Impact of Coercion on Treatment Outcome

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Introduction

It is common in Western countries that legislation allows for the involuntary treatment of the mentally ill. Involuntary treatment is motivated by either dangerousness to others (for the good of society) or by need for treatment (for the good of the patient) or by both. Dangerousness to self is more closely related to need for treatment as it also is justified as occurring for the good of the patient. In Finland, once a patient is mentally ill, both treatment criteria and dangerousness criteria are accepted as motivation for compulsory treatment. Usually, involuntary psychiatric treatment in Finland takes place by referring to treatment criterion: In 1986 it was applied in 95.7% of involuntary treatment decisions (Pylkkänen & Lönnqvist 1986; Kaltiala-Heino, R. & Laippala, P. 1996, manuscript submitted for publication.)

Involuntary treatment on treatment criterion implies that it is possible to help by using coercion. It also implies that others could know better than the patient what is in the patient’s best interests. The patient’s rejection of hospitalization—demands of maintaining his or her liberty—may thus be overridden for values that others have defined. The question arises, however, whether compulsory treatment adds to the value preferred by the health professionals—health. Moreover, is there a need for treatment if no treatment is available that reveals the symptoms? It must also be considered whether liberty is comparable to other values, and one must remember that in a free society an individual has a right to make decisions harmful to himself, even against his standing values (Takala 1989).

On the other hand, involuntary treatment has been seen as adding to the liberty of the patient: When physical freedom is seen of no value without freedom from illness, involuntary treatment becomes acceptable in helping the patient to gain his or her psychological freedom (Chodoff 1984; Hoaken 1986; Miller 1991).

This paper studied the impact of coercion on treatment outcome from the patient’s point of view and from the point of view of assessing the mental health status of the involuntarily treated compared to those treated voluntarily.

Section snippets

Materials and Methods

The study was carried out in the Psychiatric Clinic of Tampere University Hospital. The material was derived from interviews and assessments of three series of consecutively admitted psychotic patients during random weeks in autumn 1990, spring 1991, and summer 1992. The patients, living in the former North-Häme mental health care district, were 15 to 64 years old and were suffering from functional psychoses as diagnosed by a Finnish modification of DSM-III-R from January 1987. The legal status

Patients

The mean age of the sample patients was 41 years (SD 11.3, range 20–63 years). Of the patients, 52% were female, 32% were married, 53% were unmarried, 15% divorced or widowed, 34% were living alone, 53% lived with a family, and 13% were in therapeutic homes or rooming houses. A majority had low level of education. The basic education was most commonly comprehensive school or less (67%). Only a small majority were academic (6%) or had completed college (10%). A majority (86%) belonged to the two

Discussion

This study was done on a relatively small sample of individuals. This might weaken the possibilities to consider the results as representing the opinion of psychiatric inpatients. However, the sample proved to correspond with earlier samples of psychotic inpatients in Finland, which adds to the generalizability. Initial participation was also very satisfactory, but looking at the results from the follow-up, the greater number of the dropouts must be kept in mind as they might cause some bias.

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