Table 2 Case vignettes

Case Vignette 1

The patient is a 30-year-old woman with bipolar disorder who has had several admissions to the hospital over the years, often as involuntary hospitalisation. Between hospital treatments, she keeps well and functions as long as she accepts medication and support. Without these, she quickly becomes unwell.

Persuasion

The clinician in the out-patient service is increasingly concerned about the situation and keen to try and avert another damaging relapse. The clinician talks to the patient and explains the evidence for medication in bipolar disorder and the fact that her pattern of relapse indicates that this applies to her.

Interpersonal leverage

The clinician tries to appeal to the patient because they have known each other for a long time; he has always been there to help and would not advise her to do something that was not in her best interests.

Inducement

The appeals did not work, and the patient is starting to show early signs of deterioration. There is a sale of children’s clothes coming up, and the patient wants to buy something to give to her daughters when she next sees them. The clinician offers to give her a lift but says he can only do so if she is reasonably well. Whether or not the clinician means to imply she needs to take treatment to gain his assistance is left unclear, but that is the patient’s assumption.

Threat

The following week the patient is due to see her daughters. She is still refusing treatment and now shows signs of irritability, which for her, is an early sign of relapse. The clinician explains that the access visit might have to be cancelled if she gets any more irritable or is still refusing treatment and that he must let social services know about the situation.

Case Vignette 2

The patient is a 40-year-old man with chronic schizophrenia. He lives alone in a flat with practically no social contact, and he tends to self-neglect. He hears voices and believes the neighbours are spying on him, which makes him very distressed. In the past, he has shown marked improvement when on medication. He has never harmed himself or others. He is willing to see the staff of the community mental health team, but not to take medication or leave the flat to participate in activities.

Persuasion

The clinician in the community team who has known the patient for a long time is concerned about the situation and keen to try and reduce the patient’s distress. The clinician talks to the patient and explains the importance of taking medication and engaging in social activities, emphasizing that further refusal of treatment may lead to continued or increased distress and impaired quality of life.

Interpersonal leverage

The clinician has repeatedly helped to prevent the patient from being evicted from his flat despite the obvious neglect and inconsistent rent payments. The clinician now says that it is frustrating to continue providing care to the patient unless the patient shows more engagement with treatment.

Inducement

The patient is keen on getting a new TV set, but can only afford it if social welfare provides the funding, which requires an application that needs to be supported by the community team. The clinician brings this up and promises to help with such an application if the patient shows more engagement with treatment.

Threat

The patient has received another letter from the landlord with the intention to evict him from the flat. The clinician declares that the team will only help the patient to avoid eviction again if he takes medication and/or regularly attends a drop-in centre for some structured activity and social contact.