Table 2.

Case vignette 1

The patient is a 30-year-old woman with bipolar disorder who has had a number of admissions to 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 on the basis that 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 has a duty to let social services know about the situation