Risk management or improving the life for the patient? Court rulings concerning compulsory community care in Sweden

Background/Objectives: The presentation discusses an ongoing project regarding compulsory community care (CCC) in Sweden. CCC was introduced in 2008 following a series of incidents of assault involving people with mental illness that were widely reported in mass media. The stated purpose of CCC, however, is to facilitate the transfer of inpatients to community care. Decisions about CCC are made by an administrative court after application by the treating psychiatrist. The court also has decision power over the special provisions that patients on CCC are subjected to. Throughout the world, CCC has been controversial because it involves new ethical questions. For example, coercive measures may be invoked over longer time periods and they infringe into new and more private spheres of citizens. On an organizational level, it requires improved cooperation between health and social service providers. The objective of the paper is to provide descriptive statistics about court rulings and to analyse how courts discuss issues of integrity, risk management and the content of care. Which categories of patients are concerned, what types of coercive measures are applied, to what extent are social services involved and to what extent do courts rule against psychiatrists'’ motions to initiate or extend CCC?

Methods: Data consist of all court rulings regarding CCC in Sweden during 6 months (548 civil and 418 forensic cases). 40 variables were coded. In addition, 30 cases were examined using qualitative analysis.

Results: Virtually all applications about CCC from psychiatrists are approved by the courts. The most common special provisions that courts subject patients are: medication, staying in touch with service providers and housing. For forensic patients, abstaining from drugs/alcohol and restrictions on leaving either a treatment home or the home town are also common. Social services are mainly involved through providing for housing. There is a considerable variation between regional courts, e.g. in the extent in which they delegate decisions about special provisions to the treating psychiatrist.

Discussion/Conclusions: By and large, CCC has reached the targeted population of patients: long-term with a wide array of contact with service providers. With regards to risk management, the rulings only seldom contain explicit descriptions and deliberations about patients being dangerous to others. Some of the findings raise concerns about legal rights of patients: the scarcity of cases where psychiatrists are overruled, the delegation of decisions about special provisions to psychiatrists, the grounds for special provisions seldom are explained and certain provisions seem to be applied as a routine matter for all patients. The two rationales for CCC are to prevent violence and to promote health. We will discuss how these sometimes competing ends are managed in the rulings.

Funding: Swedish Research Council for Working Life and Social Research.

Keywords: Coercive treatment, outpatient commitment, court rulings.