Treatment pressures, coercion and compulsion in mental health care

There is probably no more unpleasant task for a clinician working in mental health than imposing treatment on an unwilling patient; and probably no experience for the patient that is more humiliating. Yet this area of practice has received scant attention. For instance, how many clinicians have trained in approaches aimed at reducing the distress surrounding involuntary treatment? There are no clinical guidelines (as opposed to prescriptive ‘codes of practice’). A form of ‘denial’ seems to be operating; these interventions seem not to be regarded as ‘clinical’ or ‘professional’ - but as a kind of duty ancillary to the ‘real’ task of treatment. The papers in this issue of the Journal examine some of these matters, and provide help in resolving them.

As Hoyer (2008) shows, despite uncertainties in the measures, there are large international differences in rates of involuntary hospitalisation, probably five-fold or higher. Indeed, there are also large differences across regions within one nation. Where involuntary outpatient treatment has been introduced, there is again more than a five-fold variation in its use (Dawson, 2005). Changes over time are also noteworthy. In England and Wales, involuntary admissions to hospital increased by about 70% between 1987 and 1997, and for those detained in hospital after an informal admission, by a similar percentage (Department of Health, 2006). There is no reason to believe there has been any change in the nature or frequency of mental disorders over this time. Evidently then, the use of involuntary treatment is not predominantly, perhaps not even significantly, determined by the nature of mental illness itself, nor by the absolute level of associated risk. The structure of mental health services and the details of relevant legislation account for some of the differences. But so do cultural attitudes to the mentally ill, as well as what might be termed local ‘custom and convention’. In a society increasingly preoccupied with ‘risk’, more attempts to control troubling people, as many mentally disordered persons are perceived to be, are not surprising.

Few would disagree that the use of compulsion should be reduced to the minimum necessary. The distress of involuntary treatment, together with the key influence of socio-cultural factors unrelated to the specific characteristics of mental disorders, point to the need for an analysis of how decisions concerning such treatment are reached. As values are central, ethical analysis is also required. Such study has become more urgent still as the scope for involuntary treatment now extends beyond the confines of the hospital, and as potentially intrusive interventions such as ‘assertive community treatment’ have become commonplace.

As shown by Szmukler and Appelbaum (2008) and Dawson and Mullen (2008) in this issue of the Journal, substantial work is still needed to develop a useful vocabulary of ‘coercion’ and related concepts. The law offers limited guidance. Even buttressed by ‘human rights’ legislation, it provides little help for the clinician considering the appropriateness of involuntary treatment. As Richardson (2008) concludes: “In relation to coerced treatment the ECHR (European Court of Human Rights) sets a high threshold of severity before it will regard such treatment as unlawful and it places considerable reliance on medical opinion through the notion of medical necessity … … … … It may be concluded that European human rights law fails to capture much of the coercion experienced by patients in practice”. The Mental Health Act 2007 in England and Wales will offer even more scope for discretion than current legislation. Dawson and Mullen (2008) examine how the concept of ‘insight’, commonly raised in discussions about compulsory treatment, has been employed in decision making in relation to Community Treatment Orders. There is a risk that ‘woolly’ clinical concepts of this type can become proxy criteria for decisions about the instigation or discharge of involuntary treatment orders where the law provides large latitude for interpretation.

In relation to a vocabulary of ‘coercion’, Szmukler and Appelbaum (2008) outline a hierarchy of ‘treatment pressures’. This ranges from ‘persuasion’, through ‘interpersonal leverage’, ‘inducements’, ‘threats’ (properly termed ‘coercion’), to ‘compulsion’. They argue that morally relevant distinctions between these forms of pressure provide a useful aid to decision-making.

As noted above, despite the huge significance for both patients and clinicians of interventions aimed at inducing treatment acceptance by a reluctant or unwilling patient, and the scope for discretion that is afforded, little guidance exists of a clinical or ethical kind. Decision-making about the use of ‘inducements’, ‘coercion’ or ‘compulsion’ deserves as much deliberation as that aimed at determining the most appropriate medical treatment. Szmukler and Appelbaum describe two frameworks that may help us make such decisions. One is based on a ‘capacity-best interests’ model, consistent, for example, with recent mental capacity legislation in England and Wales or guardianship in some other countries; the other is based on an analysis of ‘paternalistic’ actions by (Gert et al., 2006). Other ‘values-based’ frameworks might also be useful (Fulford, 2006). Whichever is chosen, a choice should be made urgently.

Particular clinical approaches may also reduce the patient's distress when a decision about involuntary treatment is being made. Observance of the principles of ‘procedural justice’ (Lidz et al., 1995) may help to reduce the ‘coercion’ perceived by the patient. Unfortunately, this has not been tested so far. Hoyer (2008) suggests that ‘capacity-based’ mental health legislation could lead to a reduction of involuntary treatment. The proposition is tenable, but there are few data on the matter (Owen et al., in press).

On a positive note, evidence is growing for interventions that reduce the need for involuntary treatment. The most promising involve an ‘advance statement’– patient preferences for treatment, expressed at a time when the patient is capable, which anticipate a time in the future when as a result of relapse (usually of a psychosis), the patient becomes incapable. Swanson et al. (2008) provide evidence, albeit not drawn from a randomised controlled trial (RCT), that psychiatric advance directives (PAD) (in this case with the patient being assisted by a facilitator) can reduce the number of ‘coercive’ interventions to which the patient will be subject. In a previous report from this study, patients with a facilitated PAD said they had a better therapeutic alliance with their clinicians (Swanson et al., 2006). An RCT of Joint Crisis Plans, an advance statement negotiated and agreed between patient and clinical team, again with an independent facilitator, showed a halving of the involuntary admission rate (Henderson et al., 2004). A large multicentre RCT has just commenced to test the replicability of this finding.

The papers in this issue of the Journal make a powerful case that neglect of the study of ‘coercive’ interventions is unacceptable, as is the lack of attention to the underlying ethics. There is evidence that clinical interventions can significantly improve outcomes of predicaments that so often cause suffering and humiliation. There is every likelihood that if staff were better versed in these aspects of their work - aspects that are not marginal but fundamental to what is entailed in the treatment of mental illness - both they and their patients will be better off.