Elsevier

International Journal of Law and Psychiatry

Volume 25, Issue 6, November–December 2002, Pages 537-555
International Journal of Law and Psychiatry

The impact of mental health advance directives on patient perceptions of coercion in civil commitment and treatment decisions

https://doi.org/10.1016/S0160-2527(02)00182-6Get rights and content

Introduction

In recent years, researchers and policymakers have become increasingly interested in studying the process of how individuals with mental illness are civilly committed and treated. Many believe that this process can be significantly improved in ways that will result in therapeutic gains for these individuals.

A number of scholars have argued that providing greater procedural justice to patients and an opportunity to meaningfully express their preferences will increase patient well-being. Some researchers believe that minimizing the use of coercion during the initial commitment and subsequently during treatment will enhance treatment outcomes. Virtually everyone involved in the commitment process would prefer that patients voluntarily agree to hospital treatment whenever possible and that, if they do not, no more coercion should be used than is necessary to accomplish the purposes of involuntary hospitalization. Mental Health Advance Directives (MHADs), which allow patients with mental disorders to express their hospitalization and treatment preferences for when they may become incompetent, have significant potential to advance all of these objectives.

This article will describe the general types of MHADs and the legal relevance of these instruments in the hospitalization and treatment context. It will then consider the therapeutic potential of procedural justice and of individual choice. Next, the article will discuss various theories of coercion in the context of civil commitment. Finally, it explores how MHADs can be used to increase patient involvement in, and acceptance of hospitalization and treatment decisions, thereby enhancing prospects for appropriate and effective treatment. It will also explore how MHADs may increase patient perceptions of coercion, thereby diminishing patient acceptance of, and investment in, treatment.

This discussion will center on the law in the United States. However, this analysis may have important implications for law and policy in any country that uses involuntary civil commitment to treat persons with mental illness.

Section snippets

Mental health advance directives

A MHAD is a document that enables a person to establish his or her treatment preferences should the individual, in the future, become incompetent to make those decisions or unable to communicate those preferences to treatment providers.2 MHADs assume that a competent patient can accurately anticipate how they would make important treatment decisions at a future time, even

The legal relevance of MHADS on hospitalization and treatment decisions

It is useful at this point to briefly consider the legal relevance of MHADs to the decision to commit and the decision to accept or refuse treatment after commitment. It should be noted that MHADs do not—by themselves—create additional rights for patients subject to civil commitment. Nor do they alter the respective legal authority to make hospitalization or treatment decisions presently allocated by state civil commitment statutes and case law to patients, to the state and its agents, or to

The therapeutic potential of procedural justice

Since the late 1960s, most states in the United States have adopted a legal model of involuntary civil commitment.35 This model assumes that patients have a liberty right protected by the US Constitution to live freely in the community unless the state can demonstrate an

The therapeutic potential of individual choice

Bruce Winick builds on Tyler's research and its implications.46 In addition, he relies on theoretical work in the psychology of choice, which suggests “people perform more effectively and with greater motivation when they the choose to do something, and perform less well, with poor motivation and sometimes with psychological reactance, when they are coerced into doing

Theories and definitions of coercion

In the last decade or so, researchers have examined the use of coercion in civil commitment.52

Implications for coercion in civil commitment

An important research issue awaits resolution. Does elimination or reduction of coercion in the civil commitment process enhance positive treatment outcomes for patients who are subjected to civil commitment? Listening to patients and persuading rather than coercing them to accept hospitalization and treatment should enhance their sense of being afforded appropriate procedural due process. And, as Winick persuasively argues,63

Perceptions of coercion and the potential therapeutic impact of mhads65

MHADs may minimize patient perceptions of coercion, thereby enhancing treatment outcomes for patients with mental illness committed to hospitals.66 Conversely, there are some situations in

Summary

MHADS have tremendous potential to reduce patient perceptions of coercion in the commitment process. Minimizing patient perceptions of coercion may increase their perception that they have been afforded procedural due process and that their choices have been honored whenever possible. In turn, the patient may participate more assiduously with his treatment and invest him/herself in its success.

Unfortunately, MHADs can also increase patient perceptions of coercion when staff do not abide by the

Acknowledgements

An earlier version of this article was presented at the XXVIth International Congress of Law and Mental Health in Montreal, Canada, July 3, 2001. The authors would like to acknowledge the talented research assistance of Matt O'Laughlin, a student at the University of Missouri-Kansas City School of Law.

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