THE MacARTHUR COERCION STUDY
May 2004 Update of the Executive Summary
All of the active research on coercion to inpatient mental health treatment undertaken by the Network was completed by 2001. Many studies are now incorporating the measures of perceived coercion developed by the Network. (For a review, see Poythress, N., Petrila, J., McGaha, A., & Boothroyd, R. (2002). Perceived coercion and procedural justice in the Broward County Mental Health Court. International Journal of Law and Psychiatry, 25, 517-533).
Since 2001, research on coercion supported by the MacArthur Foundation
has shifted from coercion in the context of inpatient treatment to coercion
in the context of treatment in the community. Information on the Research
Network on Mandated Community Treatment can be found on the web at www.macarthur.virginia.edu/researchnetwork.html
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 with patients' experience of coercion in their hospital admission. This study relied only on patients' accounts of the hospital admission process. Since the same events may be differently perceived by others involved in the patients' hospitalization, we then undertook a second and more ambitious study, using a sample of 433 randomly-selected adult patients from the same jurisdictions. This study compared the perceptions of patients -- at admission and later a month after discharge into the community -- with (a) the perceptions of their involved family members, (b) the perceptions of their admitting clinicians, and (c) our own triangulated "most plausible factual account" of what had actually transpired during the process of hospital admission.
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.
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 force, engender feelings of coercion; the use of "positive" pressures, such as persuasion and inducements, do not.
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.
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 who report being pressured to be hospitalized.
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.
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. (1999). 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. (1998). Coercion in psychiatric care: What have we learned from research? Journal of the American Academy of Psychiatry and the Law, 26, 631-637.
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. (2000). Sources of coercive behaviors in psychiatric admissions. Acta Psychiatrica Scandinavica, 101, 73-79.
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., Mulvey, E., Eisenberg, M., Roth, L., Gardner, W., & Bennett, N. (1999). 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 -- International Perspectives. Stamford, Connecticut: JAI Press (pp. 13-30).
Morrissey, J. & Monahan, J. (Eds) (1999), Research
in Community and Mental Health, Vol. 10: Coercion in Mental Health Services
-- International Perspectives. Stamford, Connecticut: JAI Press.
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: firstname.lastname@example.org).