Perceived Coercion and the Therapeutic Relationship: A Neglected Association?

Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
Psychiatric services (Washington, D.C.) (Impact Factor: 2.41). 05/2011; 62(5):471-6. DOI: 10.1176/appi.ps.62.5.471
Source: PubMed
ABSTRACT
Increasing patient autonomy and decreasing coercion are frequently cited goals in mental health care. Research suggests that the therapeutic relationship and patients' experiences of coercion may be associated. This study investigated the association between the therapeutic relationship and perceived coercion in psychiatric admissions.
Associations between perceived coercion and the therapeutic relationship and sociodemographic and clinical variables were examined by using data from structured interviews with 164 patients consecutively admitted to two psychiatric hospitals in Oxford, England.
High levels of coercion were experienced by 48% of voluntarily and 89% of involuntarily admitted patients. A high perceived coercion score was significantly associated with involuntary admission and a poor rating of the therapeutic relationship. The therapeutic relationship confounded legal status as a predictor of perceived coercion.
Similar factors may influence patients' experience of both coercion and the therapeutic relationship during psychiatric hospital admission. Hospitalization, even when voluntary, was viewed as more coercive when patients rated their relationship with the admitting clinician negatively. Interventions to improve the therapeutic relationship may reduce perceptions of coercion.

Full-text

Available from: Tom Patrick Burns
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T
he therapeutic relationship
between patient and clinician
is essential to the practice of
psychiatry. Although the term was
first used in psychotherapy, the con-
cept of the therapeutic alliance and
its role in engaging patients in psychi-
atric treatment are now well recog-
nized (1–5). In the literature, the
therapeutic relationship is broadly
defined as the relationship between
the patient and any clinician involved
in the patient’s care. It can reflect re-
lationships that “last for seconds or
decades” and can have positive or
negative effects on treatment out-
come (4,5). Patients have identified
the therapeutic relationship as the
most crucial factor for good psychi-
atric care (6) and for the establish-
ment of a “safe and therapeutic mi-
lieu” during treatment (7). The use of
coercion in psychiatry has been hy-
pothesized to undermine this thera-
peutic relationship between patient
and clinician (7–9).
Psychiatry is one of the few areas of
medical practice where the use of co-
ercion is legally and ethically sanc-
tioned under limited conditions
(10,11). This remains one of the most
controversial issues in mental health
care policy (9,12–15). Some argue
that legally mandated treatment is
beneficial because it helps to alleviate
illness and restore an individual’s abil-
ity to make autonomous decisions
(16). Others believe that individuals
subjected to coercion may not engage
in treatment and may avoid future
contact with mental health services
for fear of being subjected to involun-
tary care again (17). A qualitative
study of patients’ experiences during
psychiatric hospitalization by Gilburt
and colleagues (7) concluded that
“coercion was always experienced
negatively and had a negative impact
on relationships” between patients
and staff.
The lack of a standard definition of
coercion in psychiatric care has ham-
pered the investigation of its impact
on psychiatric care. The primary issue
is how to operationalize and measure
the experience of coercion. Some
studies use legal status at admission,
either voluntary or involuntary, as a
proxy for experience of coercion
(18–20). However, more recent re-
search has determined that legal sta-
tus is a poor measure of patient expe-
rience (21–24) and that coercion is
not necessarily a function of the legis-
lation that mandates treatment but of
the relationship with those who en-
force that legislation (7).
The incongruence between legal
status and experience of coercion led
to the development of a subjective
measure of perceived coercion, the
MacArthur Perceived Coercion
Scale, which assesses patients’ beliefs
about the influence, freedom, con-
trol, or choice they had in the deci-
sion to enter treatment (8,23,25). Re-
search using this measure indicates
that patients’ “experiences of coer-
Perceived Coercion and the Therapeutic
Relationship: A Neglected Association?
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Dr. Sheehan is affiliated with the Department of Psychiatry, University of Toronto, 250
College St., 8th Floor, Toronto, Ontario M5T 1R8, Canada (e-mail: kathleen.sheehan@
medportal.ca). Dr. Burns is with the Department of Psychiatry, University of Oxford, Ox-
ford, United Kingdom. The results of this study were presented at the World Psychiatric
Association Thematic Conference on Coercive Treatment in Psychiatry, Dresden, Ger-
many, June 6–8, 2007.
Objective: Increasing patient autonomy and decreasing coercion are
frequently cited goals in mental health care. Research suggests that the
therapeutic relationship and patients’ experiences of coercion may be
associated. This study investigated the association between the thera-
peutic relationship and perceived coercion in psychiatric admissions.
Methods: Associations between perceived coercion and the therapeutic
relationship and sociodemographic and clinical variables were exam-
ined by using data from structured interviews with 164 patients consec-
utively admitted to two psychiatric hospitals in Oxford, England. Re
-
sults: High levels of coercion were experienced by 48% of voluntarily
and 89% of involuntarily admitted patients. A high perceived coercion
score was significantly associated with involuntary admission and a poor
rating of the therapeutic relationship. The therapeutic relationship con-
founded legal status as a predictor of perceived coercion. Conclusions:
Similar factors may influence patients’ experience of both coercion and
the therapeutic relationship during psychiatric hospital admission. Hos-
pitalization, even when voluntary, was viewed as more coercive when
patients rated their relationship with the admitting clinician negatively.
Interventions to improve the therapeutic relationship may reduce per-
ceptions of coercion. (Psychiatric Services 62:471–476, 2011)
Page 1
cion are largely shaped by their social
experiences in the process of treat-
ment entry” (9).
Despite the hypothesized associa-
tion between the therapeutic rela-
tionship and the experience of coer-
cion, this is the first study to our
knowledge to quantitatively examine
this association. The study was con-
ducted in England, where psychiatric
care is provided to patients in small
geographical catchment areas by a
dedicated multidisciplinary team.
When hospitalization is required, this
team usually organizes the admission
and remains responsible for the pa-
tient while he or she is hospitalized.
The Mental Health Act, used in in-
voluntary admission, also promotes
the involvement of psychiatrists with
prior knowledge of the patient.
In this study, we interviewed a con-
secutive sample of patients admitted
to a psychiatric hospital and investi-
gated the association between the
therapeutic relationship and per-
ceived coercion. Taking a patient-
centered approach, we used validated
subjective scales to measure patient
experiences of both the therapeutic
relationship and perceived coercion.
Methods
We conducted a cross-sectional co-
hort study of perceived coercion in a
consecutive sample of admissions to
five acute adult wards at two psychi-
atric hospitals in Oxford, England.
Ethics approval was granted by the
Mid and South Buckinghamshire Re-
search Ethics Committee.
Sample
All patients admitted between Janu-
ary and May 2005 and August and
December 2005 were assessed for in-
clusion in the study. Participants
were interviewed only if they had
been admitted to a participating ward
within the previous seven days, and
patients were excluded from the re-
cruitment process if discharged with-
in 24 hours of admission, insufficient-
ly proficient in English to participate
in an interview, or deemed by ward
staff to be too ill or dangerous to take
part. Ward staff introduced the re-
searcher, who was independent of
their care team, to eligible patients.
After receiving a complete descrip-
tion of the study, interested patients
provided their written informed con-
sent. Patients were approached up to
three times in the week after their ad-
mission but were interviewed only
once, even if readmitted during the
study period. Interviews took place
on the ward in a location that was pri-
vate and amenable to the patient
(such as an examination room or bed-
room). Interviews took between 30
and 60 minutes to complete.
Instruments
The interview schedule was designed
to collect data on sociodemographic
and clinical characteristics and on
variables about the admission experi-
ence. Data collected during the inter-
view were verified and supplemented
by a review of case notes and com-
puterized medical records. The fol-
lowing instruments were used.
The MacArthur Admission Experi-
ence Survey (AES) consists of 14
items that require a patient’s true or
false response to statements about
being admitted to the hospital (23). It
has three subscales: perceived coer-
cion (AES-PC, with five items; scores
range from 0 to 5, with higher scores
reflecting a high degree of perceived
coercion), negative pressure (AES-
NP, with six items; scores range from
0 to 6, with lower scores reflecting
high levels of negative pressure) and
procedural justice (AES-PJ, with
three items; scores range from 0 to 3,
with higher scores reflecting low lev-
els of procedural justice). The scale
has good internal consistency with re-
spect to variation in site, instrument
format, patient population, and inter-
view procedure (23).
The Helping Alliance Scale (HAS)
is a therapeutic relationship measure
that was modified for use in an inpa-
tient setting (3). It consists of five
items examining the extent to which
the patient feels understood by his or
her clinician and how much the pa-
tient’s treatment reflects mutually
agreeable goals. The HAS has been
found to be a simple, brief, and reli-
able measure of therapeutic alliance
and is acceptable to patients with
acute psychiatric illness (26,27). Pa-
tients were asked to name the clini-
cian they felt was most responsible
for their admission and to respond to
the HAS items on the basis of their
relationship with this individual.
The Global Assessment of Func-
tioning (GAF), which takes into con-
sideration the patient’s psychological,
social, and occupational functioning,
was used to measure overall function-
ing on a continuum of mental health
to mental illness (28).
Statistical analysis
Data were analyzed with the Statisti-
cal Package for Social Sciences (SPSS
14.0). Descriptive statistical analyses
were performed on baseline sociode-
mographic and clinical characteristics.
The sample was divided into low
(AES-PC score 0–2) and high (AES-
PC score 3–5) perceived coercion
groups by dichotomizing scores at the
midpoint of the scale, as in previous
studies (23). Associations between
perceived coercion level and sociode-
mographic and clinical characteristics
were tested with t and Mann-Whitney
tests for continuous variables and chi
square tests for categorical variables.
Multiple-variable logistic regres-
sion analysis was also conducted to in-
vestigate the relationship between
variables that were significantly asso-
ciated with perceived coercion in the
univariate analysis. Hierarchical logis-
tic regression analyses were used to
evaluate the relative contributions of
sociodemographic and clinical char-
acteristics and the therapeutic rela-
tionship to the prediction of per-
ceived coercion level (24,29). The or-
der of inclusion of variable blocks was
based on previous studies of per-
ceived coercion (24,29,30).
Results
Recruitment
There were 342 admissions during
the study period, of which 122 were
ineligible: 46 patients were dis-
charged or transferred shortly after
admission, 34 were readmissions, 13
had insufficient proficiency in Eng-
lish for participation, 11 had original-
ly been admitted to nonparticipating
wards, 11 were too ill to provide in-
formed consent, four had intellectual
impairment, and three were too dan-
gerous to approach.
Of the 220 eligible admissions, 217
were approached to take part (three
were not contactable). Interviews
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Page 2
were obtained from 164 (response
rate 75%). Fifty patients refused to
participate because they “did not feel
like talking” or were “too tired,” and
three agreed to take part but were un-
willing to sign the consent form. Par-
ticipating patients were asked to iden-
tify their admitting clinician and re-
spond to statements included in the
HAS with respect to this individual.
Most patients identified the consult-
ant psychiatrist (N=127, 77%) or jun-
ior psychiatrist working with their
consultant (N=9, 5%). The other pa-
tients identified their psychiatric
nurse (N=20, 12%), social worker
(N=6, 4%), or general practitioner
(N=2, 1%).
Sample characteristics
As shown in Table 1, the sample was
predominantly male (N=94, 57%),
white (N=145, 88%), middle aged
(mean±SD age 38.8±12.0 years), sin-
gle (N=89, 54%) and living independ-
ently (N=131, 80%). Over half had
completed at least basic secondary
education, which in England is com-
pleted by age 16 (N=98, 60%). Al-
most half had an affective disorder
(N=74, 45%), and approximately one-
third had a co-occurring substance
use disorder (N=56, 34%). The mean
GAF score was 35.3±14.1. A total of
82 patients (50%) reported that they
had previous contact with their ad-
mitting clinician. Most patients
(N=113, 70%) had been previously
admitted to the hospital, although
less than one-third (N=50, 32%) had
ever been detained under the Mental
Health Act. Over three-quarters
(N=128, 78%) were admitted to the
hospital voluntarily, with 22% (N=36)
admitted involuntarily under a sec-
tion of the Mental Health Act.
Perceived coercion
McArthur AES-PC, AES-NP, and
AES-PJ scores were calculated. The
mean AES-PC score was 2.8±1.8,
with a median of 3.0. The distribu-
tion was relatively even across the
range of scores, although a majority
experienced high levels of coercion.
The mean AES-NP score was 4.3±
2.0, with a median of 5.0. The distri-
bution was negatively skewed; almost
half of the patients (N=76, 46%) re-
ported no negative pressure. The
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TTaabbllee 11
Characteristics of 164 patients recently admitted to a psychiatric hospital, by
level of perceived coercion
Perceived coercion
a
Low High
Total % or % or Test
Characteristic N N range N range statistic df p
Age (M±SD) 39.7±12.0 38.2±12.1 t=.79 162 .43
Sex
χ
2
=.54 1 .46
Male 94 43 46 51 54
Female 70 28 40 42 60
Ethnicity
χ
2
=.36 1 .55
White 145 64 44 81 56
Nonwhite 19 7 37 12 63
Marital status
χ
2
=3.5 2 .17
Single 89 36 40 53 60
Married 42 16 38 26 62
Divorced 33 19 58 14 42
Living arrangement
χ
2
=1.44 2 .49
Independent 131 55 42 76 58
Supported 22 12 54 10 45
Incarcerated or homeless 11 4 36 7 64
Education
χ
2
=.03 1 .85
Age <16 66 28 42 38 58
Age16 98 43 44 55 56
Disorder
χ
2
=2.62 2 .27
Affective 74 37 50 37 50
Schizophrenia 64 25 39 39 61
Other 26 9 35 17 65
Comorbid substance
use disorder
χ
2
=.84 1 .36
Yes 56 27 48 29 52
No 108 44 41 64 59
GAF score (M±SD)
b
37.5±13.8 33.6±14.2 t=1.71 148 .09
Prior contact with
clinician being rated
χ
2
=1.22 1 .27
Yes 82 39 48 43 52
No 82 32 39 50 61
Previous admission
c
χ
2
=.57 1 .45
Yes 113 52 46 61 54
No 48 19 40 29 60
Previous involuntary
admission
d
χ
2
=.01 1 .90
Yes 50 22 44 28 56
No 107 46 43 61 57
Legal status
χ
2
=19.46 1 .001
Voluntary 128 67 52 61 48
Involuntary 36 4 11 32 89
Helping Alliance Scale
score (median, range)
e
315 0–450 245 50–450 z=–3.90 .001
Negative pressure
(median, range)
f
6 1–6 3 0–6 z=–7.00 .001
Procedural justice
(median, range)
g
0 0–3 2 0–3 z=–6.08 .001
a
As measured with a subscale of the MacArthur Admission Experience Survey. Low, score of 0–2;
high, score of 3–5
b
Global Assessment of Functioning. Possible scores range from 0 to 100, with higher scores indi-
cating better functioning. There were 14 missing values (N=150).
c
Three missing values (N=161)
d
Seven missing values (N=157)
e
Higher scores indicate better rating of the therapeutic alliance by the patient.
f
As measured with a subscale of the MacArthur Admission Experience Survey. Lower scores indi-
cate greater perceived negative pressure.
g
As measured with a subscale of the MacArthur Admission Experience Survey. Higher scores indi-
cate lower perceived justice.
Page 3
mean AES-PJ score was 1.1±1.1,
with a median of 1.0. The distribu-
tion was positively skewed, with 66
(40%) patients experiencing the max-
imum AES-PJ score.
Associations with
perceived coercion
There were no significant associations
between any sociodemographic char-
acteristics and perceived coercion
level (Table 1). Compared with pa-
tients who were voluntarily admitted
(48%), a significantly higher propor-
tion of involuntarily admitted patients
(89%) reported high coercion (p<
.001). HAS scores were significantly
associated with level of perceived co-
ercion (p<.001). Patients experienc-
ing low levels of perceived coercion
had higher ratings on the HAS thera-
peutic alliance scores (Table 1). Low
levels of coercion were significantly
associated with less negative pressure
(p<.001) and with higher ratings of
procedural justice (p<.001) (Table 1).
Logistic regression model
of perceived coercion
Table 2 shows the blockwise decom-
position of the hierarchical logistic re-
gression analysis. In the first block,
sociodemographic characteristics (gen-
der, age, race [white or nonwhite],
education [below age 16 and age 16
and above] were entered. These vari-
ables did not significantly improve
the prediction of perceived coercion
and explained approximately 2% of
the variance in perceived coercion
level. Clinical characteristics (diagno-
sis [affective disorder versus other
disorder] and GAF score) were added
in the second block but without sig-
nificant improvement in the predic-
tion of perceived coercion, explaining
approximately 5% of the variance. In
the third block, legal status (voluntary
or involuntary admission) was en-
tered and significantly improved the
prediction of perceived coercion, ex-
plaining approximately 15% of the
variance. Adding the HAS score in
the fourth block increased the
amount of variance explained to ap-
proximately 21%, significantly im-
proving the prediction of perceived
coercion level and partially confound-
ing the effect of legal status.
Discussion
To our knowledge, this is the first
study to quantitatively investigate
the correlation between the thera-
peutic relationship and perceived
coercion. The finding of a significant
association between these variables
indicates that similar factors affect
the assessment of both. Whereas
perceived coercion was also associat-
ed with legal status at admission, the
multiple-variable analysis suggests
that the therapeutic relationship may
have modified these perceptions
among patients regardless of wheth-
er their admission was voluntary or
involuntary.
Therapeutic relationship
and perceived coercion
Acquiring a better understanding of
the association between the thera-
peutic alliance and perceived coer-
cion is important because of the com-
plexities of the relationship between
patient and clinician in mental health
care. In few areas of medicine do cli-
nicians have the power, which is reg-
ularly exercised, to involuntarily hos-
pitalize and treat their patients. The
correlation between legal status and
perceived coercion found in this
study replicates the findings of other
studies in this area (24,25,31–35). Of
greater interest and clinical relevance
is the association between the thera-
peutic relationship and perceptions
of coercion. Patients who experi-
enced high levels of coercion tended
to rate their relationship with the ad-
mitting clinician more poorly than
those who experienced low levels of
coercion. This was true for both vol-
untarily and involuntarily admitted
patients. This quantitative finding
supports recent qualitative studies
showing that coercion, as experienced
by the patient, consistently had a neg-
ative impact on relationships (7,36,
37). Gilburt and colleagues (7) con-
cluded that coercion was the main
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TTaabbllee 22
Relative contributions of sociodemographic, clinical, and admission experience variables to explain variance in perceived
coercion
R
2
(N=149)
95% CI for exp b
Hosmer & Cox & Nagel-
Factor B SE p Lower Exp b Upper
χ
2
df p Lemeshow Snell kerke
Block 1: sociodemographic 2.50 4 .64 .01 .02 .02
Gender (male versus female) –.32 .35 .36 .37 .73 1.44
Age –.02 .02 .22 .96 .98 1.01
Race (white versus nonwhite) .26 .52 .62 .47 1.30 3.62
Education (age 16 versus age <16) .10 .34 .77 .56 1.11 2.16
Block 2: clinical 7.55 6 .27 .04 .05 .07
Diagnosis (affective disorder
versus schizophrenia or other) .44 .34 .20 .79 1.56 3.06
Global Assessment of
Functioning score –.02 .01 .07 .96 .98 1.00
Block 3: legal status (voluntary
versus involuntary) 2.07 .58 .00 2.53 7.95 24.97 24.65 7 .001 .12 .15 .20
Block 4: therapeutic alliance
(Helping Alliance Scale score) –.01 .00 .01 .99 1.00 1.00 32.25 8 .001 .16 .20 .26
Page 4
barrier to the formation of a thera-
peutic relationship and that the coer-
cive experience of involuntary admis-
sion is “not necessarily a function of
the Mental Health Act, but of the re-
lationship with the staff enforcing as-
pects of it.”
The cross-sectional nature of our
study, however, does not allow the
causality of this relationship to be
determined. It is unclear whether
patients felt less coerced because of
their more positive relationship with
their clinician or whether feeling co-
erced prompted them to rate this re-
lationship more poorly. It is also
possible that factors that contribute
to these ratings influence each one
independently of the other. There is
some concern that several of the ap-
parently distinct measures of psychi-
atric patients’ assessments of their
care (including their quality of life,
satisfaction with services, and thera-
peutic relationship) may all reflect a
more unitary disposition toward
care (38). Further research is re-
quired to investigate this associa-
tion. It is not a question that can eas-
ily be tested in a controlled trial, but
longitudinal studies should be able
to determine the time sequence of
the relationship and thereby suggest
directionality.
The multiple-variable analysis dem-
onstrated that the therapeutic rela-
tionship and sociodemographic and
clinical variables explained approxi-
mately 21% of variance in perceived
coercion level. This low percentage
may reflect that the study addressed
only the relationship between the
patient and the clinician whom the
patient felt was most responsible for
the admission. Although most pa-
tients identified a psychiatrist as be-
ing most responsible, their experi-
ence may also be influenced by oth-
er individuals in their social net-
work, including family, friends, and
colleagues (5). Moreover, clinicians
are embedded within a complex
mental health system. Patients’
opinions of the system and other
health professionals involved may
also play a role in their experience of
coercion. Exploring how these rela-
tionships interact and influence per-
ceptions is a promising area of fu-
ture research (5).
Therapeutic relationship
as a target for intervention
There has been only one published
study reporting the development and
testing of an intervention to reduce
perceived coercion (39). Sorgaard
(39) attempted to increase patients’
sense of procedural justice by engag-
ing them in formulating the treat-
ment plan, performing regular evalu-
ations of treatment progress, and
renegotiating these plans when nec-
essary. The intervention had no effect
on perceived coercion. One possible
explanation is that this type of inter-
vention required a positive relation-
ship between the patient and clinician
to be effective.
Our study suggests that there may
be opportunities for interventions to
reduce perceived coercion by im-
proving the therapeutic relationship.
The ability of clinicians to establish
and maintain a positive therapeutic
relationship can be enhanced through
training and supervision (40,41).
Gask and colleagues (40) found that
general practitioners trained to assess
and manage depression were rated by
their patients as better at listening
and understanding their concerns.
However, there remains a paucity of
research in this area. Priebe and Mc-
Cabe (5) have suggested that “study-
ing and improving therapeutic rela-
tionships in psychiatry is a core task
for social psychiatry.”
Limitations of this study
There are several methodological limi-
tations in this study. First, a substantial
number of patients were either exclud-
ed or refused to participate. Approxi-
mately 22% were excluded because
they were discharged or transferred
before they could be approached or
were deemed by ward staff to be too ill
or intellectually impaired to participate
or had insufficient proficiency in Eng-
lish to enage in the interview. A further
15% refused to be interviewed. Al-
though this nonparticipation rate is
similar to rates reported in other stud-
ies of perceived coercion, it is impor-
tant to recognize that the individuals
who were excluded may have had dif-
ferent attitudes toward the hospitaliza-
tion process (8,31,32).
Second, the study was single site
(one city) and may not be representa-
tive of patients in other countries or
other areas of England. Thresholds
for hospitalization and use of involun-
tary admission vary greatly within
England and Wales, and our study in-
cluded a greater proportion of volun-
tarily admitted patients and more
white and highly educated patients
than in the only published study of
perceived coercion in the United
Kingdom (24,42). Despite these dif-
ferences, our results are closest to
those of Bindman and colleagues
(24), suggesting that our findings may
generalize to England and Wales.
Third, as previously mentioned, the
cross-sectional nature of the study
makes it difficult to determine causal-
ity. Further research is required to in-
vestigate this association and establish
the directionality of the relationship.
Finally, although the rating of per-
ceived coercion made during the in-
terview was retrospective, patients’
assessment of the therapeutic rela-
tionship may have reflected an ongo-
ing relationship with the clinician
during hospitalization. To minimize
this, all patients were interviewed
during their first week of admission to
the hospital, but it is still possible that
the inpatient experience may have in-
fluenced their responses to the HAS
statements.
Conclusions
This was an initial quantitative study
of the association between the thera-
peutic relationship and perceived co-
ercion. The experience of coercion
and the therapeutic relationship dur-
ing psychiatric hospital admission
were found to be correlated, suggest-
ing that similar factors may influence
the patient’s experience of both. Hos-
pitalization, even when voluntary, was
viewed as more coercive when pa-
tients rated their relationship with the
admitting clinician negatively.
Acknowledgments and disclosures
Dr. Sheehan was funded by scholarships from
the Rhodes Trust and Christ Church, a college
of the University of Oxford. The authors thank
Helen Doll, D.Phil., for her statistical advice.
The authors report no competing interests.
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PSYCHIATRIC SERVICES o ps.psychiatryonline.org o May 2011 Vol. 62 No. 5
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    • "CGI –S) predicted a higher level of perceived coercion (Bindman et al., 2005; Kjellin et al., 2006; O'Donoghue et al., 2014). Contrary to these findings, some studies have shown no clear influence of patient related variables on perceived coercion (Poythress et al., 2002; Kjellin et al., 2006; Sheehan and Burns, 2011). Individuals with hostile-dominant interpersonal style were also known to have higher levels of perceived coercion (Anestis et al., 2013). "
    [Show abstract] [Hide abstract] ABSTRACT: Background: The current Mental Health Care Bill (MHCB) –2013 in India advocates least restrictive alternatives (LRA) in psychiatric treatment. However, we have little evidence on patient’s perspectives of coercion and LRA. Methodology: This was a hospital-based prospective pilot study. 170 subjects chosen by computer generated random number sampling were screened. In 83 eligible subjects, all assessments including coercion assessment were completed within 3 days of admission and in 75 subjects reassessment was done within 3 days of discharge. Results: Perceived coercion as measured by the MacArthur Perceived Coercion Scale (MPCS) decreased significantly from 3.72 _ 1.98 at admission to 1.77 _ 1.8 (<0.001) at discharge. This was accompanied by significant increase in global functioning, insight score (from 1.5 _ 1.0 to 3.8 _ 1.1; p < 0.001) and as well as decrease in symptom severity (CGI-S) (from 5.9 _ 1.1 to 1.8 _ 1.9; p < 0.001). Coercion is predicted by family type, employment status, socio economic status, severity of illness and level of insight. 87% patients reported that their admission was justified even though many felt coerced during hospital stay. Conclusion: Coercion is a dynamic state and changes with treatment and care. Clinical care may result in an improvement in global functioning, insight as well as in reduction in severity of illness consequently leading to less coercion. During the time of discharge, majority of patients reported that their admission was justified, even though they felt coerced during hospital stay and agreed for treatment against their will within a safe, standardised coercive practice.
    Full-text · Article · Apr 2016 · Asian Journal of Psychiatry
  • Source
    • "Interestingly, the therapeutic relationship appeared to be a stronger predictor than the level of coercion experienced by the service user. However, this finding is not fully consistent with the international literature, as two previous studies found that the level of perceived coercion was associated with the therapeutic relationship (Sheehan & Burns, 2011; Theodoridou et al. 2012). It could be argued that these are more conceivable results, as it is understandable that exposure to practices that are perceived as coercive could negatively impact the longer term therapeutic relationship . "
    [Show abstract] [Hide abstract] ABSTRACT: Objectives The ‘Service Users’ Perspective of their Admission’ study examined voluntarily and involuntarily admitted services users’ perception of coercion during the admission process and whether this was associated with factors such as the therapeutic alliance, satisfaction with services, functioning and quality of life. This report aims to collate the findings of the study. Methods The study was undertaken across three community mental health services in Ireland. Participants were interviewed before discharge and at 1 year using the MacArthur Admission Experience. Caregivers of participants were interviewed about their perception of coercion during the admission. Results A total of 161 service users were interviewed and of those admitted involuntarily, 42% experienced at least one form of physical coercion. Service users admitted involuntarily reported higher levels of perceived coercion and less procedural justice than those admitted voluntarily. A total of 22% of voluntarily admitted service users reported levels of perceived coercion comparable with involuntarily admitted service users and this was associated with treatment in a secure ward or being brought to hospital initially under mental health legislation. In comparison with the service user, caregivers tended to underestimate the level of perceived coercion. The level of procedural justice was moderately associated with the therapeutic relationship and satisfaction with services. After 1 year, 70% experienced an improvement in functioning and this was not associated with the accumulated level of coercive events, when controlled for confounders. Conclusions This study has provided valuable insights into the perceptions of coercion and can help inform future interventional studies aimed at reducing coercion in mental health services.
    Full-text · Article · Mar 2016 · Irish journal of psychological medicine
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    • "These effects where found when controlling for voluntary and involuntary admission status of consumers. To decrease perceptions of coercion, the authors note that specifically, the modality for intervention lies in increasing the therapeutic relationship (Sheehan & Burns, 2011). Similarly, researchers found that when consumers perceive civil commitment hearings negatively, they tend to report a negative working alliance with their providers (Donnelly, Lynch, Mohan, & Kenney, 2011). "
    [Show abstract] [Hide abstract] ABSTRACT: Using a sample of 60 adults with mental illness in an inpatient state hospital, the present study examined the relative contribution of mental health consumers’ reports of working alliance and provider directiveness in consumers’ perceptions of recovery-oriented service delivery, personal loss from mental illness, and individual well-being. Using a subsample of mental health consumers (n = 19) and their mental health providers (n = 9) the present study examined the congruence of perception between providers’ and consumers’ views of working alliance and provider directiveness in understanding individual well-being for consumers and providers. Findings suggest that consumers’ reports of working alliance and provider directiveness accounted for a significant proportion of the variation in their reports of recovery-orientation of services. Consumers’ reports of working alliance accounted for a significant proportion of the variance in consumers’ reports of their individual well-being. However, consumers’ scores on relationship measures were not significantly related to their reports of personal loss from mental illness. In a subsample of providers and consumers, dyadic analyses suggest that consumers’ reports of a stronger working alliance were related to providers’ reports of higher levels of directive practices. Dyadic results also suggest that greater congruence of perceptions of working alliance among consumer-provider dyads was positively related to consumers’ perceptions of recovery-oriented service delivery. Implications of findings for research and clinical practice are discussed.
    Full-text · Article · Dec 2015
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