One of the aims of crisis resolution is to offer treatment in a less coercive manner than inpatient care, which always imposes the constraints of institutional living on patients, whether or not they are also subject to legal compulsion, physical restraint or forcible injections. While many people do indeed recognise and value the freedom to be treated in their own environment, treatment at home may also be applied coercively, and crisis resolution teams (CRTs) use a range of ‘treatment pressures’ in the course of their work, including, but not confined to, the use of legal compulsion. In some cases, the degree of intrusion into the patient's home environment and social network may be so great that they may find hospital treatment preferable. This chapter describes a simple hierarchical model of treatment pressures and illustrates how these may be applied in practice by CRTs, and the dilemmas that arise. The use of legal powers to compel acceptance of treatment in the community and some of the practical difficulties of using coercive powers in a community setting are also discussed.

Defining coercion

Szmukler and Applebaum (2001) have conceptualised a hierarchy of ‘treatment pressures’ (Figure 18.1). Only the highest levels of the hierarchy (threats and force) are conventionally recognised as coercive, but the lower levels of treatment pressure, commonly used in practice, raise some of the same ethical dilemmas as the higher ones, and all can be regarded as forms of coercion.