NATIONAL CONFERENCE, OSLO, APRIL 5TH AND 6TH, 2011

Marit Følsvik SvindsethPhD clinical medicine

MHSc

Data in my study collected inAalesund Hospital, 2 locked, psychiatric emergency units

Perceived Coercion, Humiliation or Violation of Integrity?

How are these concepts related and is there a difference regarding their

impact on outcome?

Background

10 years of experience as chief nurse in a psychiatric emergency unit.

Before the chief nurse became a quasiexpert on administrating wages, controlling all economic aspects including controlling each individual employee ++++++

In other words, I spent much time with the patients

COERCION - DEFINITION

• The use of force to persuade people to do things which they are unwilling to do

The Cambridge Dictionary

• Force is explained as using physical power, influencing or as giving no choice

HUMILIATION

Lindner (2002) states:• Humiliation means to be placed, against ones

will, in a situation where one is forced to feel inferior

Statman (2000) states:• To be humiliated means to suffer an actual threat

to or fall in one´s self-esteem• Both definitions touch painful feelings, rather

than cognitive interpretation of situations

INTEGRITY

• The former definitions of humiliation tells us that

• Humiliation ≈ violation of integrity

Patients´ view on coercion

• In group sessions and individual interviews with patients (both voluntary and involuntary patients) I recognized statements, repeated by many.

• The statements seemed to have their origin in emotions, rather than cognitive interpretations of the situations they described

Patients´ statementsWhen asked about their experiences in the admissiion process, the

patients stated:• I was relieved to, at last, getting help• I felt I was worth nothing• I was not allowed to give my opinion• Nobody listened to me• I was feeling so small…• They did not let me decide anything• I was forced to follow the paramedics without extra sets of clothes• I was persuaded to the hospital and when I was involuntary

admitted, I felt so stupid and angry of those who persuaded me.

Interest in coercion

• The American Coercion Studies (MacArthur Group) inspired us to gather data in a systematic way by using chosen questions from the Admission Experience Survey (AES), the Nordic Admission Interview (NorAI and the Admission Experience Interview (AEI)

• When examining the instruments, I found that the statements in the surveys were very similar to what the patients already had told me

Questioning the scale as ”coercion scale”

• My interpretation of the statements from the patients were:

• They did not report cognitive interpretation of the situations

• They reported strong feelings and the statements covered many of the questions from the coercion surveys

MEASURING COERCION

• To me, and my discussion partners, it seemed like most of the questions in the coercion surveys measured perceived humiliation rather than perceived coercion

Setting of the study

• Aalesund Hospital, two closed psychiatric emergency units

• Each unit, eight separate rooms, two of the beds (rooms) used for seclusion purposes

• Data collected in a period from March 1st, 2005 to October 31st 2006

Exclusion criteria

• Dementia• Organically based confusion• Manic or hypomanic states• Poor ability to speak Norwegian/English• Discharge within the first 48 hours• Readmissions

The sample Involuntary (voluntary)

• 191 (160) admissions• 78 (48) met the exclusion criteria• 8 (12) declined to take part• 7 (11) were lost due to administrative reason• 98 (88) patients included• Due to a high number of voluntary admissions we

only included on predefined days of the week• Total sample: N = 186

Questions modified from the AES, NORAI and AEI

• Criterias for choosing questions were that items should be anchored in statements from patients, they should be short and easily understandable. They should be answered by yes or no. They were called negative experiences

• Coercion measured as legal coercion status• Humiliation as reports from patients on a scale

from 1 – 10 (as the ”coercion ladder”)

Back to my basic assumption

• Qualitative interviews told me that the selected questions measure perceived humiliation rather than perceived coercion

• The negative experience questions had a Cronbach`s alpha of .74, telling us that the internal concistency is good but it does not say whether we are mesuring coercion or humiliation

CORRELATIONS

HUMILIATION*r

p COERCION**r

p

Been heard .50 <0.001 .21 .005

Expressed opinion

.16 .03 .12 .08

Persuation .26 <0.001 .03 .68

Threats .41 <0.001 -.01 .89

Force .46 <0.001 .08 .30

Admission considered right

.45 <0.001 .15 .05

N = 186 * Controlled for coercion ** Controlled for humiliation

• Negative experiences are much more correlated with perceived humiliation than legal coercion

A closer look at one of the negative experiences: ”Not been heard”

Coercion explains 4.2% of the variance whileHumiliation explains 25.3% meaning a small

overlap between coercion and the variable ”not been heard” and a large overlap between humiliation and the same variable

Decision needed

• What are we measuring?• Perceived coercion? Humiliation? Violation of

integrity? • Do the patients answer after cognitive

considerations on coercion?

• Or – do they report a feeling (emotion)?• If they report an emotion, which emotion?• And – are emotions masureable?

Concequences of measuring perceived coercion

• Focus on minimizing coercion (and this is important due to the impact on the ethical implications on Autonomy,++++)

• increased focus on coercion and – hopefully – a reduction in coercion where a reduction is posssbible

• Less focus on the important issues that are closely connected with coercion

Concequences of measuring perceived coercion

Other fields in medical practice (like geriatric wards, wards concentrating on substance abuse++) may not be aware of the implications negative experiences may have on their patients

• Impact on self-esteem• The assumed long duration of humiliating events

Concequences of measuring humiliation (violation of integrity)

• Focus on minimizing negative experiences that increase perceived humiliation

• The situations that increase perceived humiliation are also associated with Coercion (legal status)

• Focus on the patients´ own coping strategies• Self-esteem issues• Better treatment compliance• Less assymetri in power structures

Concequences of measuring humiliation (violation of integrity)

• A ”side-effect” of humiliation focus may be less involuntary admitted patients

• More ”global” use of a humiliation instrument, not only in wards where coercion is a topic

Recommendations

• Develop an instrument where the outcome changes from Perceived Coercion to Perceived Humiliation (Violation of Integrity)

• Coercion should always be part of studies where Humiliation (Violation of Integrity) is the dependent variable

• Discussions on the proper ways of measuring Coercion should continue. May be we should settle on the legal admission status as coercion measure?

Recommendations

• Analyze and find which items are best fit to measure coercion

• Analyze and find which items are best fit to measure humiliation/violation of integrity

• More qualitative studies in order to determine what is ”really measured”

THANK YOU FOR THE ATTENTION