Coercion: point, perception, process

Background: The use of coercion in the treatment of persons with serious mental illness is a long debated strategy to gain adherence to treatment for persons believed to be cognitively impaired by their illness. This article examines the psychometric properties of a scale developed to measure perception of coercion. Using a psychometrically sound scale found to be both reliable and valid in a specific sample of men and women from New York State, we found no difference in perception of coercion between those court-ordered to remain in treatment following hospital discharge and those persons receiving outpatient treatment without a court order. Methods: Therefore, to understand why, given the objective difference in the use of coercion, there was no difference in the subjective perception of coercion, we conducted 20 open-ended interviews with 11 persons without court orders and 9 persons with court orders. Results: We found that where a collaborative relationship was established between the case manager, assigned to the patient with the court order to coordinate post-hospitalization treatment services, and the patient, it was much less likely that the patient perceived him/herself as coerced or forced to take treatment. Conversely, persons without advocates felt themselves to be coerced into treatment when there was no court order to insure treatment adherence. Conclusion: Since perception of coercion significantly influences adherence to treatment, it is vital to identify strategies to reduce perceived coercion for all who receive treatment for serious mental illness

AOT and treatment engagement: evidence from interviews with consumers

Background: The mental health service consumer's perspective on engagement with treatment focuses is the focus of a one year follow-up study of recipients receiving AOT orders (76) and outpatient recipients without AOT orders (108) participating in a study (n = 184) in two boroughs of New York City. Methods: These data complement information regularly collected by the New York State Office of Mental Health. Results: AOT recipients report improved relationships with their case managers and greater insight into their illness over time. Recipients also report an increased participation in services, a decrease in some forms of perceived stigma and coercion, and improved quality of life over time. The individual's relationship with the case manager in more actively engaging the individual in making choices about his own treatment importantly influences persons court ordered into treatment to remain in treatment. Specifically the case manager makes the recipient aware of treatment options that are available and support efforts to take advantage of housing and recovery opportunities. In this way the case manager assists the recipient in gaining more control over his life and may facilitate an improved quality of life. Conclusion: This study provides a unique examination of outpatient commitment from the recipient's perspective

Stigma and coercion in the context of outpatient treatment for people with mental illnesses

The policies and institutional practices developed to care for people with mental illnesses have critical relevance to the production of stigma as they can induce it, minimize it or even block it. This manuscript addresses two prominent and competing perspectives on the consequences for stigma of using coercion to insure compliance with outpatient mental health services. The Coercion to Beneficial Treatment perspective (Torrey, E. F., & Zdanowicz, M. (2001). Outpatient commitment: what, why, and for whom. Psychiatric Services, 52(3), 337-341) holds that the judicious use of coercion facilitates treatment engagement, aides in symptom reduction, and, in the long run, reduces stigma. The Coercion to Detrimental Stigma perspective (Pollack, D. A. (2004). Moving from Coercion to Collaboration in Mental Health Sevices DHHS (SMA) 04-3869. In Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration) claims that coercion increases stigmatization resulting in low self-esteem, a compromised quality of life, and increased symptoms. We examine these differing perspectives in a longitudinal study of 184 people with serious mental illness, 76 of whom were court ordered to outpatient treatment and 108 who were not. They were recruited from treatment facilities in the New York boroughs of the Bronx and Queens. We measure coercion in two ways: by assignment to mandated outpatient treatment and with a measure of self-reported coercion. The longitudinal analysis allows stringent tests of predictions derived from each perspective and finds evidence to support certain aspects of each. Consistent with the Coercion to Beneficial Treatment perspective, we found that improvements in symptoms lead to improvements in social functioning. Also consistent with this perspective, assignment to mandated outpatient treatment is associated with better functioning and, at a trend level, to improvements in quality of life. At the same time the Coercion to Detrimental Stigma perspective is supported by findings showing that self-reported coercion increases felt stigma (perceived devaluation-discrimination), erodes quality of life and through stigma leads to lower self-esteem. Future policy needs not only to find ways to insure that people who need treatment receive it, but to achieve such an outcome in a manner that minimizes circumstances that induce perceptions of coercion.USA Stigma Mental illness Outpatient commitment

Arrest Outcomes Associated With Outpatient Commitment in New York State

http://deepblue.lib.umich.edu/bitstream/2027.42/84915/1/LinkEpperson_2010.pd

Effects of assisted outpatient treatment and health care services on psychotic symptoms

An ongoing debate concerns acceptability, benefits, and shortcomings of coercive treatment such as assisted outpatient treatment (AOT). The hypothesis that involuntary commitment to outpatient treatment may lead to a better clinical outcome for a subgroup of persons with severe mental illness (SMI) is controversial. Nonetheless, positive effects of AOT may be mediated by an increased availability of healthcare resources or increased service use.; The purpose of the present study is to evaluate the course of delusions, hallucinations, and negative symptoms among patients with SMI receiving AOT compared to patients receiving non-compulsory treatment (NCT). Moreover, we assessed if the effects of AOT on psychotic symptoms were mediated by increased healthcare service use.; This study used a quasi-experimental design to examine the effect of AOT and the use of healthcare services on psychotic symptoms. In total, 76 (41.3%) participants with SMI received AOT, and 108 (58.7%) received NCT. The participants were interviewed at baseline every 3 months up to 1 year. Propensity score matching was used to control for group differences.; In the basic model, AOT was associated with lower severity of psychotic symptoms over all follow-up points. In the model including healthcare service use, the frequency of case manager visits predicted a reduction in severity of all psychotic symptoms. The frequency of visits to the outpatient clinics, frequency of emergency room, and psychiatrist visits were independently associated with lower levels of delusional symptoms. Psychiatrist visits were related to a decrease in negative symptoms.; Results indicate that the treatment benefits of AOT are enhanced with the increased use of mental healthcare services, suggesting that the positive effect of AOT on psychotic symptoms is related to the availability of mental healthcare service use. Coercive outpatient treatment might be more effective through greater use of intensive services

Structural Interventions to Reduce and Eliminate Health Disparities.

Health disparities research in the United States over the past 2 decades has yielded considerable progress and contributed to a developing evidence base for interventions that tackle disparities in health status and access to care. However, health disparity interventions have focused primarily on individual and interpersonal factors, which are often limited in their ability to yield sustained improvements. Health disparities emerge and persist through complex mechanisms that include socioeconomic, environmental, and system-level factors. To accelerate the reduction of health disparities and yield enduring health outcomes requires broader approaches that intervene upon these structural determinants. Although an increasing number of innovative programs and policies have been deployed to address structural determinants, few explicitly focused on their impact on minority health and health disparities. Rigorously evaluated, evidence-based structural interventions are needed to address multilevel structural determinants that systemically lead to and perpetuate social and health inequities. This article highlights examples of structural interventions that have yielded health benefits, discusses challenges and opportunities for accelerating improvements in minority health, and proposes recommendations to foster the development of structural interventions likely to advance health disparities research

Structural Interventions to Reduce and Eliminate Health Disparities.

Health disparities research in the United States over the past 2 decades has yielded considerable progress and contributed to a developing evidence base for interventions that tackle disparities in health status and access to care. However, health disparity interventions have focused primarily on individual and interpersonal factors, which are often limited in their ability to yield sustained improvements. Health disparities emerge and persist through complex mechanisms that include socioeconomic, environmental, and system-level factors. To accelerate the reduction of health disparities and yield enduring health outcomes requires broader approaches that intervene upon these structural determinants. Although an increasing number of innovative programs and policies have been deployed to address structural determinants, few explicitly focused on their impact on minority health and health disparities. Rigorously evaluated, evidence-based structural interventions are needed to address multilevel structural determinants that systemically lead to and perpetuate social and health inequities. This article highlights examples of structural interventions that have yielded health benefits, discusses challenges and opportunities for accelerating improvements in minority health, and proposes recommendations to foster the development of structural interventions likely to advance health disparities research