HOW
Georg Høyer
Institute of community medicine
University of Tromsø
Holmen, March 5th 2011
→ We still lack a valid measure for coercion
→ We still don’t know exactly what coercion is, how it shall be
defined and eventually how to grade and measure coercion
→ Which again is why we lack knowledge about the
effect of coercive interventions
→ There are reasons to believe that PERCEIVED
COERCION is the most important element in this
perspective, but also the most difficult to measure
Holmen, March 5th 2011
“...What makes people feel coerced - is a prerequisite to
understanding coercion as an independent variable (i.e., whether
and how coerced hospitalization is effective in producing therapeutic
outcomes)”
Monahan et al. 1995
Holmen, March 5th 2011
WHAT CONSTITUTES
COERCION?
No-choice coercion
(rotten choices)
Structural coercion
(ward rules etc)
FORMAL
(LEGAL)
COERCION
VIOLATION OF INTEGRITY
AND/OR AUTONOMY
HUMILIATION
OTHER FACTORS
PROCEDURES
PHYSICAL
(CONCRETE)
COERCION
PERCEIVED
COERCION
Holmen, March 5th 2011
HOW CAN PERCEIVED COERCION BE EXPLORED?
how
Instruments/questionnaires
Self-administered (Postal, on-site)
Filled in by interviewer (Telephone, video, on-site)
Global assessments vs structered, multidemential instruments
Qualitative interviews
Clinical interviews
Holmen, March 5th 2011
MILESTONES IN THE EXPLORATION OF
PERCEIVED COERCION
how
Late 1970th : First publications on patients’ experiences
1992: The MacArthur coercion study. Development of the AES
and the MPCS
1997: Introduction of the Coercion Ladder (CL)
Holmen, March 5th 2011
VARIOUS INSTRUMENTS
1978-1995: Mostly self-designed questionnaires, rarely used in
how
more than
one study
1995: The MacArthur Perceived Coercion Scale (MPCS), (Lidz et al, 1995)
1997: The Coercion Ladder (CL), (Høyer et al., 2002)
2001: The Community Perceived Coercion Scale, (Birmbaum, Lidz & Greenidge 2001)
2005: Psychiatric Experience Questionnaire (PEC), Frueh et al, 2005
2006: Perceived Coercion in Everyday Life (PCEL), (Steadman & Redlich, 2006)
2010: Coercion Experience Scale (CES), (Bergk, Flammer & Steinert, 2010)
Holmen, March 5th 2011
AES/MPCS
how from a 104 item semistructured interview
MPCS developed
schedule, The Admission Experience Interview (AEI), through
a 41 item questionnaire, The Admission Experience Survey, to a
15 (or 16) item version, The Admission Experience Scale, The
AES
The AES consists of 3-4 subscales (often given different names),
one of them being the MPCS. Others are Voice (or “process
exclusion”) (4 items), Negative pressures (or “Force/Threats”)
(6 Items).
Holmen, March 5th 2011
THE MACARTHUR PERCEIVED
COERCION SCALE (MPCS-5)
• (1) I had more influence than anyone else on whether
I came into the hospital (Influence)
• (4) I had a lot of control of whether I went into the
Hospital (Control)
• (7) I chose to come into the hospital (Choice)
• (14) I felt free to do what I wanted about coming into
the hospital (Freedom)
• (15) It was my idea to come into the hospital (Idea)
Holmen, March 5th 2011
MPCS-5: Some concerns
• The definition of coercion: Coercion defined as
lack of (or reduced) autonomy
• The terms influence, control, choice and freedom (and
idea) were chosen to constitute perceived coercion
because it proved difficult to ask someone directly
about coercion (The terms were chosen on basis of
their face validity as everyday synonyms for
autonomy)
• If patients tells us that influence, control and the like,
were absent, then coercion was present (Gardner et al 1993)
Holmen, March 5th 2011
MPCS-5: Some concerns II
• Validation problems (No ”Gold Standard”)
• Studies on the reliability of perceived coercion measures almost
non-existent
• Low impact of the application of coercive measures on
perceived coercion
• Focus on the admission situation only (and does not
discriminate between what happens in the community and at
arrival to the hospital)
• Cultural, socioecconomic, gender and race sensitive
• Different scoring procedures (little discussed) (True/False,
yes/no, Lickert score)
Holmen, March 5th 2011
MPCS-5: Some concerns III
Not very user friendly?
% completion of AES/MPCS/CL
AES
MPCS
CL
65.4
72.8
95.8
(The Nordic coercion study)
Missing rate (%) for individual questions in MPCS: 1.6-11.8
Gardner et al. 1993: MPCS-5:11.8 %, but MPCS-4: 2.5-3.7
Nicholson et al. 1997: More than 20% refused to fill in the AES
Holmen, March 5th 2011
MPCS-5: Some concerns III
Low test-retest reliability (consistancy)
Number of inconsistent answers when the four ”voice” questions were
repeated during the same interview (%) (The Nordic coercion study, the
Danish subsample)
1 (AES 3):
14.8 %
2 (AES 5):
14.8%
3 (AES 9):
22.2%
4 (AES 13):
12.9%
COMBINED:
INCONSISTENT: 51.9%
INCONSISTENT 68.5%
+ MISSING
Holmen, March 5th 2011
Perceved coercion: Other concerns
Relations between Perceived Coercion and:
Patient Satisfaction
Humilation
Violation of integrity
Trauma
Quality of Life
Symmptom measures
Holmen, March 5th 2011
WHAT DO WE KNOW ABOUT
PERCEIVED COERCION?
There is a tendency that patients either feel coerced or not, and not a
straight ”dose-effect” response in perceived coercion
Holmen, March 5th 2011
THE NORDIC COERCION STUDY
DISTRIBUTION OF MPCS SCORES
Legally involuntary
Legally voluntary
140
120
120
100
100
80
80
60
60
40
20
20
0
0
1
2
3
4
5
Count
Count
40
0
0
MPCS
MPCS
MPCS-5 Scores
Holmen, March 5th 2011
1
2
3
4
5
The Nordic Coercion Study
Mean scores on the MPCS-5
MPCS
ALL Vol Invol
The Nordic Study
Bindman
Hoge (1978)
Hiday (1997)
2.5
2.6
2.9
Holmen, March 5th 2011
1.7 3.5
1.9 3.4
0.6 3.2
-
WHAT MORE DO WE KNOW ABOUT
PERCEIVED COERCION?
Gender, Age, Diagnosis, Degree of symptoms, Formal legal status,
Number of previous admissions, are rarely associated with
perceived coercion (with a few exceptions)
Procedural justice/negative pressures/process exclusion/voice are
the most important predictors of perceived coercion
Surpirsingly low correspondence between use of physical coercion
and perceived coercion
Holmen, March 5th 2011
WHAT MORE DO WE KNOW ABOUT
PERCEIVED COERCION II
Perceived coercion scores seem to be stable over time, even if more
patients agree that the commitment was necessary as times go by
More than half of the committed patients feel they have recieved
help and have been treated well by the staff
Holmen, March 5th 2011
Of course no-one, but our
Honourable guest speaker
Professor Chuck Lidz
University of Massachutes
Medical School, USA
Holmen, March 5th 2011
PERCEIVED COERCION:
SOME EMPIRICAL RESULTS VII
What happened in the community before hospitalization was the best predictor
of perceived coercion measured (> 2 days after admission)
Cascardi & Poytress 1997
56.4 % af all committed patients said they would have accepted an offer to be
admitted voluntarily
Hoge et al, 1997
20-30 % of patients receiving ECT reported that they did not have the
opportunity to say no even if this procedure required informed consent
Rose et al, 2005
44% of voluntarily admitted patients beleived they would be formally detained if
they tried to leave the ward
Bindman et al, 2005
Holmen, March 5th 2011
PERCEIVED COERCION: SOME EMPIRICAL
RESULTS VI: Restraint and perceived coercion
18 % of the committed patients had been subjected to physical
coercion. However, the use of physical coercion was NOT significantly
correlated to perceived coercion
Iversen et al 2007
10 % subjected to physical force, low correlation to perceived coercion (0.27)
Lidz et al, 1998
19/138 were subjected to restraint and 29/138 were secluded. Restraint was a
significant predictor of high perceived coercion scores (p<0.02)
McKenna et al, 1999
In other words:
Surpirsingly low correspondence between use of physical coercion an
Perceived coercion
Holmen, March 5th 2011
PERCEIVED COERCION:
SOME EMPIRICAL RESULTS II
50 % of involuntarily and 40 % of voluntarily admitted
patients said their inetgrity had been violated
Kjellin et al 1996
Holmen, March 5th 2011
PERCEIVED COERCION: SOME EMPIRICAL RESULTS VI
: Accounts
of being subjected to forced medication or restraint (%)
Registered Patients’ Relatives Head nurses’
reports reports
report
Legally invol.
patients
Legally vol
patients
23
65
45
22
0
28
10
3
Kjellin & Westrin 1998
Holmen, March 5th 2011
VALIDITET
Innholdsvaliditet (content validity): Instrumentet (variabelen) må
inneholde (alle) viktige faktorer av betydning for det man ønsker å
måle, og variablene må ha et hensiktsmessig format
Kriterievaliditet (Criterion validity): Korrelasjon mellom
instrument (variabel) og gullstandard. Concurrent validity og
predictive validity er begge varianter av kriterievaliditet
Konstruksjonsvaliditet (construct validity): I hvilken grad
sammenfaller resultatene instrumentet gir med empiri som ligger til
grunn for den teoretiske konstruksjon av begrepet (fenomenet) vi vil
undersøke. Må brukes når vi ikke har noen gullstandard
Sitzia J. J for quality in health care 1999; 11(4):319-24
Holmen, March 5th 2011
Konstruksjonsvaliditet (construct validity) fortsatt:
Tre fremgangsmåter:
1. Korrelasjon mellom instrumentet og andre teoretiske og
observerbare (målbare) mål for samme fenomen
2. Analyse av empiriske data for å se hvilke andre fenomen det
aktuelle instrumentet korrelerer med
3. Anvende instrumentet for å se om det fungerer som forventet.
For eksempel skiller instrumentet klart mellom to grupper som
man ville forvente befant seg i hver enda av skalaen, dvs
instrumentets evne til å diskriminere
eller
Se på graden av korrelasjon mellom instrumentet og de
variablene det burde og burde ikke korrelere med
March 5thin2011
Sitzia Holmen,
J. J for quality
health care 1999; 11(4):319-24
VALIDITET
Intern validitet: Relaterer seg til tilfeldige feil, systematiske
feil og confounding
Ekstern validitet: Kan resultatene generaliseres og har de
praktisk betydning?
Bjørndal og Hofoss 2004
Holmen, March 5th 2011
AES-15: MPCS
Number of questions answered:
1. (AES 1): 15 missing
All five: 563
2. (AES 4): 11missing
3. (AES 7): 9 missing
Four questions: 649
4. (AES 14): 24 missing
5. (AES 15): 27 missing
Three or less: 701
Holmen, March 5th 2011
PERCEIVED COERCION; PREDICTORS
Model 1: AES-factors NOT included
MPCS
COERCION LADDER
Legal status
Own opinion of legal status
Own idea to be admitted
p<0.05
R2= 0.26
Legal status
Own opinion of legal status
Offended during the admission
Good to be admitted
GAF
p<0.05
Holmen, March 5th 2011
R2= 0.22
Perceived Coercion; PREDICTORS
Model 2: AES-factors included
(Linear regression, backwards)
MPCS
COERCION LADDER
Negative pressures
Negative pressures
Process exclusion
Process exclusion
Own opinion of legal status
Own opinion of legal status
Own idea to be admitted
BPRS-16
Necessary to be admitted
p<0.05
p<0.05
R2= 0.61
Holmen, March 5th 2011
R2=0.61
The Nordic Coercion Study
logistic regression
Low-High perceived coercion Low-High perceived coercion
(MPCS 0-3 vs 4-5)
(Ladder 1-4 vs 5-10)
OR
Own idea
to be admitted
Negative
Pressures
Process
exclusion
14.38
CI
5.71-36.22
OR
Own idea
to be admitted
3.90
1.72-8.87
0.34
0.17-0.67
Negative
Pressures
1.24
1.24-1.89
Process
Marchexclusion
5th 2011
1.27
1.27-2.08
Offended during
admission
1.44
2.30
CI
1.10-1.91
1.66-3.19
Holmen,
AES-15
Holmen, March 5th 2011
Legal status: voluntary
The patients’
reports: Came to
the hospital …
Denmark Finland Norway Sweden Iceland
n=47
n=107
n=96 n=133 n=114
%
%
%
%
%
Involuntarily
12.8
7.5
16.7
5.3
9.6
Voluntarily
74.5
87.9
81.3
85.7
86.0
Neither/don’t
know/no answer
12.8
4.7
2.1
9.0
4.6
Chi-Square = 16.91, df = 6, p = 0.010
Holmen, March 5th 2011
Legal status: involuntary
The patients’
reports: Came to
the hospital …
Involuntarily
Voluntarily
Neither/don’t
know/no answer
Denmark Finland Norway Sweden
n=48
n=122
n=162
n=93
%
%
%
%
Iceland
n=8
%
77.1
58.2
50.6
66.7
100
6.3
32.8
46.9
19.4
0
16.7
9.0
2.5
14.0
0
Chi-Square = 45.25, df = 6, p = 0.000
Holmen, March 5th 2011
The Nordic Coercion Study
Study Sample Level 3
Interviewed
Completed
AES
Completed
MPCS(5)
Completed
CL
Completed
MPCS&CL
Denmark
91
35
50
83
35
Finland
224
-
-
204
-
Iceland
131
94
99
128
93
Norway
253
214
228
250
213
Sweden
229
163
186
215
159
Total
928
506
563
880
500
Holmen, March 5th 2011
Holmen, March 5th 2011