Use of Leverage to Improve Adherence to Psychiatric Treatment in the Community

Duke University, Durham, North Carolina, United States
Psychiatric Services (Impact Factor: 2.41). 02/2005; 56(1):37-44. DOI: 10.1176/
Source: PubMed


A variety of tools are being used as leverage to improve adherence to psychiatric treatment in the community. This study is the first to obtain data on the frequency with which these tools are used in the public mental health system. Patients' lifetime experience of four specific forms of leverage-money (representative payee or money handler), housing, criminal justice, and outpatient commitment-was assessed. Logistic regression was used to examine associations between clinical and demographic characteristics and receipt of different types of leverage.
Ninety-minute interviews were conducted with approximately 200 adult outpatients at each of five sites in five states in different regions of the United States.
The percentage of patients who experienced at least one form of leverage varied from 44 to 59 percent across sites. A fairly consistent picture emerged in which leverage was used significantly more frequently for younger patients and those with more severe, disabling, and longer lasting psychopathology; a pattern of multiple hospital readmissions; and intensive outpatient service use. Use of money as leverage ranged from 7 to 19 percent of patients; outpatient commitment, 12 to 20 percent; criminal sanction, 15 to 30 percent; and housing, 23 to 40 percent.
Debates on current policy emphasize only one form of leverage, outpatient commitment, which is much too narrow a focus. Attempts to leverage treatment adherence are ubiquitous in serving traditional public-sector patients. Research on the outcomes associated with the use of leverage is critical to understanding the effectiveness of the psychiatric treatment system.

Download full-text


Available from: Allison D Redlich, Sep 07, 2015
  • Source
    • "Over recent years there have been increasing calls for a more detailed examination of relationships between caregivers and those who receive care (Scheid, 2001). Many report their experience of community support and care as coercive (Burns et al., 2011; Monahan et al., 2005; Jaeger and Rossler, 2010; Angell et al., 2007). There is little evidence as to whether perceived coercion affects outcome either positively or negatively but it is generally viewed as a negative aspect of community care (Szmukler and Applebaum, 2008). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background Coercion has always existed in psychiatry and is increasingly debated. The ‘move into the community’ in many countries over recent decades and the evolution of community services have substantially altered the locus of coercion. In many countries psychiatric services remain poorly funded and patchy. Substantial differences between regions and countries in the provision of services, the role of the family, and the wider economic and political climate are likely to lead to different sources and experiences of coercion. Discussion This paper explores a number of factors that may affect the prevalence and type of coercion in psychiatric services and in society and their impact upon those with severe mental illnesses. Differences in service provision are explored and wider societal issues that may impact are considered along with relevant evidence. Conclusions Coercion is commonly experienced by those with severe mental illnesses but is poorly understood. The vast majority of research relates to High Income Group countries with developed community services and formal mental health legislation that adopt the so-called ‘medical model’. Further research and collaboration is urgently required to increase our understanding of these issues, which are difficult to define and measure. An evidence base that is relevant worldwide, not just to a small group of countries, is needed to inform training and the care of all patients. A particular focus must be expanding our knowledge and understanding of coercion in cultures outside those where such research has traditionally taken place to date.
    Full-text · Article · Apr 2014 · Asian Journal of Psychiatry
  • Source
    • "Forging trusting, supportive relationships (Lingam and Scott 2002; Kirsh and Tate 2006; Appelbaum and Le Melle 2007; Stanhope and Matejkowski 2010) Creating partnerships through listening to patients' views, including their resistance, and communicating that one sees patients' viewpoint (Seale et al. 2005; Magnusson and Severinsson 2004; Angell et al. 2006) Showing 'human' and not exclusively 'professional' responses, developing 'therapeutic friendliness' (Olofsson et al. 1995, Gardener and Lidz 2001; Olofson and Norberg 2001; Seale et al. 2005; Kirsh and Tate 2006) Developing skills to overcome hostility and conflict (Seale et al. 2005) Reminding or persuading, including appealing to obligations to reciprocate (Solomon 1996; Lützén 1998; Angell et al. 2006; Stanhope et al. 2009; Gardener and Lidz 2001) Educating patients through motivational interviewing and psychosocial interventions, CBT or behavioral interventions (Angell et al. 2006; Stanhope et al. 2009; Gray et al. 2002; Zygmunt et al. 2002) Giving verbal reminders about potential consequences of nonadherence , drug use or self neglect, or confronting patients with these consequences (Swartz et al. 2002; Appelbaum and Le Melle 2007; Angell et al. 2006; Nath et al. 2012) Negotiating deals, including presenting choices (e.g. about use of medication) (Susser and Roche 1996; Lützén 1998; Seale et al. 2005) Using reinforcement strategies such as praise or taking patients out for coffee (Angell et al. 2006) Using incentives such as food, shelter or money (Angell 2006; Appelbaum and Le Melle 2007; Lopez 1996; Classen et al. 2007) Structuring adherence through routines, for example by bundling medication delivery with disbursement of money (Angell et al. 2006; Appelbaum and Le Melle 2007) Intensive monitoring of medication or observed consumption (Appelbaum and Le Melle 2007; Moser and Bond 2009; Nath et al. 2012) Involving family, friends or family doctors in the monitoring of medication (Seale et al. 2005; Appelbaum and Le Melle 2007) Holding back support or refraining from activities (such as caring for pets or homes) (Angell et al. 2006) Making unwanted contacts or increasing attention from care coordinator (Appelbaum and Le Melle 2007; Swartz et al. 2002) Making access to housing, children or social security benefits contingent on treatment adherence (Korman et al. 1996; Robbins et al. 2006; Anderson et al. 1993; Nicholson 2005; Monahan et al. 2005; Burns et al. 2011; Jaeger and Rossler 2010) Making access to money conditional (Appelbaum and Redlich 2006; Elbogen et al. 2003; Nath et al. 2012) Initiating actions to bring about consequences such as invoking the threat of or threaten with (re)hospitalization or the involvement of legal authorities (Appelbaum and Le Melle 2007; Angell et al. 2006) Holding back, delaying or playing down information (e.g. about side effects of medication) or telling something which is untrue (Solomon 1996; Seale et al. 2005) "
    [Show abstract] [Hide abstract]
    ABSTRACT: The emphasis on care in the community in current mental health policy poses challenges for community mental health professionals with responsibility for patients who do not wish to receive services. Previous studies report that professionals employ a range of behaviors to influence reluctant patients. We investigated professionals' own conceptualizations of such influencing behaviors through focus groups with community teams in England. Participants perceived that good, trusting relationships are a prerequisite to the negotiation of reciprocal agreements that, in turn, lead to patient-centred care. They described that although asserting professional authority sometimes is necessary, it can be a potential threat to relationships. Balancing potentially conflicting processes-one based on reciprocity and the other on authority-represents a challenge in clinical practice. By providing descriptive accounts of micro-level dynamics of clinical encounters, our analysis shows how the authoritative aspect of the professional role has the potential to undermine therapeutic interactions with reluctant patients. We argue that such micro-level analyses are necessary to enhance our understanding of how patient-centered mental health policy may be implemented through clinical practice.
    Full-text · Article · Mar 2014 · Community Mental Health Journal
    • "; Elbogen, Soriano, van Dorn, Swartz, & Swanson, 2005; Monahan et al., 2005). One recent study found that leverage is experienced less frequently in the UK than in the US (at a rate of around 30% compared to 50%) (Burns et al., 2011; Jaeger & Rossler, 2010; Monahan et al., 2005). One reason for this might be connected to differences between the US and European social welfare systems in terms of whether basic needs are seen as rights or privileges. "

    No preview · Article · May 2011 · Psychiatrische Praxis
Show more