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Objective: Paths toward referral to involuntary psychiatric admission mainly unfold in the contexts where people live their everyday lives. Modern health services are organized such that primary health care services are often those who provide long-term follow-up for people with severe mental illness and who serve as gatekeepers to involuntary admissions at the secondary care level. However, most efforts to reduce involuntary admissions have been directed toward the secondary health care level; interventions at the primary care level are sparse. To adapt effective measures for this care level, a better understanding is needed of the contextual characteristics surrounding individuals' paths ending in referrals for involuntary admission. This study aims to explore what characterizes such paths, based on the personal experiences of multiple stakeholders. Method: One hundred and three participants from five Norwegian municipalities participated in individual interviews or focus groups. They included professionals from the primary and secondary care levels and people with lived experience of severe mental illness and/or involuntary admission and carers. Data was subject to constant comparison in inductive analysis inspired by grounded theory. Results: Four main categories emerged from the analysis: deterioration and deprivation, difficult to get help, insufficient adaptation of services provided, and when things get acute. Combined, these illustrate typical characteristics of paths toward referral for involuntary psychiatric admission. Conclusion: The results demonstrate the complexity of individuals' paths toward referral to involuntary psychiatric admission and underline the importance of comprehensive and individualized approaches to reduce involuntary admissions. Furthermore, the findings indicate a gap in current practice between the policies to reduce involuntary admissions and the provision of, access to, and adaptation of less restrictive services for adults with severe mental illness at risk of involuntary admissions. To address this gap, further research is needed on effective measures and interventions at the primary care level.
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ORIGINAL RESEARCH
published: 06 August 2021
doi: 10.3389/fpsyt.2021.708175
Frontiers in Psychiatry | www.frontiersin.org 1August 2021 | Volume 12 | Article 708175
Edited by:
Sebastian von Peter,
Brandenburg Medical School Theodor
Fontane, Germany
Reviewed by:
Martin Zinkler,
Kliniken Landkreis Heidenheim
gGmbH, Germany
Marianne Wyder,
Metro South Addiction and Mental
Health Services, Australia
*Correspondence:
Irene Wormdahl
irene.wormdahl@samforsk.no
Specialty section:
This article was submitted to
Public Mental Health,
a section of the journal
Frontiers in Psychiatry
Received: 11 May 2021
Accepted: 13 July 2021
Published: 06 August 2021
Citation:
Wormdahl I, Husum TL, Kjus SHH,
Rugkåsa J, Hatling T and Rise MB
(2021) Between No Help and
Coercion: Toward Referral to
Involuntary Psychiatric Admission.
A Qualitative Interview Study of
Stakeholders’ Perspectives.
Front. Psychiatry 12:708175.
doi: 10.3389/fpsyt.2021.708175
Between No Help and Coercion:
Toward Referral to Involuntary
Psychiatric Admission. A Qualitative
Interview Study of Stakeholders’
Perspectives
Irene Wormdahl 1,2
*, Tonje Lossius Husum 3,4 , Solveig Helene Høymork Kjus 1,
Jorun Rugkåsa 5,6 , Trond Hatling 1and Marit B. Rise 2
1NTNU Social Research, Norwegian Resource Centre for Community Mental Health, Trondheim, Norway, 2Department of
Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim,
Norway, 3Centre for Medical Ethics, Institute for Health and Society, University of Oslo, Oslo, Norway, 4Faculty of Health
Sciences, Oslo Metropolitan University, Oslo, Norway, 5Health Service Research Unit, Akershus University Hospital,
Lørenskog, Norway, 6Centre for Care Research, University of South-Eastern Norway, Porsgrunn, Norway
Objective: Paths toward referral to involuntary psychiatric admission mainly unfold in the
contexts where people live their everyday lives. Modern health services are organized
such that primary health care services are often those who provide long-term follow-up
for people with severe mental illness and who serve as gatekeepers to involuntary
admissions at the secondary care level. However, most efforts to reduce involuntary
admissions have been directed toward the secondary health care level; interventions
at the primary care level are sparse. To adapt effective measures for this care level, a
better understanding is needed of the contextual characteristics surrounding individuals’
paths ending in referrals for involuntary admission. This study aims to explore what
characterizes such paths, based on the personal experiences of multiple stakeholders.
Method: One hundred and three participants from five Norwegian municipalities
participated in individual interviews or focus groups. They included professionals from
the primary and secondary care levels and people with lived experience of severe
mental illness and/or involuntary admission and carers. Data was subject to constant
comparison in inductive analysis inspired by grounded theory.
Results: Four main categories emerged from the analysis: deterioration and deprivation,
difficult to get help, insufficient adaptation of services provided, and when things get
acute. Combined, these illustrate typical characteristics of paths toward referral for
involuntary psychiatric admission.
Conclusion: The results demonstrate the complexity of individuals’ paths toward referral
to involuntary psychiatric admission and underline the importance of comprehensive and
individualized approaches to reduce involuntary admissions. Furthermore, the findings
Wormdahl et al. Between No Help and Coercion
indicate a gap in current practice between the policies to reduce involuntary admissions
and the provision of, access to, and adaptation of less restrictive services for adults
with severe mental illness at risk of involuntary admissions. To address this gap, further
research is needed on effective measures and interventions at the primary care level.
Keywords: involuntary admission, severe mental illness, mental health services, primary mental health care,
mental health, psychiatry
INTRODUCTION
Involuntary psychiatric admissions go against the fundamental
health care principle of patient autonomy (1,2). Many
individuals exposed to such admissions, along with their carers,
report experiences of fear and distress (3,4). Moreover, evidence
that coercive practices lead to better outcomes is limited (57).
Despite international and national policies to reduce the use of
involuntary admissions in mental health, numbers indicate that
rates of this practice have increased in several European countries
(8). This is cause for growing concern, and less restrictive
alternatives and effective measures in mental health services to
prevent involuntary admissions are called for (9).
Reported rates of involuntary admissions vary (8). In Italy and
Austria, the rates per 100,000 people in 2015 was 14.5 and 282,
respectively (8). Norway reports relatively high numbers, with a
rate of 186 per 100,000 persons 16 years and older in 2018 (10).
Different clinical and social factors have been associated with an
increased risk of involuntary admission; a recent review found
that a psychotic disorder, previous involuntary hospitalization,
lack of adherence to medication, police involvement in admission
process, male gender, being unemployed, living on welfare, being
single, limited social support, and living in deprived areas are
associated with higher risk of involuntary admission (11).
In most Western countries, care for people with severe
and long-lasting mental illness has moved from psychiatric
hospitals to communities, where individuals’ paths toward
referral to involuntary admissions unfold within complex
contexts, often with the involvement of multiple stakeholders
(12). Although services at the primary health care level play
a key role in providing services to people with severe mental
illness (SMI), the role of these services in such paths remains
largely undocumented (13,14). Persons with lived experience
of involuntary admission have reported lack of information
and involvement in treatment decisions (3); carers experience
difficulties getting preventive help prior to an individual’s acute
crisis and report lack of adequate support for themselves in
such situations (4). A systematic review and meta-synthesis of
multiple stakeholders’ experiences with involuntary psychiatric
admission decision-making found that collaboration between the
services involved was lacking, that medical views dominated
assessments, and that the admission process could be experienced
as heavy-handed (especially given that it often involves police)
(15). Previous studies have largely been limited to experiences
during detention, of the admission process, and of the admission
Abbreviations: SMI, severe mental illness; GP, general practitioner; PTSD,
posttraumatic stress disorder.
decision-making process (3,4,15). In the Norwegian context,
studies focusing on the involuntary admission process have
primarily been quantitative (16). Thus, studies incorporating
multiple stakeholders’ experiences in earlier phases of individuals
paths, including how primary health services are involved and
interact, can contribute to understanding how to target further
development of services at this care level so as to reduce
involuntary admissions. Therefore, this study aimed to explore
multiple stakeholders’ experiences with paths toward referral to
involuntary psychiatric admission.
MATERIALS AND METHODS
Study Setting
The current study is part of a cluster randomized controlled
trial that sought to develop and test a primary care-level
intervention aimed at reducing involuntary psychiatric
admissions (ClinicalTrials.gov, NCT03989765). Ten mid-
sized Norwegian municipalities with twenty to fifty thousand
inhabitants participated. The associated regional psychiatric
hospitals and their community mental health centers from the
secondary care level, who serve the municipalities’ populations,
were also involved. The municipalities receiving intervention
took part in developing and testing the intervention. To prepare
for this, comprehensive mapping of current practices was
conducted using qualitative methods, and the analysis presented
here is based on these data. In the following, involuntary
psychiatric admissions are those sanctioned by the Norwegian
Mental Health Care Act § 3-2 (involuntary observation) and §
3-3 (involuntary admission) (17).
In Norway mental health care is provided by two separate
health care levels: primary and secondary level. Primary mental
health care, often organized jointly with primary addiction
services, is provided by the 356 municipalities. Among other
things, it includes supportive housing (with or without resident
staff), day-care facilities, home care, therapeutic conversations,
and leisure activities. General practitioners (GPs) are organized
at the primary health care level. This includes both the GPs
(family doctors) and primary medical emergency services.
In addition, social care, (un)employment services, municipal
housing, and local police are among the services provided by
the municipalities.
The power to subject people to involuntary admission is
held by services at the secondary mental health care level.
At this level, regional psychiatric hospitals and community
mental health centers provide specialist inpatient and outpatient
treatment, including community-based ambulant treatment.
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Wormdahl et al. Between No Help and Coercion
Norwegian mental health legislation sets out stringent criteria
for involuntary admissions, requiring that options for voluntary
engagement have been exhausted (17). It is also required that
the need for involuntary admission is assessed by a medical
practitioner outside of the secondary inpatient unit (unless the
individual is under a community treatment order). Thus, referral
to involuntary psychiatric admission is usually carried out by a
primary care-level GP. The GP conducts a medical assessment
of the need for a referral. If an individual refuses the assessment,
the chief municipal medical officer has the authority to decide on
an involuntary medical examination. When a person is referred,
the individual and the referral are dispatched to secondary care,
typically the acute inpatient hospital unit.
Participants and Recruitment
This study involved 103 participants, including multiple
stakeholders from the five intervention municipalities who
had experienced or been involved in individuals’ paths
to involuntary admissions. Eligible participants were: (1)
people currently working in various services and who had
experience supporting individuals who had been involuntarily
admitted; (2) people with lived experience of SMI and/or
involuntary admission; and (3) carers of individuals with
lived experience of SMI and/or involuntary admission. The
stakeholder services represented were primary mental health
services, chief municipal medical officers, GPs, medical
emergency services, police, outpatient specialist mental health
services, and inpatient specialist mental health services. Eligible
participants in primary and secondary services were recruited
through service managers; GPs were recruited through the
chief municipal medical officers. People with lived experience
were recruited through the local groups of the advocacy
organization Mental Health Norway, and carers were recruited
through the local groups of the advocacy organizations Mental
Health Norway and Mental Health Carers Norway. Purposive
sampling was used to obtain a sample with a wide range of
participants representing multiple stakeholders. See Table 1 for
sample description.
Data Collection
A mix of individual interviews and focus groups were conducted.
For the most part, professionals were interviewed individually,
and people with lived experiences and carers participated
in focus groups. In the focus groups, the participants’ joint
experiences could be utilized but not to the same degree as an
individual focus, given that the theme of the study involved
possibly traumatic personal experiences for participants with
lived experience and for carers.
A total of 60 individual interviews were conducted. Upon
request, three interviews of professionals were conducted
as group interviews with four, two, and two participants,
respectively (n=8). Seven focus groups were conducted
(n=35). The focus groups had between two and seven
participants. Two interviews with carers were conducted as
individual interviews because we did not manage to recruit more
people in their municipalities. All interviews in one municipality
TABLE 1 | Distribution of participants.
Variable Informants
(N=103)
Percent
Sex
Male 43 42
Female 60 58
Role/service
Primary mental health services 32 31
Secondary mental health services 16 16
Primary medical services* 16 16
Police 2 2
People with lived experience 16 16
Carers 21 20
Level of education among participants working in services (n=66)
Vocational education training 1 2
3 years higher professional education 9 13
>3 years higher professional education 56 85
Municipality
Municipality 1 29 28
Municipality 2 13 13
Municipality 3 22 21
Municipality 4 17 17
Municipality 5 22 21
Type of interview
Individual interviews** 68 66
Focus groups 35 34
*Primary medical services include general practitioners (GPs), medical emergency
services (GPs and nurses), and chief municipal officers.
**Three were conducted as group interviews with four, two, and two
participants, respectively.
were conducted before we moved on to the next municipality.
Data collection was conducted in the period June 2019 to
December 2019.
The interviews were based on a semi-structured interview
guide. In individual interviews, the participants working in
different services were asked to describe one or two of the
most recent situations they had been directly or indirectly
involved in that ended up with someone being involuntarily
admitted. The interviewer probed for contextual information
and the sequence of events, including who was involved and
how. People with lived experience and carers were asked to
describe paths to involuntary admissions more generally, not
necessarily about their personal experiences (although several
of them chose to talk about this). Examples of questions
included what they believed are typical circumstances leading
up to an involuntary admission, who could be involved and
how, what services individuals commonly receive prior to an
involuntary admission, what happens in situations where an
individual is referred to involuntary admission, and how services
collaborate with the individual and their carers. All interviewees
were also asked if they were aware of the rate of involuntary
admissions in their municipality. Other themes in the semi-
structured interview guide, such as factors in current practice
that can affect pathways to involuntary admissions, and suggested
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Wormdahl et al. Between No Help and Coercion
measures to prevent such admissions, are and will be published
elsewhere (17).
All interviews were conducted face-to-face except four
that were conducted by phone. IW and TLH jointly carried
out the interviews with the participants working in different
services in the first municipality, then worked separately in two
municipalities each. The interviews lasted 25–80 min and were
conducted in meeting rooms in the municipality’s offices. Upon
request, two interviews were conducted at the participants’ home.
The focus groups and individual interviews with people with
lived experience and with carers were carried out by IW, TLH
and SHHK jointly in the first municipality, then in pairs; SHHK
worked in all municipalities, and IW and TLH worked in two
municipalities each. The focus groups lasted 90–110 min and
were conducted in meeting rooms at the primary mental health
services’ location or on the premises of the local groups of the
respective advocacy organizations.
Data Analysis
The analysis was inspired by grounded theory (18). The
inductive analysis resulted in a conceptualized model revealing
the characteristics of individuals’ paths toward referral to
involuntary admission.
In the first analytic step, IW, TLH, and SHHK wrote
comprehensive notes during the interviews and focus groups. In
the focus groups, we also logged our perceptions of the group
dynamics. After a day of interviews, the notes were immediately
used to write condensed summaries of the interviews. These
condensed summaries were then used to write a reflection
memo, including the interviewers’ preliminary analyses of
the participants’ experiences. The first reflection memo was
written after the first seven interviews of primary mental health
professionals in one municipality; for the focus groups, reflection
memos were written after each group session. In this phase,
we included characteristics seen in single interviews as well as
patterns across interviews. Throughout the interview period,
the reflection memos were regularly subjected to constant
comparison. Typically, this was performed within the scopes of
participants in the same stakeholder group and municipalities. As
we moved from one municipality to the next, new characteristics
evolved and merged into categories, which were subjects for
further exploration in new interviews. In the second analytic step,
after all the interviews were completed, IW, TLH, and SHHK
read the overall condensed summaries and reflection notes.
During this process, characteristics were merged and rearranged,
and categories were reviewed. In the third analytic step, all
authors participated in further analysis. Preliminary categories
and characteristics were reviewed several times until consensus
was reached. In the final step, we prepared quotes from the data
material to illustrate and elaborate the results. These quotes are
non-verbatim condensations of the participants’ descriptions.
Ethics
The Regional Committees for Medical and Health Research
Ethics in Norway (REC) considered the study outside their
remit (REC reference number 2018/2382 C), and the study
was approved by the Norwegian Centre for Research Data
(NSD reference number 743586). Informed written consent
in accordance with the General Data Protection Regulation
(GDPR) was obtained from all participants. No names or
personal identification information were registered in the
condensed summaries or reflection memos from the interviews.
Information about users, participants and services in the
condensed summaries presented as examples of situations are
anonymized and kept to a minimum to ensure anonymity.
RESULTS
Drawing on the experiences of multiple stakeholders in five
Norwegian municipalities, the analyses identified four main
categories: deterioration and deprivation, difficult to get help,
insufficient adaptation of services provided, and when things get
acute. In Figure 1, the model “Between no help and coercion:
Toward referral to involuntary psychiatric admission” displays
the categories and their characteristics. Although the mutual
ending point is referral to involuntary admission, the categories
in the model are not necessarily sequential. For instance, an
individual’s path could comprise characteristics from two, three,
or all four categories. Moreover, various characteristics could
apply at different times for different people, and some were
present throughout an individual’s path. Furthermore, some
described an unexpected acute life crisis that caused deterioration
of clinical symptoms without the presence of other characteristics
in the category deterioration and deprivation; these situations
quickly moved on to the category when things get acute without
including other characteristics shown in the two other categories.
Nevertheless, the majority described multiple characteristics that
were present before the severity of mental health deterioration
was said to be acute, extending the paths’ timeline and often
including characteristics from several categories.
Deterioration and Deprivation
As seen in Figure 1, the category deterioration and deprivation
indicate that a variety of clinical symptoms, behavioral
symptoms, and socioeconomic factors were present in
individuals’ paths toward referral to involuntary admission.
Examples of clinical symptoms described were psychosis,
suicidality, self-harm, drug addiction, comprehensive trauma
history (PTSD), cognitive impairment, and severe depression. In
addition, many linked self-cessation of psychotropic medication
and sleep deprivation with deterioration of clinical symptoms.
Both reserved/withdrawn behavior and aggressive behavior
were mentioned as typical symptoms, with the latter being the
dominating characteristic of described paths.
This man lived in a municipal apartment related to a supported
housing service with day-care staff. Prior to his last involuntary
admission, we understood a deterioration was in progress when he
withdrew more and more. Usually when he got like this, he had
stopped taking his medication without anybody noticing. He would
not let us in when we came to see him, and we had to persuade him
to talk to us. For a while he let himself be persuaded to let us in,
and we could motivate him to eat and go for a walk with us. But
as he kept on not taking his medication, he deteriorated more and
more. This is a man with a massive trauma history, and gradually
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Wormdahl et al. Between No Help and Coercion
FIGURE 1 | Between no help and coercion: Toward referral to involuntary psychiatric admission.
he appeared more and more psychotic, until the situation became
acute. At that point, he had not slept for several days, probably not
eaten a lot either, and he started acting out, appeared aggressive,
and threatened mental health staff that tried to get in contact with
him. (Staff, primary mental health service)
Many explained that these characteristics had been present over
time, while a few talked about acute appearance of clinical and
behavioral symptoms due to an acute life crisis.
My sister had always had a seemingly well-functioning life with a
husband, kids, house, car, and a dog. But when her husband filed
for divorce, she did not cope well. She went into an acute major
depression and tried to kill herself. (Carer, sibling)
Participants described how many individuals who were subjected
to referral to involuntary admission ended up as “revolving
door patients,” with repeated involuntary admissions. Some
professionals knew of individuals who had been involuntarily
admitted as much as 50–100 times in 1 year.
He goes out on the edge to jump in front of the train and says he
will kill himself. This happens again and again and again. When
he stands there someone from the public calls 911, the police and
ambulance turn up, get him down from the bridge, and the police
drive him to the medical emergency service, who then refers him to
involuntary admission. After a short stay at the acute ward of the
psychiatric hospital he gets discharged, usually within a few days.
Last year I think he did this over 50 times! (Staff, primary mental
health service)
People with these kinds of vulnerabilities were also described
as being exposed to combinations of the sociodemographic
vulnerabilities shown in deterioration and deprivation in
Figure 1. This was believed to increase the likelihood of entering
a path ending in a referral to involuntary admission. Participants
described individuals living in a variety of contexts: some lived in
private accommodations, others in municipal housing, supported
housing with milieu staff, or had no fixed residence. Some lived
with family members, others lived alone. Many participants
observed that inadequate living conditions were prevalent; they
described individuals with unstable housing situations, reduced
capability to manage residential living, and poorly adapted
municipal housing facilities. For instance, municipal housing
contexts where people felt unsafe were mentioned as a barrier to
recovery for individuals with SMI.
It is not ideal for him to live in that municipal building downtown
where everybody else also has severe problems. People with all
kinds of problems live there, and he gets anxious when the
neighbors act out or make noise. In addition, he is not too good
at comprehending and interpreting others when they communicate;
he often misunderstands and gets into conflict with neighbors. In
his worse periods, all this can enhance his deterioration and make it
difficult for him to regain good daily functioning. I think he should
have lived in another place where he could retire and protect himself
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Wormdahl et al. Between No Help and Coercion
a bit more from people who don’t serve him well. (Staff, primary
mental health service)
Lack of suitable employment opportunities or meaningful
daily activities were described as resulting in inactivity and
passivity. In addition, many individuals were described as having
little or no social network, which combined with inactivity
often led to loneliness. Participants with lived experience and
carers especially emphasized loneliness, and many experienced
that the stigma around SMI in the wider society heightened
the individuals’ loneliness; several participants said the cares
became the only social network for the individual. Employment,
meaningful activities, and personal networks were emphasized
as factors that, when present, could facilitate personal recovery
and could prevent deterioration and the risk of referral to
involuntary admission.
There is too much focus on just illness and too little focus on the
fact that life consists of more than just illness. You need to have
a place to live, practical help, and things that can make life a bit
easier. I think a more diverse offer of activities to those who need
it would be good, because there is not much to choose from now,
especially for men. We have a day center but they offer mostly
knitting, crocheting and reading the newspaper and stuff like that.
They should organise things like data, golf, bowling and outdoor
activities. It is time for some innovation. It is important to have
good arenas to meet, generally in the community, in the city, or
where you live, but the municipality here has no other activities to
offer outside the day center. (Individual with lived experience)
Difficult to Get Help
As seen in Figure 1, the category difficult to get help indicates
how many participants experienced that insufficient support was
available for at-risk individuals in the early phases of illness
development. In their experience, the process often started before
services got involved. Several participants with lived experience
and carers described how they had tried to contact both GPs
and other primary services several times in this phase of an
individual’s path, without receiving adequate help.
But I think there is something wrong with the system when they
did not notice my signals earlier because I did not become psychotic
overnight. Looking back, I think that it was not difficult to see the
signals. When I did not dare going to the pharmacy or did not go
to work back then when I was working, then the signals are visible.
It is strange that they could not react earlier to my deterioration.
Then, perhaps, I just needed a little more follow-up than once a
week over a period of time. And that my GP, the mental health
service, and my employer could collaborate a little more. I see that
it would cost something, but I think that socio-economically it must
be cheaper than me ending up being involuntary admitted. Maybe
if I had gotten help earlier the total cost would be less, and my
symptoms would be milder and quality of life better. (Individual
with lived experience)
She already started to get ill when she dropped out of high school,
almost a year before the involuntary admission. She isolated herself,
withdrew from her friends, and kind of changed personalities. We
suspected that she had started doing drugs. We tried to get help,
both through school and her GP, but no one seemed to understand
how severe it was. And when, several months later, she finally got
some follow-up from the mental health and addiction team in the
municipality, she had become so severely ill with psychosis and all
that it did not help. There must be something more between coercion
and absolutely nothing. (Carer, parent)
Many participants with lived experience and carers said that GPs
often relied on medication as the main treatment option for
people with SMI. In addition, participants from all stakeholder
groups, including GPs, mentioned that GPs had limited
knowledge of the available low-threshold services in primary
mental health care. Several participants with lived experience and
carers stated that GPs did not have sufficient time to conduct
comprehensive assessments of their needs and match them
with available services. This was also mentioned in relation to
other services, such as when specialist outpatient mental health
services only allocated a 1-h follow-up each week; according to
participants with lived experience and carers, this was insufficient
to help someone with SMI who deteriorated.
I felt that we did not get help fast enough when the crisis appeared.
It was like there was nothing between no help and coercion. My wife
had to become very, very, ill before they understood the severity
of her condition, and then it ended in an involuntary admission.
I believe that if the doctor had taken better time to hear us out
and gotten more insight into her problems, she could have gotten
better help and recovery before she got so ill that she had to be
involuntarily admitted. (Carer, spouse)
Some participants from the primary mental health services
described how some individuals with SMI refused to receive
mental health services in the periods prior to or between
involuntary admissions. In these situations, the professionals
felt that there was little they could do until the individual
became so ill that a referral to involuntary admission was
necessary. They described how they had limited opportunities
to work more thoroughly with individuals unless their time
allocations and work-load were reorganized to allow extra effort
to prevent further deterioration. At the same time, participants
with lived experience and carers discussed how some individuals
with SMI withdrew from services because they had experienced
former admissions as traumatic. Among other things, they
talked about being roughly handled, and often the police had
been involved. When this happened in public, the participants
experienced additional strain and stigma. Some said that the
services were not tailored to help people overcome this fear
around receiving services.
When people did not receive sufficient support, carers felt that
they had to take a lot of responsibility for their loved ones. Many
said this was stressful at times, and they could get exhausted as
their loved ones’ mental health deteriorated. According to the
carers, there was little, if any, service approach or support for
them as carers to help them manage these situations.
Insufficient Adaptation of Services
Provided
As seen in Figure 1, the category insufficient adaptation of
services provided represents characteristics emphasizing how
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Wormdahl et al. Between No Help and Coercion
the provision of essential services for people with SMI was
not sufficiently tailored to individuals’ needs. Many individuals
who received mental health services prior to a referral to
involuntary admission had done so for long periods, often years.
Some received multiple services, and from both the primary
and secondary care levels. Nonetheless, many participants
experienced that the long-term follow-up from mental health
services, both prior to and during their path toward referral
to involuntary admission, often lacked the degree of continuity
people with SMI needed.
Professional participants from primary mental health
services said they sometimes tried preventive measures
when an individual showed early signs of deterioration. For
instance, when an individual receives ambulant services, some
professionals said they could try to increase follow-up and
come by the individual’s home several times a week in critical
periods. However, several participants felt that this flexibility was
hampered by the lack of resources, service organization, and
knowledge. A few professional participants said that people with
SMI at risk of involuntary admissions had crisis plans that guided
the measures to implement, although the majority explained
that the use of crisis plans varied greatly and were often neither
established nor actively used. Poor collaboration among services,
both at the primary level and between the primary and secondary
levels, was highlighted by participants in all stakeholder groups
as affecting adaptation of services. Many of the professionals
working in mental health services experienced difficulties in
collaboration with GPs, and collaboration between primary and
secondary mental health services was also often experienced
as poor or absent. Many participants mentioned that good
collaboration depended on the people and was not part of a
systemic approach.
Many services were involved—our service [primary mental health
service], the activity center, an outpatient psychologist from the
secondary mental health service, and the GP. In addition, his
carers were there. But in my experience, the services did not
collaborate much. One service did not know what another service
did. The help provided was concurrent and not complementary,
and coordination between the primary and secondary services
were lacking. To my perception, a general lack of clarity in the
division of tasks and responsibilities in this municipality is not
good for individuals with severe mental illness, who often need
multiple services and individual adaptation. (Staff, primary mental
health service)
Many professionals from primary mental health services said
they lacked the right competence and tools to divert individuals’
paths from ending in referral to involuntary admission. This was
echoed by many GPs and professionals from secondary services.
I am not sure if this is a group of people that the primary mental
health services are capable of handling. At least, it appears like
they have too little knowledge in how to handle aggression and
agitation, and it also seems like the ones working there get anxious
in situations like that. Then the working routine might end up
with the staff calling the police as soon as the slightest indication of
conflict appears, instead of being able to help them calm down. And
you know, in a supportive housing there can be many situations that
potentially can cause conflicts, like shortage of cigarettes, money,
or a drugged neighbour frightening you. (Staff, secondary mental
health service)
Furthermore, several participants revealed insufficient access to
voluntary inpatient treatment at a secondary mental health care
facility prior to an individual’s deterioration becoming so severe
that referral to involuntary admission was deemed necessary.
In the experience of several GPs and primary mental health
professionals, the threshold for people to be voluntarily admitted
at secondary mental health inpatient services was often too
high. A lack of beds (capacity) at the secondary care level was
mentioned as a possible explanation.
When I really needed and wanted to be admitted, it was rejected.
And I know how sick I can get! But it just did not happen! Psychiatry
is a very rigid system. (Individual with lived experience)
When Things Get Acute
As seen in Figure 1, the category when things get acute
represents characteristics experienced as being present when the
deterioration has become so severe that a referral to involuntary
admission is on the cards. People from four stakeholder
groups were typically the ones who contacted GPs to express
their concern: (1) carers, private network, or others from the
community; (2) professionals working in primary health services;
(3) the police; and (4) professionals working in secondary mental
health services. Sometimes the individual’s GP received the
concern, but in most cases those with a concern contacted the
primary emergency medical service. Occasionally, carers directed
their concern to the chief municipal medical officer; this mostly
involved “revolving door patients,” where the individual and
carers knew the chief municipal officer from previous admissions.
Chief municipal officers were also contacted by others from
the community when they were concerned for an individual’s
mental health; examples of these were neighbors, animal welfare
inspectors, and the fire brigade. In addition, some participants
said that carers could express their concern with a primary
mental health service if the individual received follow-up from
this service. In situations where individuals with SMI did not
give any response or let anyone in, GPs had to contact the
chief municipal officer, who could decide on an involuntary
medical examination.
We heard about the concern through a friend of the woman when
she had not collected her mail for a while. The women did not
answer the phone and did not open the door when we went to her
home to make contact. This was a woman we had known for a long
time, and we knew she had a severe mental illness. We contacted
her GP, who contacted the chief municipal officer, who decided on
an involuntary medical examination. The GP called on the police
to break into the woman’s home. There, we—the police, GP, and
me—found her in bed in a state where she appeared to be very
psychotic. She denied that she was ill and refused to be admitted.
The GP referred her to involuntary admission, and the police had
to escort her by force out to their car to drive her to the hospital. I
think that when the police need to be involved in these situations,
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Wormdahl et al. Between No Help and Coercion
it makes the situation appear very dramatic. I think about how it
must appear to the neighbors or others passing by. (Staff, primary
mental health service)
The participants shared that sometimes the police were the first
ones in contact with people in acute situations. This could occur
when an individual acted out in public or stood on a bridge
and seemed prepared to commit suicide. In these situations,
the participants said the police were the ones who brought
the individual to the GP for medical assessment. According
to the police participants, they were mostly involved in such
cases outside their regular office hours. They said they did
not know who to call in other services when they were faced
with an acute psychiatric crisis. Consequently, the medical
emergency service became the primary available place where
they shared their concern. In the participants’ experience, a
few referrals to involuntary admissions occurred solely within
secondary mental health care; typically, this happened if an
individual was placed under a community treatment order. In
these situations, the participants explained that professionals
from outpatient secondary mental health services could direct
their concern directly to their inpatient unit, and involvement
from others besides secondary mental health services and police
could be absent.
When a GP conducted a medical assessment to see whether a
referral was warranted, they typically performed it either at the
GP’s office or in the individual’s home. However, most referrals
were described as happening outside of regular office hours. As a
result, assessments were often conducted by GPs at emergency
medical services. This meant that the doctor conducting the
assessment had no or limited knowledge of the individual
involved. Participants from all stakeholder groups expressed that,
in their experience, the GPs had inadequate knowledge of SMI.
Furthermore, they felt that GPs lacked knowledge about less
restrictive alternatives at the primary care level. As mentioned
in the category insufficient adaptation of services provided,
professional participants also said they often did not have an
available, updated crisis plan that could guide them on which
measures to implement. Consequently, involuntary admission
became the only option considered in acute situations.
When an individual comes to the medical emergency service with
mental health and addiction problems, I often just refer them
to the secondary services. I do not contact the primary services
because I simply do not know enough about them. (GP, emergency
medical service)
In addition, several GPs said that other service alternatives
were limited in an acute situation. For instance, primary mental
health services were not available outside of regular office
hours. In addition, the services could have intake time that
was incompatible with the acuteness of the situation, and
characteristic symptoms for this target group often prevented
them from using the acute inpatient beds in primary health care.
Another circumstance said to make involuntary admission the
“only” option was that medical practitioners had too little time
for individual consultations.
The medical emergency service has to take it all! We are the only
service that has to deal with all kinds of problems and illnesses,
arrange it all, fix it all. Often it is hectic and time is limited,
and we quickly have to find a solution for a critical situation. At
that point, the easiest alternative is to refer people further into the
health system, and in these situations, this means referring them
to involuntary admission at the [name of the acute ward at the
secondary mental health inpatient unit]. The police, carers, or those
who have brought the individual to the medical emergency service,
typically at night or on the weekends, also want us to request an
involuntary admission. They stand here waiting, and at the same
time many others with different problems and illnesses are waiting
too. So, the quickest and simplest solution might be to send them
with the police to [name of acute ward]. Referral to involuntary
admission often becomes the solution, because significantly longer
time is needed to find any primary services that could be an
alternative. (GP, emergency medical service)
Also, participants with lived experience mentioned that GPs often
had to little time at consultations.
GPs have to little time. It is important that the GP takes his
time when meeting us. It is important that they know you. If
you are heard and understood you can get more appropriate help.
(Individual with lived experience)
Several participants perceived that the police were often involved
in one way or another in this phase. Participants said the police
were typically called to assist with transport if an individual
was assessed as aggressive, violent, or affected by noticeable
intoxication, or if they had to break into an individual’s home
to enable access for health staff. The approach of the police
varied. For instance, some described how the police used rough
methods when breaking into homes or used force when escorting
individuals from public places. Others had experienced the
police’s approach as caring and helpful, and they described how
the police took their time and talked with the individual or let
the individual perform their morning routine or put on make-up
before they were brought away.
DISCUSSION
A conceptualized model based on multiple stakeholders’
experiences and displaying categories and characteristics of
individuals’ paths toward referral to involuntary admission
was developed from the results (Figure 1). Typically, multiple
characteristics were present, and most paths started prior to
the acute situation that resulted in a referral to involuntary
admission. The clinical and socioeconomic characteristics
described by participants in the current study generally match
what is known in the literature as factors associated with
involuntary admissions (11,16). Consequently, the discussion
will instead focus on some of the shortages in service provision
appearing within such trajectories, including difficulties in
accessing and adapting services, insufficient assessment of
possibilities to use, and lack of less restrictive service alternatives,
before implications for practice are highlighted.
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Wormdahl et al. Between No Help and Coercion
“It was like there was nothing between no help and coercion”
was a statement that is illustrative of many carers’ experiences.
Both individuals with lived experience and carers said it was
difficult to get help in an early phase of an individual’s mental
health deterioration. Many GPs had a medical focus and
lacked knowledge of primary mental health services. Individuals
with SMI who received long-term mental health services
often experienced service limitations, inadequate individual
adaptation, and limited possibilities to act upon individuals’
shifting needs. In addition, insufficient collaboration between
services was revealed. Jankovic et al. (19) also found that carers
perceived that services responded to crises rather than prevented
them. This implies a potential to prevent some involuntary
admissions, if services can be provided at an earlier stage of an
individual’s deterioration. Potential may be found especially in
the phase where people make contact with their GP or other
services asking for help. “There is too much focus on just illness
and too little focus on the fact that life consists of more than just
illness” was a statement from a participant with lived experience.
If a medical perspective dominates, assessment of the individual’s
overall situation might be limited, and thus access to services
that focus more on personal and social recovery in an early
phase of deterioration will not be provided. Furthermore, factors
that can hamper individual service adaptation include limited
resources within services, budget cuts, rigid allocation systems,
heavy caseloads, no or arbitrary use of crisis plans, and limited
opportunities for voluntary admissions prior to the situation
becoming acute (17,20). Lack of alternatives due to a narrow
range of housing, activity, and employment opportunities for
people with SMI can negatively affect personal recovery and
services’ ability to reverse individuals’ paths toward referral to
involuntary admission (12,17,21).
Reducing referrals to involuntary admission cannot be taken
separately from the provision of other services. The results in
the current study indicate that acute situations are characterized
by a lack of less restrictive care alternatives. Furthermore, even
when potential alternatives were present, they were not always
assessed as an option. For instance, busy medical emergency
services with no or limited knowledge of the individual led GPs
to choose referral to involuntary admissions instead of taking on
the more time-consuming work of arranging other alternatives.
In addition, the GPs’ knowledge of current primary mental health
services that provide alternatives were perceived as insufficient.
Mental health legislation requires that options for voluntary
engagement have been exhausted (22); therefore, it is important
to question whether some individuals might experience unlawful
referrals to involuntary admissions, if services for this group
are organized in such a way that the time-consuming nature
of considering voluntary alternatives in an acute situation
sometimes becomes the rationale for referral to involuntary
admission. A recent review of initiatives to reduce coercion in
mental health clearly state that facilitating voluntary support
requires a range of community services from which service
users can choose (23). Unavailability of less restrictive care
alternatives has been found to predict decisions of referral to
involuntary admission (24,25). In fact, a lack of alternatives
has been found to be more significant than mental disorder,
dangerousness, or individuals’ refusal of care (24). In Norway,
a discrepancy between referrals to involuntary admission and
psychiatrists’ decisions to involuntarily admit have been seen in
about one-third of the cases (10,16). This strengthens the notion
of insufficient provision of or access to less restrictive service
alternatives for this target group.
Furthermore, these paths might bring about ethical challenges
for the professionals involved. In situations where professionals
must choose between an individual’s right to autonomy
and their right to health care (26) when less restrictive
alternatives are lacking, the health care organization influences
this choice. Professionals are then left with a different ethical
dilemma: to choose between involuntary admission and neglect.
Consequently, involuntary admission might become the only
moral choice to safeguard the individual, and the rationale and
justification of the involuntary admission are potentially left
unchallenged. Floyd (27) found that most professionals were
comfortable or totally comfortable with cases they had handled
wherein people were involuntarily admitted. This indicates that
provision of less restrictive service alternatives, and services’
capability to adapt according to individuals’ shifting needs, might
be influenced by mental health professionals’ attitudes toward
involuntary admissions. In Norway, the health government’s
directives to reduce involuntary admissions have formally
addressed the secondary health care level (28). Without this being
on the agenda at all care levels, professionals at the primary care
level might simply continue their former ways of doing things
(15), leaving involuntary admissions unquestioned with regard
to the organization and provision of services between care levels.
A lack of systematic focus in primary mental health services
on reducing involuntary admissions (17) might indicate that
professionals’ attitudes toward involuntary admissions have not
been particularly challenged at this care level.
Strengths and Limitations
The results of the current study represent the experiences of
multiple stakeholders in five Norwegian municipalities. Thus,
they may not be representative elsewhere. However, the high
number of participants from several municipalities and from
multiple stakeholder groups strengthens the possibility of
generalization across settings. Including multiple stakeholders
and stakeholder groups moderated personification and
strengthened external validity. The results represent the
participants’ experiences with individuals’ paths toward referral
to involuntary admission and are limited to situations that
end with such a referral (and, subsequently, an involuntary
admission). The focus groups recruited through the advocacy
organization Mental Health Norway included both participants
with lived experience and carers. This might have limited
disagreements in the discussions between these stakeholder
groups. This study was part of a larger project that sought to
develop and test an intervention at the primary mental health
care level, aiming to reduce the use of involuntary admissions;
this could have affected the experiences and examples the
participants shared, potentially making them more inclined
to describe cases where they thought referral to involuntary
admission could have been avoided. However, our impression
Frontiers in Psychiatry | www.frontiersin.org 9August 2021 | Volume 12 | Article 708175
Wormdahl et al. Between No Help and Coercion
was that we obtained a mix of different experiences, including
those where participants perceived that such referrals could not
have been avoided. A multidisciplinary research group with three
researchers (including a peer researcher) performing interviews,
and an additional extended research group participating in the
analysis process, strengthen the internal validity of the results.
Implications for Practice and Research
The conceptual model “Between no help and coercion: Toward
referral to involuntary psychiatric admission” developed in this
study indicates a gap in current practice between, on the one
hand, the policies to reduce involuntary admissions and, on the
other hand, the provision of, access to, and individual adaptation
of less restrictive service alternatives for adults with SMI at risk
of referral to involuntary admission. Given these perspectives, we
recommend that further service development and research aim
to facilitate:
Easy access to services in early phases of deterioration.
Individualized adaptation of service provision, housing,
and activities.
Systematic use of joint crisis plans.
Enough consultation time and flexibility in service provision.
Collaboration among services facilitating complementary and
comprehensive treatment and care.
Knowledge in primary health care on SMI, involuntary
admissions, and alternatives to involuntary admissions.
Access to less restrictive service alternatives in acute situations.
CONCLUSION
The aim of this study was to explore the characteristics of
the paths toward referral to involuntary psychiatric admission
of adults with SMI. Based on the personal experiences of
multiple stakeholders in five Norwegian municipalities, the four
main categories of deterioration and deprivation, difficult to
get help, insufficient adaptation of services provided, and when
things get acute are illustrated in a conceptual model displaying
the characteristics of such paths. The model demonstrates the
complexity of individuals’ paths and underlines the importance
of comprehensive approaches, along with the flexibility to tailor
service delivery to individual needs, in working to prevent
involuntary admissions. Furthermore, the results in this study
indicate a gap in current practice between, on the one hand, the
policies to reduce involuntary admissions and, on the other hand,
access to, adaptation of, and provision of less restrictive services
for adults with SMI at risk of involuntary admission. Further
research is needed on effective measures and interventions at the
primary care level.
DATA AVAILABILITY STATEMENT
Data sharing is not applicable for the datasets generated in this
study due to their containing information that could compromise
the privacy of research participants, further inquiries can be
directed to the corresponding author.
AUTHOR CONTRIBUTIONS
IW, TLH, SHHK, and TH developed the interview guides,
recruited participants, conducted the interviews, and performed
constant comparison and preliminary analyses. SHHK had a
particular focus on the experiences of participants with lived
experience and of carers. The writing of the manuscript was
led by IW. TH, SHHK, JR, TLH, and MBR participated in
the critical review of several drafts. All authors participated in
final analyses and discussions of how the results were related to
existing literature, contributed to planning the study, and revised
and approved the final manuscript.
FUNDING
This study was funded by the Research Council of Norway,
Health, Care and Welfare Services Research (HELSEVEL project
nr. 273546). The founder had no role in the study at any phase,
nor in the decision of publication of the results.
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Author Disclaimer: The views expressed are those of the authors and not
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Conflict of Interest: The authors declare that the research was conducted in the
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Copyright © 2021 Wormdahl, Husum, Kjus, Rugkåsa, Hatling and Rise. This is an
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Frontiers in Psychiatry | www.frontiersin.org 11 August 2021 | Volume 12 | Article 708175
... In a study that evaluated provider views, Wormdahl et al. (2021), concluded that reducing referrals to involuntary admissions cannot be examined separately from the provision of other services. For example, when emergency services are busy, or general practitioners lack understanding of the individual, referrals to involuntary admissions are preferred over other options. ...
... When professionals encounter situations where they must choose between an individual's right to autonomy and health care, a health care organization influences the decision. Professionals must then choose between involuntary admission and neglect, and the rationale and justification for the decision are potentially left unchallenged (Wormdahl et al., 2021). Sugiura et al. (2020) noted that most providers tried to be empathetic and listen to their clients, but they felt coercion was necessary. ...
... As many studies revealed [20,52,53], perceived violence (risk of dangerousness to self or others) is a central factor in psychiatrists' judgments regarding IA, and this is true especially under the risk criteria provisions on IA in China. Psychiatrists' assessment would reflect their evaluation of patients as well as their attitude and understanding of risk criteria on IA [54,55]. In other words, the three factors above might be the most important for clinicians on IA decision making. ...
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Background Reducing involuntary psychiatric admissions is a global concern. In Norway, the rate of involuntary admissions was 199 per 100,000 people 16 years and older in 2020. Individuals’ paths towards involuntary psychiatric admissions usually unfold when they live in the community and referrals to such admissions are often initiated by primary health care professionals. Interventions at the primary health care level can therefore have the potential to prevent such admissions. Interventions developed specifically for this care level are, however, lacking. To enhance the quality and development of services in a way that meets stakeholders’ needs and facilitates implementation to practice, involving both persons with lived experience and service providers in developing such interventions is requested. Aim To develop a comprehensive intervention for primary mental health care aiming to prevent involuntary admissions of adults. Methods This study had an action research approach with a participatory research design. Dialogue conferences with multiple stakeholders in five Norwegian municipalities, inductive thematic analysis of data material from the conferences, and a series of feedback meetings were conducted. Results The co-creation process resulted in the development of the ReCoN (Reducing Coercion in Norway) intervention. This is a comprehensive intervention that includes six strategy areas: [1] Management, [2] Involving Persons with Lived Experience and Family Carers, [3] Competence Development, [4] Collaboration across Primary and Specialist Care Levels, [5] Collaboration within the Primary Care Level, and [6] Tailoring Individual Services. Each strategy area has two to four action areas with specified measures that constitute the practical actions or tasks that are believed to collectively impact the need for involuntary admissions. Conclusions The ReCoN intervention has the potential for application to both national and international mental health services. The co-creation process with the full range of stakeholders ensures face validity, acceptability, and relevance. The effectiveness of the ReCoN intervention is currently being tested in a cluster randomised controlled trial. Given positive effects, the ReCoN intervention may impact individuals with a severe mental illness at risk of involuntary admissions, as more people may experience empowerment and autonomy instead of coercion in their recovery process.
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Background Reducing involuntary psychiatric admissions has been on the international human rights and health policy agenda for years. Despite the last decades’ shift towards more services for adults with severe mental illness being provided in the community, most research on how to reduce involuntary admissions has been conducted at secondary health care level. Research from the primary health care level is largely lacking. The aim of this study was to explore mental health professionals’ experiences with factors within primary mental health services that might increase the risk of involuntary psychiatric admissions of adults, and their views on how such admissions might be avoided. Methods Qualitative semi-structured interviews with thirty-two mental health professionals from five Norwegian municipalities. Data were analysed according to the Systematic Text Condensation method. Results Within primary mental health care professionals experienced that a number of factors could increase the risk of involuntary psychiatric admissions. Insufficient time and flexibility in long-term follow-up, limited resources, none or arbitrary use of crisis plans, lack of tailored housing, few employment opportunities, little diversity in activities offered, limited opportunities for voluntary admissions, inadequate collaboration between services and lack of competence were some of the factors mentioned to increase the risk of involuntary psychiatric admissions. Several suggestions on how involuntary psychiatric admissions might be avoided were put forward. Conclusions Mental health professionals within primary mental health care experienced that their services might play an active part in preventing the use of involuntary psychiatric admissions, suggesting potential to facilitate a reduction by intervening at this service level. Health authorities’ incentives to reduce involuntary psychiatric admissions should to a greater extent incorporate the primary health care level. Further research is needed on effective interventions and comprehensive models adapted for this care level.
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Background Carers are key providers of care and support to mental health patients and mental health policies consistently mandate carer involvement. Understanding carers' experiences of and views about assessment for involuntary admission and subsequent detention is crucial to efforts to improve policy and practice. Aims We aimed to synthesise qualitative evidence of carers' experiences of the assessment and detention of their family and friends under mental health legislation. Method We searched five bibliographic databases, reference lists and citations. Studies were included if they collected data using qualitative methods and the patients were aged 18 or older; reported on carer experiences of assessment or detention under mental health legislation anywhere in the world; and were published in peer-reviewed journals. We used meta-synthesis. Results The review included 23 papers. Themes were consistent across time and setting and related to the emotional impact of detention; the availability of support for carers; the extent to which carers felt involved in decision-making; relationships with patients and staff during detention; and the quality of care provided to patients. Carers often described conflicting feelings of relief coupled with distress and anxiety about how the patient might cope and respond. Carers also spoke about the need for timely and accessible information, supportive and trusting relationships with mental health professionals, and of involvement as partners in care. Conclusions Research is needed to explore whether and how health service and other interventions can improve the involvement and support of carers prior to, during and after the detention of family members and friends.
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This article discusses initiatives aimed at preventing and reducing “coercive practices” in mental health and community settings worldwide, including in hospitals in high‐income countries, and in family homes and rural communities in low‐ and middle‐income countries. The article provides a scoping review of the current state of English‐language empirical research. It identifies several promising opportunities for improving responses that promote support based on individuals’ rights, will and preferences. It also points out several gaps in research and practice (including, importantly, a gap in reviews of non‐English‐language studies). Overall, many studies suggest that efforts to prevent and reduce coercion appear to be effective. However, no jurisdiction appears to have combined the full suite of laws, policies and practices which are available, and which taken together might further the goal of eliminating coercion.
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Background: Use of involuntary psychiatric hospitalisation varies widely within and between countries. The factors that place individuals and populations at increased risk of involuntary hospitalisation are unclear, and evidence is needed to understand these disparities and inform development of interventions to reduce involuntary hospitalisation. We did a systematic review, meta-analysis, and narrative synthesis to investigate risk factors at the patient, service, and area level associated with involuntary psychiatric hospitalisation of adults. Methods: We searched MEDLINE, PsycINFO, Embase, and the Cochrane Controlled Clinical Register of Trials from Jan 1, 1983, to Aug 14, 2019, for studies comparing the characteristics of voluntary and involuntary psychiatric inpatients, and studies investigating the characteristics of involuntarily hospitalised individuals in general population samples. We synthesised results using random effects meta-analysis and narrative synthesis. Our review follows Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and is registered on PROSPERO, CRD42018095103. Findings: 77 studies were included from 22 countries. Involuntary rather than voluntary hospitalisation was associated with male gender (odds ratio 1·23, 95% CI 1·14-1·32; p<0·0001), single marital status (1·47, 1·18-1·83; p<0·0001), unemployment (1·43, 1·07-1·90; p=0·020), receiving welfare benefits (1·71, 1·28-2·27; p<0·0001), being diagnosed with a psychotic disorder (2·18, 1·95-2·44; p<0·0001) or bipolar disorder (1·48, 1·24-1·76; p<0·0001), and previous involuntary hospitalisation (2·17, 1·62-2·91; p<0·0001). Using narrative synthesis, we found associations between involuntary psychiatric hospitalisation and perceived risk to others, positive symptoms of psychosis, reduced insight into illness, reduced adherence to treatment before hospitalisation, and police involvement in admission. On a population level, some evidence was noted of a positive dose-response relation between area deprivation and involuntary hospitalisation. Interpretation: Previous involuntary hospitalisation and diagnosis of a psychotic disorder were factors associated with the greatest risk of involuntary psychiatric hospitalisation. People with these risk factors represent an important target group for preventive interventions, such as crisis planning. Economic deprivation on an individual level and at the population level was associated with increased risk for involuntary hospitalisation. Mechanisms underpinning the risk factors could not be identified using the available evidence. Further research is therefore needed with an integrative approach, which examines clinical, social, and structural factors, alongside qualitative research into clinical decision-making processes and patients' experiences of the detention process. Funding: Commissioned by the Department of Health and funded by the National Institute of Health Research (NIHR) via the NIHR Mental Health Policy Research Unit.
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Background Understanding patient experiences of detention under mental health legislation is crucial to efforts to reform policy and practice. Aims To synthesise qualitative evidence on patients' experiences of assessment and detention under mental health legislation. Method Five bibliographic databases were searched, supplemented by reference list screening and citation tracking. Studies were included if they reported on patient experiences of assessment or detention under mental health legislation; reported on patients aged 18 years or older; collected data using qualitative methods; and were reported in peer-reviewed journals. Findings were analysed and synthesised using thematic synthesis. Results The review included 56 papers. Themes were generally consistent across studies and related to information and involvement in care, the environment and relationships with staff, as well as the impact of detention on feelings of self-worth and emotional state. The emotional impact of detention and views of its appropriateness varied, but a frequent theme was fear and distress during detention, including in relation to the use of force and restraint. Where staff were perceived as striving to form caring and collaborative relationships with patients despite the coercive nature of treatment, and when clear information was delivered, the negative impact of involuntary care seemed to be reduced. Conclusions Findings suggest that involuntary in-patient care is often frightening and distressing, but certain factors were identified that can help reduce negative experiences. Coproduction models may be fruitful in developing new ways of working on in-patient wards that provide more voice to patients and staff, and physical and social environments that are more conducive to recovery. Declaration of interest None.
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Background: Rising annual incidence of involuntary hospitalisation have been reported in England and some other higher-income countries, but the reasons for this increase are unclear. We aimed to describe the extent of variations in involuntary annual hospitalisation rates between countries, to compare trends over time, and to explore whether variations in legislation, demographics, economics, and health-care provision might be associated with variations in involuntary hospitalisation rates. Methods: We compared annual incidence of involuntary hospitalisation between 2008 and 2017 (where available) for 22 countries across Europe, Australia, and New Zealand. We also obtained data on national legislation, demographic and economic factors (gross domestic product [GDP] per capita, prevalence of inequality and poverty, and the percentage of populations who are foreign born, members of ethnic minorities, or living in urban settings), and service characteristics (health-care spending and provision of psychiatric beds and mental health staff). Annual incidence data were obtained from government sources or published peer-reviewed literature. Findings: The median rate of involuntary hospitalisation was 106·4 (IQR 58·5 to 150·9) per 100 000 people, with Austria having the highest (282 per 100 000 individuals) and Italy the lowest (14·5 per 100 000 individuals) most recently available rates. We observed no relationship between annual involuntary hospitalisation rates and any characteristics of the legal framework. Higher national rates of involuntary hospitalisation were associated with a larger number of beds (β coefficient 0·65, 95% CI 0·10 to 1·20, p=0·021), higher GDP per capita purchasing power parity (β coefficient 1·84, 0·30 to 3·38, p=0·019), health-care spending per capita (β coefficient 15·92, 3·34 to 28·49, p=0·013), the proportion of foreign-born individuals in the population (β coefficient 7·32, 0·44 to 14·19, p=0·037), and lower absolute poverty (β coefficient -11·5, -22·6 to -0·3, p=0·044). There was no evidence of an association between annual involuntary hospitalisation incidence and any other demographic, economic, or health-care indicator. Interpretation: Variations between countries were large and for the most part unexplained. We found a higher annual incidence of involuntary hospitalisation to be associated with a lower rate of absolute poverty, with higher GDP and health-care spending per capita, a higher proportion of foreign-born individuals in a population, and larger numbers of inpatient beds, but limitations in ecological research must be noted, and the associations were weak. Other country-level demographic, economic, and health-care delivery indicators and characteristics of the legislative system appeared to be unrelated to annual involuntary hospitalisation rates. Understanding why involuntary hospitalisation rates vary so much could be advanced through a more fine-grained analysis of the relationships between involuntary hospitalisation and social context, clinical practice, and how legislation is implemented in practice. Funding: Commissioned by the Department of Health and funded by the National Institute of Health Research (NIHR) via the NIHR Mental Health Policy Research Unit.
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Abstract Background: Grounded theory is a well-known methodology employed in many research studies. Qualitative and quantitative data generation techniques can be used in a grounded theory study. Grounded theory sets out to discover or construct theory from data, systematically obtained and analysed using comparative analysis. While grounded theory is inherently flexible, it is a complex methodology. Thus, novice researchers strive to understand the discourse and the practical application of grounded theory concepts and processes. Objective: The aim of this article is to provide a contemporary research framework suitable to inform a grounded theory study. Result: This article provides an overview of grounded theory illustrated through a graphic representation of the processes and methods employed in conducting research using this methodology. The framework is presented as a diagrammatic representation of a research design and acts as a visual guide for the novice grounded theory researcher. Discussion: As grounded theory is not a linear process, the framework illustrates the interplay between the essential grounded theory methods and iterative and comparative actions involved. Each of the essential methods and processes that underpin grounded theory are defined in this article. Conclusion: Rather than an engagement in philosophical discussion or a debate of the different genres that can be used in grounded theory, this article illustrates how a framework for a research study design can be used to guide and inform the novice nurse researcher undertaking a study using grounded theory. Research findings and recommendations can contribute to policy or knowledge development, service provision and can reform thinking to initiate change in the substantive area of inquiry. Keywords Framework, grounded theory, grounded theory methods, novice researcher, study design
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In the long history of human rights advocacy in psychiatry, the Convention on the Rights of Persons with Disabilities (CRPD) sets an important balancing point between the right to adequate care and all human rights and fundamental freedoms and draws on cross-cutting themes including empowerment, citizenship, recovery and community living as a viable alternative to institutional living. Coercion in care, such as restraints, seclusion, forced medications, locked inpatient units, warehousing and forensic institutions, must be curtailed. The optimal attainment of liberty and freedom in care processes entails change, substitution and systematization of availability of practical alternatives: open doors, open communities, open dialogues, free access, community engagement, advance directives, joint decision-making and co-production of policy with stakeholders and recovery orientation of all services. Absolutist and idealistic insistence on the abandonment of all forms of involuntary treatments straight away will not work, but CRPD has undoubtedly opened a new debate and is definitely setting a new horizon for psychiatry to approach. Deinstitutionalization is a necessary step, by substituting community for hospital care and voluntary for involuntary care wherever possible and changing legislations accordingly. Widening the new frontier involves creating a convergence of clinical and support services with strong advocacy for rights. There is an emerging evidence base for the proposition that optimizing human rights is inherently therapeutic and contributes to healing. In this framework, the WHO has launched The QualityRights Programme for improving quality of care and implementation of core articles of CRPD. An effective action includes challenging social exclusion and inequality, by acting on social determinants of health like quality and stability of home, work, income, supports, relationships and social participation. Political, legal and social action has to be combined with our own emancipation from institutional thinking and practices in mental health and social care, to vastly improve the prospects of a whole life and full citizenship and rights for persons with psychosocial disabilities.
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Background In involuntary psychiatric admission, used globally, professionals or caretakers decide upon hospitalization regardless of what the person with psychosocial disabilities decides. This raises clinical, ethical, legal, and human rights concerns, and it goes against Convention on the Rights of Persons with Disabilities (CRPD). CRPD mandates that member states respect the autonomy of people with disabilities. Through Article 12, it recognizes full enjoyment of legal capacity for persons with disabilities. Implementation of Article 12 is challenging in every country, and exploring all the stakeholders' experiences at admission decision-making will help us to understand the challenges that the current psychiatry system poses for service users to exercise their autonomy and identify the areas where service users need support to have their rights, will, and preferences respected. Aim To describe the experiences of service users, informal carers, and professionals in involuntary psychiatric admission decision-making and throughout the subsequent involuntary admission. We explored the support that the service users need to have their rights, will, and preferences respected. Method A search of twelve databases in medicine, sociology, and law in Danish, English, Japanese, Norwegian, Portuguese, Spanish, and Swedish was conducted in 2017 and 2018, limited to the past 10 years, using terms such as “involuntary,” “admission,” “mental illness,” and “experience”. The search identified 682 articles. Four researchers independently reviewed the articles to find those that completed original qualitative or mixed method studies exploring experiences of involuntary psychiatric admission among adults. We added seven publications from the articles' references, contacted experts in the field (no publications were added), and excluded two articles that were in German. Three researchers analyzed the articles' results using Thematic Analysis (PROSPERO registration number CRD42019072874). Results Overall, 37 articles were included from 11 countries; they involved 731 service users, 100 informal carers, and 291 mental health professionals. We identified a lack of communication and a power imbalance among the stakeholders, which was exacerbated by the professionals' attitudes. At admission decision-making, the service users wanted to be heard and wanted to understand the situation. The families felt responsibility for the service users, they were careful not to ruin relationships, and they struggled to obtain support from the mental health system. Professionals believed that threats or harming others should lead to admission regardless of what the service users or their families felt. Professionals sometimes felt that it was not necessary to explain the information to the service users because they would not understand. Professionals were concerned and frustrated with difficulties in coordinating among themselves. During admission, service users struggled with the ward environment and relationship with staff; they most objected to coercion, such as forced medication. Families were frustrated that they were not involved in the treatment planning, especially as the service users moved toward discharge. The professionals often rationalized that coercion was necessary, and they believed that they knew what was best for the service users. Conclusions A lack of communication and a power imbalance among the stakeholders hindered respect for the service users' rights, will, and preferences. This was exacerbated by professionals rationalizing coercion and assuming that service users were incapable of understanding information. Services that encourage communication and overcome power imbalances (e.g. Crisis Plans, Family Group Conferencing) combined with stronger community mental health support will respect service users' rights, will, and preferences and avoid substituted decision-making on issues such as involuntary admission and forced medication.
Article
Aims To examine the extent and nature of coercive practices in mental healthcare and to consider the ethical, human rights challenges facing the current clinical practices in this area. We consider the epidemiology of coercion in mental health and appraise the efficacy of attempts to reduce coercion and make specific recommendations for making mental healthcare less coercive and more consensual. Methods We identified references through searches of MEDLINE, EMBASE, PsycINFO and CINAHL Plus. Search was limited to articles published from January 1980 to May 2018. Searches were carried out using the terms mental health (admission or detain* or detention or coercion) and treatment (forcible or involuntary or seclusion or restraint). Articles published during this period were further identified through searches in the authors' personal files and Google Scholar. Articles resulting from searches and relevant references cited in those articles were reviewed. Articles and reviews of non-psychiatric population, children under 16 years, and those pertaining exclusively to people with dementia were excluded. Results Coercion in its various guises is embedded in mental healthcare. There is very little research in this area and the absence of systematic and routinely collected data is a major barrier to research as well as understanding the nature of coercion and attempts to address this problem. Examples of good practice in this area are limited and there is hardly any evidence pertaining to the generalisability or sustainability of individual programmes. Based on the review, we make specific recommendations to reduce coercive care. Our contention is that this will require more than legislative tinkering and will necessitate a fundamental change in the culture of psychiatry. In particular, we must ensure that clinical practice never compromises people's human rights. It is ethically, clinically and legally necessary to address the problem of coercion and make mental healthcare more consensual. Conclusion All forms of coercive practices are inconsistent with human rights-based mental healthcare. This is global challenge that requires urgent action.