Compulsion and “coercion” in mental health care

Abstract

"Compulsion" in mental health care is a reasonably straightforward notion: the use of force, one hopes always governed by law, to make a person accept treatment that has been refused. The term "coercion" is usually taken to include "compulsion", but encompasses a broader range of practices. Sometimes it is used almost synonymously with treatment pressures, including "interpersonal leverage", and even "persuasion". I believe that, if we are to take our thinking — including research ideas — forward, we need a more precise understanding of "coercion" 1. Most accepted is the definition proposed by Wertheimer 2, who includes "threats" as coercive. A "threat" is a conditional proposal ("if …, then …") that, if rejected by the person, leaves him/her worse off according to a "moral baseline" ("if you refuse the medication, you will be detained in hospital"). The moral baseline is that one is normally entitled not to be deprived of one's liberty. That is not to say that it can never be justified, but a special case needs to be made. Wertheimer contrasts a "threat" with an "offer" (or inducement). An example: "if you take the prescribed medication, you will receive a payment" 3. Here a rejection of the proposal does not leave the person worse off, as he/she is not entitled to a payment. Nevertheless, such an inducement can be problematic, for example, by undermining the patient's sense of agency or through corrupting the value of the treatment 4. I take coercion to cover both compulsion and threats. A further consideration is the difference between "objective" coercion and "perceived" coercion. The former follows the definitions given above. The latter is a person's perception of threat, even where no threat may be intended. A disquieting problem facing psychiatry is its "coercive shadow", the fear many patients have that non-compliance may lead to the use of compulsion. Patients may agree to treatment, including admission to hospital, "voluntarily" to avoid the humiliation and stigma of a compulsory order. Research shows this is very common, even though in most places threats are regarded as ethically unacceptable. There has been little discussion of this topic, but I suggest that, given the uncertainty of whether a proposition is a threat or not, we might look at ways of "regulating" threats: for example, making them transparent – their only being made in "good faith" (that is, the threatener really means it)— and clarifying practice in codes of practice or professional ethics. Apart from the problem of definition, research on coercion is dogged by the problem of context. There is a large variation in the rates of compulsory admission to hospital, both between countries (even without outliers, 3- to 4-fold) 5 and within countries 6. The use of seclusion, restraint and forced medication may vary hugely 7, even 10-fold from hospital to hospital in the same country 8. The sources of variation can be attributed to different service configurations, different mental health laws, different social policies (for example, the rate and extent of bed reductions; the degree of emphasis on risk and public protection), and, crucially, culture. In some countries physical restraints are regarded as unacceptable and are rarely or not at all used; in others chemical restraints are thus regarded. Furthermore, the use of compulsion may change significantly over time according to changes in policy and practice. In England, there has been a doubling over the past 20 years 9. Even if well-designed self-report or interview measures are used, ones that are interpreted similarly from place to place, the results of any one study on coercion will likely have limited generalizability. Thus, perhaps more than in any other field of health services research, international collaborative studies are needed. The EUNOMIA programme is a good example 10. Further points to be considered are where (in the community or in the hospital) and when (before discharge or after) the assessment is made, and by whom. Service user researchers may get different responses from conventional researchers. Variations here may lead to different results. Research ethics committees often struggle with research in this area. It is sensitive, and there may be concerns about consent and the "voluntariness" of participation, which may lead to bias due to the exclusion of important subgroups of patients. With careful thought these problems can be overcome. A huge challenge to involuntary treatment comes from the United Nations (UN) Convention on the Rights of Persons with Disabilities 11. By April 2015, 159 states were signatories. The elimination of discrimination by ensuring that rights may be enjoyed "on an equal basis with others" is a fundamental aim. Persons with serious mental illness are considered by the UN Committee for the Rights of Persons with Disabilities, the authoritative body set up by the UN to interpret and monitor compliance with the Convention, to fall under