Jorun Rugk åsa Research Fellow Social Psychiatry Group University Department of Psychiatry

1. Jorun Rugkåsa Research Fellow Social Psychiatry Group University Department of Psychiatry University of Oxford Jorun.rugkasa@psych.ox.ac.uk

2. CTOs are social processes, premised on coercion The MHA is based on presumptions of human nature and behaviour We need to understand the social mechanisms to fully grasp how CTOs work (or not) Why use qualitative methods in the study of CTOs?

3. What do we need to know? • Leave from hospital has been around for a long time → Why would CTOs make a difference? • In 2008/09 the UK government anticipated 400 CTOs, but 4000 CTOs were initiated →What happened?!

5. Explicit measures Objective measures e.g., involuntary hospitalisation Subjective measures e.g., MacArthur scale Implicit dynamics Subjective experiences in unstructured interviews What is said What may not be said but still shape perceptions, experiences, behaviour Measuring coercion

6. Opinions and experiences of CTOs • Some good qualitative studies (though difficult to generalise across countries) • Doctors hold largely positive views • Families find them helpful • Patients are ambivalent • This literature is largely descriptive; little theorising around the issues

7. Patients’ ambivalence • It was like a prison sentence. I could not go hunting in the forest with my sons. My psychiatrist was a fascist. The injections impair my alertness and energy. They took away my gun licence. • It brought me back into society as a normal dad. It lifted the burden of monitoring from my wife. It saved my marriage. It’s good but there’s handcuffs on it. (Gibbs, Dawson et al 2005)

8. Coercion changes social status • Loss of credible identity • Changes to self image and presentation to others • Loss of autonomy • Feeling forced to “play the game” • Loss of trust in clinicians (Gault 2009)

9. North Carolina study • “Thank-you-theory”: Patients are in retrospect grateful for coercive treatment • Little support for thank-you theory in the North Carolina RCT: most view CTO ambivalently and with little gratitude • However, those with good clinical outcome had more positive appraisal of CTO • Questions raised: • At what point does the patient express “real” attitude? • Does patients’ acceptance of force justify coercion? • We need a better understanding of patients as moral agents (Swartz et al 2003)

10. 400 patients in 4 samples interviewed about experiences of treatment pressure 40 qualitative interviews Focus groups with Family members Mental health teams Types of pressure Persuasion Interpersonal pressure Inducement Threat Areas of pressure: Housing Child care Money Criminal justice ULTIMA study

11. MH coercion is part of people’s whole lives • Coercion across all types/areas reported • Family members (parents, partners, siblings, children and friends) pressurise and are involved in sectioning • Constant monitoring and pressure contributed to strained or broken down relationships • You know, I became a real second class citizen in my own home […] it just became a nag fest […] I just fell out of love with her. (CMHT psychosis) • Family responsibilities generated internal pressure to keep well

12. Choice, control & self-determination • Many participants reported that they • did not feel coerced • that there were few or no real consequences of non-compliance • that they had the power to negotiate I had a psychiatrist come to my house to do an assessment. I lit up a cigarette like you do. He said ‘if you light that cigarette then I’m going to go’, so I said ‘piss off then’. (CMHT non-psychosis) • Many projected an image of being in control and compliance as a personal choice

13. Pressure is not all bad… • Some participants more coercion to prevent relapse • Positive ‘peer’ pressure • Care coordinator stopped drinking with Mary • Earning privileges and self-management • Creating trust between self and GP meant more involvement in decisions

14. Should we change how we conceptualise coercion to better understand the dynamics? • It may be unhelpful to assume that all forms of leverage amount to coercion • Patients hold more complex views than many research instruments measure • Should we conceptualise relationships as contractual rather than coercive? (Bonnie and Monahan 2005)

15. The importance of cultural models/values • Rather than only looking at the end point we will also explore cultural cognition involved in CTOs (Monahan et al) • People who are hierarchical and communitarian tend to support CTOs • People who are egalitarian and individualistic tend to oppose them. • Cultural values, mediated by affect, shaped individuals’ perceptions of CTO efficiency

16. OCTET qualitative research question Why do/don’t CTOs make a difference to patient outcomes? • To what extent do the following take effect in the social processes of CTOs • The lack of choice? • The availability of support? • The quality of social relationships? • The models people have for such social relationships? (cultural models)

17. What do people bring with them to MH interactions? • Cultural and personal expectations for social relationships may be significant for how these relationships unfold • We all experience coercion and have views about what constitutes legitimate social authority • It’s not so bad being coerced by someone you trust • Some coercive actions are not even questioned • Many patients take a pragmatic view to being coerced and see themselves as active negotiators • What is legitimate coercion differs between individuals, groups, cultures (including law)

18. In conclusion… • We need methods able to explore CTOs as social processes • We need theories to explain them • We need to think about what people bring to social processes and not only their outcomes

19. “It’s not really pressure though, its there for your own good… It is pressure but it’s pressure that’s for your own good… Actually it’s not pressure at all… But I see what you mean when you're saying is it like a pressure because she wasn't giving enough pressure… Looking at it like that it’s hard to say really if it’s a pressure or not. I suppose it could be construed as a pressure.” Epilogue: are we shaping self reporting?

20. Jorun Rugkåsa Research Fellow Social Psychiatry Group University Department of Psychiatry University of Oxford Jorun.rugkasa@psych.ox.ac.uk