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Trends in use of coercion in Norway
Trond HatlingHead
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Legal framework
• 1848, 1961, 1999, 2006– In principle the same since 1961
• Compulsory admissions– Compulsory observation (not allowed to treat
involuntary)– Compulsory admission
• Compulsory Outpatient Treatment– Usually at discharge – but not exclusively
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Legal framework
• Involuntary Treatment– Primarily medical– Separate decision
• Coercive measures• Open Area Seclusion
– Not coercion - Legally regulated since 1999
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Policy initiatives to reduce use of coercion
• Escalation plan 1999-2008– Money –restructuring – ideals of voluntary as the
«principle» not defined• Strategic plan to reduce and quality «assure» use
of coercion – 2006– A paper plan
• Revised plan to reduce and quality «assure» use of coercion – 2012• Requiring ditto Health region and health board plans• A paper plan?
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Policy initiatives to reduce use of coercion• Bernt-Committee (2009)
– The Health Directorate– The treatment criterion– Revising the 2006-strategy– Recommended a Law revision
• Paulsrud-Committee (2011)– Ministry of Health – Law revision– Suggested a number of revisions– Put in a drawer (one sentence in the 2012 state
budget)
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What is coercion?
• Formal coercion - legal• Experienced coercion
– Users –relatives - staff• De facto coercion
– Power ”embraces ” – house rules• Different definitions – Different parties –
Different perspectives• Coercion has legitimacy in the population – in
particular when considered dangerous – debated
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Compulsory admissions
• Compulsory admissions• Additional Mandatory Criteria• Community Treatment Orders/Compulsory
Community Treatment/Assisted Outpatient Treatment/Mandated Community Treatment
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Compulsory admissions 1848-1996
• 1848-1915 (Hospitals)
– 44/100 000 inhabitants• 1916-1935 (Hospitals – a few psych. clinics)
• 70/100 000 inhabitants• 1936-1960 (Hospitals – a few psych. clinics)
• 78/100 000 inhabitants• 1961-1984 (Hospitals – a few psych. clinics/Nursing homes)
– 98/100 000 inhabitants• 1996 (Hospitals – Nursing homes/DPC)
– 195/100 000 inhabitants
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The national picture – 2011
Institutions approved for Compulsory admissions
All institutions
Admissions 36500 45000
Patients 21000 25000
Compulsory admissions 8300
Patients compulsory admitted
5600
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2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20110
25
50
75
100
125
150
175
200
225
250
165166
187206
194
186
198
192197
136 135136150 145
217 215
Compulsory admissions (both types) and compulsory admitted per 100 000 adult inhabitants 2001-2011
Tvangsinnleggelser
Tvangsinnlagte pasienter
Tvangsinnlagte pasienter inkl overført fra frivillige opphold
Tvangsinnleggelser inkl overført fra frivillig opphold
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Additional Mandatory Criteria
1979 1984 1989 1994 1999 2003 20070
10
20
30
40
50
60
70
80
8
14
25 25 24
31
41
15
22
29
3742
51
59
76
63
47
3834
18
0
Use of Additional Mandatory Criteria. Percent. 1979-2007.
Danger Criterion Treatment Criterion Suffer Wrong Criterion
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Regional differences
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217
382226
252150
133
251247
240282
113
257269
242294
201196
184166
152166
122
150
178156
144118
94
190171169
16192
204203
170169
142141
132126125
11999
0 50 100 150 200 250 300 350 400
Landet
UNN-områdetFinnmark
NordNordland-området
Helgeland
Bergen-områdetStavanger-området
VestFonna-området
Sogn og Fjordane
TelemarkLovisenberg-området
ØstfoldSørlandet
Vestfold-områdetSør-Øst
Vestre-Viken-områdetAhus-området
Diakonhjemmets områdeOUS-området
Innlandets områdeBo
sted
Antall per 100 000 innbyggere 18 år og eldre
Tvangsinnleggelser Tvangsinnlagte
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Compulsory Community Treatment
• Since 1961• Ease compulsory admission process • Requirement for compulsory medical treatment
– But not «included»
• The last decade about 2000 (1600-2600) compulsory dicscharged• Figures uncertain
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Involuntary treatment
• About 30% of those compulsory admitted are Involuntary treated (1994-2007)– Figures uncertain
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Coercive measures
• Mechanical restraints• Forced medication• Seclusion• Holding/restraint (since 2006)
• Open area seclusion (skjerming)
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1980 1983 1986 1990 1994 2001 2003 2005 2007 20090
1,000
2,000
3,000
4,000
5,000
6,000
374 350 281492
630807
952 1,118 9671,065
3,347
3,746
5,130
4,1234,426
5142
3526
1940 1880
1140
2705
2330
36803407
4451
Mechanical Restraints. Number of Persons, Hours and Times . 1980-2009.
Persons Times Hours/10
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1994 2001 2003 2005 2007 20090
500
1,000
1,500
2,000
2,500
500586 574
764 707 712
1,250
2,106
1,314
2,146
1,8041,875
Forced Medication. Number of Persons and Times. 1994-2009.
Persons Times
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1980 1983 1986 1990 1994 2001 2003 2005 2007 20090
100
200
300
400
500
600
700
800
900
10672 56 72
42 33 4233
68
114
829
236184 175
269
619
540 553
178
80 91
3156
2254
Seclusion. Number of Persons, Hours and Times. 1980-2009.
Persons Tmes Hours/10
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Holding – 2007-2009
• 2007– 272 Persons – 999 Times
• 2009– 574 Persons – 1680 Times
• Due to changes in recording practice – more than changes in clinical practice?
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2001 2003 2005 2007 20090
500
1,000
1,500
2,000
2,500
3,000
457
786
1,1631,239
1,406
778
1,280
2,049
2,349
2,689
Open Area Seclusion. Number of Persons and Times. 2001-2009.
Persons Times
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Conclusion
• Use of coercion last 10-30 years– ”constant” – despite considerable public attention
• Regulatory means main strategy to reduce coercion– Limited – if any - effect
• Broad set of means necessary to reduce coercion– Deep into i the clinical practice– Methods exists – not applied on a broad scale
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Conclusion – Cont.
• National leadership (as good as?) absent• International research on reducing coercion
difficult to implement