paternalism and autonomy: a presentation of a nordic study on the use of coercion in the mental...

Paternalism and autonomy:

A presentation of a Nordic study on the use of coercion in

the mental health care system

Georg Hyera, Lars Kjellinb,*, Marianne Engbergc,Riittakerttu Kaltiala-Heinod, Tore Nilstune,

Maria Sigurjonsdottirf, Aslak Syseg

aProfessor, Institute of Community Medicine, University of Troms, N-9037 Troms, NorwaybResearch Manager, Psychiatric Research Centre, Orebro County Council,

P.O. Box 1613, SE-701 16 Orebro, SwedencAssociate Professor, Department of General Medical Practice, Aarhus University, DK-8000 Aarhus, Denmark

dProfessor, Tampere School of Public Health, University of Tampere, SF-33014 Tampere, FinlandeAssociate Professor, Department of Medical Ethics, Lund University, SE-222 22 Lund, Sweden

fPsychiatrist, Blakstad Psychiatric Hospital, N-1371 Asker, NorwaygProfessor, Department of Public and International Law, University of Oslo, N-0130 Oslo, Norway

1. Introduction

Though coercion is widely used in psychiatry, both in terms of involuntary hospital

admissions and coercive treatment, little is known about the effects of coercing patients. In

spite of this lack of knowledge, mental health acts worldwide authorize civil commitment to

mental hospitals. The justification for the use of coercion is basically a belief that coercion

works, meaning that compulsory treatment improves the outcome compared to the outcome

with no (coercive) intervention. In accordance with medical ethics, the moral obligation to

reduce suffering also plays an important role in justifying the use of coercion in psychiatry.

The underlying belief is that patients suffering from serious mental disorders usually are

unable to understand their needs for treatment, thus justifying paternalistic interventions, i.e.,

well-intended interference with a persons liberty of action. Medical, or more generally,

individual paternalism occurs when an action against a person is done in the interest of the

person. Social paternalism means that the action is done in the interest of others (Kjellin &

0160-2527/02/$ see front matter D 2002 Elsevier Science Inc. All rights reserved.

PII: S0160 -2527 (01 )00108 -X

* Corresponding author. Tel.: +46-19-602-58-89; fax: +46-19-602-58-86.

E-mail address: [email protected] (L. Kjellin).

International Journal of Law and Psychiatry

25 (2002) 93108

Nilstun, 1993; Nilstun, 1997), and may be justified, for instance when mental patients are

dangerous to others. At the same time, coercion is believed by many to be potentially harmful

and to have serious negative effects. Nevertheless, recommendations applying specifically to

the field of psychiatry acknowledge that the use of coercion sometimes is unavoidable and

may be used as a last resort, even if such interventions violate human right ideals (Council of

Europe, 1950, 1983, 1996; United Nations, 1948, 1966, 1991; World Psychiatric Association,

1996). On this background, there is an obvious need for research exploring whether the

existing beliefs concerning the effects of coercing patients are right or wrong.

In this article, we will present a study called Paternalism and AutonomyA Nordic

Study on the Use of Coercion in the Mental Health Care System. There has been a growing

interest in research on involuntary psychiatric hospitalization in the Nordic countries over the

last years. A pioneer study of Danish case records was done by Adserballe (1977), and in the

1980s and 1990s studies on the use of coercion have been performed in all of the Nordic

countries (Engberg, 1994; Gudmundsson & Stefansson, 1989; Hyer, 1986b; Kaltiala-Heino,

1995; Kjellin, 1996; Westrin, Nilstun, Axelsson, et al., 1990). The current study is a joint

study involving all the five Nordic countries (Denmark, Finland, Iceland, Norway, and

Sweden) and consists of three major research areas. One concerns the moral and legal

justification for civil commitment, the second is epidemiologically oriented comparing

commitment rates between and within the countries, and the third part focuses on the

patients perception of being coerced in relation to their hospital admission. In this article,

we will discuss methodological issues related to research on the use of coercion in

psychiatry, as well as presenting design and methods applying to the Nordic study. Special

attention will be paid to conceptual and methodological problems related to the measurement

of perceived coercion.

2. How can coercion be measured? Conceptual and methodological issues

2.1. What is coercion?

One of the reasons we lack empirical knowledge about the impact of coercion, is that the

concept of coercion is poorly defined. What is coercion? When reviewing the literature it

becomes quite clear that the concept of coercion is defined in many ways. In older studies

coercion has, with a few exceptions, been treated as identical to the legal status of the

patient. In a very simple way, such studies have relied on the assumption that those who

have been civilly committed are subjected to coercion, while their voluntarily admitted

counterparts are not. However, a number of more recent studies have demonstrated that a

substantial proportion of voluntarily admitted patients report they have been subjected to

coercion, and some committed patients do vice versa believe they are hospitalized on a

voluntary basis (Beck & Golowka, 1988; Edelsohn & Hiday, 1990; Engberg, 1994; Gilboy

& Schmidt, 1971; Hyer, 1986a,b; Kaltiala-Heino, 1995; Kjellin, 1996; Monahan, Hoge,

Lidz, et al., 1995; Rogers, 1993). These studies have made it quite clear that the legal status

of the patient is a poor measure for coercion. Based on this knowledge, recent research has

G. Hyer et al. / International Journal of Law and Psychiatry 25 (2002) 9310894

concentrated on perceived coercion in order to identify what kind of events patients

experience as coercive (Hoge, Lidz, Gardner, et al., 1997; Lidz & Gardner, 1995; Marlowe,

Kirby, Boniesky, et al., 1996; Monahan et al., 1995). This is a necessary first step in order

to develop a more valid and reliable concept for coercion, and a necessary prerequisite

before the impact of coercion on outcome can be explored in future studies (Monahan

et al., 1995).

2.2. How to measure subjective dimensions

One of the first methodological challenges we faced was how to measure perceived

coercion. All efforts to explore subjective dimensions, like for example quality of life,

consumers satisfaction or, as in our case, perceived coercion, face the same problem: Is it

possible to measure such subjective dimensions objectively? The intriguing fact that there is

no clear relationship between objective standards of some phenomena like good health,

standard of living, etc. and subjective well-being, makes this problem difficult (Ruggeri,

Warner, Bisoffi, & Fontecedro, 2001). Some people who, by all reasonable judgements, live

miserable lives, sometimes feel they have a good quality of life and vice versa. This

seemingly paradox applies to patients perception of being coerced as well. The poor

relationship between the patients legal status and their own opinion of their legal status

has already been mentioned. Even more surprising, a Swedish study demonstrated that some

voluntarily admitted patients, who according to the medical records had not been subjected to

any kind of coercive measures, in their self-reports claimed they had been coerced during

their in-patient period (Kjellin & Westrin, 1998). This finding further underlines the poor

relationship between perceptions and objectively recorded events.

The observed lack of correspondence between objective and perceived coercion may partly

be due to limitations in what usually is included in the coercion concept. In the referred

Swedish study (Kjellin & Westrin, 1998), observed coercion included the use of formally

approved forced medication and the use of seclusion or restraint. These measures are clear-

cut, easy to observe, and can be objectively recorded. Objective coercion can, however, be

less clear-cut and accordingly more difficult to record (Kaltiala-Heino, Laippala, & Salo-

kangas, 1999). Medication may for instance formally be taken on a voluntary basis, while in

reality various degrees of pressure are applied leaving patients in a no-choice position. The

more coercion is integrated in the structure of care and treatment, the more difficult it will be

to identify and record such coercion.

Most of the instruments used to measure subjective dimensions, like quality of life, general

well-being, psychometric measures, etc., provide one index score describing the level of the

actual subject being studied. It is generally believed that indexes, including multiple

dimensions constitute a better instrument compared to more simple measures.

The most-used instrument measuring perceived coercion, the MacArthur Perceived

Coercion Scale (MPCS, see below) is constructed according to this principle, providing a

single score based on five items. In the Nordic study, however, we wondered if one single

global measure for perceived coercion could replace more complex measurements without

loosing vital information or validity. In spite of the recommendations to use indexes, some

G. Hyer et al. / International Journal of Law and Psychiatry 25 (2002) 93108 95

support for this kind of simplification can be found in the literature (Gill & Feinstein, 1994;

Mastekaasa, Moun, Naess, & Srensen, 1988). We ended up using both the MPCS, and a

single global measure for perceived coercion in the Nordic study. Both instruments will be

described in more detail below.

It has also been argued that the quality of life concept consists of (at least) two different

dimensions, one objective dimension including elements like standard of accommodation,

level of income, health status, etc., and one subjective dimension encompassing perceived

well-being (Muldoon, Barger, Flory, & Manuck, 1998). The authors strongly recommend

treating the two factors as two different variables. The same principle obviously applies to

measurements of other subjective dimensions. Regarding measurements of perceived

coercion, the implication would be to keep observed coercion apart from self-reports of

the feeling of being coerced (perceived coercion).

2.3. Measures of perceived coercion and related concepts

When we looked into previous attempts to measure perceived coercion, we identified three

instruments designed for this purpose, namely the MPCS (Gardner, Hoge, Bennet, et al.,

1993), The Circumstances, Motivation, Readiness, and Suitability Scale (De Leon, Melnic,

Kressel, et al., 1994), and The Coercion/Noncoercion Matrix (Marlowe et al., 1996). While

the MPCS has been applied by different research groups and seems to reveal sound

psychometric properties, the two last mentioned instruments have only been used once each

and will not be further commented on in this article.

We also found a number of earlier studies addressing patients experiences of their

treatment and care in more general terms (Adams & Hafner, 1991; Bradford, McCann,

& Merskey, 1986; Conlon, Merskey, Zilli, & Frommhold, 1990; Kalman, 1983; Toews,

El-Guebaly, Leckie, et al., 1981, 1984, 1986; Weinstein, 1979). Some of these studies

concentrated on patients satisfaction (or lack of satisfaction); others focused more on

specific experiences related to hospital admission and care. These studies did almost

without exception construct their own instruments in order to measure patients satisfaction

or other subjective attitudes to psychiatric treatment. In Sweden, Hansson, in cooperation

with the Swedish health authorities, has developed a patient satisfaction questionnaire (the

SPRI patient satisfaction questionnaire, Hansson & Hoglund, 1995). Both inpatient and

outpatient versions exist. The inpatient version is composed of 44 self-administered, mostly

structured questions, of which five questions are relevant to the use of coercion and process

control. It is not surprising that there is a close association between patient satisfaction and

perceived coercion, and a study using the SPRI instrument accordingly found that the

strongest predictor of low satisfaction with all aspects of the in-patient period was perceived

coercion (Svensson & Hansson, 1994). The interesting question in our context is the

relation between measurements of patient satisfaction and perceived coercion, and to

what degree these concepts are overlapping. The same question can be asked concerning

concepts like violation of integrity, self-determination, and autonomy, just to

mention some of the concepts commonly used when coercion in psychiatry is discussed

(Kjellin, Westrin, Eriksson, et al., 1993; Nicholson, Ekenstam, & Norwood, 1996;


Vallimaki, Leino-Kilpi, & Helenius, 1996). The problem with all the concepts mentioned

above is that they are abstract, hard to define, and difficult to operationalize. The great

number of self-constructed instruments and their lack of standardization has been pointed to

as a serious problem in research on patients attitudes and perceptions (Hiday, 1992, 1996;

Hiday, Swarz, Swanson, et al., 1997; Kalman, 1983). In this situation, the need to refine

research instruments was obvious, especially as the importance of perceived coercion has

been acknowledged.

2.4. The MacArthur Perceived Coercion Scale

The scale consists of five statements to be answered in a true/false format. The five

questions are extracted from the Admission Experience Survey (AES), originally comprising

104 items, but later revised into a 41-item version (Gardner et al., 1993). The literature on the

MPCS is somewhat confusing for an outsider with regard to different names and versions.

Some of this confusion is caused by the fact that the instrument, and the context in which it is

used, has changed as the MacArthur coercion study has developed. Most studies using the

MPCS have applied a 15-item version of the Admission Experience Interview (AEI) or the

much longer AES where the five (or sometimes four) MPCS questions have been

incorporated. Yet, the other 10 items comprising the 15-item version of the AEI vary, which

is another confusing aspect of the AES/AEI/ MPCS instrument.

The AES/AEI/MPCS has been reported to have good psychometric properties, is not

time-consuming, is well understood by the patients and works well in different settings

(Gardner et al., 1993; Siegel, Wallsten, Torsteinsdottir, & Lindstrom, 1997). The questions

included in the MPCS all bear high loadings on the perceived coercion dimension, and the

patients answer the perceived coercion questions in a highly consistent way. It is important

to remember though, that these findings are not a proof of validity, meaning that we still do

not know if the MPCS questions constitute the best way of measuring perceived coercion.

The MPCS may for instance be more sensitive to inequity matters in the decision-making

process, than the impact of the factual use of coercion during admission and hospitalization.

2.5. Changes in perceived coercion over time

Another aspect to take into consideration is changes in patients perceptions over time

(Edelsohn & Hiday, 1990; Gardner, Lidz, Hoge, et al., 1999; Kaltiala-Heino, 1997; Kane,

Quitkin, Rifkin, et al., 1983; Toews et al., 1986). The usual pattern is that patients express less

negative attitudes towards the admission and treatment as time goes by. Because of these

changes, it is important to underline at what time measures of perceived coercion are made.

Fig. 1 illustrates different stages in a treatment episode. As can be seen from this figure, the

preadmission period includes extremely important deliberations and decisions, determining

the next steps to be taken in the actual situation. Impression from interviewing acutely

admitted patients in Norway indicate that patients are much more upset about negative

pressures and coercion used outside the hospital during the admission process compared to

their feelings about being confined in the hospital (Hyer, 1999). The same impressions are


reported from the MacArthur studies (Hoge, Lidz, Eisenberg, et al., 1997). If these impressions

hold true, one should look separately into the admission period and the in-patient period in

order to understand the dynamics of perceived coercion. It is also reasonable to conclude that

perceived coercion measurements should be made longitudinally (i.e., more than once) during

a treatment episode.

3. Paternalism and AutonomyA Nordic Study on the Use of Coercion in the Mental

Health Care System: Aims and general design

The Nordic study called Paternalism and AutonomyA Nordic Study on the Use of

Coercion in the Mental Health Care System has been carried out in all the five Nordic

countries. The core part of the study is confined to questions related to deprivation of

liberty (involuntary admissions). In addition to the core study, each participating country

could add topics of special national interest, and such studies have been added in Finland,

Norway, and Sweden.

The overall aims of the study are: (1) to identify the justification for the use of coercion as it

appears in the mental health acts and other legal documents in the Nordic countries, (2) to

study the reliability and validity of public statistics on civil commitments, and (3) to explore

what constitutes the concept of coercion by looking at the kind of events and circumstances

determining the patients perception of coercion. The core study includes, in accordance with

the threefold aim, three levels described below. The three levels are harmonized in a way

that make comparisons across levels possible, both within and between countries. The general

design of the study is schematically shown in Fig. 2. The study has been approved by ethical

review boards in each participating country.

Fig. 1. The admission process.


3.1. Level 1: How is paternalism (the use of coercion in the mental health care system)

justified? Value conflicts and legal regulations

To explore how the use of coercion is justified, we have studied legal documents, i.e., laws,

preparatory papers, official recommendations, instructions, and court cases. The methods

applied in this part of the study include textual analysis and interviews with ethicists, lawyers,

and physicians from each of the Nordic countries. Two international coordinators, a medical

ethicist and a lawyer, have made the comparative analysis of the material from all the five

countries. They visited all the participating countries and interviewed key persons on their

views about the value base underlying the different mental health acts and if the law was

practiced in harmony with these values.

This part of the study was carried out between 1995 and 1997 and some of the results have

been published (Nilstun & Syse, 2000; Syse, 1999; Syse & Nilstun, 1997). A major finding

was that in spite of varying degrees of coercive powers of the different mental health acts, the

Fig. 2. The general design of the core study.


agreement among the interviewed professionals on when civil commitment was justifiable

and striking. The Level 1 analysis will provide a useful frame of reference when the empirical

results of Levels 2 and 3 of the study will be discussed.

3.2. Level 2: Reliability and validity of public statistics on civil commitments

It has been well established that formal involuntary hospitalization varies greatly between

countries (Bagby, 1987; Engberg, 1991; Hyer, 1985; Kaltiala-Heino, 1995; Monahan et al.,

1995; Riecher-Rossler & Rossler, 1993). There are a number of methodological problems,

however, in comparing data on formal involuntary hospitalization between nations (Engberg,

Kaltiala-Heino, Hyer, et al., 2001). Reports from Denmark, Finland, and Sweden indicate a

decrease in commitment rates during the last decades (Engberg, 1990; Kaltiala-Heino, 1995;

Kjellin, 1997), while Norway has seen an increase (Hatling & Krogen, 1998). According to

available public statistics, commitment rates vary between 29 per 100,000 inhabitants

(Denmark) and 195 per 100,000 inhabitants aged 18 or above in Norway (Hatling & Krogen,

1998). When interpreting such data, one must be aware of the impact of differences in the

coercive powers of various mental health acts, as well as numerous other factors, like for

instance the organization, quality, and capacity of all kinds of medical and social services and

differences in the interpretation and practical application of the legal criteria authorizing the

use of coercion. For those reasons, it must be emphasized that differences in commitment

rates across jurisdictions do not necessarily reflect differences in the level of coercion of a

country. Another issue is the great variations in commitment rates and quotas within nations

or jurisdictions reported by many authors (Engberg, 1991; Kjellin, 1997; Kokkonen, 1993;

Ostman, 1983; Riecher-Rossler & Rossler, 1993). Attempts have been made to explain such

regional variations by demographic factors (Malla & Norman, 1988; Miller & Fiddleman,

1983) or by the structure and available resources of services (Engberg, 1991; Faulkner, Mc

Farland, & Bloom, 1989; Kjellin, 1997; Kokkonen, 1993; Malcolm, 1989; Ostman, 1983;

Pylkkanen, 1987). None of these studies, however, offer a comprehensive explanation of the

main factors contributing to the reported differences.

In Level 2 of the Nordic study data from medical records and related documents are

registered in a uniform way in all the Nordic countries with a registration form developed for

the study. The analysis will provide uniform measures of any period of legal deprivation of

liberty during a defined treatment episode. The reliability of public statistics is studied by

comparing consistency and completeness of public data of involuntary and voluntary

admissions with data recorded in the Nordic study. The validity is studied by exploring if

procedures for compiling public statistics are able to identify any period of involuntary

admissions during a treatment episode. A more detailed presentation of Level 2 is given in

another article (Engberg et al., 2001).

3.3. Level 3: Patients perceived coercion

We decided to use a core interview, identically performed in all the five participating

Nordic countries. The core interview was carried out between the first and fifth day after


admission. According to the inclusion criteria, all patients between 18 and 60 years of age

were eligible for inclusion in the study regardless of their legal status (i.e., both formally

voluntarily and involuntarily admitted patients). Forensic patients, patients with a primary

diagnosis of substance abuse, and patients who obviously were too disturbed to understand

what the interview was about or unable to communicate for other reasons were the only ones

to be excluded. We ended up doing 995 interviews.

The interview schedule comprised of five parts: (1) an interview specially designed for the

actual study, named the Nordic Admission Interview (NORAI), (2) a visual analogue scale

measuring a global score for perceived coercion, (3) the MacArthur AES (including the

MPCS; Gardner et al., 1993), (4) the Global Assessment of Functioning Scale (GAF) (APA,

1987), and (5) the Brief Psychiatric Rating Scale (BPRS) (Overall & Gorham, 1962). In

addition, file information including demographics, diagnosis, admission, legal status,

medication, and type of ward was collected from the hospital records. An overview of the

elements included in the core interview is given in Table 1. In the following, we will

describe in more detail the elements of the interview schedule originally designed for the

Nordic study.

3.3.1. The Nordic Admission Interview

The NORAI was constructed by selecting the questions that worked best in previous

studies carried out in Denmark (Engberg, 1994), Finland (Kaltiala-Heino, 1995), Norway

(Hyer, 1986b), and Sweden (Candefjord, 1989; Kjellin, 1996). We agreed to exclusively

focus coercion related to the deprivation of liberty in relation to admissions to mental

Table 1

The Nordic study on the use of coercion in the mental health care system

Number

of items Comments

NORAI 16 The sum of questions for each category is greater

Transportation to hospital 5 than 16, because some items have sub-questions

Self determination 8 and some items cover more than one category

Reason for admission 4

Awareness of own legal status 4

Restrictions of freedom 2

Violation of integrity 1

AES 15

MPCS 5

BPRS 16 Additional questions were asked if the interview did

not provide enough information

GAF Scores range from 1 to 90, 90 is the best possible score,

while 1 is the worst

File information 16 Sex, age, type and size of ward, medication, diagnoses,

legal status, and duration of stay

Elements included in the core interview on the patients perceived coercion.


institutions, thus leaving out the exposure to forced treatment, seclusion, restraint, or other

kinds of coercion. The NORAI questions are simple and concrete, thus making the interview

work even with very disturbed patients interviewed shortly after admission. The interview

consists of 16 questions covering the following areas: The transportation to the hospital, self-

determination in the admission process, perception of need for treatment, reason for

admission, awareness of own legal status, restrictions in freedom to leave the hospital or

the ward, and violation of integrity.

3.3.2. The global score for perceived coercion

When we considered a single measure for perceived coercion, we decided to use a visual

analogue scale. We used a modified version of the Cantril Ladder (Cantril, 1965). The

ladder (Fig. 3) is shown to the patient and the patient is asked to mark the degree of perceived

coercion on the ladder after the following instruction is read to the patient:

When a person gets admitted to a mental hospital or ward, different things will be of

importance in each case. In some cases, a lot of pressure and even physical force is used when

a person is admitted, while in other cases patients come to the ward totally at their own will. If

you think of your own admission to this hospital this time, try to consider if you were

subjected to any kind of coercion, threats, pressure, or inducements. Then try to figure what

step on the ladder shown below that best corresponds with the amount of pressure from others

you experienced when admitted, and mark the step with an X. For instance, if you came

entirely on your own initiative put an X on step 1, but if you were subjected to the maximum

use of coercion, then you put the X on step 10.

3.4. Experiences with the use of the Nordic Admission Interview

We have been positively surprised how well the interview has functioned in practice in all

of the participating countries. Taking into consideration that a substantial number of acutely

Fig. 3. The Coercion Ladder (adopted from the Cantril Ladder; Cantril, 1965).


admitted patients are in a psychotic state, we were afraid that many patients would be unable

to comply with the interview requirements, but this has not been the case. Especially the

NORAI and the Coercion Ladder worked well. Patients did almost without exception

understand the procedure for marking the ladder and fulfilled the task without much

hesitation. In most cases, the time needed to complete the whole interview schedule has

been between 30 and 45 minutes, and even very disturbed patients stayed focused and

completed the interview.

The experience with the AES has been more mixed. Originally, the AES is composed of

statements, requiring respondents to answer in a true/false format. We early recognized that

we had to change the statements into questions (which is allowed according to the AES

manual; Siegel et al., 1997). The question format asking for yes/no answers worked much

better, but still many patients found it hard to comprehend the questions, and were somewhat

reluctant to complete the AES. Experiences with the use of the AES from the USA are much

better compared to what we have experienced in the Nordic countries, but we have no good

explanation why this is the case. Our feeling is that the AES is too intellectually demanding

for acutely ill persons suffering from serious mental disorders.

4. Preliminary results and implications for further research

Preliminary data from all Nordic countries suggest that perceived coercion tends to be a

dichotomized phenomenon, measured both by the MPCS and the Coercion Ladder, and this

dichotomized pattern remains even when formally voluntarily and involuntarily admitted

patients are studied separately. This is a somewhat surprising finding, as it from a theoretical

point of view seems reasonable to expect that perceived coercion should be graded and

normally distributed (Carroll, 1991; Gardner et al., 1993; Hiday et al., 1997; Nicholson et al.,

1996), especially when measured on a visual analogue scale like the Coercion Ladder. It is

interesting, though, that two studies from North America have found the same dichotomized

pattern regarding perceived coercion (Hiday et al., 1997; Lidz, Hoge, Gardner, et al., 1995).

The implications of these findings are still unclear. One explanation for the dichotomized

distribution of the MPCS could be that this scale deliberately has excluded all measures of

objective (factual) coercion, thus making the MPCS completely related to the emotional

components of patients experiences. However, if adding factual use of coercion should

produce a more normally distributed pattern, this should be reflected in the Coercion Ladder,

which was not the case. Thus, at this stage we are unable to produce a good explanation for

the bimodal distribution of perceived coercion. Hopefully, the final analysis of the Nordic

data will be able to provide a better understanding of this somewhat surprising phenomenon.

In this process, questions about flaws in the instruments used to measure perceived coercion

must be asked, or if perceived coercion really is a dichotomized phenomenon and, in this

way, more resembles the concept of integrity. In moral philosophy, integrity can never be

gradedit is either preserved or violated (Kant, 1785; Hermeren, 1994). In this context, the

relation between perceived coercion and integrity emerges as an interesting topic to explore in

the future.


5. Conclusions and importance of the study

Before the impact of coercion on the outcome of psychiatric treatment can be studied,

future research should give priority to refining the definition of perceived coercion and to

identify and operationalize the relevant, independent variables, explaining why some mental

patients feel more coerced than others. Based on existing empirical evidence, special attention

should be given to what happens during the admission process. Concepts like procedural

justice, process control, fairness, (in)equity, process exclusion, voice, influence, pressure,

threats, autonomy, dignity, validation (of patients opinion), respect, power disparity,

asymmetry, etc. have been used to describe important determinants for perceived coercion.

These determinants are probably trying to describe some of the essential elements determin-

ing a patients feeling of being coerced. However, we still do not know what these essential

elements are, neither in terms of factual circumstances, decision-making, or communication.

In this respect, the interaction between the (potential) patient and others involved in the

admission process (family members, social workers, health professionals, police, etc.) should

be emphasized in future research. We also recommend that measures of factual coercion and

perceived coercion are measured separately and that those measures are repeated using a

longitudinal design.

Hiday (1996) once said: Given the controversy that coercive treatment has generated in

psychiatry and law, it is surprising that there is not a wealth of data on the extent and

outcomes of coercion. However, it is impossible to measure the effect of coercion on

outcome before a better validated and operational concept of coercion has been developed.

The contribution of the Nordic study, with 13 settings in five countries, will hopefully

improve the methods for registration of formal legal coercion and develop new knowledge

about what constitutes the concept of coercion, as well as determinants for variations in

perceived coercion.

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Paternalism and autonomyIntroductionHow can coercion be measured? Conceptual and methodological issuesWhat is coercion?How to measure subjective dimensionsMeasures of perceived coercion and related conceptsThe MacArthur Perceived Coercion ScaleChanges in perceived coercion over time

Paternalism and Autonomy-A Nordic Study on the Use of Coercion in the Mental Health Care System: Aims and general designLevel 1: How is paternalism (the use of coercion in the mental health care system) justified? Value conflicts and legal regulationsLevel 2: Reliability and validity of public statistics on civil commitmentsLevel 3: Patients' perceived coercionThe Nordic Admission InterviewThe global score for perceived coercion

Experiences with the use of the Nordic Admission Interview

Preliminary results and implications for further researchConclusions and importance of the studyReferences

paternalism and autonomy: a presentation of a nordic study on the use of coercion in the mental...

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