Coercion in assertive community treatment: Examining client, staff, and program predictor

Excessive use of coercion (i.e., the exercise of control and power over another to induce behavior change) would suggest indiscriminate use, which is clearly antithetical to the recovery philosophy. Few studies have assessed the rate at which various coercive practices are employed in community mental health, and particularly assertive community treatment (ACT), an evidence based practice (EBP) that has been criticized as being paternalistic and coercive. For this study, three new instruments were developed to measure several coercive practices: involuntary commitment to treatment, control of valued resources (e.g., money and housing), and intensive monitoring of medications and substance abuse. In addition to collecting data to establish much needed base rates of various coercive practices, several program, practitioner, and client caseload variables were assessed for their ability to predict the use of coercion. This study used a cross-sectional design and data were collected from 25 Indiana ACT teams and 156 frontline team members. Compared to the two subjective measures of coercion (i.e., Practitioner Self-Report of Coercion and Trainer Rating of Teams' Coerciveness), the Objective Measure of Agency Control (OMAC), which indexed the extent of control the agency has over clients, was the strongest of the three instruments. As hypothesized, there was no statistically significant correlation between the team's fidelity to the ACT model and coercion. Teams with a lower quality of fundamental clinical practices (e.g., assessment and treatment planning) were associated with greater control. Other significant predictors of coercion included the percentage of client caseload diagnosed with schizophrenia spectrum disorder and practitioners' pessimistic attitudes.