Most Plausible Factual Account and the Problem of Objective Coercion

1. Most Plausible Factual Account and the Problem of Objective Coercion Charles W. Lidz Ph.D. Research Professor of Psychiatry UMass Medical School

2. 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

3. 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

4. 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.

5. 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.

6. 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.

7. 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

8. Objective indicators • Number of involuntary commitments • Voluntary may be pressured • “Involuntary” may be agreed to. • Number of police calls • Police as a taxi service

9. 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

10. Psychiatric Admission An Example

11. Possible Sources of Data • Admission Staff accounts • Medical Records • Police or Police reports • Family or other accompanying individuals • The admitted individual

12. 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

13. 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

14. 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.

15. 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.

16. 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.

17. 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

18. 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.