Perceived coercion and need for hospitalization related to psychiatric admission

Abstract

Psychiatric hospitalization constitutes a moment of major stress to the point that occurrences of posttraumatic stress disorders have been described. Feelings of coercion are usual, whatever the legal status of admission. Patients may also consider afterwards that they needed hospitalization even if they refused it initially. A cross-sectional survey has been conducted among the inpatients of a Swiss psychiatric hospital to assess their subjective view of admission with emphasis on legal status, perceived coercion and need for hospitalization. Eighty-seven questionnaires were completed and analyzed. Results indicated that 74% of patients felt that they had been under pressure to be hospitalized, whether or not they were involuntarily admitted. Seventy percent felt their admission was necessary. More involuntary patients reported a subjective lack of improvement. Clinicians could decrease feelings of coercion of their patients while discussing need for hospitalization, legal status and subjective feeling of coercion as different dimensions. An argument is presented to favor positive pressure from social environment over legal involuntary commitment in many hospitalizations.

Introduction

Social representation of psychiatric hospitalization is usually associated with a certain degree of coercion. Psychiatric hospitalizations usually occur in the context of a major personal or family crisis to the point that occurrences of posttraumatic stress disorders have been described.¹ Unmistakably several individual and systemic factors have led to a unique situation in which psychiatric hospital admission appears to be the best or the last option available. The social network may be exhausted or absent, cooperation of patient may be limited or impossible and some danger may be present, either to self or to others. The decision to use hospital to solve the crisis can be involuntary (the patient has to be committed) or voluntary (the patient has decided or accepted to be hospitalized). The use of coercion in psychiatric hospitalizations has led to considerable debate, first between policy makers and professionals, and now between patients and relatives associations. Patients associations usually emphasize individual rights' respect, while relatives may insist more on the clinician's duty to treat mentally ill persons even against their will. Finding the appropriate dosage of coercion is always delicate for clinicians. Several issues are involved and the reasons behind their difficult decision and the manner through which it is explained to the patients and their families could influence the subjective feeling of coercion independently of the legal context of hospital admission.

Although civil commitment constitutes the strongest coercive measure available according to the law, feeling of coercion may also occur in voluntary admissions. Indeed, even if there is a strong correlation between legal status and feelings of coercion, previous studies have shown that they are not equivalent (Hoge et al., 1993, Hoge et al., 1997, McKenna et al., 1999). For example, Hoge et al. (1997) found that 10% of voluntary patients felt coerced while 35% of involuntary patients did not feel coerced. Perceived coercion may also vary according to differences in how legal procedures are applied (Lidz et al., 1995). Other data indicated that the degree of coercion felt by patients was frequently important whether or not the patient was committed (Farnham & James, 2000).

Patients may perceive some need for hospitalization in spite of a lack of collaboration. A recent survey among remitted bipolar patients and their families indicated that most of them, as well as their caretakers, preferred some degree of coercion to a laissez-faire attitude often seen as indifference in the event of recurrence of manic symptoms (Borgeat & Zullino, 2004). Gardner et al. (1999) have reported that half of the patients who stated at admission that they did not need hospitalization had changed their minds 1 or 2 months after discharge, in spite of an unchanged perception of coercion.

Coercion could be associated with negative outcome. A strong association of involuntary legal status at first admission with involuntary legal status at subsequent admissions has been observed. Houston and Mariotto (2001) reported that involuntary admitted patients were overrepresented in the poorest outcome categories. However, since coercion is usually used with severe symptoms, non-cooperation and danger, several confounding variables obscure possible causal relationships between coercion and poor outcome.

The goal of the present study was to assess the subjective perception of psychiatric admission by patients while still in hospital. It was hypothesized that subjective feelings of coercion were partially independent from the legal context of hospital admission and from the perceived need for hospitalization.