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Pressures to adhere to treatment (‘leverage’) in English mental healthcare

  • Tom Burns (a1), Ksenija Yeeles (a2), Andrew Molodynski (a2), Helen Nightingale (a2), Maria Vazquez-Montes (a3), Kathleen Sheehan (a4) and Louise Linsell (a3)...

Abstract

Background

Coercion has usually been equated with legal detention. Non-statutory pressures to adhere to treatment, ‘leverage’, have been identified as widespread in US public mental healthcare. It is not clear if this is so outside the USA.

Aims

To measure rates of different non-statutory pressures in distinct clinical populations in England, to test their associations with patient characteristics and compare them with US rates.

Method

Data were collected by a structured interview conducted by independent researchers supplemented by data extraction from case notes.

Results

We recruited a sample of 417 participants from four differing clinical populations. Lifetime experience of leverage was reported in 35% of the sample, 63% in substance misusers, 33% and 30% in the psychosis samples and 15% in the non-psychosis sample. Leverage was associated with repeated hospitalisations, substance misuse diagnosis and lower insight as measured by the Insight and Treatment Attitudes Questionnaire. Housing leverage was the most frequent form (24%). Levels were markedly lower than those reported in the USA.

Conclusions

Non-statutory pressure to adhere to treatment (leverage) is common in English mental healthcare but has received little clinical or research attention. Urgent attention is needed to understand its variation and place in community practice.

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Copyright

Corresponding author

Tom Burns, MD, DSc, FRCPsych, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK. Email: tom.burns@psych.ox.ac.uk

Footnotes

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See editorial, pp. 90–91, this issue.

Declaration of interest

None.

Footnotes

References

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Pressures to adhere to treatment (‘leverage’) in English mental healthcare

  • Tom Burns (a1), Ksenija Yeeles (a2), Andrew Molodynski (a2), Helen Nightingale (a2), Maria Vazquez-Montes (a3), Kathleen Sheehan (a4) and Louise Linsell (a3)...

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Pressures to adhere to treatment (‘leverage’) in English mental healthcare

  • Tom Burns (a1), Ksenija Yeeles (a2), Andrew Molodynski (a2), Helen Nightingale (a2), Maria Vazquez-Montes (a3), Kathleen Sheehan (a4) and Louise Linsell (a3)...
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eLetters

Leverage: Need for clarity

Raman D. Pattanayak, Senior Research Associate
05 October 2011

The study by Burns et al (1) assesses the lifetime (ever) prevalence of leverage in British mental health care. The existing literature has no consensus on the definition and concept of leverage. The review by Szmukler (2) describes a range of possible pressures: persuasion, inter-personal leverage, inducements, threats, compulsion. Leverage or pressure to adhere to treatment has not been specifically defined for the purpose of study. We felt that the questions in appendix A could have attracted a certain heterogeneity of responses, depending on patient's interpretation. The framing of some of questions appears to be too liberal, for example, the child custody question (Have you ever been told that your children might be taken into care if you did not participate in treatment) fails to distinguish between leverage, advice during course of therapeutic contact, discussion on a genuine distant possibility or an eventual consequence of untreated relapsing psychosis. It is not evident from the question if the patient was pressured, and it is also not clear if patient was in acute psychotic episode or stable phase when he was told so. In future studies, the patients may be asked to describe at least one incident and the interviewer could ascertain it against certain pre-defined criteria for corroboration of leverage. The persons with repeated hospitalization and/or involuntary treatments may fail to distinguish the formally coerced and informally coerced treatments and may not remember the timeline of events. The leverage incidents in recent one-year leverage may be asked in addition to lifetime experience.Available studies so far has mainly focused on the prevalence of leverage, however it is also important to know the intensity, persistence or outcome of the leverage. More importantly, there is a need to plan qualitative studies in order to understand leverage as a subjective experience. It is important to understand the patient's understanding and their own perceptions of the leverage. There are several ambiguities pertaining to the usage of term, the socio-cultural context, legal use of leverage in substance use treatment, and the role of leverage/coercion by family in treatment of patients. While this study adds to previous literature from U.S and Europe, there are likely be several cultural variations in the practice, perceptions and experience of leverage in Asian societies. We hope that future studies shall strive to resolve the ambiguities and clarify the concept of leverage.

1.Burns T, Yeeles, K, Molodynski, A, Nightingale, H, Vazquez-Montes, M, Sheehan, K, Linsell, L. Pressures to adhere to treatment ('leverage') in English mental healthcare. Br J Psychiatry; 199: 145-50

2.Szmuckler G, Appelbaum PS. Treatment pressures, leverage, coercion, and compulsion in mental health care. J Ment Health 2008; 17: 233-44
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Conflict of interest: None declared

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