Coercion in Mental Health

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

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Hierarchy of treatment pressures

• Persuasion
• Respect for the patients arguments
• Treatments discussed in the context of patients
  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.

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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.

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MacArthur Informal coercion (leverage) study

• N1011 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.

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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

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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
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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

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Sample

• bb

N 417
Substance misuse N101
CMHT Non-psychosis N107
CMHT psychosis N107
AOT N102
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Experience of leverage in total sample N417
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Assertive outreach
N 102
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CMHT Psychosis
N 107
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CMHT Non-psychosis
N 107
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Substance Misuse
N 101
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Experienced leverage in the four samples
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Housing Leverage helps people stay well
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Criminal Justice Leverage helps people to stay
well
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Child Custody Leverage helps people to stay
well
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Money Leverage helps people to stay well
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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

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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

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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

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• Thank you for attention.
• DONT FORGET OCTET!