Involuntary outpatient treatment as "desintitutionalized coercion": the net-widening concerns

Ethical challenges for nurses delivering coercive interventions in community mental health settings: A scoping review

The number of Australians subject to coercive interventions in community mental health services continues to increase. This is in the context of a growing awareness of the harms from coercion, increasing concerns about potential breaches of human rights and an ongoing uncertainty regarding the clinical benefits of community treatment orders, the primary instrument of legislated coercion in community mental health services. Nurses in community mental health services are on the frontline with regard to coercion. They police the requirements of the community treatment order, administer medication to people in community settings without their consent and facilitate re-hospitalisation if indicated. Coercive practice contradicts the person-centred, recovery-oriented and trauma-informed care principles that inform contemporary mental health nursing. This contradiction may generate ethical challenges for nurses and result in ethical distress. The aim of this scoping review was to map the research literature on how nurses in community mental health settings recognise and manage the harm associated with the administration of coercive interventions and consider the ethical challenges that may arise within this practice. The search strategy yielded 562 studies with author consensus determining a total of three articles as meeting the inclusion criteria. The resulting literature identified three themes: (1) maintaining the therapeutic relationship, (2) promoting autonomy and (3) using subtle forms of control. This review demonstrated that there is minimal research that has considered the ethical challenges related to the use of coercion by nurses in community mental health settings.

Is it the right time to implement Community Treatment Order in India?

India enacted the Mental Healthcare Act, 2017 (MHCA 2017) on April 7, 2017 to align and harmonize with United Nations Convention on Persons with Disabilities and the principles of prioritizing human rights protection. While MHCA 2017 is oriented toward the rights of the patients, the rights of the family members and professionals delivering treatment, care, and support to persons with severe mental disorder (SMD) often suffer. MHCA 2017 mandates discharge planning in consultation with the patients for admitted patients and makes the service providers responsible for ensuring continuity of care in the community. The concerns surrounding the chances of relapse and recurrence when a person with a SMD stops medications continue to remain largely unaddressed. The rights-based MHCA 2017 makes it difficult for the prevailing practices of surreptitious treatment by the family/caregiver and proxy consultations on behalf of the patients. This will, in turn, lead to increased chances of relapse, risk of violence, homelessness, stigma, and suicide in persons with SMDs in the community, largely due to noncompliance to treatment. This will also result in increased caregiver burden and burnouts and may also cause disruptions in the family and the community. To strike a balance over the current MHCA 2017, there is a need to amend or bring-forth a new law rooted in the principles of community treatment order.

The legal oversight of community treatment orders: A qualitative analysis of tribunal decision-making

Community treatment orders (CTOs) have been in place in various jurisdictions for over three decades, and yet are still a controversial aspect of mental health provision. One of the ethical concerns CTOs may engender is how difficult it can be to secure discharge from them, which in some jurisdictions can result in service users being subject to compulsion in the community indefinitely. Given the questions that can therefore be raised about the discharge process, it is important to understand the role of the mental health tribunal as a key safeguard in the management of CTOs. However, whilst a substantial body of literature exists on CTOs and on various aspects of tribunal practice in inpatient settings respectively, relatively little has been written about the role of the tribunal in the oversight of CTO discharge decisions. This article presents the results of an eight month ethnographic investigation into CTO use in England, focusing on the factors which contribute to tribunal decisions. A total of 62 participants were involved in the study, including 18 service users on CTOs, 36 mental health practitioners and 8 tribunal chairs. A combination of interviews, observations and documentary analysis are drawn upon to illustrate tribunal decision-making practice on CTOs. The key themes reported on are: the mediating influence of participant presentation and interaction in tribunals; tribunal framing and interpretation of insight and risk; and the importance of timing to tribunals, both in terms of the perceived stability of a service user's social circumstances, and the length of the CTO. The findings highlight the cumulative and interrelated effect of such factors on tribunal decision-making, and point to how tribunal judgements are heavily weighted towards upholding CTOs, with the implications that holds for individual rights.

Trust and Community Treatment Orders

There are conflicting views about the benefits of community treatment orders (CTOs) for people with mental illness. While there is a significant literature on the coercive nature of CTOs, there is less on the impact that CTOs have upon trust. A recovery-oriented approach requires a trusting therapeutic relationship and the coercion inherent in the CTO process may make it difficult for trust to be built, nurtured, and sustained between workers and patients. Our aim was therefore to examine the role of trust within the CTO experience for mental health workers and patients on CTOs. Methods: We conducted a thematic discourse analysis of 8 in-depth interviews with people who were currently on a CTO and 10 interviews with multi-disciplinary mental health workers in Adelaide, Australia (total N = 18 interviews). The interviews were coded and analyzed with the assistance of a patient representative. The findings reveal the challenges and opportunities for trust within the coercive relationship of a CTO. Findings: We found that patients have diverse experiences of CTOs and that trust or mistrust played an import role in whether or not they found the CTO beneficial.

Repression in Residential Youth Care: A Qualitative Study Examining the Experiences of Adolescents in Open, Secure and Forensic Institutions

Repression in residential youth care institutions can manifest itself openly in coercive measures or may be concealed in staff behavior that is endemic to residential youth care, such as soft power and strict behavioral control (i.e., structure), which threatens rehabilitative goals and might even violate children’s rights. To increase awareness of particularly the more hidden aspects of repression, this qualitative study follows the framework method to examine processes that cause adolescents to experience repression. Semistructured interviews were conducted with an ethnic diverse sample of 32 adolescents from open, secure, and forensic (i.e., youth prisons) residential youth care institutions in the Netherlands. Results indicated that adolescents tend to accept structure, rules, coercion, and punishments, and that they expect staff to use their power to create order and safety. However, results also showed that restrictive measures may be approved by adolescents to cope with repression, taking the form of rationalization. Staff behavior perceived as unfair or excessive by the adolescents was conceived of as repressive. Respect for autonomy and providing treatment that is experienced as meaningful by the adolescents seem to decrease experienced repression.

Coercion in mental health: a trial of the effectiveness of community treatment orders and an investigation of informal coercion in community mental health care

Background

Coercion comprisesformal coercionorcompulsion[treatment under a section of the Mental Health Act (MHA)] andinformal coercion(a range of treatment pressures, includingleverage). Community compulsion was introduced in England and Wales as community treatment orders (CTOs) in 2008, despite equivocal evidence of effectiveness. Little is known about the nature and operation of informal coercion.

Design

The programme comprised three studies, with associated substudies: Oxford Community Treatment Order Evaluation Trial (OCTET) – a study of CTOs comprising a randomised controlled trial comparing treatment on CTO to voluntary treatment via Section 17 Leave (leave of absence during treatment under section of the MHA), with 12-month follow-up, an economic evaluation, a qualitative study, an ethical analysis, the development of a new measure of capabilities and a detailed legal analysis of the trial design; OCTET Follow-up Study – a follow-up at 36 months; and Use of Leverage Tools to Improve Adherence in community Mental Health care (ULTIMA) – a study of informal coercion comprising a quantitative cross-sectional study of leverage, a qualitative study of patient and professional perceptions, and an ethical analysis.

Participants

Participants in the OCTET Study were 336 patients with psychosis diagnoses, currently admitted involuntarily and considered for ongoing community treatment under supervision. Participants in the ULTIMA Study were 417 patients from Assertive Outreach Teams, Community Mental Health Teams and substance misuse services.

Outcomes

The OCTET Trial primary outcome was psychiatric readmission. Other outcomes included measures of hospitalisation, a range of clinical and social measures, and a newly developed measure of capabilities – the Oxford Capabilities Questionnaire – Mental Health. For the follow-up study, the primary outcome was the level of disengagement during the 36 months.

Results

Community treatment order use did not reduce the rate of readmission [(59 (36%) of 166 patients in the CTO group vs. 60 (36%) of 167 patients in the non-CTO group; adjusted relative risk 1.0 (95% CI 0.75 to 1.33)] or any other outcome. There were no differences for any subgroups. There was no evidence that it might be cost-effective. Qualitative work suggested that CTOs’ (perceived) focus on medication adherence may influence how they are experienced. No general ethical justification was found for the use of a CTO regime. At 36-month follow-up, only 19 patients (6% of 329 patients) were no longer in regular contact with services. Longer duration of compulsion was associated with longer time to disengagement (p = 0.023) and fewer periods of discontinuity (p < 0.001). There was no difference in readmission outcomes over 36 months. Patients with longer CTO duration spent fewer nights in hospital. One-third (35%) of the ULTIMA sample reported lifetime experiences of leverage, lower than in the USA (51%), but patterns of leverage experience were similar. Reporting leverage made little difference to patients’ perceived coercion. Patients’ experiences of pressure were wide-ranging and pervasive, and perceived to come from family, friends and themselves, as well as professionals. Professionals were committed to patient-centred approaches, but felt obliged to assert authority when patients relapsed. We propose a five-step framework for determining the ethical status of offers by mental health professionals and give detailed guidance for professionals about how to exercise leverage.

Conclusions

Community Treatment Orders do not deliver clinical or social functioning benefits for patients. In the absence of further trials, moves should be made to restrict or stop their use. Informal coercion is widespread and takes different forms.

Trial registration

Current Controlled Trials ISRCTN73110773.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Commitment without confinement. Outpatient compulsory care for substance abuse, and severe mental disorder in Sweden

In Sweden, a person with severe substance abuse or a severe mental disorder may be committed to compulsory care according to two different legislations. Both acts include an option of providing involuntary care outside the premises of an institution - care in other forms (COF) and compulsory community care (CCC), respectively. As co-occurring disorders are commonplace many individuals will be subject to both types of compulsory care. The structures of both legislations and their provisions for compulsory care in the community are therefore scrutinized and compared. Based on a distinction between "least restrictive" or "preventative" schemes the article compares COF and CCC in order to determine whether they serve different purposes. The analysis shows that COF and CCC both share the same avowed aims of reducing time spent in confinement and facilitating transition to voluntary care and the community. But they also serve different purposes, something which is reflected in disparate scopes, eligibility criteria, rules, and practices. Overall, COF was found to be a more "least restrictive" and CCC a more "preventative" scheme. The distinction is associated with COF being an established part of legislation on compulsory care for substance abuse with a universal scope and CCC being a recent addition to compulsory psychiatric care legislation with a selective character.

The compliant court--procedural fairness and social control in compulsory community care

Compulsory community care (CCC) was introduced in Sweden in 2008. This article investigates all written court decisions regarding CCC over a 6 month period in 2009 (N=541). The purpose is to examine how the legal rights of patients are protected and what forms of social control patients are subjected to. 51% of CCC patients are women and 84% are being treated for a psychosis-related disorder. In the court decisions, only 9% of patients are described as dangerous to themselves, while 18% are regarded a danger to others. The most common special provisions that patients are subjected to are medication (79%) and a requirement that they must maintain contact with either community mental health services (51%) or social services (27%). In the decisions, both the courts and court-appointed psychiatrists agree with treating psychiatrists in 99% of cases. Decisions lack transparency and clarity, and it is often impossible to understand the conclusions of the courts. There is considerable variation between regional courts as regards the provisions to which patients are subjected and the delegation of decision-making to psychiatrists. This means that decisions fail to demonstrate clarity, transparency, consistency and impartiality, and thus fail to meet established standards of procedural fairness. Surveillance techniques of social control are more common than techniques based on therapy or sanctions. Because of the unique role of medication, social control is primarily imposed on a physical dimension, as opposed to temporal and spatial forms. The article concludes that patients are at risk of being subjected to new forms of social control of an unclear nature without proper legal protection.

Community treatment orders in New Zealand: regional variability and international comparisons

OBJECTIVES

Community treatment orders (CTOs) have been used in New Zealand since 1992 and are now used in most Commonwealth countries. There is little research on the rate of use of CTOs in New Zealand. This study compares the prevalence of CTO use across New Zealand's 20 health districts and makes comparisons with international prevalence rates.

METHODS

New Zealand Ministry of Health reports provided data on rates of CTO use in New Zealand between 2005 and 2011. International rates were obtained from published reports and academic literature on CTO use.

RESULTS

Rates of CTO use in New Zealand show marked and persistent regional variation over the period of data collection. National average rates increased from 58 per 100,000 in 2005 to 84 per 100,000 in 2011. Rates of use of CTOs are increasing internationally. New Zealand's CTO use is high by international comparisons.

CONCLUSIONS

New Zealand's high and increasing rate of CTO use by international standards raises questions about the delivery and functioning of mental health services, and about mental health service users' experience of mental health care. The high rate of CTO use needs to be addressed as a human rights issue as well as a clinical issue.

Involuntary outpatient treatment in patients with severe mental illness: a one-year follow-up study

INTRODUCTION

Involuntary outpatient treatment (IOT) aims to ensure adherence to therapy in patients with serious mental disease who are unaware of their illness and for whom treatment discontinuation carries a high risk of relapse.

OBJECTIVES

To evaluate the effectiveness of IOT in preventing relapse among patients with serious mental disease.

METHOD

A retrospective observational study was carried out on all of the patients (n=140) receiving IOT in the city of Valencia, Spain. Hospital service uses (emergency care, admissions and mean stay times) during the 12 months before and after the introduction of IOT were compared.

RESULTS

Patients with schizophrenia, delusional disorder or schizoaffective disorder showed a significant reduction in the number of admissions and days spent in the psychiatry ward during the year of IOT. The reduction in the number of visits to the emergency department was only significant for the patients with schizophrenia.

DISCUSSION

We conclude that involuntary outpatient treatment may be effective for patients with serious mental disease who are unaware of their illness and for whom treatment discontinuation carries a high risk of relapse.

Leverage and other informal pressures in community psychiatry in England

PURPOSE

Informal practices aimed at managing psychiatric patients in the community setting fall outside legal and policy provision or guidance. "Leverage" is an informal practice whereby practitioners attempt to influence patients' treatment adherence by, for example, making patients' access to subsidised housing conditional upon adherence to treatment or by making treatment adherence a condition of patients' avoidance of financial control. Lower rates of leverage are reported in the UK compared to the USA, possibly due to differences between the US and European social welfare systems. These differences raise questions as to the international comparability of leverage practices described in the literature. The study aimed to capture patients' experiences and perceptions of pressures and to explore (a) whether "leverage" can be distinguished from other pressures, and (b) how a concept of leverage derived from patient experiences in England might fit with the literature to date. In this article we present the different types of pressure that we identified from patients' accounts, and a set of criteria derived for the purpose of distinguishing between these different types of pressure.

METHOD

Twenty-nine qualitative interviews with a purposive subsample from a study of leverage in the English mental health system were analysed.

RESULTS

Participants reported a range of what can be classified as both leveraged and non-leveraged pressures. These were perceived as pressures to adhere to treatment, as well as "staying well." Leveraged pressures were distinguishable from non-leveraged pressures by the presence of three features: conditionality, a lever and direct communication.

CONCLUSIONS

The portrayal of "leverage" in the current literature does not fully capture patient experiences of pressure. Our analysis offers a clearer concept of leverage and other pressures that influence patients, and which may have different legal, ethical and clinical implications.

Why community compulsion became the solution - Reforming mental health law in Sweden

The aim of this article is to understand how compulsory community care (CCC) has become a solution in mental health policy in so many different legal and social contexts during the last 20 years. The recent introduction of CCC in Sweden is used as a case in point, which is then contrasted against the processes in Norway, England/Wales and New York State. In Sweden, the issue of CCC was initiated following high-profile acts of violence. Contrary to several other states, there was agreement about the (lack of) evidence about its effectiveness. Rather than focusing on dangerousness, the government proposal about CCC was framed within an ideology of integrating the disabled. The new legislation allowed for a broad range of measures to control patients at the same time as it was presented as a means to protect positive rights for patients. Compared to previous legislation in Sweden, the scope of social control has remained largely the same, although the rationale has changed - from medical treatment via community treatment and rehabilitation, to reducing the risk of violence, and then shifting back to rehabilitation in the community. The Swedish approach to CCC is similar to Norway, while New York and England/Wales have followed different routes. Differences in ideology, social control and rights orientations can be understood with reference to the general welfare and care regimes that characterize the four states.

Net-Widening and the Diversion of Young People From Court: A Longitudinal Analysis With Implications for Restorative Justice

Internationally, many youth justice systems aim to divert young people from court through informal mechanisms, such as police cautions and restorative conferences. Among other things, diversion avoids the potentially criminogenic effects of formal contact with the criminal justice system. However, in some instances, the sum of court appearances and diversionary procedures indicates an overall increase in the numbers of young people having contact (formal or informal) with the criminal justice system — a phenomenon known as net-widening. This article summarises previous debates about the risks of net-widening. It then presents results from analysis of over 50,000 police records pertaining to young people's contact with the Tasmanian criminal justice system between 1991 and 2002. Across that decade, court appearances markedly reduced, while a corresponding increase in diversions was recorded. There was no evidence of net-widening. However, there was a significant increase in detention orders. Implications for policy and future research are considered.

Compulsory community mental health treatment: literature review

Following their introduction in the United States in the 1970s various forms of compulsory treatment in the community have been introduced internationally. Compulsory treatment in the community involves a statutory framework that mandates enforceable treatment in a community setting. Such frameworks can be categorized as preventative, least restrictive, or as having both preventative and least restrictive features. Research falls into two categories; descriptive, naturalistic studies and controlled and uncontrolled comparative studies. The research has produced equivocal results, and presents numerous methodological challenges. Where programmes have demonstrated improved outcomes debate continues as to whether these outcomes are associated with legal compulsion or enhanced service provision. Service user, family and clinician perspectives demonstrate a divergence of views within and across groups, with clinicians more strongly in support than service users. The issue of compulsory community treatment is an important one for nurses, who are often at the forefront of clinical service provision, in some cases in statutory roles. Critical reflection on the issue of compulsory community treatment requires understanding of the limitations of empirical investigations and of the various ethical and social policy issues involved. There is a need for further research into compulsory community treatment and possible alternatives.

Community treatment orders: the ethical balancing act in community mental health

Community treatment orders (CTOs) are legal mechanisms by which an individual with a mental illness and a history of non-compliance and potential for violence can be mandated (against their will) to undergo psychiatric treatment in an outpatient setting. Although CTOs are increasingly being adopted by governments as a means of protecting both mentally ill persons and society itself, their use continues to stimulate considerable debate. While there is some evidence of their potential benefits in promoting treatment compliance and reducing hospital stays, there is concern that they infringe on the mental health client's human rights and freedoms. Consideration of the ethical and practical implications of the use of CTOs must continue. In this paper, some of the most pressing issues are identified and discussed.

The mental health service crisis of neoliberalism -- an antipodean perspective

Major transformations in forms of governance of the liberal state have been wrought over the course of the last century, including the rise of neoliberalism and 'new public management.' Mental health too has witnessed change, with pharmacological treatment displacing residential care, a shift to community-based services, mainstreaming with general health care, and greater reliance on civil society institutions such as the family or markets. This article considers whether mental health law, and its court/tribunal 'gatekeepers' have kept pace with those changes. It argues that the focus of the liberal project needs to shift to measures which will better guarantee access to mental health services, and keep a more watchful eye on both 'hidden' coercion of people on community treatment orders, and passive neglect of human need.

Mental health legislation in the commonwealth

PURPOSE OF REVIEW

Mental health law is changing in some common law jurisdictions. Questions are being asked about whether special legislation is still needed, whether it is a health or a legal issue, and how this part of the law relates to cognate laws about patient consent to healthcare and determinations about competence. The role of tribunal or court adjudication of the need for admission is also debated, along with the capacity of the law to harness resources or manage care. It is therefore timely to review these debates.

RECENT FINDINGS

Renewed support is evident in the literature for subsuming mental healthcare within the general laws governing consent to care or determinations of competence. Socio-legal and interdisciplinary research suggests that health perspectives are already quite dominant in mental health law, while involuntary detention may correlate poorly with levels of need. The mesh between the law and service systems remains problematic, and there is little evidence that law has yet developed a significant capacity for leveraging treatment resources.

SUMMARY

This review suggests that the priority for future research lies in exploring the factors which enhance treatment access and outcomes for the mentally ill rather than debating the shape or content of mental health law.