaly, Leckie, & Harper, 1984;Bradford, McCann, & Mersky, 1986). ...
... This is the largest national prospective study of involuntary hospitalization to date. Although patients' views on whether their commitment was appropriate or beneficial have been sought in earlier, smaller studies, using mostly single items (7,11,12,24), satisfaction with treatment on an established scale has rarely been assessed among involuntary patients. The scale used in this study is likely to provide more reliable scores than single items and reflects a relatively wide concept of satisfaction. ...
This study aimed to assess involuntary inpatients' satisfaction with treatment and explore how coercion and other factors are associated with satisfaction.
An observational prospective study was conducted in 67 acute wards in 22 hospitals in England. A total of 778 involuntary inpatients were recruited, and their satisfaction with treatment was assessed a week after admission and at the one-month, three-month, and one-year follow-ups. Perceived and documented coercion at admission and during hospital treatment, sociodemographic and clinical characteristics, and clinical improvement were tested as potential predictors of satisfaction.
Mean scores on the Client's Assessment of Treatment Scale measuring satisfaction with treatment ranged from 5.5 to 6.0 (on a scale with possible scores ranging from 0 to 10) at different time points and improved significantly from admission to the follow-ups. Patients who perceived less coercion at admission and during hospital treatment were more satisfied overall, whereas coercive measures documented in the medical records were not linked to satisfaction. Patients with more symptom improvement expressed higher levels of treatment satisfaction.
Satisfaction with treatment among involuntary patients was associated with perceptions of coercion during admission and treatment, rather than with the documented extent of coercive measures. Interventions to reduce patients' perceived coercion might increase overall treatment satisfaction.
... Alternatively, these patients may have believed that their acquiescence to their psychiatrist's view that they had needed treatment was socially desirable and might confer an advantage by hastening discharge. Edelsohn and Hiday (1990) interviewed a group of patients who had been involuntarily hospitalized 6 months after discharge. In retrospect, a majority (54%) of these patients believed that they should have been hospitalized, whereas an even greater proportion (57.8%) viewed involuntary hospitalization as necessary; however, somewhat paradoxically, only a minority (25.1%) believed that they had met commitment criteria at the time. ...
This study examines whether individuals who experienced involuntary outpatient commitment (OPC) attribute benefit to this intervention. It was found that the majority of experimental subjects who underwent a period of OPC did not personally endorse OPC's benefits at the end of the study, either because they did not think it improved treatment adherence or because they rejected their own need for continued treatment. However, at the end of the study, a positive appraisal of benefit was roughly twice as likely among subjects who actually experienced positive treatment outcomes. These data provide little support for acceptance and "gratitude" as a rationale to support decision making about OPC continuation. Rather, clinicians need to rely on other clinical and empirical data for such decision making.
Although states differ in how they regulate involuntary civil commitment and involuntary (court-ordered) treatment (ICC/IT), all allow this intervention as a means to safeguard individuals who, as a result of serious and active mental illness, are at significant risk of harming themselves and/or others or are at serious risk of physical harm from self-neglect. However, invoking ICC can create significant conflicts for professionals who must balance competing ethical obligations. The psychiatrist may be faced with economic and other disincentives when ICC/IT is considered. Nonetheless, the treating psychiatrist, tasked with advocating for the patient's best medical interests, may find ICC/IT clinically necessary at times, and under such circumstances should be able (and willing) to meaningfully participate in the necessary legal processes. [ Psychiatr Ann . 2024;54(5):e137–e140.]
Despite the growing use of civil commitment for drug use disorders, little is known about attitudes among individuals who might be subject to civil commitment. This study examined attitudes of persons with opioid use disorder toward civil commitment for drug misuse and for psychiatric illness. Consecutive persons entering a brief, inpatient opioid detoxification (n = 254) were surveyed regarding their attitudes about civil commitment for mental illness and for drug use, and responses were compared by commitment type and by individual history of being civilly committed for opioid misuse. Participants endorsed high support for civil commitment (both psychiatric and drug misuse-related) when used to address risk of harm to self, to others, and of criminal activity. Respondents were more likely to support civil commitment for psychiatric disorders than for drug misuse, expressing higher support for civil commitment in general, higher agreement with the criteria used to justify civil commitment, and greater perceived efficacy of commitment. Individuals previously committed for opioid misuse were less likely to support drug misuse-related commitment on the basis of its perceived efficacy. These results suggest individuals with opioid use disorder hold more favorable views toward civil commitment for mental health disorders than for drug misuse, and reinforce the need for more research on the procedures and outcomes related to civil commitment for drug misuse.
Admission to a mental health facility is often a complex and cumbersome process, particularly when the person is not entering the hospital voluntarily. This chapter will describe the various admission criteria and the rights of a mentally disabled person when civil commitment procedures are contemplated. The chapter articulates the legal theory which permits the state to involuntarily hospitalize someone. The requirements set forth by the statutes to accomplish this action are also explained. The clinical issues which arise in determining when someone meets civil commitment criteria and the expectations of the mental health professional during the process of seeking hospitalization are presented. An appendix is included to illustrate the key features of laws related to the hospitalization of the mentally ill.
Coerced mental health treatment in the community that is mandated by court order is known as outpatient commitment. This official mandatory mental health treatment in the community grew out of the 1960s and 1970s civil rights reform of mental health law when basic principles of due process and protection of individual liberties were applied to mental patients (Chambers, 1972; Hiday & Goodman, 1982; LaFond & Durham, 1992). Interpreting the Constitution as requiring a state to use the least drastic means when basic liberty is at stake (Shelton . Tucker, 1960), both state statutes and federal appellate courts called for application of the least restrictive alternative in civil commitment cases.1
Objectives:
In view of the apparent public discontent that has been expressed by individuals towards temporary certification and involuntary treatment, this study was set up to assess patients' reactions to their involuntary admission. The study compared the demographic characteristics of voluntary and involuntary patients and assessed their attitudes towards and knowledge of the certification process that presently exists in Ireland.
Method:
A total of 68 patients, 38 involuntary patients consecutively admitted over a six month period and 30 voluntary patients selected over the same period, were interviewed with a standard questionnaire, on average six months after discharge.
Results:
Involuntary patients were more likely to be single, live with their families and showed no demonstrable gender bias. Involuntary patients had limited knowledge of specific aspects of their individual certifications, particularly with regard to knowledge of their rights, admission status and knowledge of the identity of the applicant of the certificate. Of these, 10% were aware of their rights on admission and only 14% could recall that their rights had been explained to them on admission.
Conclusion:
Although patients initially expressed strong feelings of anger on admission towards committal, these feelings were found to reduce over time. Recommendations for improving the present Mental Health Act were suggested by those interviewed and these included a need for an initial assessment period before certification is completed and a need for improved communication by medical staff regarding information on the admission status, the identity of the applicant and on the person's rights.
The origins of patients’ perceptions of coercion during short-term psychiatric hospitalization are varied. The purpose of this study was to elucidate the characteristics of patients that are associated with higher levels of perceived coercion and to determine whether these perceptions remain stable one year after admission. One hundred and twenty-five patients were recruited within three days of admission to the acute units at the Alfred Hospital Inpatient Psychiatry Department, Melbourne, Australia. In the initial recruitment phase, patients’ perceptions of coercion, psychiatric symptoms and interpersonal style were assessed using the Macarthur Admission Experience Scale, the Brief Psychiatric Rating Scale-18 and the Impact Message Inventory–Circumplex. Admission status (voluntary versus involuntary) and demographic characteristics were also assessed. Follow-up assessments were conducted approximately one year later. Results suggest that a significant but small positive correlation existed between perceived coercion and a Hostile–Dominant interpersonal style at initial recruitment. Females reported significantly higher perceptions of coercion than males, but admission status and severity of psychiatric symptoms were unrelated to perceived coercion. Despite perceptions of coercion appearing to lessen over time, there is a need for specific interventions for these patients during their admission to hospital. There was a statistically significant decrease in perceived coercion over time.
Internationally there has been a long debate regarding the use, and potential misuse, of coercion in psychiatry. One of the topics that has gained most attention is compulsory admissions. Only a few studies have published cross-country comparisons on the magnitude of compulsory admissions. This study presents data on voluntary and compulsory admissions to psychiatric hospitals in Norway in 1996. Approx 47% of all admissions were compulsory, and the rates were 147 per 100 000 inhabitants. These are both high figures compared to other countries. Regarding patient characteristics, our study confirms the international findings in most fields, except for a higher proportion of women and nonpsychotic patients admitted compulsory. The observed substantial regional differences in compulsory admission are primarily explained by variations in diagnoses. Whether the recent changes in the Norwegian Mental Health Act will reduce these figures are discussed.
Despite a long-standing tradition of the use of coercion in psychiatric care, such as involuntary admission and treatment, few have systematically addressed this issue. In recent years, more research has been carried out, suggesting that the use of coercion has important and complex legal, ethical, and clinical implications. In the present article, types and rates of coercion are presented and central topics including competency, ethics, and the reasons given for the use of coercion, are critically discussed.
In an interview study carried out in the Psychiatric Clinic of Tampere University Hospital, patients with functional psychoses showed positive attitudes towards involuntary psychiatric hospitalization as a societal issue. The legal status of the interviewees did not distinguish between their opinions, but the patients' personal experience of being coerced was related to less favourable attitudes. Patients' attitudes are discussed in relation to civil rights, paternalism, individualism, and collectivism.
This paper reviews studies on the diagnostic profile of committed psychiatric patients. Most studies find that schizophrenia is the commonest diagnosis among these patients. The percentage of schizophrenics among committed patients varies, but many studies find figures between 30% and 50%. Comparison of commitments internationally is, however, problematic, and various sources of error and methodologic problems are discussed. These include limited representativity in the individual study, the risk of selection bias due to lack of drop-out analyses, and poor external validity. Attempts to reduce the number of commitments must be based on knowledge of the main target group among committed patients. This seems to be patients with schizophrenia and, therefore, ensuring optimal treatment of these patients in both an inpatient and an outpatient setting is essential.
If the law provided for accessible and efficient means to facilitate mental health treatment, the law itself could be a component of the comprehensive care system.
Given the controversy that coercive treatment has generated in psychiatry and law, it is surprising that there is not a wealth of data on the extent and outcomes of coercion. One would expect that the most basic data on the incidence of formal, legal involuntary hospitalization within a nation would be published by each government. Most nations, however, do not compile and/or publish data on involuntary hospitalization or on any other type of compulsory psychiatric treatment as they compile and publish demographic, economic, social and health data; accordingly, there is no such compilation by nation published by the United Nations or any of its agencies. Where national statistics are published, as in the United States, they are subject to variation by hospital type and region, and the individual studies we have make generalizations tentative. There is still much we do know. From legislation, court decisions, and legal and psychiatric writings, we know that the dominant philosophy in Western Europe and North America favors community treatment without coercion and favors a maximum of patient autonomy in all treatment modes (26;52;68;106). Congruent with this philosophy are data that show that the number of persons residing in psychiatric institutions and their lengths of stay have been declining. Some national data also indicate that formal legal involuntary admissions have been declining. When individual studies from within nations are taken together, they also indicate declines in legal coercive hospitalization, though they may not be representative of their respective nations at one point in time. Data on the extent of nonformal coercive mental hospitalization and other coercive psychiatric treatments are much less available and less informative of trends. Data on the admission process of voluntary hospitalization indicate that coercion is common, that other coercive psychiatric treatments are used with voluntary as well as involuntary patients, and that ECT and psychosurgery are seldom used with involuntary patients. Because of small sample sizes, lack of representativeness, and variation in definitions, we do not know whether these indications from individual studies can be generalized, that is, whether they actually hold throughout the nations with studies and whether they hold in nations where there are no studies. Most notable is the little we know about the extent of involuntary hospitalization and other coercive measures in less developed countries. We encourage more research to fill in the missing information. Most basically, efforts should begin to encourage governments and the World Health Organization to collect and publish periodically data on the incidence of formal, legal categories of mental hospital admissions. Until then, researchers might combine in international working groups to obtain such basic data from official governmental sources of nations representing political or geographic regions. We encourage researchers to coordinate their efforts in investigating outcomes of coercion so that studies may have comparable measures, a greater opportunity for natural field experiments, and if efforts are combined, larger sample sizes with the ability to control relevant variables statistically. Researchers in nations with in- and outpatient case registers should take advantage of the possibilities of record linkage, which eases the collection of follow-up data between hospital and community treatment; however, because of legal restrictions in some nations, reliability problems with secondary data, and lack of important variables in patient records, primary data collection following individual patients is necessary if we are to obtain answers to many of the aforementioned questions. We also need more qualitative and quantitative investigation at the front end of the coercive process to identify reasons for resorting to coercion and to identify mechanisms by which both formal and informal coercion can be avoided. In this research, attention should be paid to the definitions and criteria for coercion, placing our understanding in the wider context of caring and respect for patients, as the work of Hoge, Lidz, Westrin, and their colleagues are doing in the United States and Sweden (8;24;42;50;56;57;114). A major question in coercive psychiatric treatment is whether these treatments are abusive, that is, used for social control without beneficence. Numerous studies show that involuntary hospitalization and other coercive measures are used for both social control, i.e., to protect the individual patient and to protect others, and beneficence, i.e., to bring treatment to patients and reduce illness-induced suffering (31;32;93;94). However, a full assessment of coercive psychiatric technology would seek to answer the question of whether the social control and beneficence can be achieved without formal invocation of the state's coercive power. Because of methodological problems with existent outcome studies, we do not know whether we can avoid the coercive measures and yet achieve positive outcomes. It may be that by reaching out more than is currently done to meet the needs and address the concerns of mentally ill persons, particularly those who are severely and persistently ill, both social control and beneficence can be achieved (99). That is surely an important research task yet to be done.
Our analysis confirms the findings of previous studies that considerable variation exists in patient perceptions of coercion. That we find such variance even among our sample members who were all legally involuntarily hospitalized supports the findings of previous studies that objective legal status and subjective feelings of coercion are not equivalent. Not surprisingly, the modal score indicated high levels of perceived coercion; but at the same time, an almost equal number of patients perceived little or no coercion. Our distribution on this variable is very similar to that reported by Gardner et al. (1993) whose sample had a majority of legally voluntary patients, a majority without a diagnosis of psychosis, and a much larger proportion with a primary diagnosis of substance abuse. Both samples were distributed across the full range of the perceived coercion scale with marked bimodality, although the proportion in our sample experiencing high coercion was almost 50% larger, and the proportion experiencing low coercion was approximately 50% smaller. As with perceived coercion, considerable variation existed across the full range of the negative pressures and process exclusion scales, indicating that the process of civil commitment does not necessarily involve the stereotypical picture of a resisting mental patient being dragged into a mental institution. Approximately two-fifths of our sample reported little or no negative pressures and little or no process exclusion in their hospital admission. These findings suggest that involuntary admission to a mental hospital can permit patients to feel like they have voice and validation, and can avoid force even in the absence of choice. The challenge is to try to extend to all patients at the time of their admission a demonstration in word and action that they are person with opinions, desires, rights, and dignity, and not just mental patients in an acute crisis. Clinical variables could not account for differences in outcome variables. Neither type of disorder, secondary substance abuse, personality disorder, hostility/suspiciousness, severity of symptoms nor number of recent hospital admissions affected how patients viewed the hospital admission process. This may suggest that some element of the shared characteristic of chronicity or recidivism negates expected differences among clinical groups. Patients who were young, urban, unmarried, and of low education were no more likely to perceive coercion, negative pressures, or process exclusion. This finding was unexpected because they are more likely to resist hospitalization, more likely to be seen as dangerous and in need of force to be hospitalized, and more likely to have had previous negative experiences with authority. Instead, it was white, female, unmarried respondents with more education who were more likely to perceive higher levels of our dependent variables. Such higher status persons have more resources, autonomy, and control in their daily work and family roles. They are the ones more likely to perceive coercion, negative pressures, and process exclusion in hospital admission, possibly because their expectation levels and reference groups make them more aware of the use of coercion and any deprivation in autonomy. The MacArthur study has found that patients who have little voice or validation, and against whom force and threats are used to get them hospitalized, perceive high levels of coercion; that is, procedural inequity and negative pressures predict perceived coercion (Lidz et al., 1995). Our sample, with different measures of these three constructs, found strong positive correlations among the three. When Negative Pressures and Process Exclusion were added to the model predicting perceived coercion, they were highly significant and wiped out the associations of perceived coercion with gender, race, cohabitation, and education. Although those basic and acquired demographic variables predict Negative Pressures and Process Exclusion, they do not predict perceived coercion directly. Rather, as the MacArthur group found, the two procedural variables, using force with patients and including patients in the process of hospital admission, are the most important factors in perceiving coercion.
The authors argue for the extension of mandatory treatment to persons gravely disabled by substance abuse. The problem is examined from ideological, clinical, legal, economic, and ethical perspectives.
A cohort of 72 persons who had entered a rural Oregon county's involuntary treatment system in 1979 through 1982 was followed for six years. While schizophrenia was the most frequent diagnosis, several other conditions were represented including adjustment disorders, organic mental disorders, and substance abuse. The majority (55%) of persons with organic mental disorders died as did 12% of the individuals with schizophrenia. The overall mortality rate was three times the expected figure (p = .002). During the follow-up period, only 39% of the initial cohort received treatment from a community mental health program whereas 28% were newly admitted (involuntarily) to a state mental hospital. Hospital recividism was most likely among individuals who had had prior involuntary treatment. At least in rural areas, the civil commitment system seems to serve both "infrequent" and "persistent" users. Infrequent users mainly have diagnoses of adjustment disorders and/or substance abuse. Persistent users chiefly have diagnoses of organic mental disorders, mood disorders, or schizophrenia. Modifying the involuntary treatment system to take account of this heterogeneous population's diverse needs is discussed.
Eighteen involuntarily hospitalized psychiatric patients narrated their experiences of being subjected to coercion and their thoughts on how to prevent the coercion. A qualitative content analysis identified recurring themes, which were incorporated in two core themes describing the participants' experience. The core theme Not being respected as a human being included most of their narrated experiences, described in the themes Not being involved in one's own care, Receiving care perceived as meaningless and not good, and Being an inferior kind of human being. The core theme Being respected as a human being included a minor part of the narrated experiences and how the participants wanted things to be, described in the themes Being involved in one's own care, Receiving good care, and Being a human being like other people. The participants' plea for respect is discussed in relation to the ongoing deinstitutionalization of psychiatric care and the need for attitude changes in care and community, leading to the treating of mentally disordered people with more respect.
According to Swedish legislation (LVM) compulsory treatment shall be decided on if someone, due to ongoing abuse of alcohol, drugs or volatile solvents, is in need of care to overcome abuse and if a voluntary intervention is not possible. Very little research has been conducted in Sweden on this particular legislation with regard to the clients' experiences of entire process from assessment to aftercare. We interviewed 74 subjects who were being assessed prior to the court's decision on involuntary care (n=39), or with previous experience of assessment and involuntary care (n=35). The assessment group more often reported having the opportunity to express their opinions to the social worker during the assessment period (55% vs. 21%, p<.05) and they were more positive towards the final decision (60% vs. 24%, p<.05). In spite of the law, 18% were not contacted by the social services while in coercive treatment. The clients who did meet with a social worker, often described the conferences as more of a perfunctory nature with a lack of focus on the actual situation and aftercare planning. This study points at a need of studying the subjects' experiences of the whole continuum of the coercive process: from the investigation, to treatment and to aftercare. It also points at the need for new instruments to be developed covering all aspects of the coercive process and in particular the period of investigation prior to the decision on involuntary care.
International variation in compulsory admissions to psychiatric care has mainly been studied in terms of civil commitment rates. The objectives of this study were to compare and analyse the levels of perceived coercion at admission to psychiatric in-patient care among the Nordic countries and between centres within these countries, in relation to legal prerequisites and clinical practice.
From one to four centres each in Denmark, Iceland, Norway, Finland and Sweden, a total of 426 legally committed and 494 formally voluntarily admitted patients were interviewed within 5 days from admission.
The proportion of committed patients reporting high levels of perceived coercion varied among countries (from 49% in Norway to 100% in Iceland), and in Sweden, only, among centres (from 29 to 90%). No clear variations in this respect were found among voluntary patients. A wide concept of coercion in the Civil Commitment Act and no legal possibility of detention of voluntary patients were associated to low levels of perceived coercion at admission among committed patients.
For committed patients, differences in national legal prerequisites among countries were reflected in differences in perceived coercion. The results from Sweden also indicate that local care traditions may account for variation among centres within countries.
Whereas the distinction between committed and voluntary admissions in mental health is clear from a legal point of view, this clarity is not always present in the patients' experiences. Voluntary patients may be pressured or persuaded and committed patients may want admission.
To compare three groups of patients--committed, voluntary and persuaded--admitted to acute psychiatric inpatient care as regards different aspects of satisfaction, treatment and experienced coercion.
The Sjukvårdens Planerings- och Rationaliseringsinstitut form and the Coercion Ladder were administered to all admitted patients on two acute wards. A total of 189 patients participated (86%). Data were analysed with nonparametric (Kruskal-Wallis, chi-square) and parametric tests (multinominal regression). Results: A substantial proportion of the patients did not know of their legal status. Many reported restrictions on movement, forced medication and patronising communication. Satisfaction with the treatment was generally high. Compared to the voluntary patients, the two other groups were characterized by lack of influence, forced medication and high satisfaction with the key worker.
Involuntariness was associated with increased likelihood of feeling excluded from participation in the treatment. The key worker seems to have an important position with regard to committed and pressured patients. Limitations: The data were limited to the patients' subjective reports.
ResearchGate has not been able to resolve any references for this publication.