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

1. 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

2. Early Studies: Coercion to Hospitalization 1989-2001

3. Findings from the Early Studies • Legal status is a blunt index of perceived coercion

4. 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.

5. 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.

6. 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.

7. Affective Correlates of Perceived Coercion (%)

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

9. Findings from the Early Studies • Legal status is a blunt index of perceived coercion • Negative pressures to be hospitalized increase perceived coercion

10. 2. Pressures to be Hospitalized and Perceived CoercionNo Pressures = 46%; Pressures = 54% Positive Pressures (%) Negative Pressures (%) Threats = 9 Force = 19 Persuasion = 38 Inducement = 4

11. High Perceived Coercion by Pressures to be Hospitalized

12. 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

13. 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.

14. High Perceived Coercion by Procedural Justice: Inpatient Hospitalization

15. 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.”

16. 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.

17. 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.”

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

19. “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.”

20. Current Studies: Coercion to Community Treatment 2001-2010

21. “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.

22. 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)

23. 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

24. 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

25. Views on Outpatient Commitment and Mental Health Services Bazelon Center 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.” “[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.”

26. “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

27. Why Outpatient Commitment Now? Violence to Others

28. 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.”

29. Kendra’s Law (NY, 1999) Kendra Webdale

30. Laura’s Law (CA, 2002)

31. Kevin’s Law (MI, 2005)

32. Nicola’s Law (LA, 2008)

33. Arabella’s Law (NV, pending, 2009)

34. Seung-Hui Cho (Virginia Tech, April 2007)

37. 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…

38. “How likely is it [John/Mary] would do something violent to other people?” % very/somewhat likely • Schizophrenia: 61 • Major depression: 34 • Drug dependence: 87

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

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

41. 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.”

42. 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. ”

43. The Pennsylvania Hospital, 1751-2009

44. From Outpatient Commitment to “Mandated Community Treatment”

45. Community ≠ Hospital

46. Community ≠ Hospital

47. Community ≠ Hospital

48. Community ≠ Hospital

49. Community ≠ Hospital

50. Mandated Community Treatment HOUSING AS LEVERAGE ŽSubsidized housing