Transcript Slide 1

Jorun Rugkåsa
Research Fellow
Social Psychiatry Group
University Department of Psychiatry
University of Oxford
[email protected]
Why use qualitative methods in the
study of CTOs?
• CTOs are social processes, premised on
coercion
• The MHA is based on presumptions of human
nature and behaviour
• We need to understand the social mechanisms
to fully grasp how CTOs work (or not)
What do we need to know?
• Leave from hospital has been around for a
long time
→ Why would CTOs make a difference?
• In 2008/09 the UK government anticipated
400 CTOs, but 4000 CTOs were initiated
→ What happened?!
Bindman 2000 CTO survey
2009/10
In favour of
46%
CTO/prefer
system with
Against/ prefer 35%
system
without
Unsure
19%
61%
17%
20%
Measuring coercion
Explicit measures
• Objective measures
e.g., involuntary
hospitalisation
• Subjective measures
e.g., MacArthur scale
Implicit dynamics
• Subjective
experiences in
unstructured
interviews
– What is said
– What may not be
said but still shape
perceptions,
experiences,
behaviour
Opinions and experiences of CTOs
• Some good qualitative studies (though
difficult to generalise across countries)
– Doctors hold largely positive views
– Families find them helpful
– Patients are ambivalent
• This literature is largely descriptive; little
theorising around the issues
Patients’ ambivalence
• It was like a prison sentence. I could not go
hunting in the forest with my sons. My psychiatrist
was a fascist. The injections impair my alertness
and energy. They took away my gun licence.
• It brought me back into society as a normal dad. It
lifted the burden of monitoring from my wife. It
saved my marriage. It’s good but there’s
handcuffs on it.
(Gibbs, Dawson et al 2005)
Coercion changes social status
• Loss of credible identity
• Changes to self image and presentation to
others
• Loss of autonomy
• Feeling forced to “play the game”
• Loss of trust in clinicians
(Gault 2009)
North Carolina study
• “Thank-you-theory”: Patients are in retrospect
grateful for coercive treatment
• Little support for thank-you theory in the North
Carolina RCT: most view CTO ambivalently and
with little gratitude
• However, those with good clinical outcome had
more positive appraisal of CTO
• Questions raised:
– At what point does the patient express “real” attitude?
– Does patients’ acceptance of force justify coercion?
– We need a better understanding of patients as
moral agents
(Swartz et al 2003)
ULTIMA study
• 400 patients in 4
samples interviewed
about experiences of
treatment pressure
• 40 qualitative
interviews
• Focus groups with
– Family members
– Mental health teams
• Types of pressure
–
–
–
–
Persuasion
Interpersonal pressure
Inducement
Threat
• Areas of pressure:
–
–
–
–
Housing
Child care
Money
Criminal justice
MH coercion is part of
people’s whole lives
• Coercion across all types/areas reported
• Family members (parents, partners, siblings,
children and friends) pressurise and are involved
in sectioning
• Constant monitoring and pressure contributed to
strained or broken down relationships
– You know, I became a real second class citizen in my
own home […] it just became a nag fest […] I just fell
out of love with her. (CMHT psychosis)
• Family responsibilities generated internal
pressure to keep well
Choice, control & self-determination
• Many participants reported that they
– did not feel coerced
– that there were few or no real consequences of noncompliance
– that they had the power to negotiate
I had a psychiatrist come to my house to do an
assessment. I lit up a cigarette like you do. He said ‘if
you light that cigarette then I’m going to go’, so I said
‘piss off then’. (CMHT non-psychosis)
• Many projected an image of being in control and
compliance as a personal choice
Pressure is not all bad…
• Some participants more coercion to
prevent relapse
• Positive ‘peer’ pressure
– Care coordinator stopped drinking with Mary
• Earning privileges and self-management
– Creating trust between self and GP meant
more involvement in decisions
Should we change how we
conceptualise coercion to better
understand the dynamics?
• It may be unhelpful to assume that all
forms of leverage amount to coercion
• Patients hold more complex views than
many research instruments measure
• Should we conceptualise relationships as
contractual rather than coercive? (Bonnie and
Monahan 2005)
The importance of cultural
models/values
• Rather than only looking at the end point
we will also explore cultural cognition
involved in CTOs (Monahan et al)
– People who are hierarchical and
communitarian tend to support CTOs
– People who are egalitarian and individualistic
tend to oppose them.
– Cultural values, mediated by affect, shaped
individuals’ perceptions of CTO efficiency
OCTET qualitative research question
Why do/don’t CTOs make a difference to
patient outcomes?
• To what extent do the following take effect in the
social processes of CTOs
–
–
–
–
The lack of choice?
The availability of support?
The quality of social relationships?
The models people have for such social
relationships? (cultural models)
What do people bring with them to
MH interactions?
• Cultural and personal expectations for social
relationships may be significant for how these
relationships unfold
• We all experience coercion and have views
about what constitutes legitimate social authority
– It’s not so bad being coerced by someone you trust
– Some coercive actions are not even questioned
– Many patients take a pragmatic view to being coerced
and see themselves as active negotiators
• What is legitimate coercion differs between
individuals, groups, cultures (including law)
In conclusion…
• We need methods able to explore CTOs
as social processes
• We need theories to explain them
• We need to think about what people bring
to social processes and not only their
outcomes
Epilogue: are we shaping
self reporting?
“It’s not really pressure
though, its there for your own
good… It is pressure but it’s
pressure that’s for your own
good… Actually it’s not
pressure at all… But I see
what you mean when you're
saying is it like a pressure
because she wasn't giving
enough pressure… Looking
at it like that it’s hard to say
really if it’s a pressure or not. I
suppose it could be construed
as a pressure.”
Jorun Rugkåsa
Research Fellow
Social Psychiatry Group
University Department of Psychiatry
University of Oxford
[email protected]