Building mental health professionals' decisional models into tests of predictive validity: the accuracy of contextualized predictions of violence.

To safely manage potentially violent patients in the community, mental health professionals (MHPs) must assess when and under what conditions a patient may be involved in a violent act. This study applies a more ecologically sensitive approach than past research by building the conditions that MHPs believe make patient violence more likely into tests of their predictive validity. In specific, the accuracy of MHPs' predictions that patients were more likely to become violent when they consumed alcohol was assessed based on a sample of 714 patients. The results indicate that MHPs do not discriminate well between patients who are likely to become violent during periods in which they drink from those who are not. MHPs' predictions appear more descriptive of the drinking behavior of a high-risk group than predictive of alcohol-related violent incidents. Thus, even when their apparent decisional processes are considered in tests of accuracy, MHPs' predictions of violence are only moderately more accurate than chance. This paper analyzes the implications of these findings for risk assessment practice and for conducting further clinically relevant research.

Sources of coercive behaviours in psychiatric admissions.

OBJECTIVE: Coercion during psychiatric admissions has been a topic of debate for many years. Although there has been considerable research on patients' perceptions of coercion, there has been no work on who places pressures on patients to be admitted. METHOD: This article integrates interview data from interviews with patients, admitting staff and family and friends to describe the pressures brought to bear on patients to be admitted. RESULTS: Health-care professionals appear to be the most important source of pressures on patients, and to have the most impact on patients' perceptions of coercion. However, there are differences in type of pressure, and the pressures used by family and friends appear to have the most longstanding impact. CONCLUSION: Legal and clinical efforts to reduce the level of coercive pressures on patients need to recognize the importance of mental-health professionals, including especially those who are not legally mandated to participate in the admission process.

Patients' revisions of their beliefs about the need for hospitalization.

OBJECTIVE: An influential rationale for involuntary hospitalization is that prospective patients who refuse hospitalization at the time it is offered are likely to change their belief about the necessity of hospitalization after receiving hospital treatment. The authors examine how patients changed their evaluations of psychiatric hospitalization following hospital treatment. METHOD: The authors studied 433 patients who were interviewed about their hospitalization within 2 days of their admission to a psychiatric hospital; 267 of these patients were reinterviewed 4-8 weeks following discharge. RESULTS: When reinterviewed at follow-up, 33 (52%) of 64 patients who said at admission that they did not need hospitalization said that, in retrospect, they believed they had needed it. Only 9 (5%) of 198 patients who said at admission that they needed hospitalization shifted to saying that they had not needed it. CONCLUSIONS: Many of the patients who initially judged that they did not need hospitalization revised their belief after hospital discharge and reported that they had needed hospital treatment. However, perceptions of coercion were stable from admission to follow-up, and patients' attitudes toward hospitalization did not become more positive. Coerced patients did not appear to be grateful for the experience of hospitalization, even if they later concluded that they had needed it.

Clinical prediction of violence as a conditional judgment.

Previous research on the prediction of violence in mentally ill individuals has focused primarily on determinations about the appropriateness of institutional confinement. The assessment and management of violent, mentally ill individuals in the community, however, requires clinicians to take a more detailed look at the factors that might precipitate or inhibit violence in the community. This paper examines a model of conditional prediction, in which clinicians provide assessments of the factors that they expect to be associated with violence in particular patients. These types of predictions were elicited from clinicians for a sample of 712 patients seen in an urban psychiatric emergency room. These patients were then followed in the community for 6 months, using both interviews and official records. Results showed that clinicians were generally accurate about the seriousness and location of the violence, but overestimated the role of medication compliance and drug use in the violent incidents.

Factual sources of psychiatric patients' perceptions of coercion in the hospital admission process.

OBJECTIVE: The purpose of this study was to determine what predicts patients' perceptions of coercion surrounding admission to a psychiatric hospital. METHOD: For 171 cases, the authors integrated data from interviews with patients, admitting clinicians, and other individuals involved in the patients' psychiatric admissions with data from the medical records. Using a structured set of procedures, coders determined whether or not nine coercion-related behaviors occurred around the time of admission. Correlation and regression analyses were used to describe the predictors of patients' scores on the MacArthur Perceived Coercion Scale. RESULTS: The use of legal force, being given orders, threats, and "a show of force" were all strongly correlated with perceived coercion. A least squares regression accounted for 43.3% of the variance in perceived coercion. The evidence also suggested that force is typically only used in conjunction with less coercive pressures. CONCLUSIONS: Force and negative symbolic pressures, such as threats and giving orders about admission decisions, induce perceptions of coercion in persons with mental illness. Positive symbolic pressures, such as persuasion, do not induce perceptions of coercion. Such positive pressures should be tried in order to encourage admission before force or negative pressures are used.

Coercion in psychiatric care: what have we learned from research?

The use of coercion to assure that people with a mental illness receive treatment has been the focus one of the longest running controversies among mental health professionals. Until quite recently, however, this debate has been almost entirely based on abstract principles. Empirical research concerning coercion was quite limited. Recently, however, research in this field has blossomed. The development of a validated measure of perceived coercion has spawned a variety of new studies. A five-nation study in Scandinavia has begun the difficult task of assessing the impact of different legal systems and systems of care on perceived coercion. Two new studies have used random assignment designs to study the impact of outpatient commitment. This article reviews these and other studies and describes what they do, and do not, tell us about coercion in mental health treatment.

The validity of mental patients' accounts of coercion-related behaviors in the hospital admission process.

Although the recent development of a measure for perceived coercion has led to great progress in research on coercion in psychiatric settings, there still exists no consensus on how to measure the existence of real coercive events or pressures. This article reports the development of a system for integrating chart review data and data from interviews with multiple participants in the decision for an individual to be admitted to a psychiatric hospital. The method generates a "most plausible factual account" (MPFA). We then compare this account with that of patients, admitting clinicians and other collateral informants in 171 cases. Patient accounts most closely approximate the MPFA on all but one of nine dimensions related to coercion. This may be due to wider knowledge of the events surrounding the admission.

Letting go: family willingness to forgo life support.

OBJECTIVE: To describe the process of family decision making about life support in the critical care setting. DESIGN: Descriptive, exploratory. SETTING: A northeastern United States university-affiliated medical intensive care unit. SAMPLE: Thirty family members of 16 critically ill patients. RESULTS: Letting go or becoming willing to forgo life support involved three interrelated and complex processes: (1) family members sought out, obtained, and tried to understand information about the critical illness; (2) they reviewed the life story of the patient, seeking meaning in the patient's life and the critical illness; and (3) they struggled to maintain family roles and relationships. For most families, interpersonal and intrapsychic work during each process created a reframing of the issues related to the critical illness: (1) they came to believe that they had done all that could be done and were able then to relinquish the goal of recovery for acceptance of a peaceful death; (2) they reviewed the patients's life, finding some meaning and a sense that, given the situation, the patient would not want to continue on life support, and then they moved toward closure; and (3) they were able to bring about (at least within a small group of the closest family members) a sense of doing the "right thing", and they were able to develop some sense that forgoing life support for the ill relative would not destroy important family relationships. For a few other families this movement toward resolution did not occur, and although family members attempted to deal with the issues of life support, their efforts were fraught with conflict and prolongation of the end-of-life period. CONCLUSIONS: Little is known about the actual experience of family members as they are involved in life-support decision making. Identification of the needs of family members to work through the decision-making experience cognitively, emotionally, and morally is essential to communicating effectively about the ill relative's condition and to providing understanding and support to families involved in life-support decision making in the critical care unit.

Clinical versus actuarial predictions of violence of patients with mental illnesses.

This study compared the accuracy of an actuarial procedure for the prediction of community violence by patients with mental illness with the accuracy of clinicians' ratings of concern about patients' violence. Data came from a study in which patients were followed in the community for 6 months after having been seen in a psychiatric emergency room. Accuracy of actuarial prediction was estimated retrospectively, with a statistical correction for capitalization on chance. Actuarial prediction had lower rates of false-positive and false-negative errors than clinical prediction. The seriousness of the violence correctly identified by the actuarial predictor (the true positives) was similar to the seriousness identified by clinicians. Actuarial predictions based only on patients' histories of violence were more accurate than clinical predictions, as were actuarial predictions that did not use information about histories.

Perceived coercion in mental hospital admission. Pressures and process.

BACKGROUND: Patients' perceptions of coercion in admission may affect their attitude toward subsequent treatment, including their inclination to adhere to treatment plans. This study looks at the determinants of patients' perceptions of coercion. METHODS: A sample of 157 patients admitted to a rural Virginia state hospital and a Pennsylvania community hospital were interviewed within 48 hours of admission about their experience of coming to the hospital. All subjects were 17 years or older. Diagnoses were diverse, and 42% were involuntarily committed. The interview gathered an open-ended description of the admission experience followed by a structured interview that included several measures. RESULTS: Perceptions of being respectfully included in a fair decision-making process ("procedural justice") and legal status were most closely associated with perceived coercion, and a significant relationship was found with perceived negative pressures, ie, force and threats. However, only procedural justice was related to the perception of coercion at both sites and with both voluntary and involuntary patients. CONCLUSIONS: Patients' feelings of being coerced concerning admission appears to be closely related to their sense of procedural justice. It may be that clinicians can minimize the experience of coercion even among those legally committed by attending more closely to procedural justice issues.

Characteristics of violence in the community by female patients seen in a psychiatric emergency service.

OBJECTIVE: This study examined differences in factors associated with violence toward others by female and male patients evaluated in a psychiatric emergency service. METHODS: A sample of 812 psychiatric patients recruited in the emergency service of an urban psychiatric hospital were followed in the community over a six-month period. Patients provided self-reports of violent incidents, and collateral informants also provided reports of the incidents. Official records were also reviewed. During the followup period, 369 patients (213 male and 156 female patients) engaged in violence, defined as laying hands on another person in a threatening manner or threatening another person with a weapon. RESULTS: Male and female patients did not differ significantly in frequency and seriousness of violence, but they did differ on who the co-combatant was and where the incident took place. CONCLUSIONS: Gender is not a strong predictor of involvement in violence by psychiatric patients. The observed gender differences in location in which violence took place and identity of the co-combatant may be related to differences in the social worlds of men and women, with men having more opportunity for public violence with strangers.

Short-term clinical prediction of assaultive behavior: artifacts of research methods.

OBJECTIVE: The apparent accuracy of predictions of assaultive behavior in psychiatric inpatients varies substantially, depending on the method used to study the prediction. The authors explored the effects of different measures and sampling strategies on short-term clinical predictions of dangerousness. METHOD: The index subjects were patients who were rated by intake clinicians as potentially highly assaultive on the ward (N = 32) and patients who were involuntarily committed on grounds of danger to others (N = 32). The respective comparison groups comprised patients predicted by clinicians not to be assaultive (N = 32) and patients committed for reasons other than danger to others (N = 40). The text of unit meetings and data from chart reviews were used to determine the occurrence and dates of violent acts, seclusions for violent acts or threats, and violent threats. RESULTS: There was a significant difference in the rate of inpatient violence between the subjects rated at admission as potentially assaultive (75.0%) and patients rated as not potentially assaultive (12.5%), but the difference in the rates of violence between the patients who were (56.0%) and were not (42.0%) involuntarily committed as dangerous to others was not significant. Most of the violent acts occurred relatively late in the hospitalization, but seclusions occurred almost exclusively in the initial stages of hospitalization. CONCLUSIONS: The reported accuracy of clinical predictions of assaultive behavior is markedly affected by the choice of sampling strategy, comparison group, outcome measures, and follow-up period. Including seclusion and violent threats in the outcome variable appears to lead to deceptive findings.