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

2. 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):

3. Hierarchy of treatment pressures
Persuasion
Respect for the patient’s arguments
Treatments discussed in the context of patient’s 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):

4. 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):

5. MacArthur Informal coercion (‘leverage’) study
N=1011 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):

6. 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

7. (Use of Leverage Tools in Mental Healthcare)
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

8. 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

9. Sample bb N = 417 AOT N=102 CMHT psychosis N=107 CMHT Non-psychosis
Substance
misuse
N=101

10. Experience of leverage in total sample N=417

11. Assertive outreach
N = 102

12. CMHT Psychosis
N = 107

13. CMHT Non-psychosis
N = 107

14. Substance Misuse
N = 101

15. Experienced leverage in the four samples

16. Housing Leverage ‘helps people stay well’

17. Criminal Justice Leverage ‘helps people to stay well’

18. Child Custody Leverage ‘helps people to stay well’

19. Money Leverage ‘helps people to stay well’

20. 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

21. 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

22. 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

23. Thank you for attention. DON’T FORGET OCTET!