Trends in use of coercion in Norway

Trond HatlingHead

2

Legal framework

• 1848, 1961, 1999, 2006– In principle the same since 1961

• Compulsory admissions– Compulsory observation (not allowed to treat

involuntary)– Compulsory admission

• Compulsory Outpatient Treatment– Usually at discharge – but not exclusively

3

Legal framework

• Involuntary Treatment– Primarily medical– Separate decision

• Coercive measures• Open Area Seclusion

– Not coercion - Legally regulated since 1999

4

Policy initiatives to reduce use of coercion

• Escalation plan 1999-2008– Money –restructuring – ideals of voluntary as the

«principle» not defined• Strategic plan to reduce and quality «assure» use

of coercion – 2006– A paper plan

• Revised plan to reduce and quality «assure» use of coercion – 2012• Requiring ditto Health region and health board plans• A paper plan?

5

Policy initiatives to reduce use of coercion• Bernt-Committee (2009)

– The Health Directorate– The treatment criterion– Revising the 2006-strategy– Recommended a Law revision

• Paulsrud-Committee (2011)– Ministry of Health – Law revision– Suggested a number of revisions– Put in a drawer (one sentence in the 2012 state

budget)

6

What is coercion?

• Formal coercion - legal• Experienced coercion

– Users –relatives - staff• De facto coercion

– Power ”embraces ” – house rules• Different definitions – Different parties –

Different perspectives• Coercion has legitimacy in the population – in

particular when considered dangerous – debated

7

Compulsory admissions

• Compulsory admissions• Additional Mandatory Criteria• Community Treatment Orders/Compulsory

Community Treatment/Assisted Outpatient Treatment/Mandated Community Treatment

8

Compulsory admissions 1848-1996

• 1848-1915 (Hospitals)

– 44/100 000 inhabitants• 1916-1935 (Hospitals – a few psych. clinics)

• 70/100 000 inhabitants• 1936-1960 (Hospitals – a few psych. clinics)

• 78/100 000 inhabitants• 1961-1984 (Hospitals – a few psych. clinics/Nursing homes)

– 98/100 000 inhabitants• 1996 (Hospitals – Nursing homes/DPC)

– 195/100 000 inhabitants

9

The national picture – 2011

Institutions approved for Compulsory admissions

All institutions

Admissions 36500 45000

Patients 21000 25000

Compulsory admissions 8300

Patients compulsory admitted

5600

10

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20110

25

50

75

100

125

150

175

200

225

250

165166

187206

194

186

198

192197

136 135136150 145

217 215

Compulsory admissions (both types) and compulsory admitted per 100 000 adult inhabitants 2001-2011

Tvangsinnleggelser

Tvangsinnlagte pasienter

Tvangsinnlagte pasienter inkl overført fra frivillige opphold

Tvangsinnleggelser inkl overført fra frivillig opphold

11

Additional Mandatory Criteria

1979 1984 1989 1994 1999 2003 20070

10

20

30

40

50

60

70

80

8

14

25 25 24

31

41

15

22

29

3742

51

59

76

63

47

3834

18

0

Use of Additional Mandatory Criteria. Percent. 1979-2007.

Danger Criterion Treatment Criterion Suffer Wrong Criterion

12

Regional differences

13

217

382226

252150

133

251247

240282

113

257269

242294

201196

184166

152166

122

150

178156

144118

94

190171169

16192

204203

170169

142141

132126125

11999

0 50 100 150 200 250 300 350 400

Landet

UNN-områdetFinnmark

NordNordland-området

Helgeland

Bergen-områdetStavanger-området

VestFonna-området

Sogn og Fjordane

TelemarkLovisenberg-området

ØstfoldSørlandet

Vestfold-områdetSør-Øst

Vestre-Viken-områdetAhus-området

Diakonhjemmets områdeOUS-området

Innlandets områdeBo

sted

Antall per 100 000 innbyggere 18 år og eldre

Tvangsinnleggelser Tvangsinnlagte

14

Compulsory Community Treatment

• Since 1961• Ease compulsory admission process • Requirement for compulsory medical treatment

– But not «included»

• The last decade about 2000 (1600-2600) compulsory dicscharged• Figures uncertain

15

Involuntary treatment

• About 30% of those compulsory admitted are Involuntary treated (1994-2007)– Figures uncertain

16

Coercive measures

• Mechanical restraints• Forced medication• Seclusion• Holding/restraint (since 2006)

• Open area seclusion (skjerming)

17

1980 1983 1986 1990 1994 2001 2003 2005 2007 20090

1,000

2,000

3,000

4,000

5,000

6,000

374 350 281492

630807

952 1,118 9671,065

3,347

3,746

5,130

4,1234,426

5142

3526

1940 1880

1140

2705

2330

36803407

4451

Mechanical Restraints. Number of Persons, Hours and Times . 1980-2009.

Persons Times Hours/10

18

1994 2001 2003 2005 2007 20090

500

1,000

1,500

2,000

2,500

500586 574

764 707 712

1,250

2,106

1,314

2,146

1,8041,875

Forced Medication. Number of Persons and Times. 1994-2009.

Persons Times

19

1980 1983 1986 1990 1994 2001 2003 2005 2007 20090

100

200

300

400

500

600

700

800

900

10672 56 72

42 33 4233

68

114

829

236184 175

269

619

540 553

178

80 91

3156

2254

Seclusion. Number of Persons, Hours and Times. 1980-2009.

Persons Tmes Hours/10

20

Holding – 2007-2009

• 2007– 272 Persons – 999 Times

• 2009– 574 Persons – 1680 Times

• Due to changes in recording practice – more than changes in clinical practice?

21

2001 2003 2005 2007 20090

500

1,000

1,500

2,000

2,500

3,000

457

786

1,1631,239

1,406

778

1,280

2,049

2,349

2,689

Open Area Seclusion. Number of Persons and Times. 2001-2009.

Persons Times

22

Conclusion

• Use of coercion last 10-30 years– ”constant” – despite considerable public attention

• Regulatory means main strategy to reduce coercion– Limited – if any - effect

• Broad set of means necessary to reduce coercion– Deep into i the clinical practice– Methods exists – not applied on a broad scale

23

Conclusion – Cont.

• National leadership (as good as?) absent• International research on reducing coercion

difficult to implement