Holmen, March 5th 2011 Georg Høyer Institute of community medicine University of Tromsø HOW

Holmen, March 5th 2011

Georg HøyerInstitute of community medicine

University of Tromsø

HOW


→ 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


“...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


WHAT CONSTITUTES COERCION?

FORMAL (LEGAL)

COERCION

PHYSICAL(CONCRETE)COERCION

PERCEIVED COERCION

PROCEDURES

VIOLATION OF INTEGRITYAND/OR AUTONOMY

HUMILIATION

OTHER FACTORS

No-choice coercion (rotten choices)Structural coercion(ward rules etc)


how HOW CAN PERCEIVED COERCION BE EXPLORED?

Instruments/questionnairesSelf-administered (Postal, on-site)Filled in by interviewer (Telephone, video, on-site)

Global assessments vs structered, multidemential instruments

Qualitative interviews

Clinical interviews


how

MILESTONES IN THE EXPLORATION OF PERCEIVED COERCION

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)


how

VARIOUS INSTRUMENTS

1978-1995: Mostly self-designed questionnaires, rarely used in 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)


how

AES/MPCS

MPCS developed from a 104 item semistructured interview 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).


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)


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)


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)


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


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)

COMBINED: INCONSISTENT:

INCONSISTENT + MISSING

1 (AES 3): 14.8 %

2 (AES 5): 14.8%

3 (AES 9): 22.2%

4 (AES 13): 12.9% 51.9%51.9%

68.5%68.5%


Perceved coercion: Other concerns

Relations between Perceived Coercion and:

Patient Satisfaction

Humilation

Violation of integrity

Trauma

Quality of Life

Symmptom measures


WHAT DO WE KNOW ABOUTPERCEIVED COERCION?

There is a tendency that patients either feel coerced or not, and not a straight ”dose-effect” response in perceived coercion


MPCS

543210

Co

un

t

140

120

100

80

60

40

20

0

MPCS-5 Scores

MPCS

543210

Co

un

t

120

100

80

60

40

20

0

THE NORDIC COERCION STUDYDISTRIBUTION OF MPCS SCORES

Legally involuntary Legally voluntary


The Nordic Coercion The Nordic Coercion StudyStudy

Mean scores on the Mean scores on the MPCS-5MPCS-5 MPCS

ALL Vol Invol

The Nordic Study 2.5 1.7 3.5Bindman 2.6 1.9 3.4 Hoge (1978) - 0.6 3.2 Hiday (1997) 2.9 - -


WHAT MORE DO WE KNOW ABOUTPERCEIVED 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


WHAT MORE DO WE KNOW ABOUTPERCEIVED 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


Of course no-one, but ourHonourable guest speaker

Professor Chuck Lidz

University of MassachutesMedical School, USA


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


PERCEIVED COERCION: SOME EMPIRICAL RESULTS VI: Restraint and perceived coercion

18 % of the committed patients had been subjected to physicalcoercion. However, the use of physical coercion was NOT significantlycorrelated 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 asignificant predictor of high perceived coercion scores (p<0.02)

McKenna et al, 1999

In other words:Surpirsingly low correspondence between use of physical coercion anPerceived coercion


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


PERCEIVED COERCION: SOME EMPIRICAL RESULTS VI: Accounts of being subjected to forced medication or restraint (%)

Registered Patients’ reports

Relatives reports

Head nurses’ report

Legally invol. patients 23 65 45 22

Legally vol patients 0 28 10 3

Kjellin & Westrin 1998


VALIDITETInnholdsvaliditet (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


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 Sitzia J. J for quality in 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


AES-15: MPCSMPCS

All five: 563

Four questions: 649

Three or less: 701

1. (AES 1): 15 missing

2. (AES 4): 11missing




Number of questions answered:


PERCEIVED COERCION; PREDICTORSPREDICTORS

MPCS

Legal status

Own opinion of legal status

Own idea to be admitted

p<0.05 R2= 0.26

Model 1: AES-factors NOT included

COERCION LADDER

Legal statusOwn opinion of legal status

Offended during the admissionGood to be admitted

GAF

p<0.05 R2= 0.22


Perceived Coercion; PREDICTORSPREDICTORS

MPCS

Negative pressures

Process exclusion


Own idea to be admitted

Necessary to be admitted

p<0.05 R2= 0.61

Model 2: AES-factors included(Linear regression, backwards)

COERCION LADDER

Negative pressures

Process exclusion


BPRS-16

p<0.05 R2=0.61


The Nordic Coercion Studylogistic regression

Low-High perceived coercion(MPCS 0-3 vs 4-5)

OR CI Own ideato be admitted 14.38 5.71-36.22

NegativePressures 1.44 1.10-1.91

Process exclusion 2.30 1.66-3.19

Low-High perceived coercion(Ladder 1-4 vs 5-10)

OR CI Own ideato be admitted 3.90 1.72-8.87

Offended during 0.34 0.17-0.67admission

NegativePressures 1.24 1.24-1.89

Process exclusion 1.27 1.27-2.08


AES-15


Legal status: voluntary

Neither/don’t know/no answer

Voluntarily

Involuntarily

The patients’ reports: Came to the hospital …

12.8

74.5

12.8

%

Denmark

n=47

4.7

87.9

7.5

%

Finland

n=107

2.1

81.3

16.7

%

Norway

n=96

9.0

85.7

5.3

%

Sweden

n=133

Chi-Square = 16.91, df = 6, p = 0.010

4.6

86.0

9.6

%

Iceland

n=114


Legal status: involuntary

Chi-Square = 45.25, df = 6, p = 0.000

Voluntarily

Neither/don’t know/no answer

Involuntarily

The patients’ reports: Came to the hospital …

6.3

16.7

77.1

%

Denmark

n=48

32.8

9.0

58.2

%

Finland

n=122

46.9

2.5

50.6

%

Norway

n=162

19.4

14.0

66.7

%

Sweden

n=93

0

0

100

%

Iceland

n=8


The Nordic Coercion StudyStudy Sample Level 3

500

159

213

93

-

35

Completed MPCS&CL

880

215

250

128

204

83

Completed CL

563

186

228

99

-

50

Completed MPCS(5)

506

163

214

94

-

35

Completed AES

928

229

253

131

224

91

Interviewed

Total

Sweden

Norway

Iceland

Finland

Denmark


Documents

Holmen, March 5th 2011 Georg Høyer Institute of community medicine University of Tromsø HOW