Clinician attitude and perspective on the use of coercive measures in clinical practice from tertiary care mental health establishment - A cross-sectional study.

BACKGROUND: Use of coercive measures in mental health care is an important issue for research. There are scarce data available on perception and attitudes toward coercion among Indian psychiatrists. AIMS: This study aims to study psychiatrists' attitude and perspectives on the use of coercive measure in clinical practice against the background of family and patients' opinion.
MATERIALS AND METHODS: The study was conducted at the Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, India. Psychiatrist in charge of the inpatients was asked about their general opinion on coercion and was administered Staff Attitude to Coercion Scale questionnaire. Findings were compared to previously published studies on patients' opinion and family opinion in the same sample. Data were analyzed using descriptive statistics.
RESULTS: Coercion proved to be a common measure applied in nearly 70% of the patients studied. The 189 psychiatrists participating in the study almost all perceived coercion as care, protection and safety, and as protection from dangerous situations. About 66% of psychiatrists perceived physical and chemical restraint (sedation) as necessary and acceptable in acute emergency care. One-third of the psychiatrists felt their patients lost autonomy, dignity, and the possibility of interpersonal contact. The same amount agreed that some patients could have been treated with less restriction and fewer coercive measures.
CONCLUSION: Psychiatrists felt that physical and chemical restraints are necessary and acceptable in acute emergencies. Most psychiatrists considered coercion as a caring protective and safety attitude but also acknowledged its potential negative impact on patient dignity and therapeutic relationships.

INTRODUCTION

Coercion is defined as the intentional overriding of one person's known preferences or actions by another person, where the person who overrides justifies the action by the goal of benefiting or avoiding harm to the person whose preferences or actions are overridden.[12] In the modern era of psychiatric care, coercive measures are legally sanctioned under certain circumstances.[3] They are common in clinical care and include involuntary medication administration, isolation, seclusion, physical restraints, and chemical restraints.[4]

Reasonably good data exist for the following areas of coercion: prevalence of coercive measures,[56] influence of diagnosis and severity on coercion,[7] patients' subjective perception of coercion, factors influencing that perception,[68] and its dynamic nature.[9] Gender of the patient also plays a role.[10] Factors influencing coercive experiences and differences across cultures have also been studied.[1112] Most studies showed nurses to be instigators of coercion after being targets of aggression.[13] In India where relatives usually stay with psychiatric patients on the ward, they were found to be both triggering factors and targets of aggression. Doctors are less likely to be targeted, but targeting a doctor leads to an increased likelihood of coercive measures.[14] Indian psychiatrists believe coercion to be a treatment modality, but their attitude to it is as yet almost unexplored.[15] Most studies so far have been patient centered and very few studies are available on staff attitude to coercion. Studies also observed that coercion in the admission process had different role-dependent perspectives. Individual staff level factors including their personality are an important factor in implementing coercive measures.[1617]

In India, society places a relatively lower value on individual patient autonomy compared to some European and American societies.[3] However, Indian society is complex and fast changing. Perception and attitude toward coercion vary among patients, patient's family, and clinicians. The recent Indian Mental Health Care Act of 2017 (MHCA-2017)[18] advocates compulsory treatment in the least coercive setting and as a least coercive alternative. However, India lacks studies to help us understand clinician attitudes toward coercive practice. In this context, we assessed clinicians' attitude and perspective on the use of coercive measures in psychiatric practice.

MATERIALS AND METHODS

Setting and sample selection

This study was carried out between June 2013 and September 2014 at the Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru – 29. For the purpose of this paper, data were derived from a larger study that looked into the patient, family, and clinician's perspective on admission, treatment, and coercive experiences during psychiatric inpatient care. The details about patient, family, and clinician selection were provided elsewhere.[89] Patient, family, and clinicians' written consent was obtained in accordance with the ethical approval obtained for the study, after a comprehensive description of the study. A total of 189 clinicians (psychiatrists) in charge of patients consented to the study.[89]

Study assessments

We studied clinician attitudes and perspectives on coercion in psychiatric inpatients using a semistructured interview questionnaire covering six questions on opinions about the use of coercion, together with the Staff Attitude to Coercion Scale (SACS).[16] The initial part of the interview was open ended. Here, the clinicians were encouraged to describe the process of using different coercive measures for the respective patient during admission. These questions were also posed to the families of the patients.

In the second part of the interview, we asked clinicians to complete the SACS short, 15-item questionnaire on staff Attitude to Coercion.[16] It captures (a) coercion as offending (critical attitude), (b) coercion as care and security (pragmatic attitude), and (c) coercion as treatment (positive attitude). These dimensions were scored as dichotomous yes or no categories in our study. This scale showed an overall Cronbach's alpha of 0.58 in the staff sample in a recent Indian study. In other words, these dimensions can be scored in items scored on a 5-point Likert-type scale, with 1 = disagree strongly up to 5 = agree strongly. In the European sample using the Likert scale, the three subscales showed a Cronbach's alpha coefficient of 0.70, 0.73, and 0.69, while the total scale showed an alpha of 0.78.[17]

Ethical considerations

The study was approved by the Institutional Ethical Committee (Sl. No: 03, Behavioural Sciences/NIMH/DO/SUB-COMMITTEE/2013, dated 01/06/2013)

Statistical analysis

Statistical analysis was performed using descriptive statistics. Furthermore, reliability was calculated to investigate the scale consistency of the SACS in the current sample.

RESULTS

Table 1 presents the frequency of patients subject to coercive measures. This figure shows that coercion is a common measure used in near to 66% of the admitted patients. In 58% of the sample, chemical restraint was used. Isolation and electroconvulsive therapy (ECT) were used far less frequently.

Table 1

Restraint measure used (n=200)

Measures	n (%)
Physical restraint	40 (20)
Chemical restraint	116 (58)
ECT	29 (14.5)
Isolation/closed ward	36 (18)
Involuntary medication	64 (32)
Any coercion/restraint measure (one or a combination of the above)	132 (66)

ECT – Electroconvulsive therapy

Table 2 describes the clinician perspective on the use of coercive measure in clinical practice. One hundred and eighty-nine psychiatrists participated, the mean age was 26.63 (2.02) years; 117 (62%) were males. Clinicians considered physical and chemical restraints necessary in acute emergencies and acceptable for their patients (66% and 66%, respectively). One-third of clinicians felt that their respective patient may perceive a loss of individual autonomy, loss of dignity, feel isolated, and a loss of interpersonal contact. About 31% of clinician felt that their patients could sometimes have been treated with less restriction and fewer coercive measures.

Table 2

Clinician perspective on the use of coercive measure in clinical practice (n=189)

Question	Clinician perspective, n (%)
Physical restraints are necessary and acceptable in acute emergency care	124 (65.6)
Chemical restraints (sedation) is necessary and is acceptable in acute emergency care	125 (66.1)
Admission has caused him/her loss of individual autonomy	60 (31.7)
Admission has made him/her feel isolated/secluded	66 (34.9)
Admission has restricted their interpersonal contact with other people	79 (41.8)
Could have been treated with less restriction/coercive measures	58 (30.7)

Table 3 describes clinician attitudes on the use of coercive measure in clinical practice using the SACS Scale. We added two more additional questions to the attitude scale: establishing a good rapport and taking verbal consent before using physical and chemical restraints.

Table 3

Clinician attitude on the use of coercive measure in clinical practice (modified Staff Attitude to Coercion Scale)

Subscale	Question	n (%)
Coercion as offending subscale	Coercion could have been much reduced, giving more time and personal contact	121 (64.0)
	Scarce resources lead to more use of coercion	103 (54.5)
	Coercion violates the patient’s integrity	121 (64.0)
	Too much coercion is used in the treatment	100 (52.9)
	Use of coercion can harm the therapeutic relationship	125 (66.1)
	Use of coercion is a declaration of failure on the part of the mental health services	84 (44.4)
Coercion as care and security subscale	For security reasons, coercion must sometimes be used	178 (94.2)
	Coercion may represent care and protection	187 (98.9)
	Use of coercion is necessary as protection in dangerous situations	176 (93.1)
	For severely ill patients, coercion may represent safety	187 (98.9)
	Coercion may prevent the development of a dangerous situation	178 (94.2)
	Use of coercion is necessary toward dangerous and aggressive patients	178 (94.2)
Coercion as treatment subscale	Patients without insight require the use of coercion	59 (31.2)
	Aggressive patients require use of coercion	159 (84.1)
	More coercion should be used in the treatment	19 (10)
Coercion preventing attitude	Verbal consent from the patient before using physical/chemical restraints by treating clinician reduce perceived coercion	133 (70.4)
	Coercion can be reduced by establishing a good rapport with the patient	155 (82.0)

DISCUSSION

This is the first study to involve clinicians to understand the role-dependent perspective on the use of coercion in clinical practice. It may help us to better understand and conceptualize coercion in practice. First, we found that coercion was used in nearly 70% of the observed sample. When asked about these patients, one-third of clinicians felt that their respective patient may perceive a loss of individual autonomy, loss of dignity; feel isolated, secluded and feel a loss of interpersonal contact. These findings were in line with patient family member perception on subjective coercion,[19] but patients perceived to be coerced in more than 50% of cases.[82021]

Sixty-six percent of clinicians agreed that physical and chemical restraints may be necessary in acute emergency care and considered it acceptable. This perspective is in line with perspective on coercion by patient family members.[19] Patients, on the other hand, felt coerced during their hospital stay, but at the time of discharge, 67% of them considered the coercive measures to have been necessary and justifiable.[89] Our findings are similar to one previous observational Indian study on restraint, in which 80% of psychiatrists considered restraint to be an integral part of clinical care. They used restraints in the violent or agitated and to prevent violence or aggression.[14]

In the current study, most psychiatrists felt coercive measures were used for safety, security, care and to prevent dangerous or aggressive situations. One other national survey on 210 psychiatrists from India showed more than 80% had similar attitudes to coercion.[22] Regarding the subscale items of coercion as an offending measure, more than 50% of participants agreed that there is an offending aspect to coercion, including scarce resource leading to coercion, harm to the therapeutic relationship, and use of coercion as a declaration of failure on the part of mental health services. Seeing coercion on the offending attitude subscale is associated with the lesser degree, lesser professional experience, male gender, and seeing patients with severe mental health problems.[1722]

Most psychiatrists agree that aggressive patients require the use of coercion, but only one-third agreed that patients without insight require coercion and only around 10% agreed that more coercion was required in treatment. These findings are in line with two previous studies from Mysore and Norway. Overall, psychiatrists agreed that aggression is a reason for using coercive measure but absent insight into one's illness without aggression is not.

In India, the use of coercive measures is legally sanctioned under the Mental Health Act (1987).[23] However, the recent Indian MHCA-2017 advocates compulsory treatment in the least coercive setting or as a least coercive alternative or least coercive option. The MHCA-2017 banned seclusion or solitary confinement, unmodified form ECT and chaining in any manner or form of a person with mental illness. Regarding another form of coercion such as restraints, the Act advocates to restrict their use only to situations when it is absolutely necessary, such as to prevent immediate harm to the person concerned or to others. According to the Act, psychiatrists can authorize the use of physical restraint for no longer than is necessary to prevent the immediate risk of significant harm. It requires the medical team to monitor the patient regularly. Restraint shall not be used as a form of punishment and informed to a nominated representative within a period of 24 h. All instances of restraints should be documented and the report should be sent to the concerned board on a monthly basis.[18] Clinical practice in India may become more rights based as a consequence of the new MHCA-2017. Coercive measures should become less common. There is a need for training and standard operating procedures regarding the documentation of restraint measures in line with the MHCA-2017. All mental health professionals in India may have to undergo training in the use of noncoercive and least coercive measures in patient care such as de-escalation, other preventative measures, and judicious use of restraints in practice.

It is difficult to give comprehensive advice of how to deal with coercion in a humane way in this paper, given the complexity of the issue, space restraints, and the focus of our paper on attitudinal issues. However, we would like to point out some existing guidance for the Indian context. There is no unifying guideline regarding the use of coercive measure in India, except one initial attempt, published as the Mysore Declaration on Coercion[4] by Prof. Raveesh et al. during the first Indo European Symposium on Coercion. We propose the following strategies to clinicians on how to deal with coercion based on previous Indian studies, and in relation to the Indian MHCA 2017.

Identifying factors which make a patient more likely to be subjected to coercion such as involuntary admission, substance use, past episode of aggression, history of abuse, and increased severity of illness

Repeatedly checking for these factors and knowledge about them will help clinicians to focus on patients at risk and allows the implementation of individual coercion prevention strategies as part of the patient's care plan. This should be done in conjunction with regular risk assessments as mandated by MHCA-2017, based on international evidence-based research

A previous study by our group on restraint use among Indian patients shows physical restraint to be associated with the highest perceived coercion, followed by involuntary medication, seclusion, chemical restraint, and finally ECT. Physical restraint was therefore seen as more coercive than other types of coercive measures.[24] These data inform practice when clinicians decide which form of coercion to use. However, further evaluation of clinicians' understanding of less coercive measures is necessary

There is a clear association between aggression toward staff and the use of coercion in India.[14] It is therefore essential to work on both aspects together. There are guidelines for methods to reduce the incidence of violence such as the use of verbal de-escalation techniques,[25] as well as the use of recommended noncoercive measures.

In summary, our results show similar clinician attitudes in India when compared to Norway. However, Indian psychiatrists do agree more with using coercion as a therapeutic measure. They share with Norwegian colleagues the dilemma between seeing coercion as potentially damaging, but sometimes necessary and justified. This dilemma produced an equilibrium in clinical practice and is clearly shared between Indian psychiatrists and those from high-income countries. The Indian MHCA-2017 advocates the use of least restrictive measures.[18] Our data suggest that Indian psychiatrists are actually well in line with the underlying principles of the MHCA-2017 when asked individually for their attitudes. The introduction of any new legislation invariably creates anxieties among clinicians.[26] However, our data would confirm that Indian psychiatrists are well prepared to develop a new equilibrium between the use of coercion and the rights of their patients over the next few years because they already appreciate the ambiguous aspects of coercion in the management of acutely disturbed patients.

Strength and limitation

This study was a part of a bigger project on Coercion, where we looked into role-dependent perspective (patient, his/her respective family, and the clinician) on the use of coercion and coercive measures in clinical practice.[891924] This study provides details clinician attitude on coercive measure using a validated scale. However, the study had a limitation; subject included in the study was from one government institute, so it may not reflect the attitude and practice of the private sector or psychiatrist from another part of the country.

Future directions

It would be prudent to include other members of the treating team such as the psychiatric nursing staff, psychiatric social workers, psychologists, and supporting healthcare worker in further such studies as their perspectives might differ and also help in better understanding of the factors involved in coercion.

CONCLUSION

Psychiatrists felt that physical and chemical restraints are necessary and acceptable in acute emergencies. Most psychiatrists considered coercion as a caring protective and safety attitude but also acknowledged its potential negative impact on patient dignity and therapeutic relationships.

Financial support and sponsorship

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Except – Eric O Noorthoorn is funded by the Dutch government to collaborate with researchers for 2014–2016, grant 5152 ministry of Health, Wellbeing and Sports.

Conflicts of interest

There are no conflicts of interest.