Patients’ moral views on coercion in mental healthcare

Abstract

Background:

Coercion in mental healthcare has led to ethical debate on its nature and use. However, few studies have explicitly explored patients’ moral evaluations of coercion.

Aim:

The purpose of this study is to increase understanding of patients’ moral views and considerations regarding coercion.

Research design:

Semi-structured focus-group and individual interviews were conducted and data were analysed through a thematic content analysis.

Participants and research context:

A total of 24 adult participants with various mental health problems and experiences with coercion were interviewed in 2012–2013 in three regions of Norway.

Ethical considerations:

Ethical approval and permissions were obtained according to required procedures. Informed consent and confidentiality were also secured.

Findings:

Ethical considerations regarding coercion included seven main themes: the need for alternative perspectives and solutions, the existence of a danger or harm to oneself or others, the problem of paternalism, the problem of discrimination and stigma, the need for proportionality, the importance of the content and consequences of coercion and concerns about way that coercion is carried out in practice.

Discussion:

The participants’ views and considerations are in line with previous research and reflect the range of normative arguments commonly encountered in ethical and legal debates. The study accentuates the significance of institutional factors and alternative voluntary treatment opportunities, as well as the legal and ethical principles of proportionality and purposefulness, in moral evaluations of coercion.

Conclusion:

Broader perspectives on coercion are required to comprehend its ethical challenges and derive possible solutions to these from a patient perspective.

Keywords

Coercion mental healthcare nursing ethics patient acceptance of healthcare user involvement

Introduction

Coercion is a common practice in mental healthcare. The serious effects of coercion on individual autonomy and liberty make coercion an inherently value-laden practice. Consequently, there has been much debate on the ethical justifications for and the best practices of coercive interventions, including mental health nursing.^1

–4

Persons with experiences of mental health problems and coercion have, until recent years, seldom participated in ethical debates and research regarding coercion.^2,5 However, prevailing research shows variations in patients’ moral views on coercion; some find involuntary hospitalisation to be right or wrong and others are ambivalent.² Studies have found that important values for patients are having freedom of choice, autonomy and a feeling of safety during hospital stays, together with being listened to and being treated non-paternalistically by staff.^5,6 Many patients view participation in the decision-making process during involuntary admission as important for justifying coercion.⁷ Other factors identified as influential for patients are their perceptions that others hold beneficial motives, act fairly and have the necessary qualifications,⁸ and that the expected outcomes will be positive, such as having therapeutic value or contributing to the recovery process.^2,6,9 These go together with patient views on the necessity of coercion during illness and whether they feel that voluntary alternatives or less restrictive measures should be used instead.² Several studies have revealed that the moral significance of the way coercion is carried out, such as patients being acknowledged and treated with respect, trust and as a human being in the context of a therapeutic relationship and receipt of sufficient information.^5,10
–12 Correspondingly, patients evaluate staff’s abusive behaviour and violations, failure to listen or restrictions of freedom due to labelling and stigma as morally reprehensible.⁵

Research aims

Previous research provides valuable information on patients’ views on coercion. However, there is still limited empirical research explicitly exploring patients’ moral views and considerations regarding coercion.^2,5,13 Increased understanding of patients’ values and considerations might point to aspects of ethical theory and legal regulations that need to be revised or refined, or to quality improvements for coercive interventions in mental health practice. Furthermore, increased knowledge of patients’ perspectives might contribute to improved management of ethical conflicts in clinical practice or stimulate dialogue about ethical challenges between stakeholders.^5,13

This study, therefore, aims to contribute to understanding of patients’ perspectives through a qualitative study of people with coercive experiences in Norway. It explores which ethical considerations and normative arguments are included in the participants’ moral evaluations of coercion, the participants’ reasons for viewing coercion as right or wrong and their views on the best practices for coercion. Most of their considerations regarding coercion are retrospective, although a few experienced coercion also during the study period. Finally, the findings are compared with prevailing research and current ethical debates on coercion. Implications for ethics, as well as mental health practice, are discussed.

Methods

Study context and design

Mental healthcare in Norway is publicly funded and organised as ‘specialised health services’ – that is, hospital trusts (hospitals and outpatient clinics) – and as ‘community health services’ (general practitioners and local emergency and home care). Formal coercion mainly takes place within specialised health services, though community health services may request involuntary hospitalisation.

This study is part of a large-scale project in Norway called ‘Mental healthcare, ethics and coercion’, which started in 2011. This project was inspired by discourse ethics¹⁴ and aims to explore the ethical challenges regarding coercion from all stakeholder perspectives. The study used a qualitative design with individual and group interviews across various service user and patient settings. Focus-group interviews were chosen as the primary method for gathering empirical data because group interactions can stimulate moral deliberation and open, democratic discussions about coercion.¹⁵ This is particularly important because coercive experiences are easily individualised, stigmatised and silenced.^13,16 Individual inpatient interviews were used as a supplementary source of data.

Interviews and sample

Three semi-structured focus-group interviews were conducted, each with five to seven participants, in eastern, central and northern Norway. Additionally, individual interviews were conducted with three inpatients from a psychiatric rehabilitation ward and two users who contacted us to share their views and experiences. Focus-group participants were recruited and interviewed between November 2012 and May 2013, and individual interviews were completed in March and August 2013.

As seen from Table 1, the sample consisted of 24 adults who reported various mental health problems and coercion experiences. The time period since their coercion experiences differed from years to recent episodes. Many participants were still using mental health services, and some were experiencing coercion at the time of the interviews.

Table 1.

Overview of participants (N = 24).

Age	22–60 years
Gender	10 women and 14 men
Type of mental health problems	Psychosis Bipolar disorder Schizophrenia Prenatal psychosis Depression/suicidal thoughts Anxiety Substance abuse problems
Experiences with coercion	Involuntary commitment, forced medication, seclusion, mechanical and physical restraints, coercive treatment in community health services (CTO) From one to several episodes; some had many experiences over several years
Time-period since coercion	More than 15 years (up to 35 years) Up to 15 years (some recent episodes) Ongoing

CTO: community treatment order.

Recruitment and data collection

A combination of purposive and convenience sampling and recruitment strategies was used due to challenges in recruiting participants and to provide a heterogeneous sample appropriate for this kind of qualitative study.¹⁷ Wide inclusion criteria were used since the study aim was to explore ethical considerations among people with experiences of coercion in general rather than specific diagnoses or coercive measures. Hence, the inclusion criteria were adults with first-hand experience of coercion in mental healthcare who wanted and were able to attend long group interviews. Exclusion criteria were having only indirect knowledge of coercion or finding such interviews too strenuous. Participants were mainly recruited through the National Centre for Knowledge through Experience (NCKE) and its network of users and user organisations. First, the researchers (first author (R.N.)) presented the study at on-going user-led workshops on alternatives to coercion. Then, several key users, who served as ‘gate-keepers’, distributed an information letter locally, contributing to a ‘snowball-sample’ of participants. Inpatients recruited by staff from a hospital participating in the larger research project (PET) were included to ensure sufficient variation.

The focus-group interviews occurred in a meeting room in a user-organisation’s office, a county house and a hotel. The interviews were 3 h in length and included lunch and short breaks. Individual interviews occurred in the hospital’s visiting room or in R.N.’s office and lasted from 25 to 60 min. An interview guide was finalised by the two authors after it was reviewed by the PET research group and users collaborating in the recruitment process. The individual interviews were conducted by one researcher (R.N.) and the focus-group interviews by two researchers. One researcher (R.N.) was the moderator and ensured that all voices were heard. The researchers supplemented each other in monitoring alertness to the group dynamic, participants’ well-being and follow-up questions. The interview guide included the following main questions: (1) What is coercion? (2) Is coercion right or wrong, and why? (3) Are there alternatives to coercion? (4) What are your views on participating in treatment and care? The answers to questions (2)–(4) are the main focus of this article. Participants were encouraged to illustrate their views with concrete examples and experiences.

In all focus-group interviews, the atmosphere and discussions were positive, and all participants actively participated. Most participants found the interviews to be meaningful and perceived the sharing of their experiences as a form of social support, though some participants found the process tiring. Given the potential burden of recollecting difficult experiences, the authors were careful to create a safe and accepting atmosphere, guided by advice from experienced users and the NCKE. The authors encouraged sufficient breaks and self-regulation of privacy, as well as the possibility of leaving the interview if needed. Additionally, the user organisations acted as a social security net by offering peer support. Afterwards, the researchers contacted all participants in case they needed further support.

Data analysis

Interviews were audio recorded and transcribed verbatim in Norwegian. Data were analysed using qualitative thematic content analysis as described by Malterud.¹⁷ This is an inductive, phenomenologically -inspired method that offers structured ways of thematically analysing qualitative data, yet it has many similarities to general strategies for analysing qualitative data. The analytic procedure consists of four steps: (1) obtaining an overall impression and recognising preliminary themes; (2) agreeing on code groups, identifying meaning-units and coding these; (3) condensing the meaning content of each code group and identifying illustrative quotations; and (4) synthesising the condensates by presenting reconceptualised descriptions and concepts.

Both authors read through the transcripts to obtain an overarching impression of participants’ views and experiences and agreed on important themes. Afterwards, one researcher (R.N.) conducted more systematic and detailed analyses. First, answers and discussions were sorted by R.N. into 15 categories in NVivo Version 10, 2012. To grasp participants’ perspectives, an initial analysis of their understandings of the concept of coercion was conducted. This showed that participants had wide-ranging accounts of coercion, including formal and informal coercion across health and welfare services.¹⁸

More in-depth analyses of participants’ moral views and considerations of coercion were then carried out. Data from the categories concerning participants’ moral views were coded as meaning-units and condensed into short statements expressing the essence of their meaning. The researchers sought explicit statements about coercion being right or wrong and implicit statements touching on values (e.g. ‘respect’) and normative evaluations (e.g. ‘should’, ‘ought’, ‘must’). These meaning-units were arranged in data matrices for comparative analyses of the participants’ views across interviews and in relation to the interviews as a whole. Finally, both authors synthesised the meaning-units and sorted them into broader descriptive themes displaying the main concerns and considerations of the participants’ moral evaluations of coercion. These themes are presented in the ‘Findings’ section together with selected illustrative quotations. Fictive names are used to underscore a holistic patient’s perspective that the participants are real persons, as well as to make it easier for the reader to understand the personal and existential dimensions of coercion. The two authors met regularly throughout the analytic process to ensure intercoder reliability.¹⁹ Ethical theory and empirical research were referred to throughout the analyses.

Research ethics

In accordance with Norwegian law, the study was formally evaluated by the Regional Committee for Medical and Health Research Ethics, which deemed the study ‘health services research’ falling outside its responsibility (REK South-East, 13 September 2012, project number 1329). Therefore, the study was assessed and approved by the National Data Protection Official for Research (Approval 18 September 2012, project number 31302) and the local research committee at the participating hospital. In line with the Helsinki Declaration, written and oral information were provided, including participants’ right to withdraw at any stage, and consent and confidentiality were secured.

Findings

The participants’ broad perspectives on coercion, as described above, influenced their moral evaluations of coercion. Their moral views and considerations regarding coercion included seven main themes, often reflecting current legal criteria and ethical debates on coercion. An overview of these themes is presented and elaborated in Table 2.

Table 2.

Main themes of the participants’ ethical considerations about coercion.

No.	Main themes
1	A need for alternative perspectives and solutions
2	‘Dangerousness’ and ‘harm’ (1) Danger to others: violence and aggression (2) Danger or harm to self
3	Paternalism
4	Content and consequences of coercion
5	Discrimination
6	Proportionality
7	The way coercion is carried out

A need for alternative perspectives and solutions

In their moral evaluations of coercion, many participants highlighted the need to include alternative perspectives of and solutions to mental health problems. These alternatives should create changes in the underlying understanding of people with mental health problems and the nature of mental illness (specifically psychosis), along with changes in treatment philosophies and available alternatives. For example, instead of using coercion, professionals should focus on increasing patients’ capacities to overcome and express their problems in constructive ways, as well as voluntary treatment options.

Several participants stated that the use of coercion was not always related to a patient’s lack of insight or refusal of help. Many had sought help from the health services but had been rejected until they became so ill that coercion was considered necessary. Others wanted help but were refused voluntary treatment such as activities and counselling, which they found more helpful than seclusion and medication. Ethical discussions on coercion should, therefore, address the possible lack of voluntary opportunities and the potential use of alternative solutions at home or in the community. Some participants related wrongful use of coercion to a systemic shaping of mental healthcare towards the use of coercion instead of voluntary treatment as a first choice. For example, one participant said, ‘Wrongful use of coercion is connected to the system’s wrongful modelling of treatment’. As a consequence, they thought that too much money was spent on ineffective and even damaging treatment, especially forced medication, without adequate scientific evidence. Coercion could, in this way, be an inexpedient solution to mental health problems.

Dangerousness and harm

Another important ethical consideration raised in the interviews concerned the need to balance the legal criterion of ‘being a danger to oneself or others’ (sometimes also discussed as ‘harm’) with the potential harm from coercion. The discussions revealed a broad understanding of danger and harm, including patients’ possible inability to act in their own best interests and take care of themselves.

Danger to others: violence and aggression

Most participants found coercion to be morally justified if a person was violent. As one participant explained, ‘When they are in danger to others’ life or health, then I hold no doubt. I don’t find it mean to put hand-cuffs on someone who is trying to kill another person’.

However, ethical considerations regarding aggression were often characterised by moral complexity. Several considered moral justifications for coercion to be dependent on the subjective reasoning behind the aggression, the interactional processes leading up to the aggression or acting out (e.g. violating behaviour from staff) and the availability of alternative solutions. Moreover, they distinguished between anxiety, frustration, anger and violent aggression due to substance abuse. Some participants also stated that both living under the constant threat of coercion and actual experiences of coercion could lead to aggressive and violent behaviour in patients who displayed neither under more normal circumstances. Hence, the use of coercion or expectations of patient dangerousness could lead to a vicious circle or self-fulfilling prophecy of acting out or violence.

Danger or harm to self

Several participants considered involuntary hospitalisation to be morally justified (even if it caused temporary anger) in situations where people were not able to take care of themselves, such as when people lacked an understanding of the seriousness or acuteness of their mental health problems or when they were confused, psychotic or emotionally driven by fear or rage. A person wandering around in a confused state could, for example, end up being run over by a car. As Johanna explained,

I think, regarding deprivation of liberty, that it is OK to put someone behind thick walls (and that might actually feel like safety after a while) when a person is wandering around without being able to ask for this kind of safety himself. Then, maybe someone has to do something – to take this person who is wandering around and put him behind locked doors, even if that may create a lot of despair and anger for a period of time and you need to reassure them and so forth. But I always put my foot down when it comes to medication. […] It is so hard for me to accept that someone would put chemicals into me to regulate my behaviour.

Several participants considered that coercion required serious psychosis to be morally justified and should be a last resort after trying voluntary options. Also, many participants found forced medication to be more morally problematic than involuntary hospitalisation. This was due to the serious side effects of medication and involuntary medication’s intrusive effects on personality – or a lack of experience with positive effects of medication.

The participants expressed uncertain and divergent moral views on coercion when a person was suicidal or conducting self-harm. A few participants mentioned the right to commit suicide. However, several participants considered the use of coercion to be morally right and, to some extent, a moral duty when a person was obviously suicidal. Susie argued,

Thinking about being a danger to yourself, I find this to be a huge dilemma. Because when you are in such a state, you might have lost your whole perspective. And I would appreciate being saved if I were so close [to committing suicide]. After all, I want to live.

She said that a person ought to be saved when his or her actual preference is to live.

Participants often indicated that the risk of self-harm or health impairment due to mental health problems should be balanced against the risk of harm related to the use of coercion. For example, Kenneth argued,

I believe that coercion may, and I underline may, be right when the patient is psychotic and a great danger to himself or others. On the other side, […] coercion may or will result in traumas that may have negative consequences for self-esteem and zest for life later on, along with all the problems following involuntary commitment or compulsory treatment. So I agree that it’s important […] to avoid a coercive experience.

The participants’ considerations of possible risks from coercion included physical, psychological and social harm, as well as a negative impact on the course of people’s lives or a deprivation of valuable lifetime. Coercion could also lead to experiences of torture, trauma and humiliation, along with psychological brokenness, shame and social anxiety. Moreover, the side effects of medication could be severe, including physical injuries, suicidal thoughts, inability to take care of oneself, oversleeping, and loss of free thinking, creativity and sexuality.¹⁸

Paternalism

Several participants discussed coercion in connection with paternalism and freedom of choice. Few used the need for care and protection as an argument for paternalism. Rather, the overly paternalistic culture of mental healthcare was criticised. Such paternalism was considered wrong because it reduced genuine voluntariness or freedom of choice and indicated a lack of attention to patients’ views on and experiences with their own problems. This could lead to unfortunate situations, such as continuing inappropriate medication or underestimating the treatment value of other types of interventions. Martin said,

I didn’t want to begin using medication at all. I believed that milieu therapy and such things could help me out of my depression, or whatever I had. But my therapist said, ‘No, it’s going to be medication’. And I felt that I had no choice, really. And I was not even involuntarily committed. […] I didn’t think it was right then, nor do I today. [Interviewer asks why.] Because I had found it helpful to go outside and meet people, I felt I really got a boost out of it and that more of that would help me out of the situation. And it was really bad medication she put me on, as well. I think it was […] antipsychotics. […] I had a lot of side effects. Retrospectively, I find it totally irresponsible to make that decision, to put me on that medication.

Several participants also argued that the arguments from paternalism or citing patients’ ‘lack of insight’ could be used in an oppressive way to discredit patients’ opinions or abilities to participate in decision-making. For example, Mary said, ‘If I have objections towards something, I either lack insight into my illness or lack the ability to cooperate, and this is written in my medical record’. Furthermore, although some found that a lack of insight could be a problem during illness, they thought health personnel often underestimated patients’ abilities to make reasonable judgements or informed choices on their own behalves when given enough, adjusted information and time to process it. ‘Insight’ should, therefore, in their views, be understood in a more nuanced and process-oriented way because patients often gain insights into their illnesses over time.

The content of and consequences of coercion

Another key theme in the participants’ moral evaluation of coercion was the content of and consequences (or outcomes) of coercion. As Willy explained, ‘But, I think […] – and I know that many patients talk about it as well – that it is not necessarily coercion in itself that is always wrong, but the content of it’. This was also reflected in Susie’s considerations. ‘On the other hand’, she said, ‘it’s a question of what you are forced into as well. […] It’s precisely that. It has to be something that saves you’.

In line with this, participants with more approving views found that coercion (including forced medication) had led to many positive outcomes, such as being well. For example, June stated, ‘Coercion can sound negative, but it results in many positive things’. Martin also considered his involuntary hospitalisation due to depression to be morally justified because it had put him on a different track and made him more receptive to help.

Similarly, many participants related wrongful use of coercion to a lack of positive content in the coercive measures used (e.g. the content of seclusion or involuntary hospital stays) or to worse outcomes than voluntary solutions could have achieved. For example, Emma described situations in which coercion would be morally wrong in her eyes:

But what I don’t respect is being taken by force to a more or less empty, vacuous, vapid treatment, and chemicals. In a way, I can respect and accept coercion if it leads me to a place where I want to be. That is to say, when coercion results in something constructive. […] Sometimes I don’t understand what’s best for me; I’m not bothered. I lack motivation, and then I might need someone to give me a kick up the backside, to make me do what is good for me. Then, coercion is constructive. […] But the coercion I have experienced […] didn’t have anything constructive in it. Then it is totally objectionable. It is such a terrible waste of resources.

Coercion was also considered morally wrong when it obstructed patients’ own work on their recovery (e.g. by reducing their capacities to cope with difficult emotions) or when it worsened problems by increasing anger, fear, stress and psychosis (e.g. through forced passivity and social isolation during seclusion or through stimulating a vicious cycle of coercion and distrust). As Ruth explained,

Well, my experience is that I only get worse and worse and worse from the compulsory treatment that I have been exposed to. […] I just get hostile and start acting out in any way to demonstrate my opposition towards the system. And then you get punished for that, of course, and then it just gets worse.

Some participants also reported that such negative experiences contributed to loss of trust in the health services and to avoidance of seeking help. Consequently, they found that a justified use of coercion required good quality care and continuous and integrated care planning in the community to support patients and prevent further use of coercion.

Discrimination

Several participants related their moral evaluation of coercion to societal discrimination against people who are viewed as different or who have mental health problems.

Some participants argued that coercion is morally wrong according to the United Nations Convention on the Rights of Persons with Disabilities when it is used solely to secure normalisation and conformity. This can be seen in Liam’s critique of being forcibly medicated due to social disapproval of his ‘unusual’ life views:

Then you have this thing of forcing attitudes on me that I can’t answer for and that my perception of reality – it’s not approved of, so it has to be medicated away. […]. But my life views are pathologised. And that is in fact rather offending. […] I mean, it’s not approved of, and then you’re crazy. That is a quite provoking statement that is pathogenic in itself.

Furthermore, coercion was evaluated as morally wrong when people with mental illness were considered more dangerous than they actually were due to stigmatisation, resulting in overuse of police force during admissions or excessive focus on security in hospital wards (such as the use of scanning and searching) and creating unnecessary anxiety in patients.

Several participants considered it morally problematic that the legal criteria for coercion were not followed in practice, and that the use of coercion was based on biased or superficial assessments by therapists. Another problem was what participants saw as insufficient and ineffective legal protections. This made it futile for patients to raise legal complaints about what they regarded as unnecessary coercion, abuse or dehumanising care.

Several participants also found a lack of information, especially regarding medication, to be morally problematic. Some said that they had experienced a trivialisation of side effects or being refused opportunities to seek information or a second opinion during hospitalisation. This had resulted in their taking medication for years without knowing about potentially serious side effects or being unprepared for frightening side effects. For example, John pointed to the ‘tiptoeing’ side effect he experienced (called ‘tripping’ in Norwegian) from antipsychotics:

And then I was better. But a few years later, when I was walking down the street, I suddenly saw a book about the chemical power of psychiatry. And then I turn it over, and it said that Trilafon is nicknamed ‘Trippafone’. And that what they [the staff] said was just my imagination actually was real. And I bought the book and found out that I had been tricked and lied to.

Such episodes of faulty information or trivialisation of serious side effects were seen as deceitful and particularly unjustified.

Proportionality

Another main theme was the importance of a proper relationship between the kinds and scope of coercive measures used and the seriousness of patients’ mental health problems or the actual danger of harm.

Participants felt that coercion was morally justified in situations where they had been ‘really ill’ and not able to take care of themselves. Conversely, they characterised unjustified coercion as disproportionate uses of coercive measures (e.g. restraints), hard-handed physical force towards non-dangerous patients (e.g. being held down by five big, male staff members) or ‘overly heavy medications’ (often antipsychotics). Coercion was seen as especially wrong if used in situations characterised by less-disturbing behaviour, unfounded staff anxiety or lack of compliance towards rigid house rules or prescribed medication.

Disproportionate use of coercion was considered morally wrong because it was unfair and did not fulfil the legal requirements of being absolutely necessary, proportional and the only possible solution. It was also seen as wrong because it amplified the experience of coercion being a violation or punishment. Sophie explained,

Some of the episodes with mechanical restraints that I experienced almost felt like an act of kindness or care. […] But, most of the situations were different and felt more like a kind of violation, especially because punishment was a significant element. I found that, ‘If you don’t behave or if you act out in this way, then we have to punish you’. And the punishment was not proportionate to the situation at hand.

The way coercion is carried out

Most participants agreed that the way coercion is carried out is important in determining whether it is morally justified. Some described coercion as a social situation with great potential for humiliation and offence, yet in which some humiliation could easily be avoided by improving communication and care. The punitive aspect of coercion, as described by Sophie above, was an important marker for whether coercion was viewed as morally right or wrong.

The participants characterised the best ways of carrying out coercion in practice: it should be as short term and gentle as possible, the patient should be thoroughly informed and prepared, there should be dialogue and possible alternatives to coercion should be thoroughly assessed. Furthermore, it was important that participants be valued and respected and treated like human beings and that staff acknowledge and be attentive towards their problems and views. For example, Sophie reflected on her coercive experiences:

I’ve thought a lot about what characterised those coercive situations that became very dramatic and harsh. What was it that distinguished them from other situations that weren’t like that? And then I remembered individuals who showed me respect, who were nice fellow humans, who didn’t speak to me as if I were an ape from a foreign planet or something like that. But [if staff] merely took me seriously, listened to me, then things were solved in totally different ways.

Overall, coercion was more acceptable if staff were flexible, trusting, friendly and oriented towards collaboration on equal terms. In contrast, coercion was evaluated as morally wrong when done in a punitive, rigid, cold or uncaring way, leading to disempowerment, humiliation and offence. Lack of information about the use or timing of coercion (e.g. forced medication) could also increase feelings of powerlessness and fear – sometimes described as ‘torture’.

Discussion

The strength of the study is that it explicitly sought ethical perspectives on coercion from people who have experienced coercion. However, the findings are based on a small sample and thus might reflect the recruitment strategy, group dynamics or policy discourses in user settings. Yet, participants were recruited from several outpatient and inpatient settings, and the lengthy and active group interviews provided rich and varied data on individuals’ views and experiences, stimulating more systematic insight into their moral perspectives. Recruiting participants from mental health organisations outside the health services might also have contributed to participants’ free expression of their critical views.¹³

The findings in this study are consistent with previous research on patients’ views on coercion, as described in the introduction. The study shows that people with coercive experiences hold various and balanced moral views on coercion and confirms the moral significance of the way coercion is carried out^5,10
–12 Nevertheless, good staff relations are not always sufficient to transcend the intrusive and burdensome character of coercion caused by the loss of individual liberty and autonomy.^13,16,18

Moreover, the study displays that patients’ moral views on coercion are influenced by common legal and ethical discourses on coercion.³ Their considerations draw on a wide range of normative arguments from the perspectives of both human rights and medical ethics, for example, the need for care while ill, danger/harm and discrimination.^1,4 This might indicate that these normative considerations are relevant and significant for users. However, their threshold for using coercion seemed higher than that of medical professionals, and many held more critical views than professionals on the potential benefits of forced medication and paternalism.^20,21 Similar to users internationally, participants emphasised the potential harm from coercion and underlined the need for more nuanced and process-oriented perspectives on patient insight and capacity, as well as on aggression and violence.^13,16

Furthermore, the study supports the moral importance for patients of the institutional characteristics of the mental health system and the lack of voluntary alternatives to coercion.^13,16,18 It particularly underlines the moral significance of proportionality, positive treatment content and outcomes of coercion, as found in recent studies.^2,6,9 These findings accentuate the importance of including the ethical principles of ‘proportionality’ and ‘purposefulness’ in evaluations of coercion, as required by mental health law and discussed in other areas of healthcare.^22,23 The principle of proportionality requires that the level of coercive intervention be restricted to what is necessary for the situation and provide an appropriate balance between risk versus safety, benefits versus harm and autonomy versus paternalism. The principle of purposefulness means that coercion should not be used without an advance, clearly specified purpose that is adapted to the needs and preferences of the patient and supported by evidence. In short, coercion in mental healthcare should always be used as a last resort and lead to positive treatment outcomes for the patient.

Conclusion

The study shows that people with mental health problems are well able to participate in ethical discussions about coercion and should be included in such discussions. The participants’ considerations reflected the normative arguments found in prevailing legal and ethical debates on coercion. However, participants also stressed the need for more proportional and therapeutic use of coercion, a critical assessment of benefit versus harm, increased patient involvement and the development of alternative perspectives, treatment methods and solutions in mental healthcare services. Hence, the study displays the need to view coercion within a broader context to understand what is important from patients’ perspectives and to promote voluntary alternatives and legitimate care.¹³

Footnotes

Acknowledgements

The authors wish to thank NCKE and key informants for helping them to recruit participants for the study and for their valuable feedback. They would also like to give special mention to participants for sharing their views and experiences with them.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors received funding from the Norwegian Directorate of Health (2011–2016).

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