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

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. An Example Psychiatric Admission

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.