Service Users’ Experiences of Involuntary Hospital Admission Under the Mental Health Act 2001 in the Republic of Ireland

Internationally, legislative processes and procedures governing the involuntary detention of people with a mental disorder differ greatly (1). However, common across most jurisdictions is a concern about the human rights aspect of involuntary admission (2,3) and the potential for the admission process to have a significant negative impact on an individual’s psychological well-being (4–6).

In the Republic of Ireland, the legislative framework within which a person with a mental disorder can be admitted and treated involuntarily is the Mental Health Act (MHA) 2001 (7). This legislation, which in 2006 replaced the Mental Treatment Act of 1945 (8), strengthened legal oversight of the involuntary admission process and ensured that Ireland was on a par with international standards of human rights (9,10). Individuals admitted under the MHA 2001 are required to have a mental disorder resulting in a serious likelihood of the person causing immediate harm to self or others or to have judgment so impaired by the mental disorder that failure to admit would likely lead to a serious deterioration of the person’s condition (7,11). [Additional information about the MHA 2001 is included in an online supplement to this article.]

In 2015, the involuntary admission rate to psychiatric inpatient units in the Republic of Ireland was 51.5 per 100,000 population (12), virtually unchanged from the rate noted just prior to implementation of the MHA 2001 (13). In other European countries, rates of involuntary admission vary greatly, from six per 100,000 population per year in Portugal to 218 per 100,000 per year in Finland (14). However, comparisons between countries should be interpreted with caution because of heterogeneous study designs and differences between countries in legislative frameworks (15). For example, in the Republic of Ireland, there is no legal provision for community treatment orders.

International research has documented that service users who are detained involuntarily express concerns about violations of their autonomy, human rights, personal integrity, and self-efficacy (6,16–19). Although positive experiences and person-centered care have been reported by service users (17,20), the pervasive narrative is one of fear, distress, and loss; service users report feeling disempowered, coerced, disconnected from decision-making processes (17,21–25), and traumatized by their experience (6,26–33).

Research examining involuntary admission under the MHA 2001 in the Republic of Ireland has been mainly quantitative. Although this research has provided valuable information on the negative impact of detention on relationships with the treating psychiatrist and family members (34), rates of detention (35–39), the relationship between detention and diagnosis (40–42), and factors that may predict service users’ attitudes to involuntary admission (34,43,44) or future engagement with services (45), there is limited research using qualitative methodologies to explore the experiences of service users. In addition, most international qualitative studies draw on small samples (eight to 25 participants) and focus on one aspect of the detention experience, such as the hospital experience (22,25).

In this large qualitative study, we aimed to comprehensively explore service users' experiences throughout the trajectory of their involuntary admission, including transfer and postdischarge phases. Participants were interviewed three months after revocation of the involuntary admission order, at which point they were considered optimally able to reflect on their experience.

Methods

A qualitative descriptive study design was used because it provided the flexibility needed to explore the experiences of people admitted involuntarily under the MHA 2001 throughout the trajectory of the involuntary admission process. In addition, this design allowed for the emergence of any unanticipated findings.

Participants were recruited from a larger cohort of 156 individuals who had taken part in a quantitative prospective study of attitudes toward admission and care, which was conducted with a representative cohort of service users from three inpatient psychiatric units in the Republic of Ireland (46). Data were collected during 2011 and 2014 by using in-depth, semistructured, audio-recorded, face-to-face interviews, guided by an interview schedule. In total, 50 participants (29 men and 21 women) were interviewed. The sample size was determined by a desire to achieve maximum variation in the sample rather than to provide an epidemiologically representative sample.

With assistance from the computer software package Nvivo (47), thematic analysis (48) of the data was conducted. Ethical approval for the study was obtained from the Research Ethics Committees of National University of Ireland Galway, Galway University Hospitals Clinical Research Ethics Committee, and Roscommon Hospital Ethics Committee. [Additional information about the research process, inclusion criteria, and ethical procedures is included in the online supplement.]

Results

Participants’ Demographic Profile

Table 1 presents information about the 50 participants who were interviewed. For seven participants, the involuntary admission was initiated from within the approved center. Forty-three participants were transferred from the community to the hospital under the MHA 2001 (37 were subsequently detained, and six were held in the approved center for a period of 24 hours but were not found to meet the criteria for detention). The most common diagnosis was nonaffective psychotic disorder. Thirteen (26%) participants had a diagnosis of schizophrenia. For 24 participants, this was their first admission under the MHA 2001. Forty-two participants (84%) identified their nationality as Irish, with other participants identifying as English (N=3), Iranian (N=1), Malaysian (N=1), Spanish (N=1), French (N=1), and Slovenian (N=1).

Themes

Analysis of the data resulted in the following four themes: feeling trapped and coerced, lack of emotional and informational support, admission-induced trauma, and person-centered encounters. Tables 2–5 present selections of participants’ statements from the interview that most effectively capture and articulate these themes and their primary concerns. Two authors (RM and AH) reached consensus on the inclusion of these quotes as representative of the themes.

Feeling trapped and coerced.

Two-thirds of participants (N=34) reported feeling confined and coerced at various times over the course of their admission experience (Table 2). Of the 50 participants, 43 were transferred to the hospital by the National Assisted Admissions Team or the Gardai Siochana (Irish police). During initial transfer and admission to the hospital, 18 of these participants reported that the stakeholders involved in the transfer process took a firm stance—and sometimes a physically forceful stance. Many participants reported being unaware of the forthcoming plans for their admission; 12 described feeling shocked and confused by the unexpected arrival of the National Assisted Admissions Team at their home, workplace, or other public place (Table 2, quote A1); 15 reported feeling “ambushed” and “surrounded” (A2 and A3); and 20 recounted that they were offered no alternative options to hospitalization and that their opinion and concerns went unheard (A4 and A5). For a number of participants, the coercive manner adopted was intensified by the involvement of the Gardai (N=35) (A6 and A7), the use of physical force to transport them to the hospital (N=8) (A8), and the use of ultimatums (N=3) (A9 and A10). Under the circumstances they described, these participants felt that they had no choice but to comply reluctantly with hospital admission.

Feelings of being trapped and coerced during their hospital stay also emerged in the narratives of 26 participants. Rather than being a place of therapeutic refuge and compassion, the hospital was likened by 17 participants to imprisonment (A11 and A12). From these participants’ perspective, the duration of their involuntary admission was shrouded in uncertainty, impinged on their civil rights, and offered limited opportunities for involvement, negotiation, or personal control (A13). Twenty-two participants were also of the view that medication was the primary treatment available, and they believed that they had no choice but to comply and take the medication prescribed to ensure their discharge (A14 and A15). Such was the fear of not being discharged that 16 participants spoke of compliance with language describing a feeling of being psychologically “ground down” and beaten by the system (A14 and A15).

Lack of informational and emotional support.

Thirty-four participants also described a lack of informational and emotional support (Table 3). At various stages during their involuntary admission, participants reported that the reasons for their admission (N=24) or their plan of care (N=14) were not sufficiently explained (B1 and B2) and that there was limited consideration of their opinion, needs, or concerns (B3 and B4). Twenty-three of the 50 participants attended a mental health tribunal or had the experience of the preparatory process for such a tribunal. Ten of these participants reported receiving little information about the upcoming tribunal and as a result lacked an awareness of the purpose and format of the tribunal (B5 and B6). Consequently, eight of these participants believed that the view of the psychiatrist was given primacy over their opinion at the tribunal; 11 stated that tribunal members did not adequately facilitate their involvement in the tribunal process (B7 and B8).

In addition to lack of information, 23 of the 50 participants described experiencing a deficit in emotional support at perceived critical time points, including their initial transfer to the hospital and before, during, and after their tribunal. In particular, participants who were physically restrained during their transfer to the hospital (N=8) recalled that the absence of a familiar person was extremely disconcerting and frightening at this time (B9). Three participants also described feeling scared and anxious about their upcoming tribunal and its outcome and feeling as if they had no one to talk to or support them at this time (B10). Although this was not the experience of all participants, these participants spoke of the need for someone to explain and help them feel part of the tribunal process and someone to talk to about the process (B11).

Admission-induced trauma.

Nineteen of the 50 participants indicated that aspects of their involuntary admission had a detrimental and prolonged negative impact on their mental health (Table 4). Twelve participants likened the impact of their detention and admission to that of enduring a trauma (C1) and described feeling worse after discharge from the hospital than prior to admission (C2). These participants recalled experiencing panic, flashbacks, and nightmares about events that occurred during the transfer and admission process, including persistent thoughts about their experience or nightmares regarding being physically restrained or coerced in their own homes (C3, C4, and C5). Six participants spoke of a debilitating level of apprehension and self-surveillance that permeated their lives postdischarge and described living in a constant state of fear that they could lose their liberty and be readmitted at any moment (C6). These participants reported experiencing significant panic when they observed or were in contact with people or objects that reminded them of their admission. For example, seeing a vehicle that was similar to the one used for transport to the hospital induced panic for one participant (C7). In addition, six participants were of the view that they were being monitored or watched at home (C8) and that all their actions and responses were filtered and interpreted by family and others through the lens of mental illness. Such was some participants’ level of apprehension that four reported withdrawing physically or emotionally from family or social activities (C9). Six others spoke of having reduced confidence about trusting their own judgment and of no longer feeling in control of their life (C10).

Person-centered encounters.

Eighteen participants’ narratives were interspersed with examples of interactions with people who initiated a collaborative, informative, and compassionate approach (Table 5). For six of these participants, transfer to the hospital was conducted in a calm and considerate manner, in which they felt actively included, listened to, and cared for (D1 and D2). Similarly, 16 participants recalled that at times they felt supported during their time in the hospital, eight reported that they received sufficient information about their care and treatment (D3 and D4), and five stated that the role of the mental health tribunal was explained in an accessible way (D5). However, rather than reflecting a systemic culture, experiences of humanizing care frequently appeared to depend on a particular staff member. As a result, these positive and empowering experiences were not consistently evident across all stages of participants’ involuntary admission.

Discussion

The findings of this study indicate that participants’ principal concerns regarding their involuntary hospital admission were about violations of their autonomy, limited provision of information and support, and the detrimental impact that the involuntary admission process had on their psychological well-being. These findings reiterate concerns identified in other studies in which service users’ experiences of involuntary admission were characterized by coercion and diminishment of their autonomy, human rights, and personal integrity (16,20,49); feelings of not being listened to, cared for, or actively involved in decision making (16,19); and limited provision of information and the exacerbating effect that this can have on an already diminished sense of control (16).

The long-term adverse effects of coercive treatments have been identified in previous research (6,27,50). However, the participants’ narratives in this study differ. Unlike participants in previous research, participants in this study did not specifically link their experiences of trauma to specific interventions, such as seclusion or coercive administration of intramuscular medication. Instead, participants were of the view that the entire process of involuntary admission had induced a traumatic effect. The severity and persistence of this trauma were reflected in participants’ description of their postdischarge worry and panic, with features of posttraumatic stress disorder, including increased anxiety, hypervigilance, and flashbacks. The participants’ narratives reaffirm the need for mental health services staff to be as cognizant of these additional deleterious effects on emotional and psychological well-being, which are specifically associated with the experience of detention, as they are of other patient safety concerns, such as risks of self-harm (51–53). Although there is a need to improve the entire process of detention, participants’ narratives particularly highlighted the need for significant improvement in the critical preadmission phase, when individuals are assessed and transferred to a hospital. Improving preadmission practices has the potential to positively affect the hospital experience and reduce trauma. It is equally important to implement interventions among persons voluntarily admitted to hospitals, because research demonstrates that those admitted voluntarily may also feel coerced during their hospital stay (54–56).

The care of individuals who are involuntarily detained is a complex and difficult process to navigate successfully. However, the findings of this and similar studies (16,19) attest to the fact that if person-centered collaborative care and respect are embedded systemically, then some of the adverse impact of involuntary detention can be mitigated. Successful implementation of such an approach requires all staff involved to be mindful of the need for ongoing respectful dialogue and promotion of choice and control when possible and the importance of repeatedly providing accessible information over the course of the person’s involuntary admission. Open acknowledgment and discussion of the person’s experience have been shown to mitigate the potentially traumatizing nature of involuntary admissions (57,58) and to induce increased acceptance of compulsory treatment, feelings of empowerment, and restored self-value and self-worth (19).

The participants’ narratives also highlighted the need to develop supportive strategies to minimize the persistent state of apprehension and self-surveillance that permeated people’s lives long after their discharge from the hospital. In addition, further research is needed to identify the most effective and cost-effective interventions to reduce the negative emotional impact of involuntary admission.

The qualitative design of this study provided needed insight into service users’ experiences of involuntary admission in the Republic of Ireland, which to date have been predominantly explored through quantitative methods. It also provided important information about individuals’ perspectives on the entire process, especially in relation to the pre- and posthospital experience, which are critical time points. However, because participants were recruited with purposive sampling as opposed to stratified randomization, selection bias was possible, and findings may not be universally representative or applicable within the Republic of Ireland or to services in other countries. In the absence of a control group, it is not possible to say to what extent participants’ experience of coercion was directly related to having an involuntary hospital admission rather than to being in an approved center. Because we did not conduct subgroup analyses, neither is it possible to determine whether perceptions of those detained after an initial voluntary admission or those experiencing an involuntary admission for the first time differed from the perceptions of the overall sample. Such analyses will be the focus of a future qualitative study examining service user experience of involuntary admission under the MHA 2001.

Conclusions

Despite the potential beneficial effects that hospital admission can have on mental well-being, this qualitative study of service users’ views across the trajectory of their involuntary admission identified a number of factors that had a negative impact on their psychological well-being. These included disempowering and controlling practices, feeling uninvolved in decision making, and a lack of accessible information and emotional support. Many of these issues can be addressed. Indeed, some participants indicated that a person-centered approach can be achieved in the pressured and difficult context of involuntary admission. However, consistently applying such an approach across the entire trajectory of involuntary admission is challenging and will require a multifaceted strategy that includes ongoing education and training of all stakeholders in the principles and practices of person-centered care and a shift among all stakeholders to an attitude that recognizes the traumatic and debilitating impact of forced detention on personhood and psychological well-being. Although this study was undertaken in the Republic of Ireland, given the many commonalities across jurisdictions in mental health legislation regarding procedures for detention and review of involuntary detention, our findings are potentially informative to mental health services in other jurisdictions.