COERCION AND AGGRESSIVE COMMUNITY TREATMENT

A NEW FRONTIER IN MENTAL HEALTH LAW

THE PLENUM SERIES IN SOCIAL/CLINICAL PSYCHOLOGY Series Editor: C. R. Snyder

University of Kansas Lawrence, Kansas

Current Volumes in this Series:

AGGRESSIVE BEHAVIOR Current Perspectives

Edited by L. Rowell Huesmann

COERCION AND AGGRESSIVE COMMUNITY TREATMENT A New Frontier in Mental Health Law

Edited by Deborah L. Dennis and John Monahan

THE ECOLOGY OF AGGRESSION Arnold P. Goldstein

EFFICACY, AGENCY, AND SELF-ESTEEM Edited by Michael H. Kernis

HUMAN LEARNED HELPLESSNESS A Coping Perspective

Mario Mikulincer

PATHOLOGICAL SELF-CRITICISM Assessment and Treatment

Raymond M. Bergner

PROCRASTINATION AND TASK AVOIDANCE Theory, Research, and Treatment

Joseph R. Ferrari, Judith L. Johnson, and William G. McCown

THE PSYCHOLOGY OF VANDALISM Arnold P. Goldstein

SELF-EFFICACY, ADAPTATION, AND ADJUSTMENT Theory, Research, and Application

Edited by James E. Maddux

A Continuation Order Plan is available for this series. A continuation order will bring delivery of each new volume immediately upon publication. Volumes are billed only upon actual shipment. For further information please contact the publisher.

COERCION AND AGGRESSIVE COMMUNITY TREATMENT

A NEW FRONTIER IN MENTAL HEALTH LAW

EDITED BY

DEBORAH L. DENNIS Policy Research Associates, Inc.

Delmar, New York

AND

JOHN MONAHAN University of Virginia

Charlottesville, Virginia

SPRINGER SCIENCE+BUSINESS MEDIA, LLC

Library of Congress Cataloging-in-Publication Data

Coercion and aggress1ve community treatment a new front1er 1n mental health law I ed1ted by Deborah L. Dennis and John Monahan.

p. em. -- !The plenum series in soclal/cllnlcal psychology! ISBN 978-1-4757-9729-9 ISBN 978-1-4757-9727-5 (eBook) DOI 10.1007/978-1-4757-9727-51. Community mental health serv1ces. I. Dennis. Deborah L.

II. Monahan, John, 1946- III. Ser1es. RA790.C666 1996 362.2'2--dc20

ISBN 978-1-4757-9729-9

95-51527 CIP

©1996 Springer Science+Business Media New YorkOriginally published by Plenum Press, New York in 1996

Softcover reprint of the hardcover 1st edition 1996

All rights reserved

10 9 8 7 6 54 3 2 1

No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming,

recording, or otherwise, without written permission from the Publisher

CONTRIBUTORS

NANCY S. BENNETT, Bronx, New York 10463

JESSICA WILEN BERG, Department of Psychiatry, University of Massachusetts Medical Center, Worcester, Massachusetts 01655

RICHARD J. BONNIE, School of Law, University of Virginia, Char­lottesville, Virginia 22903

SUZAN HURLEY COGSWELL, Legislative Office of Education Over­sight, Columbus, Ohio 43266

DEBORAH L. DENNIS, Policy Research Associates, Inc., Delmar, New York 12054

RONALD J. DIAMOND, Department of Psychiatry, University of Wisconsin Hospital, Madison, Wisconsin 53792-2475

MARLENE M. EISENBERG, Institute of Law, Psychiatry, and Public Policy, University of Virginia, Charlottesville, Virginia 22902

DIANE ENGSTER, 3825 Gibbs Street, Alexandria, Virginia 22309

WILLIAM P. GARDNER, Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania 15213

VIRGINIA ALDIGE HIDAY, Department of Sociology, North Carolina State University, Raleigh, North Carolina 27695

v

vi CONTRIBUTORS

STEVEN K. HOGE, Institute of Law, Psychiatry, and Public Policy, University of Virginia, Charlottesville, Virginia 22902

KIM HOPPER, Nathan Kline Institute for Psychiatric Research, Orangeburg, New York 10962

HENRY KORMAN, Cambridge and Somerville Legal Services, Cam­bridge, Massachusetts 02141

CHARLES W. LIDZ, Western Psychiatric Institute and Clinic, Pitts­burgh, Pennsylvania 15213

MARGARITA LOPEZ, 606 East 11th Street, New York, New York 10009

ANNE M. LOVELL, Department of Sociology, University of Tou­louse, Le Mirail, 31058 Toulouse, Cedex, France

BONNIE M. MILSTEIN, David L. Bazelon Center for Mental Health Law, Washington, D.C. 20005

JOHN MONAHAN, School of Law, University of Virginia, Char­lottesville, Virginia 22903

EDWARD P. MULVEY, Western Psychiatric Institute and Clinic, Pitts­burgh, Pennsylvania 15213

BRENDA ROCHE, Division of Epidemiology and Community Psy­chiatry, New York State Psychiatric Institute, Columbia Presbyterian Medical Center, New York, New York 10032

LOREN H. ROTH, Western Psychiatric Institute and Clinic, Pitts­burgh, Pennsylvania 15213

PHYLLIS SOLOMON, School of Social Work, University of Pennsyl­vania, Philadelphia, Pennsylvania 19104

EZRA SUSSER, Division of Epidemiology and Community Psychia­try, New York State Psychiatric Institute, Columbia Presbyterian Med­ical Center, New York, New York 10032

PREFACE

Although it is a relatively new field, mental health law has undergone major developments in the past decade, including landmark judicial decisions, dramatic legislative initiatives, and the publication of pro­fessional standards and guidelines in both criminal and civil law. All of these developments, however, have been predicated on plausible but untested assumptions about persons with mental disorders, the service delivery system, and the law-and about how these elements affect one another.

In 1988, the John D. and Catherine T. MacArthur Foundation cre­ated a Research Network on Mental Health and the Law with the goal of building the empirical foundation for the next generation of mental health laws. The Network has two overriding mandates: to develop new knowledge about the relationship between mental health and the law and to turn that understanding into improved tools and criteria for evaluating individuals and making decisions that affect their lives.

The Network's research portfolio focuses on three pivotal issues facing the field of mental health law: the competence of people with mental disorders to make autonomous decisions, the risk of violence that sometimes accompanies mental disorder, and the coercion that often characterizes interventions to redress incompetence or reduce risk. It is with the last of these that this book deals.

The coercive imposition of mental health services has always been the most controversial issue in mental health law. Debates on the involuntary inpatient hospitalization of persons with mental disor­ders are several centuries old. Debates on whether people so hospital-

vii

viii PREFACE

ized have a right to refuse mental health treatment are now several decades old. While these controversies over involutary institutional­ization and inpatient treatment have by no means been resolved, they have to a considerable extent been overtaken by events in recent years. As the locus for the provision of mental health services has moved from the hospital to the community, so has the venue for de­bates about coercion. Once, the legal and ethical issues to be resolved included whether and for how long a person could be hospitalized before a formal judicial hearing took place. Now, the legally and ethi­cally perplexing questions are more likely to concern whether a per­son with a mental disorder but without a home in the community can be made dependent on an outreach worker's food and friendship as a method of inducing compliance with outpatient treatment.

Little is known about how mental health services are actually provided on the street level. Even less is known about how coercion is used to engage and maintain in community treatment people with se­vere mental disorders who have rejected-or been rejected by-more traditional interventions. It is to address this sea-change in the con­text in which mental health services are coercively administered that this volume was developed.

The Network invited leaders in the field of community treat­ment, including consumers of that treatment, to describe and discuss the issues that arose when treatment was "aggressively" pursued. We were struck with how often treatment providers told us that "we never talk about coercion, but we do it all the time," and with the depth of ambivalence that community coercion generated in both providers and recipients. It was to widen and deepen the conversa­tion about coercion in the community that the Network decided to commission these original chapters.

We hope that this book will interest mental health professionals providing front line services in communities throughout the coun­try, those in legal and policy-making positions who are influencing the content of service provision, and health service researchers who can document the costs and the consequences of coercion in the com­munity.

We are grateful to the members of the Network-in particular to Henry Steadman, who encouraged us to commit this fascinating in­terdisciplinary dialogue to print-to the participants at our meetings, and to the authors of these timely chapters, for sharing their experi­ences and their insights.

ACKNOWLEDGMENT

This volume was conceived and supported by the Research Network on Mental Health and the Law of the John D. and Catherine T. MacArthur Foundation.

CONTENTS

Introduction

Deborah L. Dennis and John Monahan

Aggressive Community Treatment Defined ...................... 2 Setting the Stage: From Hospital to Community .................. 3 Defining Coercion in Community Care ......................... 4 The Social Context of Aggressive Community Treatment .......... 5 The Need for More Research ................................... 7 Legal and Ethical Implications of

Community-Based Coercion ............................... 7 Conclusion .................................................. 8 References ................................................... 9

PART I. CoERCION: FRoM THE HosPITAL TO THE CoMMUNITY

Chapter 1

Coercion to Inpatient Treatment: Initial Results and Implications for Assertive Treatment in the Community

John Monahan, Steven K. Hoge, Charles W. Lidz, Marlene M. Eisenberg, Nancy S. Bennett, William P. Gardner, Edward P. Mulvey, and Loren H. Roth

Perceived Coercion and Formal Legal Status .................... 15

xi

xii CONTENTS

The MacArthur Coercion Study ............................... 16 References .................................................. 27

Chapter 2

Outpatient Commitment: Official Coercion in the Community

Virginia Aldige Hiday

Application of Outpatient Commitment ........................ 33 Patient Responses to Coercion ................................ 35 Effects of Outpatient Commitment ............................ 38 Issues Needing Investigation ................................. 41 References .................................................. 44

PART II. COERCION AND TREATMENT:

THE CoMMUNITY PROVIDER's PERSPECTIVE

Chapter 3

Coercion and Tenacious Treatment in the Community: Applications to the Real World

Ronald J. Diamond

Paternalism in Assertive Community Treatment Programs ....... 53 Coercion in the Community .................................. 55 Court-Ordered Treatment-The Extreme

End of the Continuum ................................... 58 Decreasing the Need for Coercion ............................. 65 Conclusion ................................................. 68 References .................................................. 70

Chapter4

"Coercion" and Leverage in Clinical Outreach

Ezra Susser and Brenda Roche

Background ................................................ 7 4 Leverage in Outreach ........................................ 75 Forms of Leverage ........................................... 76

CONTENTS xiii

Illustrative Cases ............................................ 79 Conclusions ................................................ 82 References .................................................. 82

Chapter 5

The Perils of Outreach Work: Overreaching the Limits of Persuasive Tactics

Margarita Lopez

The Street Is a Home when Your Client Lives There .............. 87 Meeting the Stranger Who Could Be a Client ................... 87 Knocking on a Client's Door .................................. 88 What Is Coercion? ........................................... 90 Conclusion ................................................. 92

Chapter 6

PART III. THE SociAL CoNTEXT oF AGGRESSIVE

COMMUNITY TREATMENT

Housing as a Tool of Coercion

Henry Korman, Diane Engster, and Bonnie M. Milstein

Civil Rights for People with Disabilities: Living in the Least Restrictive Environment, the Right to Choose Treatment, and the Promise of Integration ............................. 96

Obtaining the Ideal: The Diminishing Supply of Affordable Housing ................................... 98

Foreshadowing Exclusion: Section 202 Housing for the Elderly and Handicapped ............................ 100

Exclusion and Segregation as National Policy: The Housing and Community Development Act of 1992 .................... 101

Life on the Ground: Coercion in Service-Based Housing ......... 102 Mitigating Coercion: Fair Process, Good Process ............... 106 The Civil Rights Buffer: Reasonable Accommodation

for People with Disabilities .............................. 108 Conclusion ................................................ 110 References ................................................. 112

xiv

Chapter 7

Entitlements, Payees, and Coercion

Suzan Hurley Cogswell

CONTENTS

Meeting the Demand for Entitlement Payees ................... 116 Making Money Decisions .................................... 118 Minimizing Coercion in the Client-Payee Relationship ......... 121 Conclusion ................................................ 123 References ................................................. 125

PART IV. REsEARCH AGENDA oN CoERCION IN THE CoMMUNITY

Chapter 8

Research on the Coercion of Persons with Severe Mental Illness

Phyllis Solomon

Significance of Researching Coercion in the Community ........ 129 Defining Coercion .......................................... 131 Measurement Development in Community Coercion ........... 132 Formalized Mechanisms of Coercion ......................... 133 Informal Mechanisms of Coercion ............................ 139 Counterbalance: Client Control and Choice .................... 142 Conclusion ................................................ 143 References ................................................. 144

Chapter 9

Coercion and Social Control: A Framework for Research on Aggressive Strategies in Community Mental Health

Anne M. Lovell

Visible and Invisible: Coercion in Outpatient Mental Health ..... 148 A Social Control Framework for Understanding Coercion ....... 151 Getting at the Big Picture: Contextual Determinants of Coercion ... 155 Determinants and Effectiveness of Noncoercive Practices ....... 157 Reconstructing the Picture: Some Research Strategies ........... 160 Conclusion ................................................ 162 References ................................................. 163

CONTENTS

PART V. CoERCION IN THE CoMMUNITY: THE OPEN QuESTIONS

Chapter 10

When Push Comes to Shove: Aggressive Community Treatment and the Law

Jessica Wilen Berg and Richard J. Bonnie

XV

Outpatient Commitment .................................... 172 Conditional Access to Benefits ............................... 181 Representative Payee ....................................... 189 Informal Interventions ...................................... 191 Conclusion ................................................ 194 References ................................................. 194

Chapter 11

Regulation from Without: The Shadow Side of Coercion

Kim Hopper

The World Without ......................................... 198 Some High Points .......................................... 201 Conclusion ................................................ 209 References ................................................. 210

Index ..................................................... 213