Coercion and ‘voluntary’ admission: An examination of psychiatric patient views

Behavioral Sciences and the Law, Vol. 11,259-267 (1993)

Coercion and “Voluntary” Admission: An Examination of Psychiatric Patient Views Anne Rogers Ph.D.

This article examines coercion in voluntary psychiatric patients. Three main themes are highlighted using qualitative and quantitative data from a sample of 412 psychiatric patients surveyed in 1990 who had experienced at least one period of hospitalisation. The themes are: the extent to which the label of “voluntary” was an indicator of the patients’ experience of being in hospital of their own voli- tion; aspects of admission which patients considered to be coercive; and the impact that coercion might have on patients’ views about their problem, professionals and treatment. The findings suggest that a substantial number of nominally voluntary patients reported coercive aspects of their hospitalisation. The impact of feeling coerced was found to produce a more rejecting attitude towards psychiatric services. The findings are discussed in relation to British mental health legislation and care.

VOLUNTARY ADMISSION UNDER BRITISH MEDICAL HEALTH LAW

The 1930 Mental Treatment Act introduced voluntary admission to mental hospitals in Britain. Up until that time it had only been possible for people to be admitted as “certified” lunatics (i.e. involuntary hospitalization). Voluntary admission was associated with an increasing medical view of mental disorder. Such a view was considered to be less morally condemning of mental patients than in the 1890 Lunacy Act, which emphasised the need for their segregation from society. Despite the introduction of the new status there was, immediately after the 1930 Act, only a modest number of voluntary admissions. Ninety percent of patients remained in hospital under compulsion (Bean, 1986). Greater use of voluntary admission followed the introduction of the 1959 Mental Health Act, which allowed admission to psychiatric hospitals on the same footing as admission to general hospitals for physical ailments. According to official statistics, the overwhelming numbers admitted to psychiatric

Anne Rogers Ph.D. is Senior Lecturer in the Department of Sociology and Social Adminstration, Roe- hampton Institute, Southlands College, London SW19 5NN, UK.

I particularly want to thank David Pilgrim for his collaboration with the research which made this article possible and for his useful and supportive comments. I am also indebted to John Monahan for his helpful comments on an earlier draft of this paper.

0735-3936/93/030259-09$09.50 0 1993 by John Wiley & Sons, Ltd.

260 A. Rogers

facilities are now voluntary (called in the statute “informal”). Only about 7% enter hospital under compulsory detention orders (DHSS, 1987).

Voluntary status has always been conditional and has not been as distanced from coercion as has sometimes been portrayed. Under the 1930 Act, once admitted, voluntary patients had to give 72 hours notice in writing of their wish to leave, and those incapable or unwilling to receive treatment could be dealt with under section 5 (compulsory admission) as “a person of unsound” mind. The 1959 Act also made provision for the detention and control of informal patients and these “holding powers” were extended under current legislation. Section 5 of the 1983 Mental Health Act (MHA) provides a statutory procedure to prevent voluntary inpatients from leaving hospital which can be used by the Responsible Medical Officer or by his or her substitute, or where it is not practicable by a Registered Mental Nurse. Grounds for detention are the same as for an application for civil compulsory admission outside of hospital. That is, it appears that the patient is suffering from a mental disorder to such a degree that it warrants their detention in the interests of health and safety to themselves or for the protection of other people.

In addition to statutory procedures, common law and other powers allow for the detention and control of voluntary patients. One general power established by case law is that staff in mental hospitals have the right to control patients in their care. However, the right to control is thought to be less extensive where the patient is a voluntary patient, although precise parameters have never been established (Fen- nell, 1984). Restraint in specific circumstances is provided by a number of special powers. The Criminal Law Act 1967 (s3(1)) allows force to be used to prevent any patient committing a criminal offense (e.g., assault). This may include physical restraint or the use of seclusion (solitary confinement).

The prevailing ethos of current mental health care favors informal admission. The guidance included in the Code of Practice covering the 1983 Act states “where admission to hospital is considered necessary and the patient is willing to be admitted informally this should in general be arranged” (DOH, 1990, 2.7). On the face of things, the single figure (of 7%) for compulsory detention suggested by official statistics for England and Wales compares well with rates in other Western countries. In the United States, for example, about 25% of inpatients are compulsorily detained (Rosenstein, Steadman, Macaskill, & Manderscheid, 1986). However, this overall admission figure does not accurately reflect the extent of compulsory detention. Firstly, there are regional differences. In its bi-ennial report the Mental Health Act Commission (MHAC) expressed concern about the high rate of compulsory admission in London compared to the rest of England and Wales (MHAC, 1991). A national survey of the use of compulsory powers showed extreme variations even within similar geographical areas. In the London local authority areas rates of civil compulsory detention vaned from 103 per 100,000 to 26 per 100,000 population (Barnes, Bowl, & Fisher, 1990). Secondly, the overall compulsory admission numbers recorded are likely to be a gross underestimate since official statistics do not take account of renewals of compulsory orders or the number of informal patients who subsequently become detained patients. Barnes et al. (1990), have estimated that approximately 8,000 patients per annum are detained in this manner. This suggests about a 60% increase over and above the recorded figures of involuntary patients. The Barnes et al. study also showed that patients who are already inpatients

Coercion and “voluntary” admission 261

are likely to fare worse when an assessment is made for compulsory detention. There was a greater likelihood of alternative disposals not being arranged for those who were already in hospital compared to those outside of hospital.

In line with the code of practice noted above, British mental health professionals tend to view voluntary admission as preferable to compulsory admission. For example, Bean (1 980) found that assessing professionals sometimes juxtaposed informal to compulsory admission when persuading patients to enter hospital. Barnes et al. (1990), note that some patients being assessed for compulsory detention agree to go into hospital on a voluntary basis as a result of social workers’ “persuasive powers’’ (p. 63) . One of the expectations of the 1983 Act was that it would lead to a greater use of the least restrictive means of dealing with mentally disordered people. As part of their role, Approved Social Workers are obliged to consider less confining alternatives to compulsory admission as a means of diversion. Thus, it is generally considered legitimate practice to use persuasion in gaining patient’s compliance to enter hospital. However, what still remains unclear is how patients perceive these persuasive powers. Do recipients find it coercive and unwelcome or unhelpful and benign? It is this issue to which the current article is addressed.

PATIENTS PERCEPTIONS OF COERCION

There are no studies which the author is aware of that have systematically examined patients perceptions of coercion. However, recent studies have shed some light on this area. Beck and Golwaka (1988) found that half of the voluntary patients they studied reported a major element of coercion on entering hospital. A Canadian study (Bradford, McCann, & Mersky, 1986), found that a substantial number of inpatients were unaware of their informal status. Some studies have also compared voluntary with compulsorily detained patients. An Australian study (Shannon, 1976), found that voluntary patients were more likely than their compulsorily detained counterparts to accept hospitalization as appropriate and to view staff as more benign and helpful. However, there are a number of limitations to these studies. These include the failure to isolate specific aspects of hospital admission which are viewed as coercive and the impact of staff behaviour on patient’s perception. None have compared informal patients who feel coerced with those that do not, across a number of variables. In the light of studies suggestive of the importance of experienced coercion in “voluntary” patients, the present paper is concerned with three questions:

1. T o what extent is the nominal label of “voluntary” an indicator of patients entering and remaining in hospital of their own free will?

2. What were the range of perceptions, beliefs and circumstances surrounding those who had entered hospital as voluntary patients but felt themselves to be there under duress?

3. What differences of view, if any, exist about treatment and services between those patients who construed their status to be genuinely voluntary compared to those who did not?

In posing these question the concern was with patients’ perceptions. Account was not taken of the views of others (e.g., family members or professionals) nor all the details of the circumstances of the patients’ admissions. Thus the aim here

262 A.Rogers

is not to evaluate whether admissions were appropriate but simply what patients thought about their ascribed voluntary status.

METHOD

The data discussed here is derived from a sample of psychiatric patients surveyed during 1990 on behalf of national MIND, the largest British mental health charity. The aim of the survey was to investigate users’ views of mental health services. Following piloting, a questionnaire, which contained 241 questions, 38 of them open ended, was distributed to ex-patients via social services departments and mental health groups in the voluntary (charity) sector in England and Wales.

Subjects Subjects were derived from two sources. Respondents attending voluntary sector services made up 68% of the total sample, the remaining 32% were drawn from contact on an out-patient basis with statutory services (social and health services).’ “Caseness” was defined by the respondents having at least one psychiatric admission to hospital. Those who reported having been voluntarily admitted to hospital form the basis of analysis here. The questions about voluntary admission were completed by 80% (412) of the original sample (516). Although a third of the 412 subjects had been admitted to hospital in the preceding year, none were in-patients at the time of the survey. Whilst the sample can not be viewed as a random sample of service users, given that such a large number were drawn from the voluntary sectorY2 there appears to be no obvious indications that the sample was systematically biased in any way. A comparison of the MIND responses with the statutory sector respondents revealed no statistically significant differences between the two groups in relation to socio-demographic background, contact with services, and views about treatment and information received.

Procedure As all questions were not answered by all respondents, numbers lower than 412 in the data below imply missing values in relation to particular questions. The lengthy questionnaire was filled in by volunteer interviewers. Interviews took between 2 and 3 hours to complete. The questionnaire examined a range of user experiences. Data presented here is taken from items pertaining to patient experience of hospital admission and inpatient stay. Most data relates to fixed choice responses and so is quantitative. Data was analysed using SPSSX. Regarding the statistical analysis, the main procedures used were those of cross tabulation-using the Chi square X ) test as a measure of statistical significance. Generally, only associations and relationships which were statistically significant at the p < .01 level are reported.

’ Statutory mental health services are those funded and delivered by the state (e.g., the National Health Service). Voluntary sector provision is non-profit making and independent of State admnistration (although it is financed by both state and privately made donations). It tends to combine campaigning with informal service provision.

Although within the voluntary organizations themselves, where there were comprehensive lists of people a random sample was selected.


To ascertain the nature of physical and psychological coercion qualitative data was also provided by 54 responses to the open-ended question, “If pressurized, please give details of who pressurized you and how”?

RESULTS

The overwhelming majority of the overall sample 80% (4 12) reported being informally admitted to hospital at some time during their psychiatric career. However, in response to the question, “If you were admitted as an informal patient do you feel that the choice was a real one?”, a substantial minority of this group (44% or 183) did not regard their status as being genuinely informal. Comparing those who felt their voluntary status to be genuinely informal (GI group), with those who did not, the “forced informal” (FI group) revealed a discrepancy between the percentage of people who felt forced into admission. The GI group reported being coerced in 21% of instances, compared to the FI group who reported this in 80% of instances (p < .OOO 1).

There were slightly greater numbers of women in the FI group than in the GI group (53% and 49% respectively), and of younger people (14.2% and 9.2% under 26 years old, respectively) but overall differences were not statistically significant. The FI group were more likely to be unmamed and to receive a diagnosis of schizoph- renia or psychosis. Sixty four percent of the GI group were single compared to 76% of the FI group (p = < .0041). Twenty two percent of the GI group received a label of psychosidschizophrenia compared to 44% of the FI group (p = < .0324). It may have been that those with neurotic conditions were more in touch with reality and had more insight into their condition. Consequently, they may have been more willing to view their hospitalisation as non-coercive than those who received a diagnosis of psychosis. However, it may also have been the case that professionals considered it more legitimate to coerce those who they view as psychotic. It is a common part of the professional discourse that psychotic conditions risk graver potential consequences for the patient and other people. Also, those who are single may be viewed as in need of professional help in the absence of support that a partner or spouse might provide. Alternatively it may have been easier to coerce single unsupported people in the absence of significant others who may have acted as advocates on the patient’s behalf.

The Experience and Circumstances of Coercion Pressure or coercion for one patient is not the same as it is for another. This can be seen from the diversity of experience amongst the patients. Some comments suggested that it was a person’s mental state which was responsible for forcing admission rather than the involvement of another person:

“Choice wasn’t real because there was no alternative. I was pressured from within, from my own indecision and inability to think what I wanted or needed at a time of acute distress.”

Patients’ reports about experienced coercion included details of those involved. A recognition of the impairment of judgment led some patients to view another person’s insistence as legitimate-as indicated by this patient:

264 A.Rogers

“My social worker seems to know when I need treatment better than myself sometimes. Her and my parents seem to have the final say. I am oblivious to reason.”

However, overall, being subjected to duress by another person was related to patients feeling that their informal status was not authentic. Of those in the FI group who felt themselves to have been coerced, professionals were more likely to be cited than friends or relatives (64% felt identified professionals compared to 36% who felt friends or family were responsible). Psychiatrists were the most commonly mentioned professional. This is perhaps not surprising, given the primary responsibility they have for admitting patients to hospital. General practitioners and psychiatric nurses were the next most frequently cited agent. The coding frame used for patient responses meant that they identified the main person who persuaded or coerced them. However, indications from their more lengthy replies suggested that a combi- nation of people were often involved. “On one occasion my mother and the GP pressurized me.” Another woman described how emotional pressure was placed on her by her boyfriend being upset, her mother making her feel guilty and doctors emphasising admission for her personal safety.

The point at which patients felt that they were forced into a decision differed. Sometimes patients were influenced at the point of referral. At other times pressure was exerted at the time of admission. The third point of coercion appeared to be after admission when patients attempted to leave. These contexts are illustrated by accounts from respondents. First at the point of referral:

“I was tricked by a social worker into going into a hospital to see a psychiatrist for an interview and then sectioned and prevented from leaving.” “Wife would call in nurse and doctor and tell them lies. I would go in under threat of section.”

At the point of admission some patients were told that if they did not come in informally they would be compulsorily detained (e.g., “Consultant psychiatrist said that if I would not go voluntarily he would arrange for compulsory admission”). The identification of a “Hobson’s choice” in forcing patients to enter hospital echoes the findings by Bean (1980) in his study of compulsory admissions. He observed that this “no option” strategy was sometimes used by professionals assessing patients for compulsory admission.

The third point at which patients reported being coerced was when some patients tried to test the limits of their informal status by attempting to leave.

“I usually went into hospital voluntarily. But the consultant psychiatrist refused to give me my clothes when ever I wanted to leave. I didn’t know I had any

“I was told that I should not leave hospital and if I did try I would be sectioned to stay in”.

rights.”

Respondent’s comments also revealed something of the strategies used to gain compliance. These ranged from repressive force to gentle persuasion. The use of overt force usually meant involvement with the criminal justice system: “two police cadets beat me up and took me into hospital by force,” “Judge ordered admission, altema- tive offered was prison.” One female respondent mentioned a social worker who


threatened to take away her child if she did not enter hospital. Deceit was another strategy. This was implicit in the cases of referring agents bringing patients to hospital for assessment for admission. At times one strategy was attempted and replaced by another when it had outlived its utility as in the following example.

“They admitted me on section without my knowledge. When I knew I was sectioned, I was put on a locked ward because I would not agree to stayvoluntar- ily”.

Restraint and containment were also used at times by relatives trying to persuade patients to enter hospital.

“My brother tried to control me even not allowing me to go to the toilet-would only let me phone to commit myself to hospital”.

Other tactics identified as coercive were, the threat of loss of employment by work colleagues if the person did not agree to admission and verbal persuasion. The latter included psychiatrists saying that a person’s mental state would deteriorate seriously if the person did not come into hospital.

Views about Treatment and Services A number of consequences seem to follow patients feeling coerced. First, from Table 1 it can be seen that unsurprisingly, those who considered their informal status to be false were more likely to consider admission to be an unnecessary response to their problem (p < .OOOO) and more likely to think that an alternative to hospitalization should have been offered to them (p < .OOO 1).

Table 1. Summary of findings regarding informal patients evaluation of psychiatric management’

Genuine Informal, forced Informal n = 229 n = 183

Admission unnecessary

Wanted alternative to hospital

Accepted diagnosis

Received unwanted treatment

3 4 . 9 66.0

36.5 60.0

77.0 59.0

47.5 71.0

Received adequate treatment information 30.0 12.0

Dissatisfied with explanation of condition 58.0 75.5

Outpatients unhelpfil 14.2 34.0

Numbers refer to percent answering “yes”. Numbers expressed as a proportion of those answering the question.

There were also differences in the response to medical regimen. Patients who perceived their status to be genuinely informal were more likely to have accepted a medical account of their problem. A larger proportion of the GI group were prepared to accept the diagnosis they were given (77% compared to 59% (p < .0034)). They were also more likely to view diagnosis as helpful (77% compared to 59% (p < .0034).

The GI group were less likely to report receiving unwanted treatment than the

266 A. Rogers

FI group (47.5% compared to 7 1% (p < .OOOO)). One reason for this finding may be that the GI patients were less likely to view themselves as receiving unwanted treatment because of a readiness to accept all aspects of the inpatient regime. There were for example differences in relation to the provision of information and consent being sought for treatment. Despite a majority in both groups, reporting dissatisfaction with the explanation they were given of their condition, the FI group were even more likely to report dissatisfaction in this regard (58% compared to 75.5%, p = .0007). In relation to consent to treatment with medication, whilst a majority in both groups considered that information provided about treatment was insufficient the FI group were more likely to consider this to be the case (30% compared to 12% (p < .OOO 1)). This more negative view towards psychiatric management seemed to continue beyond hospitalisation, 14.2% of the GI group found outpatients unhelpful compared to 34% of the FI group (p < .0002).

Differences in attitudes extended to perceptions of the two main groups of hospital professionals-psychiatrists and psychiatric nurses. Based on a set of three ratings the GI group were more likely to view psychiatrists positively (54% compared to 39% (p < .0056), view them as helpful (64% compared to 47%, p < .0105) and have found them “easy to talk to” (62% compared to 38%, p < .0004). Nearly 70% of the GI group reported themselves to be satisfied with nursing care compared to just under 50% of the FI group.

DISCUSSION

The status of the sample of patients under scrutiny here were all nominally voluntary. Yet a substantial minority did not regard themselves as being in hospital out of genuine choice. This suggests that the way in which voluntary admission to psychiatric hospital has traditionally been viewed is faulty in two main respects. Firstly, it confirms the view that the voluntarykompulsory distinction is blurred rather than sharp (Brakel, Parry, & Weiner, 1985). Thus, an implication from this study is that coercion should be viewed as a continuum that cuts across the legal and adminis- trative boundaries of voluntary and involuntary status categories. The second, and related, point is that the official numbers of forcibly detained patients is likely to be even more of an underestimate than was reported in the introduction. Not only do official statistics take no account of the substantial numbers of patients who have their status changed from voluntary to involuntary whilst in hospital, but those who enter and remain as “voluntary” patients, but are effectively there under threat or coercion, are also not included.

The blurring of the voluntarykompulsory status distinction has implications for the administration of mental health law. Fears were expressed prior to the introduction of the 1983 legislation that the rights and civil liberties of voluntary patients would be jeopardized (Ramon, 1983). The remit of the 1983 Mental Health Act in the main covers formally detained patients. (For example, the Mental Health Act Commission has a statutory obligation to visit compulsorily detained patients once a year, and the Mental Health Tribunal is there to hear appeals for those detained under certain parts of the act.) However, none of the appeal mechanisms or consent to treatment sections apply to informal patients. Informal patients who feel themselves to be in hospital under coercion have no external means of redress.


Given this, although such de fucto compulsorily detained patients have some rights over and above their formally compulsorily detained counterparts, in some respects they may be worse off.

The findings of this study suggest there are implications for the way in which patients perceive services. Those who did not view their status as genuinely voluntary were less accepting of medical definitions of their problem and more likely to view services negatively. This has particular relevance in the light of the relocation of provision. Many professionals and carers and patients are concerned about the conti- nuity of care that is provided after discharge from hospital. If coercion sets up the conditions under which services are viewed negatively, then compliance with treatment and negotiation of an ongoing satisfactory professional client relationship after discharge from hospital is likely to be impaired. The presence or absence of coercion seems to be a crucial factor to consider in setting up the conditions for successful continuing support and preventing readmission. The issue of coercion is therefore something that needs to be taken seriously not only by civil libertarians and service users but by mental health professionals.

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Coercion and ‘voluntary’ admission: An examination of psychiatric patient views

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