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Findings from 20 Years of Research on
Coercion, 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 (%)
Negative Pressures (%)
Persuasion = 38
Threats = 9
Inducement = 4
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
60
50
40
30
20
10
0
Low Procedural
Justice
Moderate High Procedural
Procedural
Justice
Justice
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’ Beliefs
Gardner 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
Did Not Need
Hospitalization
Needed
Hospitalization
Belief at Hospital Admission
Did Not Need
Needed
Hospitalization
Hospitalization
48
5
52
95
“It may be somewhat misleading to call a retrospective
rationale for hospitalization a “thank you” theorythere
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
Treatment Advocacy 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.”
“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: Schizophrenia
1996 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:
• Major depression:
• Drug dependence:
61
34
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
Housing
Disability
benefits
Order
maintenance
Treatment
Mandated
Mandated
Institutional Tx Community Tx
Hospital
Hospital
Hospital
Hospital
Community ≠ Hospital
Housing
Disability
benefits
Order
maintenance
Treatment
Mandated
Mandated
Institutional Tx Community Tx
Hospital
Housing agency
Hospital
Hospital
Hospital
Community ≠ Hospital
Housing
Disability
benefits
Order
maintenance
Treatment
Mandated
Mandated
Institutional Tx Community Tx
Hospital
Housing agency
Hospital
Hospital
Hospital
Welfare agency
Community ≠ Hospital
Housing
Disability
benefits
Order
maintenance
Treatment
Mandated
Mandated
Institutional Tx Community Tx
Hospital
Housing agency
Hospital
Welfare agency
Hospital
Criminal justice
system
Hospital
Community ≠ Hospital
Housing
Disability
benefits
Order
maintenance
Treatment
Mandated
Mandated
Institutional Tx Community Tx
Hospital
Housing agency
Hospital
Welfare agency
Hospital
Criminal justice
system
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 Custody
Busch 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
60
50
40
30
20
10
0
Low Procedural
Justice
Moderate High Procedural
Procedural
Justice
Justice
High Perceived Coercion by Procedural
Justice: Community Treatment
70
60
50
40
30
20
10
0
Low Procedural
Justice
Moderate High Procedural
Procedural
Justice
Justice
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 Courts
Steadman et al, in preparation
Findings on Mental Heath Courts
Redlich 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 Courts
Christy 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.org
10,000 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.
Mary Douglas’s Group/Grid “Culture Theory”
Hierarchist
Individualist
Communitarian
Egalitarian
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 “selfregulation”
– High group or communitarian way of life favors
“depending on each other.”
Mary Douglas’s Group/Grid
“Culture Theory” 2
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.”
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
Just a little
Some
A lot
60
26
12
2
Have you personally ever had a family member or a close
friend who had a psychiatric condition like schizophrenia? (%)
Yes
No
28
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: [email protected]