Techniques for Gaining Outpatient Compliance: Findings from the National Research

The Use of “Leverage” to Obtain Adherence to Outpatient Treatment: Findings from the

MacArthur Research

John Monahan, Ph.D.Shannon Professor of Law, Psychology, and Psychiatry

University of Virginia

Hospital ≠ Community

Mandated Institutional Tx

Mandated Community Tx

Housing Hospital

Disability benefits

Hospital

Ordermaintenance

Hospital

Treatment Hospital




Housing Hospital Housing agency

Disability benefits

Hospital

Ordermaintenance

Hospital

Treatment Hospital





Disability benefits

Hospital Welfare agency

Ordermaintenance

Hospital

Treatment Hospital





Disability benefits


Ordermaintenance

Hospital Criminal justice system

Treatment Hospital





Disability benefits


Ordermaintenance

Hospital Criminal justice system

Treatment Hospital Mental health system

Mandated Community Treatment

MONEY AS LEVERAGE

Ž Money managers (“representative payees”)

~ 1,000,000 people in the U.S. receive benefits for psychiatric disability through a “rep payee.”

“Recipient Responsibilities”

“You are receiving benefits based on the mental health problems that you have. The Social Security Administration requires that you be involved in mental health services so that you will feel better. [Otherwise,] you may lose your benefits.”


HOUSING AS LEVERAGE

Ž Subsidized housing

In 41 states, the mean rent for a 1-bedroom apartment exceeds 100% of federal disability benefits.

Standard Lease: Alliance for the Mentally Ill of Delaware

“Refusing to continue with mental health treatment means that I do not believe I need mental health services. I understand that since I am no longer a consumer of mental health services, it is expected that I will find alternative housing. I understand that if I do not, I may face eviction.”


JAIL AS LEVERAGE

Ž Treatment as a condition of probation

Persons Under the Jurisdiction of the Criminal Justice System in the U.S.

From J. Skeem. Sources: Bureau of Justice Statistics (2007); Skeem, Emke-Francis, et al. (2006)

Probation

Prison

Parole Jail

AZ S001 S002

CA S004 S006 S007 S022 S031 S032 S067 S083

CO S033

CT S094

FL S035

IL S081

IA S071 S008

MD S009 MO

S010 S037 S068

NJ S068

NM S057

NY S011

OH S012 S082 S059 S013 S014 S060 S025 S026

OR S040 S027

PA S069 S073 S028 S078 S041 S084 S042 S043 S017 S061 S044

TX S074 S046 S075 S018 S047 S048 S049 S050 S019 S029 S062 S051 S063 S052 S020 S030 S064

UT S02

1

WA S065

WI S070 S054

People with serious mental illness are overrepresented in criminal justice system

Depression Schizophrenia Bipolar Any0

5

10

15

20

25

Community menIncarcerated menCommunity womenIncarcerated women

From J. Skeem; Sources: Teplin, 1990; Teplin, Abram, & McClelland, 1996

%

United States Code, Title 18, §3563

“The court may provide, as further conditions of a sentence of probation…that the defendant … undergo available medical, psychiatric, or psychological treatment.”


JAIL AS LEVERAGE

Ž Treatment as a condition of probation

Ž Mental health courts

Mental Health Courts

• are criminal courts, with separate dockets dedicated to defendants with mental illness

• divert defendants from jail and/or prison to community treatment

• monitor community treatment and can impose sanctions for treatment nonadherence

• 1997 = 1 MH Court; late 2009 = 250 MH Courts.


HOSPITALIZATION AS LEVERAGE

Ž Outpatient commitment

Research Findings to Date

3 Questions

(1) How often is treatment mandated?

(2) What are the general effects of mandated treatment?

(3) What are the effects of specific forms of “leverage”?

Question 1:

How Often Is Treatment Mandated?

The Prevalence of Leverage Monahan et al, 56 Psychiatric Services 37

Five Sites• Durham, NC• Worcester, MA• Chicago, IL• Tampa, FL• San Francisco, CA

• Overall N: 1,011• Refusal Rate: 6.8%

Eligibility Criteria

• 18-65 years old

• English or Spanish-speaking• Currently in outpatient treatment with a

public MH service provider

• In treatment at least 6 months.

Prevalence of Mandated Community Treatment

Form of Leverage % with Leverage

Obtaining Housing 32




Avoiding Jail 23




Avoiding Jail 23

Avoiding Hospital 15




Avoiding Jail 23


Obtaining Money 12




Avoiding Jail 23


Obtaining Money 12

At Least 1 Form 51

Question 2:

What Are the General Effects of Mandated Community Treatment?

Perceived Coercion Scale

• Influence: I had more influence than anyone else on whether I went ..

• Control: I had a lot of control over whether I went ..• Choice: I chose to go.. • Freedom: I felt free to do what I wanted about

going..• Idea: It was my idea to go …

...to the mental health clinic.

Procedural Justice Scale

• Voice: How much of a chance did you have to say everything you wanted to about…?

• Validation: How seriously did people consider what you had to say about…?

• Satisfaction: How satisfied are you with the way people treated you when you were…?

• Fairness: How fair was the process of…?… coming into the clinic.

High Perceived Coercion by Procedural Justice: Mandated Community Treatment

0

10

20

30

40

50

60

70

Low ProceduralJustice

ModerateProcedural

Justice

High ProceduralJustice

Question 3:

What Are the Effects of Specific Forms of “Leverage”?

Findings on Money as Leverage Elbogen et al , 29 Law and Human Behavior 563

• Patients assigned a money manager are 4 times more likely than other patients to adhere to treatment

• Money managers who are family members are more likely than other money managers to report using money as leverage to obtain treatment adherence

• Having a family member act as a money manager doubles the likelihood of patient violence. The more a patient interacts with a family member who is a money manager, the more likely the violence.

Violence and Money Managers

0.1

0.2 0.21

0.32

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

Non-Family + Low Contact

Non-Family +High Contact

Family +Low Contact

Family +High Contact

Pro

bab

ilit

y o

f F

amil

y V

iole

nce

From Elbogen et al., 28 LHB 563

Characteristics of Family Representative PayeesElbogen et al, 58 Psychiatric Services 1433

Consumers (n=50)

Family Payees (n=50)

Improves tx adherence 36% 36%Reduces homelessness 52 44


Consumers (n=50)


Improves tx adherence 36% 36%Reduces homelessness 52 44Payee has withheld money 44 36


Consumers (n=50)


Improves tx adherence 36% 36%Reduces homelessness 52 44Payee has withheld money 44 36Withholding money led to family conflict/arguments

36 50


Consumers (n=50)


Improves tx adherence 36% 36%Reduces homelessness 52 44Payee has withheld money 44 36Withholding money led to family conflict/arguments

36 50

Can add the total amount owed on a credit card bill.

34 43

Findings on Jail as Leverage 1

Mental Health CourtsSteadman et al, in preparation

Intervention Logic Model

Identify and Enroll People in Target Group

Linkage Comprehensive/ Appropriate Community-Based Services

Improved Mental Health /Individual Outcomes

Improved Public Safety Outcomes

Stage 1 Stage 2 Stage 3

Findings on Mental Heath CourtsRedlich et al, 30 Law & Human Behavior 347

Christy et al, 23 Behavioral Sciences & the Law 227

• 95% of MD defendants choose a MH court

• Much less experience of coercion

• Much more satisfaction with court process • Judges more likely to use jail as a sanction for

nonadherence with felons.

Mental Health Courts v Treatment as Usual

Mental Health Courts

Low Enforcement (<5%)• San Francisco, CA• Indianapolis, IN

High Enforcement (>20%)• Santa Clara, CA• Minneapolis, MN

• Total N = 448

Treatment as Usual

• Defendants in jails at each site

• Identified as having a mental illness

• Matched for charge and diagnosis with the mental health court sample

• Total N = 599







Findings on Jail as Leverage 2

Treatment as a Condition of ProbationSkeem et al, in preparation

Treatment as a Condition of Probation:Traditional v Specialty Agencies

• Traditional agency: assign MI probationers to any officer as part of a large, general caseload (Los Angeles; n=180)

• Specialty agency: assign MI probationers to trained officers with a reduced, exclusively MI caseload (Dallas; n=180).







Is the Use of Leverage Always “Coercive”? Bonnie and Monahan , From Coercion to Contract, 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.

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.”

Potential Problems With Judge’s Offer:

• Selective arrest or sentencing can unfairly manipulate the legal baseline

• A lack of zealous advocacy can lead to mis-representation by counsel.

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

• Person does not meet criteria for inpatient commitment. Legal baseline: free to choose

• 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” to “accept services”)

• 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 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.

• Web: http://macarthur.virginia.edu

• Email: [email protected]

Health & Medicine

Techniques for Gaining Outpatient Compliance: Findings from the National Research