Patients in court-ordered substance abuse treatment. Studies in the involuntary process by interview, assessment and randomised trial.

Summary, in English

Commitment to involuntary care is a multistage process comprising many different aspects; legal, psychological, medical, social and ethical among others. It can also be analyzed from the perspective of a continuum starting from the report to the social authorities, the evaluations on whether to commit or not, the actual commitment and aftercare following involuntary treatment. Enhancing knowledge on the total process of commitment requires intense research studies with an application of a wide array of research methods. This thesis includes interviews, assessments and a randomised trial performed in the different stages of court-ordered care of patients with substance abuse; evaluation, decision to petition the court for commitment, the commitment, the care at an involuntary institution and aftercare. We interviewed 74 patients about their experiences of evaluation and the patients reported initial feelings of anger and violation and only half of the group had any contact with the social worker in charge of the case. Of the interviewed patients, 35 had previous experience of commitment. They were satisfied with the care at the institution and felt that they could influence the care even though a majority of the patients also reported that coercive measures had been applied during care. The patients though, were not satisfied with the contact with the social worker while planning aftercare and few plans were carried through. We explored the decision by the social welfare board to petition the court for commitment by having experts assessed 106 cases that the board previously had made decisions about. The comparison between the boards’ decisions and the experts’ assessments revealed that there was an association between patients’ social variables and the board’s decision contrary to the experts’ assessment that showed no such association. This could create a legal uncertainty about the boards’ application of the legal criteria. Prior to an amendment of the involuntary legislation, the difference between municipalities in rate of petitions was very small. After the responsibility to petition the court for commitment was transferred from central authority to local authority, differences emerged. We contrasted two municipalities with high rate (55%) and two with low rate (12%) in order to measure global outcome two years after evaluation, but found no significant difference in regard to substance abuse, housing and means of support between the evaluated patients from the two types of municipalities. Seven patients had deceased during two years after evaluation, none of the deceased patients had been committed. Finally, case management was used as an intervention in aftercare following commitment and 36 patients were randomised to either case management or treatment-as-usual. The patients in the case manager group seem to have retained their abstinence in a higher degree than the patients in the control group. Despite the fact that one of the core components of case management is to link to care, the use of care did not differ between groups. Patients with a continued severe substance abuse had significantly more contact with in-patient care and social services, while abstinent patients had less contact with care and service. The study involved eleven municipalities and three involuntary institutions and the research design, instruments and intervention was well received by patients as well as participating units. The study had to end prematurly due to few committed patients and needs to be replicated with a larger population.

• Författare: Marianne Larsson Lindahl
• Avdelning/ar: Kliniskt Centrum för Hälsofrämjande Vård; EpiHealth: Epidemiology for Health
• Publiceringsår: 2011
• Språk: Engelska
• Publikation/Tidskrift/Serie: Lund University Faculty of Medicine Doctoral Dissertation Series
• Volym: 2011:98
• Dokumenttyp: Doktorsavhandling
• Förlag: Lund University
• Ämne: Public Health, Global Health, Social Medicine and Epidemiology
• Nyckelord: Court-order; commitment; involuntary care; substance abuse; legal criteria; randomised trial; mortality; case management.
• Status: Published
• Forskningsgrupp: Clinical Health Promotion Centre
• Handledare: Hanne Tønnesen; Agneta Öjehagen
• ISBN/ISSN/Övrigt: ISSN: 1652-8220; ISBN: 978-91-86871-47-5
• Försvarsdatum: 11 november 2011
• Försvarstid: 10:00
• Försvarsplats: Kvinnokliniken, Aulan, ing. 74, 3 v., Skånes universitetssjukhus, Malmö
• Opponent: Lars Kjellin (Docent)