Patients’ moral views on coercion in mental healthcare

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.

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 ethics ¹⁴ 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.

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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.

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.

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.

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.

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.

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.

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.

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.

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.