NATIONAL CONFERENCE, OSLO,
APRIL 5TH AND 6TH, 2011
Marit Følsvik Svindseth
PhD clinical medicine
MHSc
Data in my study collected in
Aalesund 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´ statements
When 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 while
Humiliation 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