Consensual vs. Coercive Treatments: New Manifestations of an Old Dilemma


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Paul S. Appelbaum, M.D. is the Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law, and Director, Division of Law, Ethics, and Psychiatry, Department of Psychiatry, College of Physicians and Surgeons of Columbia University. He was previously A.F. Zeleznik Distinguished Professor of Psychiatry, Chairman of the Department of Psychiatry, and Director of the Law and Psychiatry Program at the University of Massachusetts Medical School. He is the author of many articles and books on law and ethics in clinical practice and research. Dr. Appelbaum is a Past President of the American Psychiatric Association, the American Academy of Psychiatry and the Law, and the Massachusetts Psychiatric Society, and twice served as Chair of the Council on Psychiatry and Law for the American Psychiatric Association. He has been elected to the Institute of Medicine of the National Academy of Sciences.

Dr. Appelbaum was the moderator at The Second Curtis Berger Symposium on Mental Health and the Law, "Assisted Outpatient Treatment in Context: Gaining Compliance in the Community."

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Consensual vs. Coercive Treatments: New Manifestations of an Old Dilemma

  1. 1. Consensual vs. Coercive Treatments: New Manifestations of an Old Dilemma Paul S. Appelbaum, MD Dollard Professor of Psychiatry, Medicine, and Law Columbia University
  2. 2. History of Coercive Approaches to Mental Health Treatment <ul><li>Can be traced back to beginnings of organized care in U.S. </li></ul><ul><li>Mentally ill persons often confined in jails and almshouses in Colonial and Federal eras </li></ul><ul><li>With inception of state hospitals, only one option for admission: involuntary commitment </li></ul>
  3. 3. Voluntary Hospitalization Authorized <ul><li>Massachusetts is first state (1881) to enact a voluntary admission provision </li></ul><ul><li>Prior to this, never considered as a legitimate option </li></ul><ul><li>Other states soon follow suit (NY 1882) </li></ul><ul><li>But the majority of admissions remain involuntary—why? </li></ul>
  4. 4. Factors Reinforcing Coercive Approaches - 1 <ul><li>Presumption that committed, mentally ill persons are incompetent </li></ul><ul><ul><li>Written into statutes until mid-20 th century </li></ul></ul><ul><ul><li>Burden on committed person to demonstrate that competence has been restored </li></ul></ul>
  5. 5. Factors Reinforcing Coercive Approaches - 2 <ul><li>Association between mental illness and violence </li></ul><ul><ul><li>Police power rationale preempts patients’ decisions </li></ul></ul>
  6. 6. New Approach to Psychiatric Treatment (1960-1979) <ul><li>Institutional care viewed as inherently inferior to community-based care </li></ul><ul><ul><li>CMHC movement </li></ul></ul><ul><li>Legitimate scope of state’s power to intervene seen as limited to danger to self/others </li></ul><ul><li>Movement for statutory change explicitly aimed at reducing use of coercion </li></ul>
  7. 7. Results of Legal Reform <ul><li>By 1979, every state limits commitment criteria to danger to self/others </li></ul><ul><li>By mid-1980s, most states adopt rules restricting involuntary treatment of committed patients </li></ul><ul><ul><li>Variety of approaches, but most aimed at reducing extent of coercive treatment </li></ul></ul><ul><li>Similar changes internationally </li></ul>
  8. 8. Expectations of Reformers <ul><li>Involuntary hospitalization will be uncommon </li></ul><ul><li>Most treatment will be voluntary </li></ul><ul><li>Coercive approaches will wither away </li></ul>
  9. 9. Aftermath of Reform: Coercion Still Exists <ul><li>Coercive approaches have not disappeared, and may not even have diminished </li></ul><ul><li>But the locus of coercion has moved from the institution to the community </li></ul>
  10. 10. Focus of Today’s Symposium <ul><li>Use of a variety of techniques intended to influence patients’ adherence to treatment </li></ul><ul><li>Arrayed along a spectrum of pressures, from overtly coercive to “leveraged” </li></ul><ul><li>Data now becoming available on: extent, effectiveness, cost </li></ul><ul><li>Ultimate question: how legitimate are these approaches? </li></ul>