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Treatment pressures, coercion, and compulsion 

Treatment pressures, coercion, and compulsion
Treatment pressures, coercion, and compulsion

George Szmukler

and Paul S. Appelbaum

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date: 14 July 2020

In the last half of the 20th century and beginning of the 21st century, psychiatrists and other mental health clinicians became increasingly sensitive to the effects and implications of treatment that was not fully consensual. The number of psychiatric inpatients declined by more than two-thirds during that period. Many countries have tightened their procedures and standards for involuntary commitment (Appelbaum, 1997; Dressing and Salize, 2004). Mental health systems have worked harder to protect patients’ liberty interests, and to avoid circumstances in which non-consensual treatment occurs.

Nonetheless, the nature of mental illness — with patients frequently manifesting denial of their disorder or of a need for care — and the public’s concerns about the propensity of mentally ill persons to injure others or themselves, will probably make it impossible for non-consensual treatment ever to be abandoned completely. Indeed, with the movement to community care, new mechanisms for exerting pressures on patients have developed in services such as Assertive Community Treatment (ACT) (Stein and Santos, 1998). A major focus of ACT — usually targeted at persons with chronic mental illness who are thought likely to drift away from care — is to prevent defaulting from treatment, since loss of contact is likely to lead to relapse and readmission to hospital. Treatment is brought assertively to the patient making disengagement difficult. ‘Compliance’ or ‘adherence’ with medication is often a central issue. In the background also remains the possibility of compulsory admission to hospital.

This chapter has three aims:

To outline a spectrum of treatment pressures in contemporary practice, drawing ethically relevant distinctions between them

To consider when the exercise of such treatment pressures can be justified

To suggest approaches aimed at reducing the need for treatment pressures in community mental health services.

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