1. Trends in use of coercion in Norway Trond Hatling Head

2. 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. 3 Legal framework Involuntary Treatment –Primarily medical –Separate decision Coercive measures Open Area Seclusion –Not coercion - Legally regulated since 1999

4. 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. 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. 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. 7 Compulsory admissions Additional Mandatory Criteria Community Treatment Orders/Compulsory Community Treatment/Assisted Outpatient Treatment/Mandated Community Treatment

8. 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. 9 The national picture – 2011 Institutions approved for Compulsory admissions All institutions Admissions3650045000 Patients2100025000 Compulsory admissions8300 Patients compulsory admitted 5600

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11. 11 Additional Mandatory Criteria

12. 12 Regional differences

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14. 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. 15 Involuntary treatment About 30% of those compulsory admitted are Involuntary treated (1994-2007) –Figures uncertain

16. 16 Coercive measures Mechanical restraints Forced medication Seclusion Holding/restraint (since 2006) Open area seclusion (skjerming)

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20. 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?

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22. 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. 23 Conclusion – Cont. National leadership (as good as?) absent International research on reducing coercion difficult to implement