John Monahan, PhD, a psychologist, holds the Shannon Distinguished Professorship in Law at the University of Virginia, where he is also a Professor of Psychology and of Psychiatry and Neurobehavioral Sciences. He was the founding President of the American Psychological Association's Division of Psychology and Law. Dr. Monahan is the author or editor of 15 books and has written over 200 articles and chapters. His casebook with Laurens Walker, Social Science in Law, is in its 7th edition. He has twice won the Manfred Guttmacher Award of the American Psychiatric Association, and has been elected to membership in the Institute of Medicine of the National Academy of Sciences. He directs the MacArthur Foundation’s Research Network on Mandated Community Treatment.

1. 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

2. Hospital ≠ Community

3. Hospital ≠ Community

4. Hospital ≠ Community

5. Hospital ≠ Community

6. Hospital ≠ Community

7. Mandated Community Treatment MONEY AS LEVERAGE ŽMoney managers (“representative payees”) ~ 1,000,000 people in the U.S. receive benefits for psychiatric disability through a “rep payee.”

8. “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.”

9. Mandated Community Treatment HOUSING AS LEVERAGE ŽSubsidized housing In 41 states, the mean rent for a 1-bedroom apartment exceeds 100% of federal disability benefits.

10. 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.”

11. Mandated Community Treatment JAIL AS LEVERAGE ŽTreatment as a condition of probation

12. Persons Under the Jurisdiction of the Criminal Justice System in the U.S. Probation Prison Parole Jail From J. Skeem. Sources: Bureau of Justice Statistics (2007); Skeem, Emke-Francis, et al. (2006)

13. People with serious mental illness are overrepresented in criminal justice system % From J. Skeem; Sources: Teplin, 1990; Teplin, Abram, & McClelland, 1996

14. 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.”

15. Mandated Community Treatment JAIL AS LEVERAGE ŽTreatment as a condition of probation ŽMental health courts

16. 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.

17. Mandated Community Treatment HOSPITALIZATION AS LEVERAGE ŽOutpatient commitment

18. Research Findings to Date 3 Questions How often is treatment mandated? (2) What are the general effects of mandated treatment? (3) What are the effects of specific forms of “leverage”?

19. Question 1: How Often Is Treatment Mandated?

20. 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%

21. 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.

22. Prevalence of Mandated Community Treatment

23. Prevalence of Mandated Community Treatment

24. Prevalence of Mandated Community Treatment

25. Prevalence of Mandated Community Treatment

26. Prevalence of Mandated Community Treatment

27. Question 2: What Are the General Effects of Mandated Community Treatment?

28. 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.

29. 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.

30. High Perceived Coercion by Procedural Justice: Mandated Community Treatment

31. Question 3: What Are the Effects of Specific Forms of “Leverage”?

32. 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.

33. 0.35 0.32 0.3 0.25 0.21 0.2 0.2 Probability of Family Violence 0.15 0.1 0.1 0.05 0 Non-Family + Non-Family + Family + Family + Low Contact High Contact Low Contact High Contact Violence and Money Managers From Elbogen et al., 28 LHB 563

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

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

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

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

38. Findings on Jail as Leverage 1 Mental Health Courts Steadman et al, in preparation

39. Intervention Logic Model Stage 1 Stage 2 Stage 3 Improved Mental Health /Individual Outcomes Identify and Enroll People in Target Group Linkage Comprehensive/ Appropriate Community-Based Services Improved Public Safety Outcomes

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

41. 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

42. Intervention Logic Model Stage 1 Stage 2 Stage 3 Improved Mental Health /Individual Outcomes Identify and Enroll People in Target Group Linkage Comprehensive/ Appropriate Community-Based Services Improved Public Safety Outcomes

43. Findings on Jail as Leverage 2 Treatment as a Condition of Probation Skeem et al, in preparation

44. 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).

45. Intervention Logic Model Stage 1 Stage 2 Stage 3 Improved Mental Health /Individual Outcomes Identify and Enroll People in Target Group Linkage Comprehensive/ Appropriate Community-Based Services Improved Public Safety Outcomes

46. 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.

47. 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.”

48. 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?

49. 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.”

50. 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.

51. 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.

52. 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.

53. Web: http://macarthur.virginia.edu Email: jmonahan@virginia.edu