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Reducing ‘coercion’ in mental health care George Szmukler Institute of Psychiatry South London & Maudsley NHS Foundation Trust Institute of Psychiatry.

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Presentation on theme: "Reducing ‘coercion’ in mental health care George Szmukler Institute of Psychiatry South London & Maudsley NHS Foundation Trust Institute of Psychiatry."— Presentation transcript:

1 Reducing ‘coercion’ in mental health care George Szmukler Institute of Psychiatry South London & Maudsley NHS Foundation Trust Institute of Psychiatry at The Maudsley

2 2 ‘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

3 3 Outline Defining ‘coercion’ Review studies aiming to reduce coercion Implications for further research

4 4 ‘Coercion’ Not synonymous with pressures on reluctant patient Specific, narrow meaning Prefer the less moralised general term – ‘treatment pressures’

5 5 Spectrum of treatment pressures 1.Persuasion 2.Interpersonal leverage 3.Inducements 4.Threats 5.Compulsory treatment

6 6 Treatment pressures 1.Persuasion –Appeal to reason 2.Interpersonal leverage –Exercised through emotional dependency –Patient’s wish to please

7 7 Spectrum of treatment pressures 1.Persuasion 2.Interpersonal leverage 3.Inducements 4.Threats 5.Compulsory treatment

8 8 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)

9 9 ‘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

10 10 Threats v Offers Some examples: Second hand furniture Mental health courts SSI/SSDI representative payee

11 11 ‘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)

12 12 Coercion Deception Failing to correct a misconception that carries a threat e.g. real versus perceived powers associated with outpatient commitment orders

13 13 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

14 14 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?

15 15 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?

16 16 Spectrum of treatment pressures 1.Persuasion 2.Interpersonal leverage 3.Inducements 4.Threats 5.Compulsory treatment (and associated interventions - forced medication, physical restriction, seclusion)

17 17 Compulsion Inpatient Community treatment orders: –Substitute for inpatient order - ‘less restrictive alternative’ –Early discharge - ‘less restrictive alternative’ –Prevent relapse - ‘preventive’

18 18 Interventions Is there scope for reducing ‘coercion’? Studied interventions –1. Inpatient coercion –2. Advance statements

19 19 Is there scope for reducing ‘coercive’ interventions?

20 20 Involuntary admissions in EU countries International variation Salize & Dressing (2004)

21 21 Kjellin et al, Int J Law Psychiatry 2008 Compulsory treatment in Sweden Intra-national variation

22 22 Compulsory admissions to NHS facilities, including high security hospitals and private mental nursing homes Total orders, changes from informal to section, and court orders

23 23 Kjellin et al, Int J Law Psychiatry 2008 Compulsory treatment in Sweden

24 24 Mental Health Review Board (Victoria, Australia): statistics 1996/ / /2007% change Cases listed 10,52213,19618, to % 1999 to % Mental Health Review Board of Victoria Annual Report

25 25 Janssen et al, Social Psychiatry & Psychiatric Epidemiology 2008 Use of seclusion - international variation

26 26 Kjellin et al, Nordic J Psychiatry, 2004 ‘Coercive’ measures: Intra-national variation Sweden

27 27 Coercive Measures

28 28 Interventions to reduce coercion: the evidence Inpatient coercion Advance statements

29 29 Reducing inpatient ‘coercion’ 1 ‘Perceived coercion’ 2 Seclusion and restraint

30 30 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

31 31 Results: Sorgaard 2004 But, problems with rate of compliance with intervention; low level of coercion overall; perhaps ‘perceived coercion’ mainly determined during admission process

32 32 2 Reducing restraint and seclusion on inpatient units No RCTs Range of ‘systems’ interventions - unique to each organisation Leadership, 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’

33 33 2 Reducing restraint and seclusion on inpatient units Hallerstein et al, 2007

34 34 Use of ‘advance statements’ to reduce coercion What is an ‘advance statement’? Types of ‘advance statement’ Research evidence

35 35 ‘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.

36 Typology of ‘advance statements’ Crisis Card Joint Crisis Plan Psychiatric Advance Directive (PAD) Facilitated PAD CPA Involvement of care provider noyesno yes Independent facilitator noyesnoyesno Legally binding no yes (but…)*yes (but…)no Consumer led 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)

37 Dimensions of Advance Statements Patient autonomy Shared decision making Provider led PAD, Crisis card, WRAP fPAD Joint Crisis Plan Care Programme Approach Risks lack of clinician awareness or ‘buy in’ Risks provider pressure Targets therapeutic alliance

38 38 Advance statements to reduce ‘coercion’ ‘Joint Crisis Plans’ (Henderson et al) ‘Psychiatric Advance Directives’ (Papageorgiou et al) ‘Facilitated Psychiatric Advance Directives’ ( Swanson et al)

39 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

40 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.

41 41 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)

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45 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

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47 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) Ethnicity, n (%) White Black Other 29 (36) 44 (55) 7 (9) 34 (42) 40 (50) 6 (7) Number of previous psychiatric admissions (median) 55

48 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)2942 Ever admitted as involuntary patient, n (%)70 (87)73 (91) History of self harm, n (%) None Yes, not resulting in admission or observations Yes, resulting in admission or observations Missing 53 (66) 5 (5) 20 (25) 2 (2) 45 (56) 6 (7) 19 (24) 10 (12) History of violence, n (%) None Yes, non major 1 Yes, major 2 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

49 Results: Hospital admissions Intervention group (n=80) Control group (n=79) Test statistic 1 P Admissions (one or more), n (%) 24 (30)35 (44) Bed days: whole sample Mean Median Chi-square values from Mann-Whitney tests, except proportions admitted or on section, which were from Pearson’s chi-squared tests.

50 Admissions under the Mental Health Act 1983 Intervention group (n=80) Control group (n=80) Test statistic 1 P Sections applied (one or more) n (%) 10 (13%) 21 (27%) Time on section (days): Mean Median Chi-square values from Mann-Whitney tests, except proportions admitted or on section, which were from Pearson’s chi-squared tests.

51 Self-harm and violence Intervention Group (n=74) n (%) Control Group (n=76) n (%) P (Fisher’s Exact test) Self Harm None Not resulting in admission or close observations Resulting in admission or close observations 73 (99) 1 (1) 0 (0) 69 (91) 5 (6) 2 (3) 0.09 Violence None Non major 1 Major 2 71 (96) 1 (1) 2 (3) 65 (85) 9 (12) 2 (3) 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

52 Further findings 80% of patients still had their JCP at 15 months follow-up 45% had used their JCP during this period

53 53 JCP holders’ views, immediate follow-up Response JCP is reflection of holder’s wishes (%) Pressure at crisis planning meeting (%) Definitely not 273 Probably not 222 Undecided 00 Probably yes 552 Definitely 412

54 Further findings Patients with JCPs reported Immediate FU 15 months FU Better relationship with team46%24% More involved in care76%50% More control over mental health problem 71%56% More likely to continue treatment59%28% Would recommend it to others90%82%

55 55 Cost effectiveness of Joint Crisis Plans * 78% probability that JCPs are more cost effective than standard care in reducing admissions

56 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

57 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.

58 58 ii) Psychiatric advance directives and reduction of coercive crisis interventions (Swanson et al, 2008)

59 59 ii) Psychiatric advance directives and reduction of coercive crisis interventions (Swanson et al, 2008)

60 60 ii) Psychiatric advance directives and reduction of coercive crisis interventions (Swanson et al, 2008)

61 61 ‘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 RCT London, Birmingham, Manchester (N= 540) – in progress

62 62 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’.

63 63 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

64 64 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.


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