Best Practices: Visions for Best Practices in Using Coercion in Mental Health Care

This issue of Psychiatric Services features three related Best Practices columns. All authors appear to agree: “forced recovery” is an oxymoron, coercive interventions may sometimes be required, and coercive interventions do not supersede voluntary treatment strategies. However, a closer look is warranted.

Ashcraft and colleagues (1) advocate for “no force first.” Force may be used as a last resort. They describe “emergency forced psychotropic medication” administered during a “supportive hold,” which itself would be defined as restraint in many inpatient settings. Thus their claim that no restraint was used during the study period is a matter of definition. Nonetheless, their credo of no use of force to coerce staff-desired outcomes and use of force only as a last resort is commendable.

Wisdom and colleagues (2) provide an overview of an innovative reform of the licensure process for outpatient clinics in New York State. The approach emphasizes recovery-oriented values. Of note, there are no explicit indicators related to coercion among the 31 measurable criteria. However, measures listed in the column's online supplement include safety plans for all “at-risk” individuals; engagement and retention efforts, including follow-up after missed appointments; a “system-wide effort to track and reduce disengagement”; and follow-up after hospital discharge. It seems that clients of an exemplary clinic would find it difficult to “just be left alone.”

O'Reilly and colleagues (3) review the use of involuntary outpatient treatment (IOT) in Commonwealth countries—thus focusing directly on coercion. Their model of IOT is applied only to individuals with impaired competence to refuse treatment. And then the treatment is used only if it can be reliably expected to prevent deterioration that would result in serious risk—and only when the individual, if competent, would not want that outcome.

Although Ashcraft and colleagues regard the use of seclusion and restraint as a treatment failure, others view it as an effective tool—not a treatment—to be used judiciously in an emergency to prevent injury. Although O'Reilly and colleagues hold that IOT is an efficacious intervention for a cohort of persons with debilitating illness living in the community, others proclaim involuntariness has no place outside highly regulated inpatient facilities. Ashcraft and colleagues hedge their bets by the inclusion of a restraint procedure, O'Reilly and colleagues suggest IOT be used only after voluntary treatment fails, and Wisdom's group shows New York ignoring the topic of explicit community coercion.

Looking past labeling and force-fitting ideology into patterns of practice, all three columns seem to agree on the importance of conducting excellent assessments, defining effective engagement strategies, involving families, using a strengths-based approach, collaborating maximally with the patient in developing a treatment plan, sharing risk, minimizing coercion, using no force in the community to achieve compliance, and honoring choice and stated needs to the greatest extent possible. The nuances can be found in the thresholds for withholding coercion to the maximum extent possible. And it is about these nuances that we should all be talking more, and more collegially.

For example, IOT procedures are implemented inconsistently across and even within states and provinces. This variability is a function of such factors as availability of resources and ideological viewpoint. The best practices process should focus on leveraging evidence from studies of variability to guide the field. To this end, we need to establish benchmarks for the appropriate use of IOT. For example, what is an acceptable percentage of patients participating in IOT in a defined treatment setting for a specified time frame? What is an acceptable rate of fidelity to established clinical criteria for IOT? What amount of clinical improvement should we expect to see?

With benchmarks we can strive to improve IOT practices with a goal of ensuring that it is employed as appropriately and effectively as possible. These three Best Practices columns contribute to the goal of limiting the use of coercion to situations in which it is clinically and ethically justified.