Users' Experience of Treatment and Coercion in an Inpatient Medium‐Stay Psychiatric Rehabilitation Unit: A Mixed Methods Study

ABSTRACT

Introduction

Coercion influences mental health services users' experience of care and can hinder their recovery process, so it is essential to understand how it is perceived in rehabilitation settings oriented towards recovery.

Aim

To describe and measure users' experience of coercion and explore their perception of the treatment received in an inpatient medium‐stay psychiatric rehabilitation unit (IMSPRU).

Method

This study, in which 75 service users participated, used a mixed methods approach. Twenty participants were administered a semistructured interview and completed quantitative measures for coercion and 55 additional service users completed the quantitative measurements only. The perception of coercion was measured using the Coercion Experience Scale.

Results

The content analysis of qualitative data resulted in two main themes: treatment received and experience of coercion in the IMSPRU. The participants made a distinction between good treatment and mistreatment or unfair treatment. Experience of coercion in the IMSPRU included the feeling of freedom or lack thereof in the unit, forms of formal and informal coercion, and the positive or negative impact of rules on the unit. The quantitative data revealed a low perception of formal coercion among the users.

Discussion

Individuals had different views of what it meant to be treated well, but all agreed on the importance of communication and the need to feel respected. Informal coercion was the most frequent type of coercion identified, but users were often unaware of its existence.

Implications for Practice

Knowledge of how IMSPRU users experience the treatment received from nursing staff and how they perceive coercive situations will help to lay the foundations of a system of care oriented towards good treatment and noncoercive practices.

Summary.

• What is known on the subject?

  • ○
    Formal coercive measures are the most clearly based on coercion, while the so‐called informal and perceived coercion are other approaches employed within the mental healthcare system.
  • ○
    Professional attitudes and professional–user interactions are important factors that condition the subjective experience of users regarding coercion and the treatment and care received in mental health institutions and can hinder or promote their recovery process.
• What the paper adds to existing knowledge?

  • ○
    Users were often unfamiliar with the term ‘coercion’ but can generally identify situations in which they have felt a loss of freedom or a violation of their rights.
  • ○
    Quantitatively, users expressed low levels of perceived formal coercion.
• What are the implications for practice?

  • ○
    The evidence‐based insights derived from this study offer a foundation for developing and enhancing IPNS‐related healthcare policies, which can promote accessible, personalised care for older people with T2DM.
  • ○
    Knowledge and understanding of the experience of treatment received of users of inpatient medium‐stay psychiatric rehabilitation units and their perception of coercive situations could help to orientate care towards good treatment and noncoercive practices.

1. Introduction

The use of coercive practices in mental health is often justified as a means to manage complex situations and to ensure the safety of the environment, for example, to prevent a user from self‐harming or injuring others (Fletcher et al. 2017). However, it should be borne in mind that the overuse of coercive measures in a psychiatric setting, such as physical restraint or the forced administration of psychotropic drugs, is considered negative and may very well be ineffective, unethical, antitherapeutic and a violation of the individual's human rights. Therefore, to avoid imminent harm, they should always be used as a last resort, when other approaches have failed, and as sparingly as possible (United Nations 2016, 2017; Krieger et al. 2018; Gooding et al. 2018).

Coercive measures are in conflict with the principle of autonomy, central to the Convention on the Rights of Persons with Disabilities (CRPD), which aimed to empower users of mental health services to make their own decisions (European Union 2006; United Nations 2017; Marinetti 2019). Both medical and nursing ethics value respect for the autonomy and dignity of users, prioritising their decisions over paternalistic practices and striving to build a strong therapeutic relationship based on respect, a relationship that can be compromised by the use of coercive measures (Ye et al. 2017; Zaami et al. 2020; Liégeois 2023).

Previous studies regarding coercion in mental health described three types of coercion: formal coercion (World Health Organization 2017; Aguilera‐Serrano et al. 2017; Hotzy et al. 2018), informal coercion (Szmukler and Appelbaum 2008; Hotzy and Jaeger 2016) and perceived coercion (Hem et al. 2018; Elmera et al. 2018).

Formal coercion during psychiatric hospitalisation is described in the literature as formally regulated and documented and covers five practices: involuntary admissions, seclusion, restriction of movement (physical or mechanical restraint), compulsory treatment and forced medication administration (World Health Organization 2017; Aguilera‐Serrano et al. 2018; Elmera et al. 2018). To date, this phenomenon related to psychiatric hospitalisation has been explored mainly in acute psychiatric care units. In the reports published, users describe formal coercive measures as ‘traumatic’, causing them intense distress, resulting in serious difficulties in their recovery process and a profound loss of trust in the therapeutic relationship (Sashidharan, Mezzina, and Puras 2019). The restriction of movement can also have major impacts on the subject's physical health, ranging from bruises or circulatory problems to, in the worst case, death by suffocation (Lan et al. 2017; World Health Organization 2017, 2019; Kersting, Hirsch, and Steinert 2019). Formal coercive measures are the most clearly related to coercion, but Norvoll and Pedersen (2016) concluded that coercion is a far‐reaching phenomenon of which formal coercion is just the tip of the iceberg.

Informal coercion is neither regulated nor well‐documented and includes negative pressures, stigmatisation by professionals (Aguilera‐Serrano et al. 2018; Elmera et al. 2018), the application of strict rules in units (Verbekea et al. 2019) and the confiscation of personal items, all of which are considered by users as a violation of their human rights (Staniszewska et al. 2019). This phenomenon, although common in any mental healthcare setting, has received very little attention, and the limited research carried out in the past has focussed mainly on acute psychiatric care units (Hotzy and Jaeger 2016). Negative pressure refers to psychological pressure manifested through communicative strategies used by professionals and informal caregivers to influence the decision‐making of service users and improve their adherence to the recommended treatment and social norms. This strategy is also commonly known as informal coercion, covert coercion or treatment pressure (Valenti and Giacco 2022; Potthoff et al. 2022). Research on this type of treatment usually refers to Szmukler and Appelbaum's hierarchy of treatment pressures Szmukler and Appelbaum (2008), which categorises them into four forms: persuasion, interpersonal influence, incentives and threats. Both professionals and users report adverse effects of informal coercion, such as increased stigmatisation of mental health services, deterioration of the therapeutic relationship and avoidance of mental health care. However, both parties can also view it positively when it is applied ethically in a way that shows respect for the user's autonomy and transparency in communication. When this occurs, both sides describe potential desirable effects, such as improved adherence to treatment, enhanced clinical stability and prevention of relapse (Hotzy and Jaeger 2016).

Perceived coercion is the users' feeling or perception of being coerced, whether or not a coercive measure has been applied (Hem et al. 2018; Elmera et al. 2018). This form of coercion can overlap with both formal and informal coercive measures. In this sense, even assertive and outreach care have been associated in the literature with feelings of perceived coercion, as they often imply providing healthcare to people who do not seek it or even actively avoid it (Claassen and Priebe 2006; Liégeois, Berghmans, and Destoop 2021; Liégeois 2023). Levels of perceived coercion are especially related to the user's legal status at the time of their admission, to the negative pressure perceived at the time of admission (due to the use of threats and force) and to a sense of being treated without respect or consideration (Sampogna et al. 2019). In this line, treatment is provided through the professionals' attitudes and professional–user interactions. They have been highlighted as having a particularly strong emotional impact, which pinpoints the importance of mental health workers' behaviour and the treatment provided to users, especially during episodes of hostility or agitation (Aguilera‐Serrano et al. 2018).

Coercion continues to be used worldwide in all psychiatric care settings (Aragonés‐Calleja and Sánchez‐Martínez 2024). It influences mental health service users' experience of care (Woodward, Berry, and Bucci 2017; Staniszewska et al. 2019), can hinder the recovery process (Sashidharan, Mezzina, and Puras 2019), causes a deterioration of therapeutic relationships and results in avoidance of mental health care (Hotzy and Jaeger 2016). Consequently, current models and paradigms of mental health care are focussed on user recovery and self‐determination, and explicitly advocate for coercive measures to be reduced. Although coercive measures are applied in all care settings, most of the research related to coercion has been conducted in acute care units, where the main aims are to restore the clinical stability of users or to treat acute symptoms. However, the severity of the clinical conditions of the users, the conditions in which therapeutic relationships are established and the different purposes of hospitalisation in other units, such as recovery‐oriented rehabilitation units, mean that the application of coercive measures may differ both in type and frequency, and also the users' perceptions of treatment. Therefore, it is important to continue improving the collective understanding of formal, informal and perceived coercion by exploring the perceptions and experiences of mental service users, especially those admitted to rehabilitation settings oriented towards recovery, as these are factors that can have an impact on their recovery process. To the best of our knowledge, users' experience of treatment and coercion in inpatient psychiatric rehabilitation units has not been explored previously. The treatment provided includes the professionals' attitudes and professional–user interactions, and these may represent forms of informal or perceived coercion different from those found in acute care units. Thus, we set out to describe and measure users' experience of coercion and to explore their perception of the treatment received in an inpatient medium‐stay psychiatric rehabilitation unit (IMSPRU) in Valencia, Spain.

2. Methods

2.1. Design

This is a sequential mixed methods exploratory study consisting of qualitative and quantitative components. Through semistructured interviews with users in an IMSPRU, qualitative data were collected to explore their experience of treatment and coercion until data saturation was reached. Quantitative data were collected to further analyse their experience of coercion using an explanatory approach (Creswell and Clark 2017).

Our aim to describe the perception of coercion from each participant's point of view and to construct a collective perspective led us towards a generic qualitative descriptive design with phenomenological overtones (Sandelowski 2000).

We have presented the study methods and results in line with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist for reporting qualitative studies (Tong, Sainsbury, and Craig 2007; Supporting Information S1) and with the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines for quantitative data (Von Elm 2007; Supporting Information S1).

2.2. Participants and Study Setting

2.2.1. Participants

The study population was composed of users of the IMSPRU of Padre Jofré Hospital.

2.2.2. Selection Criteria

Intentional or convenience sampling was employed, by which individuals who met the selection criteria were included consecutively. The following inclusion criteria were applied: admission in the IMSPRU for at least three months; understanding of the concept of the study; voluntary participation and signed informed consent; and competent communication in Spanish. No exclusion criteria were established.

2.2.3. Setting

Pare Jofré Hospital, which opened in October 2005, offers outpatient care in the day hospital and inpatient care in the IMSPRU. The IMSPRU is comprised of two wards with a total of 50 beds. Each ward has a multidisciplinary team consisting of eight nurses, 10 care assistants, a psychologist, two psychiatrists, a social worker and two occupational therapists. It is a healthcare facility for adults who, following one or more acute psychiatric admissions, may benefit from a longer stay (4–6 months) during which a comprehensive and individualised rehabilitation program can be implemented, or for those who have treatment‐resistant disorders beyond the scope of outpatient care. The main aim of this clinical strategy is that those admitted find their purpose in life and achieve it by recovering the highest possible degree of autonomy, integrating them in their social environment and increasing their personal satisfaction and quality of life (Dalton‐Locke et al. 2021).

In recent years, care in IMSPRUs has moved away from coercive measures in general, but some formal coercive measures—involuntary admissions, compulsory treatment and, occasionally, forced medication continue to be used. Admissions should be voluntary; if not, the person's situation is constantly re‐assessed so that the measure lasts as short a time as possible. The user's consent is obtained before any drug administration, restraint is very rarely used, and only in extreme security situations, and users are never secluded. This IMSPRU does not have an official open‐door policy, but users can move freely around the facilities.

2.3. Procedure

The first author, who had met the users beforehand, explained the study and its implications to those who were soon to be discharged and met the inclusion criteria. Each user willing to take part in the study was provided with an information sheet and an informed consent form. Those who chose not to engage were not asked to provide reasons.

To facilitate users' participation, a suitable moment for the interview and completion of the questionnaire was agreed with each person. Upon accepting to take part in the study, the first author collected the user's sociodemographic and clinical data and cross‐checked the clinical information provided by the individual with the medical records held at the IMSPRU. While each participant completed the coercion questionnaire, which was self‐administered, MAC was present to answer any queries about the items. If any participant was unfamiliar with the concept of coercion before completing the questionnaire, they were provided with a definition.

For the qualitative component of the study, participants were recruited until data saturation was reached, which occurred after 20 interviews. A total of 26 users were invited to be interviewed and to complete the questionnaire, six of whom declined by refusing the required consent for audio recording. Recruitment for the quantitative component of the study was developed for 3 years. After this period, the authors decided to work with a sample size of 75 participants in order to avoid the significant changes in how care is provided in a unit over time and depending on the unit's management.

To ensure identification and anonymisation, each participant was assigned a unique code consisting of the date of data collection and the sequential order of participation. The qualitative data collection took place between March and December 2020, and quantitative data were collected between March 2020 and May 2023. The restrictions due to the COVID‐19 pandemic affected the functioning and regulations of the unit, and so no data were collected between mid‐March and July 2020.

2.4. Qualitative Data Collection

2.4.1. Semistructured Interview

The interviews were conducted by a single interviewer, except for the four first interviews, which were conducted by VSM while MAC observed with the aim of assessing the adequacy of the script and homogenising data collection among the interviewers. Subsequently, MAC conducted the remaining interviews. All interviews were audio‐recorded.

The semistructured interviews were designed by MAC and VSM based on insight gained during preparation of a systematic review on coercion (Aragonés‐Calleja and Sánchez‐Martínez 2024) and bearing in mind the set objectives. The questions were designed to be open‐ended and notes were taken during the interviews if necessary. The interviewee could express their opinions, clarify their answers and even deviate from the initial question if the interviewer felt that the information in question warranted exploration. At no time was it necessary to add further questions to the initial script. Data saturation was determined when at least two consecutive interviews did not provide new information, which was the case for interviews 18 to 20. The interviews were carried out in two rooms with minimal external stimuli (little outside noise), with a comfortable temperature, without the presence of third parties and with an atmosphere that encouraged communication and fostered trust. The interviewer's attitude was assertive, but respectful and open in order to facilitate communication. The interviews lasted between 25 and 45 min, including the initial explanation of the aim of the interview, the interview itself and closure.

2.5. Quantitative Data Collection

The following sociodemographic and clinical variables were collected for each participant: age (in years); gender; months admitted to the IMSPRU; previous admission to the IMSPRU (yes or no); nationality (open question); marital status (single, married or in a relationship, or divorced); form of cohabitation (with their family of origin, with their own family, living alone, homeless, sharing a flat, chronic care unit and sheltered housing); employment status (unemployed, temporary incapacity for work, permanent incapacity for work, working and studying); educational level (studies completed: none, compulsory education, intermediate education and higher education); main psychiatric diagnosis (schizophrenia, schizoaffective disorder, dual pathology, bipolar disorder, depression and other); time of diagnosis (years since psychiatric diagnosis); and previous admissions to acute psychiatric care (number of admissions).

The perception of coercion was measured using the Coercion Experience Scale (CES‐18).

2.6. Instrument

2.6.1. Coercion Experience Scale, in Its Short Version in Spanish (CES‐18)

The original version of this scale consists of 32 items and was designed by Bergk, Flammer, and Steinert (2010) to assess the perception of coercion after mechanical restraint and seclusion. The scale was adapted linguistically and conceptually to the Spanish language by Gómez‐Durán et al. (2016). Aguilera‐Serrano et al. (2019) later validated a short version in Spanish of the original scale; it consists of 18 items and is referred to as CES‐18 and has adequate internal consistency (Cronbach α = 0.940) and a two‐factor structure (Coercion and Humiliation and Fear) explaining 64.2% of the total variance. The correlation between the original CES and CES‐18 was adequate (r = 0.968). The scores suggested good divergent and convergent validity, thus confirming adequate psychometric properties to assess perceived coercion during psychiatric hospitalisation. The items of this scale are scored from 1 to 5, and the total score is obtained by adding the scores of all the items and can range from 18 to 90 points. Scores above 53 indicate a high level of coercion experienced.

Among the quantitative instruments available to measure the experience of coercion, the most appropriate option was the CES‐18. Although seclusion is not applied in our IMSPRU and physical restraint is used very rarely, this scale allowed us to assess the experience of coercion in the form of forced medication, compulsory treatment and involuntary admission.

2.7. Researchers' Reflexivity

Two female researchers (MAC and VSM) designed the study and analysed the data described herein. The study was carried out in the IMSPRU where MAC worked as a mental health nurse, which meant all the participants had met her before being interviewed. They were informed that this study was part of her doctoral thesis and was focussed on treatment and coercion in mental health practice. As explained in the quantitative data collection subsection, four semistructured interviews were conducted by VSM (RN, MHN, PhD, lecturer at the University of Valencia) and MAC (RN, MHN, PhD Student), while the other 16 interviews were conducted by MAC. Both authors were trained qualitative researchers and had ample previous experience in the field.

The motivation behind this study was a concern that arose while observing, during years of practice, how people treated in mental health facilities oriented towards recovery were deprived of certain rights and freedom. The study was carried out in the IMSPRU with the end aim of laying the foundations of measures to help reduce or abolish coercive practices.

2.8. Data Analysis

2.8.1. Qualitative Data

Each interview was transcribed verbatim after completion. After the 20 interviews had been conducted, a qualitative analysis was performed by means of the inductive content analysis technique, which was suitable for this methodology (Graneheim and Lundman 2004; Graneheim, Lindgren, and Lundman 2017; Lindgren, Lundman, and Graneheim 2020; Im et al. 2023). This corroborated that no new codes related to the aims of the study were generated from interview 18 onwards.

The researchers carried out several independent readings of the transcriptions to gain an in‐depth understanding of the content, thus serving as a pre‐analysis of the texts. The analysis was carried out over several consecutive stages. Open coding was the first stage, in which the two researchers re‐read the text independently and identified meaning units and codes describing the experience of coercion and loss of freedom among the participants. The codes were then grouped into categories, subthemes and themes through discussion and consensus. The content analysis allowed the data—including the descriptions of manifest content and interpretations of latent content—to be interpreted as part of the process of recontextualisation, thereby ensuring a comprehensive analysis and uncovering underlying meanings in the text (Elo and Kyngäs 2008; Moser and Korstjens 2018). Therefore, some subthemes were named as the concepts to which the codes grouped in that section referred, according to the researchers' conclusions and based on their knowledge of the topic. This content analysis was supported by the ATLAS.ti software, version 9.0 (Scientific Software Development GmbH).

The interviews were developed and analysed in Spanish. The most illustrative quotes reflecting each code were translated into English by an accredited native translator. The authors revised the translated version to verify that the expressions had not lost their original meanings.

2.8.2. Quantitative Data

A database of all the quantitative data was created, and they were analysed using the Statistical Package for the Social Sciences (SPSS) version 28.0. A descriptive analysis of the data was carried out. Normality tests were applied, and only age in years adapted to a normal distribution. The quantitative variables were expressed using the mean and standard deviation, or the median and interquartile range (IQR). The categorical sociodemographic and clinical data were explained using frequencies and percentages. The experience variables were expressed in medians and IQR, as they did not follow a normal distribution.

2.8.3. Integration of Qualitative and Quantitative Data

The codes extracted from the qualitative analysis were cross‐checked with the items included in the quantitative instrument to identify coincidences or inconsistencies.

The coercion scores and meaning units obtained in the interviews were contrasted to explore potential relationships between the two sources of information, and bearing in mind if the subject in question had suffered any formal coercive measure.

2.9. Ethics

The study was conducted in accordance with the basic principles of the protection of human rights and dignity set out in the Declaration of Helsinki (World Medical Association 2013) and was approved by the Padre Jofré Hospital Medical Research Ethics Committee (CEIm Code 127/19). Participants were informed that their collaboration was completely voluntary and that all information would be treated confidentially. Prior to their collaboration, all participants were informed in writing and signed an informed consent document.

3. Results

3.1. Qualitative Results

Twenty users were interviewed, 13 of whom were male. The mean age of participants was 38.8 ± 10.95 years, in a range of 22 to 60 years. The mean number of months of admission at the time of data collection was 5 months, in a range of 3–12 months. 75% of those interviewed were single, 40% lived with their family of origin (parents or parents and siblings), and 40% lived alone. 50% of the interviewees were pensioners. In terms of educational level, the majority had completed secondary education. 50% of the users had been diagnosed with schizophrenia. 33% of the participants had been receiving psychiatric treatment and follow‐up for more than 15 years, and six participants had been admitted to hospital for acute care admission on more than five occasions. Of the 20 participants who were interviewed, 16 had a low experience of coercion. The CES scores of the users who participated in the qualitative component of the study are presented in Table 1.

TABLE 1.

Interviewees' Coercion Experience Scale scores.

Interviewee identification number	CES‐18 score
P01	24
P02	22
P03	31
P04	18
P05	18
P06	72
P07	18
P08	18
P09	56
P10	18
P11	18
P12	18
P13	74
P14	76
P15	18
P16	18
P17	18
P18	39
P19	18
P20	18

The content analysis yielded 49 codes, eight subthemes and two themes. The product of the inductive content analysis is offered as a code tree in Supporting Information S1. Tables 2 and 3 describe the two main themes: experience of treatment and care received in the IMSPRU and experience of coercion in the IMSPRU. To illustrate each of the subthemes and categories in a narrative way, selected participants' quotes are presented as representing different codes; in this way, we have sought to facilitate the reading and understanding of the data. The code it represents is cited before each textual quote.

TABLE 2.

Theme 1, subthemes, categories and codes emerged from the qualitative analysis.

Theme	Subthemes	Categories	Codes
Experience of treatment and care received in the IMSPRU	Perceptions of good treatment		Feeling of being well‐treated Good treatment is good care or attention Good treatment is a good therapeutic relationship Good treatment is respectful and without prejudice Good treatment is to be the users' ‘buddies’ Individualised treatment is necessary Treatment considers the projection of the person's future
	Feeling treated unfairly or badly	Poor professional communication	Inadequate communication A poor response or intervention can lead to a crisis
		Unfair treatment by professionals	Unfair treatment Infantilising treatment Abuse of power Dehumanisation of the user Bad treatment caused by burned‐out staff Professional apathy The treatment given by some professionals could be improved The staff gets on our nerves Professionals take out their frustrations with users Staff need to control their bad reactions You are obliged to repeat a task in front of the staff The user's pace in their daily routine is not respected

TABLE 3.

Theme 2, subthemes, categories and codes emerged from the qualitative analysis.

Theme	Subthemes	Categories	Codes
Experience of coercion in the IMSPRU	Perceived freedom		A feeling of having enough freedom in the unit The hospital resembles a hotel In the unit, you can do whatever you want, as long as you show respect The freedom enjoyed is compared with respect to other units
	Feeling of being coerced		Feeling of loss of freedom Feeling of being trapped Feeling of being very controlled Feeling of being forced to do something Feeling of not being listened to Feeling of not being able to express your opinion Feeling of not being able to make decisions Feeling like a delinquent after having belongings taken away The hospital resembles a prison Longing for more independence
	Descriptions of negative pressures through treatment		Manipulation or persuasion Blackmail Restriction of access to belongings Loss of autonomy in managing own affairs
	Formal coercion		First‐person coercion (involuntary admission or forced medication) Coercion witnessed applied on another partner There is hardly any formal coercion in the unit
	Justifications for coercion		Coercion is for the good of the user Coercion is for safety Coercion helps when you don't know how to handle the situation any other way Coercion should be last resort
	Perception of the unit's standards	Coexistence in the unit requires rules	Coexistence in the unit requires rules
		Rules perceived as negative	The rules are too rigid or inflexible Some rules are difficult to understand

3.1.1. Theme 1. Experience of Treatment and Care Received in the IMSPRU

The participants underlined the importance of the treatment received from the unit's staff in feeling well looked after or cared for and were very clear when identifying situations where good or inadequate treatment was provided, thus yielding the two subthemes and 21 codes.

The first subtheme grouped together definitions of what users considered good treatment and their perception of the treatment provided by the staff. The majority of users rated the treatment as good and positive and were satisfied with the attention provided by staff and the care received. Six individuals explicitly stated that they felt well‐treated. For some users, being treated well was synonymous with good care or attention; for others, it was related to having a good therapeutic relationship or being treated with respect and without prejudice. In one specific case, the individual explained that professionals needed to become buddies with the users in order to establish an adequate relationship and for users to feel well‐treated. Lastly, a minority pointed out the need for more individualised treatment that focussed on a projection of the future if optimal care were to be achieved.

At no point have I felt judged. I'd say I felt understood; things were put down to my illness, and I felt I was treated as a person. P03 (Good treatment is respectful and without prejudice)

If there is to be good care, there has to be good treatment. One‐to‐one treatment, and a different treatment for each person… if you treat us all the same, you'll fail… The staff have to be friendly, courteous… here you have to be buddies with the users, not enemies, to be able to give them a push and say, ‘look, that's the path you need to take’. P10 (Good treatment is good care or attention; individualised treatment is necessary; good treatment is to be the user's “buddy”)

I feel they treat me well… For me, looking after me well means specialised attention and more emphasis on the projection of each person's future. P09 (Feeling of being well treated; Individualised treatment is necessary; Treatment considers the projection of the person's future)

In contrast to the good treatment received, participants also described instances of feeling treated unfairly or badly, either verbally or through certain behaviours or attitudes. These perceptions were grouped as a second subtheme.

The participants mentioned some forms of inadequate communication, such as being snapped at, raised voices or inappropriate replies from staff, which caused discomfort and could even trigger a crisis:

…telling a user, ‘go and take a shower, you smell’, those words make people feel terrible. P18 (Inadequate communication)

There are some professionals who provoke crises in patients. P10 (A poor response or intervention can lead to a crisis)

…also, some professionals treat (users) very aggressively… verbally… P13 (Inadequate communication)

Regarding behaviours and attitudes, users described easily identifiable examples of unfair treatment, infantilising treatment, instances of abuse of power and/or dehumanisation of the individual through inappropriate behaviours or actions. In contrast, one user explained how sometimes it is the user who starts the conflict and understandably triggers a negative response from the staff.

…there are many cases in which the staff are wrong, but you have to let it go because you're just another (service) user. P18 (Unfair treatment; abuse of power)

…currently, the procedure is to deal with patients in batches… all 24 or 30 at once… P19 (Dehumanization of the individual)

Users also described more subtle perceptions, such as feeling that the pace at which they could perform certain tasks was not taken into account, or feeling pressured and having to repeat certain activities because staff didn't believe they had done them.

…they don't respect the fact that the person might already be tidying up and doing their things and they keep rushing them… they try to make them hurry, which stresses them out. P05 (The user's pace in their daily routine is not respected)

…there were two days when they made me shower twice, just because they didn't believe me; I mean, am I supposed to spend the whole day in the shower? P18 (You are forced to repeat a task in front of the staff)

In the eyes of some users, this treatment was a consequence of the staff feeling burnt out by their job and taking out their frustration on those admitted to the unit, as well as professional apathy (lack of motivation and interest in their work). This led to the conclusion that the staff should know how to control their own reactions and that the care provided could be better in this respect.

…I value the willingness of some professionals to cure people… there are professionals who don't really want to work in this speciality and others who come to work with an enthusiastic attitude. Vocation is very important. There are people who come to work just to get paid and be able to go out on weekends, and if they have to work a weekend, they turn up in a bad mood… P09 (Professionals take out their frustrations with users; professional neglect)

…I understand that some professionals can lose their temper, but they have to understand that they are in charge of the unit and should always show respect, even if they don't feel it. You shouldn't react to other people's situations, a little self‐control is needed. P15 (Staff need to control their bad reactions)

3.1.2. Theme 2. Experience of Coercion in the IMSPRU

Experience of coercion in the IMSPRU was the most extensively touched on theme and was comprised of six subthemes and 28 codes.

Positive sensations and perceptions related to a sensation of freedom were grouped in the first subtheme. Approximately half of the participants said they felt quite free to express themselves, give their opinions, or ask questions, and said they enjoyed freedom of movement within the hospital, unlike that experienced in other acute psychiatric care units. Four participants likened the hospital to a hotel, and one explained that, within the IMSPRU, users could do as they wanted, as long as they respected their fellow users and staff.

Other units are normally very strict, but not this one. This one feels like a five‐star hotel. P04 (The freedom enjoyed is compared with respect to other units; the hospital resembles a hotel)

We can do whatever we want in the unit, as long as we show respect. P17 (You can do whatever you want in the unit, as long as you show respect)

The second subtheme was the feeling of being coerced. Negative perceptions included feeling trapped, very controlled, forced to do something, not being listened to, not being able to express their opinions, the feeling of not being able to make their own decisions and/or feeling like a delinquent after having their belongings taken away. This subtheme grouped comparisons of the IMSPRU with a prison and users' requests for more independence.

… yes, I would like to have free choice, to have the freedom to say ‘I'm not taking this medication because it doesn't agree with me’. P05 (Feeling of loss of freedom; feeling of not being able to make decisions)

In reality, this is a prison disguised as something different, but it's a prison all the same, where you have to stay for four months whether you like it or not, with prison guards… the guards are the nurses and the auxiliary staff (laughs). P19 (The hospital resembles a prison)

Another of the subthemes gathered descriptions of negative pressures through treatment, such as manipulation or persuasion, blackmail, restriction of access to belongings or loss of autonomy when managing their affairs.

The only thing they told me is that if I didn't take my medication, I wouldn't be able to go out on my own in the morning, or that they wouldn't give me the medication if I didn't eat breakfast. I didn't want to have breakfast and they kept insisting, and I kept saying I didn't want it, and they said ‘I won't give you permission to go out’ and I said that wasn't right. It upset me because they don't have the right to force me to eat if I'm not hungry. P07 (Blackmail)

Sometimes I get the feeling that they manipulate information, because they give certain information to some and different information to others. P13 (Manipulation or persuasion)

Seven participants had a lived experience of formal coercion, such as involuntary admission and forced medication, and had witnessed coercive measures being employed on other users, which was grouped as a fourth subtheme. Some participants claimed there was hardly any coercion in the IMSPRU, and their references to the use of mechanical restraint tended to apply to previous admissions in other acute care units.

I'm forced to be here. I was at home, and they took me away by force and these things are imposed on me, I don't feel right… In my case, I don't want to take the medication I'm on, so I feel coerced, that I'm not being respected as a person. P05 [First‐person coercion (involuntary admission or forced medication)]

Although the interviewees generally disagreed with the use of coercive measures, some justified their use, and these justifications are reflected in the fifth subtheme; for example, some measures were coded as necessary for the good of the individual, for the sake of safety, or as an instrument when other methods were unavailable, as a last resort.

That… seen from the outside… that person wasn't well, it had to be done, it had to be done. The nurses, if they didn't do it (administer forced medication), they couldn't, they couldn't… either they did it or something would happen. P17 (Coercion is for the good of the user; coercion is for safety)

Participants also gave their own evaluations or opinions concerning the rules in the unit, which were compiled as the sixth subtheme. In general, they understood the need for rules to ensure a certain harmony among the users, but they were sometimes perceived as negative for being too rigid or inflexible, or simply difficult to understand.

…you have to respect schedules because there are a lot of people here and it's perfectly understandable. There have to be timetables; you can't have people eating whenever they feel like it or waking up whenever they want. P03 (Coexistence in the unit requires rules)

I agree with them… because if there were no rules, this would be anarchy, and rules are fundamental and you have to live with that. P20 (Coexistence in the unit requires rules)

Sometimes the staff impose certain rules—for example, the nighttime snack is served at 10 pm—but there are people who get up at 11 pm and they don't give it to them. The rules shouldn't be so rigid. P05 (The rules are too rigid or inflexible)

Sometimes, even though it's necessary, they won't open your locker, and to me, that… (pauses) … if something is important, it should take precedence over the rules at a given moment. P01 (Some rules are difficult to understand)

3.2. Quantitative Results

The quantitative component of the study involved 75 participants, of which 57.3% were male. Mean age was 39 ± 11.9, in a range of 19–62 years. 73.3% had been admitted to the unit for the first time, and the median length of stay was 4 months, in a range of 3 to 16 months. 82.6% were single, and 60% lived with their family of origin (parents or parents and siblings). 60% of the participants had been declared permanently incapacitated for work, and 52% had completed compulsory education. 45.5% of the participants had been diagnosed with schizophrenia, and 49.3% had been diagnosed with a disorder for over 15 years. Twenty‐one of the participants had been admitted to acute hospitalisation units more than six times. The sociodemographic and clinical characteristics of the participants are shown in Table 4.

TABLE 4.

Sociodemographic and clinical characteristics of the participants.

Age (years) mean (SD)	39.0
Average months admitted to the IMSPRU	4,76
N = 75	N (%)
Gender
Men	43 (57.3)
Women	32 (42.7)
Previous admission to the IMSPRU
Yes	20 (26.7)
No	55 (73.3)
Nationality
Spanish	73 (97.4)
Argentine/German	1 (1.3)
Ecuadorian	1 (1.3)
Marital status
Single	62 (82.6)
Married or in a relationship	4 (5.3)
Divorced	7 (9.3)
Not specified	2 (2.7)
Form of cohabitation
With their family of origin	45 (60.0)
With their own family	3 (4.0)
Living alone	17 (22.7)
Homeless	4 (5.3)
Sharing a flat	2 (2.7)
Chronic care unit	2 (2.7)
Sheltered housing	1 (1.3)
Not specified	1 (1.3)
Employment status
Unemployed	10 (13.3)
Temporary incapacity for work	5 (6.7)
Permanent incapacity for work	45 (60.0)
Not specified	13 (17.3)
Working or studying	2 (2.7)
Educational level
None	2 (2.7)
Compulsory education	39 (52.0)
Intermediate education	27 (36.0)
Higher education	7 (9.3)
Main psychiatric diagnosis
Schizophrenia	34 (45.3)
Schizoaffective disorder	20 (26.7)
Dual pathology	5 (6.7)
Bipolar disorder	9 (12.0)
Depression	2 (2.7)
Other	5 (6.7)
Time from diagnosis in years
0–2	5 (6.7)
3–5	6 (8.0)
6–8	9 (12.0)
9–11	13 (17.3)
12–15	5 (6.7)
> 15	37 (49.3)
Previous admissions to acute psychiatric care
0	8 (10.7)
1	12 (16.0)
2	5 (6.7)
3	10 (13.3)
4	10 (13.3)
5	6 (8.0)
6	3 (4.0)
> 6	21 (28.0)

Note: SUD: substance use disorder; main psychiatric diagnosis: other (conversive disorder, personality disorder, conduct disorder or not specified).

The scores obtained when measuring coercion using the CES‐18 showed that most responses were clustered at a low level of perceived coercion, though 10 participants reflected the perception of a high level of coercion, with scores over 53 points. The median score was 18, with an IQR of 18–31, in a range of 18–84.

3.3. Relationship Between Qualitative and Quantitative Data

Some of the items measured by the quantitative instrument also emerged as codes in the semistructured interviews. The items of the CES‐18 coercion scale appeared in the theme ‘experience of coercion’, specifically in the subthemes ‘feeling of being coerced’, ‘descriptions of negative pressures through treatment’ and ‘formal coercion’. Some of the codes representing these concordances were ‘feeling of being forced to do something’, ‘feeling of not being listened to’, ‘feeling of not being able to express your opinion’, ‘feeling of not being able to make decisions’, ‘feeling like a criminal after having belongings taken away’, ‘manipulation or persuasion’, ‘blackmail’, ‘restriction of access to belongings’, ‘loss of autonomy in managing own affairs’ or ‘first‐person coercion’.

The quantitative component of the study revealed a general experience of a low level of coercion among the participants. However, a few users obtained scores indicating experience of a high level of coercion, specifically P06, P09, P13 and P14, of whom all but P09 had been subject to measures of formal coercion during their stay in the IMSPRU (involuntary admission or compulsory treatment).

Although participant P09 obtained a high coercion score, during the interview he recognised feeling well‐treated despite explaining how the individual's opinion was not taken into consideration when planning their future. Similarly, both Participant P05 and Participant 19 displayed a low perception of coercion. However, during the interview, P05 expressed discontent with the application of formal coercion measures during their stay in the IMSPRU; specifically, involuntary admission and compulsory treatment. Some of this participant's comments were contradictory, as they also stated not feeling obliged to do things. The same occurred with P02, who at times during the interview described feeling very controlled, while at others said they felt free. On the other hand, Participant P19 manifested a perception of informal coercion, saying the IMSPRU was ‘like a prison’ and complaining that treatment was dished out ‘in batches’, implying that the treatment received was dehumanising.

4. Discussion

This study explores the lived experience of coercion and perception of treatment among users in an IMSPRU in Spain. Data were obtained through a mixed methodology. The data obtained through quantitative methods enriched the information provided by the unit users through interviews, and vice versa.

Over half of the participants were unfamiliar with the term ‘coercion’ when initially questioned about it, but all admitted having witnessed or experienced coercive or ‘unfair situations’ in the IMSPRU, in which they had felt a loss of freedom and a violation of their rights.

Exploring how the IMSPRU users felt they were treated was an objective for this work since feeling well or badly treated influences the perception of coercion. Informal and perceived coercion are mainly applied through therapeutic relations and interpersonal treatment. In this sense, considering that perceived coercion is the users' feeling or perception of being coerced, the feelings of being treated disrespectfully (Sampogna et al. 2019) or that their opinions are not taken into account (Ivar Iversen et al. 2002) implies that interpersonal treatment can reflect informal coercion.

The information provided by users in the qualitative interviews addressed experiences of both good and inadequate or unfair treatment. The qualitative descriptions of good treatment provided by the users showed how each individual had a different view of what it meant to be well‐treated. During the interviews, participants stressed the importance of communication and the way in which staff in the unit communicated with them, as well as the need to feel heard and respected. Some users said they felt they were in a prison, restricted and bound by rules, and stripped of their rights and dignity. These responses are in line with the findings of previous studies (Tingleff et al. 2017; Mellow, Tickle, and Rennoldson 2017; Akther et al. 2019; Askew, Fisher, and Beazley 2019; Plunkett and Kelly 2021). They also echo previous findings of a perception of dehumanisation due to a lack of human interaction and isolation experienced in units (Newton‐Howes and Mullen 2011). Our results also align with those of Staniszewska et al. (2019), who concluded that the experiences of users are influenced by the quality of therapeutic relationships, experiences of coercion, the existence of a safe environment and the provision of individual‐centred care.

The loss of autonomy and freedom is central to coercion, which is why we set out to address the perception of freedom—and whether it existed or not—among individuals admitted to an IMSPRU. The users' accounts were sometimes contradictory; for example, the same individual might state on the one hand that they enjoyed a lot of freedom, while on the other describing how they felt confined and forced to take medication or carry out certain activities. Some individuals with previous admissions to acute psychiatric care units explained how it made it easier to see the positive aspects and freedom allowed in the IMSPRU. Conversely, those who had never been admitted before to any other psychiatric inpatient unit tended to be more critical and to have a stronger perception of a loss of freedom. In this way, some participants equated the hospital with a hotel, while others likened it to a prison. Those who had been admitted to acute psychiatric units on multiple occasions, might had normalised the experience of coercion or considered it the only way to act, in line with the view of some professionals, as described by Chieze et al. (2021).

The quantitative component of the study revealed an overall experience of low levels of coercion in the IMSPRU, with a median score of 18. This finding is in contrast with another study in which Aguilera‐Serrano et al. (2019) used this scale and reported a mean score of 52.8 among persons involuntarily admitted to two acute care units in Spain. In acute care units, the predominant coercive measures are formal ones, as their purpose is to stabilise the psychopathological decompensation and treat acute symptoms that can sometimes pose a danger to the person and others. However, in the IMSPRU, the most common form of coercion was informal, probably because it is a unit oriented towards recovery, where episodes of hostility hardly ever occur and the main working tool is the therapeutic relationship.

Because the most common form of coercion in the unit was informal coercion, some participants were not generally conscious of having suffered it. Others could identify negative pressure during communication with staff, such as manipulation, blackmail or threats. Informal coercion includes rules, norms or routines whose aim is for users to behave in a socially acceptable manner (Pelto‐Piri et al. 2019; Potthoff et al. 2022). For some time now, there has been a debate about whether mandatory hygiene measures or certain types of social activities can be perceived by users as coercion (Eriksson and Westrin 1995). In our case, the majority viewed the norms and rules as necessary for a harmonious living environment, though they generally felt that some norms were too rigid, arbitrary or unjustified, such as restricted access to belongings, money and tobacco.

For the quantitative measurement of the perception of coercion, we employed the CES‐18, which was validated in the cultural context in which the study was conducted. This scale specifically measures the perception of coercion following the use of mechanical restraint, seclusion or forced medication. We used CES‐18 to measure formal coercion, to which the users made little reference during the interviews. It allowed us to determine that the level of formal coercion was low, as one would expect in a such a rehabilitation facility. However, it did not allow us to explore the users' experiences of informal and perceived coercion, something we were able to achieve in the qualitative component of the study. The majority of participants described experiences of low coercion, probably because these formal coercive measures were not usually applied in the unit. Though infrequent, the most common forms of formal coercion were involuntary admission and compulsory treatment. Using the scale, we were able to assess the participants' perception of coercion in relation to these two coercive measures. As expected, individuals who had been/were being subjected to some form of formal coercion (involuntary admission or compulsory treatment) scored higher on the coercion scale, in line with that reported in other studies (Guzmán‐Parra et al. 2019; Hirsch et al. 2021). Some of these individuals referred to coercion in the interviews, reflecting the perception of both coercion and unfair treatment in their responses to the quantitative instrument.

5. Strengths and Limitations

Among the strengths of this work, we would like to highlight the mixed methods research approach used to explore the experience of treatment and coercion among service users, which has allowed for a deeper understanding of the research problem.

The study has some limitations. The main limitation lies in the scale used; the absence of an instrument to measure perceived coercion or informal coercion that was validated in our cultural context limited our ability to measure this phenomenon quantitatively. The CES‐18 scale was designed to measure the experience of different formal coercive measures and its structure allows it to be applied to any other form of formal coercion, but it has only been validated for the assessment of mechanical restraint, seclusion and forced medication. The only formal coercive measures experienced by some of the participants were involuntary admission and compulsory treatment, but the psychometric properties of CES‐18 for measuring these parameters are still unknown, so our findings should be considered cautiously.

6. Conclusion

The definition of good treatment among users in the IMSPRU varied widely, but they all emphasised its importance in improving their experience in the unit and thus their perception of coercion. There was a view among users of negative pressure or informal coercion that negatively influenced their opinion of treatment in the unit. At the same time, coercion scores quantitatively measured were low, reflecting a divergence away from formal coercive measures in this recovery‐oriented unit.

Implications for Practice

In the interviews, the participants provided a description of what appropriate treatment meant to them; some viewed it as a fundamental pillar of their care, for others, it was synonymous with a good therapeutic relationship. Mental health nurses must strive to ensure that they provide treatment in line with these perspectives if productive therapeutic relationships are to be constructed.

Some rules were valued by the participants as necessary in certain mental healthcare facilities; for example, sticking to the schedules of psychoeducation workshops or the prohibition of smoking in certain areas of the unit. However, users positively valued knowing the reasoning behind the rules, which implies that rules need to be explained. In the same way, there was a widespread perception that rules should be flexible or adapted to the individual in specific cases.

The users also valued it positively when their expectations and preferences were taken into account when planning their rehabilitation process in the unit. In the same way, in situations where they perceived this was not the case, they reported a sense of unfair treatment or coercion. This underlines the need to place the individual at the centre of their rehabilitation process and for them to be a facilitator of this process.

Unfair or inadequate treatment is unacceptable in any healthcare setting, and those being cared for in our IMPRU were able to detect it. Mental health nurses and other professionals have a duty to protect the autonomy and dignity of users in order to support their recovery process. It is necessary to inform users of their rights and the cases in which they might be infringed, and mental health care professionals need to be capable of expressing concern and empathy towards those being cared for and to improve communication skills.

As expected in a recovery‐oriented rehabilitation unit, the quantitative measures of coercion were low. This suggests that the work done in the IMSPRU to move away from coercive measures is appropriate, at least in terms of formal coercive measures.

Being aware of users' experience of the treatment received from nursing staff and of their perception of coercive situations is likely to help professionals working in inpatient medium‐stay psychiatric rehabilitation units to lay the foundations of a working culture oriented towards noncoercion. This culture should embrace permanent reflection and debate on the ethical behaviour of professionals towards each user.

Future Research

This study highlights the need to create or validate instruments that allow informal and perceived coercion to be evaluated. It also provides the basis for the development of new instruments to measure different forms of informal and perceived coercion.

It is pertinent to determine the psychometric qualities of CES‐18 for measuring perceived coercion following the use of formal coercion measures, such as compulsory treatment orders or involuntary admission.

Relevance Statement

This paper addresses the users' experience of coercion in an inpatient medium‐stay psychiatric rehabilitation unit. The participants described a low perception of formal coercion and made a distinction between good treatment and mistreatment or unfair treatment. Their experience of coercion included the feeling of freedom or lack thereof in the unit, forms of formal and informal coercion, and the positive or negative impact of rules on the unit. Understanding the experience of treatment and their perception of coercive situations could help to orientate care towards good treatment and noncoercive practices.

Author Contributions

All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors, and all are in agreement with the manuscript. Miriam Aragonés‐Calleja and Vanessa Sánchez‐Martínez: conception and design of the work, acquisition and interpretation of data for the work; analysis and interpretation of the data; drafting and critical revision for important intellectual content; final approval of the version to be published and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Disclosure

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Data S1.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.