How to Successfully Encourage, Improve, and Implement Research on

Coercion in Mental Health Services

John Monahan

1. Framing the Questions for Research

2. The Experience of the MacArthur Research Networks

3. Personal Reflections from 20 Years of Collaborative Research.

Framing the Questions for Research

• What do we mean by “coercion”?

• Ask the most controversial questions

• Ask the least controversial questions.

What Do We Mean by Coercion?

From Coercion to Contract, Bonnie and Monahan 29 Law and Human Behavior 487

Problems with Framing Leverage as “Coercion”

• Legal: Not clear what “rights,” if any, are being violated

• Political: “Rights talk” is not conducive to compromise and negotiation.

Mary Ann Glendon, Rights Talk: The Impoverishment of Political Discourse

“Our rights talk, in its absoluteness, promotes unrealistic expectations, heightens social conflict, and inhibits dialogue that might lead toward consensus, accommodation, or at least the discovery of common ground… All of these traits promote mere assertion over reason-giving.”

The Philosophy of Coercion

• Wertheimer: “Threats coerce, but offers do not”

• Threat: The person is worse off than in a baseline position if he or she refuses an option

• Offer: The person is no worse off than in a baseline position if he or she refuses an option

• Problem: What is the person’s baseline position?

Treatment as a Condition of ProbationLegal Baseline: Jail

“If you accept my offer of treatment in the community, criminal punishment will be reduced or eliminated; if you reject my offer of treatment in the community, your case will be decided as it would have been had this offer not been made.”

Preventive Outpatient Commitment (OPC): A Threat: Clearly Coercive

• Person does not meet criteria for inpatient commitment. Legal baseline: freedom

• Options are not being expanded (e.g., from “jail” to “jail or treatment”)

• Options are being reduced (i.e., from “accept or do not accept services in the community” to “accept services in the community”)

• OPC may still be justified, but it is not contractual.

From Coercion to Contract?• Legal, not moral, baseline

• Legal baseline is often unclear or contradictory

• But “contract” often better captures current state of the law—at least U.S. law—than does “coercion”

• To say leverage is a contract is not to endorse it; the “deal” may not work, or may be inefficient. But a deal is still a deal.

Coercion at Its Most Controversial

Is Outpatient Commitment Racially Biased?Swanson et al, Health Affairs, in press.

New York Lawyers for the Public Interest (2005)

• “Blacks were nearly five times as likely as whites to be the subject of court orders stemming from Kendra’s Law.”

• "It’s important to know if our mental health policy is disproportionately taking away the freedom of groups of people who have historically been oppressed."

Implications (Swanson et al, in press) • Question of racial disparity in outpatient commitment (OPC) is

ambiguous:– Disparity in access to treatment (a public “good”) versus disparity

in limitations on personal liberty (a public “bad”)

• Interpretation may depend on assumed baseline situation: – Hospitalization OPC as a less restrictive alternative– Community OPC as initiating coercion

• Findings suggest that the source of overrepresentation of African-Americans in OPC… – Is not intrinsically related to race and discrimination– Lies “upstream” from the decision to put someone on OPC – Lies in broader social/economic racial disparities and the

organization/financing of public mental health care in the U.S.

“Coercion” at Its Least Controversial

Can a Professional License be Used as Leverage? Monahan and Bonnie, 3 International J of Forensic MH 131

Treatment as a Condition of Continued Professional Licensing

• Generally uncontroversial, even among the professionals on whom it is imposed

• Reported to be very effective (75-90%)

• Consider 3 groups: physicians, attorneys, airline pilots.

Why is Using a License as Leverage Uncontroversial? (1)

• Highly favorable conditions for treatment effectiveness

– Disorder (depression) leaves competence unimpaired– Strong economic incentive for adhering to treatment– High quality treatment offered, and paid for– Adherence closely monitored.

Why is Using a License as Leverage Uncontroversial? (2)

• Leverage has a strong legal and ethical basis

– Professional’s claim on the license is weak (there is no legal “right” to be a doctor, a lawyer, or a pilot)

– State’s interest in protecting the public is very strong.

Implications of License as Leverage for Other Forms of Leverage

• If the same high quality treatment now available to professionals were made available to others, would the same positive outcomes be achieved?

• If the same intensive monitoring now applied to professionals were applied to others, would the same high rates of treatment adherence be obtained?

1. Framing the Questions for Research

2. The Experience of the MacArthur Research Networks

The Four Stages of Network Development

Kahn, An Experiment in Scientific Organization See also http://robertmrose.com/

Stage I: Listening Across the Interdisciplinary Gulf

• “The early meetings of Networks showed a familiar pattern of academic behavior: successive pronouncements on the subject at hand by various speakers, heard with varying degrees of attention and comprehension by their listeners

• The underlying task at this stage is the search for a

common theme.”

Stage 2: Conceptual Translation • "The underlying task of the 2nd stage is to develop a

common language, a prerequisite for collaborative work. Developing a common conceptual language is essentially a process of translating from the vocabulary of one discipline to another

• As the process continues, Network members gain a

sense of equivalencies across disciplinary lines, and they acquire a kind of multidisciplinary vocabulary that they can use without pausing for definition or explanation.”

Stage 3: The Onset of Collaboration • “Questions about purpose and mission have been

worked through, and meetings have become increasingly exciting. Network members know each other and share a common language, making communication across disciplinary lines relatively easy

• This stage is marked by a high degree of mutual appreciation and tolerance, a willingness to work through people’s weaknesses to get to their strengths.”

Stage 4: Active Involvement in Joint Projects

• “Stage 4 is marked by the commitment of individual members to the Network’s research goals, and by the close interpersonal relationships that develop through collaborative research

• Finally, in stage 4 the products of collaborative research begin to emerge.”

1. Framing the Questions for Research

2. The Experience of the MacArthur Research Networks

3. Personal Reflections on 20 Years of Collaborative Research.

Setting an Ambitious Agenda

• Usual way: start with the present and move forward– “What do we know now about coercion, and what are

the next steps we need to take to learn more?”

• Better way: start with the future and move backward– “What will the most important questions about

coercion be at the time the Network is over, and what will we need to know then to answer these questions?”

Choosing the Right People• Not too many• Different disciplines: different strengths (and weaknesses)• Different stages in their careers: senior to post-doc• People with a breadth of interests• People willing to commit the time and effort needed• No prima donnas, no matter how smart they are!– “Plays well in groups”

• Leadership: someone must be in charge, and he or she must be seen as fair by everyone in the group.

The Roles That Collaborators Play• Conceptualizers: The “Big Picture” people

• Managers: The people who actually do the work

• Statisticians: The people who tell you what you’ve found

• Writers: The people who clearly and accurately—different skills!—communicate the findings, to many different audiences.

The Process That Unfolds

• Meet face-to-face on a regular basis; plan meetings far in advance

• Power shifts over the course of the project (conceptualizers → writers)

• Stagger the start times of different studies• An analysis plan is theoretically helpful• A publication plan is essential: “core” papers and

specialty papers• A communication plan can be useful.

“Hopefully Helpful Hints”

• Minimize bureaucracy!• Have fun! Structure social events (like this one)• Have one brief—several page—document to reflect

the group’s current thinking; revise often• Bring in outsiders, in moderation• Establish an online presence early, keep it current• Everyone must “own” the Network and be

personally invested in making the collaboration succeed.

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