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Published Online: May 2013

Leverage, the Treatment Relationship, and Treatment Participation

Abstract

Individuals with severe mental disorders who do not adhere to community-based treatments are often subject to pressures to leverage participation, including pressures related to the criminal justice system, housing, and money. In this study, researchers interviewed nearly 200 outpatients in San Francisco, 40% of whom reported experiencing leverage in the past six months. Those who reported greater coercion were more likely to report taking their medications as prescribed. But higher perceived coercion came at a cost in terms of satisfaction with care.

Abstract

Objective

Although many psychiatric patients experience various forms of pressure or leverage to participate in community treatment, the association between such experiences and treatment participation is controversial. This study evaluated the hypothesis that aspects of the treatment relationship, such as the working alliance, psychological reactance, and perceived coercion, could be important in understanding treatment adherence and satisfaction in a group of patients at risk of experiencing leverage.

Methods

A total of 198 outpatients at two community mental health centers completed structured interviews including measures of the treatment relationship, treatment participation, experience of leverage, and clinical functioning. Regression analyses were used to assess associations between the treatment relationship and treatment adherence and satisfaction while concomitantly considering experiences of leverage, demographic characteristics, and clinical functioning.

Results

Approximately four in ten participants reported experiencing some form of leverage to adhere to treatment during the previous six months, such as pressures related to the criminal justice system, money, housing, and outpatient commitment. Patients who perceived greater coercion to participate in treatment were more likely to report taking their medications as prescribed. Higher satisfaction with treatment was associated with lower perceived coercion, a better working alliance, and lower levels of psychological reactance.

Conclusions

Benefits in medication adherence associated with interventions that patients perceive as coercive may come at a cost of decreased satisfaction with treatment. Aspects of the treatment relationship hold promise for individualizing treatment planning in a way that addresses satisfaction as well as adherence.

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Go to Psychiatric Services
Go to Psychiatric Services

Cover: Portrait of a Woman, by William Beckman, ca. 1988. Oil on board. Photo credit: Jerry L. Thompson/Art Resource, New York City.

Psychiatric Services
Pages: 431 - 436
PubMed: 23412399

History

Published in print: May 2013
Published online: 15 October 2014

Authors

Details

Barbara Gormley, Ph.D.
Renée L. Binder, M.D.
Dr. McNiel and Dr. Binder are affiliated with the Department of Psychiatry, University of California, San Francisco, 401 Parnassus Ave., San Francisco, CA 94143 (e-mail: [email protected]).
Dr. Gormley is with the Department of Psychology and Counseling, Governors State University, University Park, Illinois.

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