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Charles W. Lidz Ph.D.Research Professor of Psychiatry
UMass Medical School
Most Plausible Factual Account and the Problem of Objective Coercion
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The Importance of Perception This is the patients’ experience
We want them to have as positive an experience as possible.
Compliance with treatment may be related to how they experience their treatment.
Trauma may come in many forms including psychiatric treatment
The importance of procedural justice
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The Limits of Perceived Coercion We can only affect actual behavior. No laws or regulations are made about
perceived behavior We want to know what is “really”
happening to people with MI We want to know what behaviors affect
patients’ perceived coercion
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What “Really” Happened
This is much less easy than it sounds What is to be the criterion about
what is real? Does that sound silly?Consider
some concepts“Excessive force”Demeaning“necessary”
These are inherently ambiguous.
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Coercion is a Meaningful Event Putting someone in chains may not be
experienced as coercive. Giving someone a medication maybe
perceived as coercive. Is it really? Thus there are limitations to the
meaning of behavioral data.
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Sources of Behavioral Data - Direct observation
We can usually only see public behavior Even then we don’t know what
happened before. Directly observable coercion is rare and
thus inevitably unsystematic and/or very expensive to accomplish.
Efforts will be made to hide it.
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Using Official Records
This takes one account as the best Officials have interests and ideologies Officials have their own truth theories
Which motives to believe Which sources of information to believe
Officials have only a partial view as well Reports are in a format - experience is not
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Objective indicators
Number of involuntary commitments Voluntary may be pressured “Involuntary” may be agreed to.
Number of police calls Police as a taxi service
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MPFA as Method
Why not use all sources of data? Triangulation as a method of identifying
a “best guess” How to choose among conflicting
evidence. If it is to be science, we need rules for
assessing the diverse sources of data
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An Example
Psychiatric Admission
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Possible Sources of Data
Admission Staff accounts Medical Records Police or Police reports Family or other accompanying
individuals The admitted individual
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Possible Types of Pressures
Legal Force Physical Force Show of Force (call hospital security
police) Threats Giving an Order Persuasion Inducement Deception Whether patient asked what s/he wanted
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Sources of Pressure - Admission 1. Admitting clinical staff 2 parents 3. spouses and other lovers. 4. children. 5. other family 6. friend 7. acquaintance - Includes landlords,
employer, etc. 8. other healthcare professionals
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The Reconciliation Problem
Okay, so what do you do with all that data?
If it is to be science (i.e., repeatable) we need rules for reconciliation.
These are certainly debatable. Others with different biases might make
different rules.
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MPFA Reconciliation Rules 1
believe an eyewitness account before a second-hand report.
Accept the fuller account of an incident rather than the sparser one.
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MPFA Reconciliation Rules 2
Always believe an individual's own account of his or her motives rather than someone else's account. (question that account only based on objective evidence not another’s account)
If the previous rules do not yield a choice of account, believe multiple sources before a single source.
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What Counts as a Pressure
Any pressure must follow the last hospitalization (previous pressures don’t count in assessing current hospitalization)
Committed by someone involved as directly related to the current hospitalization
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MPFA and Coercion
Coercion is a meaningful event. Whether actions occur is independent of
depends on motives and people’s interpretation of them
Whether it is coercive, however, depends on how the participants interpret those acts.