Perceived Coercion – The MacArthur Studies Charles W. Lidz Ph.D. UMass Medical School Center for Mental Health Services Research
One View of Hospitalization I have been illegally committed once to three times a year. While an inpatient on Unit A, I could not come out of my room even for meals. I was not allowed to use the telephone to call my attorney, my medication doctor, my therapist, my case manager or my outreach worker or any social or business-related contacts. I had to request an attorney to represent me who came to see me and gave me my human rights back. If it was not for the attorney, I would have been isolated and confined to my room without music, television, or reading material. I was only allowed to leave the room supervised to bathe or shower.
They commit you because of the falsities that the nurses and psychiatrists and therapists say about their patients, when the judge reads the patient's chart, he commits the patient without giving the patient a lawyer or allowing the patient to speak in the court hearing. The patient is forced to remain silent or he/she will be in contempt of court. They use restraints illegally All of the nurses discriminate and write illegalities in each consumer's chart, so when the social worker returns the following morning, she has to figure out who is lying; the patient or the nurses. After several hours of observation, the social worker realizes that the nurses were lying and that the patient was telling the truth. Feel free to obtain my records and see for yourself.
They isolate patients and exacerbate their anxiety, depression and PTSD, which hence lengthens the patient's stay because the staff does not know why the patient is not getting any healthier and it also requires more work by the patient's outpatient treatment providers after discharge.
Controversy • The legal status of coercive pressures has been controversial since the origins of efforts to treat mental illness. • Phillipe Pinel • Institutions • 2 physician certificates • “Dangerous to self or others” • The routinization of coercion
The Origins of the Dilemma • Protestant Reformation and the sanctity of Conscience • Secularization & Respect for Individual Choice • But Obligation to maximize the individual • standards for adequate individual and need for improvement • Psychiatry as the secular implementer • Coercion to help improve the individual • But does coercion violate respect for the person
MacArthur Research Network on Law and Mental Health • John Monahan led MacArthur Foundation Network • 3 Primary goals • Develop method for predicting violence among people with MI • Technique for assessing competence to consent. • Determine whether coercion improves mental health outcomes. • Obviously I will only talk about coercion
What is Coercion? • We will talk about this a lot more I trust • Wertheimer’s analysis • Based on legal cases • A “moralized” concept • Coercion is pressure that is not legitimate • Thus it is both contextual and judgmental • Whose judgment? • It depends on who is looking at the behavior
A Strategy for Studying Coercion • If Wertheimer is right, a study must collect multiple perspectives. • We were looking at admission decisions so we interviewed • “patient” • Admitting clinician • Accompanying person when available (family, police, friend, etc.) • I will talk more about this tomorrow.
Two Approaches to Measurement • We did in depth interviews about the experience of admission with “patients” • copies of the interviews available • they were extensive and semi-structured • My colleague Loren Roth insisted on a structured scale. • We tried many versions • Eventually MacArthur Admission Experience Scale
The MacArthur Admission Experience Scale (MAES) • This name was just meant as a disguise • We did multiple versions • Eventually 15 questions • Only 5 are used as perceived coercion questions • Others may or may not be relevant. • Several authors use all of the questions as the scale • Other authors use some as measures of “procedural justice” or “voice”, etc.
MAES -5 Questions • I felt free to do what I wanted about coming into the hospital. • I chose to come into the hospital. • It was my idea to come into the hospital. • I had a lot of control over whether I came into the hospital. • I had more influence than anyone else on whether I came into the hospital.
Features of the Scale • “My idea” question did not load as a scale in the interview data. • Similar troubles with other data sets. • Two forms correlate .89 • Test retest on questionnaire form .81 • Coherence (alpha = .77) • Correlate with legal status .62 • Correlates well with Nordik Coercion Ladder.
The Discovery of Procedural Justice • Disjunction between objective coercion and perceived coercion – correlates .62 with legal status • Our initial interpretation • Bennett’s analysis of the interview themes • Inclusion in the decision making process • Beneficent Motivation of the others participating • Good Faith - Openness and honesty on the part of others involved. • Subsequent quantitative confirmation paper
Some results • Stronger relationship with procedural justice than with legal status as voluntary or not. • There are substantial differences from one site to another. • Threats and physical force are strongly correlated with perceived coercion. • Offers and persuasion are not associated with perceived coercion.
Others Research with MPCS • Hiday et al. measured perceived coercion among people who were outpatient committed. • Cusack et al. looked at coercion among jail divertees who were mentally ill. • Moser et al. looked at perceived coercion in prison to enter a hypothetical research project • Bryne et al. and Festinger et al. perceived coercion created by financial incentives.
More Research with MPCS • Bindman et al. studied the effect of perceived coercion subsequent treatment involvement • Angell researched the impact of perceived coercion on outpatient treatment outcomes • Bacharz studied it among jailed people who were recruited into sex offender treatment. • Wild et al. studied perceived coercion among clients entering substance abuse treatment.
Summary of Other Research with MPCS • Scale appears to work in a variety of setting but no systematic testing. • Perceived Coercion does not appear to have large effects on subsequent behavior