In this study, we have presented an analysis of how 10 therapists experienced establishing a working alliance with patients in involuntary treatment settings, which resulted in the identification of two interrelated major themes and five sub-themes. How can we understand these findings and what implications do they hold for treatment and care?
The unsolvable tension between autonomy and coercion and potential clinical implications
As one main finding, we discovered that the therapists characterised their experience of negotiating working alliances and reaching agreement as somewhat easy or manageable. The therapists did point out difficulties during treatment courses. However, the overall impression was that these disagreements were manageable. This was surprising, as research implies this might be a greater challenge [
7,
11] and that the conceptual definition requires patient agreement, which is absent prior to and sometimes throughout involuntary treatment. The therapists exhibited a will to consider their patients’ goals and methods, but only when they were in agreement, and they ultimately made decisions themselves. This might be viewed as a tokenistic or artificial form of involvement as opposed to equal participation and thus may oppose basic elements of a working alliance. In interpreting our results in this way, we question to what degree the working alliance as a defined concept of mutual agreement is present in the involuntary treatment we investigated. However, working alliances still seem achievable, though in a different form than in voluntary treatment.
Building on contemporary research on therapeutic alliances, alliances might experience ruptures and reparation of these might serve as useful interventions in therapy [
28,
29]. In the context of involuntary treatment, the patient might perceive the starting point of involuntary admission as a rupture, thus complicating the working alliances from the start [
30]. However, the therapists in this study experienced negotiating working alliances as somewhat easy. Although a number of difficulties might arise underway, findings imply it as possible to achieve and repair working alliances, i.e. solving treatment discussions. Yet, we question, is this because the therapists serve as the main decision maker and, to a certain degree, excludes patients from decision-making processes? Further, we question, whether the therapists are relying on relational aspects, i.e. establishing trust and safety, when agreement seems difficult to achieve? As our results indicate, the mere absence of conflict, when the patient resists from opposing coercive treatment, may be interpreted as equivalent to a good working alliance. If so, the therapists arguably emphasise subjectively chosen aspects of the working alliance rather than considering all components of the concept.
Across the themes observed, patient autonomy opposes therapists’ decisions on expedient treatment. Mol [
38] referred to these contradictory absolutes as (1) the
logic of choice where patients have the freedom to choose between treatment alternatives and (2) the
logic of care where health professionals assess the need for care and further define and decide on treatment options. She asks: “If it is compared with ‘force’, then ‘choice’ is more often than not a great good. But what about comparing it with ‘care’?” [
38, p. xii]. Consistently, the participants expressed a will for patient involvement, yet concluded in what we consider to be in accordance with the
logic of care. Within this framework, the therapists considered it irresponsible and uncaring not to subject their patients to involuntary treatment due to potential consequences such as worsened mental illness conditions or potential death. This dilemma was concluded by evaluating whether a patient could consent to treatment or not. This finding could be viewed as part of a global trend towards an increasing use of coercive psychiatric interventions both in inpatient and outpatient settings [
39]. Further, it could be argued that the increased use of coercion, “prioritises risk management over individual health and social needs [which] is likely to be counterproductive” [
39]. Conversely, if the therapists had used the
logic of choice in its absolute form, involuntary treatment might arguably not be an option. This illustrates extremes of two
logics discovered in our analysis: involuntary treatment can be life-saving and oppressive whereas voluntary treatment can be self-determinative but with potential consequences of death. Our analysis shows that therapists oscillate between these absolutes or attempt to apply both at the same time by allowing patients to live their lives as long as they are not a danger to themselves or society. It is well established that mental health services, in the context of this study, can be viewed as trying to reconcile interests for patient autonomy and safety for society [
40]. However, these interests may not be synergistic; further, they seem to be a great challenge to achieve. For the therapists participating in this study, patient autonomy for those with serious mental illnesses appeared difficult to achieve.
Recovery-oriented practice, in a sense, opposes Mol’s
logic of care, as a treatment focus is based on first-person definitions of how to live a meaningful life within the context of mental illness [
21]. This does not mean that recovery-oriented practice opposes all uses of involuntary treatment, for example, when a person is considered to be suicidal; however, here, emphasis is placed on doing so with respect, dignity and transparency [
41]. A central aspect of such processes is in a recovery-oriented practice based on shared decision-making [
42‐
44], and an important implication of our study is the need to develop and implement tools for working with shared decision-making in context of involuntary treatment. As this is clearly a complex issue with people’s opinions and values continuously being shaped by numerous factors such as mental health professionals, their close relations and society at large [
45], a high degree of reflexivity [
46] is called for in the application of such tools.
Our findings imply that there is an abstract boundary between when and under what circumstances patients’ wishes are considered. It is unknown where this boundary ends, as the decisive conclusion lies with the therapist. This is problematic, as patients who are offered options are more likely to engage in treatment, to join interventions, and to experience better treatment outcomes [
47] and studies underscore self-agency as central to recovery processes [
48]. It is also problematic that patient inclusiveness is not clearly defined, as this gives an unknown amount of power to the therapist. Recently, the development of the Power Threat Meaning Framework [
49] has highlighted how power operates and impacts the lives of those with mental illnesses both within and outside of mental health services. Participants of our study preferred non-coercive interventions, which is in line with findings of a comprehensive study of Norwegian health professionals’ attitudes towards coercive care [
50]. At the same time, therapists described limiting treatment options to what they believed to be best for each patient. Taking this final point into account, we find it difficult to conclude that therapists participating in this study are supporting patients as equal agents in shaping treatment plans.