Perceived coercion in psychiatric hospital admission: validation of the French-language version of the MacArthur Admission Experience Survey

In 1793, Philippe Pinel advocated freeing people with mental disorders from their chains and giving them back their dignity. Despite his desire to make psychiatric treatment more humane, he could not get rid of coerced institutionalisation and, ten years later, he was to recommend the use of the straitjacket as a new form of treatment. Since then, politicians, jurists and mental health professionals have been caught between their duty to respect patients’ fundamental rights and autonomy and the necessity to protect patients (and others) from themselves. Involuntary psychiatric treatments aim to protect people with mental disorders and improve their health status [1]. However, some authors have argued that there is scarce evidence of any patient benefits from compulsory inpatient admission [2]. Indeed, coercive measures may have severe, enduring negative effects on the people targeted, such as increased use of future coercive measures [3, 4], worse quality of life [5], reduced treatment adherence [6] and lower satisfaction with care [7].

A corpus of scientific literature has demonstrated that patients’ feelings of being coerced into psychiatric treatment—their level of perceived coercion—negatively influence their prognoses, more than the formal coercive measures themselves [8]. Perceived coercion is not exclusively related to formal coercive measures or the patient’s legal status at admission [9]; it also depends on the amount of information shared with the patient, participation in medical decision-making and a lack of knowledge about legal issues. Moreover, informal coercion, such as leverage, can influence the level of perceived coercion [10]. Even voluntary patients can therefore report high levels of perceived coercion [11, 12]. Patients’ perceptions of coercion can be influenced by their gender, the severity of symptoms, their level of social functioning and the quality of their therapeutic relationships [13, 14]. Perceived coercion damages the patient’s perception of the therapeutic relationship [15], and lower levels of perceived coercion are linked to higher treatment satisfaction [16]. The long-term impact of high levels of perceived coercion on patients is nevertheless controversial and needs further evaluation [17].

Several approaches have been developed to decrease levels of perceived coercion. These have highlighted that patient empowerment, cooperation with professionals [18], a moral approach to coercion [19], and respect for patients’ freedom of choice and values [20] are determining factors.

One of the most widely used tools for studying perceived coercion is the Admission Experience Survey (AES) short form developed for the MacArthur Coercion Study [21]. More precisely, this 16-item dichotomous (true-or-false) questionnaire was derived from a structured interview (the MacArthur Admission Experience Interview) so that patients’ perceptions of psychiatric hospital admission could be obtained rapidly using a paper and pencil. Among other scoring variants, three subscales were proposed: the Perceived Coercion score focuses on freedom, choice, initiative, control and influence over coming into hospital; the Negative Pressures score focuses on being forced, threatened or physically forced to come into hospital; and the Voice score focuses on having a chance to voice an opinion about coming into hospital [21‐24]. One item (#9) was eventually dropped from these subscales, and the last item (#16) is a series of adjectives used to evaluate the patient’s affective reaction to hospitalisation. Items and scoring instructions from the original English version are available on the MacArthur Research Network on Mental Health and the Law website [22].

To the best of our knowledge, there is no specific French-language tool available for the study of perceived coercion. This current lack of proper research tools makes any investigation of coercion in French-speaking countries difficult at best. This study’s goal, therefore, was to assess the psychometric properties of a French-language version of the AES. Validation of a French-language perceived coercion scale will promote further research projects on this topic in French-speaking countries and enable an international comparison of results. A better understanding of the factors influencing patients’ perceptions of coercion and, consequently, its impact on their welfare and prognoses, will help us to develop new, alternative models of care that enable a reduction in the use of compulsory admission.

The reliability of the French-language Admission Experience Survey (AES) scores was very satisfactory. Furthermore, these scores underwent no systematic changes at the second assessment, which is a desirable feature in evaluation settings. The internal validity of the one- and three-factor AES models was shown to be very good. Correlations between the three factors suggested that Perceived Coercion, Negative Pressures and Voice shared a lot of variance. This was in line with other studies that have shown that perceived coercion was also associated with the use of negative pressures such as threats and physical force. Additionally, perceived coercion was found to be inversely related to a patient’s sense of procedural justice, that is, the patient’s belief that he had been able to voice his opinion and had been treated with fairness, concern and respect [9]. Although the computation of a single total coercion score was perfectly adequate, the comparison between the one- and three-factor models suggested that Perceived Coercion, Negative Pressures and Voice should not be considered as indistinguishable. Despite the large amount of shared variance, there are further benefits to conceptualising an AES with three subscales. The high correlation between subscales only suggests that patients are likely to have similar scores on average. However, this will not always be the case, and differences may highlight important clinical situations. Furthermore, examination of the Total Information Curves suggested that the AES Negative Pressures subscore provided more information on respondents who scored above average on the latent trait, whereas the AES Voice score was more informative about respondents with below-average latent scores. Consequently, using the subscales may add to the AES’s sensitivity with patients presenting different levels of perceived coercion.

Correlations between the French-language AES scores and the Coercion Ladder score, the Coercion Experience Scale and the Global Assessment of Functioning scale were largely in line with expectations, suggesting that the French-language version of the AES is a valid measure of perceived coercion. The correlation patterns between each of the four AES scores and the other scales were very similar, which is not surprising given the high correlation between the factors. However, the three-factor model’s superiority over the single-factor model suggests that distinguishing between these three subscores could be useful, adding information above and beyond that provided by a single summary score.

Finally, all four scores derived from the French-language AES were able to discriminate between patients who had been voluntarily and involuntarily admitted to hospital, which confirmed our hypothesis.

The French-language version of the AES demonstrated very good psychometric properties. The validation of this questionnaire was a mandatory first step towards testing other hypotheses and conducting future clinical or interventional studies. We hope that it will promote the development of further research projects on these topics in French-speaking countries and comparisons with the English or German-speaking countries where these tools are already in use.