Coercion in Psychiatry

1. Coercion in Psychiatry An Introduction

2. What is coercion? • Oxford English Dictionary definition: • ‘to constrain or restrain by the application of superior force, or by authority resting upon force’. • Coercion can be further explained: • As a relationship where one party has power over the other. • Coercion does not necessarily require obvious threats of force, it is often achieved through the implication that force could be an outcome.

3. Coercion within Psychiatry • Compulsion within Psychiatry • The power to compel someone to accept mental health treatment has long-existed in psychiatry via the use of legislation. This can take the form of admission to a treatment facility. • Inevitably, when there is the threat of compulsion or use of compulsion, an individual could experience coercion. • Coercion is therefore an aspect of psychiatry and used in psychiatric practices.

4. Objective and Subjective Coercion • There are both ‘subjective’ and ‘objective’ aspects to coercion and these aren’t mutually exclusive. • Objective coercion • This is the actual use of coercion through compulsion, or the threat of compulsion or other types of force. • Subjective coercion • The perception that a threat or force may be applied if the other party’s request is not adhered to.

5. More on Subjective Coercion • Perceived coercion to accept mental health treatment does not only come directly from mental health services. • Pressure to accept treatment can arise from family and carers. • One can feel coerced to accept treatment through social and cultural expectations (Canvin, 2012)

6. Coercion in Modern Psychiatric Practice • Over the last few decades in most developed nations, the movement towards treating people with mental health difficulties in the community, instead of in hospital, has increased. • This has changed the debate about what is considered coercive. • Traditionally, coercion in psychiatry was limited to the use of compulsory admission and the use of restraint and force. • Community treatment has raised new questions regarding how coercion is experienced by people accessing mental health services. • The majority of patients in the community are not subject to any legislative compulsion1. However rates of reported coercion are high in community populations (Burns et al., 2011; Monahan et al., 2005). 1. New legislation in some countries now allows compulsion in the community through the use of ‘outpatient commitment’ or Community Treatment Orders.

7. Coercion in the community • While compulsion is used in the community, ‘informal coercion’ or ‘leverages’ are more commonly used to encourage treatment adherence. • This informal coercion can include persuasion, leveraging, inducements (i.e. making access to service dependant on treatment), eventually leading more objective coercion in threats and compulsion (Szmuckler and Appelbaum, 2008). • Therefore coercion can take many forms in the treatment of people with mental health difficulties.

8. Is coercion damaging to patients? • There are a variety of different approaches to investigating this: • Legal approaches • Investigates the state’s role in intervening in a person’s treatment • Moral and ethical approaches • Evaluates whether coercion is appropriate in relation to civil liberties and human right • Clinical approaches • Examines the effect of coercion on outcomes such as symptoms, hospital use, and engagement with services.

9. Is coercion damaging to patients? • It is difficult to determine the effect of coercion on patients and the results of studies are mixed. • Due to the various of ways coercion can be experienced. How do you identify or define it? • Due to the difficulty of factoring out other variables impact on patient outcomes. Was being coerced the only factor? • Some patients do not perceive having been coerced after a coercive intervention (Hoge, 1997), so further research needs to investigate the relationship between perceived and objective coercion. • This is why it is important to continue efforts to investigate coercion in psychiatry.

10. Summary • Coercion is when one party makes another party act against their will, either through force or the threat of force. • Coercion is commonplace in the treatment of people with mental health problems and takes a variety of forms. • Research is required to investigate the impacts of coercion and how to limit these impacts.

11. References • Burns, T., Yeeles, K., Molodynski, A., Nightingale, H., Vazquez-Montes, M., Sheehan, K. & Linsell, L (2011) Pressures to adhere to treatment ('leverage') in English mental healthcare. The British Journal of Psychiatry, 199, 145-150. • Canvin, K., Rugkasa, J., Sinclar, J., & Burns, T. (2012). Leverage and other informal pressures in community psychiatric services in England: What can patients’ experiences add to our understanding? International journal of Law and Psychiatry • Monahan, J., Redlich, A.D., Swanson, J., Robbins, P.C., Appelbaum, .P.S., Petrila, J., et al. (2005) Use of leverage to improve adherence to psychiatric treatment in the community. Psychiatric Services, 56, 37–44. • Szmukler, G., Applebaum, P. (2008)Treatment pressures, leverage, coercion and compulsion in mental health care. Journal of Mental Health, 17, 233-44