Approximately three-quarters of subjects with psychiatric illness who
report committing serious violent crimes also report experiencing some form of"
A number of demographic and clinical factors are associated with the
experience of leveraged treatment. These include younger age, male gender,
poorer clinical functioning, more years in treatment, more frequent
hospitalizations, higher frequency of outpatient visits, and negative
attitudes toward medication adherence.
Those findings suggest that a combination of concerns about safety and
treatment nonadherence may influence decisions by clinicians and judges to
apply legal leverage, wrote Jeffrey Swanson, Ph.D., and colleagues in the
August American Journal of Psychiatry.
Leveraged treatment refers to any of a wide range of strategies to induce
patients to comply with treatment. These may include mandated community
treatment whereby incarceration or placement in subsidized housing can be made
contingent on compliance, appointment of a money manager to make a patient's
access to funds contingent on treatment adherence, and lenient sentencing by
judges on the condition that a person participate in treatment.
"The findings suggests that a history of violence per se is not
considered a sufficient rationale for applying legal leverage to psychiatric
outpatients, assuming the patient is willing to accept treatment
voluntarily," Swanson told Psychiatric News. "They also
suggest that a patient's unwillingness to take medication is not, in and of
itself, sufficient to warrant legally mandating treatment in the community, as
long as the patient poses no risk of violence. However, if a potentially
violent patient is unwilling to take medication, psychiatrists are more likely
to resort to legal leverage, partly out of concern for their own professional
liability in an adverse event. Similarly in the criminal-justice system, a
judge may order a defendant with mental illness to participate in treatment as
a condition of living in the community, especially if the person isn't likely
to accept treatment voluntarily and may become violent without it."
Swanson is an associate professor of psychiatry at Duke University School
In the study, approximately 200 out-patients were recruited at publicly
funded mental health treatment programs in each of five cities: Chicago,
Durham, N.C., San Francisco, Tampa, Fla., and Worcester, Mass. A single
structured interview lasting about 90 minutes was administered in person by a
trained lay interviewer. Participants were paid $25 for the interview.
The researchers assessed whether respondents had experienced no leverage,
social leverage only (such as leverage involving money or housing), legal
leverage only (outpatient commitment or leverage applied through the criminal
justice system), or both types of leverage.
They used the MacArthur Community Violence Interview to assess study
participants for violent and aggressive behavior during the previous six
Across study sites, 18 percent to 21 percent of participants reported
having committed violent acts in the prior six months. Those who reported
having used or made threats with a lethal weapon, committed sexual assault, or
caused injury ranged from 3 percent to 9 percent.
About three-quarters of subjects who reported such serious violence also
reported having experienced some form of leveraged treatment, compared with
about one-half of subjects who did not report serious violence.
Across the five sites, the proportion of respondents reporting social
welfare leverage alone ranged from 15.7 percent to 26.3 percent of
respondents. Legal leverage alone was reported by 11.2 percent to 17.0
The proportion of respondents who experienced both types ranged from 12.8
percent to 18.5 percent.
People who reported any physically assaultive behavior and also did not
take medication voluntarily were more than twice as likely to have experienced
legal leverage (see FIG1).
"Treating clinicians should understand that the use of leveraged
community treatment is now a common part of the landscape of mental health
services for adults in the United States," Swanson told Psychiatric
News. "Violence risk is sometimes cited as the reason for this, but
clearly leverage is not all about preventing violence. In fact, the use of
leverage is far more common than violence itself is among public psychiatric
Is leverage being applied appropriately? "We don't know enough about
that," Swanson said. "It's likely that the use of leverage to
ensure adherence does prevent violence to some extent. That's probably why
about three-quarters of patients with serious violent behavior have received
some type of legally leveraged mental health treatment. But the main goal in
the application of leverage should be to improve the effectiveness of
treatment in the community—that is, to help meet the complex needs of
people with severe mental illness and not to focus only on reducing serious
violence, which is actually quite a rare phenomenon among these patients.
Otherwise it's going to be a misapplied policy in most cases."
Paul Appelbaum, M.D., chair of APA's Council on Psychiatry and Law, said
the study brings to light for the first time the frequency with which various
forms of leverage are used.
Appelbaum was in charge of the study site at Worcester, Mass., and was
involved in planning the study and analyzing the data.
"Until the study from which these data were drawn, we had no idea of
the frequency of these forms of leverage," he said. "So a major
effect of the underlying study, as well as this analysis, has been to surface
these behaviors and enable discussion about their legitimacy to begin.
"It can be concluded that people who are subject to leverage are at
higher risk for reporting violence, but it's not clear that violence was the
reason that they were subjected to leverage," Appelbaum told
Psychiatric News. "As an alternative hypothesis, it could be
that violent patients are also more symptomatic, and it was their higher
levels of symptomatology that led to leverage use."
In an editorial accompanying the article, appelbaum noted that "it
remains an open question" whether leveraged treatment is effective in
"Among the variables likely to determine effectiveness in a given
population are the extent to which violence is linked to psychiatric symptoms,
the efficacy of treatment in reducing those symptoms, the availability of
treatment, the degree of compliance with treatment (which may relate to how
aggressively the mandates are enforced), and the degree to which positive
effects carry over after the termination of the mandate," he wrote.
In his comments to Psychiatric News, Appelbaum drew a distinction
between mandated out-patient treatment and the forms of leverage experienced
by most of the patients in the study.
"Only a minority of subjects in this study were exposed to outpatient
commitment," he said. "The other forms of leverage that were used
tend to be much less visible, though they may—ironically—be more
coercive. Most outpatient commitment statutes lack real enforcement
provisions. But treatment requirements imposed by the criminal justice system
are ignored only at the risk of being incarcerated, and leverage using housing
or control of money has real consequences as well."
"Violence and Leveraged Community Treatment for Persons with
Mental Disorders" is posted at<http://ajp.psychiatryonline.org/cgi/content/full/163/8/1404>.
Appelbaum's editorial is posted at<http://ajp.psychiatryonline.org/cgi/content/full/163/8/1319>.▪