Coercion and Compulsion in
community mental healthcare
Andrew Molodynski
Department of Social Psychiatry,
Oxford
Context
• Continuing change in the locus of
psychiatric care through
deinstitutionalisation
• Began in the mid part of the last century
and has continued apace
• Happening in most western countries, with
varying speed and varying levels of
community provision
Recent UK developments
• NSF modernisation teams( assertive outreach,
early intervention, and crisis teams):
• Allow more intensive long and short term
support in the community
• More palatable
• ‘in vivo’ treatment with minimal disruption
• Expensive
• Potentially allow for more coercive treatment as
better resourced and more intensive
Mental health act amendments
• Have recognised this changing locus of
care and coercion/compulsion
• Have helped to focus minds upon the
debate regarding these crucial issues and
professional accountability within services
Main changes
• Approved Mental health Practitioners
(AMHPs)
• Responsible Clinicians (RCs)
• Detention criteria change ‘slightly’
• Community Treatment Orders (CTOs)
CTOs
• Only for those already detained in hospital ( or on S25 at
1st)
• To be considered once patient having any significant
leave ( 1 week)
• Renewable
• Rights of appeal
• Potentially wide ranging conditions:
residence
freedom of movement
attendence for therapy sessions
medication
Evidence
• Cohort studies and naturalistic data suggest an
effect in terms of service use and clinical
outcome
• Randomised trials and before and after analyses
have shown no statistically significant results
• “ More research urgently needed” as current
evidence suggests a number needed to treat of
85 to prevent 1 admission (Cochrane review
2007)!!
But……
•
•
•
•
Swartz et al 1999
Large US RCT of 250 patients
Found no overall significant effects
A subgroup of people kept on orders for up to a
year and receiving weekly (at least) support had
reduced readmission rates (57%fewer
readmissions and 20 days less overall and 72%
and 28 days if psychotic)
• Concluded that they may work, but only with
high levels of support ( for US)
Questions
• Are they really much different to S17
leave?
• Are they any more useful than S25?
• Do they reduce symptoms and improve
functioning?
• Are they palatable, and to whom?
• Will we use them?
The Oxford Community Treatment
Order Evaluation Trial (OCTET)
• Randomised controlled trial
• 300 patients, half assigned to CTO and
half assigned to current management (S17
etc)
• 1 year follow up
• Clinical outcomes, satisfaction, hospital
use, adverse events , economics, carer
perspectives
Wider Context
• It’s not that we don’t use coercion
• However, we struggle to acknowledge this
at times
• It is being increasingly acknowledged and
attempts are being made to measure it
and look for correlates etc
Treatment pressures
• Persuasion-an ‘appeal to reason’
• Leverage-use of interpersonal pressure
• Inducement-offers of help contingent upon
remaining well
• Threat-withdrawal of support/help if
uncooperative
• Compulsion-use of legislation (ie MHA)
Szmukler & Appelbaum 2000
Monahan et al 2005
•
•
•
•
•
•
1000 US patients( in 5 places)
Housing leverage 23-40%
Criminal sanction leverage 15-40%
Financial leverage 7-19%
Outpatient commitment 12-20%
Childcare leverage reported but not
measured systematically
Monahan…
• Leverage ubiquitous in standard mental health
care
• Actual nature depended on available methods,
but overall rates similar
• Correlations: substance misuse
younger
high BPRS
low GAF
long term/intensive treatment
Our Preliminary results (n=287)
70
60
50
40
any leverage
30
20
10
0
AO
CMHT P
CMHT N
SM
Tentative conclusions…
• Leverage is very commonly reported by
patients
• It is often, but not always reported
negatively
• Housing(26%) and criminal justice(28%)
are the most common
• Childcare leverage is important and rarely
discussed
Summary
• New community powers seem to form part
of a continuum of pressure rather than
‘standing alone’
• There is limited and often conflicting
evidence about their effectiveness
• Where they are available they are used
often
Scenarios
We will think about 3 different scenarios in
which CTOs might or might not be used:
Good points
Bad points
Ethical issues
Practical issues
Any other issues
Scenario 1
• GN is a 45 yr old man with schizophrenia
who lives alone. He just about manages
with support but often doesn’t take
medication properly and at these times
often becomes unwell and can relapse
and become aggressive.
• Consider a CTO to just give a depot 2
weekly
Scenario 2
• SD is a young man who lives alone. He can’t
really look after his money, personal care, or
shopping etc. he is psychotic much of the time
despite medication and neglects himself much of
the time. He is no risk to others. He is currently
ready to leave the ward but is felt to need
residential care of some sort, which he is
reluctant to accept.
• Consider a CTO to insist on residence
Scenario 3
• PR is a 45 year old lady with a long history of
relapsing psychosis. She drinks a lot, can’t really
manage her affairs, and doesn’t much like
medication. She is reluctant to see people and
has no family support.
• She’s just about to leave hospital after a lengthy
admission after a serious collapse at home after
XS alcohol. Her house has been condemned by
environmental health!
• Consider a CTO for residence, medication, and
attendence at day centre
Scenario 1-Depot
•
•
•
•
Doesn’t address whole person
Minimally disruptive to routines of life
Social care responsibility/reciprocity?
Practicality
Scenario 2-residence
•
•
•
•
•
Similar to existing powers
Reduces self determination
No medication
Practicality?
Responsibility/reciprocity?
Scenario 3-medication, residence,
activity
• Cuts across many areas of life
• Does address more of the person/less
narrow
• Perhaps better in terms of reciprocity?
• Practical/enforceable?
• Are these dilemmas and trade offs
between self determination and treatment
anything new?
• Or is it just the same old stuff dressed in
different clothes??
Please do get in touch…
• Jorun.rugkasa@psych.ox.ac.uk
• andrew.molodynski@obmh.nhs.uk