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International Journal of Law and Psychiatry

25 (2002) 93 108

Paternalism and autonomy:


A presentation of a Nordic study on the use of coercion in
the mental health care system
Georg Hyera, Lars Kjellinb,*, Marianne Engbergc,
Riittakerttu Kaltiala-Heinod, Tore Nilstune,
Maria Sigurjonsdottirf, Aslak Syseg
a

Professor, Institute of Community Medicine, University of Troms, N-9037 Troms, Norway


b
rebro County Council,
Research Manager, Psychiatric Research Centre, O
rebro, Sweden
P.O. Box 1613, SE-701 16 O
c
Associate Professor, Department of General Medical Practice, Aarhus University, DK-8000 Aarhus, Denmark
d
Professor, Tampere School of Public Health, University of Tampere, SF-33014 Tampere, Finland
e
Associate Professor, Department of Medical Ethics, Lund University, SE-222 22 Lund, Sweden
f
Psychiatrist, Blakstad Psychiatric Hospital, N-1371 Asker, Norway
g
Professor, Department of Public and International Law, University of Oslo, N-0130 Oslo, Norway

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 &

* Corresponding author. Tel.: +46-19-602-58-89; fax: +46-19-602-58-86.


E-mail address: lars.kjellin@orebroll.se (L. Kjellin).
0160-2527/02/$ see front matter D 2002 Elsevier Science Inc. All rights reserved.
PII: S 0 1 6 0 - 2 5 2 7 ( 0 1 ) 0 0 1 0 8 - X

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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.

2. How can coercion be measured? Conceptual and methodological issues


2.1. What is coercion?
One of the reasons we lack empirical knowledge about the impact of coercion, is that the
concept of coercion is poorly defined. What is coercion? When reviewing the literature it
becomes quite clear that the concept of coercion is defined in many ways. In older studies
coercion has, with a few exceptions, been treated as identical to the legal status of the
patient. In a very simple way, such studies have relied on the assumption that those who
have been civilly committed are subjected to coercion, while their voluntarily admitted
counterparts are not. However, a number of more recent studies have demonstrated that a
substantial proportion of voluntarily admitted patients report they have been subjected to
coercion, and some committed patients do vice versa believe they are hospitalized on a
voluntary basis (Beck & Golowka, 1988; Edelsohn & Hiday, 1990; Engberg, 1994; Gilboy
& Schmidt, 1971; Hyer, 1986a,b; Kaltiala-Heino, 1995; Kjellin, 1996; Monahan, Hoge,
Lidz, et al., 1995; Rogers, 1993). These studies have made it quite clear that the legal status
of the patient is a poor measure for coercion. Based on this knowledge, recent research has

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concentrated on perceived coercion in order to identify what kind of events patients


experience as coercive (Hoge, Lidz, Gardner, et al., 1997; Lidz & Gardner, 1995; Marlowe,
Kirby, Boniesky, et al., 1996; Monahan et al., 1995). This is a necessary first step in order
to develop a more valid and reliable concept for coercion, and a necessary prerequisite
before the impact of coercion on outcome can be explored in future studies (Monahan
et al., 1995).
2.2. How to measure subjective dimensions
One of the first methodological challenges we faced was how to measure perceived
coercion. All efforts to explore subjective dimensions, like for example quality of life,
consumers satisfaction or, as in our case, perceived coercion, face the same problem: Is it
possible to measure such subjective dimensions objectively? The intriguing fact that there is
no clear relationship between objective standards of some phenomena like good health,
standard of living, etc. and subjective well-being, makes this problem difficult (Ruggeri,
Warner, Bisoffi, & Fontecedro, 2001). Some people who, by all reasonable judgements, live
miserable lives, sometimes feel they have a good quality of life and vice versa. This
seemingly paradox applies to patients perception of being coerced as well. The poor
relationship between the patients legal status and their own opinion of their legal status
has already been mentioned. Even more surprising, a Swedish study demonstrated that some
voluntarily admitted patients, who according to the medical records had not been subjected to
any kind of coercive measures, in their self-reports claimed they had been coerced during
their in-patient period (Kjellin & Westrin, 1998). This finding further underlines the poor
relationship between perceptions and objectively recorded events.
The observed lack of correspondence between objective and perceived coercion may partly
be due to limitations in what usually is included in the coercion concept. In the referred
Swedish study (Kjellin & Westrin, 1998), observed coercion included the use of formally
approved forced medication and the use of seclusion or restraint. These measures are clearcut, easy to observe, and can be objectively recorded. Objective coercion can, however, be
less clear-cut and accordingly more difficult to record (Kaltiala-Heino, Laippala, & Salokangas, 1999). Medication may for instance formally be taken on a voluntary basis, while in
reality various degrees of pressure are applied leaving patients in a no-choice position. The
more coercion is integrated in the structure of care and treatment, the more difficult it will be
to identify and record such coercion.
Most of the instruments used to measure subjective dimensions, like quality of life, general
well-being, psychometric measures, etc., provide one index score describing the level of the
actual subject being studied. It is generally believed that indexes, including multiple
dimensions constitute a better instrument compared to more simple measures.
The most-used instrument measuring perceived coercion, the MacArthur Perceived
Coercion Scale (MPCS, see below) is constructed according to this principle, providing a
single score based on five items. In the Nordic study, however, we wondered if one single
global measure for perceived coercion could replace more complex measurements without
loosing vital information or validity. In spite of the recommendations to use indexes, some

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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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Fig. 1. The admission process.

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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Fig. 2. The general design of the core study.

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
O
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

Additional questions were asked if the interview did


not provide enough information
Scores range from 1 to 90, 90 is the best possible score,
while 1 is the worst
Sex, age, type and size of ward, medication, diagnoses,
legal status, and duration of stay

Elements included in the core interview on the patients perceived coercion.

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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.

3.4. Experiences with the use of the Nordic Admission Interview


We have been positively surprised how well the interview has functioned in practice in all
of the participating countries. Taking into consideration that a substantial number of acutely

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.

4. Preliminary results and implications for further research


Preliminary data from all Nordic countries suggest that perceived coercion tends to be a
dichotomized phenomenon, measured both by the MPCS and the Coercion Ladder, and this
dichotomized pattern remains even when formally voluntarily and involuntarily admitted
patients are studied separately. This is a somewhat surprising finding, as it from a theoretical
point of view seems reasonable to expect that perceived coercion should be graded and
normally distributed (Carroll, 1991; Gardner et al., 1993; Hiday et al., 1997; Nicholson et al.,
1996), especially when measured on a visual analogue scale like the Coercion Ladder. It is
interesting, though, that two studies from North America have found the same dichotomized
pattern regarding perceived coercion (Hiday et al., 1997; Lidz, Hoge, Gardner, et al., 1995).
The implications of these findings are still unclear. One explanation for the dichotomized
distribution of the MPCS could be that this scale deliberately has excluded all measures of
objective (factual) coercion, thus making the MPCS completely related to the emotional
components of patients experiences. However, if adding factual use of coercion should
produce a more normally distributed pattern, this should be reflected in the Coercion Ladder,
which was not the case. Thus, at this stage we are unable to produce a good explanation for
the bimodal distribution of perceived coercion. Hopefully, the final analysis of the Nordic
data will be able to provide a better understanding of this somewhat surprising phenomenon.
In this process, questions about flaws in the instruments used to measure perceived coercion
must be asked, or if perceived coercion really is a dichotomized phenomenon and, in this
way, more resembles the concept of integrity. In moral philosophy, integrity can never be
gradedit is either preserved or violated (Kant, 1785; Hermeren, 1994). In this context, the
relation between perceived coercion and integrity emerges as an interesting topic to explore in
the future.

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5. Conclusions and importance of the study


Before the impact of coercion on the outcome of psychiatric treatment can be studied,
future research should give priority to refining the definition of perceived coercion and to
identify and operationalize the relevant, independent variables, explaining why some mental
patients feel more coerced than others. Based on existing empirical evidence, special attention
should be given to what happens during the admission process. Concepts like procedural
justice, process control, fairness, (in)equity, process exclusion, voice, influence, pressure,
threats, autonomy, dignity, validation (of patients opinion), respect, power disparity,
asymmetry, etc. have been used to describe important determinants for perceived coercion.
These determinants are probably trying to describe some of the essential elements determining a patients feeling of being coerced. However, we still do not know what these essential
elements are, neither in terms of factual circumstances, decision-making, or communication.
In this respect, the interaction between the (potential) patient and others involved in the
admission process (family members, social workers, health professionals, police, etc.) should
be emphasized in future research. We also recommend that measures of factual coercion and
perceived coercion are measured separately and that those measures are repeated using a
longitudinal design.
Hiday (1996) once said: 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. However, it is impossible to measure the effect of coercion on
outcome before a better validated and operational concept of coercion has been developed.
The contribution of the Nordic study, with 13 settings in five countries, will hopefully
improve the methods for registration of formal legal coercion and develop new knowledge
about what constitutes the concept of coercion, as well as determinants for variations in
perceived coercion.
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