Why is coercion research so difficult?

George SzmuklerInstitute of Psychiatry, King’s College London

Oslo, May 2013

Institute of Psychiatry at The Maudsley

Key problems

When asking a meaningful question Definitions of ‘coercion’ & its measurement The problems of context Ethical issues

Meaningful questions

How often are coercive measures used? What factors are associated with the use of

coercive measures? What are the short- and long-term effects on

patients; on staff; on others? How can we reduce the use of such

measures?

and we especially value generalisable findings

Definition of ‘coercion’

Philosophical analysis (e.g. Feinberg, Wertheimer, Rhodes)

‘Objective’ (important for law and ethics; interventions at various levels)

‘Subjective’ (important for service delivery, interventions, engaging service users in services or research)

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Spectrum of treatment pressures

1. Persuasion2. Interpersonal leverage3. Inducements4. Threats5. Compulsory treatment

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‘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

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Problems of 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? Highly problematic inducements

Financial incentives to take treatment

Research definition of ‘coercion’

Which instrument? Purpose

What assumptions or theories underlie the measure What meaning is being adopted

Have we done enough qualitative research to create meaningful quantitative measures?

Research definition of ‘coercion’ Effect of context on use of instruments

The general ‘coercive backdrop’ (including the legal and ‘rights’ context)

e.g. 47% of informal inpatients reported high coercion (Sheehan & Burns, 2011)

Types of coercion that are favoured (e.g. forms of restraint, medication) may affect nature or experience of coercion

E.g. Steinert & Lepping vignette study, 2009)

Culture; how mental disorder is understood; language of coercion Possible variations in what is understood as coercive; nuances

Assessed where; when; by whom As inpatient or community; who interviewed by; independence;

when; any perceived consequences Researching the E Hughes’ ‘dirty work’

Disciplinary perspectives Whose questions? Whose analysis? Including role of service users

Context: International variation

Variation Laws (medical discretion v legal control; appeals, advocacy; legal

representation, etc)

Regulation (e.g. CPA; risk emphasis)

Services (e.g. accessibility; bed numbers; staffing levels; training; community services; alternatives to admission)

Social and cultural attitudes (stigma; discrimination; ‘failure of care in the community’)

Language relevant to ‘coercion’ (e.g. interpretation of questionnaire)

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‘OBJECTIVE COERCION’Involuntary admissions in EU countries 1999 - 2000

International variation

Salize & Dressing (2004)

International variation

Bak & Aggernaes, 2011

International variation

Bak & Aggernaes, 2011

International variation

International variation

Admission Experience Survey

Perceived Coercion Scale1. I felt free to do what I wanted about coming into the hospital.4. I chose to come into the hospital.7. It was my idea to come into the hospital.13. I had a lot of control over whether I went into the hospital.14. I had more influence than anyone else on whether I came into the hospital. Negative Pressures Scale2. People tried to force me to come into the hospital.6. Someone threatened me to get me to come into the hospital.8. Someone physically tried to make me come into the hospital.9. I was threatened with sectioning.10. They said they would make me come into the hospital.11. No one tried to force me to come into the hospital. Procedural Justice/Voice Scale3. I had enough of a chance to say whether I wanted to come into the hospital.5. I got to say what I wanted about coming into the hospital.12. My opinion about coming into the hospital didn't matter.

Context: National variation1. Time

Services change Community services; reduction in beds Risk emphasis Effect of service reorganisation

Changes in service structure; teams; staff Effect on research capacity at times of change: e.g. people are more

worried about their jobs than facilitating research

Laws change Introduction of ‘involuntary outpatient treatment’

Culture changes Changes in society – drug use; crime trends; unemployment Growth of ‘patient voice’

Compulsory admissions to NHS facilities, including high security hospitals and private mental nursing homes

1987/88-2009/10Total orders, changes from informal to section, and court orders

2008/09 2009/10 2010/11

s2 191 234 297

s3 232 243 240

TOTAL 719 813 925

Quarter 3 MHA statistics South London & Maudsley NHS foundation Trust

Health and Social Care Information Centre, KP90

Why CTOs increase

Broadening of criteria for compulsion huge scope for discretion ‘lobster-pot’ phenomenon

Risk averse society Loss of ‘ceiling effect’ Less resources

will lead to changing relationships between patients and clinicians

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Kjellin et al, Int J Law Psychiatry 2008

Compulsory treatment in Sweden 1979 - 2002

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Mental Health Review Board (Victoria, Australia): statistics

1996/1997 1999/2000 2006/2007 % change

Cases listed 10,522 13,196 18,719 1996 to 2006 + 78%

1999 to 2006 + 42%

Mental Health Review Board of Victoria Annual Report - 2007-2008

Context: National variation

2. Place Large variation despite similar service

configurations and legal framework ‘Custom and convention’ Influential local treatment ‘opinion formers’ (such as

a local university professor)

Variation in use of coercive measures in psychiatric hospitals B. Lay et al, 2011

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Kjellin et al, Int J Law Psychiatry 2008

Compulsory treatment in Sweden 2001 - 2002Intra-national variation

Husum et al, 2010

Norway

Janssen et al, 2013

Netherlands29 wards

Factors studied:1 patient characteristics2 ward characteristics (mostly unspecified)

‘Perceived Coercion’ and its associations

Variation and inconsistency in findings Strongest support for

role of ‘procedural justice’ (or voice) quality of therapeutic relationship

From: Newton-Howes & Mullen, Psychiatric Services (2011)

And some recent studies:Hoyer, 2007Katsakou et al, 2011Thorgerson et al, 2010Sheehan & Burns, 2011

Therapeutic relationship in the context of perceived coercion in a psychiatric population:Anastasia Theodoridoun, et al (2012)

Perceived coercion and therapeutic relationship

Sheehan K & Burns T: Psychiatric Services (2011)

Perceived coercion and therapeutic relationship

Galon & Wineman (2011)

Perceived coercion and ‘procedural justice’

Physical coercion, perceived pressures and procedural justice in the involuntary admission and future engagement with mental health services. O'Donoghue B, et al. Eur Psychiatry. 2011

Perceived coercion and ‘procedural justice’

Perception of coercion:Was involuntary admission justified?

Priebe et al, 2010: Patients’ views of involuntary hospital admission after 1 and 3 months: prospective study in 11 European countries

Variation: Interventions

Interventions to reduce coercion will inevitably be ‘complex’

The ‘control’ condition may vary greatly There may be major difficulties in ensuring

fidelity across centres

Crimson study: variations by site

Centre Site 1 Site 2 Site 3

‘Individualised’ CPA crisis plan at baseline

17% 40% 20%

At least one treatment refusal in JCP

18% 39% 43%

JCP word-count 444 378 536

Ethical issues

Some RCTs would not be ethical Important groups of patients are excluded

Capacity to consent When can research proceed without capacity?

Sensitivity about research in this area Vulnerability v. fear of negative reactions

So what can we do?

Research is crucial if we seek improvements in practice Accept that it is primarily of local significance (and accept the

consequences of this for researchers; provide important details of local context) Think about interventions that might be generalisable

(e.g. advance statements)

For intervention studies, an adequate ‘formative period’ is necessary

Think about whether models developed elsewhere could be applied locally (e.g. the contexts share similar features)

RCTs may have only a limited role Involve patients as collaborators in the research (and

encourage a dialogue between them and clinician researchers)