CLINICAL HANDBOOK OF SCHIZOPHRENIA

49. Involuntary Commitment 519It has been suggested that coercion can helpfully be understood as forming part of aspectrum of “treatment pressures” placed on people. Szmukler and Applebaum (2001)have conceptualized a hierarchy of “treatment pressures” (Table 49.2) that may assist inunderstanding and making decisions to treat an individual involuntarily.Persuasion, Leverage, and InducementThese may be described as “positive pressures” to take treatment—the “carrots” ratherthan the “sticks.” The lowest level of treatment pressure is persuasion, in which the professionalsets out for the client the benefits of a particular course of action and attemptsto counter objections. The patient is free to reject advice. The next level of pressure, leverage,assumes an interpersonal relationship between the client and professional that has anelement of emotional dependence. This gives the professional power to pressure the clientby demonstrating approval of one course of action or disapproval of another. Greaterpressure may be exerted by inducement, in which acceptance of treatment is linked tomaterial help, such as support in accessing charitable or welfare funds over and aboveany basic entitlement.Threats and CompulsionThese “negative pressures” are overtly coercive. A threat could be made to withdraw serviceson which the client normally relies (which is more coercive than simply failing to offerinducements over and above normal services), or to detain the client in the hospital.Finally, involuntary commitment, at the highest level of the hierarchy of pressure, carrieswith it the power to use physical force to overcome resistance to treatment.PERTINENT RESEARCH FINDINGSThe act of detaining a patient is a legal intervention, though one with clinical consequences.Depending on the research question being addressed, legal analysis, the principallyqualitative methods of the social sciences, or the epidemiological and statisticalmethods of the medical sciences may be required.An example of a question requiring legal analysis arose when the United Kingdompassed the Human Rights Act (2000), which introduced into domestic law the rights affordedby the European Convention on Human Rights (ECHR). It was suggested thatthis might lead to widespread challenges to psychiatric practice in the United Kingdom asarticles of ECHR protecting the liberty and privacy of the subject were invoked, andsome commentators predicted a “flood” of cases. An analysis of decisions of the Euro-TABLE 49.2. Hierarchy of Treatment Pressures• Persuasion• Leverage• Inducements• Threats• Compulsion (including the use of physical force)Note. From Szmukler and Applebaum (2001). Copyright 2001by Oxford University Press. Adapted by permission.