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Coercion and Science

Conspicuous by their absence are studies comparing voluntary and involuntary patients. It would not be exaggerated to say that fairly nothing is known about the similarities and differences. This is all the more surprising, as well as alarming, considering that specifically the issue of whether involuntary commitment and treatment are ethically admissible, desirable, or even necessary, has generated much theoretical discourse, but until now is still not anchored in empirical research. There is a huge discrepancy between the emphasis on the beneficial effects on the patients, and the almost total absence of any empirical confirmation of such effects. According to Hiday (1996): “Given the controversy that coercive treatment has generated in psychiatry and law, it is surprising that there is not a wealth of data on the extent and outcomes of coercion.” Possibly one of the reasons for this is the uncertainty whether research on coercion should focus on formal aspects (involuntary versus voluntary patients) or on contextual aspects. If the latter, the question rises, is the hospitalization experienced as coercive? Voluntary patients are also exposed to all kinds of coercion. Contrarily, occasionally a person committed by court order may not experience his hospitalization as coercive, or not realize that he is being coerced. A Finnish study revealed that only half of the voluntary patients and about a third of the involuntary patients were capable of correctly identifying the legal status of their hospitalization.

There is no reason to believe this would be much different anywhere else. One factor in this is the policy generally followed in institutions of not distinguishing between the treatment of voluntary and involuntary patients. No matter how important this policy is, unfortunately, it renders insight into the consequences of formal involuntary commitment, including on treatment and outcomes, unachievable. Of the few studies comparing patients who agree to treatment with those who refuse, I will mention here that of Kasper et al. Forty-one patients who refused antipsychotic medication while hospitalized were compared with forty-one patients who accepted medication. All of the patients who refused were administered medication by force. The refusers appeared to be more seriously disordered according to the Brief Psychiatric Rating Scale. In addition, their attitude towards the hospitalization was more negative, the hospitalization lasted longer, they resisted more, and they were more often placed in solitary confinement or otherwise constrained. Oddly, the authors did not reveal whether the need for constraint arose from the conflict with the medical staff about their treatment, or was to be ascribed to their mental disorder. Even though it may not be conclusively determinable, this distinction should not be overlooked. Psychiatrists typically ascribe behavior of which they disapprove to either the severity of the disorder or lack of disease insight, rather than to the manifest conflict in which these people find themselves.

Ramsay et al compared the outcome of 81 voluntary anorexia nervosa patients with 81 such involuntary patients. Although both groups gained the same amount of weight during hospitalization, which is supported by other research as well, five years later ten of the patients from the involuntary group had died, as opposed to only two from the voluntary group. Here, too, the question rises to what extent conflicts with therapists have complicated the course of the illness. No conclusions can be drawn from this study about which treatment is advisable for best long-term results. It can be neither proved nor disproved that the involuntary group was more severely disordered. Yet it seems likely that coerced treatment produces poorer results than voluntary treatment, a rather obvious conclusion. It would be wise to give the possibility of escalating conflict between therapist and patient serious consideration. The tendency to ascribe refusal of treatment to the severity of the patient’s psychopathology does not do justice to the disparity in motivation that simply exists among people.

Altogether, the conclusions of research comparing voluntary to involuntary therapy are neither representative nor consistent. But it does seem possible, through such research, to learn more about situations and disorders regarding which forced treatment can be productive of the contrary. In that case decisions about whether to resort to coercion could be better justified.
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