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.

Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods.

BACKGROUND: The public perception that mental disorder is strongly associated with violence drives both legal policy (eg, civil commitment) and social practice (eg, stigma) toward people with mental disorders. This study describes and characterizes the prevalence of community violence in a sample of people discharged from acute psychiatric facilities at 3 sites. At one site, a comparison group of other residents in the same neighborhoods was also assessed. METHODS: We enrolled 1136 male and female patients with mental disorders between the ages of 18 and 40 years in a study that monitored violence to others every 10 weeks during their first year after discharge from the hospital. Patient self-reports were augmented by reports from collateral informants and by police and hospital records. The comparison group consisted of 519 people living in the neighborhoods in which the patients resided after hospital discharge. They were interviewed once about violence in the past 10 weeks. RESULTS: There was no significant difference between the prevalence of violence by patients without symptoms of substance abuse and the prevalence of violence by others living in the same neighborhoods who were also without symptoms of substance abuse. Substance abuse symptoms significantly raised the rate of violence in both the patient and the comparison groups, and a higher portion of patients than of others in their neighborhoods reported symptoms of substance abuse. Violence in both patient and comparison groups was most frequently targeted at family members and friends, and most often took place at home. CONCLUSIONS: "Discharged mental patients" do not form a homogeneous group in relation to violence in the community. The prevalence of community violence by people discharged from acute psychiatric facilities varies considerably according to diagnosis and, particularly, co-occurring substance abuse diagnosis or symptoms.

A prospective comparison of four insanity defense standards.

OBJECTIVE: Controversy about the formulation of the insanity defense has been intense, but little empirical work is available regarding how different standards affect court findings. The major aims of the present study were to determine if different standards for determining insanity produced different judgments and to provide a broad descriptive picture of those cases in which the standards appeared to make a difference. METHOD: Four forensic psychiatrists were asked to indicate whether they thought 164 defendants met any or all of four insanity tests: 1) the American Law Institute (ALI) cognitive criterion, 2) the ALI volitional criterion, 3) the APA test, and 4) the M'Naghten rule. RESULTS: The four psychiatrists determined that 97.5% of the defendants met the ALI volitional criterion, 73.9% met the APA criterion, 70.3% met the M'Naghten rule, and 69.5% met the ALI cognitive criterion. Nearly two-thirds of the defendants met all four insanity tests, and 24.4% met only the ALI volitional test. Few defendants met cognitive tests without also meeting the ALI volitional test. Elimination of the volitional test for insanity reduced the rate of psychiatric recommendations of acquittal by 24.4%. CONCLUSIONS: These findings highlight the fact that the primary logical division between volitional and cognitive standards appears to be powerful but that distinctions between types of cognitive standards are not terribly powerful. In addition, the variation among individual raters must be viewed as an important determinant of how any insanity standard is applied.

Commitment: the consistency of clinicians and the use of legal standards.

The reliability and validity of the application of legal criteria for commitment were investigated as part of a larger study. Evaluations of 411 patients by 96 different clinicians showed good interrater reliability for assessment of dangerousness and committability. A strong relationship between ratings of committability and ratings of dangerousness suggests that clinicians were conforming to the logic of the commitment law. Discrepant cases involved patients who desired voluntary admission or whose commitment was completed elsewhere. Results suggest fair application of commitment standards but that two issues of statutory interpretation confused participating clinicians.

Short-term clinical prediction of assaultive behavior: artifacts of research methods.

OBJECTIVE: The apparent accuracy of predictions of assaultive behavior in psychiatric inpatients varies substantially, depending on the method used to study the prediction. The authors explored the effects of different measures and sampling strategies on short-term clinical predictions of dangerousness. METHOD: The index subjects were patients who were rated by intake clinicians as potentially highly assaultive on the ward (N = 32) and patients who were involuntarily committed on grounds of danger to others (N = 32). The respective comparison groups comprised patients predicted by clinicians not to be assaultive (N = 32) and patients committed for reasons other than danger to others (N = 40). The text of unit meetings and data from chart reviews were used to determine the occurrence and dates of violent acts, seclusions for violent acts or threats, and violent threats. RESULTS: There was a significant difference in the rate of inpatient violence between the subjects rated at admission as potentially assaultive (75.0%) and patients rated as not potentially assaultive (12.5%), but the difference in the rates of violence between the patients who were (56.0%) and were not (42.0%) involuntarily committed as dangerous to others was not significant. Most of the violent acts occurred relatively late in the hospitalization, but seclusions occurred almost exclusively in the initial stages of hospitalization. CONCLUSIONS: The reported accuracy of clinical predictions of assaultive behavior is markedly affected by the choice of sampling strategy, comparison group, outcome measures, and follow-up period. Including seclusion and violent threats in the outcome variable appears to lead to deceptive findings.

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.

Regression analyses of counts and rates: Poisson, overdispersed Poisson, and negative binomial models.

The regression models appropriate for counted data have seen little use in psychology. This article describes problems that occur when ordinary linear regression is used to analyze count data and presents 3 alternative regression models. The simplest, the Poisson regression model, is likely to be misleading unless restrictive assumptions are met because individual counts are usually more variable ("overdispersed") than is implied by the model. This model can be modified in 2 ways to accomodate this problem. In the overdispersed model, a factor can be estimated that corrects the regression model's inferential statistics. In the second alternative, the negative binomial regression model, a random term reflecting unexplained between-subject differences is included in the regression model. The authors compare the advantages of these approaches.

Psychopathy and community violence among civil psychiatric patients: results from the MacArthur Violence Risk Assessment Study.

Although psychopathy is recognized as a relatively strong risk factor for violence among inmates and mentally disordered offenders, few studies have examined the extent to which its predictive power generalizes to civil psychiatric samples. Using data on 1,136 patients from the MacArthur Violence Risk Assessment project, this study examined whether the 2 scales that underlie the Psychopathy Checklist: Screening Version (PCL:SV) measure a unique personality construct that predicts violence among civil patients. The results indicate that the PCL:SV is a relatively strong predictor of violence. The PCL:SV's predictive power is substantially reduced, but remains significant, after controlling for a host of covariates that reflect antisocial behavior and personality disorders other than psychopathy. However, the predictive power of the PCL:SV is not based on its assessment of the core traits of psychopathy, as traditionally construed. Implications for the 2-factor model that underlies the PCL measures and for risk assessment practice are discussed.

Clinical versus actuarial predictions of violence of patients with mental illnesses.

This study compared the accuracy of an actuarial procedure for the prediction of community violence by patients with mental illness with the accuracy of clinicians' ratings of concern about patients' violence. Data came from a study in which patients were followed in the community for 6 months after having been seen in a psychiatric emergency room. Accuracy of actuarial prediction was estimated retrospectively, with a statistical correction for capitalization on chance. Actuarial prediction had lower rates of false-positive and false-negative errors than clinical prediction. The seriousness of the violence correctly identified by the actuarial predictor (the true positives) was similar to the seriousness identified by clinicians. Actuarial predictions based only on patients' histories of violence were more accurate than clinical predictions, as were actuarial predictions that did not use information about histories.

The inherent limits of predicting school violence.

The recent media hype over school shootings has led to demands for methods of identifying school shooters before they act. Despite the fact that schools remain one of the safest places for youths to be, schools are beginning to adopt identification systems to determine which students could be future killers. The methods used to accomplish this not only are unproven but are inherently limited in usefulness and often do more harm than good for both the children and the school setting. The authors' goals in the present article are to place school shootings in perspective relative to other risks of violence that children face and to provide a reasonable and scientifically defensible approach to improving the safety of schools.

Violent juvenile delinquents. Treatment effectiveness and implications for future action.

Traditionally, the juvenile justice system has emphasized the goals of treatment and rehabilitation of young offenders, while protecting them from punishment, retribution, and stigmatization. Violent juvenile offenders have posed a challenge to this rehabilitative ideal because of mounting public pressure to ensure societal protection. Juveniles who are perceived as dangerous or persistent in their criminal activity are increasingly transferred to the adult criminal justice system, where they may receive much harsher consequences. Whether violent delinquents can be successfully treated is a key point in the debate regarding the wisdom of this trend in juvenile justice. This article considers the available research to address the policy question of how society should reasonably invest in the treatment of violent juvenile offenders.

Characteristics of violence in the community by female patients seen in a psychiatric emergency service.

OBJECTIVE: This study examined differences in factors associated with violence toward others by female and male patients evaluated in a psychiatric emergency service. METHODS: A sample of 812 psychiatric patients recruited in the emergency service of an urban psychiatric hospital were followed in the community over a six-month period. Patients provided self-reports of violent incidents, and collateral informants also provided reports of the incidents. Official records were also reviewed. During the followup period, 369 patients (213 male and 156 female patients) engaged in violence, defined as laying hands on another person in a threatening manner or threatening another person with a weapon. RESULTS: Male and female patients did not differ significantly in frequency and seriousness of violence, but they did differ on who the co-combatant was and where the incident took place. CONCLUSIONS: Gender is not a strong predictor of involvement in violence by psychiatric patients. The observed gender differences in location in which violence took place and identity of the co-combatant may be related to differences in the social worlds of men and women, with men having more opportunity for public violence with strangers.

A primer on school violence prevention.

Violence has reached epidemic proportions in the United States with particularly serious health implications for school-age children and adolescents. Schools that experience the daily threat of potential student violence have their primary mission of education eroded at great cost to students. This article reviews the problem of violence in public schools and summarizes existing knowledge on school violence prevention. Violence prevention programs that use educational, regulatory, technological, or combined approaches are reviewed. Recommendations are presented addressing both policy and program needs related to control of violence in public schools. School health professionals should be active participants in violence prevention efforts. A critical need exists to carefully evaluate any planned prevention program so future efforts can be built on methods proven successful.

Ethical and legal duties in conducting research on violence: lessons from the MacArthur Risk Assessment Study.

This article addresses the ethical and legal duties that must be confronted in any study of the risk of interpersonal violence in the community. Ongoing research--the MacArthur Risk Assessment Study--on the markers of violence among released mental patients is taken as illustrative. Methods by which the researchers are discharging their legal and ethical duties are described and justified. Strategies center around the duty to protect research subjects from their own violence, and the duties to protect research staff and third parties from subjects' violence. By airing these rarely discussed issues, the authors hope to initiate a professional dialogue on crucial ethical and legal aspects of the research process.