Exploring the experiences of people receiving psychiatric treatmentrelated soft or subtle coercion: A systematic review of qualitative research
protocol
Introduction
Background to the review
One of the most contentious issues within psychiatry has been the
administration of psychiatric treatment on people who have not wanted to be
treated (Monahan, 2011), much of which has involved coercion. Coercive
measures are routinely used in order to administer treatments to the extent that
psychiatry is, according to Szasz (2007), “the theory and practice of coercion”
(pxi). The extent of coercion is such that, in 2007, an historic World Psychiatric
Association conference specifically to review coercive treatment in psychiatry
took place (Kallert et al., 2007). This was to mark a global opportunity for world
leading experts in this field to commence dialogue with psychiatric service user
and survivor1 groups. Furthermore, it acknowledged the need for global scale
recognition of the complexity and widespread use of coercion.
Coercion is commonly defined being “the act or process of persuading someone
forcefully to do something that they do not want to do” (Dictionary, 2012).
However, there is no single, uniformly agreed definition of coercion in clinical
practice. Further, upon examination of the literature, it can be seen that within
psychiatry coercion is seemingly defined by the way in which it is practiced
rather than by the way in which it is understood. In general, though, coercion is
used to exercise power to control another person, either by the threat of or the
actual use of coercive measures (Arboleda-Florez, 2011). There are various
terms used to describe coercion in the literature detailing different ways as to
how this power is exercised. Arguably the broadest term is ‘treatment
pressures’, which describes a hierarchy of coercive measures, ranging from
persuasion through to leverage, to threats and to the use of legal jurisdiction
(Szmukler and Appelbaum, 2008). Other terms commonly found in the literature
to describe coercion include ‘involuntary admission’, ‘involuntary treatment’,
‘leverage’, ‘soft coercion’, ‘hard coercion’, and ‘subtle coercion’. This variation of
terms, to some extent, relates to international cultural differences in the use of
coercive measures and makes understanding the meaning of coercion difficult.
Broadly, coercion can be categorised into 3 themes:
1. Coercion as a result of legal or environmental constraints.
This type of coercion is encapsulated by the use of legal jurisdiction or the use of
specific physical boundaries within an environment. For example, the Mental
Health Act (Department of Health, 2007) is applied to ensure that service users
maintain engagement with psychiatric services and receive treatment (see
Canvin et al., 2014). Additionally, service users can perceive there to be a threat
of the Mental Health Act being applied to administer treatment (see Carrick et
1The
term survivor arose from civil rights activism of the 1960s and 1970s, particularly the seminal work of
Judi Camberlin (Chamberlin, 1978), herself an ex-patient, who is cited as a key figure in the development of
the psychiatric survivors movement. There is variation in terms (i.e. survivors and consumers) but,
essentially, this reflects a shift from being passive patients to survivors of psychiatry and consumers of
services. There are many thousands of organisations and individual members internationally(Goldstrom et
al., 2006).
al., 2004). The physical environment of a psychiatric ward influences the
perception of coercion (see Larsen and Terkelsen, 2014), such as the use of a
seclusion room, which can apply pressure and firm boundaries to ensure people
who are non-compliant with treatment or who exhibit behaviour perceived by
healthcare practitioners to be unacceptable, receive treatment (see Kontio et al.,
2012).
These types of coercion commonly fall under the term ‘involuntary admission’ or
‘involuntary ’treatment’, which refers to the admission and treatment of a person
under the use of legislation such as the Mental Health Act (see McGuinness et al.,
2013, Katsakou et al., 2012, Hughes et al., 2009, Johansson and Lundman, 2002).
Another term, ‘leverage’, refers to the way in which treatment adherence is
influenced whereby, for example, unless a service user adheres to treatment
then they would be unable to access subsidised housing or maintain control of
their own finances (Canvin et al., 2013). This type of coercion typically includes
compulsory treatment (see Ridley and Hunter, 2013) and Community Treatment
Orders (see Canvin et al., 2014, Gibbs et al., 2004).
2. Coercion as a result of the use of physical power by a healthcare
practitioner.
This type of coercion, commonly referred to as ‘hard coercion’, is defined by the
use of physical restraint, whereby typically several healthcare practitioners
simultaneously surround and lay hands on a person in order to exert physical
control over them, often through forcibly positioning the person onto the ground
or into a restrained position. Once in this position, often the person will then
usually be forcibly administered an injection of a psychiatric drug. Examples of
studies exploring hard coercion include the physical restraint and forced
administration of medication (Meehan et al., 2000, Hoekstra et al., 2004, Kontio
et al., 2012, Wynn, 2004) and the use of straight-jackets in a Dutch study (Carrick
et al., 2004). This latter example demonstrates the cultural differences regarding
the use of coercive measures (i.e. straight-jackets are no longer used in UK
psychiatry).
3. Coercion as a result of the way in which a practitioner uses verbal
persuasion.
This type of coercion is commonly referred to as ‘soft coercion’. Rather than the
actual application of a coercive measure (hard coercion), soft coercion involves
the perceived threat of punishment or perceived use of force (see Lloyd-Evans et
al., 2010, Gilburt et al., 2010). This is closely aligned with the description of
‘subtle coercion’. In a UK study of 10 psychiatric nurses, (Lützén, 1998) reported
subtle coercion to involve a number of processes and to include persuasion and
encouragement, making decisions for service users, manipulation, and tradingoff. Lützén conceptualized it as an interpersonal and dynamic interaction in
which a person exerts their will upon another and, effectively, becomes a “type of
weak paternalism” (p106).
2
These categories of coercion take place across both inpatient and community
care. Within the literature, it is evident that hard coercion such as physical
restraint exclusively occurs within inpatient environments, whereas leverage is
predominantly used in the delivery of community-based care. Other forms of
coercion within these categories can occur across both settings. Arguably, hard
coercion implies the service user to have relatively little potential influence in
the administration of treatment. Should treatment be refused, hard coercion
would involve the use of physical force, legislative leverage or seclusion within a
locked environment. Subtle or soft coercion is much less explicit and can involve
a dynamic interaction between people, within a context of practitioners being
expected to develop so-called helping or therapeutic relationships with people
receiving treatment. For example, this can occur in the way in which a
practitioner and a service user speak with one another in relation to treatment
being administered. With regards to self-determination so that one can become
empowered to take back one’s own life and recovery, as advocated by the
survivor and consumer movement, it is important to understand not only the
impact of coercion on this relationship but to understand this relationship from
the perspective of people experiencing coercion-related treatment. This is
important because, as commonly found in the coercion literature, service users
report both a lack of understanding of reasons for coercive measures and to
being persuaded into accepting treatment, often without full knowledge of what
this might be or what the consequences might be (see Rose et al., 2005). It is this
soft or subtle coercion that will be the focus for this review.
Constructing knowledge of psychiatric treatment and how it is perceived by
those who receive it has been limited due to the exclusion from research of those
receiving treatment. However, international demand from survivors of
psychiatric treatment calls for a shift in the passive ‘patient role’ to instead
become an active partner in treatment for mental (ill) health (Mezzich, 2011). As
such, there has been increasing recognition in both the literature (see Larsen and
Terkelsen, 2014) and UK policy (see NHS five year Forward View (NHS England
2014)) and Raising the Bar (Health Education England 2015)) of the importance
of including the perspectives of those being treated in psychiatric services in the
contribution of the evidence-base for treatment for mental (ill) health.
In terms of current knowledge of the use of coercion in psychiatric treatment,
this too has been informed by research that has overwhelmingly edged out the
voice of people who have received psychiatric treatment. It is evident that the
terms used to describe coercion are defined, largely, from a professional
perspective. For example, there are several studies acknowledging the
marginalization of people who have received treatment in the construction of
this knowledge (Landeweer et al., 2011, Jarrett et al., 2008, Hannigan and
Cutcliffe, 2002, Olofsson and Norberg, 2001, Lützén, 1998). Despite this
acknowledgement around the lack of service user involvement in the creation of
an evidence base, current knowledge regarding coercion has become perceived
to be the knowledge about coercion (Russo and Wallcraft, 2011). Within this
context of excluding service user perspectives, coercion has become accepted as
3
common practice (Gaebel and Zäske, 2011, Mezzich, 2011, Russo and Wallcraft,
2011).
Excluding perspectives of those who have experienced psychiatric treatment has,
consequently, also led to knowledge acquisition based on outside perspectives
rather than the perspectives of those subjected to psychiatric treatment. Thus,
there is insufficient understanding of the human meaning(s) that underpin the
lived experience of being coerced into accepting psychiatric treatment and the
impact of this on the construction of therapeutic relationships. Critical of the
research questions and methodologies examining coercion in psychiatry, Russo
and Wallcraft (2011) argue that the quantitative methods used to investigate
perceptions of coercion fail to sufficiently capture the experiences and meanings
that coercion holds for people. Instead, they advocate for qualitative
methodology to enable the researcher to get closer to the complexity of a
person’s experiences and the impact this has on their lives. Consequently, there
is a need to consider qualitative research studies to enable an in-depth
exploration of the way coercion exists between people and the impact it has on
therapeutic relationships. Further, this qualitative research must be considered
in a context of all relevant qualitative research and contribute towards a
cumulative knowledge. This is to say, all relevant qualitative research must be
brought together in a systematic way and as a whole avoiding the biases
associated with traditional literature reviews (Saini and Shlonsky, 2012).
Therefore, this will be a systematic review of qualitative research that will detail
a transparent and rigorous approach to methods of searching, inclusion, quality
criteria and synthesis to inform mental health policy and practice.
There are several methods for conducting systematic reviews for qualitative
literature (see Flemming, 2007). The method chosen for this systematic review is
a thematic synthesis, which has evolved from other systematic review methods
(i.e. thematic analysis, first used by Thomas et al. (2004)) and was developed by
(Thomas and Harden, 2008). This method analyses and draws conclusions from
a variety of themes from primary research and formulates a new interpretation,
‘going beyond’ the original findings. It is important to note, however, that the
different methods for qualitative systematic reviews are debated and there are
new ones still emerging (Saini and Shlonsky, 2012, Thomas and Harden, 2008).
With this in mind, it is interesting that one approach to a thematic synthesis has
been reported to include primary studies with different study designs (Thomas
and Harden, 2008) whereas another clearly stipulates that a thematic synthesis
should include only comparable study designs (Saini and Shlonsky, 2012).
However, rather than restrict the number of studies for analysis, this thematic
synthesis will be informed by Thomas and Harden’s method in order to identify
and analyse themes from relevant primary qualitative research regardless of the
study design.
Review aim
Through a systematic review of qualitative research, explore how people
experience soft or subtle coercion in the context of psychiatric treatment
and the effect of this on their interactions with practitioners.
4
Research objective
1. To identify peoples’ experiences of soft or subtle coercion during their
admission/treatment in psychiatric services
2. To understand the effect of this coercion on their interactions with
healthcare practitioners.
Methods and methodology
Inclusion criteria
This review will consider primary qualitative studies involving people
who have experienced soft or subtle coercion during their
admission/treatment in psychiatric services.
1. Studies reporting the lived experience of soft or subtle coercion
during admission/treatment in psychiatric/mental health services.
2. Studies reporting the effect of this coercion on the interactions
between people receiving treatment and practitioners.
3. Studies using qualitative research methods, including but not limited
to, phenomenology, grounded theory and ethnography.
4. Mixed methods studies with inclusion of qualitative findings.
5. Participants aged over 18 years.
6. UK-only studies.
Exclusion criteria
1. Studies referring to predominantly hard coercion or leverage.
Literature search and selection
This qualitative synthesis will focus on interpretive explanation (rather than
‘prediction’ associated with quantitative approaches) and, consequently, the
sample for the literature search will be purposive and underpinned by the
principle aim of reaching conceptual saturation (Thomas and Harden, 2008).
Using this approach it is deemed unnecessary for comprehensive searching to
identify all literature on a subject, however detailed and systematic searches will
be undertaken. The search strategy will be developed in conjunction with an
information scientist and aims to find published and unpublished studies,
comprising of 3 stages:
1. An initial limited search of CINAHL, MEDLINE and PsycINFO will
be conducted followed by an analysis of text words contained in
the title and abstract and index terms used to describe identified
papers.
2. A further search using all identified keywords and index terms will
be conducted across all included databases.
3. The reference list of all identified articles will be searched for
additional studies. Studies published in English will be considered
for inclusion and there will be no date restriction.
5
Search terms will be broadly categorized into 4 areas relating to (i)
coercion, (ii) relationships, (iii) mental health, and (iv) qualitative
research. Initial search terms will include ‘coercion’, ‘coercive measures’,
‘leverage’, ‘psychiatry’, ‘mental health’, ‘patient’, ‘client’, ‘service user’,
‘experience’, ‘lived experience’, ‘relationship’. Truncations and subject
headings will be used where possible. Following stage 1, further search
terms will be informed by the initial limited search. Published and
unpublished literature in English and indexed in the following databases
will be searched:
CINAHL
Embase
Cochrane Library
Medline
PsycINFO
OpenGrey
Web of Science
HMIC
UKCRN Study Portfolio
Social Care Online EThOS
Dept of Health
Networked digital library of theses and dissertations
Proquest Dissertations and Theses Fulltext
NHS Evidence Search: Health and Social Care
(PubReMiner will be accessed for further search terms)
Appraisal
Assessment of methodological quality
Qualitative papers meeting the inclusion criteria will be assessed for
methodological quality prior to inclusion in the review in accordance with
the Critical Appraisal Skills Programme (CASP) tool. In so doing,
consideration will also be given to the 12 criteria Thomas & Harding
(2008) recommend from previous research. This covers 3 main quality
issues, namely:
1. Quality of reporting – study’s aims, context, rationale, methods,
findings
2. Strategies employed – reliability and validity of data collection
tools, methods of analysis, validity of findings
3. Appropriateness of study methods.
Additionally, the quality of each study will be considered in terms of the
context of the review objective rather than the context of the primary
study in itself (Thomas and Harden, 2008).
Synthesis of findings
Data extraction
A data extraction form will be developed to allow different data from
different studies to be recorded. This will include details such as
methodology, methods, and data analysis.
6
As described by (Thomas and Harden, 2008), data will include text
labelled as ‘results’ or ‘findings’ in the main report and also in the
abstract. This data will be entered verbatim into ATLAS.ti for analysis.
Data synthesis
Thematic synthesis will involve 3 stages, as described by Thomas and
Harden (2008).
1. Free line-by-line coding of primary study findings.
In this stage each line of text, previously entered verbatim into
ATLAS.ti from the primary studies (during the data extraction stage),
will then be coded to capture the meaning and content of each
sentence to produce ‘free’ codes. This will involve the ‘translation’ of
concepts from one study to another, whereby each sentence
(transferred into ATLAS.ti) from each study will be coded and, hence,
new initial codes developed from the studies.
2. Free codes will then be organised into related areas to construct
descriptive themes.
The codes will then be grouped into a hierarchical tree structure in
order to organise descriptive themes.
3. Finally, analytical themes will be developed.
According to Thomas and Harden (2008), although up to this stage of
the process the themes combine all the studies as a whole, the
synthesis will have produced themes close to the original findings
rather than address directly the original objective of the review.
Therefore it will be necessary to ‘go beyond’ (Thomas and Harden,
2008) these primary study findings and develop additional concepts,
understandings or hypotheses in order to answer the review
objective/question. From an iterative, cyclical process of using the
descriptive themes to answer the research question/objective there
will emerge new analytical themes. This will continue until sufficiently
abstract and new analytical themes explain all the initial descriptive
themes.
Results
The final, analytical themes will be presented and discussed.
7
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