Coercive Intervention in Inpatient Psychiatry - Literature review Example

Coercive intervention in inpatient psychiatry Psychology which is the study, analysis, control and correction of human behaviors is one of the most complicated fields of study. This view relates to fact psychology involves consideration of numerous theories and ideas, some being confusing and contradicting. In addition, the different strategies though contradicting may sometimes prove effective in treating certain psychological conditions. Here, psychological conditions mean every human condition such as mental illness, conduct disorder, and behavior problem that require psychologically oriented treatment processes. Coercion is one of the many psychological strategies of treating psychologically related conditions. Coercion treatment refers to voluntary or involuntary treatment of a person in manner that is inconsistent with their desires or wishes. The common coercion methods used in treatment of psychological conditions include seclusion and restraint of the clients. Restraining a client with conduct disorder usually involves employment of crude punishment methods. Seclusion involves locking or placing clients in isolated conditions so that to keep harm away from the likely victims. This research will investigate the effectiveness of the use or coercion intervention in inpatient psychiatry. The paper will conduct reviews of literatures, and so doing, discuss methods of research. The paper will also highlight findings from the previous researches, and discuss implication. Introduction, research question, background, search process, critical analysis of discussion and conclusion will follow in that order. Introduction Coercive intervention is one of the traditional methods of psychiatry used in treatment of psychological conditions. Coercion refers to the use of compulsive strategies in the process of treating patients with psychological problems. Coercive interventions include measures such as compulsory admission and involuntary subjection to certain treatment conditions. Legislations in many countries permit compulsory admission especially when conditions justify that a client is dangerous to the life of the surrounding community. Coercive intervention has been subject to numerous controversies as to its appropriateness and effectiveness in treating clients with psychological problems. While some people have lauded the effectiveness of the technique for treating psychological conditions, other have continually faulted it. Opponents of coercive intervention concern with ethical considerations prescribed for psychological treatment. There are widespread arguments that coercive interventions are subject to abuse with psychiatrists likely to employ techniques that ruin the relationship with clients. The technique itself breaches medical ethics that agitate for respect for autonomy and choice made by individual clients (Sisti, Caplan & Rimon-Greenspan, 2013). Many clients subjected to coercive also seem to refuse and dislike the treatment strategy. To clients, the technique causes more harm than positive treatment outcomes. Proponents of coercive interventions believe that it assists in easy handling of clients with social problems that make them difficult to manage. Finding the correct view of coercive intervention especially in inpatient psychiatry requires thorough researches that involve review and critical analysis of the literature on this topic. Research question For effectiveness, it is usually appropriate that researches have questions to guide in the study and investigation process. The question for this research is: Does coercive interventions improve outcomes for patients in inpatient psychiatry? Methods JAEGAR, S. et al. (2013). Long-term effects of involuntary hospitalization on medication adherence, treatment engagement and perception of coercion. Accessed April 25, 2015. . The article employed the naturalistic multi-center observational techniques. With that technique, the researchers studied 84 involuntary and 290 voluntary patients hospitalized with schizophrenic disorder, and followed for over a period 2years including half-yearly assessments. Assessments used in the study included adherence to self-rated medication, perceived coercion, engagement in the treatment process, and externally judged adherence to medication as dictated by blood levels. During the research documented in the article, statistical analysis relied on multilevel hierarchical organization of the data. Development and level of outcomes were subject to control on the basis of socio-demographic characteristics, involuntariness, and clinical history. GEORGIEVA, I., MULDER, C. & WHITTINGTON, R. (2012). Evaluation of behavioral changes and subjective distress after exposure to coercive inpatient interventions. Accessed April 25, 2015. . The research discussed in the article took place between November 2007 and October 2010, in a psychiatrist hospital and specifically in the acute ward. The hospital that has the samples is in the southwestern Netherlands and serves 276000. The description of the hospital housing sample patients already sufficiently gives evidence of high credibility of the source of data. The methodology also included use of prospective design that examined the associations between the dependent and independent variables. The research also limited evaluation to index intervention, which made it easy to ensure high credibility of the data. The fact the local Medical Committee on ethics approved the research eliminated any doubts about the research. The fact that the research considered definition and clarification of the dependent and independent variables, and coercive intervention makes the method sufficiently clear. The domains of assessments used and that include social skills, psychological impairments, daily living activities and occupation skills, and violence are adequately appropriate for measuring the variables in the study. KJELLIN, L. & WALLSTEN, T. (2009). Accumulated coercion and short-term outcome of inpatient psychiatric care. Accessed April 25, 2015. . The study targeted 233 voluntary and involuntarily patients admitted in the acute wards of four Swedish psychiatrist establishments for a period lasting from 1997 to 1999. With this kind of spread of the samples, it is undoubted that the data collected had good reliability and validity. The method of data collection involved interviews of the admitted patients within the first five days of admission and at discharge, and after three weeks under care. Measurement of coercion based on the number of the coercive incidents. Measurement of outcomes based on both subjective improvements of the subject’s mental health and as improvement based of professionally assessed conditions as per GAF. KALLERT, T. W. (2011). Coercive treatment in psychiatry: clinical, legal and ethical aspects. Chichester, Wiley-Blackwell. The article gathered the information from published books and articles based on original researches. In fact, the article largely relied on the data findings from the EURONOMIA study. For purposes of reliability and validity, the author of the article discussed the findings in the EURONIMA project alongside other secondary materials. Search process GEORGIEVA, I., MULDER, C. & WHITTINGTON, R. (2012). Evaluation of behavioral changes and subjective distress after exposure to coercive inpatient interventions. Accessed April 25, 2015. . The search process for this article involved browsing for the words “coercive intervention in inpatient psychiatry.” KJELLIN, L. & WALLSTEN, T. (2009). Accumulated coercion and short-term outcome of inpatient psychiatric care. Accessed April 25, 2015. . The search process for the article involved browsing of the key works mainly “coercion intervention.” JAEGAR, S. et al. (2013). Long-term effects of involuntary hospitalization on medication adherence, treatment engagement and perception of coercion. Accessed April 25, 2015. . Searching for the article involved simple browsing of the key words “coercive intervention in psychiatry.” KALLERT, T. W. (2011). Coercive treatment in psychiatry: clinical, legal and ethical aspects. Chichester, Wiley-Blackwell. Browsing of the key words “coercive treatment in psychiatry” led to finding of this article. Background Coercive intervention in psychiatry has a long history. Most of the old methods of treating persons with mental disorders are now coercive and inadequate fir treatment of psychological conditions. In the traditional societies, there was a widespread belief globally that mental illnesses and disorders are results of evil spirits or magic. The first institutions for treatment of mentally ill persons came into existence in Europe during the 13th century. The purpose of the institution was to lock up the patients rather than subject them to any form of treatment. Locking the ill persons was a way to protect the society from possible aggression. Staying in the mental institution seemed very stigmatizing to the mentally ill patients. During holidays, people could paid entrance fees to see the ill people. Until 18th century upon the emergence of a French Psychiatrist name Philippe Pinel, disruptive patients were to chaining to the walls (Georgieva, Muler & Whittington, 2012). However, Philippe still used a straightjacket that was a way of intimidation to ensure patients complied with treatment. Later, Philippe began using asylum as a therapeutic way to give patients hope and confidence. The approach became famous and named moral treatment. In the 19th century, psychologists among them Sigmund Freud introduced new understanding about mental illness. Freud argued that mental illness was due to issues such as childhood trauma or inability to connect between internal and external reality. Treatment procedure was majorly verbal. However, clinicians still used a number of restrain techniques to control patients. One of the techniques was thermal therapy that involved confining of patients in warm bath using sailcloth that restricted movements. According to Georgieva, Mulder and Whittington (2012), clinicians used the technique for calming aggressive patients. In 1949, a Lisbon Nobel Prize winner named Antonio E. Moniz performed the first experiment with leucotomy in treating psychosis. Leucotomy involved cutting of connections coming from and going to prefrontal cortex. After treating approximately 50000 patients, it emerged that the process associated to with serious side effects. The complications included personality changes, paralysis, and loss of intellect. Later, other methods such electroshock therapy (ECT) and use of sedative drugs to cause immobilization, came into effect. Most European countries approve use of coercive interventions in psychiatry only when the conditions meet the standards based on the United Nation’s General Assembly’s resolution of December 1991. Part of the resolution clarified that patients have the right for treatment in the least restrictive environments characterized with least restrictive or intrusion as appropriate to the health of a patient (Millon et al., 2013). Another aspect of the resolution banned physical restraint and/or involuntary isolation of a patient unless the conditions meet the standards and procedures officially approved by a mental facility, and when it is the only treatment method available to reduce imminent harm to others or the patient (Angling, Prendergast, Farabee, 1998). When very necessary, such treatment should not prolong the period that is necessary for the purpose. The resolution also advocated for recording of reasons and manners of handling g of the patient on a day-today basis. Another aspect of the resolution directed for humane treatment and supervision by qualified professionals of the patients placed on involuntary seclusion and physical restraint. Even though there are certain exceptions, Europe, New Zealand, USA, Canada, and Australia practice mechanical restraint, forced food, seclusion, isolation, and forced medication. Currently, mechanical restraint is almost becoming unknown in the United Kingdom, as seclusion suffer ban in Italy. In Luxembourg and Austria, net beds are common methods of coercive intervention. As the some countries in the world accommodate elements of coercive model of treatment in inpatient psychiatry, the World Health Organization (WHO) is against the use of involuntary electro-convulsive therapy. The stand brings about confusion as to the best practices in handling mental health problems (Saks, 2002). Findings JAEGAR, S. et al. (2013). Long-term effects of involuntary hospitalization on medication adherence, treatment engagement and perception of coercion. Accessed April 25, 2015. . According to Jaegar (2013) index-hospitalization for involuntariness did have any effect on adherence to medication as judged by the blood levels or on the treatment engagement during follow-up with models subject to controls for clinical history and socio-demographic variables. Instead, index-hospitalization for involuntariness associated with continuous low self-rated adherence to medication. The findings of the study also showed that former patients involuntarily hospitalized often felt to be victims of coercion in many aspects of treatments during the follow-up assessments. Furthermore, the findings showed that there was no clear difference between involuntary and voluntary patients upon consideration of the experiences of coercion over time or levels medication adherence. KALLERT, T. W. (2011). Coercive treatment in psychiatry: clinical, legal and ethical aspects. Chichester, Wiley-Blackwell. A EURONOMIA project conducted between 2002 and 2006, and targeting 12 centers spread in 13 countries studied the effects of coercion on 2326 patients involuntarily admitted to the mental departments of hospitals (Kallert, 2011). The project employed interview within the first week, one month and three months of admission of the patients. The purpose of the interviews was to understand the perception of the patients about the effectiveness of the involuntary admission. About 39% to 71% of the patients in the different countries considered the admissions as appropriate after one month. After the third month, about 46% to 86% of the patients in the different countries perceived involuntary admission as appropriate. Single females and patients with schizophrenia reported negative results with respect to the admissions. The variation in the results across countries at to the appropriateness of involuntary admissions depended on the legislations on mental health. According to the research, the level of perceived coercion was high the participants. Female subjects recorded higher levels of perceived coercion probably among due to their feelings of vulnerability. As time increased, there was an improvement in the level of perceived coercion. As evident from the results, patients interviewed after one month demonstrated slightly lower support for the admission compared to those interviewed after three months. Kallert (2011) confirms that perceived coercion had negative implication on treatment outcomes due to its likelihood to ruin therapeutic relationships. According to Kallert (2011), the frequent reasons that necessitate application of coercive treatment are aggression other people (59%), threat to personal health (27%), aggression on property (24%), auto-aggression (22%), escape (13%), and the inability to ensure self-care at 11%. In many countries, physicians decide the use of coercive treatment on 91% of mental health problems, with 71% likely to write forms to the effect of the decision. Kallert (2011) elucidates that it is only in England that nurses have the privilege at (41%) to order for psychiatric treatment. GEORGIEVA, I., MULDER, C. & WHITTINGTON, R. (2012). Evaluation of behavioral changes and subjective distress after exposure to coercive inpatient interventions. Accessed April 25, 2015. . The results from the research showed that 125 patients were subject to coercion through the period of the research. About 65% of the subjects were males, 69% involuntarily hospitalized, 72% were Dutch, and 75% were single. Patients suffering from psychotic disorder were 39%. Those diagnosed with mood disorder represented 33%, addiction 26%, personality disorder 12%, and post-traumatic disorder 4%. About 37% of the subjects admitted to be victims of coercion during the previous time in the hospital. As at the study time, 52 patients had received forced medication. According to the article, the Dutch’s Mental Health Act allows psychiatrists to apply five methods of coercive treatment in inpatient psychiatry. Nonetheless, psychiatry has to prove that reasons for coercive treatment and the last options to ensure safety to the client and immediate environment. The five methods are as follows: Seclusion Involuntary medication Isolation Mechanical restraint Forced feeding The study found a significant improvement in effectiveness all groups of intervention after subjection of the patients to coercion for 24 hours. However, it was evident combined coercive interventions were less effective compared to single coercive intervention. Of the groups of coercive interventions, coercive medication is the most appropriate for the clients. The research also found that coercive methods other than seclusion and/or mechanical restraint were much effective for treating clients with different conditions. KJELLIN, L. & WALLSTEN, T. (2009). Accumulated coercion and short-term outcome of inpatient psychiatric care. Accessed April 25, 2015. . The research published in the article found that 37% of the 233 subjects reported no coercive incidents, 11% reported 1 coercive incident, 14% (2 incidents), 10% (3 incidents), 9% (4 incidents), 10% (5 incidents), 7% (6 incidents), and 2% (7 incidents). Improved patients classified alongside conditions were 36% (psychosis), 43% (mood disorders), and 20% (other diagnoses). The corresponding percentages for unimproved patients were 34%, 29% and 39% in that order. Subjective improvements did rely on the coercive incidents. In addition, assessed improved based on GAF did not rely on coercive incidents. Patients with other diagnoses has high tendency to be improve subjectively. Implications One of the implications of the findings by published in the articles is that involuntary hospitalization does not impair future engagement of patients with schizophrenia during treatment. However, former patients hospitalized involuntarily are sensitive to real coercion into treatment and more likely not to adhere to medication. For the reason, former patients are in a high risk of involuntary hospitalization in the future. Another implication is that there are no clear lines as the effectiveness of coercive intervention in psychiatry. This lack of clarity is due to the variation in results at every instance of varying the study techniques and variables. Discussion Coercion refers to the use of force or compulsive strategies to induce somebody into doing things they do not like. Coercion has been great issue in the field of psychiatry and debates around the issue continue to exist despite great extensive efforts and campaigns to settle the issue of coercion. Coercive treatment in inpatient psychiatry is a real matter of discussion considering numerous mixed expressions. It is true that mental illness compromise ability of victim to make rightful decisions that are good and safe for their health (Jaegar et al., 2013). This fact ethical places psychiatrists at the position to plan and dictate treatment procedures to the patients. In some instances, coercive treatment becomes an option settled upon by legal practitioners, usually judges. Many mental health laws acknowledge the impact of coercive treatment in inpatient psychiatry, and have measures to ensure safety (Elder, Evans & Nizette, 2009). For instance, most of the mental health legislations allow admission of a person in inpatient psychiatry when satisfactorily determined that the patient poses imminent danger to self and immediate community. Even though involuntary admissions are diminishing due to laws established to discourage, it is apparent that even the voluntary admissions sometimes become coercive. The coercive aspect comes about due to the attempts by psychiatrists to use their knowledge attend to the patients. In some cases, patients may demand planning of treatment or medications that case managers consider unsafe (Feiring & Ugstad, 2004). Even though the situation may cause coercive issues, it is the ethical and professional responsibility of a psychiatrist to ensure safety of the patients. Medical activities in the recent times have steadily shifted from doctor-directed care to information sharing and independent and autonomous decision-making by patients. Generally, this trend has appeared to both progressive and positive to doctors and patients. The view has worked greatly in increasing well being among patients. Subsequently, the field of psychiatry has witnessed a spontaneous shift from the asylum based care to more humane community based care for the mentally ill persons (Richard & Lauterbach, 2007). In the transformation process, many governments have enacted mental health legislations with the intention to protect patients and the surrounding public (Hamlin, 2015). Despite the transformations in the psychiatry, many patients with mental and conduct disorders have continuously felt coercion in the hands of psychiatrists. This aspect has led societies into viewing community-based care as modern form of psychiatry coercion (Kirk, Gomory & Cohen, 2013). Legislation like the Mental Health Act directs for locking of mental patients into hospitals’ psychiatry and application of community-based treatment orders that community patients must accept. Such legal elements work to limit autonomy and liberty, and instead coerce patients into accepting management of psychiatry. Patients with psychiatric diagnoses report less satisfaction with medical and psychiatric hospitalization and primary care than patients with any psychiatric diagnoses. A coercive treatment is the main cause of patients’ dissatisfactions with inpatient psychiatric care. For instance, people committed involuntary or perceive involuntary commitment report significantly less satisfaction with inpatient care than others who perceive their commitment to be voluntary (Klejjin & Wallsten, 2009). Many empirical studies have showed that patients voluntarily admitted to health care institutions reported high levels of coercion than the involuntarily admitted ones. For that reason, it becomes difficult to use involuntary to measure or detect level of coercion in psychiatric treatment. One study involving interview of 104 people with schizophrenic spectrum disorders found that about 36% of the patients expressed fear seeking treatment in mental health institutions because of coercion. Research conducted by Strauss et al. (2013) targeted about 240 inpatients with psychiatric conditions. Approximately 14.6% were involuntary patients to health care centers. About 40.34% of the subjects were victims of prior involuntary admission. About 50% of the population expressed perceptions of some coercion during admission. Reports about forced medication reached 22.03% while 45.61% reported being under the company of law enforcement officers into the hospital emergency rooms (Strauss, 2013). Issuance of forced medication and denial of requested medication by inpatients appeared as coercive to the inpatients, and subsequently unsatisfying. A survey of 173 inpatients discharged from a Swedish hospital reported that individuals who participated in their treatment plans demonstrated higher satisfaction than those denied participation. Positive treatment outcomes manifest when there are certain elements of satisfaction and ease among patients. From the findings, it is clear that satisfaction among patients in psychiatry inpatient is possible in case of minimum or no coercion (Brewerton & Dennis, 2014).Individuals who report high satisfactions tend have a greater participation in the treatment process. Through patient participation, the relationship with psychiatrists becomes close to facilitate effective communication. The challenge with research on the effectiveness of coercive intervention in inpatient psychiatry is the lack of conclusive data (Swartz et al., 1997). Most of the sources used in the research lack concrete data to help in understanding the level of effectiveness of coercion in treating mental health problems. Much of the discussion are qualitative, and denies a person the crucial qualitative data that can provide strong evidence as to the claim. However, the data present in most of the published articles seem to condemn use of coercion in inpatient psychiatry. Researchers in this field should embark on determining the actual implications of the coercion in inpatient psychiatry to confirm the theoretical explanations of relationship between positive patient recovery and friendliness of psychiatrists (Scheid & Brown, 2010). Another issue requiring further determination is the short-term and long-term effects due to coercion when applied in voluntary and involuntary admission for treatment. According to Strauss et al. (2013), depending on mode of admission, coercion can have positive and negative and effective effects on short-term and long-term duration. In that case, it is not right to subject coercion to outright condemnation. According to Strauss et al. (2013), use of coercion on violent clients upon involuntary admission can calm the patient and enable psychiatrists gain the opportunity to understand their conditions and plan for effective treatment. Conclusion Coercive treatment involves compulsive and forceful admission, and dictated treatment plan. Coercive treatment in inpatient psychiatry disregards autonomy of the patient under treatment. The technique involves seclusion and physical restrain of mentally ill people to ensure safety of the individual patient and the whole society. The concept has been subject to numerous controversies with debates featuring ethical practices and human rights. Psychiatrists have ethical responsibility to ensure maximum safety and wellbeing of their patients. In that line, they have the discretion to decide the best mode of treatment to manage their clients. Some clients with mental illness may be aggressive, unreasonable, antisocial, and violent beyond the manageability of psychiatrists. In some cases, courts may order for involuntary admission of patients for psychiatric care. Irrespective of the nature of admission, as either voluntary or involuntary for inpatient psychiatry, coercion becomes imminent in inpatient psychiatry. This view applies particularly in situations where the patient is aggressive and the only ways to ensure effective management are use of forced medication, physical restraints, and seclusion. However, coercion has not been an effective mode of treatment in inpatient psychiatry. Coercion used in voluntary or involuntary inpatient psychiatry is generally ineffective. Good relationship and understanding between patients and clinicians are usually important in quick and sustainable recovery. Coercion rules out possibility of having good relationship with patients in inpatient psychiatry. Instead of supporting effective recovery, coercion is likely to worsen patients’ conditions. Coercion has proved to re-traumatize clients, cause helplessness, mistrust, punish, and disrupt therapeutic alliance. 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