Patients’ perception of coercion in acute

psychiatric wards. An intervention study

KNUT W. SØRGAARD

Sørgaard KW. Patients’ perception of coercion in acute psychiatric wards. An intervention study.
Nord J Psychiatry 2004;58:299
/304. Oslo. ISSN 0803-9488.
Nord J Psychiatry Downloaded from informahealthcare.com by Universitat Autonoma Barcelona on 10/30/14

A project based on the ‘‘Breakthrough series’’ for reducing the patients’ perception of coercion
in psychiatric acute wards is presented. Three different measures were chosen: 1) engagement of
the patients in the formulation of the treatment plan, 2) frequent and regular joint patient and
staff evaluations, and 3) renegotiation of treatment plans if necessary. A 5-week baseline was
followed by a 12-week intervention period. Anonymously administered self-rating scales were
used: the Coercion Ladder and the SPRI questionnaire. Two questions addressing aversive
events (verbal and physical) were added. Participation rates were 86% (patients). Data from 190
admissions were analysed. The interventions resulted in only marginal changes in two of eight
parameters (the staff’s respect and understanding and on total satisfaction with the received
help) and no change in experienced coercion. Seclusion accounted for 46% of the explained
variance (62%) and participation in the formulation of the treatment plan for only 8% in
regression analyses where perceived coercion was the dependent variable; a third of the patients
had experienced insulting communication from the staff, and 10% physical harassment during
For personal use only.

their stay. It was concluded that: 1) the average value of experienced coercion was low, 2) taking
part in the planning and evaluation of the treatment had marginal effect on experienced
coercion, and 3) the main predictor of felt coercion was seclusion. Actions taken primarily to
control behaviour were more strongly related to perceived coercion than aspects of compulsory
treatment. More thorough analysis of seclusion and improved routines for its implementation
are needed.
’ Inpatient treatment, Perceived coercion, Seclusion.
Knut W. Sørgaard Psychologist, Ph.D., Nordlandssykehuset, Kløveråsveien 1, NO-8002 Bodø,
Norway, E-mail: kso@nlsh.no; Accepted 4 August 2003.

lthough generally considered necessary in psychi-
A atric treatment (1), use of coercion has negative
effects on the patients exposed to it (2), the relations
between the patients and the staff (1) and may delay the
treatment progress (3). It contributes to a lower status of
the psychiatric institutions, can stigmatise the staff in the
eyes of the general public and negatively effect help-
seeking. Its use is influenced by treatment ideologies
(4, 5) and non-clinical factors (1). Amount of use varies
between institutions (1) and countries (6
/8). Legal
status is not a good proxy for the patients’ experience
of being coerced (9), and aversive events during inpatient
treatment do not overlap with formal restrictions such as
closed doors and formal coercion.
This article presents the results of an intervention
study aimed to reduce the level of patient-perceived
coercion in two acute wards at a psychiatric hospital in
Northern Norway. The interventions consisted of pro-
cedures aimed to include the patients in the processes of
formulating their treatment plan and in a continuous
evaluation of their stay. The hypothesis was that such
participation would lower the level of perceived coercion
and increase general satisfaction with the treatment and
the professionals. A requirement of the intervention was
that it easily could be implemented in the ordinary
services of the wards.
The context of the study
The study took place in two acute wards at Nordland
Psychiatric Hospital, located in a rural region in North-
ern Norway. The hospital receives patients from the
whole county (10). Each ward has 12 beds, and total
staffing is about 25 professionals (day and night staff),
mainly psychiatric nurses, practical nurses, a psychia-
trist, one intern and two psychologists.
Aim of the study
The main aim of the intervention was to reduce the
overall level of perceived coercion, identify factors
associated with perceived coercion and reduce the
frequency of aversive (verbal and physical) events as
experienced by the patients. To accomplish this, three

# 2004 Taylor & Francis DOI: 10.1080/08039480410005819

 KW SØRGAARD
different actions were chosen: 1) engage the patients in
formulating the plan for their treatment, 2) perform
regular joint patient and staff evaluations about the
progress, and 3) renegotiate treatment plans if necessary.
The measures were arrived at through discussions
among the staff. Joint treatment planning started as
soon as the patients were considered able to take part.
The evaluation consisted of regular meetings with the
patients at least once a week in addition to writing daily
case notes jointly. The measures fit into Lidz’ concept of
‘‘procedural justice’’ (11), which refers to the meaningful
participation in decision-making processes and the
perception of being listened to and taken care of in a
Nord J Psychiatry Downloaded from informahealthcare.com by Universitat Autonoma Barcelona on 10/30/14
respectful way. The intervention model was based on the
Breakthrough series developed at the Institute for
Healthcare Improvement in Boston (12), and the study
was part of the ‘‘Breakthrough project psychiatry
/ use
of coercion’’ initiated by the Norwegian Medical Asso-
ciation (13).
Methods and material
Patients
Patient satisfaction was measured with the SPRI form
(‘‘Sjukvårdens Planerings- och Rationaliseringsinstitut’’,
For personal use only.
Sweden), which is a 50-item patient satisfaction ques-
tionnaire (14). The questions measuring satisfaction are
in Likert format (1 /strongly disagree, 5/strongly
agree). It has been translated into Norwegian and has
been extensively used in studies of patient satisfaction in
the Nordic countries. This scale also records basic
information about the patient’s stay (compulsive/volun-
tary, length of stay, whose initiative lay behind the
admission, satisfaction with the treatment, satisfaction
with different professionals etc.) and some patient
demographics. Two items (not tested for reliability and
validity) were added to the scale: one addressed the
extent to which the patients reported that they had been
subjected to patronizing communication. The other
recorded the patients’ experience of having been sub-
jected to some form of physical harassment. Perceived
coercion was measured with the Coercion Ladder (15). It
is a visual analogue scale in the same format as
the Cantrill ladder. The patients are asked to mark on
a 10-step hierarchy the level of experienced coercion. A
score of zero indicates no perceived coercion, whereas 10
indicate maximum coercion. In this study, a 10-cm scale
was used and the scores were measured in millimetres.
The study consisted of a 5-week baseline phase and a
12-week intervention phase. In both phases, a member of
the ward staff approached the patients shortly before
discharge. The staff explained the purpose of the study
(improving the services with the help of information
from the users) and asked the patients to fill out the two
forms. It was emphasized that participation was volun-
tary and that the study was anonymous. After filling out
300
the forms, the patients put the forms in an envelope
addressed to the hospital’s research unit. The only
exclusion criterion was lack of necessary language skills
for filling out the forms. Total participation rate was
86%. The non-responders were mainly patients with very
short stays (1
/2 days), and instances where the staff
forgot to give the forms to the patients before discharge.
One hundred and ninety complete forms were returned;
54% of the patients were men, mean age (9/standard
deviation, sd ) was 36.79/13.4 years, 33% had not been
admitted to the hospital before, 41% stayed less than a
week and 52% said that they were admitted against their
own will. Comparing the patients from the baseline
period with those from the project phase showed
no significant differences with regard to ICD-10 diag-
nosis (psychosis: 26.8% vs. 28.6%; mood disorders
53.6% vs. 41.2%, substance related 8.9% vs. 11.8%,
primary personality disorders 3.6% vs. 5.0%, others
7.1% vs. 13.6%), mean age, sex, earlier admittances
and average length of stay. Fifty-three per cent in the
baseline period had been involuntary admitted com-
pared with 42% in the project period [F (6.34), p B/0.05].
Statistics
Non-parametric tests (Mann
/Whitney, chi-square and
Spearman rank correlations) were used to find factors
associated with experienced coercion and differences in
scores from the two phases of the study. In the chi-
square analyses, a recategorization of the rank-order
variables was used: negative (0
/2), intermediate (3) and
positive scores (4, 5) scores were used. Multiple regres-
sion analysis was performed to find parameters asso-
ciated with perceived coercion and discriminant analyses
used to characterise patients who had been secluded in
contrast to those who had not. All statistical computa-
tions were performed with SPSSWIN 11.00.
Results
Changes from baseline to project-period
Table 1 shows changes from baseline to project period in
nine different variables. Two different computations were
performed. First, Mann
/Whitney analyses of differ-
ences in mean between baseline and the project period,
and (the two columns to the right) chi-square analysis of
the changes in proportion of the lowest two scores
compared with the rest of the scores.
The results showed changes in the predicted direction
in six out of eight variables. None of the changes was
close to significance. In the chi-square analyses, six out
of eight variables changed in predicted direction, but
only two of them were significant: reduction in the
proportions of the lowest score with regard to the staff’s
respect and understanding and on total satisfaction with
the received help.
NORD J PSYCHIATRY×VOL 58 ×NO 4 ×2004
 PATIENTS’ PERCEPTION OF COERCION

Table 1. Changes in average values vs. in proportion of lower vs. higher scores.

Changes in mean values, Changes in proportion of

5/highest score lowest vs. the rest of scores %
Variables Baseline Project Baseline Project

Respect for the patient’s meaning about the treatment 2.9 3.0 25.5 25.2
The contact person’s respect and understanding 3.8 4.0 18 6$
The patient’s influence on the treatment plan 2.4 2.5 43 42
Did the contact person understand your problems 3.7 3.7 18 9
Did the therapist understand your problems 3.7 3.7 21 13
Patronizing communication 4.1 4.3 26 19
Physical harassment 3.8 4.1 9 6
Satisfaction with the received help 3.8 4.1 19 7*
Perceived coercion (CL)/10 /maximum coercion 1.6 1.5
Nord J Psychiatry Downloaded from informahealthcare.com by Universitat Autonoma Barcelona on 10/30/14

*p B/0.05; $p B/0.01 (Pearson chi square).

Extent of insulting communication, physical Factors associated with felt coercion

harassment and experienced coercion
Table 2 shows the frequency distribution of patronizing
communication and physical harassment reported by the
patient disregarding the phases of the study.
Close to a third had experienced what they perceived
as insulting communication. About one in ten reported
For personal use only.
A series of Mann
/Whitney test were performed with the
Coercion Ladder as dependent variable to find factors
associated with high level of experienced coercion. After
Bonferonni corrections, the following were associated
with coercion (all p B/0.001): readmissions (vs. first
admissions; Z / /3.34), admission wanted by others

that they had been subjected to physical harassment in
some way. Eighty per cent of those who reported
physical harassment also reported that they had experi-
enced insulting communication, 16% (n /30) reported
that they had been secluded and 47% (n/90) that they
received forced medication. The changes from baseline
to project period were not significant.
Coercion Ladder
Figure 1 shows the frequency distribution of the
Coercion Ladder.
Sixty-seven per cent scored below 10.0, 84% below 25
and 16% above 25.0 on this scale where 0 is ‘‘no
perceived coercion’’ and a score of 100 indicates the
highest perceived coercion. The average values (9/s) for
the baseline and intervention phase were 15.89/25.0 and
15.19/23.3, respectively.
(vs. by self or self and others; Z / /3.78), no/little
respect for the patient’s meaning about the treatment
(Z / /4.05), forced medication (Z / /5.00), physical
harassment (Z / /5.24), patronizing communication
(Z / /6.61) and seclusion (Z / /6.37). Not significant
were: influence on the treatment plan, being committed
and restrictions on movement outside the ward. There
were moderate to low negative correlations between
scores on the Coercion Ladder and how the contact
persons ( /0.34, p B/0.001), the psychiatrist/psychologist
(/0.35, p B/0.001) understood the patient’s problems
and how the patients evaluated the help they received
during their stay ( /0.27, p B/0.001).
To answer the question of which factors interacted in
influencing the patients’ subjective experience of coer-
cion, two multiple regression analyses were performed

Table 2. Percentage of subjectively perceived patronizing

communication and physical harassment.

Patronizing Physical
communications harassment
Baseline Intervention Baseline Intervention

Often 10.5 10.2 3.4 0.8

5
/10 times 5.3 1.7
/ 1.7
2
/5 times 10.5 6.8 5.2 2.5
Once 8.8 9.3 8.6 3.3
Never 64.9 72.0 82.8 91.7
Total 100 100 100 100 Fig. 1. Coercion Ladder
/ distribution of scores, percentages
(0/minimum, 100/maximum).

NORD J PSYCHIATRY ×VOL 58×NO 4×2004 301

 KW SØRGAARD

with ‘‘felt coercion’’ as dependent, and other theoreti-
cally meaningful variables as explanatory variables. The
analyses were performed in three steps: first with basic
demographic variables (sex, age), then with variables
which could be interpreted as reflecting coercive aspects
of the treatment (compulsory admittance, whose deci-
sion was behind the admittance, forced medication,
freedom of movement etc), and then with what could
be identified as communicative aspects or relationships
with the staff’s (the staff’s understanding and sympathy,
participation in the formulation of treatment plans,
insulting approaches etc.).
Nord J Psychiatry Downloaded from informahealthcare.com by Universitat Autonoma Barcelona on 10/30/14
gender and whose decision lay behind the admission (the
patient’s or other’s).
An identical analysis was performed but this time only
for patients who had not been secluded (Table 4).
The total model now explained only about a fifth of
the variance and significant variables were whether the
contact person understood the patients’ problems,
influence on the treatment plan and compulsory medi-
cation.
Seclusion
Discriminate analysis was performed to find character-
istics that separated patients who had been secluded

Table 3 shows the results of the regression analysis of

all admissions (n /190). Sex and age were unrelated to
perceived coercion. When the analysis was restricted
only to variables reflecting coercive actions, a model
consisting of seclusion (no/yes), forced medication (no/
yes) and length of stay explained 45% of the variance.
Seclusion was by far the strongest explanatory variable.
Restricting the explanatory variables to different
measures of patronizing attitudes and behaviour, a
model consisting of insulting communication, physical
harassment, lack of influence on the treatment plan
and lack of respect for the patient’s opinion of what
For personal use only.
from those who had not been. This gave a Wilk’s lambda
of 0.76 and the following standardized canonical dis-
criminate function coefficients: earlier admissions (0.50),
length of stay (0.47), the admission was others’ idea
(0.42), male vs. female sex (/0.36), compulsory admit-
tance (0.20) and age (/0.17).
Discussion
The intervention part of the study consisted of strategies
for including the patients in the planning and evaluation

of their stay and fit well into the concept of procedural

would be the best treatment explained 44% of the
variance. Again, one single variable
/ insulting commu-
nication
/ explained most of the variance. A combined
analysis showed seclusion to be by far the strongest
predictor in addition to influence on the formulation of
the treatment plan, patronizing communication, female
justice defined as the inclusion of patients in important
decision-making processes (11). This did not bring about
a reduction in the mean scores of perceived coercion, nor
did it result in an increase in the average scores on the
different satisfaction measures. The only significant
change was a reduction in the proportion of patients

Table 3. Predictors of perceived coercion: multiple regression analyses (n /190), backward.

R2 change
Predictors Beta 95% CI (adj. R2 change)

Sex, age 0.00

Coercive measures
Seclusion 3.69 2.75, 4.63 0.39
Forced medication 0.99 0.20, 1.77 0.04
Length of stay 0.45 0.02, 0.87 0.02
Total model based on coercive measures 0.45 (0.43)
Patronizing attitudes and behaviour
Insulting communication 1.84 1.13, 2.55 0.31
Physical harassment 2.34 1.37, 3.30 0.09
Influence on the treatment plan /0.38 /0.73, /0.03 0.03
Respect for the patient’s view of best treatment /0.37 /0.73, /0.01 0.01
Total model bases on patronizing attitudes 0.44 (0.42)
Total model
Seclusion 3.24 2.44, 4.05 0.46
Influence on the treatment plan /0.53 /0.84, /0.22 0.08
Insulting approaches (no/yes) 1.39 0.72, 2.07 0.04
Male/female 0.77 0.24, 1.30 0.02
Decision to be admitted: self and other (vs. other OR self) /0.85 /1.43, /0.26 0.02
Total model 0.62 (0.61)

CI, confidence interval.

302 NORD J PSYCHIATRY×VOL 58 ×NO 4 ×2004


Table 4. Factors associated with perceived coercion for persons who had not been secluded (n /160).
Predictors Beta
Sex, age
Coercive measures
Compulsory medication 1.00
Patronizing attitudes and behaviour
Insulting approaches (no/yes) 1.21
Influence on the treatment plan /0.44
Total model
Total model
The contact person understood my problems /0.56
Influence on the treatment plan /0.36
Nord J Psychiatry Downloaded from informahealthcare.com by Universitat Autonoma Barcelona on 10/30/14
Compulsory medication 0.60
Total model
CI, confidence interval.
who used the lowest categories when they evaluated the
help they had received during the stay, and the ward
staff’s understanding of their problems.
In the univariate analyses, coercion was associated
with being readmitted, other persons (in contrast to self
and self and others) as the primary agents behind the
For personal use only.
admission, a lack of respect for the patients’ own
meaning about the treatment, compulsory medication,
physical harassment, patronizing behaviour on the
part of the staff and seclusion. Coercion was also
negatively correlated with three measures of satisfaction
(with the contact person, their therapist and with the
treatment as a whole). The main reason why the aim of
the study
/ reduction in perceived coercion
/ was not
achieved became evident in the regression analysis that
showed that the chosen measures were only marginally
related to perceived coercion. In contrast to studies of
the admittance processes where procedural justice is
strongly related to the patients’ perception of coercion,
here being able to influence the treatment planning and
continually take part in the evaluation of the stay was
explained only a small part of variance of perceived
coercion. The study documented low average scores of
coercion (15.3 on a scale from 0 to 100).
The results were contrary to expectations. In addition
to not addressing the
/ in retrospect
/ main cause of
perceived coercion, another explanation may be that the
measures used, in spite of regular reminders at ward
meetings and use of bulletin boards at the wards, were
not implemented satisfactorily. Even in the project
period one-third of the patients reported that they had
no treatment plan or that their influence on the plan was
marginal. A second explanation is the very low average
level of coercion resulting in only small general margins
for improvement. Large differences in perceived coercion
were found between patients who had and who had not
NORD J PSYCHIATRY ×VOL 58×NO 4×2004
PATIENTS’ PERCEPTION OF COERCION
R2 square change
95% CI (adj. R2 change)
0.00
0.28, 1.72 0.06 (0.05)
0.49, 1.19 0.12
/0.8, /0.11 0.04
0.16 (0.15)
/0.91, /0.21 0.14
/0.63, /0.09 0.04
0.04, 1.16 0.03
0.21 (0.19)
been secluded (47 vs. 9), and it appears that, at least in
this sample, the processes surrounding seclusion is a
more relevant target for improvement than procedural
justice when the aim is to reduce the general level of
coercion. Of the two principle types of coercion in
psychiatric care
/ coercive treatments and measures
applied to control behaviour (7)
/ actions taken
primarily to control behaviour were more strongly
related to perceived coercion than aspects of compulsory
treatment.
About one-third of the patients reported aversive
experience such as patronizing behaviour and physical
harassment. The amount of aversive experiences was
lower than in a study from two mental hospitals in
England (16). This difference can be explained by a more
restricted definition of aversive event in the present
study, use of different methodology (self-report vs.
interviews), differences in patient populations and
context characteristics (rural vs. urban) and. This study
was conducted in a rural area that is ethnically homo-
genous and among first-time admissions only 7% are of
non-Norwegian heritage. The proportion of patients
with mental and drug/alcohol problems is also lower
than in most urban areas.
The conclusions from this study are: 1) the average
level of perceived coercion among the patients from
acute wards was low, 2) interventions aimed at reducing
perceived coercion by engaging the patients in planning
and evaluation of their treatment did not bring about
significant changes in perceived coercion, and only led to
marginal changes in two satisfaction measures, 3) the
main factor associated with perceived coercion was the
patients’ reports of being secluded, 4) actions taken
primarily to control behaviour were more strongly
related to felt coercion than aspects of compulsory
treatment.
303
 KW SØRGAARD
Limitations
There was a higher proportion of committed patients in
the baseline phase compared with the intervention. On
the other hand, neither Mann
/Whitney nor the regres-
sion analyses could find significant associations between
perceived coercion and being committed. The data in the
study was also restricted to the patients’ perception of
coercion and as such influenced by possible lack of
insight, psychosis, misinterpretations etc. Lack of con-
gruence between staff and patients’ assessment of
coercion has been found in studies where patients
reported more use of compulsory medication than was
verified in their medical records (17), but studies
Nord J Psychiatry Downloaded from informahealthcare.com by Universitat Autonoma Barcelona on 10/30/14
focusing on the admittance processes in compulsory
treatment have shown that the patients’ accounts of the
processes were as complete and plausible as were those
of either family members or professionals (18).
References
1. Fisher WA. Restraint and seclusion. Am J Psychiatry
1994;11:1584
/91.
2. Blanch KA, Parrish J. Reports of three round table discussions on
involuntary interventions. Psychiatr Rehab Commmunity Support
Monograph Series, 1. Boston: The Centre for Psychiatric Rehabi-
litation; 1994.
For personal use only.
3. Kjellin L, Andersson K, Candejord I-L, Palmstierna T, Wallsten T.
Ethical benefits and costs of coercion in short-term inpatient
psychiatric care. Psychiatr Serv 1997;48:1567
/70.
4. Soloff P, Turner S. Patterns of seclusion. A prospective study. J
Nerv Ment Dis 1981;269:37
/44.
5. Okin R. Variation among state hospitals in use of seclusion and
restraint. Hosp Community Psychiatry 1985;36:648
/51.
304
6. Eriksson KI, Westrin G-G. Coercive measures in psychiatric care.
Acta Psychiatr Scand 1995;92:225
/30.
7. Kaltiala-Heino R, Korkeila J, Tuohimäki C, Tuori T, Lehtinen V.
Coercion and restrictions in psychiatric treatment. Eur Psychiatry
2000;15:213
/9.
8. Høyer G, Drange H. Bruk av tvangsmider i norske psykiatriske
institusjoner. Tidsskr Nor Laegeforen 1991;111:1709
/13.
9. Monahan J, Hoge S, Lidz C, Roth LH, Bennett N, Gardner W,
Mulvey E. Coercion and commitment: Understanding involuntary
mental hospital admission. Int J Law Psychiatry 1995;18:249
/63.
10. Sørgaard KW, Sørensen T. Decentralising Psychiatry in a rural
Area. Changing patterns of care. Nordic J Psychiatry
1996;50:193
/202.
11. Lidz CW, Hoge SK, Gardner W, Bennet NS, Monahan J, Mulvey
EP, Roth LH. Perceived coercion in mental hospital admission.
Pressures and process. Arch Gen Psychiatry 1995;52:1034
/9.
12. Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. The
improvement guide. San Francisco: Jossey-Bass; 1996.
13. Gjennombruddsprosjekt psykiatri:Bruk av tvang. Skriftserie for
leger:Den norske lægeforening. Oslo; 2002.
14. Hansson L, Höglund E. Patient satisfaction with psychiatric
services. The development, reliability, and validity of two patient-
satisfaction questionnaires for use in inpatient and outpatient
settings. Nord J Psychiatry 1995;49:257
/62.
15. Iversen KI, Høyer G, Sexton H, Grønli OK. Perceived coercion
among patients admitted to acute wards in Norway. Nordic J
Psychiatry 2002;56:433
/9.
16. Greenwood N, Key A, Burns T, Bristow M, Sedgewick P.
Satisfaction with in-patient psychiatric services. Br J Psychiatry
1999;175:159
/63.
17. Poulsen HD, Engberg M. Validation of psychiatric patients’
statements on coercive measures. Acta Psychiatr Scand
2001;103:60
/5.
18. Lidz CW, Mulevy EP, Hoge SK, Kirsch BL, Monahan J, Bennett
NS, et al. The validity of mental patients’ accounts of coercion-
related behaviours in the hospital admission process. Law Hum
Behav 1997;21:361
/76.
Knut W. Sørgaard, Psychologist, Ph.D., Nordlandssykehuset
psykiatri, Bodø, Norway.
NORD J PSYCHIATRY×VOL 58 ×NO 4 ×2004