Consensual vs. Coercive Treatments: New Manifestations

of an Old Dilemma

Paul S. Appelbaum, MD Dollard Professor of Psychiatry, Medicine, and Law Columbia University/NY State Psychiatric Institute

Goals

  To briefly review the history of coercive approaches in psychiatry

  To consider the extent to which the use of coercive interventions has diminished over time—or merely changed its form

History of Coercive Approaches to Mental Health Treatment

  Can be traced back to beginnings of organized care

  Will focus on examples from U.S., but history is similar in other countries

Pre-institutional period (1607-1751)

  Approaches to dealing with mentally ill persons   Commitment under the poor laws   Jailing for minor offenses   “Warning out”

Early Institutional Period (1752-1833)

  Hospitalization limited; few public or private facilities

  Controlled by family and physician   No legal oversight   Identical to process for other medical

disorders

Development of Public Hospitals (1833-1881)

  System of large state hospitals is developed as progressive reform

  Preexisting system codified

  Family/physician control maintained

Voluntary Hospitalization Authorized (1881)

  Massachusetts is first state to enact voluntary admission provision

  Prior to this, never considered as a legitimate option

  Other states soon follow suit

Involuntary Treatment Predominates (1882-1980)

  Despite voluntary admission statutes, majority of admissions remain involuntary

  Why?

Factors Reinforcing Coercive Approaches - 1

  Presumption that committed, mentally ill persons are incompetent   Written into statutes until mid-20th century   Burden on committed person to

demonstrate that competence has been restored

  If incompetent, patients’ consent was considered irrelevant and interventions used regardless of their desires

Factors Reinforcing Coercive Approaches - 2

  Association between mental illness and violence   Common assumption in the popular mind—

notwithstanding the empirical data

  Police power rationale preempts patients’ decisions, so again treatment can be undertaken regardless of patients’ desires

New Approach to Psychiatric Treatment (1960-1979)

  From a psychiatric perspective, institutional care—especially if involuntary—viewed as inherently inferior to community-based care—especially if voluntary   Evolution from CMHC movement to recovery movement

  From a legal and moral perspective, the legitimate scope of the state’s power to intervene seen as limited to danger to self/others

  Movement for statutory change draws on both and is explicitly aimed at reducing use of coercion

Results of Legal Reform   By 1979, every state limits commitment

criteria to danger to self/others   By mid-1980s, most states adopt rules

restricting involuntary treatment of committed patients   Variety of approaches, but most aimed at

reducing extent of coercive treatment   Medications, ECT, seclusion and restraint were

all targets   Similar changes internationally

Expectations of Reformers

  Involuntary hospitalization will be uncommon

  Most treatment will be voluntary   Coercive approaches will wither away

Aftermath of Reform: Coercion Still Exists

  Coercive approaches have not disappeared, and may not even have diminished

  But the locus of coercion has moved from the institution to the community

  And the form has changed from recognizable coercion to more subtle “leverage”

Concept of Leverage

  Leverage is the regulation of access to benefits that patients want (e.g., freedom, money, shelter, interpersonal support) based on patients’ adherence to treatment recommendations

  Leveraged approaches can be formal or informal, legal or extralegal, overt or subtle

The Prevalence of Community-Based Leverage

Five Sites   Durham, NC   Worcester, MA   Chicago, IL   Tampa, FL   San Francisco, CA

  Overall N: 1,011   Refusal Rate: 6.8%

Monahan et al. (2005). Use of leverage to improve adherence to psychiatric treatment in the community. Psychiatric Services, 56, 37-44.

Eligibility Criteria

  18-65 years old   English or Spanish-speaking   Currently in outpatient treatment with a

public MH service provider   In treatment at least 6 months

Prevalence of Leveraged Community Treatment

Form of Leverage % with Leverage

Obtaining Housing 32

Avoiding Jail (MHCs) 23

Avoiding Hospital (OPC)

15

Obtaining Money (SSDI)

12

Other Forms of Leverage

  Parental custody/visitation   Professional licensure   Student status in primary and

secondary schools, and in colleges and universities

Coercive Approaches Today

  Plausible case that coercion has not diminished (and may have increased)

  But the forms of coercion have morphed (and may have softened)

What Accounts for the Persistence (Growth?) of Coercive Approaches?

  Effects of fear and stigma   Especially prevalent after horrendous

acts of violence by persons with mental illness

DSM-IV Vignette: Schizophrenia (Pescosolido, Monahan, Link, et al, 1999)

NAME is a RACE/ETHNICITY, MAN/WOMAN, who has completed EDUCATION. Up until a year ago, life

was pretty okay for NAME. But then, things started to change. He/She thought that people around him/her were making disapproving comments, and talking behind his/her back. NAME was convinced that people were spying on him/her and that they could hear what s/he was thinking. NAME lost his/her drive to participate in his/her usual work and family activities and retreated to his/her home, eventually spending most of his/her day in his/her room. NAME became so preoccupied with what s/he was thinking that s/he skipped meals and stopped bathing regularly. At night, when everyone else was sleeping, s/he was walking back and forth in his/her room. NAME was hearing voices even though no one else was around. These voices told him/her what to do and what to think. S/he has been living this way for six months.

“How likely is it [John/Mary] would do something violent to other

people?”

% very/somewhat likely

  Schizophrenia: 61   Major depression: 34   Drug dependence: 87

“Do you think that people like [John/Mary] should be forced by law…

to get treatment at a clinic or from a doctor?” (% yes)

Schizophrenia 49

Depression 22

Drug 67

“Do you think that people like [John/Mary] should be forced by law…

to get treatment… if he or she is dangerous to others?” (% yes)

Schizophrenia 49 → 95

Depression 22 → 94

Drug 67 → 96

Could Factors Other Than Fear/Stigma Also Be Operative?

  Coercion/leverage extraordinarily prevalent and diverse

  Might commonsense view that coercion is often necessary be based in reality as well?

Nature of Mental Illness Plays a Role in Prevalence of Coercion-1

  Severe mental illnesses impair decision making in a subset of persons   Competence to consent to treatment may

be limited   Unawareness of illness may lead to failure

to get treatment

Unawareness of Illness Common Among Persons with Some Mental

Illnesses

  Denial vs. anosognosia   Typical finding: 57% of patients with

schizophrenia had “moderate to severe unawareness of having a mental disorder” (Amador, et al., 1994)

Rates of Treatment of Severe Mental Illnesses

  National Comorbidity Survey reported 1-year treatment rate of 48.5% for all persons with severe mental illnesses

  Majority of persons not receiving treatment reported that they did not need it

“Revolving Door” Patients   Geller (1986) identified 12 patients in

one hospital’s records with 276 admissions (range 15-46)

  Nationwide survey (Geller, 1992) of “worst recidivists” showed mean of 31 admissions (range 5-121)   63% schizophrenia   21% bipolar

Justification for Soft Paternalism

  Legitimate to intervene when people   Badly in need of treatment   Likely to suffer harm   Cannot recognize illness/need for

treatment

Nature of Mental Illness Plays A Role in Prevalence of Coercion-2

  Some people with mental illnesses likely to be violent

  Risk is increased compared with general population   Attributable risk varies by country/base

rate of violence

Violence in First 10 Weeks After Discharge – Pittsburgh

Violence in First 10 Weeks by Substance Abuse Symptoms – Pittsburgh

Justification for Hard Paternalism

  Society has right to protect citizens from danger

  Degree of competence may not be material

  Threshold lower if benefit provided

Coercive Approaches Reflect Belief That Paternalism is Justified

  Expectation of eliminating coercion appears to have been overly ambitious

  Hence, coercion has moved from institutions to the community along with patients

  New forms of leverage have been developed

Appropriate Use of Coercion Requires Caution

  Blanket endorsement unwarranted   Many people with mental illnesses can and

should make decisions for themselves

  Blanket rejection also unwarranted   Nature of mental illnesses may justify

coercive intervention

Challenges for Policy Makers

  Limit use of coercion by identifying circumstances that justify it

  Even within these contexts, encourage maximum possible exercise of autonomy