All Being Equal: Compulsory Treatment in Sweden

Dr Stefan Sjöström (Umeå University) is a sociologist and mental healthcare expert who has been looking at the use of compulsory treatment orders in Sweden since their formal introduction in 2008. How does the Swedish example compare to Victoria? In conversation with Bernadette McSherry.

Transcript

Bernadette McSherry
Hello! I’m Bernadette McSherry, the director of the Melbourne Social Equity Institute.

One of the most controversial issues in mental health care is the use of coercion to treat people with severe mental health problems. Community or compulsory treatment orders exist to enable mental health practitioners to enforce treatment for severe mental health problems outside of hospitals. They’ve existed here in Victoria since 1986 and are used around Australia and other countries but there are varying views and conflicting evidence about the positive and negative effects of compulsory treatment orders on key outcomes. What effect do they have on hospital readmission, length of stay, medication compliance or quality of life? There’s very little evidence out there.

Today I’m speaking with Dr Stefan Sjöström, an associate professor in social work and a lecturer in sociology in Umea University in Sweden, about his research into what’s called compulsory community care in Sweden.

Stefan welcome to the Melbourne Social Equity Institute.

Can you tell us a little bit about the research that you’ve been doing in this field and how you became interested in the topic?

Stefan Sjöström
Yeah. Well it starts back in the 90s I suppose. I studied sociology and also worked in a mental health hospital in Uppsala in Sweden, and so I connected the dots and saw that there are a lot of sociological questions involved in mental healthcare. Then when I started to do my PhD I decided I wanted to do something related to mental health, psychiatry and then we happened to have new legislation about compulsory care so that’s where the money was [laughs]. That became my topic. For my PhD I wrote a book based on ethnographic fieldwork, I stayed for about 18 months at an emergency psychiatric clinic in Sweden’s south, following the staff, sitting in during admission with patients and also following coercive practices in everyday situations. And then I also followed some of these patients into the courtroom where the cases were tested, in administrative courts. The idea to do that was to; the book is called Party or Patients? in the hospital setting the individuals subjected to coercion has the status of a patient, with all the connotation that brings, but then in the courtroom they become an adverse party to their treating psychiatrist. So the psychiatrist, instead of being the therapist, becomes a kind of prosecutory.

That’ is an interesting situation for both parties, and it’s difficult to make sense of. And also we have a class of two very strong institutions, of law and of medicine, so lawyers, legal experts have to make sense of medical decision making, which, because of the nature of expertise, is a hard thing to do. I was interested in how that came out in the court hearings.

Bernadette
So with compulsory care, who actually makes that order?

Stefan
The order is made by any doctor in Sweden and then that provides the power to bring the person to hospital, where within 24 hours a psychiatrist has to approve to the first decision. After that the patient can be treated with compulsory powers. After four weeks there is a mandatory court hearing, the patient can also appear before that.

Bernadette
And when there’s the hearing, is the hearing a matter of confirming the order or does the court actually make that order?

Stefan
It’s about confirming the order.

Bernadette
Because that’s how it used to be, and still is the case in many states in Australia, but here in Victoria we’ve moved to a mental health tribunal actually making that order, so I suppose it’s shifting somewhat from the clinician deciding to a tribunal deciding.

Stefan
Yeah.

Bernadette
And what have you found – because this is only quite new in Sweden right, it’s only since about 2008?

Stefan
Compulsory community care is a new thing since 2008, although like most other countries there has been a practice of something similar before that. We had something way back in history called conditional release, then there were possibilities to have long-term leave for patients who were formerly inpatients but might be out of the hospital for years. But in a formal sense it was introduced in 2008.

Bernadette
And tell us a bit about your research. What have you been finding with how this scheme is working?

StefanCompared with the old practices it hasn’t made a huge difference really. When you talk to practitioners, the thing that they really highlight is how it has improved the coordination between different service providers. Sweden has had a tradition of problems with coordination of health services and social services. The care of this group of patients really falls sort of between those chairs. It’s about treatment, it’s about providing support in the home and it’s about rehabilitation. There are a lot of grey zones about who is going to pay for what kinds of services. So what happened then was that when the law was passed about compulsory community care, maybe I should call it CCC, although CTOs is pretty much the same thing, was that it became mandatory for the psychiatrist who applied for the CTO then to attach aa so-called coordinated care plan and this was, since he had to do that, he actually had to arrange a meeting with social services and they had to sit down and talk about what special provisions should we have for this patient, what should be the order in which this happens, this they claimed made a difference and actually has made a difference to improve services. Interestingly it doesn’t really have anything to do with coercing patients; it’s rather a way of coercing service providers to provide better services

Bernadette
So that’s I suppose one of the benefits in that it is a vehicle for coordination rather than coercion. In your research did you actually talk to some of the people subject to these orders?

Stefan
I did yeah.

Bernadette
What were their views?

Stefan
First it’s very hard to pinpoint what the experience of being under compulsory community care is because it’s so fuzzy really. You are there, you’re getting on with life, you’re watching television, you’re having lunch, and all the while you are under compulsion, but most people I imagine don’t think that much about it. So many of them struggle to really see that much about it, there was sort of a general sense that while I don’t want to be subjected to coercion on the other hand most patients weren’t that concerned. They didn’t feel that it was too bad. There are exceptions but most folk, interestingly, when they talk about what they like about it, they tended to talk about services – well the staff is good, it has become easier to access medicines, I don’t have to pay for the meds now, which again doesn’t at all have to do with the coercing someone to take their meds.

Bernadette
In terms of your wider research, we’re very interested to explore issues of social equity, and you mentioned resources just then. Do you think that if more resources are put into the mental health system and service delivery then there would be less need for coercion?

Stefan
Yes absolutely. Some evidence of that is that the Swedish law states that one of the criteria for allowing compulsory admission is that there is an indispensable need for hospital care in the first stage. But that really depends. The indispensability of that need is depending on the resources and the quality of care, of course. That is also perhaps one way, one plausible explanation for the vast regional variations. It varies a lot within Sweden how many patients per 100,000 inhabitants who would be subjected to CTOs, and there is also a huge variation internationally. I believe so also in Australia how much compulsory care you have. The other side of that is that it also seems to have something to do with some kind of cultural tradition within psychiatry; different places seem to have different kind of treatment traditions. Although some tend to be more inclined to use coercion and some not.

Bernadette
And Stefan you’ve been in New Zealand for some time doing some research there. I know you haven’t been doing empirical research as such on the use of community treatment orders, but have you gained a sense, perhaps, of the mental health system there and how it may compare to Sweden or Europe in general.

Stefan
Good question. I think that if I were to compare with Sweden, there is a bit of paradox because Swedish mental health care is quite well funded, so if you take into account what I just said you might expect that we don’t have much compulsory care, but on the other hand we also have this strong tradition of a belief in the welfare state, so we tend to be perhaps a bit less concerned about the human rights issues. We tend to believe that if the State does something with people it’s generally for a good porpoise and it’s not too bad. We have a large proportion of people under compulsory care in Sweden as well actually. I think the discussion regarding risk management, you see more of that here, and we tend to be less concerned about that in Sweden. I was just picking up my son from a friend’s school and they asked me what I did – if I tell people that I do research into mental health law, everyone immediately here jumps to well okay then, then it’s about dangerous people. You always get into those discussions and that doesn’t happen so much in Sweden I don’t think.

Bernadette
So if there’s one less you think those of us in Australia and New Zealand could learn from Sweden, what would that be.

Stefan
I’m quite critical of a lot of issues in how this works in Sweden. But perhaps we are quite sensible regarding those dangerousness issues actually, and we tend to be, there has been a national project called – let me see if I can translate this – ‘Better Services, Less Coercion’, where the ambition has been to try to find both techniques in relation to patients under compulsory care but also in general, how do we do things in treatment wards and social housing facilities and so on to minimise the need for care. I guess one problem with having, even if you could argue and it’s quite easy to argue that under some circumstances what we have is quite reasonable, but one of the biggest problems I think is that when you have that option it’s always an easy way out, so it doesn’t really force service providers to work as hard as they can to try to persuade or motivate the patients to accept the treatment that they think is the best option.

Bernadette
Great. Well Stefan thanks for much for coming in today and sharing some of your research with us. We wish you a great stay while you’re here in Melbourne and all the best for your future research.

Stefan
Thank you.