Treatment pressures, leverage, coercion, and compulsion in mental health care

Background: Questions concerning non-consensual treatment in mental health services have assumed an increased salience. In significant part, this has been due to changes in professional practice, as well as the perceived risks, associated with the movement of treatment from hospital to community. Aims: To define the main forms of pressure aimed at inducing reluctant patients to accept treatment and to examine frameworks for their justification. Method: Review of the literature on coercion focusing on morally relevant distinctions between its different forms. Findings: A hierarchy of treatment pressures can be defined based on distinctions having moral relevance. These range from persuasion, through interpersonal leverage, inducements (offers), threats, to the use of compulsion. Contemporary ideas about coercion suggest that the use of this term should be reserved for particular types of threat. The relationships to coercion of unwelcome predictions, exploitation and deception can be defined. Conclusions: As one ascends the hierarchy, the stronger must be the justification for intervention by the clinician. Two frameworks can prove helpful in decision-making, one based on a capacity-best interests approach, the other on an analysis of paternalism. Interventions for the protection of others rather than in the health interests of the patient may present special difficulties in their justification.