Factors associated with perceived coercion in adults receiving psychiatric care: a scoping review protocol

Abstract

Introduction

Coercion is inevitably linked to psychiatric and mental healthcare. Though many forms of coercion exist, perceived coercion appears to be a less studied form despite its marked prevalence and negative consequences. In the literature, several factors have been studied for their association with perceived coercion, but few literature reviews have focused on this precise subject. Gaining knowledge of the association between these factors and the degree of perceived coercion is essential to guide future research and develop informed interventions. The purpose of this review will be to identify, in the literature, factors associated with perceived coercion by adults receiving psychiatric care.

Methods and analysis

A scoping review will be conducted by following the Joanna Briggs Institute methodology. A search with descriptors and keywords will be performed in the following databases: CINAHL, MEDLINE, PUBMED, EMBASE and PsycINFO. Then, a search for grey literature will be conducted, psychiatric and mental health journals will be searched, and reference lists will be examined to identify further pertinent literature. All literature on factors (human, health related, organisational, etc) and their association to perceived coercion by adults (18 and older) in inpatient, outpatient and community-based psychiatry will be included. A quality assessment of the literature included will be performed. The extracted data will be analysed with a method of content analysis. An exploratory search was conducted in September 2021 and will be updated in September 2022 once the evidence selection process is planned to begin.

Ethics and dissemination

No ethics approval is required for this review. The results of this scoping review will be submitted to a scientific journal for publication, presented in conferences and shared with clinicians working in psychiatric and mental healthcare.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This scoping review will present results from an extensive literature search conducted in various databases, specialised journals and grey literature.

• The target population, including not only adults receiving psychiatric care in the hospital but also in outpatient clinics or directly in the community, will allow for a broader exploration of factors associated with perceived coercion.

• A consultation with relevant stakeholders to review the preliminary results will allow to further develop and refine the results.

• Only literature in French and English will be included, limiting the inclusion of possible relevant sources in other languages.

• The absence of involvement from a person with lived experience from the early stages of this scoping review could limit the preciseness and relevance of the search strategy and the depth of the findings.

Introduction

Coercion is still used regularly in mental health and psychiatric care, with a marked increase in involuntary hospitalisations and community treatment orders¹ and no steady reduction in the use of mechanical restraint.² Despite controversy and ethical debates, as well as various initiatives to reduce its use,³ the prevalence of coercion remains high.^4–8 While coercion can be broadly defined as using pressures to make a person act according to another person or organisation’s wishes,⁹ it is a more complex concept in psychiatry, where different forms of coercion coexist: formal, informal and perceived coercion.¹⁰ Formal coercion refers to the use of coercive measures (eg, involuntary hospitalisation, seclusion) under the mental health legislation.¹¹ Informal coercion consists of pressure, manipulation and various control strategies used by health professionals to promote treatment adherence.⁵ Persuasion, inducement and threats are examples of informal coercion.⁹ The current review will focus on perceived coercion, the individual’s subjective experience of being coerced.⁷

Although less studied than other forms of coercion, perceived coercion is nevertheless experienced by 74% of involuntarily hospitalised individuals and 25% of those voluntarily admitted due to a mental illness.⁷ Perceived coercion has many consequences for the person experiencing it, such as an increased risk of suicide after discharge,¹² avoidance of mental health services¹³ and feelings of dehumanisation and isolation.⁷ Many studies have presented results on the association between different factors and perceived coercion, for example, by studying the influence of age,¹⁴ legal status,¹⁵ the quality of interactions with health professionals¹⁶ or procedural justice.¹⁷ Consequently, a number of literature reviews have looked at perceived coercion, as a main or secondary outcome, by exploring the impacts of seclusion and restraint,^{18 19} forced medication,¹⁹ the patients’ legal status^{7 20–23} and the patients’ decision-making capacity.²⁴ We found only one systematic review, dating back to 2011, that considered other factors, such as the patients’ quality of life or their sociodemographic characteristics.²¹ This review had several limitations, including the selection of studies in English only and the absence of consideration for grey literature. Furthermore, more recent studies suggest that perceived coercion may be linked to other factors such as the perception of fairness and justice during treatment, also known as procedural justice.16 17 25 26 Considering the lack of literature reviews that take into account all the factors that may be associated with perceived coercion, a more global and recent portrait of this subject is needed.

A scoping review method will be used to present the state of knowledge on the factors associated with perceived coercion, which could help guide the development of interventions specifically designed to minimise the experience of this phenomenon. The purpose of this article will be to identify, in the literature, factors associated with perceived coercion by adults receiving psychiatric care. The following research question will be asked:

1. What factors are associated with perceived coercion by adults receiving psychiatric care?

Methods and analysis

This review will follow the Joanna Briggs Institute (JBI) methodology for scoping reviews.²⁷ This method was chosen because of its clear guidelines that allows the reviewers to conduct a thorough review that may be reciprocated by readers to ensure its validity. The JBI methodology follows nine steps: (1) defining the objectives, (2) developing the inclusion criteria, (3) planning (4) searching the evidence, (5) selecting the evidence, (6) extracting the evidence, (7) analysing the evidence, (8) presenting the results and (9) summarising the evidence. A 10th step of consultation with relevant stakeholders will be added to this review. Though optional, consultation is recommended in other scoping review methodologies to add rigour.^{28 29} For this review, the consultation will take place after the initial data analysis (step 7) and preliminary results will be presented to the following stakeholders: a person with lived experience of perceived coercion, a clinician with extensive experience in psychiatry and a researcher in this field. Their contributions will be acknowledged in the final review and reported in the results section. The final version of the scoping review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). For the designing of this protocol, PRISMA-Protocols checklist was followed (see online supplemental additional file 1)³⁰ and the protocol was registered on Open Science Framework (https://osf.io/kc7gw). The source of evidence selection for this scoping review is scheduled to begin in September 2022. A first completed version of this review is planned for September 2023.

Inclusion criteria

Following the JBI methodology for the development of a scoping review protocol, this section presents the type of participants, concept, context and type of evidence that will be included.

Participants

The target population will be adults aged 18 years or older who are receiving or have received psychiatric care. Studies with participants that are 16 years of age and older will be included if the majority of participants are over 18 years of age. While no upper age limit will be applied, literature focusing specifically on geriatric psychiatry will be excluded considering the particularities associated with this subspecialty (eg, physical comorbidities, neurodegenerative disorders). Literature on intellectual disability, perinatal psychiatry or eating disorders will be excluded. Other than general psychiatry, the following subspecialties will be included: psychiatric rehabilitation, forensic psychiatry, community psychiatry and addiction psychiatry.

Concept

This review will include literature on the factors (human, organisational, sociodemographic, etc) associated with perceived coercion, that is, the subjective experience of coercion. The different factors will be determined and classified during the analysis phase of the review. The association between the factor and perceived coercion can be measured quantitatively (with specific scales that measure perceived coercion, that is, The MacArthur Admission Experience Survey) or discussed qualitatively by participants of a study (themes related to their subjective experience of coercion).

Context

All mental healthcare settings will be included: inpatient, outpatient and community-based care.

Type of evidence

Any existing literature on the concept of interest will be considered. It could include, but not be limited to, primary studies (quantitative, qualitative, mixed methods), literature reviews (systematic reviews, meta-analyses, etc), conference abstracts, guidelines, theoretical articles and grey literature (theses, etc). The literature whose full text is in French or English will be included only.

Search strategy

First, a search will be conducted in five databases: CINAHL, MEDLINE, PUBMED, EMBASE and PsycINFO. Based on two main concepts derived from the research questions, ‘perceived coercion’ and ‘psychiatry/mental illness,’ a list of terms was generated with the assistance of a librarian (table 1), from which a search will be conducted using descriptors and keywords (table 2). An exploratory search was conducted in September 2021 (see online supplimental additional file 2), which will be updated once the evidence selection begins (planned date: September 2022). Based on the librarian’s recommendation, ‘factors’ were not considered in the search given the ambiguous nature of this concept but will be used as an inclusion criterion. There will be no restrictions for years of publication to obtain the entire scientific literature on the topic of interest. Next, a search will be conducted specifically in mental health periodicals to identify articles that might not be in the databases. A search will also be conducted to identify grey literature by searching OpenGrey, university thesis sites and government agencies. Lastly, the reference lists of the selected articles will be searched to include any other literature deemed relevant according to the inclusion criteria. The search will be conducted in an iterative manner, meaning that the search strategy may be refined as we find pertinent evidence and become more familiar with the subject of interest.

Table 1.

Main concepts and their associated lists of descriptors and keywords.

Coercion	Perception	Psychiatry/mental illness
Descriptors (MeSH) “Coercion” “Involuntary Treatment, Psychiatric” “Commitment of Mentally Ill” “Restraint, Physical” Keywords Coercion Coercing Coercive Coerced Involuntary Involuntarily Commitment(s) Restraint restrained Restraining Seclusion Secluding secluded Constraint Constrained Constraining Forced Force Compulsory Intimidation Intimidate intimidated	Descriptors (MeSH) “Perception” “Social Perception” Keywords Perception(s) Perceived Perceive Perceiving Experience(s) Experienced Experiencing Subjective	Descriptors (MeSH) “Mental Disorders” “Bipolar and Related Disorders” “Schizophrenia Spectrum and Other Psychotic Disorders” “Mentally Ill Persons” “Hospitals, Psychiatric” “Psychiatric Department, Hospital” Keywords Psychiatric Psychiatry Mental health Mental illness(es) Mentally ill Mental disorder(s) Mentally disordered Schizophrenia Schizophrenic Psychosis Psychotic bipolar

Table 2.

Example of a pilot search

Database	Search using descriptors and keywords	Results
PubMed	((“Coercion”(Mesh) OR “Involuntary Treatment, Psychiatric”(Mesh) OR “Commitment of Mentally Ill”(Mesh) OR “Restraint, Physical”(Mesh:NoExp)OR Coercion(TIAB) OR Coercing(TIAB) OR Coercive(TIAB) OR Coerced(TIAB) OR Involuntary(TIAB) OR Involuntarily(TIAB) OR Commitment(TIAB) OR commitments(TIAB) OR Restraint(TIAB) OR restrained(TIAB) OR Restraining(TIAB) OR Seclusion(TIAB) OR secluded(TIAB) OR Secluding(TIAB) OR Constraint(TIAB) OR constrained(TIAB) OR Constraining(TIAB) OR forced(TIAB) OR force(TIAB) OR compulsory(TIAB) OR intimidation(TIAB) OR intimidate(TIAB) OR intimidated(TIAB)) AND (“Perception”(Mesh:NoExp)OR “Social Perception”(Mesh:NoExp)OR Perception(TIAB) OR perceptions(TIAB) OR Perceived(TIAB) OR Perceive(TIAB) OR Perceiving(TIAB) OR Experience(TIAB) OR experiences(TIAB) OR Experienced(TIAB) OR Experiencing(TIAB) OR Subjective(TIAB))) AND (“Mental Disorders”(Mesh:NoExp)OR “Bipolar and Related Disorders”(Mesh) OR “Schizophrenia Spectrum and Other Psychotic Disorders”(Mesh) OR “Mentally Ill Persons”(Mesh) OR “Hospitals, Psychiatric”(Mesh) OR “Psychiatric Department, Hospital”(Mesh) OR Psychiatric(TIAB) OR Psychiatry(TIAB) OR “Mental health”(TIAB) OR “Mental illness”(TIAB) OR “mental illnesses”(TIAB) OR “Mentally ill”(TIAB) OR “Mental disorder”(TIAB) OR “mental disorders”(TIAB) OR “Mentally disordered”(TIAB) OR Schizophrenia(TIAB) OR Schizophrenic(TIAB) OR Psychosis(TIAB) OR Psychotic(TIAB) OR bipolar(TIAB))	4963

Source of evidence selection

All citations will be uploaded in Covidence software (2022) and duplicates will be removed. A first selection will be based on title and abstract examination of the articles for assessment against the inclusion criteria. The selection will be conducted independently by two main reviewers following a pilot test. A second selection will be made based on full-text examination of the literature selected in the first stage. The help of a third reviewer will be sought if any disagreements arise between the other reviewers at each stage of the selection process. The reasons for exclusion will be documented and reported in the final scoping review. The results of the selection process will be reported and presented in a PRISMA-ScR flow diagram.³⁰

Data extraction

Data extraction will be done according to the categories proposed in the JBI methodology for scoping reviews²⁷ and adapted to the purpose and research questions of the present study: authors, year of publication, country of origin, purpose, population, sample size, context of care, method, type of factor assessed and its description, method of data collection used (scale, questionnaire, interview, …), key findings and quality assessment. Using the Covidence software (2022), two authors will independently extract data from three papers to verify that all relevant data have been extracted. In the case of disagreement, a discussion will take place between the two authors to clarify the items to be extracted, and the step will be repeated with a different article until an interjudge agreement is reached. We will assess the quality of the literature by using the following tools: the Mixed Methods Appraisal Tool,³¹ the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses,³² and the Authority, Accuracy, Coverage, Objectivity, Date, Significance checklist for grey literature.³³

Data analysis and presentation of the results

First, a description of the included literature, its main characteristics and the factors examined will be presented in a tabular form accompanied by a narrative summary. Miles et al’s (2020) content analysis method will be used to allow for the presentation of the factors and their association with perceived coercion. The extracted data will be coded (using QDA Miner software) according to the specific factors presented in the literature and organised in a table to proceed with their comparison. Next, broad categories will be identified, allowing different factors to be grouped into a single category. The preliminary results will be presented to the stakeholders and discussed through a meeting. Their input will be considered and incorporated in the results. Finally, conclusions will be presented, and recommendations formulated, taking into account the state of knowledge on the subject and possible research gaps.

Patient and public involvement

No patient was involved in the development of this review protocol. However, a person with lived experience in psychiatry will be involved in reviewing the preliminary results of the scoping review.

Conclusion

The aim of this scoping review is to identify the factors that are associated with perceived coercion by people receiving psychiatric care. Since the concept of perceived coercion remains a relatively understudied form of coercion, using a scoping review approach is relevant to ensure that a global portrait of the literature on this issue is presented. Indeed, it is now clear that coercion in psychiatry is not just about control measures, but rather a complex and multifactorial phenomenon that requires a better understanding of its various components. As the human rights-based approach to mental healthcare is gaining traction,^{34 35} it is essential that perceived coercion, which includes the perception of being treated fairly,⁹ be considered in the development of initiatives aspiring to be respectful of human rights. Therefore, this review will provide a better understanding of the underlying factors that might contribute to the perception of coercion in psychiatric and mental healthcare, while allowing the distinction between human and organisational factors. We anticipate that the findings of this study will inform the development of interventions to reduce perceived coercion in psychiatric and mental healthcare by identifying modifiable factors that are associated with its prevalence. In addition, we believe that the results of this review will benefit all psychiatric and mental health stakeholders wishing to increase the quality of care and services provided to this population.

Ethics and dissemination

No ethics approval is required for this review. The results of this scoping review will be submitted to a scientific journal for publication. In addition, the results will be presented in international mental health conferences and shared with clinicians working in psychiatric and mental healthcare.

Ethics statements

Patient consent for publication

Not applicable.