Compulsory admission and use of coercion in institutions towards people with substance use problems: a mixed methods systematic review
Systematic review
|Published
We conducted a mixed method systematic review of Scandinavian studies on the preva-lence, extent, consequences and experiences of compulsory admission in institutions and the use of coercion towards people with substance use problems.
Key message
In Norway, people with long-term and severe substance use problems can be involuntarily admitted if they pose a danger to themselves. We conducted a mixed method systematic review where we examined the prevalence, extent, consequences and experiences of compulsory admission and other forms of coercion in institutions for people with severe substance use problems. We carried out systematic literature searches for studies from Scandinavia, assessed the methodological quality of the studies and summarised their findings.
The main findings show that:
- There is very little research on how often compulsory admissions and other forms of coercion occur in institutions.
- There is little research on the consequences of compulsory admission and other forms of coercion in institutions. Nevertheless, it appears that many people who are involuntarily admitted have short-term improvements in health, functioning and substance use. However, it is not possible to say whether compulsory admission in itself has more positive or negative consequences.
- Patients have mixed feelings about being admitted against their will and subjected to coercion. Many describe coercion as degrading and unfair, while others experience it as necessary in order to reflect on and change their situation.
- What seems most important (more important than whether the admission is compulsory or not) for how they experience detention and coercion is: having good relationships with staff, meaningful activities and sufficient time. This appears to increase their motivation for treatment and helps them reduce their substance use.
- Good support after the compulsory admission appears essential for people to stay abstinent and achieve better health.
Overall, there is a fair amount of good research on how coercion is experienced by service users and staff. Nevertheless, more research is needed in many areas concerning the use of coercion towards people with severe substance use problems.
Summary
Introduction
Use of alcohol and other psychoactive substances can lead to serious health problems, dependence and high mortality, particularly when combined with co-occurring mental and physical disorders. Pregnant women with substance use problems constitute a particularly high-risk group because alcohol and other substance use can cause fetal harm. In Norway, Chapter 10 of the Health and Care Services Act regulates compulsory admission in institutions without consent for children, adults and pregnant women with substance use problems. Institutions may retain a person without consent, but the law does not permit treatment without consent. The purpose of compulsory admission is to motivate the person to undergo assessment and treatment. For people under 18 years of age, municipal health and care services, specialist health services and child welfare services share responsibility, but compulsory placement in institutions is mainly based on the Child Welfare Act. Sweden has a separate act regulating compulsory care for adults with substance use problems (LVM), whereas Denmark is largely based on voluntariness and more limited possibilities for compulsory admission without consent. There is scant synthesized research from the Scandinavian countries on the prevalence, outcomes and experiences of compulsory admission and the use of coercion in institutions for people with substance use problems, particularly with respect to children and adolescents. The aim of this review is to strengthen the evidence base for further development and assessment of legislation and practice regarding the use of coercion towards people with substance use problems.
Objective
We conducted a mixed method systematic review of Scandinavian studies on the prevalence, extent, consequences and experiences of compulsory admission in institutions and the use of coercion towards people with substance use problems.
Method
We included empirical studies from Scandinavia published from 2008 onwards with data collection from 2005 or later. The population was children and adolescents, pregnant women and adults with substance use problems placed in institutions within the health services or child welfare services, as well as relatives and staff. Quantitative, qualitative and mixed-method designs were all eligible for inclusion. The literature search was conducted by a librarian in March 2025 in several international databases, supplemented by searches in Nordic repositories, publication lists from relevant organisations, Google, Google Scholar, and the OpenAlex knowledge graph. Machine learning was used to support screening of titles and abstracts. Two project team members independently assessed all potentially relevant full texts. Disagreements were resolved through discussion or by involving a third reviewer. Methodological quality was assessed in the same way, using established checklists adapted to each specific study design. Data were extracted by one project member and checked by another. We conducted a mixed-method synthesis, in which qualitative and quantitative findings were first analysed separately. Qualitative data were analysed using thematic synthesis, while quantitative data were synthesised narratively due to substantial heterogeneity. Confidence in qualitative findings was assessed using GRADE-CERQual, but we did not assess the certainty of quantitative findings because of heterogeneity in design, measures and comparison groups. Finally, we integrated the findings from the qualitative and quantitative analyses into an overall multi-method narrative synthesis.
Results
We included 46 publications published between 2009 and 2024 (37 unique samples) on the prevalence, outcomes and experiences of compulsory admission and coercion in institutions for people with substance use problems. Thirty studies examined experiences of compulsory admission and the use of coercion among adults (n=12), youth (n=9) and pregnant women (n=9), from the perspectives of service users and staff. No studies examined relatives’ experiences. Nineteen studies investigated outcomes of compulsory admission and coercion among adults (n=12), pregnant women (n=5) and youth (n=2). Five studies examined the prevalence of compulsory admission in institutions, but no studies investigated the overall extent of coercive measures in institutions towards this group. The evidence base on prevalence is limited, particularly for children and adolescents. We found no research or registry data describing the use of coercive measures in institutions towards adults or pregnant women. Aggregate numbers showed an increase in the use of coercion in child welfare institutions since 2022, but the proportion related to substance use problems is unknown.
With respect to consequences, the included studies indicate that adults subject to compulsory admission constitute a highly vulnerable group with an elevated risk of death following compulsory admission, particularly immediately after discharge. Many have periods of improvement in substance use, criminal activity and mental health. Abstinence is clearly associated with improvements in health and social functioning. At the same time, the risk of relapse and repeated compulsory admissions is high, and there is considerable uncertainty about the specific contribution of coercion itself on mortality, abstinence and other health outcomes. It cannot be concluded that coercion, as practised in Norway and Sweden, leads to better long-term outcomes than alternative interventions. The qualitative synthesis shows that coercion is understood and experienced in very different ways. The relationship and trust between those admitted and staff, the degree of user participation, meaningful institutional content and structure are crucial for whether users experience compulsory admission as helpful or as a violation. People who are involuntarily admitted often have greater substance use and psychosocial problems than others with severe substance use problems, and many describe coercion as both necessary and distressing at the same time. The distinction between voluntary and compulsory admission was nuanced, as many voluntarily admitted service users reported pressure to “consent”, while some involuntarily admitted users reported feeling limited coercion. The relationship between coercion, voluntariness and motivation for change is complex and dynamic, and the findings underscore that any positive outcomes appear to be largely linked to the admission’s content quality, and in particular, the follow-up after discharge, where high-quality and individually tailored follow-up services seem to be a prerequisite for users’ sustained abstinence and improvement.
Discussion
The evidence is limited regarding the prevalence of coercion used in institutions and the short- and long-term consequences of coercion. At the same time, the review draws on broad and diverse data, mainly from Norway and Sweden, including registry-based studies, longitudinal studies and qualitative investigations from comparable legal frameworks and institutional contexts. There is a lack of systematic registration and reporting of the use of coercive measures in institutions under Chapter 10 of the Health and Care Services Act. This hampers acquisition of an overview of practice, variation between institutions and trends over time. Further, there is limited knowledge about long-term outcomes after discharge from compulsory admission and about cumulative risk associated with repeated compulsory admissions. A particularly clear knowledge gap is the absence of studies that systematically examine relatives’ experiences.
All the same, the review has several methodological strengths. The project followed a pre-specified protocol; comprehensive systematic literature searches were conducted in multiple sources; and established tools for quality appraisal and synthesis were used, including GRADE-CERQual for qualitative findings. The qualitative evidence base is considered suitable to describe how compulsory admission and coercive measures are practised and experienced in Norway and Sweden, what ethical and organisational challenges arise, and which aspects of structures, relationships and content appear to be important. In contrast, the quantitative evidence base does not allow for causal inferences about the effect of coercion on long-term health and living conditions, due to the study designs and associated methodological limitations of the included studies.
Conclusion
The findings show that youth, adults and pregnant women with substance use problems who are involuntarily retained in institutions have complex needs, characterised by severe substance use, mental health- and social problems, and an elevated mortality risk. However, the findings do not provide grounds for concluding that coercion by itself leads to better or worse outcomes, compared to voluntary placement. Experiences of coercion are mixed: many users experience coercion as degrading, while at the same time describing it as necessary help and a turning point. Relationships with staff, meaningful activities and content, and high-quality follow-up after discharge appear to be more important for their abstinence motivation and treatment than whether their institutional stay is voluntary or compulsory. There is a need for comprehensive and individually tailored interventions and well-coordinated services that better support people with severe substance use problems after discharge.