An exploratory study of fifteen discharged psychiatric patients who had all been compulsorily detained found all participants reported to have struggled to cope with intense feelings at their admission. These included anger, fear and sadness (Joseph- Kinzelman et al., 1994). For some, these emotional needs were sufficiently met by staff; for many they were not. This study offers a useful insight into the experiences of patients during key stages of the process of involuntary psychiatric detention. It is strengthened by the use of lengthy interviews (lasting between one and three hours) using a schedule which had been piloted as part of a group interview. Despite this, the study lacks clear methodological aims and minimal detail was shared about the participants’ diagnosis or previous experience psychiatric services. Lack of methodological rigour diminishes the research as the data was not analysed using any specific qualitative approach, generating only descriptive themes. Conclusions drawn related only to implications for the role of nursing, despite this not being the proposed area of research. Such limitations undermine the value of this research and make it impossible to draw conclusions about the pattern of data, or how to apply it to a specific population.
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A study exploring patients’ perceptions of involuntary treatment in relation to self, relationships and recovery interviewed participants using a semi-structured schedule (Hughes, Hayward and Finlay, 2009). Half of the participants reported having maintained their sense of self during the admission process, while the other half expressed extreme negative experiences, including ‘feeling undervalued’. Although based on a sample size of 12, this research generated important information about the strength of fear experienced by those as a result of an involuntary admission. Purposive sampling was used in the study as a way of accessing the shared experiences of that group. The interviews were however based upon retrospective accounts, ranging from one week to seven years ago. This wide time range not only threatens the homogeneity of the sample it may also make the data vulnerable to memory based biases.
In an IPA study Johansson and Lundman (2002) detailed the experiences of five involuntary hospitalised patients, and reported that they experienced their admissions as both supportive and violating. Interviews were conducted and analysed at three levels. The second stage, which remains closer to the data than the later, more interpretative stage, included a range of themes: ‘being restricted in autonomy’, ‘being violated by intrusion’, ‘physical integrity and human value’, ‘being outside’, ‘being respected as an individual’ and ‘being cared for’. The research concluded that the findings represent a complex mix of experience within which [they found] “some
staff have failed in their task to see the patients as individuals and respect them” (Johansson and Lundman, 2002, p.645). It should be noted that five is too small a sample from which to draw firm conclusions, although the purpose of qualitative
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research is not to generalise its findings to a wider population. It is also worth considering that the research includes those who wished to share their views; it is possible that those with the most extreme experiences were likely to want to participate in this.
Narrative-based interviews were conducted upon 18 involuntarily hospitalized patients with the aim of exploring attitudes to coercion (Olofsson and Jacobsson, 2001). Qualitative interpretative content analysis was performed on the data and participant responses were primarily grouped into the categories of ‘not being respected as a human being’ and ‘being respected as a human being’. Although a ‘descriptive-explorative’ approach was reported to have been followed, it is unclear what types of questions were asked. The authors suggested that the fact participants were interviewed prior to their exit to hospital may have contributed to overly favourable reports, either for fear of jeopardising their discharge, or because their perspective was more positive at that point. Interestingly there were 13 eligible patients who refused to participate because of a reluctance to discuss difficult or painful experiences.
1.7.1.1 Qualitative Papers: What are patients’ emotional experiences of involuntary psychiatric inpatient care?
The qualitative literature reviewed suggests that in many cases the emotional needs of patients are not being sufficiently met (Joseph-Kinzelman et al., 1994). The feelings encountered by patients include frustration, anger, sadness, fear and boredom (Joseph-Kinzelman et al., 1994; Hughes et al., 2009). Feeling undervalued,
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disrespected and powerless were also common experiences (Johansson and Lundman, 2002). Fear was particularly significant in several of the studies. One patient reported the cyclical nature of such an emotion, i.e.: fear led to non compliance, which in turn triggered an increase in the use of coercive methods, and hence greater fear. This indicates the potentially counterintuitive nature of forced medication (Hughes et al., 2009). Restraint and threat to ‘physical integrity’ was viewed as slightly more coercive than forced medication (Johansson and Lundman, 2002). The latter was found to worsen patient distress, as expressed with this extract: “They took me to the back room, they put me face down on the bed, actually holding my face into the cushions, so that I couldn’t breathe. I was fighting and fighting. And they were saying, um, go on, pull her trousers down and stick it in her arse. I thought they were raping me” (Hughes et al., 2009, p.157). Some factors not necessarily viewed by professionals to be overtly coercive, were identified as being experienced as forceful, for example ‘threats of sanctions’ (Olofsson and Jacobsson, 2001) suggesting that the staff perceptions of coercion may not be attuned with patients’ experiences.
1.7.1.2 Qualitative Papers: What can be done to help minimise the negative aspects of coercion?
The qualitative literature offers suggestions for how coercion can be minimised; these can broadly be grouped into ‘environment and activity’ and ‘emotional support and communication’. The creation of a ‘calm and accepting environment’ was deemed important (Joseph-Kinzelman et al, 1994, p.31). Enabling activities and protecting patient privacy would also help to enhance the environment (Joseph-
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Kinzelman et al., 1994). Whilst for many patients, involuntary treatment was experienced as positive, a need for greater consistency in care was also identified (Johansson and Lundman, 2002).
Emotional support and communication were identified as being significant factors. Having a positive relationship with staff was found to help preserve a patient’s ‘sense of self’ and reduce their experience of coercion (Hughes et al., 2009). Staff training into the impact of coercion could support a better understanding of this, including the dynamic of disempowerment and how it appears to contribute to greater non-compliance and perpetuate the need for coercion. Patients also desired increased support in managing difficult feelings at admission (Joseph-Kinzelman, 1994). Reducing the length of coercive treatment was suggested as being another way to reduce the associated negative impact, as well as better awareness around voluntary admittance and improved outpatient care (Olofsson and Jacobsson, 2001).