Journal of Neurosciences in Rural Practice
 


 
  Table of Contents 
ORIGINAL ARTICLE
Year : 2019  |  Volume : 10  |  Issue : 2  |  Page : 261-266  

Caregivers' attitude and perspective on coercion and restraint practices on psychiatric inpatients from South India


1 Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
2 Department of Psychiatry, Mysore Medical College and Research Institute, Mysore, Karnataka, India

Date of Web Publication25-Mar-2019

Correspondence Address:
Guru S Gowda
Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru - 560 029, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnrp.jnrp_302_18

Rights and Permissions
   Abstract 


Background: Coercion and restraint practices in psychiatric care are common phenomena and often controversial and debatable ethical issue. Caregivers' attitude and perspective on coercion and restraint practices on psychiatric inpatients have received relatively less research attention till date. Aims: Caregivers' attitude and perspective on coercion and restraint practices on psychiatric inpatients. Methodology: This is a hospital-based, a descriptive, cross-sectional study. A total of 200 (n = 200) consecutive patient and their caregivers were chosen between June 2013 and September 2014 through computer-generated random numbers sampling technique. We used a semi-structured interview questionnaire to capture caregivers' attitude and perspective on coercion and restraint practices. Sociodemographic and coercion variable were analyzed using descriptive statistics. McNemar test was used to assess discrete variables. Results: The mean age was 43.8 (±14.9) years. About 67.5% of the caregivers were family members, 60.5% of them were male and 69.5% were from low-socioeconomic status. Caregivers used multiple methods were used to bring patients into the hospital. Threat (52.5%) was the most common method of coercion followed by persuasion (48.5%). Caregivers felt necessary and acceptable to use chemical restraint (82.5%), followed by physical restraint (71%) and electroconvulsive therapy (ECT) (56.5%) during acute and emergency psychiatric care to control imminent risk behavior of patients. Conclusion: Threat, persuasion and physical restraint were the common methods to bring patients to bring acutely disturbed patients to mental health care. Most patients caregivers felt the use of chemical restraint, physical restraint and ECT as necessary for acute and emergency care in patients with mental illness.

Keywords: Caregiver, coercion, India, psychiatry, restraints


How to cite this article:
Gowda GS, Kumar CN, Ray S, Das S, Nanjegowda RB, Math SB. Caregivers' attitude and perspective on coercion and restraint practices on psychiatric inpatients from South India. J Neurosci Rural Pract 2019;10:261-6

How to cite this URL:
Gowda GS, Kumar CN, Ray S, Das S, Nanjegowda RB, Math SB. Caregivers' attitude and perspective on coercion and restraint practices on psychiatric inpatients from South India. J Neurosci Rural Pract [serial online] 2019 [cited 2019 Apr 18];10:261-6. Available from: http://www.ruralneuropractice.com/text.asp?2019/10/2/261/254672




   Introduction Top


Escorting an unwilling patient to psychiatric care is always exhausting for the caregiver. The process often involves force, threat, or coercive measures in our social setting which further raise the antagonism in patients leading to refusal of care and violence.[1],[2] Unwillingness of patients for psychiatric care may due to multiple factors such as illness severity, poor insight, affective episode, psychotic disorder, young age, recent suicidal attempt, immigration, ethnic minority, male gender, and legal issue.[3],[4],[5],[6],[7],[8],[9],[10],[11],[12] This leads to involuntary admission and treatment under the mental health law. Canadian study shows nearly 70% among the first episode psychosis needed involuntary admission and treatment, in general, have been accepted as a necessary step to protect patients, caregivers, and society.[2] However, it remains a controversial ethical and legal dilemma, and sometimes, it becomes challenging to balance the rights of patients and the rights of the community/family. The process of bringing the patient with psychiatric illness to care might involve various modalities such as the involvement of private health sectors, public health sectors, agencies, nongovernmental organizations (NGO), self-help groups, or neighbors. Carer closely associated with the patient, who sees patient in the time of need, may decide to contact support such as the neighbors, NGO, or police for the help. In few occasion, the patients with a wandering tendency might be brought to the facility without the knowledge of family members by police or different social work agencies.[3],[13],[14] Unlike developed countries where there is an attempt to facilitate insight and verbally negotiate with the patients at different levels, the Indian sociocultural system does not always allow such privileges due to the lack of workforce, stigma, or understanding the problem faced by patients. Hence, it is very common for the patient to perceive a significant amount of coercion as they are often brought to the hospital by forceful means with the help of a lot of workforces or the police force. It is a sad state of affairs that often patients are not spoken to about the necessity of admission or the process involved in the way. They are often victimized physically or verbally due to the forcible ways of handling the situation. The coercive measures taken by family members might be verbal and physical abuse, humiliation, chaining, peddling, giving a large dose of sedatives, threatening by violent means such as sharp weapons or guns, and grooving by many people. It is an important phenomenon to explore as it has never been studied earlier and very important for clinicians, social activist, families, policy-makers, And in the context of the MHCA 2017.[15] With this in mind, we are systematically studying attitude, experiences, and perspective of psychiatric inpatients caregivers on coercion and restraint practices.


   Methodology Top


Setting and sample selection

The study was carried out at the Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru – 29. A larger study that looked into the patient, family, and clinician's perspective on admission, treatment, and coercive experiences during psychiatric inpatient care (IP) was used as the source of data. A total of 200 (n = 200) consecutive patient and their caregivers were chosen between June 2013 and September 2014 through computer-generated random numbers sampling technique. Inpatients above the age of 18 were randomly selected and were approached with a request to participate in the study. Exclusion criteria included patients suffering from mental retardation, organic brain syndromes, delirium, dementia, developmental disorders, and antisocial personality disorder since some cognitive ability allowing reflection on one's own experience was required for this study. Written informed consent was obtained. The attendants/family members were requested to provide consent when patients could not consent. The study was, therefore, performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki (Declaration of Helsinki 1964). Patient caregivers' written consent was obtained to participate in the study in accordance with ethical approval. All patients and their caregivers were interviewed within 3 days of admission.[4],[5],[6]

Study assessments

We used a semi-structured interview questionnaire to capture caregivers' attitude and perspective on coercion and restraint practices. This was prepared by culling out items emanating from an open-ended pilot interview of 15 participants chosen purposively and then face validated by senior consultant psychiatrists from the department of psychiatry. The initial part of the interview was open-ended. Here, the patient and the caregivers were encouraged to describe the process of coming to the hospital, their perception about coercive treatment, coercive measures and involuntary admission, deviation of patient's rights, and freedom during hospitalization. The second part of the interview focused on the patient's caregiver perceptions of (a) difficulties in the process of bringing the patient to the hospital, (b) attitude and practice toward coercive measure in hospital, and (c) perception about different treatment measures. This questionnaire captured the caregivers' attitude and perspective on coercive practices on psychiatric inpatients. The coercion ladder[16] was rated on a 100-point visual analog scale, from zero corresponding to “no coercion” to a hundred being “maximal coercion.”

Ethical considerations

The Institutional Ethical Committee approved the study.

Statistical analysis

Statistical significance was set at P < 0.05. Sociodemographic characteristics of the sample were analyzed using descriptive statistics. McNemar test was used to assess discrete variables.


   Results Top


[Table 1] shows the sociodemographic profile of the caregivers. The mean age was 43.8 (±14.9) years. About 60.5% of the caregivers were male and 69.5% were from low socioeconomic status. About 67.5% of the caregivers were family members and 43.5% had quit their jobs after the patient's illness.
Table 1: Sociodemographic profile of caregivers

Click here to view


[Table 2] depicts the attitude and perspective of the caregivers on the risk profile of patients. Caregivers used multiple methods were used to bring patients into the hospital. Threat (52.5%) was the most common followed by persuasion (48.5%). Reason for admission as per caregivers being a risk of harm to self, altered biological function, and risk of harm to others contributes the maximum percentages of 82.5%, 81.5%, and 64.5%, respectively.
Table 2: Caregivers' attitude and perspective on the risk profile of patients

Click here to view


[Table 3] shows the caregivers' perspective on coercive practices. Chemical restraint had the highest acceptability of 82.5%, followed by physical restraint (71%) and electroconvulsive therapy (ECT) (56.5%) during acute and emergency care. Most caregivers felt that does not result in either a loss of autonomy, interpersonal contact, or isolation (percentages being 69%, 72%, and 73.5%, respectively).
Table 3: Caregivers' perspective on coercive practices

Click here to view


[Table 4] shows the perspectives of the caregivers regarding the risk profile before and after the first 3 days of IP care. There have been significant changes in the perspective regarding risk to self, others, and public or private property. In all cases, perceived risk has reduced.
Table 4: Caregivers' perspectives on the risk profile of patient before and first 3 days of inpatient care

Click here to view



   Discussion Top


This study was conducted at a tertiary psychiatric training facility. This is one of the largest and oldest government-run facilities. The previous study from India using Staff Attitude on Coercion Scale (SACS) looked into the caregiver perspective and its comparison with the psychiatrist's attitude. It concluded that the lack of resources is one of the reasons for coercion in India.[17] The drawback of the previous study was that it used SACS which was developed to look at the attitude of coercion among mental health professionals. It was not meant for caregivers, and it was not suitable to assess the ground reality and attitude of Indian caregiver population. In this study, we developed a semi-structured interview questionnaire capturing all coercive experiences. This was then administered and face validated using an open-ended interview. Later, the focused interview was conducted to capture caregiver attitude toward coercion. Our study provides one of the first empirical data on caregiver attitude and perspective on coercion and restraint measures in India.

In this study, the majority of caregivers are males and is middle-aged (mean age of 44 years), these findings are in line with the Mysore study findings.[17] Caregivers, who stayed with patients during IP, are mostly family members and from low socioeconomic status. Our study shows that the patients suffering from a severe mental illness such as schizophrenia and other psychotic disorder was 48% and those suffering from mood disorders was 43.5%. All of them very extremely ill according to the Clinical Global Impression-Severity scale, most had absent insight at the time of admission.[6] Absent insight, involuntariness and severe psychopathology in patients were probably the factors that made the caregiver use multiple coercive methods to bring the patient to the hospital. It was not easy for caregivers to convince the patients. Only 16.5% of the patients agreed and consented for consultation. Caregivers described that when initially patients did not agree for consultation, they tried to persuade with him/her or else they used threats or the restraint to bring him to care. Most caregivers had felt it was necessary to bring the patient into the hospital. Some of the caregivers described they blackmailed the patients by saying (a) caregiver himself/herself was consulting for health problems and asked the patient to accompany the caregivers (role change for care), (b) caregiver brought the patients saying that they were visiting a hospital to see some other relative who was admitted, and (c) saying they are going for some social function. The most difficult thing a caregiver expressed is bringing the patient to health care than staying with the patient during IP. Most caregivers expressed the need for public service to take care of highly ill patients like 108 public ambulance service for the emergency medical condition in India. Usage of threat, persuasion, and restraint is also necessary because often the patients are in a state wherein they have no insight, are refusing food, or are dangerous to self and others. The context of events is to be given due consideration apart from patients' rights. Ultimately, if the coercive measure helps the patient achieve good health and functionality in the long run and also reduce the risk to self and society, it is not harmful.[18] Therefore, Persuade him/her and when it failed they used threats as a method of coercion to bring him to care to achieve harmony of mental health in India.

As per caregivers, most had a risk of harm to self, others, and public or private property, and those were the main reasons to bring the patients to acute and emergency psychiatric care. Apart from these reasons, an inability to take care of the patients and the patient not taking the medication are also associated with psychiatric admission in previous studies from Norway and other countries, which were not assessed in our study.[18],[19],[20] Before reaching the hospital, most of the families waited to resolve the problems, went to multiple religious places, and secluded the patient in their house. The majority got suggestions from their own family members and neighbors to seek psychiatric care when they noticed imminent danger associated with the behavior. Most caregivers were there during acute and emergency care and most of the caregivers perceived that the use of chemical restraint; physical restraint and ECT were necessary during acute and emergency psychiatry care and also felt that they did not result in either a loss of autonomy, interpersonal contact, or isolation. As per caregivers, most patients who had a risk of harm to self, others, and public or private property behavior got better within 3 days of IP.

Most caregivers consented for the use of chemical restraint; physical restraint and ECT during acute and emergency psychiatric care when a patients' decision-making capacity was lost. However, the previous study reported that the involvement of the relatives in treatment and care planning of the patient has been found to be less than required.[21] Hence, the involvement of caregivers can be increased by proper communication and joint decision-making between caregivers and health-care providers.[22] Engagement of the family in care and further initiatives like group conferences can help deal with a reduction in the experience of coercive treatment.[23] This is good for not only the patients but also their family members and friends as well as the mental health professionals themselves. It will in turn help to reduce the medicolegal litigation problems with health-care professionals. Most patients' caregivers felt that coercion does not result in loss of dignity, autonomy, and interpersonal contact. This raises one more question that, whether caregivers have adequate knowledge about restraints or them under the pressure to provide psychiatric treatment to their belonging one. This question was answered by a recent study from Nepal on family's attitude to restraint saying majority had a lack of knowledge on risk and consequence of restraints.[24]

Strengths and limitations

Our study gives a comprehensive picture of caregivers' attitudes and perspective on the use of coercion and restraint measures in mental health establishment setting. However, the population may not be representative of the entire Indian population and limited to South India.

Future directions

There is a need for studies looking at knowledge and attitude of caregivers of patient with mental illness on coercion and different restraint measures.


   Conclusion Top


Threat, persuasion and physical restraint were the common methods to bring patients to bring acutely disturbed patients to mental health care. Most patients caregivers felt the use of chemical restraint, physical restraint and ECT as necessary for acute and emergency care in patients with mental illness.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Zhang S, Mellsop G, Brink J, Wang X. Involuntary admission and treatment of patients with mental disorder. Neurosci Bull 2015;31:99-112.  Back to cited text no. 1
    
2.
Lebenbaum M, Chiu M, Vigod S, Kurdyak P. Prevalence and predictors of involuntary psychiatric hospital admissions in Ontario, Canada: A population-based linked administrative database study. BJPsych Open 2018;4:31-8.  Back to cited text no. 2
    
3.
Røtvold K, Wynn R. Involuntary psychiatric admission: How the patients are detected and the general practitioners' expectations for hospitalization. An interview-based study. Int J Ment Health Syst 2016;10:20.  Back to cited text no. 3
    
4.
Gowda GS, Noorthoorn EO, Kumar CN, Nanjegowda RB, Math SB. Clinical correlates and predictors of perceived coercion among psychiatric inpatients: A prospective pilot study. Asian J Psychiatr 2016;22:34-40.  Back to cited text no. 4
    
5.
Gowda GS, Kondapuram N, Kumar CN, Math SB. Involuntary admission and treatment experiences of persons with schizophrenia: Implication for the mental health care bill 2016. Asian J Psychiatr 2017;29:3-7.  Back to cited text no. 5
    
6.
Gowda GS, Lepping P, Noorthoorn EO, Ali SF, Kumar CN, Raveesh BN, et al. Restraint prevalence and perceived coercion among psychiatric inpatients from South India: A prospective study. Asian J Psychiatr 2018;36:10-6.  Back to cited text no. 6
    
7.
Bindman J, Reid Y, Szmukler G, Tiller J, Thornicroft G, Leese M, et al. Perceived coercion at admission to psychiatric hospital and engagement with follow-up – A cohort study. Soc Psychiatry Psychiatr Epidemiol 2005;40:160-6.  Back to cited text no. 7
    
8.
Anestis A, Daffern M, Thomas SD, Podubinski T, Hollander Y, Lee S, et al. Predictors of perceived coercion in patients admitted for psychiatric hospitalization and the stability of these perceptions over time. Psychiatry Psychol Law 2013;20:492-503.  Back to cited text no. 8
    
9.
Cusack KJ, Steadman HJ, Herring AH. Perceived coercion among jail diversion participants in a multisite study. Psychiatr Serv 2010;61:911-6.  Back to cited text no. 9
    
10.
Danivas V, Lepping P, Punitharani S, Gowrishree H, Ashwini K, Raveesh BN, et al. Observational study of aggressive behaviour and coercion on an Indian acute ward. Asian J Psychiatr 2016;22:150-6.  Back to cited text no. 10
    
11.
Fiorillo A, Giacco D, De Rosa C, Kallert T, Katsakou C, Onchev G, et al. Patient characteristics and symptoms associated with perceived coercion during hospital treatment. Acta Psychiatr Scand 2012;125:460-7.  Back to cited text no. 11
    
12.
Raveesh BN, Pathare S, Lepping P, Noorthoorn EO, Gowda GS, Bunders-Aelen JG, et al. Perceived coercion in persons with mental disorder in India: A cross-sectional study. Indian J Psychiatry 2016;58:S210-20.  Back to cited text no. 12
    
13.
Gowda GS, Gopika G, Manjunatha N, Kumar CN, Yadav R, Srinivas D, et al. Sociodemographic and clinical profiles of homeless mentally ill admitted in mental health institute of South India: ‘Know the unknown’ project. Int J Soc Psychiatry 2017;63:525-31.  Back to cited text no. 13
    
14.
Gowda GS, Gopika G, Kumar CN, Manjunatha N, Yadav R, Srinivas D, et al. Clinical outcome and rehabilitation of homeless mentally ill patients admitted in mental health institute of South India: “Know the unknown” project. Asian J Psychiatr 2017;30:49-53.  Back to cited text no. 14
    
15.
The Mental Health Care Act; 2017. Available from: http://www.prsindia.org/uploads/media/Mental%20Health/Mental%20Healthcare%20Act,%202017.pdf. [Last accessed on 2018 Sep 06].  Back to cited text no. 15
    
16.
Cantrill H. The Pattern of Human Concern. New Brunswyck, New Jersey: Rutgers University Press; 1965.  Back to cited text no. 16
    
17.
Raveesh BN, Pathare S, Noorthoorn EO, Gowda GS, Lepping P, Bunders-Aelen JG, et al. Staff and caregiver attitude to coercion in India. Indian J Psychiatry 2016;58:S221-9.  Back to cited text no. 17
    
18.
De Sousa A. Coercion and admission in psychiatric facilities. J Neurosci Rural Pract 2017;8:1-2.  Back to cited text no. 18
[PUBMED]  [Full text]  
19.
Joa I, Hustoft K, Anda LG, Brønnick K, Nielssen O, Johannessen JO, et al. Public attitudes towards involuntary admission and treatment by mental health services in Norway. Int J Law Psychiatry 2017;55:1-7.  Back to cited text no. 19
    
20.
Solomon P, Beck S, Gordon B. Family members' perspectives on psychiatric hospitalization and discharge. Community Ment Health J 1988;24:108-17.  Back to cited text no. 20
    
21.
Kjellin L, Andersson K, Bartholdson E, Candefjord IL, Holmstrøm H, Jacobsson L, et al. Coercion in psychiatric care – Patients' and relatives' experiences from four Swedish psychiatric services. Nord J Psychiatry 2004;58:153-9.  Back to cited text no. 21
    
22.
Dirik A, Sandhu S, Giacco D, Barrett K, Bennison G, Collinson S, et al. Why involve families in acute mental healthcare? A collaborative conceptual review. BMJ Open 2017;7:e017680.  Back to cited text no. 22
    
23.
Meijer E, Schout G, de Jong G, Abma T. Regaining ownership and restoring belongingness: Impact of family group conferences in coercive psychiatry. J Adv Nurs 2017;73:1862-72.  Back to cited text no. 23
    
24.
Shrestha Y. Knowledge and attitude of family member of mentally ill patient regarding restraint, 2016. Arch Psychiatr Nurs 2018;32:297-9.  Back to cited text no. 24
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   Methodology
   Results
   Discussion
   Conclusion
    References
    Article Tables

 Article Access Statistics
    Viewed79    
    Printed0    
    Emailed0    
    PDF Downloaded18    
    Comments [Add]    

Recommend this journal