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Research group: Tom Burns, Ksenija Yeeles, Helen Nightingale, Andrew Molodynski, Kathryn Davies, Montserrat De la Huerta, Krysia Canvin, Anna Sulman



The coercive imposition of mental health care services on patients has long been a controversial issue in psychiatry.  In recent years the locus for treatment of mental illness has shifted from the hospital to the community and with this change has come a host of new legal and ethical issues.

In England and Wales, the possible introduction of legal compulsion in community mental healthcare has attracted much attention.  Community Treatment Orders (CTOs) have formally proposed on two occasions in the past 20 years.  The proposals, reviewed by the Royal College of Psychiatrists in 1988 and 1993, met with considerable opposition from psychiatrists, nurses and social workers.  The latest draft Mental Health Bill indicates that a form of CTO is likely to be legislated in the near future.  The rationale behind this legislation would be to improve treatment adherence in the community.

Most of the discussion surrounding coercive practices in community treatment has focused on the use of legislation to mandate compliance.  In service provision, however, it is clear that other forms of coercion are often used to engage and maintain patients in community treatment.  The linking of social services and mental healthcare has resulted in tools, such as housing and welfare benefits, being used as leverage to ensure compliance with treatment.  For example, in some cases, patients must remain in treatment for their mental illness to keep occupancy in service-based housing.

Monahan et al. (2005) conducted the first study of leverage tool use to improve treatment adherence in the community.  Examining the use of formal legal leverages (outpatient commitment, avoidance of criminal sanction) and more informal leverages (housing, management of finances), they found that approximately 50% of patients had been subject to the use of at least one leverage tool.  Interestingly outpatient commitment, the most hotly debated leverage tool investigated, was the least used in practice.  Housing, financial management and avoidance of criminal sanction were the most used respectively.  Some demographic characteristics (i.e. being male and young) were associated with the use of leverage tools, as were some clinical characteristics (i.e. lower functioning and insight).

While not yet published, another component of the Monahan study also examined whether patients perceived the use of these tools as coercive.  The MacArthur Research Network on Mental Health and the Law has developed a psychometrically valid scale for measuring patients’ perceptions of coercion.  Primarily used in research investigating experiences of coercion during the hospital admissions process, these studies have indicated that perceived coercion is not absolutely correlated with legal status at admission.  Perceived coercion has been found to be associated with the use of negative pressures, like threat and physical force, and inversely related to a patient’s sense of procedural justice.  There is evidence that treatment expectations and the nature of the therapeutic relationship between clinician and patient also affects the sense of coercion.  As feeling coerced into treatment has been linked with disengagement from services, this is an important consideration when using leverage tools in the community.

The purpose of the current study is to examine the use of leverage tools in England.  As outpatient commitment does not formally exist in England and Wales (until October 2008), we will investigate the use of Supervised Discharge Orders (SDOs; referred to as Section 25 or ACUS) and Section 17 leave (extended community leave for patients legally detained in hospital) as current de facto community treatment orders.  Housing, financial management, avoidance of criminal sanction and child custody will also be examined.


1. Assess the prevalence and pattern of leverage tool use among three patient groups in England (Assertive Outreach, Community Mental Health, Substance Misuse) 2. Compare the prevalence and patterns of leverage tool use between England and the United States 3. Determine whether patients perceive the use of leverage tools as coercive 4. Conduct detailed qualitative assessments with  patients, staff and carers to explore experiences and perceptions of the utility of leverage and to address ethical questions raised in the study design and the use of leverage


1. The prevalence and pattern of leverage tool use will vary according to the type of service provided 2. The overall prevalence of leverage tool use will be lower in England compared to the United States 3. The pattern of leverage tool use will be similar in the England and the United States 4. Patient baseline characteristics associated with leverage use will be in same in England as in the United States


Sample 400 patients recruited from four patient populations:  100 psychosis patients  in Assertive Outreach care – from Oxford,  South Central  and London  100 psychosis patients in Community Mental Health care– from Oxford and Buckinghamshire  100 long-term disabled non-psychosis patients in Community Mental Health care from Oxford and Buckinghamshire  100 Substance Misuse patients– from Oxford and Southampton

10 patients from each group (substance misuse, assertive outreach, psychosis and non-psychosis CMHT patients) will be selected through purposive sampling based on gender, age, ethnic background and level of experienced leverage for a series of semi-structured , in-depth interviews. A total of 40 qualitative interviews with patients will be conducted within a year after the quantitative interview. Group interviews, when not already formed as a naturally occurring group will be similarly composed; at least one separate carer group and staff group will be convened for each patient group. A total of at least 4 group interviews with carer and 4 group interviews with staff will be conducted.

Inclusion Criteria and Justification  18-65 years of age (in line with local administrative procedures for adult mental health services)  written and informed consent (in line with ethical guidelines)  adequate proficiency in English  (to participate in interview)  under care of service for a minimum of 6 months (to allow for comparison over a sustained period)  minimum of one service contact in the past 6 months (to allow for comparison between this study and USA study)

Exclusion Criteria and Justification  severe dementia (unable to give informed consent)

Methodology 100 patients, meeting the inclusion criteria, will be randomly selected from each of the services involved in the study.  Patients will be introduced to the study by their keyworker at the end of a regularly scheduled appointment.  The patient will be given the study information sheet and a verbal explanation of the research.  They will be asked whether they would like to meet with the researcher to discuss the study further.  Upon agreement by the patient, the keyworker will set up a meeting between the researcher and the patient.  If possible, this will take place following another regularly scheduled appointment.  The patient will be given contact information for the researcher in case they choose to cancel the meeting at a later date.

At the initial patient/researcher meeting, the patient will again be provided with the study information sheet and another verbal explanation of the study.  If interested in participating, the patient will be asked to sign a consent form.  Upon gaining informed consent, the researcher will conduct the interview.  This will take approximately up to 50 minutes.  A review of the patient’s medical notes will also for further data collection and verification of information.

The following data will be collected during the interview and by a review of the patients’ medical notes (where appropriate validated instruments will be used, as indicated below):

Interview Schedule and Notes Review

 demographics o age o sex o ethnicity o education level o marital status o living arrangements o employment

 diagnosis o working diagnosis by clinician

 illness history o age at onset o first contact with psychiatric services o previous hospitalization for mental illness o previous involuntary hospitalization for mental illness o medication use  substance abuse history o self report alcohol and drug abuse o CAGE

 experience of leverage o housing o financial/benefit management o avoidance of legal sanction o outpatient commitment o child custody

 symptom severity o Brief Psychiatric Rating Scale (BPRS)

 general functioning o Global Assessment of Functioning (GAF)

 insight o Insight and Treatment Attitudes Questionnaire (ITAQ)

 perceived coercion o MacArthur Admission Experience Survey (AES)

 therapeutic relationship

o Scale to Assess Therapeutic Relationship (STAR), patient  and key-worker version

 attitudes toward drugs o Drug Attitude Inventory (DAI)

 satisfaction with community-based mental health services   o Client Satisfaction Questionnaire (CSQ)

 service outcomes and costing o Client Service Receipt Inventory (CSRI)

Upon completion of the interview, patients will receive a payment of £10 to reimburse them for travel expenses and their time.

For the qualitative part of the study selected patients who give written consent to be contacted  after their structured interviews will be contacted by a researcher and invited to take part. They will be  given the study information sheet and a verbal explanation of the qualitative part of the research.  They will be asked to give consent to be interviewed and audio recorded. Data collection will be by individual interview with patients and group discussions for separate groups of carers and staff using a semi-structured schedule designed for the purpose. The schedule will use structured questions and vignettes to spark discussion of specific concerns, followed by a more open topic guide for elaboration of participants driven concerns. Carers and staff data collection will be by separate group interviews, using a modified version of the schedule used with patients. All interviews will be audio recorded and transcribed.

Upon completion of the interview, patients will receive a payment of £15 to reimburse them for travel expenses and their time.