Procedural justice in the context of civil commitment: an analogue study

Gender Differences in Civil Commitment Hearing Experience for Persons Who Use Opioids

OBJECTIVES

Civil commitment has increasingly served as a court-based legal intervention for severe opioid use, but little research has examined the civil commitment (CC) hearing process from the perspective of the person who is committed. Despite documented gender differences in opioid use and experiences within the legal system, past research has also not investigated gender differences in perceptions of the CC process for persons who use opioids.

METHODS

Participants were 121 persons (43% female) with opioid use who were interviewed upon arrival at the CC facility about their experience of the CC hearing process in Massachusetts.

RESULTS

Two thirds of participants were taken to the commitment hearing by police, and 59.5% shared a cell with others while waiting. Overall, the commitment intake process at the courthouse took over 5 hours. Participants spent, on average, less than 15 minutes with their lawyer before the hearing, and a majority of CC hearings lasted less than 15 minutes. Once transferred to a CC facility, opioid withdrawal management began within 4 hours. Compared with women, men reported longer wait times between the hearing and transfer, as well as longer wait times for withdrawal management at the facility ( P < 0.05). Women perceived worse interactions with the judge and greater dissatisfaction with the commitment process compared with men ( P < 0.05).

CONCLUSIONS

There were few gender differences in the experience of CC. However, overall, participants reported a lengthy court process and low levels of perceived procedural justice.

Exploring Patients' Feeling of Being Coerced During Psychiatric Hospital Admission: A Qualitative Study

Various coercive measures can be used to legally compel a person suffering from psychiatric disorder to undergo treatment. However, evidence suggests that patients' feeling of being coerced is not determined solely by their being submitted to formal coercion. This study aimed to explore voluntary and involuntary patients' experience of coercion during psychiatric hospitalisation and to identify which factors, from their perspective, most affected it. We chose a qualitative design inspired by a hermeneutic-phenomenological approach. Participants were purposively selected from six psychiatric hospitals in Switzerland. Maximum variation sampling was used to ensure the inclusion of patients with different levels of perceived coercion and different admission statuses. In-depth, semi-structured interviews were co-conducted by a research psychologist and a service-user researcher. The transcribed data underwent thematic analysis. All twelve interviewed patients described the hospitalisation as an experience of loss of control over their life due to either external or internal pressures. During the process, perceptions of these pressures varied and sometimes overlapped, leading some patients to describe their admission as a form of simultaneous protection and violation. The balance between these two contradictory feelings was affected by a variety of contextual and relational factors, as well as by the meaningfulness of the experience and the patient's subsequent satisfaction with it. Increasing policy-makers' and clinicians' awareness about the main factors influencing patients' experience of loss of control is of paramount importance in order to develop skills and strategies able to address them, reinforcing patients' empowerment, reducing their feeling of coercion and improving their well-being.

Feeling coerced during voluntary and involuntary psychiatric hospitalisation: A review and meta-aggregation of qualitative studies

Objective

This review aimed to provide an aggregative synthesis of the qualitative evidence on patients' experienced coercion during voluntary and involuntary psychiatric hospitalisation.

Design

A qualitative review.

Data sources

The search was conducted, in five bibliographic databases: Embase.com, Ovid MEDLINE(R) ALL, APA PsycINFO Ovid, Web of Science Core Collection and the Cochrane Database of Systematic Reviews.

Review methods

Following the Joanna Briggs Institute approach, a systematized procedure was applied throughout the review process, from data search to synthesis of results. The reporting of this review was guided by the standards of the PRISMA 2020 statement. The quality of the included studies was critically appraised by two independent reviewers using the JBI Critical Appraisal Checklist. Included findings were synthesized using meta-aggregation. Confidence in the review findings was assessed following the Confidence in the Output of Qualitative research synthesis (ConQual) approach.

Results

A total of 423 studies were identified through the literature search and 26 were included in the meta-aggregation. Totally, 151 findings were extracted and aggregated into 27 categories and 7 synthesized findings. The synthesized findings focused on: the patients' experience of the hospitalisation and the associated feeling of coercion; the factors affecting this feeling, such as the involvement in the decision-making process, the relationships with the staff and the perception of the hospital treatment as effective and safe; the coping strategies adopted to deal with it and the patients' suggestions for alternatives. All synthesized findings reached an overall confidence score of "moderate". The seven findings were downgraded one level due to dependability limitations of the included studies.

Conclusion

Based on these findings, seven recommendations for clinical practice where developed, such as fostering care ethics, promoting patients' voice and shared decision-making, and enhancing patients' perceived closeness, respect and fairness. Five recommendations for future research were also prompted, for instance improving the methodological quality and cultural variation of future qualitative studies, and exploring the psychosocial impact of experienced coercion on patients. For these recommendations to be effectively implemented, a profound change in the structure and culture of the mental health system should be promoted. The involvement of patients in the design, development and scientific evaluation of this change is strongly recommended.

What's Fair in Child Welfare? Parent Knowledge, Attitudes, and Experiences

Parents play a critical role in the progression and outcomes of juvenile dependency (child welfare court) cases. Yet, very little is known about these parents' knowledge, attitudes, and experiences. We examined legal understanding and attitudes among 201 parents involved in ongoing dependency cases in California and Florida via semi-structured, in-person interviews. We expected parents' understanding to be low and attitudes to be negative, particularly among parents of color and low SES parents. We expected greater dependency understanding to be related to more positive justice attitudes, and procedural and distributive justice attitudes to be indistinguishable in this population. Findings partially confirmed expectations. Parents' understanding of the system was low, especially among parents of color and less educated parents. Parents felt less than satisfied about the fairness of procedures and decisions. However, procedural and distributive justice attitudes were distinguishable. Finally, and unexpectedly, parents' knowledge and attitudes were negatively related. The consistently low levels of knowledge across CA and FL suggest the critical need to increase parental knowledge. It is also important to promote fair court procedures and decision-making to improve parents' attitudes about procedural and distributive justice, which were found to be distinct and important factors among parents navigating juvenile dependency cases.

The Role of Kinship and Siblings in Young Children's Placement Preferences

Although considerable attention has been directed toward the most appropriate placement for children following removal from home due to maltreatment, very little of this attention has focused on children's stated preferences, particularly when children are young. Specifically, children below 12 years of age are often presumed incompetent to form reasoned judgments about their best interests in placement. This assumption, however, has rarely been tested directly. We surveyed 100 4- to 11-year-olds removed from home because of maltreatment about their placement preferences. Children were less likely to indicate they wanted to return home if they were placed with siblings or with kin, consistent with statutory placement preferences. These results suggest that young children may express more mature preferences than recognized by the law, and that there may be value in asking even relatively young children about with whom they would like to live following their removal from home as a result of maltreatment.

Engaging Caregivers and Providers of Children With Sickle Cell Anemia in Shared Decision Making for Hydroxyurea: Protocol for a Multicenter Randomized Controlled Trial

BACKGROUND

Sickle cell anemia (SCA) is a genetic blood disorder that puts children at a risk of serious medical complications, early morbidity and mortality, and high health care utilization. Until recently, hydroxyurea was the only disease-modifying treatment for this life-threatening disease and has remained the only option for children younger than 5 years. Evidence-based guidelines recommend using a shared decision-making (SDM) approach for offering hydroxyurea to children with SCA (HbSS or HbS/β0 thalassemia) aged as early as 9 months. However, the uptake remains suboptimal, likely because caregivers lack information about hydroxyurea and have concerns about its safety and potential long-term side effects. Moreover, clinicians do not routinely receive training or tools, especially those that provide medical evidence and consider caregivers' preferences and values, to facilitate a shared discussion with caregivers.

OBJECTIVE

The aim of this study is to understand how best to help parents of young children with sickle cell disease and their clinicians have a shared discussion about hydroxyurea (one that considers medical evidence and parent values and preferences).

METHODS

We designed our study to compare the effectiveness of two methods for disseminating hydroxyurea guidelines to facilitate SDM: a clinician pocket guide (ie, usual care) and a clinician hydroxyurea SDM toolkit (H-SDM toolkit). Our primary outcomes are caregiver reports of decisional uncertainty and knowledge of hydroxyurea. The study also assesses the number of children (aged 0-5 years) who were offered and prescribed hydroxyurea and the resultant health outcomes.

RESULTS

The Ethics Committee of the Cincinnati Children's Hospital Medical Center approved this study in November 2017. As of February 2021, we have enrolled 120 caregiver participants.

CONCLUSIONS

The long-term objective of this study is to improve the quality of care for children with SCA. Using multicomponent dissemination methods developed in partnership with key stakeholders and designed to address barriers to high-quality care, caregivers of patients with SCA can make informed and shared decisions about their health.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03442114; https://clinicaltrials.gov/ct2/show/NCT03442114.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/27650.

Comparing views on civil commitment for drug misuse and for mental illness among persons with opioid use disorder

Despite the growing use of civil commitment for drug use disorders, little is known about attitudes among individuals who might be subject to civil commitment. This study examined attitudes of persons with opioid use disorder toward civil commitment for drug misuse and for psychiatric illness. Consecutive persons entering a brief, inpatient opioid detoxification (n = 254) were surveyed regarding their attitudes about civil commitment for mental illness and for drug use, and responses were compared by commitment type and by individual history of being civilly committed for opioid misuse. Participants endorsed high support for civil commitment (both psychiatric and drug misuse-related) when used to address risk of harm to self, to others, and of criminal activity. Respondents were more likely to support civil commitment for psychiatric disorders than for drug misuse, expressing higher support for civil commitment in general, higher agreement with the criteria used to justify civil commitment, and greater perceived efficacy of commitment. Individuals previously committed for opioid misuse were less likely to support drug misuse-related commitment on the basis of its perceived efficacy. These results suggest individuals with opioid use disorder hold more favorable views toward civil commitment for mental health disorders than for drug misuse, and reinforce the need for more research on the procedures and outcomes related to civil commitment for drug misuse.

Physical coercion, perceived pressures and procedural justice in the involuntary admission and future engagement with mental health services

Objectives

We sought to determine the level of procedural justice experienced by individuals at the time of involuntary admission and whether this influenced future engagement with the mental health services.

Methods

Over a 15-month period, individuals admitted involuntarily were interviewed prior to discharge and at one-year follow-up.

Results

Eighty-one people participated in the study and 81% were interviewed at one-year follow-up. At the time of involuntary admission, over half of individuals experienced at least one form of physical coercion and it was found that the level of procedural justice experienced was unrelated to the use of physical coercive measures. A total of 20% of participants intended not to voluntarily engage with the mental health services upon discharge and they were more likely to have experienced lower levels of procedural justice at the time of admission. At one year following discharge, 65% of participants were adherent with outpatient appointments and 18% had been readmitted involuntarily. Insight was associated with future engagement with the mental health services; however, the level of procedural justice experienced at admission did not influence engagement.

Conclusions

This study demonstrates that the use of physical coercive measures is a separate entity from procedural justice and perceived pressures.

Perceptions of key stakeholders on procedural justice in the Consent And Capacity Board of Ontario's hearings

The Consent and Capacity Board (CCB) of Ontario is an independent administrative tribunal that adjudicates on matters of consent to medical treatment including involuntary admission to a psychiatric facility and findings of incapacity with regard to treatment decisions. This study explores the perspectives of multiple stakeholders on procedural justice in CCB hearings in Ontario. Using purposeful and snowball sampling, participants including CCB panel members and staff, patients, and other professionals (e.g., lawyers, psychiatrists) were recruited from different sites across the city of Toronto. Using focus groups (n = 10) and individual interviews (n = 14), data were collected from 44 participants including 6 patients and 38 other stakeholders who have participated in CCB hearings. Using thematic analysis, we identified five themes - (i) Inclusiveness (ii) Respect (iii) Fairness (iv) Finding and using one's voice, and (v) Balancing interests. Findings revealed that despite efforts by CCB panel members to conduct hearings in an inclusive manner, the legalistic nature of the proceedings, as well as patients' uncertainty regarding the benefits of testifying, may be perceived as barriers to patients' meaningful participation. There was a general belief that patients are respected during CCB hearings by physicians and panel members; however, patients and their lawyers had mixed perceptions about this issue. Almost all stakeholders, excluding CCB panel members, perceived that CCB hearings were not procedurally fair. Our findings indicate that CCB hearings, as currently conducted, are not perceived as procedurally just by many of the relevant stakeholders. This perception may improve by adopting a more informal and less adversarial hearing format as well as enhancing patients' education and understanding of the CCB hearings' processes and potential outcomes.

Civil commitment experiences among opioid users

INTRODUCTION

Civil commitment is an increasingly used policy intervention to combat the opioid epidemic. Yet little is known about persons who get committed and outcomes following commitment for opioid use. In the current cross-sectional study, we compared the characteristics of persons with and without a history of civil commitment, and the correlates of post-commitment abstinence.

METHODS

Between October 2017 and May 2018, we surveyed consecutive persons entering a brief, inpatient opioid detoxification (n = 292) regarding their lifetime experiences with civil commitment for opioid use.

RESULTS

Participants averaged 34.6 years of age, 27.1% were female, and 78.1% were White. Seventy-eight (26.7%) experienced civil commitment for opioid use at least once in their lifetime. Committed individuals had significantly higher rates of fentanyl, heroin, and injection drug use, drug overdoses, past incarceration, current criminal justice involvement, and past medication treatment for opioid use (p < .05). The average time to relapse following commitment was 72 days, although 33.8% relapsed on the same day of their release. Longer post-commitment abstinence was significantly associated with post-commitment medication treatment, higher perceived procedural justice (i.e., fairness) during the commitment hearing, positive attitude and higher motivation at the end of commitment, and improvement in attitude during commitment (p < .05).

CONCLUSION

Opioid users who experience civil commitment constitute an especially high risk group. A positive commitment experience and post-commitment medication treatment are associated with longer post-commitment abstinence.

Service users' perspective of their admission: a report of study findings

OBJECTIVES

The 'Service Users' Perspective of their Admission' study examined voluntarily and involuntarily admitted services users' perception of coercion during the admission process and whether this was associated with factors such as the therapeutic alliance, satisfaction with services, functioning and quality of life. This report aims to collate the findings of the study.

METHODS

The study was undertaken across three community mental health services in Ireland. Participants were interviewed before discharge and at 1 year using the MacArthur Admission Experience. Caregivers of participants were interviewed about their perception of coercion during the admission.

RESULTS

A total of 161 service users were interviewed and of those admitted involuntarily, 42% experienced at least one form of physical coercion. Service users admitted involuntarily reported higher levels of perceived coercion and less procedural justice than those admitted voluntarily. A total of 22% of voluntarily admitted service users reported levels of perceived coercion comparable with involuntarily admitted service users and this was associated with treatment in a secure ward or being brought to hospital initially under mental health legislation. In comparison with the service user, caregivers tended to underestimate the level of perceived coercion. The level of procedural justice was moderately associated with the therapeutic relationship and satisfaction with services. After 1 year, 70% experienced an improvement in functioning and this was not associated with the accumulated level of coercive events, when controlled for confounders.

CONCLUSIONS

This study has provided valuable insights into the perceptions of coercion and can help inform future interventional studies aimed at reducing coercion in mental health services.

Exploring experiences with compulsory psychiatric community treatment: A qualitative multi-perspective pilot study in an urban Canadian context

As medical, ethical and clinical effectiveness debates about the use of compulsory psychiatric treatment continues, it is important to further explore the actual experiences and perspectives of all relevant stakeholders in community treatment orders (CTOs). This qualitative pilot study engaged a total of twenty-seven clients, their family members, and care providers in Toronto, Canada. Semi-structured, one-on-one interviews were conducted between February and July 2013 and analyzed using thematic analysis. Top key themes from all the participants identified include, among others: 1) clients' experiences of coercion while treated under CTO, but a preference for CTOs compared to involuntary hospitalization, nevertheless; 2) limited real opportunities for collaboration in treatment decisions expressed by clients and family members; 3) acceptance of the potential for clinical recovery on CTOs while debating the role of CTO in a broader recovery journey by all stakeholders; 4) general preservation of therapeutic relationships between clients and care providers, while acknowledging the tension of taking on an "enforcer" role by providers; and 5) existence of different avenues for asserting agency by clients. The findings of this research illuminate the nuanced, complex, and adaptive perspectives held by different stakeholders, point to the importance of preserving and enhancing procedural justice in their use, and alert the field to incorporate recovery-based approaches in this controversial practice that is a widely and commonly used clinical tool across many jurisdictions.

Examining changes in procedural justice and their influence on problem-solving court outcomes

The number of problem-solving courts has grown substantially since the mid-1990s. Research consistently indicates that participation in these courts lowers recidivism, which is often attributed to defendants' increased perceptions of procedural justice in these programs. Yet, prior studies are limited in their focus, often examining interactions with the judge in a single court or examining defendant perceptions and outcomes at a single time point. In the present study, we investigate defendant perceptions of procedural justice with judges and case managers across multiple problem-solving courts over time. Findings indicate that procedural justice varies across court actors and over time. Procedural justice is lower among judges than among case managers; however, changes in perceptions of procedural justice with the judge are associated with improved court outcomes. We suggest that defendant perceptions are variable and complex but important in explaining variations in outcomes.

Gender and mental health: An examination of procedural justice in a specialized court context

The procedural justice framework has been applied in the criminal justice contexts of policing, corrections, and courts. According to this perspective, fair treatment, respectful dialogue and being given a proper voice will contribute to citizens' positive views of authority figures. While this literature has grown immensely, several questions remain unanswered. Do males and females perceive similar levels of procedural justice? Does mental health status influence perceptions of fair treatment? Whether procedural justice is a general perspective that can be applied across social groupings has important implications for correctional treatment in that programs that truly "work" for all are more cost-effective. Toward that end, the current study investigates the relationships among procedural justice perceptions, gender, and mental health status in specialized drug courts, a context that has received little empirical attention. We do so using secondary data originally collected between 2003 and 2009 for Rossman, Roman, Zweig, Rempel and Lindquist's Multisite Adult Drug Court Evaluation (MADCE). Results from a full-sample analysis reveal that women report higher levels of procedural justice; that drug court participation significantly influences procedural justice perceptions; and that depressive symptomology is a significant predictor of procedural justice perceptions. In male- and female-specific subsamples, drug court participation exerts similar effects for males and females, as does depressive symptomology. Implications for theory, research, and practice are discussed.

Children's Decision-Making Involvement About Research Participation: Associations With Perceived Fairness and Self-Efficacy

The primary objective of this study was to examine the associations of children's involvement in decisions about research participation with their perceptions of the decision-making process and self-efficacy. Participants were children (ages 8-17) who enrolled in research studies in the prior 2 months. Children completed a questionnaire that yielded three decision-making involvement subscales: Researcher Engages Child, Researcher Supports Autonomy, and Child Participates. Children reported on fairness of the decision-making process and health-related decision self-efficacy. After adjusting for age, higher scores on Researcher Engages Child were associated with greater self-efficacy, and higher scores on Researcher Supports Autonomy were associated with greater perceived fairness. These data underscore the potential importance of researcher-child interactions about research participation when assent is sought, including proactively involving children in the decision by asking for their opinions and communicating their central role in the decision, which are likely to be more meaningful to children than receiving information or signing a form.

The experiences of the legal processes of involuntary treatment orders: tension between the legal and medical frameworks

3An involuntary treatment order (ITO) allows a person to be treated for a mental illness without consent under some circumstances. While the treatment and assessment of mental illness are essentially clinical decisions, involuntary mental health admissions are governed by a framework of legal principles, safeguards and procedures. The underlying philosophy of these laws is based on therapeutic jurisprudence. This approach focuses on the importance of the legal process as a social force and suggests that this can either protect or empower people. The legal processes can however adversely impact upon people's states of mind. This study reports on 25 qualitative interviews with involuntary inpatients of a major teaching hospital. The interviews were analysed thematically using a general inductive approach. The analysis focused on the patients' general experience of being placed under an ITO and their understanding of the ITO process. Generally, those who described the experience of an ITO in more positive terms, also experienced the ITO as a positive right. In addition to providing them with the treatment needed, they also felt that the ITO gave them protection and guidance. Conversely, those who experienced being placed under an ITO in more negative or mixed ways, described feeling powerless in the process, as they felt that the ITO took away their rights. By and large the ITO process was experienced as arbitrary when patients did not understand the reasons for their admission. In addition, these patients had limited or no information about their involuntary treatment order and they did not know what was expected of them to have the ITO revoked. Most importantly, they did not feel that there were any meaningful legal protections in place. These experiences highlight the importance of the legal processes and how these can be used as clinical tools.

Perceptions and experiences of people with mental illness regarding their interactions with police

This study examined the perceptions and lived experiences of people with mental illness in relation to their interactions with the police. A community-based participatory research approach was used and a procedural justice theoretical perspective guided the study. In-depth, semi-structured interviews were conducted by peer researchers with 60 people with mental illness who had interacted with the police and were living in Metro Vancouver, Canada. Among the study participants, contact with the police was frequent and occurred under a diverse range of circumstances. The majority of participants perceived being treated in a procedurally just manner by the police officer(s) who were involved in their most recent interaction. Almost three-quarters (n=43, 72%) of participants were generally satisfied with how the police officer(s) had handled their most recent interaction. The slight majority of participants (n=30, 51%) rated their previous contacts with the police as a positive experience overall, with 32% (n=19) indicating that their previous interactions with the police were negative life experiences. The findings paint a more balanced picture than that which is often portrayed by the media. Emphasizing a procedural justice framework for police handling of situations involving people with mental illness is a vital step toward improving how these interactions are experienced and perceived.

Procedural justice and the judge-probationer relationship in a co-occurring disorders court

Although a considerable amount of research has been conducted on treatment-based courts, there is little quantitative evidence that describes the relationship between the judge and the probationer. The present study examines perceptions of the judge-probationer relationship (JPR), procedural justice, and outcome satisfaction within a co-occurring disorders court (CODC) in Orange County, California. Based on interview and survey data from a sample of probationers within the CODC (n=24), this article argues that perceptions of procedural justice are linked to perceptions of relationship quality between the judge and probationer. Analysis of the data found that probationers in the CODC have very positive views of their relationships with the judge, and elements of relationship quality are significantly linked with perceptions of procedural justice. Procedural justice is also a predictor of satisfaction with outcome in this sample. The results show promise that procedural justice and the quality of the judge-probationer relationship can positively affect probationers with co-occurring disorders in specialty courts.

What influences perceptions of procedural justice among people with mental illness regarding their interactions with the police?

According to procedural justice theory, a central factor shaping perceptions about authority figures and dispute resolution processes is whether an individual believes they were treated justly and fairly during personal encounters with agents of authority. This paper describes findings from a community-based participatory research study examining perceptions of procedural justice among sixty people with mental illness regarding their interactions with police. The degree to which these perceptions were associated with selected individual (e.g., socio-demographic characteristics), contextual (e.g., neighborhood, past experiences), and interactional (e.g., actions of the officer) factors was explored. The results of regression analyses indicate that the behavior of police officers during the interactions appears to be the key to whether or not these interactions are perceived by people with mental illness as being procedurally just. Implications of these findings for improving interactions between the police and people with mental illness are discussed.

Perceived coercion in voluntary hospital admission

The legal status of service users admitted to psychiatric wards is not synonymous with the level of coercion that they can perceive during the admission. This study aimed to identify and describe the proportion of individuals who were admitted voluntarily but experienced levels of perceived coercion comparable to those admitted involuntarily. Individuals admitted voluntarily and involuntarily to three psychiatric hospitals were interviewed using the MacArthur Admission Experience Interview and the Structured Clinical Interview for DSM-IV diagnoses. One hundered sixty-one individuals were interviewed and 22% of the voluntarily admitted service users had levels of perceived coercion similar to that of the majority of involuntarily admitted service users. Voluntarily admitted service users who experienced high levels of perceived coercion were more likely to have more severe psychotic symptoms, have experienced more negative pressures and less procedural justices on admission. Individuals brought to hospital under mental health legislation but who subsequently agreed to be admitted voluntarily and those treated on a secure ward also reported higher levels of perceived coercion. It needs to be ensured that if any service user, whether voluntary or involuntary, experiences treatment pressures or coercion that there is sufficient oversight of the practice, to ensure that individual's rights are respected.

Predictors of Criminal Justice Outcomes Among Mental Health Courts Participants: The Role of Perceived Coercion and Subjective Mental Health Recovery

Internationally, one effort to reduce the number of people with serious mental illness (SMI) in jails and prisons is the development of Mental Health Courts (MHC). Research on MHCs to date has been disproportionately focused on the study of recidivism and re-incarceration over the potential of these problem-solving courts to facilitate mental health recovery and affect the slope or gradient of opportunity for recovery. Despite the strong conceptual links between the MHC approach and the recovery-orientation in mental health, the capacity for MHCs to facilitate recovery has not been explored. This user-informed mental health and criminal justice (MH/CJ) community based participatory (CBPR) study assesses the extent to which MHC practices align with recovery-oriented principles and may subsequently affect criminal justice outcomes. We report on the experiences and perceptions of 51 MHC participants across four metropolitan Mental Health Courts. Specifically, the current study assesses: 1) how defendants' perceptions of court practices, particularly with regard to procedural justice and coercion, relate to perceptions of mental health recovery and psychiatric symptoms, and, 2) how perceptions of procedural justice and mental health recovery relate to subsequent criminal justice outcomes. The authors hypothesized that perceived coercion and mental health recovery would be inversely related, that perceived coercion would be associated with worse criminal justice outcomes, and perceptions of mental health recovery would be associated with better criminal justice outcomes. Results suggest that perceived coercion in the MHC experience was negatively associated with perceptions of recovery among MHC participants. Perceptions of "negative pressures," a component of coercion, were important predictors of criminal justice involvement in the 12 month period following MHC admission, even when controlling for other factors that were related to criminal justice outcomes, and that an increase in procedural justice was associated with a decrease in symptoms but curiously not to an increase in attitudes toward recovery. Implications and future directions are discussed.

Procedural justice in mental health courts: judicial practices, participant perceptions, and outcomes related to mental health recovery

Research on mental health courts (MHCs) to date has been disproportionately focused on the study of recidivism and reincarceration over the potential of these problem solving courts to facilitate the recovery process and affect the slope of recovery. This study attempts to shift the focal point of interest from well-established criminal justice outcomes to the experiences and perceptions of MHC participants. The authors hypothesize that the actions of MHC judges that are consistent with procedural justice theory will engender high perceptions of procedural justice among this sample of divertees with SMI. Defendant perceptions of procedural justice in 4 NYC-area MHCs were also compared to those of uninvolved observers. Results suggest that defendant perceptions are distinct from observer perceptions, which tended to be more sensitive to the differences in judges between the four courts. Overall, participants' perceptions of procedural justice were moderate and increased between baseline and 4-month follow-up. Procedural justice was negatively correlated with symptoms at baseline and was positively correlated with participant's attitudes toward their own recovery. Between baseline and 4-month follow-up, participants in our sample tended to increase in perceptions of procedural justice; interestingly, the increase in procedural justice was associated with a decrease in symptoms but not to an increase in attitudes toward the recovery. Implications and future directions are discussed.

Influence of race on outpatient commitment and assertive community treatment for persons with severe and persistent mental illness

Critics of outpatient commitment (OPC) suggest that African Americans with severe and persistent mental illness may be more frequently subjected to coercive treatment. This study examines the frequency of use of OPC and assertive community treatment and compares their influence on the perceptions of procedural justice/choice and coercion/negative pressure on African Americans and Whites. No significant differences were found in the rate at which OPC was applied to African Americans or in the use of assertive community treatment. Although procedural justice/choice does contribute significantly to the perception of coercion/negative pressure in both groups, its influence is diminished in African Americans.

Examining attitudes about and influences on research participation among forensic psychiatric inpatients

Although a growing body of research has examined various types of coercive practices that may occur among psychiatric patients over the years, almost no attention has been given to coercive influences that may occur specifically in the context of recruitment into research projects. Particularly for those who are institutionalized (e.g., in-patient insanity acquittees), there are significant concerns that their autonomous decision-making to consent or not may be significantly impaired due to the highly restrictive and controlled environment in which they live. This exploratory study sought to examine patients' perceptions of coercive influences by presenting them with hypothetical research vignettes regarding possible recruitment into either a biomedical or social-behavioral research project. Among 148 multi-ethnic male and female participants across two facilities, participants reported relatively minimal perceptions that their autonomous decision-making would be impacted or that various potentially coercive factors (e.g., pressures from staff) would impair their free choice to participate (or not) in such research. To the extent that such perceptions of coercion did occur, they were moderately associated with patients' more general personality traits and attitudinal variables, such as alienation and external locus of control. Limitations of this study and their implications for future research are discussed.

Quasi-experimental comparison of coercive interventions on client outcomes in individuals with severe and persistent mental illness

This study compares outpatient commitment (OPC) and Assertive Community Treatment (ACT) as forms of coercive treatment interventions to evaluate the influence of each individually and in combination on clients' perception of procedural justice and coercion, as well as clinical outcomes that include treatment compliance, quality of life, symptom distress, empowerment, and violence/victimization. Findings support that the perception of procedural justice and coercion are inversely related; persons subject to OPC experience higher levels of perceived coercion, and higher levels of perceived coercion do not influence treatment compliance. ACT alone does not increase the perception of coercion nor is there any interaction effect.

Working alliance, interpersonal trust and perceived coercion in mental health review hearings

Background

There is some evidence that when mental health commitment hearings are held in accordance with therapeutic jurisprudence principles they are perceived as less coercive, and more just in their procedures leading to improved treatment adherence and fewer hospital readmissions. This suggests an effect of the hearing on therapeutic relationships. We compared working alliance and interpersonal trust in clinicians and forensic patients, whose continued detentions were reviewed by two different legal review bodies according to their legal category.

Methods

The hearings were rated as positive or negative by patients and treating psychiatrists using the MacArthur scales for perceived coercion, perceived procedural justice (legal and medical) and for the impact of the hearing. We rated Global assessment of Function (GAF), Positive and Negative Symptom Scale (PANSS), Working Alliance Inventory (WAI) and Interpersonal Trust in Physician (ITP) scales six months before the hearing and repeated the WAI and ITP two weeks before and two weeks after the hearing, for 75 of 83 patients in a forensic medium and high secure hospital.

Results

Psychiatrists agreed with patients regarding the rating of hearings. Patients rated civil hearings (MHTs) more negatively than hearings under insanity legislation (MHRBs). Those reviewed by MHTs had lower scores for WAI and ITP. However, post-hearing WAI and ITP scores were not different from baseline and pre-hearing scores. Using the receiver operating characteristic, baseline WAI and ITP scores predicted how patients would rate the hearings, as did baseline GAF and PANSS scores.

Conclusions

There was no evidence that positively perceived hearings improved WAI or ITP, but some evidence showed that negatively perceived hearings worsened them. Concentrating on functional recovery and symptom remission remains the best strategy for improved therapeutic relationships.

Reflecting on forced medication

There are multiple concerns regarding the practice of forced medication of clients with mental illness. Clients often report that side effects outweigh the benefits of psychotropic medication, while mental health clinicians often think the client may become dangerous without medication. Who should have the right to decide whether a client takes medication? Nursing plays an integral role in the decision making by considering alternative therapies and current research, addressing the diversity among our clients, and ensuring comprehensive assessments. This article presents circumstances that may lead to forced medication and explores beliefs of clients, mental health clinicians, and mental health advocacy groups.Building upon Johns' (2008) model for structured reflections of clinical experiences, this article reflects upon the experience of forced medication in psychiatric nursing practice. First, the process and consequences of forced medication are explored. Next, the factors influencing the thoughts and responses of psychiatric clinicians, clients, and advocacy groups is discussed. Finally, possible alternative actions are presented.

Coercion and procedural justice in psychiatric care: state of the science and implications for nursing

Coercive treatment regimens have increased in variety and intensity over the past decade and include such options as outpatient commitment (OPC) and mental health courts. The intimate involvement of nurses in coerced treatment situations in both inpatient and outpatient settings necessitates a closer examination of its effects. OPC presumably offers greater flexibility and freedom for consumers than lengthy inpatient stays but also extends the state's control over their lives beyond the institution. Although OPC has been shown to decrease rates of rehospitalization and violence, it also is associated with increased levels of perceived coercion. The relationship of the perception of coercion to treatment outcomes is complex and not clearly understood. The goal of OPC is treatment adherence and ultimately increased quality of life, but research has produced conflicting results in those areas. Numerous episodes of OPC may have a cumulative effect on the perception of coercion and contribute to treatment avoidance. However, there is evidence that the perception of coercion can be mitigated by procedural justice that is demonstrated by fairness, patient inclusion in the process, and benevolence on the part of authority figures. Implications for nursing practice and research concerning coercion, procedural justice, and OPC are discussed.

Procedural justice and the mental health court judge's role in reducing recidivism

Based on qualitative observation and quantitative data from eight mental health courts (MHCs), this article argues that observed reductions in recidivism from participation in MHC are caused in part by the role of the judge in conveying elements of procedural justice. Specifically, the judge provides: (1) a heightened level of interpersonal treatment of participants that accords them dignity, respect, and voice; (2) accountability for participants and service providers alike; and (3) transparency for decisions reached through an open negotiation process. Procedural justice theory predicts that participants will thereby be more likely to see legal decisions as legitimate and incorporate the court's values and goals as their own. Preliminary qualitative and quantitative data are presented from interviews of a sample of participants in the Superior Court of the District of Columbia's Mental Health Diversion Court (DCMHDC) that support these hypotheses. DCMHDC participants hold strongly positive views about the procedural justice they receive from their court experience and of the judge's role in providing justice.

Outpatient commitment: A therapeutic jurisprudence analysis

This article analyzes the legal and therapeutic jurisprudence considerations raised by outpatient commitment. Although older forms of outpatient commitment have both legal and therapeutic advantages, preventive outpatient commitment raises serious legal problems and potential antitherapeutic consequences that may outweigh its claimed therapeutic value. As a result, alternatives are proposed, including wider availability of community treatment and outreach and case management services, assertive community treatment, police and mental health court diversion programs, and creative uses of advanced directive instruments and behavioral contracting. Proposals also are made for how preventive outpatient commitment can be applied more therapeutically, including hearings that accord patients a sense of procedural justice and techniques designed to motivate individuals facing such hearings to agree to accept treatment voluntarily.