The purpose of this study was to reveal the factors that psychiatric triage clinicians regard as important when they consider the use of coercive care. Important factors in the assessment were the severity of psychotic symptoms, risk of suicide and danger to others, and difficult social circumstances. In cases of doubt, the triage clinicians considered various professional and ethical issues as part of the decision-making process. They highlighted the ethical dilemma that inevitably accompanies the coerced treatment of a person who has not expressed a wish for such assistance.
Several of the triage clinicians who were interviewed were in doubt as to whether voluntary hospitalisation of the patient would be sufficient. Patients could appear ambivalent during the interviews, making it uncertain whether they would remain in the ward or discharge themselves prematurely. Moreover, it was sometimes unclear whether it would be possible to establish proper follow-up at home. Some were in doubt as to the severity of the patient's symptoms, for example, to what degree he or she was psychotic. Other respondents experienced substantial pressure from the patient's relatives regarding the need for hospitalisation, while having little prior knowledge of the patient's situation themselves. In general, there was good agreement between the opinions of the relatives and those of the triage clinicians regarding the need for hospitalisation.
One triage clinician stated that there would always be room for doubt in emergency interviews because the interviews provide only a snapshot of the situation. The course of a patient's illness may fluctuate, however, with periods of severe functional deterioration. As a result, such interviews are often challenging.
When considering whether or not the patient felt they had been met with respect, the triage clinicians placed particular emphasis on whether the patient had been given the opportunity to express his or her opinions. This has been shown in several other studies (3, 16, 17, 18). There was also a strong correlation between beliefs about whether the patient had insight into his or her illness and those about whether the patient had been included in the discussion. In a further article under preparation, we will highlight the patients' experiences and impressions of the same interviews. We will look at whether they consider they were treated with respect during the interview and whether they felt they were able to influence the decision. We will also examine to what extent these impressions differ from those of the clinicians.
Patients subjected to coercive care may sometimes say afterwards that they consider the hospitalisation to have been necessary. Nevertheless, they will often maintain their negative view of the use of coercive care and continue to feel that they were subjected to unfair, disrespectful and/or humiliating treatment (19). Use of coercion is in general associated with reduced user satisfaction (20).
Involving the patient in the decision-making process is not only a professional but also a legal obligation. According to the amendment of the Norwegian Mental Health Care Act, 1 September 2017, patients with the capacity to provide consent may refuse help from the mental healthcare services, unless they pose an immediate and serious risk to themselves or to the lives or health of others (2). The patient's right to make choices with respect to his or her own mental health, including those that therapists consider to be bad choices, is to be strengthened. If the patient is considered capable of providing consent, coercion may not be used to impose treatment. Self-harm that does not endanger a person's life, or discontinuation of antipsychotics with an associated risk of relapse, are examples of such situations. Our study was conducted prior to the amendment. It will be interesting in future studies to investigate the consequences of the amendment for emergency assessment interviews that involve decisions regarding the use of coercion.
The psychiatric triage clinicians in our study highlighted measures that can be used to help include the patient in the decision-making process: Set aside enough time. Give the patient an opportunity to talk about his or her situation and to express his or her views and any disagreement. Try to establish a good rapport and alliance with the patient. Spend time explaining the reasons for your actions, take things slowly, repeat important questions and build a framework of care. Listen and take the patient seriously. Explore actively and clearly the patient's own experiences and impressions.
One limitation of the study is that standardised methods were not used for qualitative analysis of transcribed interviews. The outpatient clinics involved were also from a limited geographical area.
Performing an emergency assessment is challenging, especially when it is unclear whether coercive or voluntary treatment is the correct choice. Extensive demands are placed on the ability of psychiatric triage clinicians to include the patient in the decision-making process. A key question is whether the doctors and psychologists that perform these interviews receive sufficient, systematic education and training in methods for reducing the patient's experience of uneasiness, loss of integrity, and powerlessness related to assessment of their need for coercive mental health care. In our opinion, too little is known about the quality of provision in this area by educational institutions, and this is an important topic for further research. It is interesting to note that many of the triage clinicians stated that the interview in this study was helpful in providing them with an opportunity to reflect on the process. In everyday clinical practice too, there should be latitude for ethical and professional reflection around the emergency psychiatric interview.