Charles W. Lidz Ph.D.Research Professor of Psychiatry

UMass Medical School

Most Plausible Factual Account and the Problem of Objective Coercion

The Importance of Perception This is the patients’ experience

We want them to have as positive an experience as possible.

Compliance with treatment may be related to how they experience their treatment.

Trauma may come in many forms including psychiatric treatment

The importance of procedural justice

The Limits of Perceived Coercion We can only affect actual behavior. No laws or regulations are made about

perceived behavior We want to know what is “really”

happening to people with MI We want to know what behaviors affect

patients’ perceived coercion

What “Really” Happened

This is much less easy than it sounds What is to be the criterion about

what is real? Does that sound silly?Consider

some concepts“Excessive force”Demeaning“necessary”

These are inherently ambiguous.

Coercion is a Meaningful Event Putting someone in chains may not be

experienced as coercive. Giving someone a medication maybe

perceived as coercive. Is it really? Thus there are limitations to the

meaning of behavioral data.

Sources of Behavioral Data - Direct observation

We can usually only see public behavior Even then we don’t know what

happened before. Directly observable coercion is rare and

thus inevitably unsystematic and/or very expensive to accomplish.

Efforts will be made to hide it.

Using Official Records

This takes one account as the best Officials have interests and ideologies Officials have their own truth theories

Which motives to believe Which sources of information to believe

Officials have only a partial view as well Reports are in a format - experience is not

Objective indicators

Number of involuntary commitments Voluntary may be pressured “Involuntary” may be agreed to.

Number of police calls Police as a taxi service

MPFA as Method

Why not use all sources of data? Triangulation as a method of identifying

a “best guess” How to choose among conflicting

evidence. If it is to be science, we need rules for

assessing the diverse sources of data

An Example

Psychiatric Admission

Possible Sources of Data

Admission Staff accounts Medical Records Police or Police reports Family or other accompanying

individuals The admitted individual

Possible Types of Pressures

Legal Force Physical Force Show of Force (call hospital security

police) Threats Giving an Order Persuasion Inducement Deception Whether patient asked what s/he wanted

Sources of Pressure - Admission 1. Admitting clinical staff 2 parents 3. spouses and other lovers. 4. children. 5. other family 6. friend 7. acquaintance - Includes landlords,

employer, etc. 8. other healthcare professionals

The Reconciliation Problem

Okay, so what do you do with all that data?

If it is to be science (i.e., repeatable) we need rules for reconciliation.

These are certainly debatable. Others with different biases might make

different rules.

MPFA Reconciliation Rules 1

believe an eyewitness account before a second-hand report.

Accept the fuller account of an incident rather than the sparser one.

MPFA Reconciliation Rules 2

Always believe an individual's own account of his or her motives rather than someone else's account. (question that account only based on objective evidence not another’s account)

If the previous rules do not yield a choice of account, believe multiple sources before a single source.

What Counts as a Pressure

Any pressure must follow the last hospitalization (previous pressures don’t count in assessing current hospitalization)

Committed by someone involved as directly related to the current hospitalization

MPFA and Coercion

Coercion is a meaningful event. Whether actions occur is independent of

depends on motives and people’s interpretation of them

Whether it is coercive, however, depends on how the participants interpret those acts.