1. Findings from 20 Years of Research on Coercion, 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 (%) AffectLow CoercionHigh Coercion Angry3763 Sad6072 Relieved8231 Frightened5668

8. Legal Status of Patients in State Hospitals on December 31, 2007 (%) JurisdictionVoluntaryInvoluntaryForensic U.S. Average175231 California11782 New York483319 Virginia85339 West Virginia07426 Washington, DC71128

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 Coercion No Pressures = 46%; Pressures = 54% Positive Pressures (%) Persuasion = 38 Inducement = 4 Negative Pressures (%) Threats = 9 Force = 19

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 didnt 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 doesnt matter, you know, youre going anyway. He didnt 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 Beliefs Gardner 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 (%) Belief After Discharge Belief at Hospital Admission Did Not Need Hospitalization Needed Hospitalization Did Not Need Hospitalization 485 Needed Hospitalization 5295

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 [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. 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.

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 its 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. Kendras Law (NY, 1999) Kendra Webdale

30. Lauras Law (CA, 2002)

31. Kevins Law (MI, 2005)

32. Nicolas Law (LA, 2008)

33. Arabellas Law (NV, pending, 2009)

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

37. DSM-IV Vignette: Schizophrenia 1996 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… to get treatment at a clinic or from a doctor? (% yes) Schizophrenia49 Depression22 Drug67

40. Do you think that people like [John/Mary] should be forced by law… to get treatment… if he [she] is dangerous to others? (% yes) Schizophrenia49 95 Depression22 94 Drug67 96

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 Mandated Institutional Tx Mandated Community Tx HousingHospital Disability benefits Hospital Order maintenance Hospital TreatmentHospital

46. Community Hospital Mandated Institutional Tx Mandated Community Tx HousingHospitalHousing agency Disability benefits Hospital Order maintenance Hospital TreatmentHospital

47. Community Hospital Mandated Institutional Tx Mandated Community Tx HousingHospitalHousing agency Disability benefits HospitalWelfare agency Order maintenance Hospital TreatmentHospital

48. Community Hospital Mandated Institutional Tx Mandated Community Tx HousingHospitalHousing agency Disability benefits HospitalWelfare agency Order maintenance HospitalCriminal justice system TreatmentHospital

49. Community Hospital Mandated Institutional Tx Mandated Community Tx HousingHospitalHousing agency Disability benefits HospitalWelfare agency Order maintenance HospitalCriminal justice system TreatmentHospitalMental health system

50. Mandated Community Treatment HOUSING AS LEVERAGE Ž Subsidized housing

51. Standard Lease: Alliance for the Mentally Ill of Delaware Refusing to continue with mental health treatment means that I do not believe I need mental health services. I understand that since I am no longer a consumer of mental health services, it is expected that I will find alternative housing. I understand that if I do not, I may face eviction.

52. Mandated Community Treatment MONEY AS LEVERAGE Ž Money managers

53. Recipient Responsibilities You are receiving benefits based on the mental health problems that you have. The Social Security Administration requires that you be involved in mental health services so that you will feel better. [Otherwise,] you may lose your benefits.

54. Mandated Community Treatment JAIL AS LEVERAGE Ž Treatment as a condition of probation

55. United States Code, Title 18, §3563 The court may provide, as further conditions of a sentence of probation…that the defendant … undergo available medical, psychiatric, or psychological treatment.

56. U.S. v Holman, 532 F.3d 284 (2008) Holman became a danger to himself and others when he was off his medication, and injections of long-lasting antipsychotic drugs provide the only means of insuring that Holman takes his medication…Requiring intramuscular injections of antipsychotic medications as a special condition of supervised release was consistent with the… requirements set out by the Supreme Court.

57. Mandated Community Treatment JAIL AS LEVERAGE Ž Treatment as a condition of probation Ž Mental health courts

58. Mental Health Courts are criminal courts have separate dockets dedicated to defendants with mental illness divert defendants from jail and/or prison to community treatment monitor community treatment and potentially impose sanctions for non-adherence.

59. Mandated Community Treatment HOSPITALIZATION AS LEVERAGE Ž Outpatient commitment

60. Psychiatric Advance Directives An Antidote to Coercion, or Self-Mandated Treatment?

61. Psychiatric Advance Directives (PADs) Legal instruments that allow competent persons to give or to refuse consent to future psychiatric treatment May authorize an agent to make future decisions about a persons mental health care, if the person becomes incapacitated.

62. How Often Is Treatment Mandated?

63. The Prevalence of Leverage Monahan et al, 56 Psychiatric Services 37 Five Sites Durham, NC Worcester, MA Chicago, IL Tampa, FL San Francisco, CA Overall N:1,011 Refusal Rate: 6.8%

64. Eligibility Criteria 18-65 years old English or Spanish-speaking Currently in outpatient treatment with a public MH service provider In treatment at least 6 months.

65. Prevalence of Mandated Community Treatment Form of Leverage% with Leverage Obtaining Housing32

66. Prevalence of Mandated Community Treatment Form of Leverage% with Leverage Obtaining Housing32 Avoiding Jail23

67. Prevalence of Mandated Community Treatment Form of Leverage% with Leverage Obtaining Housing32 Avoiding Jail23 Avoiding Hospital15

68. Prevalence of Mandated Community Treatment Form of Leverage% with Leverage Obtaining Housing32 Avoiding Jail23 Avoiding Hospital15 Obtaining Money12

69. Prevalence of Mandated Community Treatment Form of Leverage% with Leverage Obtaining Housing32 Avoiding Jail23 Avoiding Hospital15 Obtaining Money12 At Least 1 Form51

70. Findings on an Additional Form of Leverage: Child Custody Busch and Redlich, 58 Psychiatric Services 999 Experienced by 5% of sample 75% of these were women 11% of all mothers 6% of all fathers.

71. Conclusions from the Prevalence Study Focusing the policy debate on outpatient commitment is much too narrow The use of leverage to obtain adherence to mental health treatment in the community is pervasive.

72. Mandated Community Treatment: Findings to Date (April 28, 2009)

73. Findings on General Effects of Leverage Monahan and Redlich, unpublished data, 2009

74. 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 …...to the mental health clinic.

75. 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 clinic.

76. High Perceived Coercion by Procedural Justice: Inpatient Hospitalization

77. High Perceived Coercion by Procedural Justice: Community Treatment

78. Findings on Specific Forms of Leverage

79. Money as Leverage

80. Findings on Money as Leverage Elbogen et al, 29 Law and Human Behavior 563 Patients assigned a money manager are four times more likely to adhere to treatment than other patients Money managers who are family members are more likely than other money managers to report using money as leverage to obtain treatment adherence Unexpectedly, having a family member act as a money manager doubles the likelihood of patient violence. The more a patient interacts with a family member who is a money manager, the more likely the violence.

81. Housing as Leverage

82. Findings on Housing as Leverage Robbins et al, 33 Administration and Policy in MH and MH Services Research 226 Housing often used in combination with money as leverage Requiring adherence to treatment is usually imposed by landlords, rather than by their clinicians Housing as leverage strongly increases perceived coercion BUT, patients who experience housing as leverage are as satisfied as other patients with the treatment they receive AND, patients who experience housing as leverage are more likely to believe that using housing as leverage is effective in helping people.

83. Jail as Leverage Mental Health Courts Steadman et al, in preparation

84. Findings on Mental Heath Courts Redlich et al, 30 Law and Human Behavior 347 7,560 defendants currently subject to MH Court jurisdiction 1997 = 1 MH Court; 2009 = 125 MH Courts 40% exclusively misdemeanors 50% both misdemeanors and felonies 10% exclusively felonies More likely to use jail as a sanction with felons.

85. Findings on Mental Heath Courts Christy et al, 23 Behavioral Sciences and the Law 227 95% of MD defendants choose a MH court Much less experience of coercion Much more satisfaction with court process Much more likely to adhere to MH services Less time in jail No higher rates of recidivism over 1 year.

86. Psychiatric Advance Directives

87. Findings on Psychiatric Advance Directives Swanson et al, 34 Journal of the American Academy of Psychiatry & Law 43 Only 7% of all patients have completed a PAD Over two-thirds of all patients say they want to complete a PAD, but do not know how to do so Almost half of all patients (compared to 10% of family members) believe that patients should be able to change a PAD even when they are ill Three-quarters of patients believe that a psychiatric advance directive will help avoid unwanted treatment, but only one-quarter of clinicians agree.

88. PADS and Coercive Crisis Interventions Swanson et al, 17 Journal of Mental Health 255 taken by police to ER for psych evaluation placed in handcuffs involuntarily civilly committed placed in seclusion placed in restraints forcibly medicated

89. Decisional Incapacity Retrospective self-report at each follow-up: Since your last interview, has there been any time when you became ill and were not able to think clearly enough to make your own decisions about treatment or let others know what you wanted?

91. [In the hospital] we talked about what was in the PAD. I did not receive any treatments that I did not want. They were very respectful. I really felt like the hospital took better care of me because I had my PAD. The doctor didnt treat me like a nut case because some hospitals do. You know what the doctor said to me? [He said] Youve got rights and its great that you know you have them. Well try to respect those completely. I never take [PAD wrist bracelet] off. My other wrist has my dialysis bracelet. I never take either of these off because I hope this doesnt happen but if Im in a situation where Im out of my mind, at least people can just look at my wrist and see that Ive got a PAD and that I better not get that ECT and that they better contact [health care proxy] before doing anything to me.

93. www.nrc-pad.org 10,000 visits per month

94. Outpatient Commitment 1: MacArthur Prevalence Study Monahan et al, 56 Psychiatric Services 37

95. Who gets outpatient commitment? Recipients of outpatient commitment had higher rates of... Past involuntary hospitalizations Police encounters around mental health crises Past violent behavior Functional impairment Low social support.

96. Outpatient Commitment 3: NY State Assisted Outpatient Treatment Study Swartz, Swanson, Steadman, Robbins, and Monahan, in progress

97. The Carrot: Fiscal Changes $32 million directly allocated yearly in support of the OPC program $15 million -- medication grant program $4.4 million -- prison and jail discharge managers $2.4 million -- oversight programs $9.55 million -- new case management slots $0.65 million -- drug monitoring $125 million yearly for enhanced community services Used to increase Intensive Case Management and Assertive Community Treatment programs.

98. Outpatient Commitment 4: Can Support/Opposition Be Explained by Cultural Cognition? Kahan, Braman, Monahan, Callahan, and Peters, Law and Human Behavior, in press.

99. General Social Survey Do you think that people like [John/Mary] should be forced by law to get treatment at a clinic or from a doctor? Schizophrenia Vignette: 1996 Yes = 49% 2006 Yes = 50% No significant correlation (r =.03) with liberal-conservative political views The public appears to be as ambivalent as policymakers about the use of legal force to ensure that individuals receive mental health treatment.

100. Web-based Survey N = 1,496 American adults 54% female, 46% male 75% white, 11% African-American Mean age: 48 years Median income: $40,000 to $49,000 Median education: Some college.

101. Hierarchist Egalitarian CommunitarianIndividualist Mary Douglass Group/Grid Culture Theory

102. Mary Douglass Group/Grid Culture Theory 1 The group dimension represents the degree to which the individuals life is absorbed in and sustained by group membership – Low group or individualistic way of life favors self- regulation – High group or communitarian way of life favors depending on each other.

103. The grid dimension measures the pervasiveness and significance of social differentiation – Low grid or egalitarian way of life: minimizes differences between groups of people – High grid or hierarchical way of life: justifies differences between groups as enabling people to live together with greater harmony and effectiveness. Mary Douglass Group/Grid Culture Theory 2

104. Individualist-Communitarian [One] thing people in our society often disagree about is the relationship between society's responsibilities, on the one hand, and individuals' responsibilities, on the other. How strongly you agree or disagree with each of these statements? Sample Items: Too many people today expect society to do things for them that they should be doing for themselves People should be able to rely on the government for help when they need it.

105. Hierarchist-Egalitarian People in our society often disagree about issues of equality and discrimination. How strongly you agree or disagree with each of these statements? Sample Items: Nowadays it seems like there is just as much discrimination against whites as there is against blacks We need to dramatically reduce inequalities between the rich and the poor, whites and people of color, and men and women.

106. Description of Outpatient Commitment Outpatient commitment laws give courts the power to order people diagnosed with certain mental illnesses, including schizophrenia, to receive treatment from a doctor and to follow prescribed treatment procedures, which usually include taking medication. The prescribed treatment does not require hospitalization. However, if someone refuses an order to see a doctor and to follow treatment procedures, the person can be brought to a mental health facility against their will for an evaluation and, if necessary, involuntarily hospitalized for treatment.

107. Background Questions (n = 1,496) How much did you know about outpatient commitment laws before today? (%) Nothing at all60 Just a little26 Some12 A lot 2 Have you personally ever had a family member or a close friend who had a psychiatric condition like schizophrenia? (%) Yes28 No72

108. Estimated Response to Item People with psychiatric conditions like schizophrenia should be forced by law to get outpatient treatment from a doctor, by Individualist-Communitarian

109. Estimated Response to Item People with psychiatric conditions like schizophrenia should be forced by law to get outpatient treatment from a doctor, by Hierarchist-Egalitarian

110. Percent of Respondents Mildly, Moderately, or Strongly Supporting Outpatient Commitment

111. Takk! Web: http://macarthur.virginia.edu Email: jmonahan@virginia.edu