Perception and use of informal coercion in outpatient treatment: a focus group study with mental health professionals of Latin culture

Abstract

Introduction. In addition to compulsion (involuntary hospitalization, seclusion, restraint, etc.), there are broader forms of coercion (persuasion, interpersonal pressure, inducement or threat), called informal or covert coercion, all of which try to improve patients adherence to treatment. Objective. To analyse the use of covert coercion in mental health outpatients and the mental health professionals´ views on this practice comparing four countries (Spain, Italy, Mexico and Chile). Methods. We conducted a qualitative research using four focus groups in each country with mental health professionals working in mental health centres and based on a thematic analysis approach. Sample. The total sample was made up of 98 professionals (31 psychiatrists, 25 clinical psychologists, 28 nurses, eight social workers and six other professionals). Results. The use of informal coercion was recognized in clinical practice, but its intensity was related to professionals´ characteristics and to factors related to diagnosis, clinical course, perceived risk, insight, therapeutic relationship and organizational issues in the delivery of services. Its use was justified by effectiveness in improving adherence and, generally, in seeking benefits for the patient, but sometimes in a paternalistic way. Discussion and conclusion. Our results match those described in the literature in terms of: 1. sociodemographic and clinical profile; 2. the reason that leads to its use (adherence); 3. ethical justification (search for patient´s benefit, trying not to impair his freedom); hence, the most intense forms (threat) were misperceived. Our professionals acknowledged the use of covert coercion in their clinical practice, justifying it on ethical and clinical grounds. RESUMENIntroducción. Además de la coerción formal (hospitalización involuntaria, contención, etc.), en salud mental existen otras formas de coerción (persuasión, presión interpersonal, inducción o amenaza), denominada informal o encubierta, que pretenden mejorar la adherencia. Objetivo. Conocer el uso de la coerción informal en el tratamiento ambulatorio de enfermos mentales y la percepción que de ella tienen los profesionales de salud mental de cuatro países (España, Italia, México y Chile). Método. Utilizamos una investigación cualitativa con cuatro grupos focales por país, compuestos por profesionales que trabajaban en centros de salud mental, con un enfoque basado en el análisis temático. La muestra fue de 98 profesionales (31 psiquiatras, 25 psicólogos clínicos, 28 enfermeros, ocho trabajadores sociales y otras seis profesiones). Resultados. Se reconoció el uso de la coerción informal en la práctica clínica. Su intensidad dependió de características del profesional y factores relacionados con el diagnóstico, clínica, evolución de la enfermedad, peligrosidad del paciente, conciencia de enfermedad, relación terapéutica y aspectos organizativos asistenciales. Su uso se justificó por la eficacia y la búsqueda de beneficios para el paciente, a veces de forma paternalista. Discusión y...

Coercion in psychiatric and mental health nursing: A conceptual analysis

“…Related concepts emerge from nursing research on coercion, namely that of paternalism, that is a directive and authoritarian attitude based on the notions of benevolence and clinical expertise (García‐Cabeza et al . 2017; Goulet & Larue 2018; Jaeger et al . 2019; McKeown et al .…”

“…2017; García‐Cabeza et al . 2017), presence of active symptoms (e.g. psychosis, agitation, and delusions) (Larsen & Terkelsen 2014; Perkins et al .…”

“…2018) and lack of insight, or recognition of the presence of mental illness (García‐Cabeza et al . 2017; Jaeger et al . 2019; Maharaj et al .…”

“…personality, attitude, clinical skills, and levels of experience) may also influence the presence of coercion (García‐Cabeza et al . 2017; Price et al . 2018).…”

“…For instance, García‐Cabeza et al . (2017) argue that ‘The concept of coercion implies trying to influence or pressure a patient in different ways to achieve our goals’ (p. 66). Also, O’Brien and Golding (2003) explain that coercion in psychiatric nursing means the use of authority to restrict the autonomy of another individual, which is a much broader understanding of what constitutes coercion.…”