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Patient Experiences of Autonomy and Coercion While Receiving Legal Leverage in Forensic Assertive Community Treatment

Lamberti, J. Steven MD; Russ, Ann PhD; Cerulli, Catherine JD, PhD; Weisman, Robert L. DO; Jacobowitz, David MA; Williams, Geoffrey C. MD, PhD

doi: 10.1097/01.HRP.0000450448.48563.c1

Legal leverage is broadly defined as the use of legal authority to promote treatment adherence. It is widely utilized within mental health courts, drug courts, mandated outpatient treatment programs, and other intervention strategies for individuals with mental illness or chemical dependency who have contact with the criminal justice system. Nonetheless, the ethics of using legal authority to promote treatment adherence remains a hotly debated issue within public and professional circles alike. While critics characterize legal leverage as a coercive form of social control that undermines personal autonomy, advocates contend that it supports autonomy because treatment strategies using legal leverage are designed to promote health and independence. Despite the controversy, there is little evidence regarding the impact of legal leverage on patient autonomy as experienced and expressed by patients themselves. This report presents findings from a qualitative study involving six focus groups with severely mentally ill outpatients who received legal leverage through three forensic assertive community treatment (FACT) programs in Northeastern, Midwestern, and West Coast cities. Findings are discussed in the context of the self-determination theory of human motivation, and practical implications for the use of legal leverage are considered.

From the Departments of Psychiatry (Drs. Lamberti, Russ, Cerulli, Weisman, and Williams, and Mr. Jacobowitz), Medicine (Dr. Williams), and Clinical and Social Sciences in Psychology (Dr. Williams), University of Rochester Medical Center.

Original manuscript received 25 January 2013; revised manuscript received 3 July 2013, accepted for publication 12 August 2013.

Correspondence: J. Steven Lamberti, MD, Strong Ties Community Support Program, 2613 West Henrietta Rd., Rochester, NY 14623. Email:

© 2014 President and Fellows of Harvard College
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