findings from 20 years of research on coercion, mental health, and the law john monahan, ph.d....

Findings from 20 Years of Research onCoercion, Mental Health, and the Law

John Monahan, Ph.D.Professor of Law, Psychology, and Psychiatry

University of Virginia, USA

Early Studies: Coercion to Hospitalization

1989-2001

Findings from the Early Studies

• Legal status is a blunt index of perceived coercion

1. Legal Status and Coercion as Perceived by Patients

• 39% of the legally voluntary inpatients believed they would have been involuntarily committed if they had not “volunteered”

• 56% of the legally involuntary inpatients said they would have entered the hospital voluntarily if they had been given the opportunity.

Perceived Coercion Scale

• Influence: I had more influence than anyone else on whether I went ..

• Control: I had a lot of control over whether I went ..• Choice: I chose to go.. • Freedom: I felt free to do what I wanted about going..• Idea: It was my idea to go …

…into the hospital.

Legal Status and Perceived Coercion

• 10% of the legally voluntary inpatients perceived themselves as highly coerced into hospitalization

• 35% of the legally involuntary inpatients did not perceive themselves as having been coerced at all into hospitalization.

Affective Correlates of Perceived Coercion (%)

Affect Low Coercion High Coercion

Angry 37 63

Sad 60 72

Relieved 82 31

Frightened 56 68

Legal Status of Patients in State Hospitals on December 31, 2007 (%)

Jurisdiction Voluntary Involuntary Forensic

U.S. Average 17 52 31

California 1 17 82

New York 48 33 19

Virginia 8 53 39

West Virginia 0 74 26

Washington, DC 71 1 28

Findings from the Early Studies

• Legal status is a blunt index of perceived coercion• Negative pressures to be hospitalized increase

perceived coercion

2. Pressures to be Hospitalized and Perceived Coercion

No Pressures = 46%; Pressures = 54%

Positive Pressures (%)

Persuasion = 38

Inducement = 4

Negative Pressures (%)

Threats = 9

Force = 19

High Perceived Coercion by Pressures to be Hospitalized

Findings from the Early Studies

• Legal status is a blunt index of perceived coercion• Negative pressures to be hospitalized increase

perceived coercion• A lack of procedural justice increases perceived

coercion

3. Procedural Justice Scale

• Voice: How much of a chance did you have to say everything you wanted to about…?

• Validation: How seriously did people consider what you had to say about…?

• Satisfaction: How satisfied are you with the way people treated you when you were…?

• Fairness: How fair was the process of…?… coming into the hospital.

High Perceived Coercion by Procedural Justice: Inpatient Hospitalization

0

10

20

30

40

50

60

Low ProceduralJustice

ModerateProcedural

Justice

High ProceduralJustice

Qualitative Patient Interview

“I talked to [my therapist] this morning. I said, “You didn’t even listen to me. You call yourself a therapist? Why did you decide to [hospitalize me] instead of understanding what I was going through.” And he said, “Well, it doesn’t matter, you know, you’re going anyway.” He didn’t listen to what I had to say. He had decided before he ever got to the house that I was coming up here. Either I come freely or the officers would have to subdue me and bring me in.”

Findings from the Early Studies

• Legal status is a blunt index of perceived coercion• Negative pressures to be hospitalized increase

perceived coercion• A lack of procedural justice increases perceived

coercion• Some beliefs about hospitalization do not change

after discharge; others do.

4. Change in Patients’ BeliefsGardner et al, 156 American Journal of Psychiatry 1385

• Patients interviewed at hospital admission and one month after discharge (n=433)

• “Patients’ judgments of perceived coercion, procedural justice, negative pressures, and positive pressures did not change from admission to follow-up. Nor did patients’ reports of their emotional responses to the hospital admission change.”

Belief About the Need for Hospitalization, at Admission and After Discharge (%)

Belief After Discharge

Belief at Hospital AdmissionDid Not Need

Hospitalization Needed

Hospitalization

Did Not Need Hospitalization

48 5

Needed Hospitalization

52 95

“It may be somewhat misleading to call a retrospective rationale for hospitalization a “thank you” theorythere was not much evidence that coerced patients were later grateful for the experience of hospitalization, even if they concluded that they needed it. This suggests that patients’ aversion to commitment is moral response to the loss of dignity and respect implicit in the deprival of autonomy. Mental health professionals have often justified commitment in terms of its consequences for the patients’ health. However, patients’ retrospective evaluations of these [health] consequences apparently do not change their feelings about coercion. Looking back on their hospitalization, coerced patients are likely to continue to be offended, even if they now view the hospitalization as a necessity.”

Current Studies: Coercion to Community Treatment

2001-2010

“Outpatient Commitment”

A civil court-order requiring a person to accept psychological/psychiatric services in the community.

– Conditional discharge: meets inpatient commitment criteria

– Alternative to hospitalization: meets inpatient commitment criteria

– Preventive commitment: does not meet inpatient commitment criteria.

Outpatient Commitment in the U.S.

• New York State, 1999• California, 2003• Florida, 2005• Michigan, 2005• West Virginia, 2005• Illinois, 2008 (strengthened)• Idaho, 2008 (strengthened)• Virginia, 2008 (strengthened)

Views on Outpatient Commitment: Pro

"Civil libertarians who take extreme views on [OPC] are both incompetent and inconsequential. Under the guise of civil liberties, they're inflicting cruel and unusual punishment on people despite the fact that society has science that can make a better way. It's cruelty; if we were doing it to animals, the American Society for the Prevention of Cruelty to Animals would be after us."

— U.S. Rep. Marge Roukema

Views on Outpatient Commitment: Con

“URGENT!! TOP PRIORITY!! The forced psychiatric drugging bill is on the Senate floor for a vote!! Forced psychiatric treatment is the same tactic that is used now in China to destroy people who disagree with the government, and was used the same way in the Soviet Union. Don't think that this cannot happen to YOU!”

— Stop Involuntary Outpatient Commitment Coalition

Views on Outpatient Commitment and Mental Health Services

Bazelon Center

“[O]utpatient commitment penalizes the individual for what is essentially a systems problem. Lack of appropriate and acceptable community mental health services is the issue.”

Treatment Advocacy Center

“For [a] small subset of the most mentally ill, no amount of money spent on services will ever be enough to induce their compliance with treatment.”

“Community Treatment Orders” Outside the U.S.

• Australia, 1986• Israel, 1991• New Zealand, 1992• Ontario, Canada, 2000• Scotland, 2005• England and Wales, 2008• Taiwan, 2008• Sweden, 2008

Why Outpatient Commitment Now?

Violence to Others

D. J. Jaffe, Treatment Advocacy Center

“Laws change for a single reason, in reaction to highly publicized incidents of violence. People care about public safety. I am not saying it’s right, I am saying this is the reality… So if you're changing laws in your state, you have to understand that... You have to take the debate out of the mental health arena and put it in the criminal justice/public safety arena.”

Kendra’s Law (NY, 1999)

Kendra Webdale

Laura’s Law (CA, 2002)

Kevin’s Law (MI, 2005)

Nicola’s Law (LA, 2008)

Arabella’s Law (NV, pending, 2009)

Seung-Hui Cho (Virginia Tech, April 2007)

DSM-IV Vignette: Schizophrenia1996 General Social Survey (Pescosolido et al, 1999)

JOHN is a WHITE MAN who has completed HIGH SCHOOL. Up until a year ago, life was pretty okay for JOHN. But then, things started to change. He thought that people around him were making disapproving comments and talking behind his back. JOHN was convinced that people were spying on him and that they could hear what he was thinking…

“How likely is it [John/Mary] would do something violent to other people?”

% very/somewhat likely

• Schizophrenia: 61• Major depression: 34• Drug dependence: 87

“Do you think that people like [John/Mary] should be forced by law…

to get treatment at a clinic or from a doctor?” (% yes)

Schizophrenia

49

Depression 22

Drug 67

“Do you think that people like [John/Mary] should be forced by law…

to get treatment… if he [she] is dangerous to others?” (% yes)

Schizophrenia

49 → 95

Depression 22 → 94

Drug 67 → 96

Benjamin Franklin: Argument 1 (early 1750)

“Some persons, …observing the distress of the distempered poor, [saw that] many must suffer greatly, and some probably perish, that might otherwise have been restored to health…There being no place (except the House of Correction) in which they might be confined, [we propose to build] an Infirmary, or Hospital, of the manner of several lately established in Great Britain.”

Benjamin Franklin: Argument 2 (late 1750)

“The number of persons distempered in mind and deprived of their rational faculties has increased greatly in this province. Some of them going at large are a terror to their neighbors, who are daily apprehensive of the violences they may commit… Few or none of them are so sensible of their condition as to submit voluntarily to treatment. ”

The Pennsylvania Hospital, 1751-2009

From Outpatient Commitment to “Mandated Community Treatment”

Community ≠ Hospital

Mandated Institutional Tx

Mandated Community Tx

Housing Hospital

Disability benefits

Hospital

Ordermaintenance

Hospital

Treatment Hospital

Community ≠ Hospital

Mandated Institutional Tx

Mandated Community Tx

Housing Hospital Housing agency

Disability benefits

Hospital

Ordermaintenance

Hospital

Treatment Hospital

Community ≠ Hospital

Mandated Institutional Tx

Mandated Community Tx

Housing Hospital Housing agency

Disability benefits

Hospital Welfare agency

Ordermaintenance

Hospital

Treatment Hospital

Community ≠ Hospital

Mandated Institutional Tx

Mandated Community Tx

Housing Hospital Housing agency

Disability benefits

Hospital Welfare agency

Ordermaintenance

Hospital Criminal justice system

Treatment Hospital

Community ≠ Hospital

Mandated Institutional Tx

Mandated Community Tx

Housing Hospital Housing agency

Disability benefits

Hospital Welfare agency

Ordermaintenance

Hospital Criminal justice system

Treatment Hospital Mental health system

Mandated Community Treatment

HOUSING AS LEVERAGE

Ž Subsidized housing

Standard Lease: Alliance for the Mentally Ill of Delaware

“Refusing to continue with mental health treatment means that I do not believe I need mental health services. I understand that since I am no longer a consumer of mental health services, it is expected that I will find alternative housing. I understand that if I do not, I may face eviction.”

Mandated Community Treatment

MONEY AS LEVERAGE

Ž Money managers

“Recipient Responsibilities”

“You are receiving benefits based on the mental health problems that you have. The Social Security Administration requires that you be involved in mental health services so that you will feel better. [Otherwise,] you may lose your benefits.”

Mandated Community Treatment

JAIL AS LEVERAGE

Ž Treatment as a condition of probation

United States Code, Title 18, §3563

“The court may provide, as further conditions of a sentence of probation…that the defendant … undergo available medical, psychiatric, or psychological treatment.”

U.S. v Holman, 532 F.3d 284 (2008)

“Holman became a danger to himself and others when he was off his medication, and injections of long-lasting antipsychotic drugs provide the only means of insuring that Holman takes his medication…Requiring intramuscular injections of antipsychotic medications as a special condition of supervised release was consistent with the… requirements set out by the Supreme Court.”

Mandated Community Treatment

JAIL AS LEVERAGE

Ž Treatment as a condition of probation

Ž Mental health courts

Mental Health Courts

• are criminal courts• have separate dockets dedicated to defendants

with mental illness• divert defendants from jail and/or prison to

community treatment• monitor community treatment and potentially

impose sanctions for non-adherence.

Mandated Community Treatment

HOSPITALIZATION AS LEVERAGE

Ž Outpatient commitment

Psychiatric Advance Directives

An Antidote to Coercion, or“Self-Mandated” Treatment?

Psychiatric Advance Directives (PADs)

• Legal instruments that allow competent persons to give or to refuse consent to future psychiatric treatment

• May authorize an agent to make future decisions about a person’s mental health care, if the person becomes incapacitated.

How Often Is Treatment Mandated?

The Prevalence of Leverage Monahan et al, 56 Psychiatric Services 37

Five Sites• Durham, NC• Worcester, MA• Chicago, IL• Tampa, FL• San Francisco, CA

• Overall N: 1,011• Refusal Rate: 6.8%

Eligibility Criteria

• 18-65 years old• English or Spanish-speaking• Currently in outpatient treatment with a

public MH service provider• In treatment at least 6 months.

Prevalence of Mandated Community Treatment

Form of Leverage % with Leverage

Obtaining Housing 32

Prevalence of Mandated Community Treatment

Form of Leverage % with Leverage

Obtaining Housing 32

Avoiding Jail 23

Prevalence of Mandated Community Treatment

Form of Leverage % with Leverage

Obtaining Housing 32

Avoiding Jail 23

Avoiding Hospital 15

Prevalence of Mandated Community Treatment

Form of Leverage % with Leverage

Obtaining Housing 32

Avoiding Jail 23

Avoiding Hospital 15

Obtaining Money 12

Prevalence of Mandated Community Treatment

Form of Leverage % with Leverage

Obtaining Housing 32

Avoiding Jail 23

Avoiding Hospital 15

Obtaining Money 12

At Least 1 Form 51

Findings on an Additional Form of Leverage: Child CustodyBusch and Redlich, 58 Psychiatric Services 999

• Experienced by 5% of sample

• 75% of these were women

• 11% of all mothers

• 6% of all fathers.

Conclusions from the Prevalence Study

• Focusing the policy debate on outpatient commitment is much too narrow

• The use of leverage to obtain adherence to mental health treatment in the community is pervasive.

Mandated Community Treatment:

Findings to Date (April 28, 2009)

Findings on General Effects of “Leverage”

Monahan and Redlich, unpublished data, 2009

Perceived Coercion Scale

• Influence: I had more influence than anyone else on whether I went ..

• Control: I had a lot of control over whether I went ..• Choice: I chose to go.. • Freedom: I felt free to do what I wanted about going..• Idea: It was my idea to go …

...to the mental health clinic.

Procedural Justice Scale

• Voice: How much of a chance did you have to say everything you wanted to about…?

• Validation: How seriously did people consider what you had to say about…?

• Satisfaction: How satisfied are you with the way people treated you when you were…?

• Fairness: How fair was the process of…?… coming into the clinic.

High Perceived Coercion by Procedural Justice: Inpatient Hospitalization

0

10

20

30

40

50

60

Low ProceduralJustice

ModerateProcedural

Justice

High ProceduralJustice

High Perceived Coercion by Procedural Justice: Community Treatment

0

10

20

30

40

50

60

70

Low ProceduralJustice

ModerateProcedural

Justice

High ProceduralJustice

Findings on Specific Forms of Leverage

Money as Leverage

Findings on Money as Leverage Elbogen et al , 29 Law and Human Behavior 563

• Patients assigned a money manager are four times more likely to adhere to treatment than other patients

• Money managers who are family members are more likely than other money managers to report using money as leverage to obtain treatment adherence

• Unexpectedly, having a family member act as a money manager doubles the likelihood of patient violence. The more a patient interacts with a family member who is a money manager, the more likely the violence.

Housing as Leverage

Findings on Housing as Leverage Robbins et al , 33 Administration and Policy in MH and MH Services Research 226

• Housing often used in combination with money as leverage

• Requiring adherence to treatment is usually imposed by landlords, rather than by their clinicians

• Housing as leverage strongly increases perceived coercion

• BUT, patients who experience housing as leverage are as satisfied as other patients with the treatment they receive

• AND, patients who experience housing as leverage are more likely to believe that using housing as leverage is effective in helping people.

Jail as Leverage

Mental Health CourtsSteadman et al, in preparation

Findings on Mental Heath CourtsRedlich et al, 30 Law and Human Behavior 347

• 7,560 defendants currently subject to MH Court jurisdiction

• 1997 = 1 MH Court; 2009 = 125 MH Courts• 40% exclusively misdemeanors• 50% both misdemeanors and felonies• 10% exclusively felonies• More likely to use jail as a sanction with felons.

Findings on Mental Heath CourtsChristy et al, 23 Behavioral Sciences and the Law 227

• 95% of MD defendants choose a MH court• Much less experience of coercion • Much more satisfaction with court process • Much more likely to adhere to MH services• Less time in jail• No higher rates of recidivism over 1 year.

Psychiatric Advance Directives

Findings on Psychiatric Advance Directives Swanson et al, 34 Journal of the American Academy of Psychiatry & Law 43

• Only 7% of all patients have completed a PAD

• Over two-thirds of all patients say they want to complete a PAD, but do not know how to do so

• Almost half of all patients (compared to 10% of family members) believe that patients should be able to change a PAD “even when they are ill”

• Three-quarters of patients believe that a psychiatric advance directive will help avoid unwanted treatment, but only one-quarter of clinicians agree.

PADS and “Coercive Crisis Interventions”Swanson et al, 17 Journal of Mental Health 255

• taken by police to ER for psych evaluation• placed in handcuffs• involuntarily civilly committed• placed in seclusion• placed in restraints• forcibly medicated

“Decisional Incapacity”

Retrospective self-report at each follow-up:

“Since your last interview, has there been any time when you became ill and were not able to think clearly enough to make your own decisions about treatment or let others know what you wanted?”

“[In the hospital] we talked about what was in the PAD. I did not receive any treatments that I did not want. They were very respectful. I really felt like the hospital took better care of me because I had my PAD. The doctor didn’t treat me like a nut case because some hospitals do. You know what the doctor said to me? [He said] ‘You’ve got rights and it’s great that you know you have them. We’ll try to respect those completely.’ I never take [PAD wrist bracelet] off. My other wrist has my dialysis bracelet. I never take either of these off because I hope this doesn’t happen but if I’m in a situation where I’m out of my mind, at least people can just look at my wrist and see that I’ve got a PAD and that I better not get that ECT and that they better contact [health care proxy] before doing anything to me.”

www.nrc-pad.org10,000 visits per month

Outpatient Commitment 1: MacArthur Prevalence Study

Monahan et al, 56 Psychiatric Services 37

Who gets outpatient commitment?

Recipients of outpatient commitment had higher rates of . . .

• Past involuntary hospitalizations• Police encounters around mental health crises• Past violent behavior• Functional impairment• Low social support.

Outpatient Commitment 3:NY State Assisted Outpatient Treatment Study

Swartz, Swanson, Steadman, Robbins, and Monahan, in progress

The Carrot: Fiscal Changes

$32 million directly allocated yearly in support of the OPC program• $15 million -- medication grant program• $4.4 million -- prison and jail discharge managers• $2.4 million -- oversight programs• $9.55 million -- new case management slots• $0.65 million -- drug monitoring

$125 million yearly for enhanced community services • Used to increase Intensive Case Management and Assertive

Community Treatment programs.

Outpatient Commitment 4:

Can Support/Opposition Be Explained by “Cultural Cognition”?

Kahan, Braman, Monahan, Callahan, and Peters, Law and Human Behavior, in press.

General Social Survey • “Do you think that people like [John/Mary] should be

forced by law to get treatment at a clinic or from a doctor?” Schizophrenia Vignette:

1996 Yes = 49%2006 Yes = 50%

• No significant correlation (r = .03) with liberal-conservative political views

• “The public appears to be as ambivalent as policymakers about the use of legal force to ensure that individuals receive mental health treatment.”

Web-based Survey

• N = 1,496 American adults• 54% female, 46% male• 75% white, 11% African-American• Mean age: 48 years• Median income: $40,000 to $49,000• Median education: Some college.

Hierarchist

Egalitarian

CommunitarianIndividualist

Mary Douglas’s Group/Grid “Culture Theory”

Mary Douglas’s Group/Grid“Culture Theory” 1

The group dimension represents the degree to which “the individual’s life is absorbed in and sustained by group membership”

– Low group or individualistic way of life favors “self-regulation”

– High group or communitarian way of life favors “depending on each other.”

The grid dimension measures the pervasiveness and significance of social differentiation

– Low grid or egalitarian way of life: minimizes differences between groups of people

– High grid or hierarchical way of life: justifies differences between groups as enabling people “to live together with greater harmony and effectiveness.”

Mary Douglas’s Group/Grid“Culture Theory” 2

Individualist-Communitarian [One] thing people in our society often disagree about is the relationship between society's responsibilities, on the one hand, and individuals' responsibilities, on the other. How strongly you agree or disagree with each of these statements?

Sample Items:

• Too many people today expect society to do things for them that they should be doing for themselves

• People should be able to rely on the government for help when they

need it.

Hierarchist-Egalitarian

People in our society often disagree about issues of equality and discrimination. How strongly you agree or disagree with each of these statements?

Sample Items:

• Nowadays it seems like there is just as much discrimination against whites as there is against blacks

• We need to dramatically reduce inequalities between the rich and the poor, whites and people of color, and men and women.

Description of Outpatient Commitment

“Outpatient commitment laws give courts the power to order people diagnosed with certain mental illnesses, including schizophrenia, to receive treatment from a doctor and to follow prescribed treatment procedures, which usually include taking medication. The prescribed treatment does not require hospitalization. However, if someone refuses an order to see a doctor and to follow treatment procedures, the person can be brought to a mental health facility against their will for an evaluation and, if necessary, involuntarily hospitalized for treatment.”

Background Questions (n = 1,496)How much did you know about outpatient commitment laws before today? (%)

Nothing at all 60

Just a little 26

Some 12

A lot 2

Have you personally ever had a family member or a close friend who had a psychiatric condition like schizophrenia? (%)

Yes 28

No 72

Estimated Response to Item “People with psychiatric conditions like schizophrenia should be forced by law to get outpatient

treatment from a doctor,” by Individualist-Communitarian

Estimated Response to Item “People with psychiatric conditions like schizophrenia should be forced by law to get outpatient

treatment from a doctor,” by Hierarchist-Egalitarian

Percent of Respondents Mildly, Moderately, or Strongly Supporting Outpatient Commitment

Takk!

• Web: http://macarthur.virginia.edu

• Email: jmonahan@virginia.edu