Reducing ‘coercion’ in mental health care

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

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

5. Spectrum of treatment pressures • Persuasion • Interpersonal leverage • Inducements • Threats • Compulsory treatment

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

7. Spectrum of treatment pressures • Persuasion • Interpersonal leverage • Inducements • Threats • Compulsory treatment

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

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

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. 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. 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. Spectrum of treatment pressures • Persuasion • Interpersonal leverage • Inducements • Threats • Compulsory treatment (and associated interventions - forced medication, physical restriction, seclusion)

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

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

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

20. Involuntary admissions in EU countries 1999 - 2000 International variation Salize & Dressing (2004)

21. Compulsory treatment in Sweden 2001 - 2002 Intra-national variation Kjellin et al, Int J Law Psychiatry 2008

22. 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

23. Compulsory treatment in Sweden 1979 - 2002 Kjellin et al, Int J Law Psychiatry 2008

24. Mental Health Review Board (Victoria, Australia): statistics Mental Health Review Board of Victoria Annual Report - 2007-2008

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

26. ‘Coercive’ measures: Intra-national variation Sweden 1997 -1999 Kjellin et al, Nordic J Psychiatry, 2004

27. Coercive Measures

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

29. Reducing inpatient ‘coercion’ ‘Perceived coercion’ Seclusion and restraint

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. 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. 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’

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

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

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

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. 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)

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

47. Baseline demographic and clinical characteristics of participant groups (1)

48. Baseline demographic and clinical characteristics of participant groups (2) • Non-major incidents requiring attendance of police or on-ward seclusion or special civil-law admissions to a place of safety • Major: homicide, sex attacks, attempted or actual serious assault

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