title: 'It's unbelievably humiliating'-Patients' expressions of negative effects of coercion in mental health care.
abstract: Some patients criticize coercive mental health treatment using extremely strong words. This may be connected to poor therapeutic relationships and unfavourable treatment outcomes, so a better understanding of this criticism is warranted.
  
  
  
  Data consisted of detailed notes from 15 all-day dialogue seminars on coercion and voluntariness in Oslo, Norway from 2006 to 2009. Very dissatisfied patients and ex-patients were a central voice through the seminars. To gain a better understanding of their negative experiences of coercion, we conducted a stepwise qualitative thematic analysis of the seminar notes, with a mix of inductive and deductive coding followed by focused coding and analytic induction.
  
  
  
  Coercive care was described in strong terms, such as humiliation and Nazism. To explain this, we suggest a model of two pathways towards such strong language: (i) Participants understood their symptoms as mental crises following trauma or spiritual problems, and perceived involuntary medication to harm rather than help. Some found that their complaints were dismissed as lack of insight. (ii) Minor incidents were experienced as coercive, such as being 'defined' by the medical model, receiving repeated negative remarks and feeling one needed to succumb to get care. The accumulated effect could be experienced as eroding self-confidence and trust in their own feelings and thoughts.
  
  
  
  Involuntary medication and dismissal of patient perspective, combined with the accumulated effects of minor negative incidents, can explain the feelings of humiliation, oppression and the use of metaphors such as imprisonment by totalitarian systems. Our model can help explain such patient reactions seen in clinical practice and the literature.
authors.affiliation: Division Mental Health Services, Akershus University Hospital, Lørenskog, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway. Electronic address: olav.nyttingnes@ahus.no.
authors.forename: Olav
authors.initials: O
authors.lastname: Nyttingnes
authors.affiliation: Division Mental Health Services, Akershus University Hospital, Lørenskog, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway. Electronic address: torleif.ruud@ahus.no.
authors.forename: Torleif
authors.initials: T
authors.lastname: Ruud
authors.affiliation: Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway; Department of Psychiatry, University of Oxford, Oxford, United Kingdom. Electronic address: jorun.rugkasa@ahus.no.
authors.forename: Jorun
authors.initials: J
authors.lastname: Rugkåsa
mesh_terms: D000328:Adult; D000368:Aged; D003068:Coercion; D003134:Commitment of Persons with Psychiatric Disorders; D005260:Female; D006801:Humans; D007297:Inpatients / Q000523:psychology*; D008297:Male; D001523:Mental Disorders / Q000523:psychology / Q000628:therapy; D008875:Middle Aged; D009664:Norway; D055815:Young Adult
keywords: Consumer organizations; Involuntary care; Involuntary medication; Patient experience; Psychosis; Qualitative research