Sources of coercive behaviours in psychiatric admissions.

OBJECTIVE: Coercion during psychiatric admissions has been a topic of debate for many years. Although there has been considerable research on patients' perceptions of coercion, there has been no work on who places pressures on patients to be admitted. METHOD: This article integrates interview data from interviews with patients, admitting staff and family and friends to describe the pressures brought to bear on patients to be admitted. RESULTS: Health-care professionals appear to be the most important source of pressures on patients, and to have the most impact on patients' perceptions of coercion. However, there are differences in type of pressure, and the pressures used by family and friends appear to have the most longstanding impact. CONCLUSION: Legal and clinical efforts to reduce the level of coercive pressures on patients need to recognize the importance of mental-health professionals, including especially those who are not legally mandated to participate in the admission process.

Patients' revisions of their beliefs about the need for hospitalization.

OBJECTIVE: An influential rationale for involuntary hospitalization is that prospective patients who refuse hospitalization at the time it is offered are likely to change their belief about the necessity of hospitalization after receiving hospital treatment. The authors examine how patients changed their evaluations of psychiatric hospitalization following hospital treatment. METHOD: The authors studied 433 patients who were interviewed about their hospitalization within 2 days of their admission to a psychiatric hospital; 267 of these patients were reinterviewed 4-8 weeks following discharge. RESULTS: When reinterviewed at follow-up, 33 (52%) of 64 patients who said at admission that they did not need hospitalization said that, in retrospect, they believed they had needed it. Only 9 (5%) of 198 patients who said at admission that they needed hospitalization shifted to saying that they had not needed it. CONCLUSIONS: Many of the patients who initially judged that they did not need hospitalization revised their belief after hospital discharge and reported that they had needed hospital treatment. However, perceptions of coercion were stable from admission to follow-up, and patients' attitudes toward hospitalization did not become more positive. Coerced patients did not appear to be grateful for the experience of hospitalization, even if they later concluded that they had needed it.

Factual sources of psychiatric patients' perceptions of coercion in the hospital admission process.

OBJECTIVE: The purpose of this study was to determine what predicts patients' perceptions of coercion surrounding admission to a psychiatric hospital. METHOD: For 171 cases, the authors integrated data from interviews with patients, admitting clinicians, and other individuals involved in the patients' psychiatric admissions with data from the medical records. Using a structured set of procedures, coders determined whether or not nine coercion-related behaviors occurred around the time of admission. Correlation and regression analyses were used to describe the predictors of patients' scores on the MacArthur Perceived Coercion Scale. RESULTS: The use of legal force, being given orders, threats, and "a show of force" were all strongly correlated with perceived coercion. A least squares regression accounted for 43.3% of the variance in perceived coercion. The evidence also suggested that force is typically only used in conjunction with less coercive pressures. CONCLUSIONS: Force and negative symbolic pressures, such as threats and giving orders about admission decisions, induce perceptions of coercion in persons with mental illness. Positive symbolic pressures, such as persuasion, do not induce perceptions of coercion. Such positive pressures should be tried in order to encourage admission before force or negative pressures are used.

The competence-related abilities of women criminal defendants.

A new research instrument, the MacArthur Structured Assessment of Competencies of Criminal Defendants (MacSAC-CD), was administered to three groups of women defendants: those adjudicated incompetent and committed to forensic hospitals for treatment (n = 38), jail inmates receiving mental health treatment (n = 18) who had not been adjudicated incompetent, and randomly selected jail inmates (n = 50). Measures of the competence-related abilities of understanding and reasoning were found to have satisfactory indices of internal consistency (coefficient alpha), and all measures correlated in the expected direction with measures of global psychopathology, psychoticism, and verbal cognitive functioning. Between-group mean scores were all in the expected direction and were statistically significant for four of seven measures. No differences in MacSAC-CD performance were found in comparisons of male and female defendants who had been adjudicated incompetent, nor were differences found in the performance of male and female jail inmates.

The validity of mental patients' accounts of coercion-related behaviors in the hospital admission process.

Although the recent development of a measure for perceived coercion has led to great progress in research on coercion in psychiatric settings, there still exists no consensus on how to measure the existence of real coercive events or pressures. This article reports the development of a system for integrating chart review data and data from interviews with multiple participants in the decision for an individual to be admitted to a psychiatric hospital. The method generates a "most plausible factual account" (MPFA). We then compare this account with that of patients, admitting clinicians and other collateral informants in 171 cases. Patient accounts most closely approximate the MPFA on all but one of nine dimensions related to coercion. This may be due to wider knowledge of the events surrounding the admission.

The MacArthur Adjudicative Competence Study: diagnosis, psychopathology, and competence-related abilities.

A set of measures assessing abilities related to legal standards for competence in the adjudicative process were administered to mentally-disordered criminal defendants with diagnoses of schizophrenia, affective disorder, other psychiatric disorders, and to criminal defendants without diagnosed mental disorder. Mentally-disordered defendants were recruited from two groups: those who had been committed for restoration of competence and those who had been identified by jail personnel as mentally ill. Significant impairments in competence-related abilities were found for approximately half of the defendants with schizophrenia. Defendants with schizophrenia scored lower on measures of understanding, reasoning, and appreciation related to the adjudication process. The association between symptoms and competence-related abilities was explored within diagnostic groups. Conceptual disorganization was found to be inversely correlated with performance on all measures in both defendants with schizophrenia and those with affective disorders. For other psychotic symptoms, differing patterns of correlations were found in the two major diagnostic groups. The implications for policy designed to safeguard the rights of defendants to be tried while competent are discussed.

Prospective study of patients' refusal of antipsychotic medication under a physician discretion review procedure.

OBJECTIVE: The authors examined the refusal of antipsychotic medications and associated outcomes prospectively in a group of 348 psychiatric patients admitted to three acute inpatient units in a state-operated mental health facility in Virginia where psychiatrists have the discretionary power to administer treatment over patients' objections. METHODS: Newly admitted patients were administered both a questionnaire to ascertain their attitudes toward admission and the Brief Psychiatric Rating Scale (BPRS). Patients who refused antipsychotic medication were identified, and data were collected on the length of refusal and whether the refusal episode was terminated voluntarily or involuntarily. A group of patients compliant with antipsychotic medication was selected for comparison on outcome measures, including the rate of seclusion and restraint and length of hospitalization. RESULTS: Patients who refused treatment were found to have significantly higher BPRS scores than were patients who complied with antipsychotic treatment and more negative attitudes toward hospitalization and past, present, and future treatment. Refusal episodes were brief, on average 2.8 days, and all patients, who refused treatment were treated. When compared with the compliant patients, patients who refused treatment were more likely to be assaultive, were more likely to require seclusion and restraint, and had longer hospitalizations. CONCLUSIONS: Psychiatrists exercised their discretion to promptly treat all patients who refused treatment. Nonetheless, these patients suffered more morbidity than compliant patients. This study suggests that the negative sequelae of in-hospital treatment refusal cannot be eliminated by rapid treatment. The policy implications are discussed.

The MacArthur adjudicative competence study: development and validation of a research instrument.

Assessment of competence to stand trial is a common evaluation that can have substantial consequences for defendants and the criminal justice system. Despite a voluminous literature, much remains unknown. An obstacle to progress in understanding what is better termed "adjudicative competence" is the absence of structured, standardized research measures for assessment of defendants. This article presents the legal framework, assessment strategy, instrument description, psychometric properties, and construct validation of the MacArthur Structured Assessment of the Competencies of Criminal Defendants (MacSAC-CD). The measures meet or exceed accepted indices of internal consistency, and interscorer agreement. Observed patterns of correlations among measures support the underlying theoretical structure of competence-related abilities. Moreover, the MacSAC-CD distinguishes groups of competent and incompetent defendants; reflects changes in competence status; and correlates positively with clinical judgments, negatively with psychopathology and impaired cognitive functioning, and negligibly with cynicism toward the justice system.

The MacArthur Adjudicative Competence Study: a comparison of criteria for assessing the competence of criminal defendants.

A set of measures assessing competence-related abilities was administered to three groups of criminal defendants: a group committed for restoration of competence, a group identified by jail personnel as mentally ill but not incompetent, and a group without identified mental disorder. Data from this study were used to test key assumptions bearing on the legal criteria for adjudicative competence. The data show that among defendants able to understand the nature and purpose of the criminal proceedings, a significant proportion have an impaired ability to appreciate their situations as criminal defendants or to communicate relevant information to counsel; among defendants able to understand the proceedings and to assist counsel, a significant proportion have impaired decision-making abilities; and among defendants able to understand the nature and consequences of decisions to plead guilty or waive a jury, a significant proportion have impaired abilities to appreciate the significance of these decisions or to rationally manipulate information pertinent to making them. These findings highlight the importance of disaggregating the components of adjudicative competence.

Mentally ill and non-mentally ill defendants' abilities to understand information relevant to adjudication: a preliminary study.

The legal construct of competence to stand trial, or "adjudicative competence," is based on the premise that some mentally disordered defendants have impaired abilities when compared with most defendants and that adjudication should be barred if these competence-related abilities are significantly impaired. Where the line is drawn between sufficient and insufficient abilities has important consequences: as a result of being adjudicated incompetent, defendants may be detained and treated involuntarily and their trials will be delayed. However, no studies have systematically compared the capacities of relevant groups of defendants. In this study, 84 criminal defendants--42 of whom were hospitalized as incompetent and 42 of whom were regarded as unquestionably competent--were administered three instruments measuring capacity to understand legally relevant information. Incompetent defendants performed more poorly on all measures of understanding. Twenty-eight incompetent defendants were administered the measures a second time, after restoration to competence. Restored defendants improved their performance on all measures of understanding and their performance was similar to that of normal, competent defendants.

Perceived coercion in mental hospital admission. Pressures and process.

BACKGROUND: Patients' perceptions of coercion in admission may affect their attitude toward subsequent treatment, including their inclination to adhere to treatment plans. This study looks at the determinants of patients' perceptions of coercion. METHODS: A sample of 157 patients admitted to a rural Virginia state hospital and a Pennsylvania community hospital were interviewed within 48 hours of admission about their experience of coming to the hospital. All subjects were 17 years or older. Diagnoses were diverse, and 42% were involuntarily committed. The interview gathered an open-ended description of the admission experience followed by a structured interview that included several measures. RESULTS: Perceptions of being respectfully included in a fair decision-making process ("procedural justice") and legal status were most closely associated with perceived coercion, and a significant relationship was found with perceived negative pressures, ie, force and threats. However, only procedural justice was related to the perception of coercion at both sites and with both voluntary and involuntary patients. CONCLUSIONS: Patients' feelings of being coerced concerning admission appears to be closely related to their sense of procedural justice. It may be that clinicians can minimize the experience of coercion even among those legally committed by attending more closely to procedural justice issues.

Long-term, assenting psychiatric patients: decisional capacity and the quality of care.

The objectives of this study were (1) to investigate whether the relationship between functional decisional capacity and the resulting quality of treatment posited by the informed consent theory is found in clinical practice; and (2) to describe the range of decisional impairments found in long-term psychiatric inpatients who comply with prescribed treatment. Eighty-eight long-term, compliant, psychiatric inpatients, in two public hospitals, who were prescribed antipsychotic medications were assessed. Following a formal assessment of decisional capacity, subjects were categorized according to level of impairment, using a hierarchical scheme. All subjects were evaluated for the presence of abnormal involuntary movements. The appropriateness of treatment with antipsychotic medications was determined using accepted clinical guidelines. Patients with more serious impairments of decisional capacity were more likely to receive inappropriate treatment with antipsychotic medication; and serious impairments of decisional capacity were common. The study lends empirical support to one of the bases of the doctrine of informed consent: the notion that capable patient involvement in decisionmaking plays an important role in checking the judgments of treating physicians. Remedial measures are needed to protect long-term psychiatric inpatients with impaired decisional capacity from receiving inappropriate treatment.

Proposed federal legislation jeopardizes patient privacy.

In the last year there has been a move to enact federal legislation concerning private health-care information. This move has been fueled by a growing trend toward the computerization and electronic transmission of health-care information. These advances in technology call for appropriate new protections of patients' privacy. Unfortunately, the proposed legislation has not received adequate attention in the medical community. Physicians and patients in general are not aware of the legislation and have not been engaged in shaping its contents. In its current form, the legislation would seriously undermine traditional protections of confidentiality that are ensured by physicians. The flaws of the proposed legislation are examined in this article.