1. Why is coercion research so difficult? George Szmukler Institute of Psychiatry, King’s College London Oslo, May 2013 Institute of Psychiatry at The Maudsley

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

3. 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

4. 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)

5. 5 Spectrum of treatment pressures 1. Persuasion 2. Interpersonal leverage 3. Inducements 4. Threats 5. Compulsory treatment

6. 6 ‘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

7. 7 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

8. 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?

9. 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

10. 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)

11. 11 ‘OBJECTIVE COERCION’ Involuntary admissions in EU countries 1999 - 2000 International variation Salize & Dressing (2004)

12. International variation Bak & Aggernaes, 2011

13. International variation Bak & Aggernaes, 2011

14. International variation

16. Admission Experience Survey Perceived Coercion Scale 1. 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 Scale 2. 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 Scale 3. 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.

17. Context: National variation 1. 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’

18. Compulsory admissions to NHS facilities, including high security hospitals and private mental nursing homes 1987/88-2009/10 Total orders, changes from informal to section, and court orders

21. 2008/092009/102010/11 s2191234297 s3232243240 TOTAL719813925 Quarter 3 MHA statistics South London & Maudsley NHS foundation Trust

22. Health and Social Care Information Centre, KP90

23. 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

24. 24 Kjellin et al, Int J Law Psychiatry 2008 Compulsory treatment in Sweden 1979 - 2002

25. 25 Mental Health Review Board (Victoria, Australia): statistics 1996/19971999/20002006/2007% change Cases listed 10,52213,19618,7191996 to 2006 + 78% 1999 to 2006 + 42% Mental Health Review Board of Victoria Annual Report - 2007-2008

26. 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)

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

29. 29 Kjellin et al, Int J Law Psychiatry 2008 Compulsory treatment in Sweden 2001 - 2002 Intra-national variation

30. Husum et al, 2010 Norway

31. Janssen et al, 2013 Netherlands 29 wards Factors studied: 1 patient characteristics 2 ward characteristics (mostly unspecified)

32. ‘Perceived Coercion’ and its associations  Variation and inconsistency in findings  Strongest support for  role of ‘procedural justice’ (or voice)  quality of therapeutic relationship

33. From: Newton-Howes & Mullen, Psychiatric Services (2011) And some recent studies: Hoyer, 2007 Katsakou et al, 2011 Thorgerson et al, 2010 Sheehan & Burns, 2011

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

35. Sheehan K & Burns T: Psychiatric Services (2011) Perceived coercion and therapeutic relationship

37. Galon & Wineman (2011) Perceived coercion and ‘procedural justice’

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

39. 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

40. 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

41. Crimson study: variations by site CentreSite 1Site 2Site 3 ‘Individualised’ CPA crisis plan at baseline 17%40%20% At least one treatment refusal in JCP 18%39%43% JCP word-count444378536

42. 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

43. 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)