The associations of informal coercion with legal compulsion, clinical outcomes and the therapeutic relationship in community mental health care

In addition to involuntary treatment, patients with severe mental illness are routinely subject to other pressures such as leverage to improve their adherence to treatment. Little clinical or research attention has been given to these pressures and their associations with both involuntary treatment and clinical outcomes are poorly understood. My thesis aims to test whether the imposing of compulsion affects patients' experience of leverage and whether leverage affects treatment outcomes. It also examines whether patients' relationships with clinicians influence their perception of the coerciveness of involuntary treatment. The thesis begins with a scoping review of current knowledge about non-legislated pressures and identifies their widespread use and limited associations with patient characteristics and outcomes. My empirical studies find that involuntary and voluntary patients do not report different rates of leverage, that leverage is not related to better outcomes, and that the therapeutic relationship does not moderate perceived coercion. My studies suggest that involuntary treatment does not liberate patients from other pressures, but there is also no evidence that clinicians were more controlling with involuntary patients. Unlike legal compulsion, the use of leverage may be a more integral part of clinical practice rather than a considered strategy. Such pressures restrict patient autonomy but their use is neither monitored nor regulated. I found no justification for them in benefits to patients. In contrast to the positive effects of 'procedural justice' I found no evidence that the therapeutic relationship independently alters perceived coercion. Policies and formal training should increase clinicians’ awareness of non-statutory pressures to improve their skills and reduce coercion.