Caregivers’ Attitude and Perspective on Coercion and Restraint Practices on Psychiatric Inpatients from South India

INTRODUCTION

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.[12] 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.[3456789101112] 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.[31314] 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

RESULTS

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 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 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 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.

DISCUSSION

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.[181920] 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]

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.