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Coercion and Compulsion in community mental health care Andrew Molodynski Department of Social Psychiatry, Oxford Background Substantial shifts in place of care delivery over 50 or so years, which are ongoing Services’ ability to provide intensive input in the community

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coercion and compulsion in community mental health care

Coercion and Compulsion in community mental health care

Andrew Molodynski

Department of Social Psychiatry, Oxford

  • Substantial shifts in place of care delivery over 50 or so years, which are ongoing
  • Services’ ability to provide intensive input in the community
  • Community Compulsion introduced formally last year
questions re ctos
Questions re CTOs
  • Are they a substantial change from previous powers in practice?
  • Can they help to reduce symptoms and improve functioning?
  • Are they palatable (and to whom) or will they damage fragile therapeutic relationships?
  • Will we use them?
wider context
Wider Context
  • It’s not that we don’t use coercion
  • However, we don’t always acknowledge this
  • Increasing attention is being paid to the issue from both ethical/ moral and empirical perspectives
  • It is likely that decent understanding will come from a combination of the two
treatment pressures
Treatment pressures
  • Persuasion-an ‘appeal to reason’
  • Leverage-use of interpersonal pressure
  • Inducement-offers of help contingent upon remaining well
  • Threat-withdrawal of support/help if uncooperative
  • Compulsion-use of legislation

Szmukler+ Appelbaum (2008). Treatment pressures, leverage, coercion, and compulsion in mental health care: Journal of Mental health 17(3): 233-44

monahan et al 2005
Monahan et al 2005
  • 1000 US patients( in 5 places)
  • Housing leverage 23-40%
  • Criminal sanction leverage 15-40%
  • 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) p37-44
  • Leverage ubiquitous in standard mental health care
  • Actual nature depended on available methods, but overall rates similar
  • Correlations: substance misuse


high BPRS

low GAF

long term/intensive treatment

our study ultima
Our study (ULTIMA)
  • Examination of leverage in 400 patients:
  • 100 Assertive Outreach
  • 100 CMHT psychosis
  • 100 CMHT non psychosis
  • 100 substance misuse

Quantitative and qualitative

Carer/family perspectives + staff attitudes

Partial recreation of US work
  • Attempt to reach wider group
  • Comparison across services in one geographical area to try to detect differences
  • Measurement in a system without outpatient commitment
  • Leverage is commonly reported by UK community mental health care patients (much more commonly than we might think!)
  • The highest rates appear to be in substance misuse services(63%)
  • Housing and criminal justice are the most common in our preliminary findings(24% and 15%)
  • Childcare leverage is routinely reported by patients (11%) and requires addressing in its own right as could be especially toxic.
conclusions patients views
Conclusions - patients’ views

Not as negative as expected

48% agreed / strongly agreed that child custody sanctions helped

“It always comes back to the children”

“if you’ve got a mental health problem then boy are you in trouble especially if the other person wants to play that card with the courts..”

Child custody and housing seen as most likely to help keep patients well

back to ctos evidence
Back to CTOs- evidence
  • Cohort studies and naturalistic data suggest an effect in terms of service use and clinical outcome
  • Randomised trials and before and after analyses have shown no statistically significant results
  • “ More research urgently needed” as current evidence suggests a number needed to treat of 85 to prevent 1 admission (Cochrane review 2007)!!
  • Swartz et al 1999
  • Large US RCT of 250 patients
  • Found no overall significant effects
  • A subgroup of people kept on orders for up to a year and receiving weekly (at least) support had reduced readmission rates (57%fewer readmissions and 20 days less overall and 73% and 28 days if psychotic)
  • Concluded that they may work, but only with high levels of support ( for US)
north carolina secondary analyses
North Carolina secondary analyses

Swartz et al, 1999

>180 days of outpatient commitment green, <180 days blue

≥ 3 clinical contacts per month


57% reduction in mean admissions, occupancy down 20 days (all)

73% reduction in mean admissions, occupancy down 28 days (schizophrenia)

ny state assisted outpatient programme
NY State Assisted Outpatient Programme
  • Significant reduction in days in hospital with community compulsion: 10v11v18 days in 6 months
  • Interviewed 277 patients re perceived coercion and found no difference between the 2 groups, concluding:

“Current AOT participants did not experience more adverse subjective conditions around mental health treatment than comparable individuals who weren’t under AOT”

Swartz, Swanson, Steadman, Robbins, and Monahan 2009

the oxford community treatment order evaluation trial octet
The Oxford Community Treatment Order Evaluation Trial (OCTET)
  • Randomised Controlled Trial
  • N=300 (117 so far)
  • Either CTO or ‘non CTO’
  • 1 year follow up by us
  • Variety of outcomes measured: hospital and other care use, self harm, offending, drug use, symptom levels, engagement, economic analyses etc etc
participant characteristics
Participant characteristics

Psychotic illness

Detained under S3 or S37 and CTO being considered


Have capacity (our researchers are trained to assess this)

main issues for clinical teams
Main issues for clinical teams
  • Willingness to maintain Equipoise ( basically accepting that we ‘simply do not know’) and not cross patients over
  • A few minutes time to briefly introduce idea to patient and then call us
  • A few minutes time every few months to catch up on progress
  • We do all the chasing, note reading, and interviewing so the burden is genuinely minimal
  • Clinical care is unaffected
main benefits
Main benefits
  • Helping us!
  • This will almost certainly be the only chance to get good quality evidence to inform what has been a long and heated debate for professionals and probably the defining issue of our era
  • Financial rewards to trusts for recruitment are substantial and can/should support local services
overall conclusions
Overall conclusions
  • Few relationships are entirely free
    • Our patients understand this
  • Ubiquity of leverage indicates the need to incorporate it into current training
  • More sophistication required in understanding the therapeutic relationship
  • Further research may indicate outcomes
It is imperative that we try to gather as much evidence as we can while practice in regard to community compulsion develops before it is too late
  • Continued attention needs to be paid to non legislative coercion as this can be as keenly felt as compulsion and perhaps have as profound effects upon relationships and outcomes
please do get in touch
Please do get in touch!
  • 01865 613171