Golay et al. BMC Psychiatry (2017) 17:357
DOI 10.1186/s12888-017-1519-4
RESEARCH ARTICLE
Open Access
Perceived coercion in psychiatric hospital
admission: validation of the Frenchlanguage version of the MacArthur
Admission Experience Survey
Philippe Golay1,2,3* , Imane Semlali3, Hélène Beuchat3, Valentino Pomini3, Benedetta Silva1, Laurent Loutrel4,
Jacques Thonney2, Sylfa Fassasi Gallo2, Stéphane Morandi1 and Charles Bonsack1
Abstract
Background: The MacArthur Admission Experience Survey (AES) is a widely used tool to evaluate the level of
perceived coercion experienced at psychiatric hospital admission. The French-language AES was prepared using a
translation/back-translation procedure. It consists of 16 items and 3 subscores (perceived coercion, negative
pressures and voice). This study aimed to assess the psychometric properties of the French-language AES.
Methods: 152 inpatients were evaluated. Reliability was estimated using internal consistency coefficients and a
test–retest procedure. Internal validity was assessed using a two-parameter logistic item response model.
Convergent validity was estimated using correlations between the AES scores and the Coercion Ladder (CL), the
Coercion Experience Scale (CES) and the Global Assessment of Functioning (GAF) scale. Discriminatory power was
evaluated by comparing the scores of patients undergoing voluntary or compulsory admission.
Results: The French-language AES showed good internal consistency and test–retest reliability. Internal validity of
the three-factor model was excellent. Correlations between AES and CL, CES and GAF scores suggested good
convergent validity. AES scores were significantly higher among patients subject to compulsory psychiatric hospital
admission than among those admitted voluntarily.
Conclusions: Overall, the French-language version of the AES demonstrated very good psychometric proprieties.
Keywords: Perceived coercion, Compulsion, Validation, Item response model, Reliability, Validity
Background
In 1793, Philippe Pinel advocated freeing people with
mental disorders from their chains and giving them back
their dignity. Despite his desire to make psychiatric
treatment more humane, he could not get rid of coerced
institutionalisation and, ten years later, he was to recommend the use of the straitjacket as a new form of treatment. Since then, politicians, jurists and mental health
* Correspondence: philippe.golay@chuv.ch
1
Community Psychiatry Service, Department of Psychiatry, Lausanne
University Hospital (CHUV), Consultations de Chauderon, Place Chauderon
18, 1003 Lausanne, Switzerland
2
General Psychiatry Service, Treatment and Early Intervention in Psychosis
Program (TIPP–Lausanne), Lausanne University Hospital (CHUV), Lausanne,
Switzerland
Full list of author information is available at the end of the article
professionals have been caught between their duty to respect patients’ fundamental rights and autonomy and
the necessity to protect patients (and others) from themselves. Involuntary psychiatric treatments aim to protect
people with mental disorders and improve their health
status [1]. However, some authors have argued that there
is scarce evidence of any patient benefits from compulsory inpatient admission [2]. Indeed, coercive measures
may have severe, enduring negative effects on the people
targeted, such as increased use of future coercive measures [3, 4], worse quality of life [5], reduced treatment
adherence [6] and lower satisfaction with care [7].
A corpus of scientific literature has demonstrated that
patients’ feelings of being coerced into psychiatric treatment—their level of perceived coercion—negatively
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
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Golay et al. BMC Psychiatry (2017) 17:357
influence their prognoses, more than the formal coercive
measures themselves [8]. Perceived coercion is not exclusively related to formal coercive measures or the patient’s
legal status at admission [9]; it also depends on the
amount of information shared with the patient, participation in medical decision-making and a lack of knowledge
about legal issues. Moreover, informal coercion, such as
leverage, can influence the level of perceived coercion
[10]. Even voluntary patients can therefore report high
levels of perceived coercion [11, 12]. Patients’ perceptions
of coercion can be influenced by their gender, the severity
of symptoms, their level of social functioning and the
quality of their therapeutic relationships [13, 14]. Perceived coercion damages the patient’s perception of the
therapeutic relationship [15], and lower levels of perceived
coercion are linked to higher treatment satisfaction [16].
The long-term impact of high levels of perceived coercion
on patients is nevertheless controversial and needs further
evaluation [17].
Several approaches have been developed to decrease
levels of perceived coercion. These have highlighted that
patient empowerment, cooperation with professionals
[18], a moral approach to coercion [19], and respect for
patients’ freedom of choice and values [20] are determining factors.
One of the most widely used tools for studying perceived coercion is the Admission Experience Survey
(AES) short form developed for the MacArthur Coercion
Study [21]. More precisely, this 16-item dichotomous
(true-or-false) questionnaire was derived from a structured interview (the MacArthur Admission Experience
Interview) so that patients’ perceptions of psychiatric
hospital admission could be obtained rapidly using a
paper and pencil. Among other scoring variants, three
subscales were proposed: the Perceived Coercion score
focuses on freedom, choice, initiative, control and influence over coming into hospital; the Negative Pressures
score focuses on being forced, threatened or physically
forced to come into hospital; and the Voice score focuses
on having a chance to voice an opinion about coming
into hospital [21–24]. One item (#9) was eventually
dropped from these subscales, and the last item (#16) is
a series of adjectives used to evaluate the patient’s
affective reaction to hospitalisation. Items and scoring
instructions from the original English version are available on the MacArthur Research Network on Mental
Health and the Law website [22].
To the best of our knowledge, there is no specific
French-language tool available for the study of perceived
coercion. This current lack of proper research tools
makes any investigation of coercion in French-speaking
countries difficult at best. This study’s goal, therefore,
was to assess the psychometric properties of a Frenchlanguage version of the AES. Validation of a French-
Page 2 of 8
language perceived coercion scale will promote further
research projects on this topic in French-speaking countries and enable an international comparison of results.
A better understanding of the factors influencing patients’ perceptions of coercion and, consequently, its impact on their welfare and prognoses, will help us to
develop new, alternative models of care that enable a reduction in the use of compulsory admission.
Methods
Participants
A total of 152 patients were recruited during their hospitalisation in Lausanne University Hospital’s Department
of Psychiatry. Mean age was 41.7 (SD = 12.7) years old,
and 52.6% (80) of participants were women. The average
level of general functioning, as assessed using the Global
Assessment of Functioning (GAF) scale, was 41.8
(SD = 12.9), and 30.3% (46) of patients were admitted
involuntarily, according to their caregivers. Thus, 106
patients were admitted on a voluntary basis. The majority of patients (69.1%; 105) were born in Switzerland.
Primary diagnoses based on the International Statistical
Classification of Diseases and Related Health Problems
10th Revision (ICD-10) were: 36.2% (55) schizophrenia,
31.6% (48) depression, 11.2% (17) personality disorder,
6.6% (10) mania, 5.3% (8) anxiety and stress-related disorders, 5.3% (8) drug use and 3.9% (6) alcohol use.
Measures
French-language version of the MacArthur admission
experience survey short form
The AES was translated into French by CB, SM and PG
and back-translated into English by an independent professional translator. One of the scale’s original authors
(SKH) checked the back-translation against the English
version. Although not 100% identical, all the item translations were considered very accurate and similar in
meaning. The original author therefore endorsed the
French-language version without further modifications
(Table 1).
Coercion ladder
The Coercion Ladder [25] was originally adapted from
the Cantril Ladder [26]. It is a visual analogue tool on
which the patient is asked to mark the degree of perceived coercion on a scale of 1 (Minimum use of coercion—I came totally on my own will and initiative) to 10
(Maximum use of coercion). The Coercion Ladder’s
test–retest reliability in this study was good (r = 0.77;
ICC [1, 2] = 0.77).
Coercion experience scale (CES)
The CES [27] is a 35-item scale designed to measure
patients’ experiences of coercive measures. The first
Golay et al. BMC Psychiatry (2017) 17:357
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Table 1 French-language version of the AES
Global assessment of functioning (GAF)
Instructions Répondez s’il vous plaît soit “VRAI” ou “FAUX” à chaque
énoncé. Essayez de répondre à chaque question
individuellement, sans tenir compte des ressemblances avec
d’autres questions.
The GAF [28] is a numerical scale taken from the Diagnostic and Statistical Manual of Mental Disorders Fourth
Edition (DSM-IV) and designed to evaluate an individual’s social, occupational and psychological functioning.
It ranges from 1 (severely impaired) to 100 (extremely
high functioning).
Items
1
Je me suis senti(e) libre de faire ce que je voulais en venant à
l’hôpital.
2
On a essayé de me forcer à venir à l’hôpital
3
J’ai eu suffisamment l’occasion de dire si j’étais d’accord de
venir à l’hôpital
4
J’ai choisi de venir à l’hôpital
5
J’ai pu dire ce que je voulais à propos de venir à l’hôpital
6
Quelqu’un m’a menacé pour me faire venir à l’hôpital
7
C’était mon idée de venir à l’hôpital
8
Quelqu’un a essayé de m’obliger physiquement à venir à
l’hôpital
9
Personne ne semblait vouloir savoir si j’étais d’accord de venir
à l’hôpital
10
J’ai été menacé d’être hospitalisé contre mon gré
11
On m’a dit qu’on m’obligerait à venir à l’hôpital
12
Personne n’a essayé de me forcer à venir à l’hôpital
13
Mon opinion quant au fait de venir à l’hôpital n’a eu aucune
importance
14
J’ai eu beaucoup de contrôle sur le fait de venir ou non à
l’hôpital
15
J’ai eu plus d’influence que quiconque sur la décision de venir
ou non à l’hôpital
16
Comment avez-vous ressenti le fait d’être admis(e) à l’hôpital?
a. En colère.
b. Triste.
c. Content(e).
d. Soulagé(e).
e. Troublé(e).
f. Effrayé(e).
Note. Items and scoring instructions from the original English version are
available on the MacArthur Research Network on Mental Health and the Law
website http://www.macarthur.virginia.edu/shortform.html; [22]
two items are 0–100 visual analogue scales designed to
evaluate the extent to which patients remember coercive measures (item 1) and the extent to which these
were considered stressful (item 2). All other items are
five-point Likert-type scales. We selected the Coercion
subscore and the second item (stress) score as indicators of coercion. We also computed a total score in
order to represent the overall experience of coercion.
The French-language version of the CES was backtranslated by a professional translator and was approved by the original authors. The test–retest reliability of the CES scores used in the present study ranged
from acceptable (item 2 – r = .62; ICC [1, 2] = 0.61) to
good (Coercion subscore – r = 0.80; ICC [1, 2] = 0.80;
total score – r = 0.80, ICC [1, 2] = 0.81).
Procedure
The reliability of the French-language AES scores was
assessed using a test–retest approach with an interval of
between 2 and 14 days; 43 patients participated in the
retest. Internal consistency estimates were also computed on the basis of the first assessment. To assess the
internal validity of the French-language AES scores, we
tested the original three-factor AES scoring model by
loading items 1, 4, 7, 14 and 15 on the Perceived Coercion factor, items 2, 6, 8, 10, 11 and 12 on the Negative
Pressures factor and items 3, 5 and 13 on the Voice factor. As with the original scale, item #9 was discarded.
Because the three factors were highly correlated, a
single-factor model including an overall perceived coercion factor was also estimated using all 14 items. In this
total score, the items related to Voice were reversed because they indicated less coercion. To estimate convergent validity, several indicators were used to study the
relationship between AES scores and other scales. We
hypothesised that the AES Perceived Coercion score,
Negative Pressures score and Total score would be positively correlated with the Coercion Ladder score, the
CES’s second item (stress measured on a 0–100 scale),
the CES Coercion subscore and the CES Total score. We
hypothesised that these scores would also be negatively
correlated with the GAF score under the hypothesis that
higher-functioning individuals may experience less coercion from mental health professionals. Finally, we
hypothesised that the AES Voice score would be negatively correlated with the CES, CL and GAF scores (i.e.
more voice was associated with less coercion or better
functioning).
Statistical analysis
Reliability
The reliability of the AES subscales was estimated using
McDonald’s model-based Omega (ω) [29] and Cronbach’s alpha (α) coefficients. The test–retest reliability
was estimated using both Pearson and intraclass correlation coefficients using a two-way random-effects model
and the absolute agreement definition (ICC [1, 2]). Reliability coefficients above .70 were considered satisfactory; above .80 were considered good; and above .90
were considered excellent [29, 30]. The presence of systematic changes between first and second assessments
was evaluated using paired-sample Student t-tests.
Golay et al. BMC Psychiatry (2017) 17:357
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Table 2 Reliability of AES scores
Internal Consistency (N = 152)
Test–retest reliability (N = 43)
McDonald’s ω
Cronbach’s α
Pearson’s r
ICC (2,1)
Perceived Coercion subscale
.927
.796
.764**
.766**
Negative Pressures subscale
.947
.837
.772**
.774**
Voice Subscale
.919
.787
.780**
.782**
Total Scale
.974
.913
.889**
.890**
Note. **p < .01
Internal validity
Convergent validity
Due to the items’ dichotomous nature, internal validity was estimated using two-parameter logistic (2PL)
item response models. All models were estimated
using a robust weighted least squares estimator with
adjustments for the mean and variance (WLSMV).
First, a three-factor model was estimated, as was a
single-factor model including a general perceived coercion factor. These two models were compared with
a robust chi-square test using the DIFFTEST procedure. Several indicators of model fit were used: the
root mean square error of approximation (RMSEA),
the comparison fit index (CFI) and the Tucker–
Lewis fit index (TLI). RMSEA values ≤0.06, and CFI
and TLI values ≥0.95, were interpreted as good fits,
whereas RMSEA values ≤0.08, and CFI and TLI
values ≥0.90 were considered as indicating acceptable
fit [31].
The convergent validity coefficients between the Frenchlanguage AES scores and the other scales were estimated
using Pearson correlation coefficients. There are no
well-established criteria for the interpretation of convergent validity coefficients. Given that the upper bound of
any validity coefficient is the square root of the score reliability, the acceptable range is usually lower than for
reliability coefficients. In the present study, we interpreted correlation coefficients between .40 and .60 as
good and any values higher than .30 (a medium effect
size, according to Cohen [32]) as satisfactory.
Discrimination
To test whether the French-language AES could discriminate between voluntarily and involuntarily admitted
patients, their average scores were compared using an
Table 3 Comparisons of model fit and IRT parameterisation for the AES
Model
χ2
df
p-value
RMSEA
90% C.I. for RMSEA
CFI
TLI
One-factor model
112.326
77
.005
0.055
0.031–0.076
0.987
0.985
Three-factor model
94.235
74
.056
0.042
0.000–0.066
0.993
0.991
IRT parameterisation
One-factor model
Three-factor model
Item difficulty
Item discrimination
Item difficulty
Item discrimination
Item 1
−0.347
1.130
−0.334
1.238
Item 2
0.374
2.223
0.358
3.110
Item 3
0.613
−2.018
−0.591
2.510
Item 4
0.241
2.682
0.230
5.199
Item 5
0.733
−1.401
−0.713
1.530
Item 6
1.681
0.796
1.633
0.835
Item 7
−0.100
1.530
−0.097
1.724
Item 8
1.023
1.333
0.994
1.449
Item 10
0.503
2.315
0.495
2.614
Item 11
0.538
1.580
0.527
1.708
Item 12
0.070
1.530
0.068
1.724
Item 13
0.312
−1.649
−0.302
1.891
Item 14
−0.059
0.742
−0.057
0.788
Item 15
−0.180
1.151
−0.175
1.242
Note. IRT Item Response Theory, df degree of freedom, RMSEA Root Mean Square Error of Approximation, C.I. Confidence Interval, CFI Comparative Fit Index, TLI
Tucker–Lewis Index
Golay et al. BMC Psychiatry (2017) 17:357
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independent sample Student t-test. Our hypothesis was
that the latter group would report higher levels of coercion. All statistical tests were two-tailed, and a significance level was set at α = 0.05. All statistical analyses
were performed using the Mplus statistical package
(version 7.4) and IBM SPSS 23.
Results
Reliability
Internal consistency and test–retest reliability estimates
(Table 2) were satisfactory to excellent [29, 30]. Comparisons between scores from the first and second assessments revealed no significant changes.
Internal validity
The three-factor model’s fit was excellent (Table 3). All
factor loadings were statistically significant, and the
three factors were highly correlated (76%–87% of shared
variance) with each other (Fig. 1).
The more restrictive one-factor model also showed
very good fit. Again, all factor loadings were supported
(Fig. 1). Direct comparison between the two models indicated that the three-factor solution was preferable
(Δχ2 = 16.986; Δdf = 3; p < .001).
For reference, and as a complement to the factor loadings, Table 3 gives each item’s discrimination and difficulty, for both models, as an Item Response Theory
metric. The Total Information Curves (Fig. 2) indicate
the amount of information in the latent scores that were
explained by the subscale items across different levels of
the latent construct.
Convergent validity
All correlation coefficients were significant and in the
expected direction (Table 4). As indicated by their substantive correlations, patients who reported a higher
level of coercion on the CES and the CL also tended to
report higher scores on the AES. GAF scores were also
moderately correlated with AES scores.
Fig. 1 a One- and b three-factor models of the AES scale
Discrimination according to admission status
The differences between patients admitted voluntarily
and involuntarily were large for all four AES scores. Involuntarily admitted patients scored significantly higher
on the Perceived Coercion scale (t(148) = 6.748; p < .001;
d = 1.26), the Negative Pressures scale (t(149) = 6.740;
p < .001; d = 1.18) and the Total scale (t(147) = 7.973;
p < .001; d = 1.45). They scored lower on the Voice scale
(t(148) = −6.198; p < .001; d = −1.08).
Discussion
The reliability of the French-language Admission Experience Survey (AES) scores was very satisfactory. Furthermore, these scores underwent no systematic changes at
the second assessment, which is a desirable feature in
evaluation settings. The internal validity of the one- and
three-factor AES models was shown to be very good.
Correlations between the three factors suggested that
Perceived Coercion, Negative Pressures and Voice shared
a lot of variance. This was in line with other studies that
have shown that perceived coercion was also associated
with the use of negative pressures such as threats and
physical force. Additionally, perceived coercion was found
to be inversely related to a patient’s sense of procedural
justice, that is, the patient’s belief that he had been able to
voice his opinion and had been treated with fairness,
concern and respect [9]. Although the computation of a
Golay et al. BMC Psychiatry (2017) 17:357
Fig. 2 Total Information Curves for the one- and three-factor models of the AES scale
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Table 4 Convergent validity of the AES scores
Coercion Ladder
Perceived Coercion subscale
.560**
CES
GAF
Item 2 (stress)
Coercion score
Total score
.492**
.578**
.463**
−.379**
Negative Pressures subscale
.687**
.609**
.631**
.583**
−.196*
Voice subscale
−.653**
−.560**
−.568**
−.442**
.217**
Total Scale
.706**
.622**
.679**
.592**
−.304**
Note. * = p < .05, ** = p < .01
single total coercion score was perfectly adequate, the
comparison between the one- and three-factor models
suggested that Perceived Coercion, Negative Pressures and
Voice should not be considered as indistinguishable. Despite the large amount of shared variance, there are further
benefits to conceptualising an AES with three subscales.
The high correlation between subscales only suggests that
patients are likely to have similar scores on average. However, this will not always be the case, and differences may
highlight important clinical situations. Furthermore,
examination of the Total Information Curves suggested
that the AES Negative Pressures subscore provided more
information on respondents who scored above average on
the latent trait, whereas the AES Voice score was more informative about respondents with below-average latent
scores. Consequently, using the subscales may add to the
AES’s sensitivity with patients presenting different levels
of perceived coercion.
Correlations between the French-language AES scores
and the Coercion Ladder score, the Coercion Experience
Scale and the Global Assessment of Functioning scale
were largely in line with expectations, suggesting that
the French-language version of the AES is a valid measure of perceived coercion. The correlation patterns between each of the four AES scores and the other scales
were very similar, which is not surprising given the high
correlation between the factors. However, the threefactor model’s superiority over the single-factor model
suggests that distinguishing between these three subscores could be useful, adding information above and
beyond that provided by a single summary score.
Finally, all four scores derived from the Frenchlanguage AES were able to discriminate between patients
who had been voluntarily and involuntarily admitted to
hospital, which confirmed our hypothesis.
Conclusions
The French-language version of the AES demonstrated
very good psychometric properties. The validation of
this questionnaire was a mandatory first step towards
testing other hypotheses and conducting future clinical
or interventional studies. We hope that it will promote
the development of further research projects on these
topics in French-speaking countries and comparisons
with the English or German-speaking countries where
these tools are already in use.
Abbreviations
2PL: Two-parameter logistic; AES: MacArthur Admission Experience Survey;
CES: Coercion Experience Scale; CFI: Comparison fit index; CL: Coercion
Ladder; DSM-IV: Diagnostic and Statistical Manual of Mental Disorders Fourth
Edition; GAF: Global Assessment of Functioning; ICC: Intraclass Correlation
Voefficient; ICD-10: International Statistical Classification of Diseases and
Related Health Problems 10th Revision; RMSEA: Root Mean Square Error of
Approximation; TLI: Tucker–Lewis fit index; WLSMV: Robust Weighted Least
Squares Estimator with Adjustments for the Mean and Variance
Acknowledgements
The authors would like to thank Oriane Gauthier-Jaques for her contribution
to data acquisition.
Funding
This study was based on institutional funding.
Availability of data and materials
The data sets generated and analysed during the present study are not
publicly available because their public archiving was not explicitly authorised
by the ethics committee. Nevertheless, anonymous data are available from
the corresponding author on reasonable request.
Authors’ contributions
PG, CB and SM designed this study. IS and HB acquired the data. PG, IS and
HB analysed and interpreted the data. PG drafted the first version of the
manuscript. BS, CB, SM, VP, SF, JT and LL critically revised the manuscript for
important intellectual content. All authors read and approved the final
manuscript.
Ethics approval and consent to participate
Approval for this study was granted by the Human Research Ethics
Committee of the Canton Vaud (protocol #2016–00768). Written informed
consent was obtained from all participants and all methods were carried out
in accordance with the recommendations of the Human Research Ethics
Committee of the Canton Vaud and the Declaration of Helsinki.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
Community Psychiatry Service, Department of Psychiatry, Lausanne
University Hospital (CHUV), Consultations de Chauderon, Place Chauderon
18, 1003 Lausanne, Switzerland. 2General Psychiatry Service, Treatment and
Early Intervention in Psychosis Program (TIPP–Lausanne), Lausanne University
Hospital (CHUV), Lausanne, Switzerland. 3Institute of Psychology, Faculty of
Social and Political Science, University of Lausanne, Lausanne, Switzerland.
1
Golay et al. BMC Psychiatry (2017) 17:357
Page 8 of 8
4
North Vaud Psychiatric Centre, Department of Psychiatry, Lausanne
University Hospital (CHUV), Yverdon, Switzerland.
21.
Received: 21 August 2017 Accepted: 26 October 2017
22.
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