Coercion in Mental Health

1. Coercion in Mental Health Prof Tom Burns Social Psychiatry Group, University of Oxford Oxfordshire and Buckinghamshire Mental Health NHS Foundation Trust

2. Hierarchy of treatment pressures in mental health care: Persuasion Interpersonal leverage Inducement Threats Coercion Szmukler, G. & Appelbaum,, P. (2008) Treatment pressures, leverage, coercion, and compulsion in mental health care. Journal of Mental Health, 17(3):233-244.

3. Hierarchy of treatment pressures • Persuasion • Respect for the patient’s arguments • Treatments discussed in the context of patient’s value system 2.Interpersonal leverage • Exercised through the emotional dependency of patient on the key-worker 3.Inducements • The patient will be rewarded if he/she adheres to treatment (e.g. money, football ticket). Szmukler, G. & Appelbaum,, P. (2008) Treatment pressures, leverage, coercion, and compulsion in mental health care. Journal of Mental Health, 17(3):233-244.

4. Hierarchy of treatment pressures 4. Threats* • Involves conditional propositions 5.Compulsion* • Supported by legal statute (to substitute a hospital admission, to facilitate earlier discharge from hospital and to prevent relapse) * both coercion Szmukler, G. & Appelbaum,, P. (2008) Treatment pressures, leverage, coercion, and compulsion in mental health care. Journal of Mental Health, 17(3):233-244.

5. MacArthur Informal coercion (‘leverage’) study • N=1011 US patients ( in 5 sites) • Housing leverage 23-40% • Criminal sanction leverage 15-30% • Financial leverage 7-19% • Outpatient commitment 12-20% • Childcare leverage reported but not measured systematically • Monahan, J. et al (2005) Use of Leverage to Improve Adherence to Psychiatric Treatment in the Community. Psychiatric Services, 56(1): 37-44.

6. MacArthur Informal coercion (‘leverage’) study • Leverage ubiquitous in standard mental health care • Actual nature depended on available methods but overall rates similar • Correlations with high use of leverage: • substance misuse • younger than 44 years age • high BPRS • low GAF • long term/intensive treatment • Need for research on the outcomes associated with the user of leverage

7. The ULTIMA study (Use of Leverage Tools in Mental Healthcare) Prof Tom Burns, Ksenija Yeeles, Helen Nightingale, Sarah Masson Social Psychiatry Group, University of Oxford Oxfordshire and Buckinghamshire Mental Health NHS Foundation Trust

8. ULTIMA • Aims: • Replicate US leverage study • Leverage in preceding 12 months • Is there a difference in frequency? • No CTO equivalent • Test a range of clinical populations • AOT, CMHT (psychosis and non psychosis) and methadone dependent patients • Add child care

9. Sample bb N = 417 AOT N=102 CMHT psychosis N=107 CMHT Non-psychosis N=107 Substance misuse N=101

10. Experience of leverage in total sample N=417

11. Assertive outreach N = 102

12. CMHT Psychosis N = 107

13. CMHT Non-psychosis N = 107

14. Substance Misuse N = 101

15. Experienced leverage in the four samples

16. Housing Leverage ‘helps people stay well’

17. Criminal Justice Leverage ‘helps people to stay well’

18. Child Custody Leverage ‘helps people to stay well’

19. Money Leverage ‘helps people to stay well’

20. Conclusions – rates of leverage • Like the US informal coercion (leverage) is common in the UK • Housing is more common here • Criminal sanction less • Substance misuse patients most coerced, followed by AOT patients

21. Conclusions - patients’ views • Not as negative as expected • 48% agreed / strongly agreed that child custody sanctions helped • Child custody and housing seen as most likely to help keep patients well

22. Overall conclusions • More sophistication required in understanding the therapeutic relationship • Few relationships are entirely free • Ubiquity of leverage indicates the need to incorporate it into current training • Further research may indicate outcomes

23. Thank you for attention. DON’T FORGET OCTET!