Reducing ‘coercion’ in

mental health care

George SzmuklerInstitute of Psychiatry

South London & Maudsley NHS Foundation Trust

Institute of Psychiatry at The Maudsley

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‘Coercion’

Increased salience over past 2 decades• Growing emphasis on ‘human rights’• Community care and protection of the public

– ‘Assertive community treatment’ – CTOs

• New types of clinician-patient relationships in community care

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Outline

• Defining ‘coercion’• Review studies aiming to reduce

coercion• Implications for further research

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‘Coercion’

• Not synonymous with pressures on reluctant patient

• Specific, narrow meaning• Prefer the less moralised general term –

‘treatment pressures’

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Spectrum of treatment pressures

1. Persuasion

2. Interpersonal leverage

3. Inducements

4. Threats

5. Compulsory treatment

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Treatment pressures

1. Persuasion – Appeal to reason

2. Interpersonal leverage– Exercised through emotional dependency– Patient’s wish to please

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Spectrum of treatment pressures

1. Persuasion

2. Interpersonal leverage

3. Inducements

4. Threats

5. Compulsory treatment

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Treatment pressures

Inducements (or offers) v. threats

• Involve conditional (or bi-conditional) propositions

• “If…………………, then………………”

If the patient accepts treatment A, then the clinician will do X; or if the patient does not accept treatment A, then the clinician will not do X (or will do Y)

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‘Coercion’

• Wertheimer (1987): Threats coerce, offers generally do not

• The crux of the distinction between threats and offers is that A makes a threat when B will be worse off than in some relevant base-line position if B does not accept A’s proposal; but A makes an offer when B will be no worse off than in some relevant base-line position if B does not accept A’s proposal.

• Fixing the baseline

• ‘Moral baseline’ - threat makes an ‘ought’ conditional

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Threats v Offers

Some examples:

• Second hand furniture• Mental health courts• SSI/SSDI representative payee

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‘Coercion’

Other accounts of ‘coercion’• ‘subjective’ v ‘objective’

– Rhodes (2000): • ‘perceived threat avoidance behaviour’

• then analyse the context: reasonable perception?

• possibly no threat intended (‘mobster’ example)

• can be useful perspective

– Feinberg (1986)• pressure on the will

• ‘Perceived’ coercion (research)

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Coercion

DeceptionFailing to correct a misconception

that carries a threate.g. real versus perceived powers associated with outpatient

commitment orders

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Acts which resemble ‘coercive’ threats

• ‘Unwelcome predictions’ – statement of fact v threat

– accuracy; clinician as agent?

•Exploitation– may be morally reprehensible

– background threat

– but subject not worse off according to moral base-line

– unfair advantage

– may be mutually advantageous

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Problematic offers or inducements

• Subvert patient’s decision-making• Powerful inducements

–Offers of highly desirable goods– Payment for accepting treatment

•When, if ever, is this acceptable?

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Problematic inducements

• Constraints on inducements – setting a ‘base-line’ for mental health services –

• What are the entitlements?• Paradox: the greater the range of services or help offered,

the greater the scope for threats (or coercion)– questions of ‘fairness’ –

• why should some be offered inducements and others not?

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Spectrum of treatment pressures

1. Persuasion

2. Interpersonal leverage

3. Inducements

4. Threats

5. Compulsory treatment (and associated interventions

- forced medication, physical restriction, seclusion)

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Compulsion

• Inpatient• Community treatment orders:– Substitute for inpatient order - ‘less restrictive alternative’

– Early discharge - ‘less restrictive alternative’

– Prevent relapse - ‘preventive’

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Interventions

• Is there scope for reducing ‘coercion’?

• Studied interventions– 1. Inpatient coercion– 2. Advance statements

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Is there scope for reducing ‘coercive’ interventions?

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Involuntary admissions in EU countries 1999 - 2000International variation

Salize & Dressing (2004)

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Kjellin et al, Int J Law Psychiatry 2008

Compulsory treatment in Sweden 2001 - 2002Intra-national variation

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Compulsory admissions to NHS facilities, including high security hospitals and private mental nursing homes

1987-2005Total orders, changes from informal to section, and court orders

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Kjellin et al, Int J Law Psychiatry 2008

Compulsory treatment in Sweden 1979 - 2002

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Mental Health Review Board (Victoria, Australia): statistics

1996/1997 1999/2000 2006/2007 % change

Cases listed 10,522 13,196 18,719 1996 to 2006 + 78%

1999 to 2006 + 42%

Mental Health Review Board of Victoria Annual Report - 2007-2008

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Janssen et al, Social Psychiatry & Psychiatric Epidemiology 2008

Use of seclusion - international variation

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Kjellin et al, Nordic J Psychiatry, 2004

‘Coercive’ measures: Intra-national variation

Sweden 1997 -1999

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Coercive Measures

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Interventions to reduce coercion: the evidence

• Inpatient coercion• Advance statements

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Reducing inpatient ‘coercion’

1 ‘Perceived coercion’2 Seclusion and restraint

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1 Intervention to reduce ‘perceived coercion’ on acute psychiatric wards

(Sorgaard 2004)

• Two acute wards: 5 week baseline phase - 12 week intervention phase

• 190 patients (~ 28% psychosis, ~50% mood disorders; ~50% involuntary admission)

• Intervention:– engage patient in formulating treatment plan

– regular joint evaluations of progress

– renegotiate treatment plans if necessary

– regular meetings at least once per week; jointly written daily case notes

• Outcome measures:– Patient satisfaction (SPRI) (+ patronizing communication and physical harassment)

– ‘Perceived coercion’ (Coercion ladder)

– Obtained shortly before discharge

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Results: Sorgaard 2004

But, problems with rate of compliance with intervention; low level of coercion overall; perhaps ‘perceived coercion’ mainly determined during admission process

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2 Reducing restraint and seclusion on inpatient units

• No RCTs• Range of ‘systems’ interventions - unique to

each organisationLeadership, monitoring of seclusion episodes, staff education, treatment plan improvements, emergency response teams, behavioural consultation, increased staff:patient ratios, treating patients as active participants

• All are pre- post- comparisons• 15 studies reporting significant reductions in use

of seclusion Mistral et al (2002), Schreiner et al (2004), Sullivan et al (2004; 2005), Smith et al (2005), Fowler (2006)

or restraint/seclusion Kalogjera et al (1989), Taxis (2002), Donat (2003), Donovan et al (2003), Fisher (2003), D’Orio et al (2004), LeBel et al (2004), Green et al (2006), Regan et al (2006), Hellerstein et al (2007)

• Risk of ‘publication bias’

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2 Reducing restraint and seclusion on inpatient units

Hallerstein et al, 2007

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Use of ‘advance statements’ to reduce coercion

• What is an ‘advance statement’?• Types of ‘advance statement’• Research evidence

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‘Advance Statements’

• ‘Advance Statements’ express treatment preferences, anticipating a time in the future when the patient will not be capable of stating them.

• Purpose - to prevent adverse consequences of relapse, and thus to reduce the need for coercion, by giving patient more control over treatment decisions.

Typology of ‘advance statements’

CrisisCard

Joint Crisis Plan

PsychiatricAdvanceDirective

(PAD)

Facilitated PAD

CPA

Involvement of care provider

no yes no no yes

Independent facilitator

no yes no yes no

Legally binding no no yes (but…)* yes (but…) no

Consumer led yes yes yes yes no

*Conflict with ‘community practice standards’; civil commitment. (Hargrave v Vermont – US court of Appeals (2003) – discrimination by being excluded from a public service)

Dimensions of Advance Statements

Patient autonomy

Shared decisionmaking

Provider led

PAD, Crisis card, WRAP

fPAD

Joint Crisis Plan

Care Programme Approach

Risks lack of clinician awareness

or ‘buy in’

Risks providerpressure

Targetstherapeutic alliance

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Advance statements to reduce ‘coercion’

• ‘Joint Crisis Plans’ (Henderson et al)

• ‘Psychiatric Advance Directives’ (Papageorgiou et al)

• ‘Facilitated Psychiatric Advance Directives’ (Swanson et al)

A randomised controlled trial of Joint Crisis Plans

    

Claire Henderson, Kim Sutherby, Chris Flood, Morven Leese, Graham Thornicroft, George Szmukler,

Institute of Psychiatry, King’s College London&

South London and Maudsley NHS Trust  

Institute of Psychiatry at The Maudsley

An RCT of Joint Crisis Plans

Aim to evaluate the effectiveness of JCPs on in-patient service use and objective coercion (use of the Mental Health Act 1983) during admission.

 

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Joint Crisis Plan

•Experimental intervention – Project worker explains to patient– ‘Menu’ of subheadings– JCP meeting: facilitator; attendees,

negotiation; patient decides

–Controls: detailed information leaflets; written care plan (CPA)

Methods• Study setting

– 7 south London CMHTs and one in Kent; ethnic minority mix

• Inclusion & exclusion criteria– In contact; admitted at least once in previous 2 years; psychosis

or BPD

• Outcomes– Primary: admissions; length of hospitalisation– Secondary: compulsion under Mental Health Act 1983

• Data sources: case notes; PAS; Mental Health Act Office; interviews

• Statistical analysis– Intention to treat

Baseline demographic and clinical characteristics of participant groups (1)

Intervention group(n=80)

Control group(n=80)

Age in years (mean [s.d]) 39.5 (12.1) 38.6 (10.6)

Gender: male, n (%) 47 (59) 47 (59)

Ethnicity, n (%) WhiteBlackOther

29 (36)44 (55)

7 (9)

34 (42)40 (50)

6 (7)

Number of previous psychiatric admissions(median)

5 5

Baseline demographic and clinical characteristics of participant groups (2)

Intervention group(n=80)

Control group(n=80)

Days in hospital in 6 months prior to recruitment (Median)

29 42

Ever admitted as involuntary patient, n (%) 70 (87) 73 (91)

History of self harm, n (%) NoneYes, not resulting in admission or observations

Yes, resulting in admission or observationsMissing

53 (66)5 (5)

20 (25)2 (2)

45 (56)6 (7)

19 (24)10 (12)

History of violence, n (%) NoneYes, non major1

Yes, major2

Missing

48 (60)13 (19)17 (21)

2 (2)

44 (55)15 (19)12 (15)9 (11)

Compliance rating (mean[sd]) 4.8 (1.3) 4.9 (1.3)

1.Non-major incidents requiring attendance of police or on-ward seclusion or special civil-law admissions to a place of safety

2.Major: homicide, sex attacks, attempted or actual serious assault

Results: Hospital admissions

Intervention group(n=80)

Control group(n=79)

Test statistic1

P

Admissions (one or more),n (%)

24 (30) 35 (44) 3.25 0.07

Bed days: whole sampleMeanMedian

320

360

1.52 0.15

1. Chi-square values from Mann-Whitney tests, except proportions admitted or on section, which were from Pearson’s chi-squared tests.

Admissions under the Mental Health Act 1983

Intervention group(n=80)

Control group(n=80)

Test statistic1

P

Sections applied (one or more) n (%) 10

(13%)21

(27%)4.84 0.03

Time on section (days):MeanMedian

140

310 4.13 0.04

1. Chi-square values from Mann-Whitney tests, except proportions admitted or on section, which were from Pearson’s chi-squared tests.

Self-harm and violenceIntervention

Group (n=74)

n (%)

Control Group(n=76)

n (%)

P (Fisher’s

Exact test)

Self Harm None Not resulting in admission or close observationsResulting in admission or close observations

73 (99)

1 (1)

0 (0)

69 (91)

5 (6)

2 (3)

0.09

Violence None Non major1

Major2

71 (96) 1 (1) 2 (3)

65 (85) 9 (12) 2 (3)

0.03

1.Non-major incidents requiring attendance of police or on-ward seclusion or special civil-law admissions to a place of safety

2.Major: homicide, sex attacks, attempted or actual serious assault

Further findings

• 80% of patients still had their JCP at 15 months follow-up

• 45% had used their JCP during this period

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JCP holders’ views, immediate follow-up

Response JCP is reflection of holder’s wishes

(%)

Pressure at crisis planning meeting

(%)

Definitely not 2 73

Probably not 2 22

Undecided 0 0

Probably yes 55 2

Definitely 41 2

Further findingsPatients with JCPs reported

Immediate FU

15 months FU

Better relationship with team 46% 24%

More involved in care 76% 50%

More control over mental health problem

71% 56%

More likely to continue treatment 59% 28%

Would recommend it to others 90% 82%

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Cost effectiveness of Joint Crisis Plans

* 78% probability that JCPs are more cost effective than standard carein reducing admissions

Advance directives for patients compulsorily admitted to hospital with serious mental illness:

Randomised controlled trial(A Papageorgiou et al, 2002)

Aims To evaluate whether use of ‘advance directives’ by patients with mental illness leads to lower rates of compulsory readmission to hospital.

Subjects 156 patients admitted involuntarily

Intervention ‘Advance directive’ completed with research worker, but clinical team not significantly involved. RCT.

Outcome measures Compulsory readmissions, readmissions, days in hospital, satisfaction.

Results None significant

Conclusions Users' advance instruction had little observable impact on the outcome of care at 12 months. But, providers of care not significantly involved in advance directive

i) RCT of facilitated PADS(Swanson et al, 2006)

• Method: 469 patients with severe mental illness in two county-based mental health systems (North Carolina) randomly assigned to a facilitated advance directive (F-PAD) session or control group.

• Results: 61% of the 239 patients allocated to the F-PAD group completed legal advance instructions or authorized a proxy decisionmaker, compared with 3% of control group.

• At 1 month follow-up, F-PAD participants had significantly greater working alliance and were significantly more likely to report receiving the mental health services they believed they needed.

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ii) Psychiatric advance directives and reduction of coercive crisis interventions

(Swanson et al, 2008)

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ii) Psychiatric advance directives and reduction of coercive crisis interventions

(Swanson et al, 2008)

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Pre

dict

ed P

roba

bili

ty

0

0.1

0.2

0.3

0.4

0.5

0.6 Inpacacity, no PAD Incapacity, with PADNo incapacity, no PADNo incapacity, with PAD

Follow-up wave

12 months 24 months6 months

Figure 1. Adjusted predicted probability1 of any coercive crisis interventions at follow-up for psychiatric advance directive (PAD) completers and noncompleters, by any episode of

decisional incapacity within period

1 Estimates produced from GEE regression model (see Table 2).

ii) Psychiatric advance directives and reduction of coercive crisis interventions(Swanson et al, 2008)

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‘Advance statements’

• Why effective?‘Manifest’ reasons – information

‘Latent’ reasons - empowerment, negotiation, collaboration, risk perception

• Generalisability?• Compatibility with Involuntary Outpatient

Treatment orders?• Coexistence of different types of ‘advance

statements’?• Further research: ‘definitive’ multicentre

RCTLondon, Birmingham, Manchester (N= 540) – in progress

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Conclusions

• International and national variation suggest that in many, (probably most), legislatures there is scope for (substantial) reduction of ‘coercive’ measures

• Research on inpatient settings suggests that there may be scope for substantial reductions in the use of seclusion and physical restraints - but the evidence is not based on RCTs. Interventions have been complex and facility-wide. Only one study has examined an intervention aimed at reducing ‘perceived coercion’.

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Conclusions

• An RCT of an ‘advance statement’ - the JCP - has provided evidence of reduced involuntary hospitalization. A second study, not randomised, has provided evidence of reduced coercive interventions for patients with a fPAD

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Some research suggestions• Describing and measuring ‘coercion’ -

– questionnaire or structured interview to assess the different levels of treatment pressure - persuasion, interpersonal leverage, inducements, threats.

May be useful to set against general measure of ‘perceived coercion’; compare services (or even clinicians)

– What should be the ‘base-line’ – moral, legal, expected course?

• Interventions to reduce coercion– Inpatient coercion -

• useful to measure changes as a result of systems interventions, but only suggestive

• RCTs of specific interventions - ‘procedural justice’; involving patients in care planning; agreeing when coercive interventions are warranted. Will need ‘cluster randomised trials’.

– Advance statements -• Test in different service settings and legislatures

• Assess value of facilitation, and who should facilitate.