Rates of statutory mental health detentions are rising and negative experiences are often reported. ‘Involuntary’ (formal) admissions have been associated with longer stays in hospital, higher readmission rates, higher risk of being involuntarily readmitted and a greater likelihood of dying by suicide.

Previous literature reviews (Katsakou & Priebe, 2007; Seed et al 2016) reported: restrictions of autonomy, lack of participation in decision-making, meaningless and inappropriate care and non-therapeutic environments.

It is now crucial to address, with haste and caution, how this knowledge informs the current legislative reviews for the better.

Methods

Five bibliographic databases were searched and supplemented by reference list screening and citation tracking. The search was limited to studies from 1983 to parallel the provisions of the current mental health legislation in England and Wales

Studies were included if they:

• Assessed adult patients’ experiences of statutory assessment or detention in hospital
• Collected data using qualitative methods (individual interviews or focus groups)
• Were published in a peer-reviewed scientific journal

Studies were excluded if they used a mixed sample of both involuntarily and voluntarily admitted patients with no separate analysis

Findings were produced using thematic synthesis entailing a whole-team, four-stage process:

1. Fine-grained coding
2. Reviewing descriptive themes through the discussion of similarities/differences and developing a hierarchical thematic framework
3. Applying the thematic framework, adding new themes and collapsing others in an iterative process of coding and analysis
4. Using the descriptive themes to generate analytical themes through discussion

Fifty-six studies were included. These generally reported the gender of participants but only 17 reported participants’ ethnicity. Twenty-six papers reported on the experiences of detention in hospital, 16 on the experiences of both admission and detention (although the difference of interpretation is unclear), 7 on experiences of admission only (again unclear how this differs from experiences of detention) and 7 focused specifically on coercive interventions, such as seclusion.  None focused on the process of assessment.

Thirty studies were conducted in the UK with the remainder in European countries, Australia, Israel and the USA.

The thematic framework was shared with a Lived Experience Group and quotes from service users within the studies were used to illustrate themes.

To determine the quality of eligible studies, two independent reviewers used the Critical Appraisal Skills Programme Qualitative Research Checklist to appraise each paper and any discrepancies were resolved through discussion.

Researcher reflexivity was acknowledged, with the lead researcher identifying as a researcher of colour with a particular interest in the lived experiences of severe mental illness of BAME groups. Attempts were made to minimise any undue influence by creating the initial coding framework collaboratively with three other reviewers.

Results

Five significant themes were identified, which were consistent across all studies:

Information and involvement in care

• Patients’ experiences were affected by the provision (or lack) of appropriate and timely information about the reasons and length of detention and how to access information about rights, entitlements and treatment decisions/medication
• Sharing information reduced fear and the disempowering impact of coercion, improved relationships with staff (although too much information, particularly about side-effects, can be overwhelming)
• Some were less likely to perceive a coercive process if they had previously agreed however some described their advance statements being ignored
• Some patients experienced powerlessness and coercion whatever they did: “If I were to say I agree it would be coercion anyway”
• Forced medication caused distress and was associated with punishment
• Treatment during detention is predominantly medication and there is a need for psychological therapies

Quality of the environment

• The physical environment, personal safety and the availability of meaningful activities to reduce boredom in hospital were important
• A proportion of patients reported that involuntary admission had helped avert risk and protect them from harm

Quality of relationships

• Staff who were kind, respectful, trustworthy and established a ‘human connection’ were valued
• Staff could be seen as bullying or disrespectful, at times misusing their power and position to humiliate or discriminate leading to a divided climate on the wards
• Patients spoke positively of their relationships with other patients, who provided encouragement and support

Impact of detention on feelings of self-worth

• The experience of involuntary admission was disempowering, dehumanising and linked to reduced autonomy
• Paternalistic staff attitudes and arbitrary routines and rules were problematic and these led to reduced self-efficacy
• Cultural and religious requests could be rejected without justification
• Future stigma and prejudice both within mental health services and in wider society and detention were concerning
• Police involvement induced feelings of criminalisation and shame

Emotional impact of detention

• Frequent responses were distress, anger, confusion, resentment and defensiveness. Coercive interventions could be experienced as disempowering, distressing, and reminders of past traumatic events including sexual abuse
• Some felt even worse following discharge

Conclusions

The authors concluded that certain factors such as coproduction models can help reduce negative experiences and encourage recovery.

Findings suggest that involuntary in-patient care is often frightening and distressing, but certain factors were identified that can help reduce negative experiences. Coproduction models may be fruitful in developing new ways of working on in-patient wards that provide more voice to patients and staff, and physical and social environments that are more conducive to recovery.

Strengths and limitations

The voice of service users is clear and there are some evocative first-person accounts such as feeling ‘under attack and in danger.’  The paper includes a helpful ‘lived experience commentary’ by way of summary.

Whilst the review is rigorous, the authors acknowledge that interpreting findings with such a broad remit, across multiple studies and settings and with different research methods can over-simplify and involve the loss of invaluable data e.g. that which pertains to race, ethnicity or gender due to the limitations of the primary data.

The review also uses the term ‘voluntary’ admissions to mean informal (i.e. not a statutory admission). This is controversial: ‘voluntary’ admissions are equally experienced as oppressive and coercive; and are arguably more so given the lack of access to appeals, and similar treatment on the ward. Examples of subtle coercion (as noted above) are problematic and the language of involuntary/voluntary implies that service users have choices.

The title and the aims were to consider both detention and assessment, but the reviewers acknowledge that the literature review returned no material relating to the process and experience of assessment.

The paper is based on research commissioned and funded by the National Institute for Health Research (NIHR) Policy Research Unit and it contributed to the recent independent review of the Mental Health Act in England. As such, it may be rather conservative in its scope and appeal less to radical activists in the area.

Implications for practice

The findings of this review suggest ways to improve experiences of detention including the provision of information, engaging patients in decision-making and developing trusting relationships. These themes are reflected in the MHA reforms, particularly with a new proposed Guiding Principle: Autonomy and Choice.

This is set to replace the current ‘Empowerment and Involvement’ principle which pertains to (shared?) decision-making within assessments. It appears to relate to treatment choices post-admission. We should therefore all be immediately concerned not to lose this Principle’s application to the assessment process or we risk inadvertently reducing autonomy and choice.

Finally, rising rates of formal admissions are also understood to be skewed by the reduction of resources and waiting lists for hospital beds. A more nuanced understanding may be useful.

Conflicts of interest

As described above, this paper by Akther et al (2019) is based on research commissioned and funded by the NIHR.

The author of this blog (Jill Hemmington) is currently undertaking empirical research exploring decision-making in MHA assessments and the application of the Empowerment and Involvement principle, the potential for Shared Decision-Making techniques and the ways that these may be accelerated or curtailed by future reforms.

Video presentation

Watch lead author of this systematic review, Syeda Akther, presenting the results of her work at the #MHAreview meeting in London in March 2019.

Links

Primary paper

Akther SF, Molyneaux E, Stuart R, Johnson S, Simpson A, Oram S. (2019) Patients’ experiences of assessment and detention under mental health legislation: systematic review and qualitative meta-synthesis. BJPsych Open. 2019;5(3):e37. Published 2019 Apr 24. doi:10.1192/bjo.2019.19

Other references

Katsakou, C., Priebe, S (2007) Patient’s experiences of involuntary hospital admission and treatment: a review of qualitative studies Epidemiol Psychiatr Sci., 16: 172-8 Available at https://www.ncbi.nlm.nih.gov/pubmed/17619549

Seed, T., Fox, JR, Berry, K (2016) The experience of involuntary detention in acute psychiatric care.  A systematic review and synthesis of qualitative studies Int J Nurs Stud 61: 82-94 Available at https://www.ncbi.nlm.nih.gov/pubmed/27314181

Department of Health (2018) Modernising the Mental Health Act Increasing choice, reducing compulsion: Final report of the Independent Review of the Mental Health Act 1983 (PDF).