Charles W. Lidz Ph.D.UMass Medical School

Center for Mental Health Services Research

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.

One View of Hospitalization

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.

After years of suffering the many challenges associated with

my mental illness and experiences with PTSD, I felt I was in

recovery. However, my ghosts returned. I felt the anger of an

entire army. I wanted to kill the man who had done this to me

and I wanted to kill the person who had not protected me

from him. I knew when things were getting out of control. I

needed to go to the ER for an evaluation.

Hatred was pouring into my face like blood. I had never been

so angry. I called for an ambulance, stating that I was

homicidal and suicidal.

I was admitted to the hospital at three in the morning. I was

put in a bed with restraints and taken up to the unit. I was

expecting to be approached by the staff in a way that was

consistent with the anger and agitation that was emanating

throughout my being. But, as these thoughts swirled within

my head and my defense mechanisms prepared themselves, a

gentle nurse approached me and smiled warmly saying, “How

are you feeling Mr. B?” He could tell by my facial expressions,

that I was feeling inordinately angry, but he gave me only

salvation: He treated me as if he would have wished to be

treated. This act of virtue calmed me and helped me to realize

I was truly in the right place.

ControversyThe legal status of coercive pressures has

been controversial since the origins of efforts to treat mental illness.

Phillipe PinelInstitutions2 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 trustWertheimer’s analysis

Based on legal casesA “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 CoercionIf 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 MeasurementWe did in depth interviews about the

experience of admission with “patients”copies of the interviews available they were extensive and semi-structuredMy colleague Loren Roth insisted on a

structured scale.We tried many versionsEventually MacArthur Admission Experience

Scale

The MacArthur Admission Experience Scale (MAES)

This name was just meant as a disguiseWe 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 QuestionsI 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 .89Test retest on questionnaire form .81Coherence (alpha = .77)Correlate with legal status .62Correlates well with Nordik Coercion

Ladder.

The Discovery of Procedural JusticeDisjunction between objective coercion and

perceived coercion – correlates .62 with legal status

Our initial interpretationBennett’s analysis of the interview themes

Inclusion in the decision making processBeneficent Motivation of the others participatingGood Faith - Openness and honesty on the part of

others involved.Subsequent quantitative confirmation paper

Some resultsStronger 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 MPCSBindman et al. studied the effect of perceived

coercion subsequent treatment involvementAngell researched the impact of perceived

coercion on outpatient treatment outcomesBacharz 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