Comparative Academic Review

Introduction

The aspects of psychiatric treatment of patients have been widely discussed in the academic literature on the subject in the last several decades. In two separate studies, Christina Katsakou et el. (2010) and Jelena Jankovic et. al (2011) trace the practical implications of treatment satisfaction and caregivers’ experiences respectively. Both studies cover specific aspects of psychiatric treatment in the UK.

The first study focuses on the coercion and treatment satisfaction among patients, who have been admitted for psychiatric treatment involuntarily. The research, conducted in 2010, reveals the impact of coercion on the satisfaction of treatment among patients, as well as the psychological aspects of coercion. The study has been conducted as an observation in 22 hospitals in England, where a total of 778 patients were recruited (Katsakou et. al, 2010). Their satisfaction with the treatment they received has been measured at different stages: one week, one month, three months and one year after the admission. In order to measure the levels of satisfaction, the authors have used factors such as clinical improvement and clinical characteristics. The results from this study were obtained using standard statistical analysis, and indicated an increase in the satisfaction among involuntarily admitted patients between their first admission and the different follow ups. The second study, conducted in 2011, focuses on the experiences of family caregivers during involuntary hospital admissions of their relatives. It is a qualitative study, which used as a research method semi-structured interviews, conducted with 29 caregivers whose relatives have been admitted involuntary in 12 hospitals across England (Jankovic et.al., 2011). Throughout the study, major themes have been identified, such as relief and conflicting emotions, frustration with the delay of getting help, etc. The results of the second survey have concluded that the role of the family caregivers can be enhanced if their duties are valued enough, without turning into a burden. The purpose of this brief academic review is to critically compare both studies, highlighting their strengths, weaknesses and possible contributions to the literature on the subject.

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Both studies provide valuable insight on the subject of treatment of patients with mental illnesses, and reveal the interactive nature of the clinical process as a dynamic interaction between different elements – institutions, caregivers, and patients. Both studies manage to reveal the intricacy of the connection, which exists between coercion and satisfaction in the first case, and family caregivers as active elements in the process of involuntary admission in the second case.

The first study uses a quantitative research method and statistical analysis, based on an observational study. The study has been conducted in 22 hospitals in England. The advantage of the choice of this method for the purposes of study is its accuracy and straightforwardness. Results obtained through observation are easier to analyse, and presented in a comprehensible and consistent manner. In terms of the design of the research, the use of timeline base is a feasible option, which meets the research aims of the study and unfolds different aspects of satisfaction among patients. The fact that the patients have been examined at three different periods following their first admission provides the researchers with the possibility to explore how satisfaction (or dissatisfaction) develops gradually. This is an important feature of the research design deployed, because here satisfaction is discussed in relation to memory and emotions, which change over time. This changeability has been captured with the choice of the design. Also, it is a good way to operationalize and thus measure the main variable – patients’ satisfaction.

Despite the fact that the operationalization of satisfaction was enhanced through the use of specific research design, the study could have also benefited from a bigger emphasis on open interviews, conducted with a certain (perhaps smaller) portion of the patients. This is because interviews allow for more abstract and personal issues to be uncovered in the research and these are issues which are usually unquantifiable and difficult to detect in observational studies and semi-structured interviews.

As far as data collection is concerned, the authors of the first study have used two different models, designed to measure satisfaction – one concentrating on potential base lines predictions combining satisfaction scores from all time points (baselines, one month and three months) and another one concentrating on the results from the follow ups only. The data was analysed using a three step model, and applying standard linear statistical analysis (Katskakou et.al, 2010:287-288). This comprehensive choice of methods and models for data collection has enhanced linear results, which allow readers to obtain an extensive view of satisfaction not only as an isolated variable, but also as a process, which is happening over time. However, one of the weaknesses of this study in the methodological part is the sampling. The researchers have attempted to obtain a representative sample, covering hospitals from different geographic areas and patients of different ethnic and social backgrounds. Little, if anything is mentioned however on how the eligibility of the patients has been identified (eligibility criteria). Another weakness in the methodology part is related to the decreasing number of patients interviewed at the baseline, the first month and the third month and one year. For the baseline, the patients are 778, and for the one year follow up their number has decreased almost in double – 396 (Katskakou et.al., 2010: 289). This might pose some problems related with the generalizability of the results obtained and the consistency of observations. Although it would be a formidable task to keep the number of patients at each point exactly the same, at least proximity in the numbers of interviewees could have been targeted. Another possible weakness of the study is related with the lack of causality between coercion and satisfaction. In other words, the study does not necessarily reveal a cause-effect relationship between the two, because coercion in this observation has been explored as an individual projection. However, this can also be looked at as an advantage, because a cause-effect relationship between two abstract concepts can oversimplify their existence in a particular setting.

To compare, the second study uses a very different methodology. It is a qualitative study, and the variables measured here are even more abstract compared to the first study. The psychological aspects of personal experiences relating to care are difficult to capture and quantify, and this is important to mention in the methodological review of the second study. In terms of choice of methods, the authors have used semi-structured interviews, conducted among family caregivers of 29 patients admitted involuntary against 12 hospitals in England (Jankovic et.al., 2011: 1). Compared to the first study, here the sample is much smaller. It is arguable whether such a small sample can provide results, which are generalizable. Perhaps the authors have decided to choose smaller number of participants in order to observe the matter more closely. Here it is important to note that the issue of carers’ experiences is sensitive and often a stressful one. Therefore a smaller sample would give the chance to conduct more detailed interviews, and thus capturing nuances of the matter, which remain unexamined in studies involving larger samples, due to time constraints. Another problem with the sample, just like in the first study, is its ability to represent the population. A closer look at the participant’s characteristics in the second study reveals that in more than 50 percent of the cases, the relationship of the carer to the patient is “parent” (Jankovic et.al., 2011: 3). This fact could have influenced the results, since parents tend to be much more concerned for their children. They are concerned first as patients, and then as carers – therefore a more representative selection of the carers could have taken place (for example equal number of carers who are patients, partners, siblings or children). Yet, the study manages to make good use of thematic analysis, clustering answers of the patients and identifying four important themes – relief and conflicting emotions in response to the admission, frustration with the delay in getting help, being given the burden of care by services and difficulties with confidentiality (Jankovic et.al, 2011:3-4). Just like the first study, the methodology is well-implemented in terms of coding. In the second study, two independent researchers have been selected to code the interviews, and the results have been finalized through a joint discussion (Jankovic et.al, 2011:3).

In both studies, the methods chosen have met the research criteria, and have been meticulously implemented to produce comprehensive and well-themed results. Also, the proposed hypotheses have been well tested. Here it is important to note that both studies tackle issues, which are not easily quantifiable or measurable. The first study concentrates on satisfaction among patients which have been involuntary admitted for treatment, while the other one focuses on an even more sensitive and abstract issue, related with personal experiences among family caregivers in the cases when patients have been admitted for treatment. Therefore the authors of both studies have made significant effort in the planning of the research, its design and implementation in order to make the themes of their research measurable. As a result both studies have managed to create consistent results. The first makes coercion and satisfaction measurable, with the implementation of a 0 to 5 scale of coercion and incorporating the results in a separate model. Critics would suggest that the method implemented in the first study is too rigid for the investigation of issues, which are deeply psychological and reflect the personal perceptions of patients on the way they have been treated. Although the study could have benefited from a combination of qualitative and quantitative methods, its reliance on quantitative techniques only does not affect the overall validity of the results. Perhaps one of the biggest strengths of this study is that through the interpretation of the results, the authors manage to reveal the connection between patients’ satisfaction and coercion as an individual perception. As already mentioned, the second study relies solely on a qualitative technique. They authors capture the nuances in the experiences of the caregivers, and interpret the results closely adhering to the themes, identified by them during the data analysis stage.

Both studies deal with aspects of psychiatric treatment, which are challenging due to their specificity. Therefore they both make significant contribution to the literature and theory on the subject. The first study sheds light upon the complexity of coercion as an individual perception, and its results resonate with those obtained in earlier studies (Lidz et.al, 1998; Sorgard, 2004). Observing coercion as an individual perception, projected by patients as a result of hospital surroundings and treatment, shows a major transition in clinical psychology, and a shift towards a more constructive approach for understanding patients’ reactions. In this sense, this study can be classified as a constructivist study, because it measures how perceptions are formed and exemplified by particular patients in particular environments. It deviates from earlier studies on the subject, like the ones conducted by Svensson et al. (1994) and Spenseley (1980), which observe patients’ satisfaction with treatment in their entirely empirical dimensions, ignoring individual projections. Similarly, the findings and conclusions from the second study (Jankovic et.al, 2011) resonate with conclusions from previous research on the subject (Simson et. al, 2002; Jones et.al, 2009). Therefore this study belongs to a particular body of literature in clinical psychology, which explores the psychological and social impact on families of care for people with mental disorders.

Both studies contribute to their relative subjects, and might have important implications in terms of policy reform in health care services for people with mental illnesses in the UK. Recommendations for policy-makers in this sector, stemming from Jankovic’s study include an improved service, which would ensure that carers obtain proper assistance and cooperation from hospitals prior to the admission of mentally unwell relatives. This would have positive implications to the quality of treatment of mentally unwell patients, by enhancing cooperation between carers and institutions, which would inevitably lead to a better distribution of responsibilities. Katsakou’s study might have policy implications as well, because it reveals the necessity for interventions, which would reduce patients’ perceived coercion.

In conclusion, both studies discussed in this review present specific aspects of treatment of mentally unwell patients. Despite some weaknesses in sampling, and some minor limitations, both studies make significant contributions in their relative fields, and offer new, and well-supported angles of interpretation on the themes they cover. Both studies make good use of research methods, despite the differences in the number of participants for the first and the second study. Some issues related to generalizability of the results have arisen, such as the decreasing number of observed patients in the first study and the small sample in the second study. Still, the data analysis and the interpretation of the results obtained have been meticulously carried out and well situated in the context of existing literature. In addition, both studies might serve as a basis for policy-reform in the UK healthcare system, ultimately leading to improvement of the latter. In sum, the studies present cohesive and well-researched conclusions and can be a useful reading for students and professionals, occupied in the field of Clinical Psychiatry, Health Services and Public Policy.

Reference list:

Jankovic J, Yeeles K, Katsakou C, Amos T, Morriss R, Rose D, Nichol P, McCabe R, Priebe S (2011) ‘Family caregivers’ experiences of involuntary psychiatric hospital admissions of their relatives – a qualitative study’, PLoS ONE 6(10): e25425.

Jones IR, Nilufar A, Catty J, McLaren S, Rose D, Wykes T, et al. (2009) Illness careers and continuity of care in mental health services: A qualitative study of service users and carers. Soc Sci Med 69: 632–639.

Katsakou C, Bowers L, Amos T, Morriss R, Rose D, Wykes T, Priebe S (2010) ‘Coercion and Treatment Satisfaction Among Involuntary Patients’, Psychiatric Services 61: 286-292

Lidz C, Mulvey EP, Hoge SK (1998) et al: Factual sources of psychiatric patients’ perceptions

of coercion in the hospital admission process. American Journal of Psychiatry 155:1254–1260

Simpson EL, House AO (2002) Involving users in the delivery and evaluation of mental health services: systematic review. BMJ 325: 1265–1268

Sorgaard K (2004): Patients’ perception of coercion in acute psychiatric wards: an intervention

study. Nordic Journal of Psychiatry 58:299–304

Spensley J, Edwards DW, White E (1980): Patient satisfaction and involuntary treatment. American

Journal of Orthopsychiatry 50:725–729

Svensson B, Hansson L (1994) : Patient satisfaction with inpatient psychiatric care. Acta Psychiatrica

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