Charles W. Lidz Ph.D.
UMass Medical School
Center for Mental Health Services Research
One View of Hospitalization
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.
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.
A Different View
Aft er years o f suff e rin g t he m a n y ch alle n g es a sso ciat e d w it h
m y m e n t al illn ess a n d e xp e rie nc e s w it h PTSD, I fel t I w as in
rec o ve ry. How e ve r, m y g hos t s re t u rn e d . I fe lt the a n ge r of an
e n t ire ar m y. I w ant ed to kill th e m an wh o h ad d on e t h is to me
a n d I w an t ed to kill the p erso n w h o h ad n o t p rot e ct e d me
from h im . I kne w wh e n t hin g s wer e get ti n g ou t o f co nt ro l. I
n e ed e d to go to th e ER for a n e valua t io n .
Ha t re d wa s p o u rin g into m y fac e lik e b lo o d. I h ad n e ve r be e n
so a n g ry. I cal led for an a m b u lan ce , st a ti n g t h at I wa s
h o mi cid a l a n d su icid a l.
I w a s a d mi t t e d to the h os pi t a l at t h ree in the mo rni ng . I w a s
pu t in a b e d w it h re str a in t s a n d ta ken u p to the u n it . I w a s
e xp e ct in g t o be ap proa che d by the st aff in a w a y th at w a s
co n sis t en t w ith t he a n ge r and a g it a t io n t ha t w a s em a n a ti n g
t h ro ug ho ut m y b e in g . Bu t , a s th e se tho u g hts swir led w it hi n
m y h e ad a n d m y d efens e m e ch a n ism s pr ep ar ed the m se lve s, a
g e n t le nu rse a p pro ach e d m e a n d sm iled w arm ly sa ying , “Ho w
ar e yo u fee lin g Mr. B?” He co u ld t ell b y m y fa cia l e xpr es sio n s,
th at I w a s feel in g ino rd inat e ly a ng ry, b ut h e g av e me o n ly
sa lva t io n : He t rea t ed me a s if he w o u ld h a ve w ish e d t o be
tre at e d. Th is a ct o f virt ue calm ed me a n d he lp ed me to rea lize
I w a s tr u ly in t h e rig h t pl ac e .
Controversy
 The legal status of coercive pressures has been
controversial since the origins of efforts to treat mental
illness.
 Phillipe Pinel
 Institutions
 2 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 trust
 Wertheimer’s analysis
 Based on legal cases
 A “moralized” concept
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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 Coercion
 If Wertheimer is right, a study must collect multiple
perspectives.
 We were looking at admission decisions so we
interviewed
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“patient”
Admitting clinician
Accompanying person when available (family, police, friend,
etc.)
 I will talk more about this tomorrow.
Two Approaches to Measurement
 We did in depth interviews about the experience of
admission with “patients”
 copies of the interviews available
 they were extensive and semi-structured
 My colleague Loren Roth insisted on a structured
scale.
 We tried many versions
 Eventually MacArthur Admission Experience Scale
The MacArthur Admission
Experience Scale (MAES)
 This name was just meant as a disguise
 We did multiple versions
 Eventually 15 questions
 Only 5 are used as perceived coercion questions
 Others may or may not be relevant.
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Several authors use all of the questions as the scale
Other authors use some as measures of “procedural justice” or
“voice”, etc.
MAES -5 Questions
 I 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 .89
 Test retest on questionnaire form .81
 Coherence (alpha = .77)
 Correlate with legal status .62
 Correlates well with Nordik Coercion Ladder.
The Discovery of Procedural Justice
 Disjunction between objective coercion and perceived
coercion – correlates .62 with legal status
 Our initial interpretation
 Bennett’s analysis of the interview themes
 Inclusion in the decision making process
 Beneficent Motivation of the others participating
 Good Faith - Openness and honesty on the part of
others involved.
 Subsequent quantitative confirmation paper
Some results
 Stronger 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
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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 MPCS
 Bindman et al. studied the effect of perceived coercion
subsequent treatment involvement
 Angell researched the impact of perceived coercion on
outpatient treatment outcomes
 Bacharz 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