Showing papers by "John Monahan published in 2003"

Mental Disorder, Violence, and Gender

Abstract: Recent studies have reported comparable rates of violence among men and women with mental disorder, raising important issues for clinical risk assessment. This study examines the relationship between gender and violence using data from the MacArthur Violence Risk Assessment Study. Patients in acute psychiatric wards were interviewed 5 times over the year following their discharge to the community. Results showed some differences between men and women in the violence committed immediately following discharge, with rates for men being higher. But the prevalence of violence over the 1 year was similar for female and male discharged patients. However, there were substantial gender differences in the situational context of the violence committed. Men were more likely to have been drinking or using street drugs, and less likely to have been adhering to prescribed psychotropic medication, prior to committing violence. The violence committed by men was more likely to result in serious injury than the violence committed by women, and men were more likely than women to be arrested after committing a violent act. Women were more likely to target family members and to be violent in the home.

Perceived Coercion at Hospital Admission and Adherence to Mental Health Treatment After Discharge

Abstract: The authors investigated whether mental health inpatients' perceptions of coercion were associated with later treatment adherence. Psychiatric inpatients receiving acute care at three sites were interviewed during their hospitalization and up to five times after discharge. Patients' perceptions of coercion were measured at admission. Adherence to medication and clinical treatment was measured every ten weeks for one year after discharge. Among the 825 patients who had a perceived coercion score and ten-week follow-up data and who reported that outpatient treatment was prescribed, perceived coercion scores were not associated with treatment adherence. The authors concluded that perceived coercion neither increases nor decreases psychiatric inpatients' medication adherence or use of treatment services after discharge.

Judicial decision thresholds for violence risk management

Abstract: To affect violence risk management decisions, it is necessary to apply a decision threshold to the estimates that actuarial violence risk assessments generate. Despite widespread agreement that the choice of decision threshold is a matter of policy rather than of science, no one has actually asked policy makers about their choices. A survey was conducted asking 26 judges where they would set the decision threshold for instituting short-term civil commitment as a “danger to others.” The five risk assessment options communicated to the judges were the Risk Classes obtained in the MacArthur Study. Results showed great variability among judges. As a group, however, judges chose Risk Class 3 – a 0.26 likelihood of committing a violent act – as their decision threshold for short-term civil commitment.

Mandated Treatment In The Community For People With Mental Disorders Treating people without their consent has always been the defining human rights issue in mental health law.

Abstract: PROLOGUE: The process of deinstitutionalizing people with mental illness in the United States—now a half-century in the making—has manifested itself in a dramatic decline in the populations of state and county mental hospitals: from more than half a million in 1950 to about 50,000 today. At the same time, the ranks of jails and prisons are swelling with a rising number of inmates with serious mental illness, to the point where a person with a serious mental illness is about five times more likely to find himself incarcerated rather than admitted. The juxtaposition of declining treatment and increasing incarceration rates among people with mental illness has led to considerable criticism of the deinstitutionalization movement for failing to follow through on promised community-based treatment. But the tide could be turning. Backed up by research that confirms that treatment can reduce violence in people with major psychiatric disorders and fueled by several high-profile cases of violent crimes committed by people with severe mental illness, mandated community-based treatment has now taken center stage in this drama. But the issue remains controversial, as it pits public safety concerns against the rights of individuals. The following paper explores the context within which coerced community treatment has arisen and seeks to break the impasse between advocates and opponents by placing mandated treatment within the larger conceptual framework of health care quality. The authors are all part of the Research Network on Mandated Community Treatment, a MacArthur Foundation–funded project designed to evaluate programs in which mentally ill patients are instructed by the courts to get community-based treatment. John Monahan, the network’s director and a clinical psychologist, holds the Doherty Chair in Law at the University of Virginia, where he is also a professor of psychology and psychiatric medicine. Marvin Swartz is a professor and head of the Division of Social and Community Psychiatry and codirector of the Services Effectiveness Research Program in the Department of Psychiatry and Behavioral Sciences at Duke University. Richard Bonnie is the John S. Battle Professor of Law; a professor of psychiatric medicine; and director of the Institute of Law, Psychiatry, and Public Policy at the University of Virginia.

Mandated treatment in the community for people with mental disorders.

Abstract: Commitment to community-based mental health treatment bears limited resemblance to commitment to treatment in a closed institution. It can be better understood in the context of a broad movement to apply leverage to induce treatment engagement, a movement that includes use of the social welfare and justice systems and psychiatric advance directives. Understanding "mandated community treatment" in all of its forms can be advanced by viewing it within the framework of health care quality as recently outlined by the Institute of Medicine, particularly along the dimension of patient-centeredness.

Endorsement of personal benefit of outpatient commitment among persons with severe mental illness.

Abstract: This study examines whether individuals who experienced involuntary outpatient commitment (OPC) attribute benefit to this intervention. It was found that the majority of experimental subjects who underwent a period of OPC did not personally endorse OPC's benefits at the end of the study, either because they did not think it improved treatment adherence or because they rejected their own need for continued treatment. However, at the end of the study, a positive appraisal of benefit was roughly twice as likely among subjects who actually experienced positive treatment outcomes. These data provide little support for acceptance and "gratitude" as a rationale to support decision making about OPC continuation. Rather, clinicians need to rely on other clinical and empirical data for such decision making.

Violence Risk Assessment in American Law

Abstract: Violence risk assessment is a critical and expanding part of the practice of clinical psychology and of psychiatry in the United States at the beginning of the 21st century. Dangerousness to others became one of the pivotal criteria for involuntary hospitalization of people with mental disorders in the 1960s. Tort liability was first imposed on clinicians who negligently failed to predict their patients’ violence in the 1970s. Statutes authorizing involuntary treatment in the community for otherwise “dangerous” patients were enacted in many states in the 1980s. Risk assessments of violence were explicitly mandated during the 1990s in the Americans with Disabilities Act, which protects the employment rights of people with disabilities, unless those disabilities result in an employee becoming a “direct threat” of violence to co-workers or customers.

Mandated Community Treatment: The Potential Role of Violence Risk Assessment

Abstract: This chapter summarises a new conceptual framework for understanding outpatient commitment and other forms of "mandated community treatment". People with a disability, such as a serious mental disorder, may qualify under federal or state laws in the United States to receive certain social welfare benefits. Each of the forms of leverage is described: money, housing, avoidance of jail, and avoidance of hospitalisation. The chapter argues that what policy makers and practitioners need in order to make informed decisions about mandated community treatment is an evidence base that includes answers to central, cross-cutting empirical questions, and a thorough airing of legal, moral, and political questions as well. The use of actuarial approaches to improve the prediction of violence, the MacArthur Risk Assessment Study assessed a large sample of male and female acute civil patients at several facilities on a wide variety of variables believed to be related to the occurrence of violence.