A Scale to Measure Perceived Coercion in Everyday Life: A Concept to Inform Research on the Legal Issues of Coerced Treatment

Size: px

Start display at page:

Download "A Scale to Measure Perceived Coercion in Everyday Life: A Concept to Inform Research on the Legal Issues of Coerced Treatment"

Clementine Flowers
5 years ago
Views:

1 International Journal of Forensic Mental Health 2006, Vol. 5, No. 2, pages A Scale to Measure Perceived Coercion in Everyday Life: A Concept to Inform Research on the Legal Issues of Coerced Treatment Henry J. Steadman and Allison D. Redlich The perception of how much control people have over their lives has been an enduring topic for psychologists. However, little research has been done to apply this concept of sense of control to persons with mental illness, and whether a sense of control over the everyday features of their lives may be related to other key concepts in mental health services, such as mandated treatment and treatment compliance. In the present study, a reliable and valid tool to measure the construct of perceived coercion in everyday life was developed and tested. Findings are discussed in regard to the clinical and policy implications for persons with mental illness and for mandated treatment. People s perception of how much control they have over their lives has been an enduring topic for psychologists. This is most likely related to Abeles (1991) observation that, Sense of control is a pivotal contributor to a wide variety of behaviors and to both mental and physical well-being, which are essential elements of quality of life (p. 297). One particular focus of this line of research has been locus of control (Rotter, 1966). In brief, Locus of Control, a concept first developed with college students, is the degree to which individuals feel they have control over their lives and destiny. Persons with a high Internal Locus of Control feel they wield control, whereas persons with a high External Locus of Control feel their destinies are dictated by powerful others or fate. A recent meta analysis of this research by Twenge, Zhang, and Im (2004) demonstrated substantial increases in the past 40 years in the proportion of both college students and children who report external (i.e. outside forces rather than themselves) controls over their lives. Looking at the research on perceived control in mid-life, Lachman and Firth (2004) concluded, having a sense of control over outcomes in key life domains helps one negotiate challenges and demands and to minimize the negative consequences of declines and losses associated with aging (p. 320). Little research has been done to apply these concepts of sense of control or locus of control to persons with mental illness and how a sense of control over the everyday features of their lives may be related to some other key concepts in mental health services, such as mandated treatment and treatment compliance. Some indication of why the connection between mental illness and locus of control may be important comes from the work of Lidz et al. (1997). In interviews with persons with mental illness who had been involuntarily hospitalized, many patients reported not feeling coerced despite having been brought to hospital emergency rooms by police or forcibly by family members (Hoge et al., 1997). Subsequent interviews with people evaluated for civil commitment in emergency rooms, with clinicians, and with family members reinforced a difference between objective coercion and subjective coercion, i.e., what an external observer might assess as a situation as coercive where physical force was used, but was not one reported as producing subjective reports of perceived coercion (Lidz et al., 1998). Ultimately, the distinction between subjective (perceived) coercion and objective coercion was partially explained by the respondents retrospectively reporting low levels of perceived coercion despite Henry J. Steadman, Ph.D. and Allison D. Redlich, Ph.D.: Policy Research Associates, Inc. This study was funded by the John D. and Catherine T. MacArthur Foundation. We would like to thank the members of the MacArthur Network on Mandated Community Treatment and Pamela C. Robbins for their input on various drafts. Correspondence should be directed to: Henry J. Steadman, Ph.D., Policy Research Associates, Inc., 345 Delaware Ave., Delmar, NY ( hsteadman@prainc.com) International Association of Forensic Mental Health Services

2 168 Steadman & Redlich the outward appearance of objective coercion when they were accorded procedural justice; i.e. when they felt that they were listened to by relevant clinical and judicial authorities (they had voice ) (Hoge et al., 1997; Lidz et al., 1995; Monahan et al., 1995). These data also suggested that personal coercion histories can play a major factor in subjective reports of coerced treatment. People who had a great deal of contact with the mental health, substance abuse and criminal justice systems had experienced such high levels of prior coercion that situations seen as highly coercive by external observers without similar histories were seen as just more of the same and therefore not reported as coercive. In other words, the reactions of people with mental illness to various types of leverages to participate in treatment are shaped, in part, by their past experiences with these and other leverages (Monahan et al., 2005). They adapt to a world full of pressures to do many things in their lives that persons without mental illnesses do not experience and, as a result, do not react to objective coercion with as much perceived coercion. As conceptualized here, perceived coercion in everyday life refers to the amount of control people feel they have on some of the most routine activities in daily life, such as what time they get up from sleeping, how they spend their time, and what they eat. We focused on activities that happen with great regularity and would be subject to significant constraints if a person were under formal or informal supervision by external agents, but that were also relevant to the everyday lives of persons with serious mental illness. Specifically, the research reported here is an attempt to establish a metric for the concept of perceived coercion in everyday life for people with mental illness. We were also interested in examining possible factors that influenced perceived coercion over everyday activities. Ultimately, this construct is geared towards further understanding how perceived coercion for persons who receive mandated treatment under civil or criminal auspices can impact program participation and completion, and how these two factors, in turn, may be related to outcomes in clinical, justice and social policy domains. It may well be that histories of coercion shape how current mandated treatment is experienced and these experiences are key factors in treatment participation and the ultimate clinical and social policy outcomes expected when treatment is mandated and monitored. This paper has only the modest goals of demonstrating the value of this concept, a metric for assessing it, and the offering of a tool for future research. METHOD Data presented here are from a larger study conducted by Monahan and colleagues (2005). Below we describe relevant information for this paper; however, for more detail, we refer readers to Monahan et al. (2005). In brief, the Monahan et al. research involved interviewing current outpatients with mental disorders about their mandated treatment experiences and related topics, including perceived coercion in everyday life. Participants Approximately 200 outpatients from publicly funded programs were sampled from each of five sites: Chicago, IL, Durham, NC, San Francisco, CA, Tampa, FL, and Worcester, MA (total sample n = 1,011). About half of the sample were male (n = 509, 50.4%), 61% (n = 617) had a psychotic disorder, and 22.6% (n = 228) lived in housing where services and staff were on-site. To be eligible, participants had to be under treatment for mental disorders (rather than for a substance abuse disorder without co-occurring mental illness), but not with any specific diagnosis or a given level of acuity. The specific inclusion criteria were: (1) Age: years; (2) Language: English- or Spanish-speaking; (3) Service Use: Currently in outpatient treatment for a mental disorder with a publicly-supported mental health service provider (operationally defined as at least one appointment/visit in the prior six months); and (4) Duration of Service Use: First service contact as an adult occurred at least 6 months ago. Procedure Institutional Review Board approval was obtained at all participating sites and at the study s Coordinating Center. At the Worcester, Tampa, and San Francisco sites, potential subjects were recruited

3 Perceived Coercion in Everyday Life 169 sequentially in the waiting rooms of outpatient clinics of community mental health centers. In Durham, a list of potentially eligible subjects was created from management information system data, and these patients were randomly selected to be approached regarding the study. Both of the above recruitment strategies were used at the Chicago site. Half of their sample was obtained using the waiting room approach and the other half using the eligibility list approach. Refusal rates varied from 2-13 percent across sites. After complete description of the study to the subjects, written informed consent was obtained. Next, the interview was conducted, which on average lasted 90 minutes. The interview included demographic questions, which included gender and the person s current housing situation (see Monahan et al., 2005). Diagnoses were obtained from the person s medical chart after consent was obtained. To measure perceived coercion in everyday life, a series of questions was asked relating to how much say a person has over daily activities, heretofore referred to as PCEL questions. Six PCEL questions were asked (e.g., How much say did you have about what time you got up? see Table 1). Participants were asked to think about the last week when answering the questions and to use a scale of 1 = very much say to 5 = no say at all. PCEL questions were developed by the first author. Additionally, participants were asked to indicate their agreement with seven Personal Mastery (Pearlin & Schooler, 1978) questions, such as I have little control over the things that happen to me (1 = strongly agree to 4 = strongly disagree). Finally, participants were paid $25 for their involvement. RESULTS The primary goal of this study was to examine the validity of the PCEL scale. We first looked at the frequencies of responses to the six PCEL questions (Table 1). Approximately 50% of the outpatients we sampled had very much say over all six aspects of their daily activities. In contrast, the other half of the sample perceived themselves as having less than total say. Depending on the activity, 7-14% reported having no say at all. We next examined whether the six PCEL questions formed one underlying construct by scaling the items. The six items appeared to coalesce: interitem correlations range from.36 to.57 and the Cronbach alpha is equal to.83. In a factor analysis, the items all load on a single factor with positive Table 1 Frequency of individual items in PCEL How much say do No Say A Little Some Quite a Very Much Missing you have about At All Say Say Bit of Say Say Data N % N % N % N % N % N % What time you got up? What you would do during the day? How much of your money you could spend? Who you would spend time with during the day? What programs you would watch on TV? What food you ate?

4 170 Steadman & Redlich loadings ranging from.68 to.78 and eigenvalue was equal to Thus, we formed one composite score (PCEL) by averaging responses to the six questions. The overall mean on the 5-point PCEL scale was 2.14 (SD = 1.02), and the median was Finally, in regard to the convergent validity of the PCEL, we correlated PCEL scores with Personal Mastery scores. The two scores were significantly correlated, r =.22, p <.0001, indicating that individuals who felt they had little say over their daily activities also felt they had little control over their lives generally. We also examined factors that could potentially influence the level of perceived say in everyday life. Specifically, we examined the influence of gender, presence or absence of a psychotic disorder (PD; defined as 0 = any diagnosis except schizophreniaspectrum or bi-polar, 1= schizophrenia-spectrum or bi-polar disorders), and whether the person lived in a setting with on-site mental health services and staff. We conducted a three-way analysis of variance with these three factors and the PCEL scores as the dependent measure. Significant main effects of PD and on-site services emerged. Participants who have a PD, M = 2.33 (SD = 1.04), felt they had significantly less say over their daily activities than those who do not have a PD, M = 1.98 (SD = 0.95), F (1, 993) = 6.74, p <.01, Cohen s d =.35. Similarly, not surprisingly, participants who lived where mental health services and staff were on-site, M = 2.59 (SD = 1.03), felt they had significantly less say over their daily activities than those who did not live where services and staff were on-site, M = 2.00 (SD = 0.97), F (1, 993) = 51.89, p <.0001, Cohen s d =.59. A significant main effect of gender (males, M = 2.21, SD = 1.04, feeling they had less say over their lives than females M = 2.07, SD = 0.99) was qualified by a significant interaction between on-site services and gender, F (1, 993) = 3.97, p <.05. When services and staff were on-site, men, M = 2.72 (SD = 0.98), felt they had significantly less say over their lives than women, M = 2.41 (SD = 1.07), Cohen s d =.30. When services and staff were not available at their current residence, men and women held similar views of how much say they had over their lives (Female M = 1.98, SD = 0.95; Male M = 2.03, SD = 1.00). There were no other significant interactions. DISCUSSION An important finding from this research is the strong psychometrics of the six-item scale we developed for Perceived Coercion in Everyday Life (PCEL) for persons with mental and substance use disorders. The items each have face validity for activities that are routinely part of most everyone s every day existence across major demographic factors. The Cronbach alpha of the scale was.83 and a single factor solution with an eigenvalue of 3.27 indicate this is a unidimensional measure. Additionally, PCEL demonstrated sufficient convergent validity with a standardized scale assessing personal mastery. In this sample of outpatients from five geographically diverse sites, about half feel they have less than total say over routine day-to-day activities. Additionally, it was determined that people diagnosed with psychotic disorders and those residing where mental health services are on site (especially men) feel they have less say over their daily activities. Persons diagnosed with psychotic disorders are often the people mandated to treatment, as many programs that require treatment are limited to persons with severe mental illness. Moreover, it is often the case that people who are mandated to treatment are required to live in facilities with onsite mental health services as part of the treatment plan. The possible role of PCEL in influencing people s perceptions of and reactions to mandated treatment are especially important in some rapidly expanding alternatives to civil and criminal commitments of persons with serious mental illness who could be hospitalized or charged with criminal offenses. As various mechanisms such as assisted outpatient commitment, mental health courts and other post-booking jail diversion programs proliferate (Redlich, Steadman, Monahan, Petrila, & Griffin, 2005; Monahan et al., 2001; Steadman, Davidson, & Brown, 2001; TAPA Center, 2004), there is an ever increasing number of persons with mental illness coming under the continuing and intensive supervision of the court system with terms and conditions mandating them to mental health treatment. Should the person under supervision not

5 Perceived Coercion in Everyday Life 171 adhere to these conditions, sanctions such as re-incarceration or more intensive community supervision may occur. It is quite possible that a person s subjective perception of coerciveness of any of these forms of leverage is substantially influenced by their level of personal coercion in everyday life. This proposed role of PCEL in program participation awaits vigorous empirical testing. It does not, however, await significance. This new research tool can address several unanswered questions. For example, profitable next steps are to determine the validity of the construct in a sample of persons with no known mental or substance use disorders, and to examine relations between perceived coercion in everyday life, demographics (e.g., education, age, immigration status), measures of locus of control, and constructs such as selfefficacy and attribution style. As outpatient commitment statutes and mental health courts and other forms of mandated treatment rapidly proliferate, there is an exponential increase in the civil and criminal justice system s community supervision of people with mental illness. Relevant research is sorely needed as public policy blithely proceeds in the absence of data. The research reported here suggests that as this needed research is designed that the PCEL is a construct to be included to help sort out how mandates impact on treatment participation and on the subsequent desired clinical and public policy outcomes. REFERENCES Abeles, R. (1991). Sense of control, quality of life, and frail older people. In J. Birron, J. Rowe, & D. Deutschman (Eds.), The concept and measure of quality of life in the frail and elderly (pp ). San Diego: Academic Press. Hoge, S., Lidz, C., Eisenberg, M., Gardner, W., Monahan, J., Mulvey, E., Roth, L., & Bennett, N. (1997). Perceptions of coercion in the admission of voluntary and involuntary psychiatric patients. International Journal of Law and Psychiatry, 20, Lachman, M. E., & Firth, K. M. P. (2004). The adaptive value of feeling in control during midlife. In O. G. Brim & C. D. Ryff (Eds.), How healthy are we? A national study of wellbeing at midlife (pp ). Chicago, IL: University of Chicago Press. Lidz, C., Hoge, S., Gardner, W., Bennett, N., Monahan, J., Mulvey, E., & Roth, L. (1995). Perceived coercion in mental hospital admission: Pressures and process. Archives of General Psychiatry, 52, Lidz, C., Mulvey, E., Hoge, S., Kirsch, B., Monahan, J., Bennett, N., Eisenberg, M., Gardner, W., & Roth, L. (1997). The validity of mental patients accounts of coercion-related behaviors in the hospital admission process. Law and Human Behavior, 21, Lidz, C., Mulvey, E., Hoge, S., Kirsch, B., Monahan, J., Eisenberg, M., Gardner, W., & Roth, L. (1998). Factual sources of mental patients perceptions of coercion in the hospital admission process. American Journal of Psychiatry, 155, Monahan, J., Bonnie, R., Appelbaum, P., Hyde, P., Steadman, H. J., & Swartz, M. (2001). Mandated community treatment: Beyond outpatient commitment. Psychiatric Services, 52, Monahan, J., Hoge, S., Lidz, C., Roth, L., Bennett, N., Gardner, W., & Mulvey, E. (1995). Coercion and commitment: Understanding involuntary mental hospital admission. International Journal of Law and Psychiatry, 18, Monahan, J., Redlich, A. D., Swanson, J. Robbins, P. C., Appelbaum, P. S., Petrila, J., Steadman, H. J., Swartz, M., Angell, B., & McNiel, D. (2005). Use of leverage to improve adherence to psychiatric treatment in the community. Psychiatric Services, 56, Pearlin, L. I., & Schooler, C. (1978). The structure of coping. Journal of Health and Social Behavior, 19, Redlich, A. D., Steadman, H. J., Monahan, J., Petrila, J., & Griffin, P. (2005). The second generation of mental health courts. Psychology, Public Policy, and the Law, 11, Rotter, J.B. (1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs, 80, (Whole No. 609). Steadman, H., Davidson, S., & Brown, C. (2001). Mental health courts: Their promise and unanswered questions. Psychiatric Services, 52, TAPA Center for Jail Diversion. (2004). What can we say about the effectiveness of jail diversion programs for persons with co-occurring disorders? Delmar, NY: TAPA Center. Twenge, J., Zhang, L., & Im, C. (2004). It s beyond my control: A cross-temporal meta-analysis of increasing externality in locus of control, Personality and Social Psychology Review, 8,

Subjective Experience in Community Treatment. Eliza A. Nicholson, M.A. & Kevin S. Douglas, LL.B., Ph.D. Department of Psychology

Subjective Experience in Community Treatment Eliza A. Nicholson, M.A. & Kevin S. Douglas, LL.B., Ph.D. Department of Psychology Can treatment be forced? Mental Illness is related to an increase in adverse