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ORIGINAL ARTICLE

How patients’ characteristics influence the use of coercive measures

Tomasz Pawlowski, Piotr Baranowski1
Division of Psychotherapy and Psychosomatic Medicine, 1Lower Silesian Centre of Mental Health Wroclaw,
Wroclaw Medical University, Wroclaw, Poland

ABSTRACT

Background: Coercive measures are applied in psychiatry as a last resort to control self‑ and hetero‑aggressive behaviors
in situations where all other possible strategies have failed. For ethical and clinical reasons, the number of instances of
coercion should be reduced as far as possible.
Aim: The aim of the study was to identify sociodemographic and clinical characteristics of patients that were associated
with coercion during hospital treatment.
Materials and Methods: The study has a descriptive, longitudinal design, based on a 1 year prospective observation of
patients admitted to a psychiatric hospital consisting of six inpatient psychiatric wards with a total of 236 beds.
Results: In the 12‑month period covered by the study, 1476 people (778 men and 698 women) were treated in the hospital;
226 of them (15%) were subjected to coercion on a total of 405 occasions. The most frequently implemented form of
direct coercion was mechanical restraint. The following factors involved in the use of direct coercion were identified:
Male gender, young age, mental disorders resulting from the abuse of psychoactive drugs, involuntary admission to the
hospital and the use of direct coercion in the past.
Conclusion: Assessments of patients’ sociodemographic and clinical characteristics can help clinicians recognize
patients who are particularly at risk of being subjected to coercive measures.

Key words: Coercion, involuntary treatment, physical restraint

INTRODUCTION current laws constitute a significant problem in psychiatric

In the treatment of the mentally disturbed, it is admissible
to use coercion, which in broader terms includes depriving a
patient of personal freedom and involuntary commitment.[1]
Apart from involuntary commitment  (indirect coercion),
psychiatric treatment can involve direct physical pressure
on a patient, defined as direct coercion. The admissibility of
direct coercion, the extent of its use and its compliance with
Address for correspondence: Dr. Tomasz Pawlowski,
Division of Psychotherapy and Psychosomatic Medicine,
Wroclaw Medical University, Pasteura Street 10,
50‑367 Wroclaw, Poland.
E‑mail: tomasz.pawlowski@umed.wroc.pl
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institutions and frequently affect, rightly or not, how society
at large views psychiatry, while involuntary admissions
have a legal framework in all European countries, detailed
regulations concerning coercive measures  (mechanical
restraint, seclusion, and forced medication) exist only in
some countries.[2]
In accordance with the standards of international law,
direct coercion is treated as a last resort in the treatment
of the mentally disturbed. When choosing how to apply
it, the principle of the least distress for the patient is
recommended.[3] The literature frequently emphasizes the
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DOI:
How to cite this article: Pawlowski T, Baranowski P. How
patients’ characteristics influence the use of coercive
10.4103/psychiatry.IndianJPsychiatry_100_17
measures. Indian J Psychiatry 2017;59:429-34.

© 2018 Indian Journal of Psychiatry | Published by Wolters Kluwer ‑ Medknow 429

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Pawlowski and Baranowski: Coercion in psychiatry
adverse effects – on both the patients and the personnel – of
the use of direct coercion. It can be dangerous for a patient
in bad physical condition. Infectious diseases, cardiologic,
metabolic or thermoregulatory disorders, and other ailments
requiring constant medical supervision are contraindications
to solitary confinement.[4] Reports indicate that patients
subjected to mechanical restraint are at an increased risk
of choking and peripheral thrombosis, and are also more
likely to become targets of other patients’ aggression.[5]
Isolated instances have been reported of deaths of patients
who were submitted to mechanical restraint in an acute
delirium state.[6] The reduction of sensory stimuli caused by
restraint or isolation adversely affects the mental condition
of patients with organic damage to the central nervous
system.[5]
The frequency with which coercive measures are used may
be influenced by patient‑  or ward‑related variables. This
work aims to analyze the effect of factors related to the
patient  –  such as age, gender, psychiatric diagnosis, the
number of previous hospitalizations, previous instances of
being subjected to direct coercion and the legal basis of
the hospital admission – on the frequency of use of direct
coercion in the cases of mentally disordered patients.
MATERIALS AND METHODS
The study has a descriptive, longitudinal design, based on
a 1  year prospective observation of patients admitted to
a psychiatric hospital that serves a population of 650,000
inhabitants. The hospital consists of six inpatient psychiatric
wards with a total of 236 beds. The material studied in this
work comprised all instances of the use of direct coercion
in 12  months, reported in accordance with article 18 of
Poland’s Mental Health Act.
Direct coercion was defined in accordance with article 18 of
Poland’s Mental Health Act:
1. “In the course of activities covered by this Act, mentally
disturbed persons may be submitted to physical
coercion only when such persons:
i. Make an attempt:
a. Against their own life or health, or the life or
health of another person,
b.  Or against public safety,
ii. or when such persons violently destroy or damage
surrounding objects,
iii. or when such persons seriously disturb or preclude
the functioning of the healthcare entity which
provides health services in the field of mental
health care or social welfare center, physical
restraint is warranted by special regulations of this
Act
2. Physical coercion used on persons referred to in
paragraph  1.1 and 1.2 consists in physical restraint,
forced medication, mechanical restraints or seclusion.
430
Physical coercion used on persons referred to in
paragraph 1.3 consists in physical restraint and forced
medication.”
Data analysis
The clinical and sociodemographic characteristics of the
sample were analyzed by descriptive statistics. The statistical
significance of differences between two mean values in results
with the properties of interval variables was assessed with
the parametric t‑test for independent samples if the data
distribution was normal or with the parametric Cochran Cox
test for unequal variances. To compare more than two means,
parametric analysis of variances  (ANOVA) algorithms were
used, depending on the results of tests assessing the normality
of distribution and the homogeneity of variances. A confidence
level of P = 0.05 was adopted for all the tests assessing the
statistical significance of the differences between means. If the
ANOVA showed statistically significant differences between
means, a post hoc Tukey’s honestly significant difference test
for unequal sample sizes was carried out.
RESULTS
In the 12‑month period covered by the study, 1476 people
were treated in the hospital  (778 men and 698 women).
The average age of the patients was 44  years. Among
them, 226 (15%) were submitted to coercion on a total of
405 occasions. The complete data necessary for the analysis
were obtained for 183  patients, who experienced a total
of 274 instances of direct coercion. Men predominated
in the sample: 117 (64%) as opposed to 66 women (36%).
The women were subjected to direct coercion 106 times,
and the mean number of instances of direct coercion for
a patient in this group was 1.6 (range: 1–5). In the group
of men 168 instances were noted, making the mean in this
group 1.4 incidents per patient (rang: 1–5).
In the general population of patients hospitalized during
the research period, the proportion of men and women was
53% and 47% respectively, while in the group of patients
subjected to direct coercion the proportion of men increased
to 64% and the proportion of women decreased to 36%. To
determine how a patient’s gender influences the use of direct
coercion, the proportion of men and women subjected to
it was compared with the percentage of men and women in
the general population of hospitalized patients. A two‑sided
test of proportions was carried out and revealed that this
difference was statistically significant (P < 0.000). These
results show that the structure of the group of patients
subjected to direct coercion, analyzed in terms of gender,
differs from the general population of hospitalized patients,
i.e., the proportion of men was higher in the former group.
The age of the patients in the study group ranged from 18
to 78 years, with a mean of approximately 41 years. The
mean age of women  (43  years) was higher than that of
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Pawlowski and Baranowski: Coercion in psychiatry

men (40 years). The mean age of all the patients hospitalized Table 1: The numbers and percentages of patients
in the period in question was higher than that of the patients subjected to direct coercion in relation to their
subjected to direct coercion: 44 years (P < 0.000) (41 and psychiatric diagnoses
48 years for men and women, respectively). Variables International Classification of Diseases Tenth
Edition diagnosis codes
The diagnosed mental disorders of the subjects of the study F20-29 F10-19 F00-09 F30-39 Other Total
according to the ICD‑10 are presented in Table 1. Women’s wards 49 (76) 2 (3) 9 (14) 6 (9) 0 66
Men’s wards 50 (42) 38 (32) 13 (11) 9 (8) 7 (6) 117
Patients with diagnoses of F20–29 constituted the Number of patients 99 (54) 40 (22) 22 (12) 15 (8) 7 (4) 183
greatest proportion of people subjected to direct
coercion  –  approximately 54%, while in the general
Table 2: Characteristics of patients subjected to direct
population of hospitalized patients the percentage
coercion: The legal grounds for admission
with diagnoses of F20–29 was 49%. A  one sample test of
Ward Involuntary admissions Voluntary admissions Total
proportions  (two‑sided) did not reveal any statistically
Women 34 32 66
significant differences between the proportion of patients
Men 71 46 117
subjected to direct coercion diagnosed with F20–29 and Total 105 78 183
the general population of hospitalized patients with F20–29
diagnoses.
men the proportion was approximately 60%.
The patients diagnosed with mental disorders caused by
the abuse of psychoactive drugs  (F10–19) constitute the Among the patients who were subjected to direct coercion,
second largest group, both in the overall hospitalized 57% had been admitted involuntarily, while in the general
population and among those subjected to direct hospital population the proportion of patients admitted
coercion. The proportion of patients with diagnoses of involuntarily was 24%. To determine how the legal grounds
F10–19 in the general patient population was about 15%, for admission influences the use of direct coercion, the
while in the population of patients subjected to direct proportions of voluntarily and involuntarily admitted
coercion it was approximately 21%. A  one sample test of patients subjected to direct coercion were compared with
proportions (two‑sided) confirmed that the difference was the percentages voluntarily and involuntarily patients in the
statistically significant (P < 0.05, Z = 2.30). whole population of the hospitalized patients. A two‑sided
test of proportions revealed that the difference is statistically
The next most numerous group of psychiatric diagnoses significant (P < 0.000).
among the patients subjected to direct coercion comprised
organic mental disorders (F00–09). In the general hospital, In the study group, 65 patients (36%) were subjected to direct
population organic mental disorders were diagnosed coercion in the emergency room while being admitted to
in 10% of the patients, while the proportion was 12% the hospital, including 48 men (41%) and 17 women (26%).
among the subjects of the study. A  one sample test of
proportions  (two‑sided) showed that this difference was Legally admissible forms of direct coercion were used in
not statistically significant. the hospital wards  –  restraints, forced medication, and
physical restraint; seclusion was not employed. Mechanical
The proportion of patients diagnosed with mood restraints were the most frequently used form (mean per
disorders (F30–39) among the study subjects was 8%, while patient: 1.23). The next most frequently used measure was
it was 13% in the whole hospitalized population. A  one forced medication (mean per patient: 1.06), while the mean
sample test of proportions  (two‑sided) proved that this of use of physical restraint was 0.211 per patient.
difference was statistically significant (P < 0.05, Z = 2.08).
A one‑way ANOVA in which direct coercion used in the past
Other mental disorders diagnosed in the whole population was the independent variable and the number of instances
of the hospitalized were rarely noted in the group of of direct coercion was the dependent variable showed that
patients subjected to direct coercion. there were statistically significant differences in terms of
the number of instances of direct coercion  (df group  1,
The characteristics of the population of patients subjected F  =  4.105, P <  0.046) between the group of patients
to direct coercion in terms of the legal grounds for their previously subjected to direct coercion and those who had
admission to the hospital are presented in Table  2. The not previously experienced it.
study group included 105 patients who had been admitted
involuntarily, comprising 34 women and 71 men. Among A detailed analysis of means carried out using Tukey’s test
the female subjects of the study, involuntarily admitted revealed a statistically significant difference between the
patients constituted approximately 50%, while among the means of the variable the number of instances of direct

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Pawlowski and Baranowski: Coercion in psychiatry
coercion in the two sets of patients being analyzed: A higher
mean number of instances of direct coercion per patient
was noted in the group of patients previously subjected to
direct coercion (1.853 vs. 1.4082).
DISCUSSION OF THE RESULTS
The group of patients subjected to direct coercion was
distinctly predominated by men; the proportion of men
in this group was higher than in the general population
of hospitalized patients. The influence of gender on
coercion has been explored in numerous studies, most of
which failed to identify any impact of gender on the use of
coercion.[7‑11] Only a few have reported an association with
male gender.[12‑14] This may be explained by the fact that most
of these studies discussed the effect of gender in relation
to a given coercion measure, such as isolation, physical
restraint, mechanical restraints or forced medication, while
the present study tested gender in relation to coercion in
general.
The mean age of patients subjected to direct coercion was
41 years, which was lower than that of the general population
of hospitalized patients  (approximately 44  years). The
men subjected to direct coercion were younger than the
women; the mean ages were 40 and 43 years, respectively.
These results reveal that there is a tendency for the mean
age in the group of patients subjected to direct coercion
to be lower than the mean age of the general population
of patients. A substantial number of studies have found a
relationship between younger patients and the frequency
of use of direct coercion.[9,15‑21]
The patients subjected to direct coercion were involuntarily
admitted to the hospital distinctly more frequently than
the general population of hospitalized patients. As many as
60% of the men subjected to direct coercion were admitted
involuntarily, while in the corresponding group of women
the proportion was about 50%. A correlation between the
frequency of direct coercion and involuntary admission has
been confirmed by other authors.[9,22‑25] According to an
EUNOMIA  (European Evaluation of Coercion in Psychiatry
and Harmonization of Best Clinical Practice) study, almost
40% of involuntarily admitted patients in Europe experienced
some form of coercion during their treatment. In contrast
to Spain, where the lowest level of use of coercive measures
was found (21%), patients in Poland are at the highest risk
of being subjected to coercive measures when admitted to
a psychiatric ward (59% of all patients).[26]
The patients most frequently subjected to direct coercion
were those diagnosed with schizophrenia, schizotypal,
and delusional disorders (F20–29) – both men and women.
Patients diagnosed with F20–29 also predominated in
the hospital’s general population. This study did not find
statistically significant differences between the study
432
subjects and the general population of hospitalized
patients in terms of the frequency of occurrence of
F20–29 diagnoses. Authors of previous studies have
reported that a diagnosis of a psychotic disorder was a risk
factor consistently associated with the likelihood of being
subjected to coercive measures.[23,25,27‑29]
The second most numerous group of patients subjected to
direct coercion consisted of those diagnosed with mental
disorders caused by the abuse of psychoactive drugs
(F10–19). Patients with F10–19 diagnoses constituted 15%
of the general hospital population, but approximately 21%
of the patients subjected to direct coercion– a statistically
significant difference. A diagnosis of a disorder caused by
substance abuse is recognized as a risk factor for the use of
coercive measures.[9,28]
The proportion of patients diagnosed with mood
disorders (F30–39) was lower in the group of those subjected
to direct coercion than in the general hospital population,
and the difference was statistically significant. The smaller
proportion of patients subjected to direct coercion recorded
in this diagnostic group is probably related to the lower
percentage of women in the study group than in the general
hospital population (9% and 16%, respectively).
Further analysis revealed a relationship between the use
of direct coercion in the past and the number of instances
of its use per patient: People who had experienced such
measures in the past were subjected to direct coercion
more frequently  (1.853 instances per person) than those
who had not previously experienced it (1.4082 instances
per person). Published research results confirm that
aggressive behavior in the past is a predictive factor for
the reoccurrence of instances of similar behavior.[30‑35] The
results of the present study indicate that direct coercion
noted in a patient’s medical history may also be a
significant factor enabling medical personnel to predict
the occurrence of dangerous behavior, which is the most
frequent cause of the use of direct coercion. Due to the
requirements of the Mental Health Act, information
concerning the use of direct coercion should be more
easily available in patients’ records than data concerning
aggressive behavior, which would enable the personnel to
give those patients particular attention and adjust their
medical care to their particular needs. On the other hand,
information confirming the previous use of direct coercion
may stigmatize a patient, and the medical personnel may
become prejudiced against that patient’s behavior, which
in effect may facilitate a decision to use direct coercion in
ambiguous situations.
In the present study, mechanical restraints were the most
frequently used form of coercion; Knutzen et  al.[36] found
the same. The distribution of restraint categories for the
371  patients subjected to it was as follows: mechanical
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Pawlowski and Baranowski: Coercion in psychiatry
restraint – 47.2%; mechanical and pharmacological restraint
combined – 35.3%; and pharmacological restraint – 17.5%.
The fact that 65 subjects  (36%) were subjected to direct
coercion during the process of being admitted to the
hospital means that for a substantial number of patients the
reasons for the use of coercion measures were not factors
directly connected with the hospital conditions. According
to Andersen and Nielsen,[37] being referred to the hospital,
transported and examined can induce alarming behavior
on the part of a mentally disturbed person, leading to the
admissions personnel to use direct coercion. A  patient’s
behavior may also be affected by other environmental
factors.
The factors that our study found to be related to the use of
coercion, such as male gender, young age, mental disorders
caused by psychoactive drug abuse, involuntary admission
to hospital and instances of direct coercion recorded
in the medical history, are similar to those reported by
Dack et al.[38] in their meta‑analysis of patient characteristics
associated with psychiatric in‑patient aggression.
CONCLUSIONS
Assessing patients’ sociodemographic and clinical
characteristics can help clinicians recognize patients who
are at risk for coercive measures. These factors should be
taken into consideration by programs aimed at reducing
the use of coercive measures in psychiatric wards.
Financial support and sponsorship
This research was supported by funding from Wroclaw
Medical University.
Conflicts of interest
There are no conflicts of interest.
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