THE MacARTHUR COERCION STUDY(1) EXECUTIVE SUMMARY

September 1998

Coercion plays a highly controversial role in the administration of mental health services around the world. Involuntary commitment to mental hospitals -- and "voluntary" hospitalization to avoid imminent commitment -- have long been flashpoints in arguments between clinicians and family members, on the one hand, and patients and their advocates, on the other. More recent proposals in many countries to provide for commitment to outpatient treatment have only sharpened these disagreements. Many of the issues in contention in this debate invoke the prospective patients' moral rights to decision-making autonomy and human dignity. But empirical arguments for or against given uses of coercion are often pressed as well. One set of arguments revolves around the question of whether coercion "works." That is, whether any therapeutic outcomes produced by coerced treatment are offset by patients becoming so alienated that they refuse to comply with treatment as soon as coercion is lifted, and by patients reluctance to seek voluntary treatment in the future for fear of again being coerced.

The MacArthur Coercion Study, supported by the Research Network on Mental Health and the Law of the John D. and Catherine T. MacArthur Foundation, was designed to provide information to policy makers, clinicians, patients, and family members to broaden and deepen the conversation about the appropriate role of coercion, if any, in the provision of mental health services. During its initial phase, beginning in 1988, the project conducted literature reviews, focus groups of patients, family members, and clinicians, secondary data analyses, and exploratory studies to isolate the variables to be included in more systematic investigations. We concluded that before trying to understand the effects of coercion -- what kinds of therapeutic or non-therapeutic outcomes coerced treatment tended to produce -- it was necessary to first gain a better understanding of the experience of coercion in its own right: what is it, precisely, that makes patients feel that they have been "coerced" into a mental hospital?

Following this period during which our concepts and methods developed, three studies were undertaken, beginning in 1991. The first, using a sample of 157 randomly-selected adult patients admitted to a rural Virginia state hospital and a Pennsylvania community hospital, sought to determine the factors associated

The third study, conducted in parallel with the first two, involved adding our empirically-validated measure of perceived coercion -- the Perceived Coercion Scale -- to the battery of instruments used in the MacArthur Risk Assessment Study, a prospective study of 1,136 patients recruited from acute hospitals in Massachusetts, Pennsylvania, and Missouri, who were assessed in the hospital and then followed in the community and re-assessed on a large number of variables (including compliance with outpatient treatment and both voluntary and involuntary re-hospitalization) five times over the course of a year after their hospital discharge.

RESULTS

Among the key findings that appear to be emerging from our data at this time are the following:

o Legal status is only a blunt index of whether a patient experienced coercion in being admitted to a mental hospital. A significant minority of legally "voluntary" patients experience coercion, and a significant minority of legally "involuntary" patients believe that they freely chose to be hospitalized.

o Patient accounts of the events that precede their mental hospitalization tend to be as complete and plausible as the accounts of those events provided by their family members and admitting clinicians. Patient accounts tend not to change after the hospitalization is over and the patients are back in the community. Some patients' views about the need for hospitalization, however, do change over time. Approximately half the patients who initially denied the need for hospitalization acknowledge such a need in retrospect; the other half do not.

o The kind of pressures that others apply to an individual to obtain his or her admission to a mental hospital strongly affect the amount of coercion that the individual experiences: the use of "negative" pressures, such as threats and

o The amount of coercion a patient experiences in being admitted to a mental hospital is not related to his or her demographic characteristics. Rather, the amount of coercion experienced is strongly related to a patient's belief about the justice of the process by which he or she was admitted. That is, a patient's beliefs that others acted out of genuine concern, treated the patient respectfully and in good faith, and afforded the patient a chance to tell his or her side of the story, are associated with low levels of experienced coercion. This is true for both voluntary and involuntary patients. Patients report that the hospital admission process was characterized by less of this "procedural justice" than their family members or admitting clinicians report.

CONCLUSIONS

There are two principal "take home" messages from the MacArthur Coercion Study to date. The first message is methodological: "Coercion" as a field of research in mental health law has come of age. No longer is it necessary to rely on blunt proxy measures such as "voluntary" or "involuntary" legal status as indirect measures of coercion. Valid research instruments now exist that can directly measure the amount of coercion a patient experiences in being admitted to a mental hospital, and many of the factors that are associated with that experience.

The second message is substantive: The amount of coercion a patient experiences in the mental hospital admission process is strongly associated with the degree to which that process is seen to be characterized by "procedural justice." That is, patients who believe they have been allowed "voice" and treated by family and clinical staff with respect, concern, and good faith in the process of hospital admission report experiencing significantly less coercion than patients not so treated. This holds true even for legally "involuntary" patients and for patients

Ongoing analyses of data from the studies described above may yield additional conclusions. More importantly, a large number of other researchers in the United States and in England, Australia, Scandinavia, and several nations in the former Soviet Union are now using the MacArthur instruments to study coercion in a wide variety of treatment and cultural contexts -- including the first research to use a random-assignment design to study coercion to outpatient treatment. Conducting experimental interventions to reduce patients' experience of coercion -- by enhancing the degree of "procedural justice" in the admissions process, for example -- is now both feasible and of high priority. Over the next several years, a body of international research, using common measures, will emerge in the professional literature. New understandings of the prevalence, determinants, and consequences of coercively administered mental health services will then be available to inform -- and to reform -- policy and practice on one of the most contentious issues in mental health law.

 

Publications

Bennett, N., Lidz, C., Monahan, J., Mulvey, E., Hoge, K., Roth, L. and Gardner, W. (1993). Inclusion, motivation, and good faith: The morality of coercion in mental hospital admission. Behavioral Sciences and the Law, 11, 295-306.

Dennis, D., and Monahan, J. (Eds.). (1996). Coercion and Aggressive Community Treatment: A New Frontier in Mental Health Law. New York: Plenum Publishing Corporation.

Gardner, W., Hoge, S., Bennett, N., Roth, L., Lidz, C., Monahan, J., and Mulvey, E. (1993). Two scales for measuring patients' perceptions of coercion during hospital admission. Behavioral Sciences and the Law, 20, 307-321.

Gardner, W., Lidz, C., Hoge, S., Monahan, J., Eisenberg, M., Bennett, N., Mulvey, E., and Roth, L. (1997). Patients' revisions of their beliefs about the need for hospitalization. Submitted for publication.

Hoge, S., Lidz, C., Mulvey, E., Roth, L., Bennett, N., Siminoff, L., Arnold, R., Monahan, J. (1993). Patient, family, and staff perceptions of coercion in mental hospital admission: An exploratory study. Behavioral Sciences and the Law 20, 281-293.

Hoge, S., Lidz, C., Eisenberg, M., Gardner, W., Monahan, J., Mulvey, E., Roth, L., and Bennett, N. (1997). Perceptions of coercion in the admission of voluntary and involuntary psychiatric patients. International Journal of Law and Psychiatry, 20, 167-181.

Hoge, S., Lidz, C., Eisenberg, M., Monahan, J., Bennett, N., Gardner, W., Mulvey, E., and Roth, L. (1998). Family, clinician, and patient perceptions of coercion in mental hospital admission: A comparative study. International Journal of Law and Psychiatry, 21, 1-16.

Lidz, C., Mulvey, E., Arnold, R., Bennett, N., and Kirsch, B. (1993). Coercive interactions in a psychiatric emergency room. Behavioral Sciences and the Law, 11, 269-280.

Lidz, C., Hoge, S., Gardner, W., Bennett, N., Monahan, J., Mulvey, E., and Roth, L. (1995). Perceived coercion in mental hospital admission: Pressures and process. Archives of General Psychiatry, 52, 1034-1039.

Lidz, C., Mulvey, E., Hoge, S., Kirsch, B., Monahan, J., Eisenberg, M., Gardner, W., and Roth. (1998). Factual sources of mental patients' perceptions of coercion in the hospital admission process. American Journal of Psychiatry, 155, 1254-60.

Lidz, C., Mulvey, E., Hoge, S., Kirsch, B., Monahan, J., Bennett, N., Eisenberg, M., Gardner, W., and Roth, L. (1997). The validity of mental patients' accounts of coercion-related behaviors in the hospital admission process. Law and Human Behavior, 21, 361-376.

Lidz, C., Mulvey, E., Hoge, S., Kirsch, B., Monahan, J., Bennett, N., Eisenberg, M., Gardner, W., and Roth, L. (1998). Sources of coercive behaviors in psychiatric admissions. Submitted for publication.

Monahan, J., Hoge, S., Lidz, C., Roth, L., Bennett, N., Gardner, W., and Mulvey, E. (1995). Coercion and commitment: Understanding involuntary mental hospital admission. International Journal of Law and Psychiatry, 18, 249-263.

Monahan, J., Hoge, S., Lidz, C., Eisenberg, M., Bennett, N., Gardner, W., Mulvey, E. & Roth, L. (1996). Coercion to inpatient treatment: Initial results and implications for assertive treatment in the community. In D. Dennis and J. Monahan (Eds.), Coercion and Aggressive Community Treatment: A New Frontier in Mental Health Law. New York: Plenum Publishing Corporation (pp. 13-28).

Monahan, J., Lidz, C., Hoge, S., Eisenberg, M., Roth, L.,Gardner, W.P., & Bennett, N. (in press). Coercion in the provision of mental health services: The MacArthur studies. In J. Morrissey, and J. Monahan (Eds), Research in Community and Mental Health, Vol. 10: Coercion in Mental Health Services. Stamford, Connecticut: JAI Press.

1. The Working Group responsible for conducting this research consists of Steven K. Hoge, M.D., Charles W. Lidz, Ph.D., William Gardner, Ph.D., Edward P. Mulvey, Ph.D., Marlene Eisenberg, Ph.D., John Monahan, Ph.D., and Loren H. Roth, M.D., M.P.H.

Requests for further information should be sent to:

John Monahan
School of Law
University of Virginia
580 Massie Road
Charlottesville, Virginia 22903-1789
(e-mail: jmonahan@law1.law.virginia.edu)

Updated copies of this Executive Summary, and copies of many of the instruments used in the research, are available on the Network's website:

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