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BACKGROUND: Coercion has usually been equated with legal detention. Non-statutory pressures to adhere to treatment, 'leverage', have been identified as widespread in US public mental healthcare. It is not clear if this is so outside the USA. AIMS: To measure rates of different non-statutory pressures in distinct clinical populations in England, to test their associations with patient characteristics and compare them with US rates. METHOD: Data were collected by a structured interview conducted by independent researchers supplemented by data extraction from case notes. RESULTS: We recruited a sample of 417 participants from four differing clinical populations. Lifetime experience of leverage was reported in 35% of the sample, 63% in substance misusers, 33% and 30% in the psychosis samples and 15% in the non-psychosis sample. Leverage was associated with repeated hospitalisations, substance misuse diagnosis and lower insight as measured by the Insight and Treatment Attitudes Questionnaire. Housing leverage was the most frequent form (24%). Levels were markedly lower than those reported in the USA. CONCLUSIONS: Non-statutory pressure to adhere to treatment (leverage) is common in English mental healthcare but has received little clinical or research attention. Urgent attention is needed to understand its variation and place in community practice.

Original publication




Journal article


Br J Psychiatry

Publication Date





145 - 150


Adult, Child, Coercion, Community Mental Health Services, Cross-Cultural Comparison, Cross-Sectional Studies, England, Female, Heroin Dependence, Housing, Humans, Male, Mental Disorders, Patient Compliance, Psychiatric Status Rating Scales, Psychotic Disorders, Statistics as Topic, Surveys and Questionnaires, United States