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Patient perceptions of coercion in mental hospital admission
Pergamon
International Journal of Law and Psychiatry, Vol. 20, No. 2, pp. 227-241, 1997 Copyright © 1997 Elsevier Science Ltd Printed in the USA. All rights reserved 0160-2527/97 $17.011 + .(10 PII S0160-2527(97)00004-6
Patient Perceptions of Coercion in Mental Hospital Admission Virginia Aldig~ Hiday,* Marvin S. Swartz,** Jeffrey Swanson,** and H. Ryan Wagner**
Introduction In civil commitment the state applies its police and parens patriae powers in order to coerce mentally ill persons into treatment. Coercion, thus, is central to civil commitment. It also has been central in the mental health law debate over the justification of civil commitment of mentally ill patients. Civil libertarians, concerned with deprivations to free choice and movement, have argued for imposition of formal legal procedures and limitation of this coercion of mentally ill persons to those who are dangerous (La Fond & Durham, 1992; Morse, 1982; Wald & Friedman, 1978). Mental health practitioners, concerned with reducing symptoms and providing psychiatric care, have argued for minimal procedural and substantive limits on their ability to hospitalize and treat mentally disordered persons (Stone, 1975; Torrey, 1988; Treffert, 1981). Despite this debate, empirical researchers neglected development of the construct of coercion in psychiatric treatment (Hiday, 1992; Monahan et al., 1995); and only recently have they begun to lay the foundation conceptually and empirically to advance our understanding of it (Lidz & Hoge, 1993). In the substantial empirical literature on civil commitment, the existence of coercion was assumed to be inherent in the process while the focus was on other components of commitment such as characteristics of actors and rates of commitment. With few exceptions, researchers equated the legal category of involuntary patient with coercive practices.
*Professor, D e p a r t m e n t of Sociology and Anthropology, North Carolina State University, Raleigh, NC 27695, USA. * * D e p a r t m e n t of Psychiatry and Behavioral Sciences, Duke University Medical Center, D u r h a m , NC, USA. Address correspondence to Virginia A. Hiday. This work was sponsored by Grant RO1 MH48103 from the National Institute of Mental Health. The authors wish to thank Jean Campbell, Caroline Kauffman, and H e n r y J. Steadman for their helpful c o m m e n t s on an earlier version of the paper. 227
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Although subjugation to the state's coercive power legally distinguishes involuntary from voluntary patients, coerced hospitalization or treatment may occur in the absence of legal involuntary status. Coercion in other forms may be brought to bear on voluntary patients. Mental health workers, hospital staff, public defenders, and family members often use informal means to coerce many legally voluntary patients into hospitalization. Threat of loss of valued resources (i.e., housing, work, money), threat of civil commitment, deception, and physical restraint have all been used to get mentally ill persons to volunteer for hospitalization (Decker, 1980, 1981; Gilboy & Schmidt, 1971: Goffman, 1961; Lewis et al., 1984; Rogers, 1993). On the other hand, legal involuntary hospitalization may be imposed in the absence of coercive measures such as physical force or treatment. Some legally involuntary patients often want help but their cognitive impairment may prevent them from seeking treatment; thus, others are left to petition for their commitment. Some may perform apparently dangerous acts in order to gain hospital admission by convincing clinicians that legal commitment is necessary (Miller, 1982); and some may not want hospitalization but acquiesce to involuntary admission such that no coercive measure but the signing of legal papers is taken. In all of these cases, the subjective, personal state of coercion is not congruent with the objective, legal state of coercion. A few studies have documented frequent incongruence between patients' official legal status and their subjective experience of coercion. These studies have reported that a substantial proportion of each legal status group perceives the opposite of what would be predicted by congruence: from one-fifth to one-third of involuntarily hospitalized patients report having wanted to be hospitalized at the time of their legally coerced admission (Beck & Golowka, 1988; Edelsohn & Hiday, 1990; Hoge et al., in press; Kane, Quitkin, & Rifkin, 1983); and approximately half of legally voluntary patients report having felt a large element of coercion in the decision leading to their hospitalization (Beck & Golowka, 1988; Rogers, 1993; see also Hiday, 1992, and Monahan et al., 1995 for a review of these studies). One exception was a study that found only 10% of voluntary patients perceiving coercion (Hoge et al., in press). Not only are patient perceptions of coercion frequently different from their official legal status but also their perceptions are frequently different from those of other actors in the hospital admission process. Results from two studies indicate that clinical staff and family members perceive having applied more "pressure" for hospitalization than patients felt (Bennett et al., 1993; Hoge et al., 1993). Even behavior that an observer would judge to be clearly coercive such as threats and physical pressure was not always interpreted as coercive by patients. This paper attempts to develop a better understanding of coercion in psychiatric treatment by studying patient perceptions of coercion and of two closely related constructs--patients' perceptions of negative pressures in the hospital admission process, and patients' perceptions of fair procedures in the attempts to have them hospitalized. It also examines how these constructs are influenced by sociodemographic and clinical factors. Following recent empirical development of the construct of perceived coercion, we define it as the opposite of patient perceptions of autonomy (Gardner
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et al., 1993). Accordingly, feeling coerced in mental hospital admission means perceiving that one does not have influence, control, freedom, or choice, or does not make the decision to enter the hospital (Gardner et al., 1993). Although force is a synonym for coercion in everyday language, here it is held distinct from coercion because in hospital admission force is frequently understood narrowly to mean physical compulsion. We use patient perception of coercion more broadly to reflect patients ~feelings regardless of how they were treated. How they were treated involves at least two concepts closely related to coercion but theoretically distinct: negative pressures and fair process. Negative pressures include threats and force of any kind that indicate to patients they would suffer worse consequences were they to resist hospitalization. Our definition of negative pressures is distinct from more benign pressures such as persuasion and inducement, which use reason or rewards in attempting to get patients to accept hospitalization (Lidz et al., 1995). One would expect that the more threats and force as applied in the process of hospitalization, the more a patient is likely to perceive coercion. The second closely related concept, evaluation of the hospital admission process as fair, has to do with patient perceptions of (a) whether others consider patient views and (b) the motivations of others. Having a chance to speak (voice) and having others take it into account (validation) provide a chance to influence an outcome, even though the outcome may not be what one would desire. Thibaut and Walker (1975) term this "process control" as distinguished from "outcome control" and they find it to be essential to perceptions of fairness. But having voice and validation are important to a sense of fairness of process even when they are not instrumental in influencing outcomes (Lind, Kanfer, & Early, 1990; Lind & Tyler, 1988; Tyler, 1990; Tyler, Rasinski, & Spodick, 1985). Likewise, perceptions that decision makers are acting in good faith and without bias are important components in evaluation of process fairness (Tyler, 1990). When a patient perceives that family, friends, and clinicians are acting in good faith and with impartiality, even though they may be attempting to have him hospitalized and even though he is hospitalized, that patient is likely to view the hospital admission as fair (Bennett et al., 1993; Tyler, 1992) and is less likely to perceive coercion (Hoge et al., 1993; Monahan et al., 1995). In trying to understand causes of perceived coercion, negative pressures, and process fairness, our three dependent variables, we expected sociodemographic characteristics to be important because these characteristics place individuals in groups that experience legal and medical authority differently. Age, gender, racial, and socioeconomic groups vary in their norms and experiences which affect others" reactions to them and their own interpretations of the commitment process. On one hand, patients who are young, male, African-American, urban, unmarried, and of low education might be more likely to perceive negative pressures, procedural inequity, and high levels of coercion because they are more likely to be angry and assaultive; thus, they are more likely to resist hospital admission, and to be seen as dangerous and in need of force to be hospitalized (National Research Council, 1993; Nicholson, 1986; Slovic & Monahan, 1995), and because they are more likely to have experienced directly or indirectly lack of respect from authorities (National Re-
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search Council, 1993: Tyler, 1990). On the other hand, members of these disadvantaged groups may feel so disenfranchised and expect less control of their lives that they would, by comparison, perceive only low levels of coercion in the involuntary hospitalization process. Similarly, higher status persons who exert higher levels of control and autonomy on a daily basis would be more sensitive to their loss and be more likely to perceive coercion in the admission process. Clinical factors may also predict our dependent variables. Having comorbidity of substance abuse/dependence or of personality disorder places an individual at greater risk for creating tense situations that lead to violence (Hiday, 1995). Such patients are more likely to have come into conflict with authority and are more likely to resist hospitalization; thus, they are more likely to experience negative pressures, evaluate the commitment process as unfair, and perceive coercion in hospital admission. Those with high levels of hostility and suspiciousness are more likely to perceive coercion, negative pressures, and exclusion; whereas those with high levels of symptomatology in general may be more acquiescent to hospital admission, and thus be less likely to perceive force and coercion. Finally, variation in recent mental hospital admissions could affect the dependent variables, but it is unclear in which direction. Multiple recent admissions, most likely involuntary, could lead to greater resistance or to greater submission, which would have opposite effects on our dependent variables.
Design and Sample This analysis uses baseline data on 331 subjects in a larger study of the effectiveness of outpatient commitment (Swartz et al., 1995). Subjects were involuntarily admitted, severely mentally ill patients recruited from the admissions unit of a state mental hospital and the psychiatric units of three general hospitals; they had been court-ordered to outpatient commitment following hospital discharge. To be recruited subjects had to be 18 years or older, diagnosed with severe mental disorder (schizophrenia, schizoaffective, affective, or other psychotic disorder), functionally impaired according to state criteria for severe and persistent mentally illness (SPMI) with illness duration of a year or more, and having one or more hospitalizations totaling at least 21 days within the past 2 years. Subjects also had to be approved by the hospital treatment team as appropriate candidates for outpatient commitment, ordered to outpatient commitment by the court, and be residents of counties participating in the study. We identified eligible patients from daily hospital admission records and discussion with treatment team members. While these patients were still hospitalized awaiting their period of outpatient commitment, we met with them to describe the study, the interview required, and confidentiality of information, and to obtain their consent for participation. Subjects were offered improved access to services via case management, a service not generally available, possible random assignment to release from their outpatient commitment orders, and monetary remuneration for each follow-up interview after hospital discharge. Of identified eligible patients, only 11.5% refused, a
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low refusal rate (Cascardi, Poythress, & Ritterband, in press; Lidz, Mulvey, & Gardner, 1993; Scheid-Cook, Wooten, & Hiday, 1987). Table 1 presents the characteristics of our sample: average age was 41.3 years with a range of 20 through 70 years; 53.8% were male; 66.1%, AfricanAmerican; one-fifth were married or cohabitated; 62.2% lived in the urban and suburban areas of four cities, and the rest lived in small towns or rural sections of the nine participating counties; almost three-fourths had graduated from high school. Clinically, the sample averaged 1.5 mental hospital admissions in the previous year; they had a very high mean score of 6.97 (versus 1.36 for the norm of psychiatric inpatients) on the Brief Symptom Inventory (BSI) General Severity Index, an index of number and severity of symptoms (Derogatis & Melisaratos, 1983). Just over half, 55.9% met diagnostic criteria for a primary diagnosis of schizophrenia or schizoaffective disorder; 31.1%, affective disorder; and 13.0%, other psychotic disorder. Approximately one-eighth met diagnostic criteria for a second diagnosis of personality disorder: and 21%, for substance-use disorder. Substance use, as opposed to diagnosis, was higher, with about 33% of subjects having used illicit drugs and 53% having used alcohol at least once a month during the 4 months prior to baseline hospitalization, as indicated by self-report, collateral report, or hospital record. Other research suggests that the true prevalence of problematic substance use approaches 50% in SPMI populations (although such problems often go undetected); and that any amount of alcohol or illicit drug use can lead to problems and tends to complicate treatment in SPMI populations (Drake et al., 1990, 1993b; Drake, Alterman, & Rosenberg, 1993a). Following this line of argument, we used a broad measure of comorbidity, which includes any indication of at least occasional substance use--combining self-report, family/collateral report, and hospital record information. The prevalence of co-occurring substance use in the previous 4 months with this measure was 57.4% in our sample. TABLE 1 Sample Characteristics
Mean Age (years) Male African-American a Married/Cohabiting Urban Education (years) Admissions BSI severity Schizophrenia disorder Affective disorder Personality disorder Substance abuse comorbidity
41.3 53.8% 66.1% 20.2% 62.2% 11.7 1.5 6.96 55.9% 31.1% 12.4% 31.1%
aThe remainder were all white, except for 1 Asian and 1 Hispanic.
Standard Deviation 10.7 2.7% 2.6% 2.2% 2.7% 2.7 1.0 6.68 2.7% 2.5% 1.8% 2.5%
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Measurement
Sample subjects were given an extensive interview in the hospital, which included a diagnostic assessment, measures of health and mental health functioning, and 15 true-false items of the MacArthur Interpersonal Relations Scale. We used these items to construct the three d e p e n d e n t variables: perceived coercion, perceived negative pressures, and perceived procedural inequity. Following Gardner et al. (1993), perceived coercion is represented by patients' responses to five items indicating their judgment about the amount of autonomy they did not have in the hospital admission decision in terms of influence, control, choice, freedom, and idea. ("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 went into the hospital." "I had more influence than anyone else on whether I came into the hospital.") A simple summation of these five items yields the MacArthur Perceived Coercion Scale Score with possible scores of 0-5. Both this scale and a similar version of it have shown good internal reliability (Garner et al., 1993) and the similar version has shown acceptable retest stability (Cascardi et al., in press). In our sample, item-total correlations ranged from .60 to .73, indicating satisfactory homogeneity; Cronbach's alpha was .86, indicating high internal reliability. Figure 1 presents the distribution of this scale. Perceived coercion is bimodal, with over half the responses falling at the two extremes of the scale: just over one-third felt high levels of coercion, just over one-fifth felt no coercion, with the rest being equally distributed in the middle levels. Mean score was 2.90. From six items indicating that others threatened or forced patients to come into the hospital, we constructed a perceived negative pressures scale. ("People tried to force me to come into the hospital." "Someone threatened me to get me to come into the hospital." "Someone physically tried to make me come into the hospital." "I was threatened with commitment." "They said
Percent
35 ' . -
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FIGURE 1. Perceived Coercion.
4
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they would make me come into the hospital." "No one tried to force me to come into the hospital.") Item-total correlations ranged from .54 to .70. Cronbach's alpha was .84, indicating high internal reliability on this scale. As can be seen in Figure 2, patient perceptions of negative pressures are over the full scale. Patients averaged 3.31 on this negative pressures scale, approximately at the midpoint of the scale, with a standard deviation of 2.17. One-fourth reported no threats or force. Evaluation of f a i r n e s s i o r its reverse, inequity--in the process of admission includes evaluation of both the motivations of others (impartiality and good faith) and their consideration of patient views (voice and validation). Our measure of procedural inequity, however, taps only the second. To distinguish it from the broader measure, we call it process exclusion. Two items indicate lack of voice ("I had enough of a chance to say whether I wanted to come into the hospital." "I got to say what I wanted about coming into the hospital.") and two items indicate lack of validation ("No one seemed to want to know whether I wanted to come into the hospital." "My opinion about coming into the hospital didn't matter."). These items comprise a 0-4 scale, having a Cronbach's alpha of .76 and item-total correlations between them of .52 and .60. Patients had a mean of 2.09, again approximately at the midpoint of the scale, and a standard deviation of 1.51 on this process-exclusion scale. Just over onefifth of respondents reported perceiving no process exclusions, whereas 27.1% reported having no voice or validation, that is, feeling a high level of inequity or process exclusion (see Figure 3). As one would expect, our three d e p e n d e n t variables are strongly associated with each other at the .60 level or higher (see Table 2). Prediction
We examined three sets of predictor variables in three consecutive models for each d e p e n d e n t variable. Our three d e p e n d e n t variables were modeled us-
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Percent 35 30
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FIGURE 3. Process Exclusion.
ing proportional odds ordinal logistic regression. Briefly, the technique uses a linear function of predictors to model a logit computed from the logarithmic ratio of the probability of a given event being equal to or less than a given level of outcome over 1 minus the same probability (i.e., Lj = In [P(Y _-< j)/ (1 - P(Y =< j))] where Lj represents the logit at level j). For a given predictor, X, the odds that a respondent is at or below some level of Yj are represented by the exponentiated coefficient of X as estimated by the model. Proportionality between levels of outcome is assumed constant and is tested by a score test for proportional odds. Models were tested in four stages. At Stage 1, each d e p e n d e n t variable was regressed on the basic demographic variables of age, race, and gender. Age was tested for nonlinearity. Stage 2 included acquired demographic variables: education, urban residence, and marriage/cohabitation. Clinical markers were entered at Stage 3; these included diagnosis of schizophrenia/schizoaffective disorder, affective disorder, personality disorder comorbidity, substanceabuse comorbidity, multiple admissions in the past year, the BSI total score for severity of symptoms, and the BIS Paranoid Scale score. At the fourth and final stage, interaction terms suggested by the correlation matrix were tested. In the models presented, the odds ratios are coded to show the odds of being at or above higher levels of the outcomes of perceived coercion, negative presTABLE 2 Spearman Correlations Outcome Variables
Perceived Coercion Negative Pressures Process Exclusion
Coercion
Negative Pressures
Process Exclusion
1.00
0.61 1.00
0.71 0.60 1.00
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sures, and process exclusion. Inferences are based on a minimal significance level o f p _-< .05. Results
Coercion A m o n g Stage 1 variables, males and African-Americans were significantly less likely to be at or above a particular level of coercion relative to females and whites. Age was not a significant predictor. A m o n g predictors entered at Stage 2, the odds of being at or above a particular level of coercion were significantly reduced among married/cohabiting respondents, whereas the odds of being at or above a particular level of coercion were significantly increased among respondents with higher levels of education. Urban residence made no difference. In Stage 3, no clinical markers attained significance. Based on the three main effects models, being male, African-American, and married/cohabiting was associated with lower perceived coercion scores, and education was associated with higher scores. The only interaction that reached significance at the .05 level was between education and cohabitation; but given the n u m b e r of model comparisons with interaction terms that were conducted, and indication of an unstable interaction mode, there is the possibility that bias may have occurred in estimating the model. Therefore, we dismiss this interaction term (Table 3).
Negative Pressures In the models predicting negative pressures, education is significantly associated with higher levels of negative pressures; and the interaction of gender and race also is significantly associated with negative pressures. AfricanAmerican females and white males are more likely to experience negative pressures, whereas African-American males are unexpectedly low in reporting negative pressures in the c o m m i t m e n t process (Table 4). TABLE 3 Odds Ratios a for Being at or Above a Given Level or Perceived Coercion
Main Effects
Odds Ratios*
Female Male
1.00 0.65
White African -American
1.00 0.56
Not married or cohabiting Married or cohabiting
1.00 0.48
No education Education (increase per year of)
1.00 1.15
aBy proportional Odds Ordinal Logistic Regression. *All odds ratios presented are significant at the p < .05 level,
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TABLE 4 Odds Ratios a for Being at or Above a Given Level of Negative Pressures
Main Effects
Odds Ratios*
No education Education (increase per year of)
1.00 1.10
Interaction White/Female White/Male African-American/Female African-American/Male
1.00 1.95 1.67 0.73
aBy Proportional Odds Ordinal Logistic Regression. *All odds ratios presented are significant at the p < .05 level.
Process Exclusion Results based on the main effects models followed a pattern similar to that for perceived coercion scores. Males in the Stage 1 model were associated with lower odds of being at or above a given level of process exclusion. Age and race were not significant predictors. Coefficients at Stage 2 for marriage/cohabitation were significantly associated with lower odds of being at or above some given level of process exclusion; education was associated with higher odds of being at or above some given level. Urban residence and clinical markers were nonsignificant. Thus, males and married/cohabiting respondents were associated with lower scores on the process exclusion scale, while respondents with higher levels of education were associated with higher scores. We see this presented in Table 5. Although the interaction of education and cohabiting was significant, the interaction mode was unstable, suggesting bias in the model as occurred in the interaction model of perceived coercion.
Summary and Discussion Our analysis confirms the findings of previous studies that considerable variation exists in patient perceptions of coercion. That we find such variance TABLE 5 Odds Ratios" for Being at or Above a Given Level of Process Exclusion
Main Effects
Odds Ratios*
Female Male
1.00 0.65
Not Married or cohabiting Married or cohabiting
1.00 0.55
No education Education (increase per year of)
1.00 1.18
aBy Proportional Odds Ordinal Logistic Regression. *All odds ratios presented are significant at the p < .05 level.
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even among our sample members who were all legally involuntarily hospitalized supports the findings of previous studies that objective legal status and subjective feelings of coercion are not equivalent. Not surprisingly, the modal score indicated high levels of perceived coercion; but at the same time, an almost equal n u m b e r of patients perceived little or no coercion. Our distribution on this variable is very similar to that reported by Gardner et al. (1993) whose sample had a majority of legally voluntary patients, a majority without a diagnosis of psychosis, and a much larger proportion with a primary diagnosis of substance abuse. Both samples were distributed across the full range of the perceived coercion scale with marked bimodality, although the proportion in our sample experiencing high coercion was almost 50% larger, and the proportion experiencing low coercion was approximately 50% smaller. As with perceived coercion, considerable variation existed across the full range of the negative pressures and process exclusion scales, indicating that the process of civil c o m m i t m e n t does not necessarily involve the stereotypical picture of a resisting mental patient being dragged into a mental institution. Approximately two-fifths of our sample reported little or no negative pressures and little or no process exclusion in their hospital admission. These findings suggest that involuntary admission to a mental hospital can permit patients to feel like they have voice and validation, and can avoid force even in the absence of choice. The challenge is to try to extend to all patients at the time of their admission a demonstration in word and action that they are person with opinions, desires, rights, and dignity, and not just mental patients in an acute crisis. Clinical variables could not account for differences in outcome variables. Neither type of disorder, secondary substance abuse, personality disorder, hostility/suspiciousness, severity of symptoms nor n u m b e r of recent hospital admissions affected how patients viewed the hospital admission process. This may suggest that some element of the shared characteristic of chronicity or recidivism negates expected differences among clinical groups. Patients who were young, urban, unmarried, and of low education were no more likely to perceive coercion, negative pressures, or process exclusion. This finding was unexpected because they are more likely to resist hospitalization, more likely to be seen as dangerous and in need of force to be hospitalized, and more likely to have had previous negative experiences with authority. Instead, it was white, female, unmarried respondents with more education who were more likely to perceive higher levels of our d e p e n d e n t variables. Such higher status persons have more resources, autonomy, and control in their daily work and family roles. They are the ones more likely to perceive coercion, negative pressures, and process exclusion in hospital admission, possibly because their expectation levels and reference groups make them more aware of the use of coercion and any deprivation in autonomy. The MacArthur study has found that patients who have little voice or validation, and against w h o m force and threats are used to get them hospitalized, perceive high levels of coercion; that is, procedural inequity and negative pressures predict perceived coercion (Lidz et al., 1995). Our sample, with different measures of these three constructs, found strong positive correlations among the three. When Negative Pressures and Process Exclusion were added to the
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model predicting perceived coercion, they were highly significant and wiped out the associations of perceived coercion with gender, race, cohabitation, and education. Although those basic and acquired demographic variables predict Negative Pressures and Process Exclusion, they do not predict perceived coercion directly. Rather, as the MacArthur group found, the two procedural variables, using force with patients and including patients in the process of hospital admission, are the most important factors in perceiving coercion. One may be concerned about the validity of patient responses on the items of the perceived coercion scale. Other studies of the scale have shown good criterion validity, having strong positive correlations with legal status, and with family and clinician perceptions of coercion (Hoge et al., 1993, 1996: Nicholson, 1996). Validity may also be questioned because we measured patients' perceived coercion in the hospital admission process after they had been in the hospital for at least a week. By interview time patients had been treated and many had responded positively to their treatment. Studies have shown that attitudes of patients toward their mental hospitalization change from admission to discharge, becoming more positive, and that the change is related to their feelings of being helped by hospitalization and the treatment received (Beck & Golowka, 1988: Edelsohn & Hiday, 1990; Gove & Fain, 1977: Hiday, 1992; Kaltiala-Heino, 1996; Kane et al., 1983; Kjellin et al.~ 1993: Westrin et al., 1990). It may be, therefore, that our respondents reported less coercion than they would have had we interviewed them at time of admission. Gardner and colleagues (1996) found that patients' perceptions of coercion, negative pressures, and procedural justice did not change from hospital admission to follow-up (2-6 weeks later) even though a significant proportion changed their beliefs about the need for hospitalization from negative to positive. Killian (1981) suggests an alternative explanation: processes that appear coercive and without dignity to a nonmentally ill person can appear beneficent and comforting to a mentally ill person, especially one who is in crisis and in need of others' taking control and giving care. The debate on the use of coercion in psychiatric treatment has focused on moral and legal justification (Blanch & Parrish, 1993; Wertheimer, 1993); but understanding patient perceptions of coercion in psychiatric treatment has important implications for treatment and therapeutic outcomes. Mental patients report that fear of involuntary hospitalization has kept them from seeking treatment voluntarily at least once when they thought they needed it (Campbell & Schraiber, 1989; Lucksted & Coursey, 1995). In addition, many clinicians believe that use of coercion can damage the clinician/patient relationship (Meichenbaum & Turk, 1987; Miller, 1987). If perceived coercion results in dissatisfaction with treatment and alienation from mental health care (Rogers, 1993), therapeutic outcomes for patients become tenuous because patients may be unlikely to adhere voluntarily to needed medication or psychosocial therapy once coercive conditions are removed. An alternative view holds that coercion is necessary at times to be able to treat needy patients; and that it can engage them in therapy when the treatment works (Appelbaum, 1994; Group for the Advancement of Psychiatry, 1994; Stone, 1975). We do not know which view is correct or under which conditions each view may hold since research on the therapeutic outcomes of coercion is
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limited and the findings are mixed (Hiday, 1992). Our study represents one of several studies now underway that will address the outcomes of coercion with follow-up data on the sampled described in this paper. References Appelbaum, P. S, (1994). A lmo.vt a revolution: Mental health law and the limits Of change. New York: Oxford University Press. Beck, J. & Golowka, E. (1988). A study of enforced treatment in relation to Stone's "'Thank You" theory. Behavioral Sciences aml the Law, 6, 559-566. Bennett, N. S.. Lidz, C. W., Monahan, J., Mulvey, E. P., Hoge, S. K.. Roth, L. H., & Gardner, W. (1993). Inclusion, motivation and good faith: The morality of coercion in mental hospital admission. Behavioral Sciences and the Law, 11,295-306. Blanch, A,. & Parrish, J. (1993). Reports of three roundtablc discussion on inw)luntary interventions. Psychiatric Rehabilitation and Community Support Monograph, 1. 1~1-2. Cascardi. M., Poythress, N. G., & Rittcrband. L. (in press). Stability of psychiatric patients" perceptions of their admission experience. Jourltal ¢~f Clinie~d Psychology. Campbell. J., & Schraiber. R. (1989). hi pursuit ~ f welhwss: The well-being project, Vol.6. Sacramento: California Department of Mental Health. Decker, F, H. (1980). Changes in the legal status of mental patients as waivers of a constitutional right: The problem of consent. Journal ~[' Psychiat O' arid Law, 8. 331-358. Decker, F. H. (1981). Changes in the legal status of mental patients and hospital management. Journal of Applied Behavioral Science, 1Z 153-171. Derogatis, L. R., & Mclisaratos, N. (1983). The brief symptom inventory: An introductory report. P.s3,ehological Medicine. 13, 595 605. Drake. R. E., Alterman, A. I., & Rosenberg, S. R. (1993). Detection of substance use disorders in severely mentally ill patients. Communi O, Mental Heahh Journal, 29. 175 192. Drake. R. E., Barrels, S. J., Tcague, G.B., Noordsy. D. L., & Clark, R. E. (1993b). Treatment of substance abuse in severely mentally ill patients. Journal o f Nervous attd Mental Disorder.s, 181,606-611. Drake, R. E., Osher, F. C., Noordsy. D. L., Hurlbul, C. S,. Teague, G. B., & Beaudett, M. S. (199/)). Diagnosis of alcohol use disorders in schizophrenia. Schizophrenia Btdletin, 16, 57 67. Edelsohn, G.. & Hiday. V. A. (1990). Civil commitment: A range of patient attitudes. Bulletin o f the American Academy ~fl Psychiatry and the Law, l& 65-77. Gardner, W., Hoge, S. K., Bennett, N., Roth. k.. Lidz. C. W., Monahan. J., & Mulvey. E. (1993). Two scales for measuring patients" perceptions of coercion during mental hospital admission. Behavioral Sciences and the Law, 11,307-321. Gardner, W., Lidz, C. W., Hoge. S. K.. Monahan, J., Eisenbcrg, M., Bennett, N., Mulvey, E. P. & Roth, L. H. (1996). Patients" revisions of their beliefs about the need for hospitalization (unpublished manuscript). Gilboy, J. & Schmidt. J. (1971). "'Voluntary" hospitalization of the mentally ill. Northwestern Uni~er.si O' Law Review, 66, 429-453. Goffman, E. ( 1961 ). Asylums: Essays on the social situation o f mental patients and other inmates. Garden City, NY: Anchor Books. Gore, W. R.. & Fain, T. (1977). A comparison of w~luntary and committed psychiatric patients. Archives ¢~f General Ps'ychiatry. 34, 669-676. Group for the Advancement of Psychiatry. (1994). Forced imo treatment: The role ~[' eoercion in cli,tical practice. Washington, DC: American Psychiatric Press. Hiday, V. A. (1992). Coercion in civil commitment: Process, preferences and outcome, lnternatioltal Jottrnal ~['Law and Psychiatry. 15, 359-377. Hiday, V. A. (1995). Thc social context of mental illness and violence..loutvlal ()fi Health and Social Behavior. 36. 122-137. Hiday, V. A. & Scheid-Cook, T. L. (1987). The North Carolina experience with outpatient commitment: A critical appraisal, lnternational.lottrnal o f Law and Psychiatry. 10, 235 232. Hoge, S. K., Lidz, C. W.. Eisenberg, M., Gardner, W.. Monahan, J., Mulvey, E., Roth, L.. & Bennett, N. (in press). Coercion in the admission of voluntary and involuntary psychiatric patients. International Journal o f Law and Psychiato'. Hoge, S. K., Lidz, C. W., Eisenberg, M., Monahan, J., Bennett. N., Gardner, W., Mulvcy, E. P., & Roth,
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L. H. (1996). Family, clinician, and patient perceptions of coercion in mental hospital admission: A comparative study (unpublished manuscript). Hoge, S. K., Lidz, C. W., Mulvey, E., Roth, L., Bennett, N., Siminoff, A., Arnold, R., & Monahan, .1. (1993). Patient, family and staff perceptions of coercion in mental hospital admission: An exploratory study. Behavioral Sciences and ttte Law, 11, 281 293. Kaltiala-Heino, R. (1996). Involuntary psychiatric treatment: A range of patients" attitudes. Nordic" Journal of Psychiatry, 50, 27-34. Kane, J. M., Quitkin, F. & Rifkin, A. (1983). Attitudinal changes of involuntarily committed patients following treatment. Archives of General Psychiatrv, 40, 374--377. Killian, L. (1981). The sociologists look at the cuckoo's nest: The measure of ideal types. The American Sociologist, 16, 230-239. Kjellin, L., Westrin, C. G., Erdiksson, K., Axelsson-Ostman, M., Candefjord, I. L., Ekblom, B., Machl, M., Angfors, G., & Ostman, O. (1993). Coercion in psychiatric care: Problems of medical ethics in a comprehensive empirical study. Behavioral Sciences and the Law, 11, 323-334. La Fond, J. Q. & Durham, M. L. (1992). Back to asylum: The future of mental health law and policy in the United States. New York: Oxford University Press. Lewis, D. E., Goetz, M., Schoefeld, A., Gordon, & Griffin, E. (1984). The negotiation of involuntary civil commitment. Law and Society Review, 18, 6294549. Lidz, C. W., & Hoge, S. K. (1993). Introduction to coercion in mental health care. Behavioral Sciences and the Law, 11, 237-238. Lidz, C. W., Hoge, S. K., Gardner, W., Bennett, N. S., Monahan, J., Mulvey, E. P. & Roth, L. H. (1995). Perceived coercion in mental hospital admission: Pressures and process. Archives of General Psychiatry, 52, 1034-1039. Lidz, C. W., Mulvey, E. P., & Gardner, W. P. (1993). The accuracy of prediction of violence of others. Journal of the American Medical Association, 269, 1007-1011. Lind, E., Kanfer, R., & Early, P. (1990). Voice, control and procedural justice: Instrumental and noninstrumental concerns in fairness judgments. Journal of Personality and Social Psychology, 20, 952-858. Lind, E., & Tyler, T. (1988). The socialpsychology of procedural justice. New York: Plenum Press. Lucksted, A., & Coursey, R. D. (1995). Consumer perceptions of pressure and force in psychiatric treatments. Psychiatric Services, 46, 146-152. Meichenbaum, D., & Turk, D. C. (1987). Facilitating treatment adherence: A practitioner's guidebook. New York: Plenum Press. Miller, R. D. (1982). Voluntary involuntary commitment--The briar-patch syndrome. Bulletin of the American Academy of Psychiatry and Law, 8, 305-312. Miller, R. D. (1988). Involuntary civil commitment of the mentally ill in the post-reform era. Springfield, IL: Charles C. Thomas. Monahan, J., Hoge, S. K., Lidz, C. W., Roth, L. H., Bennett, N. S., Gardner, W. P., & Mulvey, E P. (1995). Coercion and commitment: Understanding involuntary mental hospital admission. International Journal of Law and Psychiatry, 18, 249-263. Morse, S. (1982). A preference for liberty: The case against involuntary commitment of the mentally disordered. California Law Review, 70, 54-106. National Research Council. (1993). Understanding and preventing violence. A. J. Reiss, Jr. & J. A. Roth (Eds.). Washington, DC: National Academy Press. Nicholson, R. A. (1986). Correlates of commitment status in psychiatric patients. Psychological Bulletin, 100, 241-250. Nicholson, R. A,, Ekenstam, C., & Norwood, S. (1996). Coercion and the outcome of psychiatric hospitalization. International Journal of Law and Psychiatry, 19. 201-217. Rogers, A. (1993). Coercion and "voluntary" admission: An examination of psychiatric patient views. Behavioral Sciences and the Law, 11, 259-268. Scheid-Cook, T. L., Wooten, K., & Hiday, V. A. (1987). Mental patients eager and willing to help sociological research. Sociology and Social Research, 72, 57-61. Slovic, P. & Monahan, J. (1995). Probability, danger and coercion: A study of risk perception and decision making in mental health law. Law and Human Behavior, 19, 49456. Stone, A. A. (1975). Mental health and law: A system in transition. DHEW Publication No. (ADM)76-176. Rockville, MD: U.S. Public Health Service. Swartz, M., Burns, B., Hiday, V. A., George, L., Swanson, J., & Wagner, H. R. (1995). New directions in research on involuntary outpatient commitment. Hospital and Community Psychiatry, 46, 381-385.
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Thibaut, J., • Walker, L. (1975). Procedural justice: A psychological analysis. Hillsdale, N J: Erlbaum. Torrey, E. F. (1988). Nowhere to go: The tragic odyssey o f the homeless mentally ill. New York: Harper & Row. Treffert, D. A. (1981). Dying with their rights on. American Journal o f Psychiatry, 141, 1041. Tyler, T. R. (1990). Whypeople obey the law. New Haven, CT: Yale University Press. Tyler, T. R. (1992). The psychological consequences of judicial procedures: Implications for civil commitment hearings. Southern Methodist University Law Review, 46, 433-445. Tyler, T. R.. Rasinski, K., & Spodick, N. (1985). The influence of voice on satisfaction with leaders: Exploring the meaning of process control. Journal o f Personality attd Social Psychology, 48, 72-81. Wald. P. M., & Friedman, P. R. (1978). The politics of mental health advocacy in the United States. International Journal o f Law and Psychiatry, 1, 137-152. Wertheimer, A. (1993). A philosophical examination of coercion for mental health issues. Behavioral Sciences and the Law, 11, 239-258. Westrin, C. K., Nilstun, T., Axelsson, M., Candefjord, I., Kjellin, L., Ekblom, B., Eriksson, K. & Ostman, O. (1990). An empirical study of commitment and involuntary treatment in Sweden. In S. C. Stefanis, C. Soldatos, & A. Rabavilas (Eds.), Psychiatry: A world perspective, Vol. 4. (pp. 798 802), Amsterdam: Elsevier Science.
International Journal of Law and Psychiatry, Vol. 20, No. 2, pp. 227-241, 1997 Copyright © 1997 Elsevier Science Ltd Printed in the USA. All rights reserved 0160-2527/97 $17.011 + .(10 PII S0160-2527(97)00004-6
Patient Perceptions of Coercion in Mental Hospital Admission Virginia Aldig~ Hiday,* Marvin S. Swartz,** Jeffrey Swanson,** and H. Ryan Wagner**
Introduction In civil commitment the state applies its police and parens patriae powers in order to coerce mentally ill persons into treatment. Coercion, thus, is central to civil commitment. It also has been central in the mental health law debate over the justification of civil commitment of mentally ill patients. Civil libertarians, concerned with deprivations to free choice and movement, have argued for imposition of formal legal procedures and limitation of this coercion of mentally ill persons to those who are dangerous (La Fond & Durham, 1992; Morse, 1982; Wald & Friedman, 1978). Mental health practitioners, concerned with reducing symptoms and providing psychiatric care, have argued for minimal procedural and substantive limits on their ability to hospitalize and treat mentally disordered persons (Stone, 1975; Torrey, 1988; Treffert, 1981). Despite this debate, empirical researchers neglected development of the construct of coercion in psychiatric treatment (Hiday, 1992; Monahan et al., 1995); and only recently have they begun to lay the foundation conceptually and empirically to advance our understanding of it (Lidz & Hoge, 1993). In the substantial empirical literature on civil commitment, the existence of coercion was assumed to be inherent in the process while the focus was on other components of commitment such as characteristics of actors and rates of commitment. With few exceptions, researchers equated the legal category of involuntary patient with coercive practices.
*Professor, D e p a r t m e n t of Sociology and Anthropology, North Carolina State University, Raleigh, NC 27695, USA. * * D e p a r t m e n t of Psychiatry and Behavioral Sciences, Duke University Medical Center, D u r h a m , NC, USA. Address correspondence to Virginia A. Hiday. This work was sponsored by Grant RO1 MH48103 from the National Institute of Mental Health. The authors wish to thank Jean Campbell, Caroline Kauffman, and H e n r y J. Steadman for their helpful c o m m e n t s on an earlier version of the paper. 227
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Although subjugation to the state's coercive power legally distinguishes involuntary from voluntary patients, coerced hospitalization or treatment may occur in the absence of legal involuntary status. Coercion in other forms may be brought to bear on voluntary patients. Mental health workers, hospital staff, public defenders, and family members often use informal means to coerce many legally voluntary patients into hospitalization. Threat of loss of valued resources (i.e., housing, work, money), threat of civil commitment, deception, and physical restraint have all been used to get mentally ill persons to volunteer for hospitalization (Decker, 1980, 1981; Gilboy & Schmidt, 1971: Goffman, 1961; Lewis et al., 1984; Rogers, 1993). On the other hand, legal involuntary hospitalization may be imposed in the absence of coercive measures such as physical force or treatment. Some legally involuntary patients often want help but their cognitive impairment may prevent them from seeking treatment; thus, others are left to petition for their commitment. Some may perform apparently dangerous acts in order to gain hospital admission by convincing clinicians that legal commitment is necessary (Miller, 1982); and some may not want hospitalization but acquiesce to involuntary admission such that no coercive measure but the signing of legal papers is taken. In all of these cases, the subjective, personal state of coercion is not congruent with the objective, legal state of coercion. A few studies have documented frequent incongruence between patients' official legal status and their subjective experience of coercion. These studies have reported that a substantial proportion of each legal status group perceives the opposite of what would be predicted by congruence: from one-fifth to one-third of involuntarily hospitalized patients report having wanted to be hospitalized at the time of their legally coerced admission (Beck & Golowka, 1988; Edelsohn & Hiday, 1990; Hoge et al., in press; Kane, Quitkin, & Rifkin, 1983); and approximately half of legally voluntary patients report having felt a large element of coercion in the decision leading to their hospitalization (Beck & Golowka, 1988; Rogers, 1993; see also Hiday, 1992, and Monahan et al., 1995 for a review of these studies). One exception was a study that found only 10% of voluntary patients perceiving coercion (Hoge et al., in press). Not only are patient perceptions of coercion frequently different from their official legal status but also their perceptions are frequently different from those of other actors in the hospital admission process. Results from two studies indicate that clinical staff and family members perceive having applied more "pressure" for hospitalization than patients felt (Bennett et al., 1993; Hoge et al., 1993). Even behavior that an observer would judge to be clearly coercive such as threats and physical pressure was not always interpreted as coercive by patients. This paper attempts to develop a better understanding of coercion in psychiatric treatment by studying patient perceptions of coercion and of two closely related constructs--patients' perceptions of negative pressures in the hospital admission process, and patients' perceptions of fair procedures in the attempts to have them hospitalized. It also examines how these constructs are influenced by sociodemographic and clinical factors. Following recent empirical development of the construct of perceived coercion, we define it as the opposite of patient perceptions of autonomy (Gardner
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et al., 1993). Accordingly, feeling coerced in mental hospital admission means perceiving that one does not have influence, control, freedom, or choice, or does not make the decision to enter the hospital (Gardner et al., 1993). Although force is a synonym for coercion in everyday language, here it is held distinct from coercion because in hospital admission force is frequently understood narrowly to mean physical compulsion. We use patient perception of coercion more broadly to reflect patients ~feelings regardless of how they were treated. How they were treated involves at least two concepts closely related to coercion but theoretically distinct: negative pressures and fair process. Negative pressures include threats and force of any kind that indicate to patients they would suffer worse consequences were they to resist hospitalization. Our definition of negative pressures is distinct from more benign pressures such as persuasion and inducement, which use reason or rewards in attempting to get patients to accept hospitalization (Lidz et al., 1995). One would expect that the more threats and force as applied in the process of hospitalization, the more a patient is likely to perceive coercion. The second closely related concept, evaluation of the hospital admission process as fair, has to do with patient perceptions of (a) whether others consider patient views and (b) the motivations of others. Having a chance to speak (voice) and having others take it into account (validation) provide a chance to influence an outcome, even though the outcome may not be what one would desire. Thibaut and Walker (1975) term this "process control" as distinguished from "outcome control" and they find it to be essential to perceptions of fairness. But having voice and validation are important to a sense of fairness of process even when they are not instrumental in influencing outcomes (Lind, Kanfer, & Early, 1990; Lind & Tyler, 1988; Tyler, 1990; Tyler, Rasinski, & Spodick, 1985). Likewise, perceptions that decision makers are acting in good faith and without bias are important components in evaluation of process fairness (Tyler, 1990). When a patient perceives that family, friends, and clinicians are acting in good faith and with impartiality, even though they may be attempting to have him hospitalized and even though he is hospitalized, that patient is likely to view the hospital admission as fair (Bennett et al., 1993; Tyler, 1992) and is less likely to perceive coercion (Hoge et al., 1993; Monahan et al., 1995). In trying to understand causes of perceived coercion, negative pressures, and process fairness, our three dependent variables, we expected sociodemographic characteristics to be important because these characteristics place individuals in groups that experience legal and medical authority differently. Age, gender, racial, and socioeconomic groups vary in their norms and experiences which affect others" reactions to them and their own interpretations of the commitment process. On one hand, patients who are young, male, African-American, urban, unmarried, and of low education might be more likely to perceive negative pressures, procedural inequity, and high levels of coercion because they are more likely to be angry and assaultive; thus, they are more likely to resist hospital admission, and to be seen as dangerous and in need of force to be hospitalized (National Research Council, 1993; Nicholson, 1986; Slovic & Monahan, 1995), and because they are more likely to have experienced directly or indirectly lack of respect from authorities (National Re-
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search Council, 1993: Tyler, 1990). On the other hand, members of these disadvantaged groups may feel so disenfranchised and expect less control of their lives that they would, by comparison, perceive only low levels of coercion in the involuntary hospitalization process. Similarly, higher status persons who exert higher levels of control and autonomy on a daily basis would be more sensitive to their loss and be more likely to perceive coercion in the admission process. Clinical factors may also predict our dependent variables. Having comorbidity of substance abuse/dependence or of personality disorder places an individual at greater risk for creating tense situations that lead to violence (Hiday, 1995). Such patients are more likely to have come into conflict with authority and are more likely to resist hospitalization; thus, they are more likely to experience negative pressures, evaluate the commitment process as unfair, and perceive coercion in hospital admission. Those with high levels of hostility and suspiciousness are more likely to perceive coercion, negative pressures, and exclusion; whereas those with high levels of symptomatology in general may be more acquiescent to hospital admission, and thus be less likely to perceive force and coercion. Finally, variation in recent mental hospital admissions could affect the dependent variables, but it is unclear in which direction. Multiple recent admissions, most likely involuntary, could lead to greater resistance or to greater submission, which would have opposite effects on our dependent variables.
Design and Sample This analysis uses baseline data on 331 subjects in a larger study of the effectiveness of outpatient commitment (Swartz et al., 1995). Subjects were involuntarily admitted, severely mentally ill patients recruited from the admissions unit of a state mental hospital and the psychiatric units of three general hospitals; they had been court-ordered to outpatient commitment following hospital discharge. To be recruited subjects had to be 18 years or older, diagnosed with severe mental disorder (schizophrenia, schizoaffective, affective, or other psychotic disorder), functionally impaired according to state criteria for severe and persistent mentally illness (SPMI) with illness duration of a year or more, and having one or more hospitalizations totaling at least 21 days within the past 2 years. Subjects also had to be approved by the hospital treatment team as appropriate candidates for outpatient commitment, ordered to outpatient commitment by the court, and be residents of counties participating in the study. We identified eligible patients from daily hospital admission records and discussion with treatment team members. While these patients were still hospitalized awaiting their period of outpatient commitment, we met with them to describe the study, the interview required, and confidentiality of information, and to obtain their consent for participation. Subjects were offered improved access to services via case management, a service not generally available, possible random assignment to release from their outpatient commitment orders, and monetary remuneration for each follow-up interview after hospital discharge. Of identified eligible patients, only 11.5% refused, a
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low refusal rate (Cascardi, Poythress, & Ritterband, in press; Lidz, Mulvey, & Gardner, 1993; Scheid-Cook, Wooten, & Hiday, 1987). Table 1 presents the characteristics of our sample: average age was 41.3 years with a range of 20 through 70 years; 53.8% were male; 66.1%, AfricanAmerican; one-fifth were married or cohabitated; 62.2% lived in the urban and suburban areas of four cities, and the rest lived in small towns or rural sections of the nine participating counties; almost three-fourths had graduated from high school. Clinically, the sample averaged 1.5 mental hospital admissions in the previous year; they had a very high mean score of 6.97 (versus 1.36 for the norm of psychiatric inpatients) on the Brief Symptom Inventory (BSI) General Severity Index, an index of number and severity of symptoms (Derogatis & Melisaratos, 1983). Just over half, 55.9% met diagnostic criteria for a primary diagnosis of schizophrenia or schizoaffective disorder; 31.1%, affective disorder; and 13.0%, other psychotic disorder. Approximately one-eighth met diagnostic criteria for a second diagnosis of personality disorder: and 21%, for substance-use disorder. Substance use, as opposed to diagnosis, was higher, with about 33% of subjects having used illicit drugs and 53% having used alcohol at least once a month during the 4 months prior to baseline hospitalization, as indicated by self-report, collateral report, or hospital record. Other research suggests that the true prevalence of problematic substance use approaches 50% in SPMI populations (although such problems often go undetected); and that any amount of alcohol or illicit drug use can lead to problems and tends to complicate treatment in SPMI populations (Drake et al., 1990, 1993b; Drake, Alterman, & Rosenberg, 1993a). Following this line of argument, we used a broad measure of comorbidity, which includes any indication of at least occasional substance use--combining self-report, family/collateral report, and hospital record information. The prevalence of co-occurring substance use in the previous 4 months with this measure was 57.4% in our sample. TABLE 1 Sample Characteristics
Mean Age (years) Male African-American a Married/Cohabiting Urban Education (years) Admissions BSI severity Schizophrenia disorder Affective disorder Personality disorder Substance abuse comorbidity
41.3 53.8% 66.1% 20.2% 62.2% 11.7 1.5 6.96 55.9% 31.1% 12.4% 31.1%
aThe remainder were all white, except for 1 Asian and 1 Hispanic.
Standard Deviation 10.7 2.7% 2.6% 2.2% 2.7% 2.7 1.0 6.68 2.7% 2.5% 1.8% 2.5%
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Measurement
Sample subjects were given an extensive interview in the hospital, which included a diagnostic assessment, measures of health and mental health functioning, and 15 true-false items of the MacArthur Interpersonal Relations Scale. We used these items to construct the three d e p e n d e n t variables: perceived coercion, perceived negative pressures, and perceived procedural inequity. Following Gardner et al. (1993), perceived coercion is represented by patients' responses to five items indicating their judgment about the amount of autonomy they did not have in the hospital admission decision in terms of influence, control, choice, freedom, and idea. ("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 went into the hospital." "I had more influence than anyone else on whether I came into the hospital.") A simple summation of these five items yields the MacArthur Perceived Coercion Scale Score with possible scores of 0-5. Both this scale and a similar version of it have shown good internal reliability (Garner et al., 1993) and the similar version has shown acceptable retest stability (Cascardi et al., in press). In our sample, item-total correlations ranged from .60 to .73, indicating satisfactory homogeneity; Cronbach's alpha was .86, indicating high internal reliability. Figure 1 presents the distribution of this scale. Perceived coercion is bimodal, with over half the responses falling at the two extremes of the scale: just over one-third felt high levels of coercion, just over one-fifth felt no coercion, with the rest being equally distributed in the middle levels. Mean score was 2.90. From six items indicating that others threatened or forced patients to come into the hospital, we constructed a perceived negative pressures scale. ("People tried to force me to come into the hospital." "Someone threatened me to get me to come into the hospital." "Someone physically tried to make me come into the hospital." "I was threatened with commitment." "They said
Percent
35 ' . -
"
3O 25 2O 15 10 5 0 1
2
3
FIGURE 1. Perceived Coercion.
4
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OF COERCION
233
they would make me come into the hospital." "No one tried to force me to come into the hospital.") Item-total correlations ranged from .54 to .70. Cronbach's alpha was .84, indicating high internal reliability on this scale. As can be seen in Figure 2, patient perceptions of negative pressures are over the full scale. Patients averaged 3.31 on this negative pressures scale, approximately at the midpoint of the scale, with a standard deviation of 2.17. One-fourth reported no threats or force. Evaluation of f a i r n e s s i o r its reverse, inequity--in the process of admission includes evaluation of both the motivations of others (impartiality and good faith) and their consideration of patient views (voice and validation). Our measure of procedural inequity, however, taps only the second. To distinguish it from the broader measure, we call it process exclusion. Two items indicate lack of voice ("I had enough of a chance to say whether I wanted to come into the hospital." "I got to say what I wanted about coming into the hospital.") and two items indicate lack of validation ("No one seemed to want to know whether I wanted to come into the hospital." "My opinion about coming into the hospital didn't matter."). These items comprise a 0-4 scale, having a Cronbach's alpha of .76 and item-total correlations between them of .52 and .60. Patients had a mean of 2.09, again approximately at the midpoint of the scale, and a standard deviation of 1.51 on this process-exclusion scale. Just over onefifth of respondents reported perceiving no process exclusions, whereas 27.1% reported having no voice or validation, that is, feeling a high level of inequity or process exclusion (see Figure 3). As one would expect, our three d e p e n d e n t variables are strongly associated with each other at the .60 level or higher (see Table 2). Prediction
We examined three sets of predictor variables in three consecutive models for each d e p e n d e n t variable. Our three d e p e n d e n t variables were modeled us-
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6
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V.A. HIDAY et al.
Percent 35 30
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FIGURE 3. Process Exclusion.
ing proportional odds ordinal logistic regression. Briefly, the technique uses a linear function of predictors to model a logit computed from the logarithmic ratio of the probability of a given event being equal to or less than a given level of outcome over 1 minus the same probability (i.e., Lj = In [P(Y _-< j)/ (1 - P(Y =< j))] where Lj represents the logit at level j). For a given predictor, X, the odds that a respondent is at or below some level of Yj are represented by the exponentiated coefficient of X as estimated by the model. Proportionality between levels of outcome is assumed constant and is tested by a score test for proportional odds. Models were tested in four stages. At Stage 1, each d e p e n d e n t variable was regressed on the basic demographic variables of age, race, and gender. Age was tested for nonlinearity. Stage 2 included acquired demographic variables: education, urban residence, and marriage/cohabitation. Clinical markers were entered at Stage 3; these included diagnosis of schizophrenia/schizoaffective disorder, affective disorder, personality disorder comorbidity, substanceabuse comorbidity, multiple admissions in the past year, the BSI total score for severity of symptoms, and the BIS Paranoid Scale score. At the fourth and final stage, interaction terms suggested by the correlation matrix were tested. In the models presented, the odds ratios are coded to show the odds of being at or above higher levels of the outcomes of perceived coercion, negative presTABLE 2 Spearman Correlations Outcome Variables
Perceived Coercion Negative Pressures Process Exclusion
Coercion
Negative Pressures
Process Exclusion
1.00
0.61 1.00
0.71 0.60 1.00
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sures, and process exclusion. Inferences are based on a minimal significance level o f p _-< .05. Results
Coercion A m o n g Stage 1 variables, males and African-Americans were significantly less likely to be at or above a particular level of coercion relative to females and whites. Age was not a significant predictor. A m o n g predictors entered at Stage 2, the odds of being at or above a particular level of coercion were significantly reduced among married/cohabiting respondents, whereas the odds of being at or above a particular level of coercion were significantly increased among respondents with higher levels of education. Urban residence made no difference. In Stage 3, no clinical markers attained significance. Based on the three main effects models, being male, African-American, and married/cohabiting was associated with lower perceived coercion scores, and education was associated with higher scores. The only interaction that reached significance at the .05 level was between education and cohabitation; but given the n u m b e r of model comparisons with interaction terms that were conducted, and indication of an unstable interaction mode, there is the possibility that bias may have occurred in estimating the model. Therefore, we dismiss this interaction term (Table 3).
Negative Pressures In the models predicting negative pressures, education is significantly associated with higher levels of negative pressures; and the interaction of gender and race also is significantly associated with negative pressures. AfricanAmerican females and white males are more likely to experience negative pressures, whereas African-American males are unexpectedly low in reporting negative pressures in the c o m m i t m e n t process (Table 4). TABLE 3 Odds Ratios a for Being at or Above a Given Level or Perceived Coercion
Main Effects
Odds Ratios*
Female Male
1.00 0.65
White African -American
1.00 0.56
Not married or cohabiting Married or cohabiting
1.00 0.48
No education Education (increase per year of)
1.00 1.15
aBy proportional Odds Ordinal Logistic Regression. *All odds ratios presented are significant at the p < .05 level,
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TABLE 4 Odds Ratios a for Being at or Above a Given Level of Negative Pressures
Main Effects
Odds Ratios*
No education Education (increase per year of)
1.00 1.10
Interaction White/Female White/Male African-American/Female African-American/Male
1.00 1.95 1.67 0.73
aBy Proportional Odds Ordinal Logistic Regression. *All odds ratios presented are significant at the p < .05 level.
Process Exclusion Results based on the main effects models followed a pattern similar to that for perceived coercion scores. Males in the Stage 1 model were associated with lower odds of being at or above a given level of process exclusion. Age and race were not significant predictors. Coefficients at Stage 2 for marriage/cohabitation were significantly associated with lower odds of being at or above some given level of process exclusion; education was associated with higher odds of being at or above some given level. Urban residence and clinical markers were nonsignificant. Thus, males and married/cohabiting respondents were associated with lower scores on the process exclusion scale, while respondents with higher levels of education were associated with higher scores. We see this presented in Table 5. Although the interaction of education and cohabiting was significant, the interaction mode was unstable, suggesting bias in the model as occurred in the interaction model of perceived coercion.
Summary and Discussion Our analysis confirms the findings of previous studies that considerable variation exists in patient perceptions of coercion. That we find such variance TABLE 5 Odds Ratios" for Being at or Above a Given Level of Process Exclusion
Main Effects
Odds Ratios*
Female Male
1.00 0.65
Not Married or cohabiting Married or cohabiting
1.00 0.55
No education Education (increase per year of)
1.00 1.18
aBy Proportional Odds Ordinal Logistic Regression. *All odds ratios presented are significant at the p < .05 level.
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237
even among our sample members who were all legally involuntarily hospitalized supports the findings of previous studies that objective legal status and subjective feelings of coercion are not equivalent. Not surprisingly, the modal score indicated high levels of perceived coercion; but at the same time, an almost equal n u m b e r of patients perceived little or no coercion. Our distribution on this variable is very similar to that reported by Gardner et al. (1993) whose sample had a majority of legally voluntary patients, a majority without a diagnosis of psychosis, and a much larger proportion with a primary diagnosis of substance abuse. Both samples were distributed across the full range of the perceived coercion scale with marked bimodality, although the proportion in our sample experiencing high coercion was almost 50% larger, and the proportion experiencing low coercion was approximately 50% smaller. As with perceived coercion, considerable variation existed across the full range of the negative pressures and process exclusion scales, indicating that the process of civil c o m m i t m e n t does not necessarily involve the stereotypical picture of a resisting mental patient being dragged into a mental institution. Approximately two-fifths of our sample reported little or no negative pressures and little or no process exclusion in their hospital admission. These findings suggest that involuntary admission to a mental hospital can permit patients to feel like they have voice and validation, and can avoid force even in the absence of choice. The challenge is to try to extend to all patients at the time of their admission a demonstration in word and action that they are person with opinions, desires, rights, and dignity, and not just mental patients in an acute crisis. Clinical variables could not account for differences in outcome variables. Neither type of disorder, secondary substance abuse, personality disorder, hostility/suspiciousness, severity of symptoms nor n u m b e r of recent hospital admissions affected how patients viewed the hospital admission process. This may suggest that some element of the shared characteristic of chronicity or recidivism negates expected differences among clinical groups. Patients who were young, urban, unmarried, and of low education were no more likely to perceive coercion, negative pressures, or process exclusion. This finding was unexpected because they are more likely to resist hospitalization, more likely to be seen as dangerous and in need of force to be hospitalized, and more likely to have had previous negative experiences with authority. Instead, it was white, female, unmarried respondents with more education who were more likely to perceive higher levels of our d e p e n d e n t variables. Such higher status persons have more resources, autonomy, and control in their daily work and family roles. They are the ones more likely to perceive coercion, negative pressures, and process exclusion in hospital admission, possibly because their expectation levels and reference groups make them more aware of the use of coercion and any deprivation in autonomy. The MacArthur study has found that patients who have little voice or validation, and against w h o m force and threats are used to get them hospitalized, perceive high levels of coercion; that is, procedural inequity and negative pressures predict perceived coercion (Lidz et al., 1995). Our sample, with different measures of these three constructs, found strong positive correlations among the three. When Negative Pressures and Process Exclusion were added to the
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model predicting perceived coercion, they were highly significant and wiped out the associations of perceived coercion with gender, race, cohabitation, and education. Although those basic and acquired demographic variables predict Negative Pressures and Process Exclusion, they do not predict perceived coercion directly. Rather, as the MacArthur group found, the two procedural variables, using force with patients and including patients in the process of hospital admission, are the most important factors in perceiving coercion. One may be concerned about the validity of patient responses on the items of the perceived coercion scale. Other studies of the scale have shown good criterion validity, having strong positive correlations with legal status, and with family and clinician perceptions of coercion (Hoge et al., 1993, 1996: Nicholson, 1996). Validity may also be questioned because we measured patients' perceived coercion in the hospital admission process after they had been in the hospital for at least a week. By interview time patients had been treated and many had responded positively to their treatment. Studies have shown that attitudes of patients toward their mental hospitalization change from admission to discharge, becoming more positive, and that the change is related to their feelings of being helped by hospitalization and the treatment received (Beck & Golowka, 1988: Edelsohn & Hiday, 1990; Gove & Fain, 1977: Hiday, 1992; Kaltiala-Heino, 1996; Kane et al., 1983; Kjellin et al.~ 1993: Westrin et al., 1990). It may be, therefore, that our respondents reported less coercion than they would have had we interviewed them at time of admission. Gardner and colleagues (1996) found that patients' perceptions of coercion, negative pressures, and procedural justice did not change from hospital admission to follow-up (2-6 weeks later) even though a significant proportion changed their beliefs about the need for hospitalization from negative to positive. Killian (1981) suggests an alternative explanation: processes that appear coercive and without dignity to a nonmentally ill person can appear beneficent and comforting to a mentally ill person, especially one who is in crisis and in need of others' taking control and giving care. The debate on the use of coercion in psychiatric treatment has focused on moral and legal justification (Blanch & Parrish, 1993; Wertheimer, 1993); but understanding patient perceptions of coercion in psychiatric treatment has important implications for treatment and therapeutic outcomes. Mental patients report that fear of involuntary hospitalization has kept them from seeking treatment voluntarily at least once when they thought they needed it (Campbell & Schraiber, 1989; Lucksted & Coursey, 1995). In addition, many clinicians believe that use of coercion can damage the clinician/patient relationship (Meichenbaum & Turk, 1987; Miller, 1987). If perceived coercion results in dissatisfaction with treatment and alienation from mental health care (Rogers, 1993), therapeutic outcomes for patients become tenuous because patients may be unlikely to adhere voluntarily to needed medication or psychosocial therapy once coercive conditions are removed. An alternative view holds that coercion is necessary at times to be able to treat needy patients; and that it can engage them in therapy when the treatment works (Appelbaum, 1994; Group for the Advancement of Psychiatry, 1994; Stone, 1975). We do not know which view is correct or under which conditions each view may hold since research on the therapeutic outcomes of coercion is
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