Professional Documents
Culture Documents
25 (2002) 93 108
1. Introduction
Though coercion is widely used in psychiatry, both in terms of involuntary hospital
admissions and coercive treatment, little is known about the effects of coercing patients. In
spite of this lack of knowledge, mental health acts worldwide authorize civil commitment to
mental hospitals. The justification for the use of coercion is basically a belief that coercion
works, meaning that compulsory treatment improves the outcome compared to the outcome
with no (coercive) intervention. In accordance with medical ethics, the moral obligation to
reduce suffering also plays an important role in justifying the use of coercion in psychiatry.
The underlying belief is that patients suffering from serious mental disorders usually are
unable to understand their needs for treatment, thus justifying paternalistic interventions, i.e.,
well-intended interference with a persons liberty of action. Medical, or more generally,
individual paternalism occurs when an action against a person is done in the interest of the
person. Social paternalism means that the action is done in the interest of others (Kjellin &
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Nilstun, 1993; Nilstun, 1997), and may be justified, for instance when mental patients are
dangerous to others. At the same time, coercion is believed by many to be potentially harmful
and to have serious negative effects. Nevertheless, recommendations applying specifically to
the field of psychiatry acknowledge that the use of coercion sometimes is unavoidable and
may be used as a last resort, even if such interventions violate human right ideals (Council of
Europe, 1950, 1983, 1996; United Nations, 1948, 1966, 1991; World Psychiatric Association,
1996). On this background, there is an obvious need for research exploring whether the
existing beliefs concerning the effects of coercing patients are right or wrong.
In this article, we will present a study called Paternalism and Autonomy A Nordic
Study on the Use of Coercion in the Mental Health Care System. There has been a growing
interest in research on involuntary psychiatric hospitalization in the Nordic countries over the
last years. A pioneer study of Danish case records was done by Adserballe (1977), and in the
1980s and 1990s studies on the use of coercion have been performed in all of the Nordic
countries (Engberg, 1994; Gudmundsson & Stefansson, 1989; Hyer, 1986b; Kaltiala-Heino,
1995; Kjellin, 1996; Westrin, Nilstun, Axelsson, et al., 1990). The current study is a joint
study involving all the five Nordic countries (Denmark, Finland, Iceland, Norway, and
Sweden) and consists of three major research areas. One concerns the moral and legal
justification for civil commitment, the second is epidemiologically oriented comparing
commitment rates between and within the countries, and the third part focuses on the
patients perception of being coerced in relation to their hospital admission. In this article,
we will discuss methodological issues related to research on the use of coercion in
psychiatry, as well as presenting design and methods applying to the Nordic study. Special
attention will be paid to conceptual and methodological problems related to the measurement
of perceived coercion.
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support for this kind of simplification can be found in the literature (Gill & Feinstein, 1994;
Mastekaasa, Moun, Naess, & Srensen, 1988). We ended up using both the MPCS, and a
single global measure for perceived coercion in the Nordic study. Both instruments will be
described in more detail below.
It has also been argued that the quality of life concept consists of (at least) two different
dimensions, one objective dimension including elements like standard of accommodation,
level of income, health status, etc., and one subjective dimension encompassing perceived
well-being (Muldoon, Barger, Flory, & Manuck, 1998). The authors strongly recommend
treating the two factors as two different variables. The same principle obviously applies to
measurements of other subjective dimensions. Regarding measurements of perceived
coercion, the implication would be to keep observed coercion apart from self-reports of
the feeling of being coerced (perceived coercion).
2.3. Measures of perceived coercion and related concepts
When we looked into previous attempts to measure perceived coercion, we identified three
instruments designed for this purpose, namely the MPCS (Gardner, Hoge, Bennet, et al.,
1993), The Circumstances, Motivation, Readiness, and Suitability Scale (De Leon, Melnic,
Kressel, et al., 1994), and The Coercion/Noncoercion Matrix (Marlowe et al., 1996). While
the MPCS has been applied by different research groups and seems to reveal sound
psychometric properties, the two last mentioned instruments have only been used once each
and will not be further commented on in this article.
We also found a number of earlier studies addressing patients experiences of their
treatment and care in more general terms (Adams & Hafner, 1991; Bradford, McCann,
& Merskey, 1986; Conlon, Merskey, Zilli, & Frommhold, 1990; Kalman, 1983; Toews,
El-Guebaly, Leckie, et al., 1981, 1984, 1986; Weinstein, 1979). Some of these studies
concentrated on patients satisfaction (or lack of satisfaction); others focused more on
specific experiences related to hospital admission and care. These studies did almost
without exception construct their own instruments in order to measure patients satisfaction
or other subjective attitudes to psychiatric treatment. In Sweden, Hansson, in cooperation
with the Swedish health authorities, has developed a patient satisfaction questionnaire (the
SPRI patient satisfaction questionnaire, Hansson & Hoglund, 1995). Both inpatient and
outpatient versions exist. The inpatient version is composed of 44 self-administered, mostly
structured questions, of which five questions are relevant to the use of coercion and process
control. It is not surprising that there is a close association between patient satisfaction and
perceived coercion, and a study using the SPRI instrument accordingly found that the
strongest predictor of low satisfaction with all aspects of the in-patient period was perceived
coercion (Svensson & Hansson, 1994). The interesting question in our context is the
relation between measurements of patient satisfaction and perceived coercion, and to
what degree these concepts are overlapping. The same question can be asked concerning
concepts like violation of integrity, self-determination, and autonomy, just to
mention some of the concepts commonly used when coercion in psychiatry is discussed
(Kjellin, Westrin, Eriksson, et al., 1993; Nicholson, Ekenstam, & Norwood, 1996;
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Vallimaki, Leino-Kilpi, & Helenius, 1996). The problem with all the concepts mentioned
above is that they are abstract, hard to define, and difficult to operationalize. The great
number of self-constructed instruments and their lack of standardization has been pointed to
as a serious problem in research on patients attitudes and perceptions (Hiday, 1992, 1996;
Hiday, Swarz, Swanson, et al., 1997; Kalman, 1983). In this situation, the need to refine
research instruments was obvious, especially as the importance of perceived coercion has
been acknowledged.
2.4. The MacArthur Perceived Coercion Scale
The scale consists of five statements to be answered in a true/false format. The five
questions are extracted from the Admission Experience Survey (AES), originally comprising
104 items, but later revised into a 41-item version (Gardner et al., 1993). The literature on the
MPCS is somewhat confusing for an outsider with regard to different names and versions.
Some of this confusion is caused by the fact that the instrument, and the context in which it is
used, has changed as the MacArthur coercion study has developed. Most studies using the
MPCS have applied a 15-item version of the Admission Experience Interview (AEI) or the
much longer AES where the five (or sometimes four) MPCS questions have been
incorporated. Yet, the other 10 items comprising the 15-item version of the AEI vary, which
is another confusing aspect of the AES/AEI/ MPCS instrument.
The AES/AEI/MPCS has been reported to have good psychometric properties, is not
time-consuming, is well understood by the patients and works well in different settings
(Gardner et al., 1993; Siegel, Wallsten, Torsteinsdottir, & Lindstrom, 1997). The questions
included in the MPCS all bear high loadings on the perceived coercion dimension, and the
patients answer the perceived coercion questions in a highly consistent way. It is important
to remember though, that these findings are not a proof of validity, meaning that we still do
not know if the MPCS questions constitute the best way of measuring perceived coercion.
The MPCS may for instance be more sensitive to inequity matters in the decision-making
process, than the impact of the factual use of coercion during admission and hospitalization.
2.5. Changes in perceived coercion over time
Another aspect to take into consideration is changes in patients perceptions over time
(Edelsohn & Hiday, 1990; Gardner, Lidz, Hoge, et al., 1999; Kaltiala-Heino, 1997; Kane,
Quitkin, Rifkin, et al., 1983; Toews et al., 1986). The usual pattern is that patients express less
negative attitudes towards the admission and treatment as time goes by. Because of these
changes, it is important to underline at what time measures of perceived coercion are made.
Fig. 1 illustrates different stages in a treatment episode. As can be seen from this figure, the
preadmission period includes extremely important deliberations and decisions, determining
the next steps to be taken in the actual situation. Impression from interviewing acutely
admitted patients in Norway indicate that patients are much more upset about negative
pressures and coercion used outside the hospital during the admission process compared to
their feelings about being confined in the hospital (Hyer, 1999). The same impressions are
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reported from the MacArthur studies (Hoge, Lidz, Eisenberg, et al., 1997). If these impressions
hold true, one should look separately into the admission period and the in-patient period in
order to understand the dynamics of perceived coercion. It is also reasonable to conclude that
perceived coercion measurements should be made longitudinally (i.e., more than once) during
a treatment episode.
3. Paternalism and AutonomyA Nordic Study on the Use of Coercion in the Mental
Health Care System: Aims and general design
The Nordic study called Paternalism and AutonomyA Nordic Study on the Use of
Coercion in the Mental Health Care System has been carried out in all the five Nordic
countries. The core part of the study is confined to questions related to deprivation of
liberty (involuntary admissions). In addition to the core study, each participating country
could add topics of special national interest, and such studies have been added in Finland,
Norway, and Sweden.
The overall aims of the study are: (1) to identify the justification for the use of coercion as it
appears in the mental health acts and other legal documents in the Nordic countries, (2) to
study the reliability and validity of public statistics on civil commitments, and (3) to explore
what constitutes the concept of coercion by looking at the kind of events and circumstances
determining the patients perception of coercion. The core study includes, in accordance with
the threefold aim, three levels described below. The three levels are harmonized in a way
that make comparisons across levels possible, both within and between countries. The general
design of the study is schematically shown in Fig. 2. The study has been approved by ethical
review boards in each participating country.
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3.1. Level 1: How is paternalism (the use of coercion in the mental health care system)
justified? Value conflicts and legal regulations
To explore how the use of coercion is justified, we have studied legal documents, i.e., laws,
preparatory papers, official recommendations, instructions, and court cases. The methods
applied in this part of the study include textual analysis and interviews with ethicists, lawyers,
and physicians from each of the Nordic countries. Two international coordinators, a medical
ethicist and a lawyer, have made the comparative analysis of the material from all the five
countries. They visited all the participating countries and interviewed key persons on their
views about the value base underlying the different mental health acts and if the law was
practiced in harmony with these values.
This part of the study was carried out between 1995 and 1997 and some of the results have
been published (Nilstun & Syse, 2000; Syse, 1999; Syse & Nilstun, 1997). A major finding
was that in spite of varying degrees of coercive powers of the different mental health acts, the
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agreement among the interviewed professionals on when civil commitment was justifiable
and striking. The Level 1 analysis will provide a useful frame of reference when the empirical
results of Levels 2 and 3 of the study will be discussed.
3.2. Level 2: Reliability and validity of public statistics on civil commitments
It has been well established that formal involuntary hospitalization varies greatly between
countries (Bagby, 1987; Engberg, 1991; Hyer, 1985; Kaltiala-Heino, 1995; Monahan et al.,
1995; Riecher-Rossler & Rossler, 1993). There are a number of methodological problems,
however, in comparing data on formal involuntary hospitalization between nations (Engberg,
Kaltiala-Heino, Hyer, et al., 2001). Reports from Denmark, Finland, and Sweden indicate a
decrease in commitment rates during the last decades (Engberg, 1990; Kaltiala-Heino, 1995;
Kjellin, 1997), while Norway has seen an increase (Hatling & Krogen, 1998). According to
available public statistics, commitment rates vary between 29 per 100,000 inhabitants
(Denmark) and 195 per 100,000 inhabitants aged 18 or above in Norway (Hatling & Krogen,
1998). When interpreting such data, one must be aware of the impact of differences in the
coercive powers of various mental health acts, as well as numerous other factors, like for
instance the organization, quality, and capacity of all kinds of medical and social services and
differences in the interpretation and practical application of the legal criteria authorizing the
use of coercion. For those reasons, it must be emphasized that differences in commitment
rates across jurisdictions do not necessarily reflect differences in the level of coercion of a
country. Another issue is the great variations in commitment rates and quotas within nations
or jurisdictions reported by many authors (Engberg, 1991; Kjellin, 1997; Kokkonen, 1993;
stman, 1983; Riecher-Rossler & Rossler, 1993). Attempts have been made to explain such
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regional variations by demographic factors (Malla & Norman, 1988; Miller & Fiddleman,
1983) or by the structure and available resources of services (Engberg, 1991; Faulkner, Mc
stman, 1983;
Farland, & Bloom, 1989; Kjellin, 1997; Kokkonen, 1993; Malcolm, 1989; O
Pylkkanen, 1987). None of these studies, however, offer a comprehensive explanation of the
main factors contributing to the reported differences.
In Level 2 of the Nordic study data from medical records and related documents are
registered in a uniform way in all the Nordic countries with a registration form developed for
the study. The analysis will provide uniform measures of any period of legal deprivation of
liberty during a defined treatment episode. The reliability of public statistics is studied by
comparing consistency and completeness of public data of involuntary and voluntary
admissions with data recorded in the Nordic study. The validity is studied by exploring if
procedures for compiling public statistics are able to identify any period of involuntary
admissions during a treatment episode. A more detailed presentation of Level 2 is given in
another article (Engberg et al., 2001).
3.3. Level 3: Patients perceived coercion
We decided to use a core interview, identically performed in all the five participating
Nordic countries. The core interview was carried out between the first and fifth day after
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admission. According to the inclusion criteria, all patients between 18 and 60 years of age
were eligible for inclusion in the study regardless of their legal status (i.e., both formally
voluntarily and involuntarily admitted patients). Forensic patients, patients with a primary
diagnosis of substance abuse, and patients who obviously were too disturbed to understand
what the interview was about or unable to communicate for other reasons were the only ones
to be excluded. We ended up doing 995 interviews.
The interview schedule comprised of five parts: (1) an interview specially designed for the
actual study, named the Nordic Admission Interview (NORAI), (2) a visual analogue scale
measuring a global score for perceived coercion, (3) the MacArthur AES (including the
MPCS; Gardner et al., 1993), (4) the Global Assessment of Functioning Scale (GAF) (APA,
1987), and (5) the Brief Psychiatric Rating Scale (BPRS) (Overall & Gorham, 1962). In
addition, file information including demographics, diagnosis, admission, legal status,
medication, and type of ward was collected from the hospital records. An overview of the
elements included in the core interview is given in Table 1. In the following, we will
describe in more detail the elements of the interview schedule originally designed for the
Nordic study.
3.3.1. The Nordic Admission Interview
The NORAI was constructed by selecting the questions that worked best in previous
studies carried out in Denmark (Engberg, 1994), Finland (Kaltiala-Heino, 1995), Norway
(Hyer, 1986b), and Sweden (Candefjord, 1989; Kjellin, 1996). We agreed to exclusively
focus coercion related to the deprivation of liberty in relation to admissions to mental
Table 1
The Nordic study on the use of coercion in the mental health care system
Number
of items
NORAI
Transportation to hospital
Self determination
Reason for admission
Awareness of own legal status
Restrictions of freedom
Violation of integrity
AES
MPCS
BPRS
16
5
8
4
4
2
1
15
5
16
GAF
File information
16
Comments
The sum of questions for each category is greater
than 16, because some items have sub-questions
and some items cover more than one category
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institutions, thus leaving out the exposure to forced treatment, seclusion, restraint, or other
kinds of coercion. The NORAI questions are simple and concrete, thus making the interview
work even with very disturbed patients interviewed shortly after admission. The interview
consists of 16 questions covering the following areas: The transportation to the hospital, selfdetermination in the admission process, perception of need for treatment, reason for
admission, awareness of own legal status, restrictions in freedom to leave the hospital or
the ward, and violation of integrity.
3.3.2. The global score for perceived coercion
When we considered a single measure for perceived coercion, we decided to use a visual
analogue scale. We used a modified version of the Cantril Ladder (Cantril, 1965). The
ladder (Fig. 3) is shown to the patient and the patient is asked to mark the degree of perceived
coercion on the ladder after the following instruction is read to the patient:
When a person gets admitted to a mental hospital or ward, different things will be of
importance in each case. In some cases, a lot of pressure and even physical force is used when
a person is admitted, while in other cases patients come to the ward totally at their own will. If
you think of your own admission to this hospital this time, try to consider if you were
subjected to any kind of coercion, threats, pressure, or inducements. Then try to figure what
step on the ladder shown below that best corresponds with the amount of pressure from others
you experienced when admitted, and mark the step with an X. For instance, if you came
entirely on your own initiative put an X on step 1, but if you were subjected to the maximum
use of coercion, then you put the X on step 10.
Fig. 3. The Coercion Ladder (adopted from the Cantril Ladder; Cantril, 1965).
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admitted patients are in a psychotic state, we were afraid that many patients would be unable
to comply with the interview requirements, but this has not been the case. Especially the
NORAI and the Coercion Ladder worked well. Patients did almost without exception
understand the procedure for marking the ladder and fulfilled the task without much
hesitation. In most cases, the time needed to complete the whole interview schedule has
been between 30 and 45 minutes, and even very disturbed patients stayed focused and
completed the interview.
The experience with the AES has been more mixed. Originally, the AES is composed of
statements, requiring respondents to answer in a true/false format. We early recognized that
we had to change the statements into questions (which is allowed according to the AES
manual; Siegel et al., 1997). The question format asking for yes/no answers worked much
better, but still many patients found it hard to comprehend the questions, and were somewhat
reluctant to complete the AES. Experiences with the use of the AES from the USA are much
better compared to what we have experienced in the Nordic countries, but we have no good
explanation why this is the case. Our feeling is that the AES is too intellectually demanding
for acutely ill persons suffering from serious mental disorders.
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