See all required articles to use attached.The use of mandated, or legally coerced, treatment is widespread. Yet research demonst

PSY699: Master of Arts in Psychology Capstone The Ethics of Mandated Treatment Scenarios

Scenario 1: A client with a well-established history of repeated dangerous behavior and inpatient commitment has been treated, stabilized, and discharged into the community. The treating psychiatrist believes that the client’s success in the community is far more likely if treatment is continued. However, the client wishes to terminate treatment. A request for mandated treatment is filed by the psychiatrist with the court. During the hearing, the psychiatrist testifies that while the client is not imminently dangerous, he potentially could become dangerous again without treatment.

Scenario 2: A long-term client appeared quite excited during a recent session with her therapist. Speaking rapidly, she told the therapist that she was planning a gambling trip that would win her millions of dollars. After some probing, the therapist learned the client had recently stopped taking the medication prescribed for her bipolar disorder because she had been feeling so happy. The client also indicated that she no longer saw a need for therapy and was planning to stop treatment.

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AN EXAMINATION OF MANDATED VERSUS VOLUNTARY REFERRAL AS A DETERMINANT OF CLINICAL OUTCOME Snyder, Christine M J;Anderson, Stephen A Journal of Marital and Family Therapy; Jul 2009; 35, 3; ProQuest Central pg. 278

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Care, Control, or Both? Characterizing Major Dimensions of the Mandated Treatment Relationship

Sarah M. Manchak University of Cincinnati School of Criminal Justice

Jennifer L. Skeem and Karen S. Rook University of California, Irvine

Current conceptualizations of the therapeutic alliance may not capture key features of therapeutic relationships in mandated treatment, which may extend beyond care (i.e., bond and affiliation) to include control (i.e., behavioral monitoring and influence). This study is designed to determine whether mandated treatment relationships involve greater control than traditional treatment relationships, and if so, whether this control covaries with reduced affiliation. In this study, 125 mental health court participants described the nature of their mandated treatment relationships using the INTREX (Benjamin, L., 2000, SASB/ INTREX: Instructions for administering questionnaires, interpreting reports, and giving raters feedback (Unpublished manual). Salt Lake City, UT: University of Utah, Department of Psychology), a measure based on the interpersonal circumplex theory and assesses eight interpersonal clusters organized by orthogonal axes of affiliation and control. INTREX cluster scores were statistically compared to existing data from three separate voluntary treatment samples, and structural summary analyses were applied to distill the predominant theme of mandated treatment relationships. Compared with voluntary treatment relationships, mandated treatment relationships demonstrate greater therapist control and corresponding client submission. Nonetheless, the predominant theme of these relationships is affiliative and autonomy- granting. Although mandated treatment relationships involve significantly greater therapist control than traditional relationships, they remain largely affiliative and consistent with the principles of healthy adult attachment.

Keywords: mandated treatment, therapeutic alliance, treatment alliance, interpersonal circumplex, SASB, INTREX

The quality of the therapist– client relationship is the strongest controllable predictor of outcome in psychotherapy (Horvath, Del Re, Flueckiger, & Symonds, 2011; Klinkenberg, Calsyn, & Morse, 1998; Krupnick et al., 1996; Luborsky, Chandler, Auerbach, Co- hen, & Bachrach, 1971; Martin, Garske, & Davis, 2000). This relationship reflects an accumulation of interpersonal interactions over time that vary in their degree of (a) affiliation or connected- ness (ranging from hostile to friendly) and (b) control or influence

(ranging from controlling to autonomy-granting on the part of the therapist or from submissive to autonomy-taking on the part of the client; see Benjamin, Rothweiler, & Critchfield, 2006; Henry, Schact, & Strupp, 1990; Kiesler, 1983).

Conceptualizations of high-quality therapeutic relationships tend to focus almost exclusively on strong affiliation between therapist and client (see Bordin, 1979; Horvath & Luborsky, 1993). For example, the most widely used measure of the thera- peutic alliance (Horvath & Symonds, 1991; Martin et al., 2000; Tryon, Blackwell, & Hammel, 2007), the Working Alliance In- ventory (WAI; Horvath & Greenberg, 1989), emphasizes an inter- personal bond between the therapist and client and collaboration in working toward shared goals. In contrast, the role of control in these relationships tends to be neglected or explicitly minimized (see Curtis & Hirsch, 2003; Rogers, 1957).

Therapist Control and Assertive or Involuntary Treatment

In contemporary service contexts for clients with serious mental illnesses (e.g., schizophrenia, bipolar disorder, major depression), control may play a prominent role in treatment relationships, because services are often assertively delivered, leveraged, or even mandated by the court. This may be because individuals with serious mental illness often have co-occurring substance abuse problems and difficulty following treatment recommendations (see American Psychiatric Association, 1994; Cramer & Rosenheck,

This article was published Online First July 8, 2013. Sarah M. Manchak, University of Cincinnati School of Criminal Justice;

Jennifer L. Skeem and Karen S. Rook, Department of Psychology and Social Behavior, University of California, Irvine.

This research was funded by the American Psychology-Law Society Grant-in-aid program and the University of California, Irvine Newkirk Center for Science and Society. The authors also thank Shaudi Adel and Felicia Keith for their assistance with interviewing participants; Ken Critchfield and Edward Shearin for providing the raw data from their studies and input on this paper; Aaron Pincus for his assistance with the Structural Summary analyses; and the Orange Country, California, and San Bernardino County, California, mental health courts and their affiliated probation departments and treatment agencies/providers for their approval and support of this research project.

Correspondence concerning this article should be addressed to Sarah M. Manchak, University of Cincinnati School of Criminal Justice, 665-BA Dyer Hall, Clifton Ave, P.O. Box 210389, Cincinnati, OH 45221-0389. E-mail: [email protected]

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Law and Human Behavior © 2013 American Psychological Association 2014, Vol. 38, No. 1, 47–57 0147-7307/14/$12.00 DOI: 10.1037/lhb0000039

47

1998; Fenton, Blyler, & Heinssen, 1997; Karberg & James, 2005; Kessler et al., 1996; Regier et al., 1990).

There are clear signs that therapist control plays a role in treatment services for this population. For example, Assertive Community Treatment (ACT; see Dixon, 2000; Drake et al., 1998; McCabe & Priebe, 2004) is one of the best-known evidence-based treatment programs for clients with serious mental illness. Studies of ACT teams have revealed that therapists often try to increase their clients’ medication adherence by applying pressure, with- holding assistance, and occasionally threatening to pursue invol- untary hospitalization (see Angell, 2006; Neale & Rosenheck, 2000).

There may be a similar “pull” toward therapist control when clients are informally or formally mandated to take part in treat- ment. Informally, services in the community can be “leveraged,” or made contingent upon treatment compliance. In a study of more than 1,000 patients, Monahan et al. (2005) found that patients were often required to participate in therapy and/or take medication to obtain discretionary money (7%–19%) or maintain housing (23%– 40%; see Monahan et al., 2005). Treatment may also be formally mandated by a court, in both civil (i.e., inpatient or outpatient commitment) and criminal contexts. In fact, Monahan et al. (2005) found that among patients who had ever been arrested, up to half were told that they would be incarcerated unless they complied with treatment. When patients are required to participate in treat- ment, control may become an important component of the rela- tionship.

Does Therapist Control Necessarily Reduce Affiliation?

Does increased control in a therapeutic relationship come at the expense of affiliation? Data relevant to this question are available from studies of voluntary psychotherapy (K. Critchfield, personal communication, June, 2011; Coady & Marziali, 1994; Critchfield, Henry, Castonguay, & Borkovec, 2007; Harrist, Quntana, Strupp, & Henry, 1994; Henry et al., 1990; Najavits & Strupp, 1994; Shearin & Linehan, 1992) that apply the interpersonal circumplex model of relationships (Freedman, Leary, Ossorio, & Coffey, 1951; Gurtman, 1992; Kiesler, 1983; Leary, 1957). We provide a brief introduction to the model here, using Benjamin’s (1996) operationalization.

As shown in Figure 1, the circumplex is defined by a horizontal axis of affiliation (“Attack” to “Love”) and a vertical axis of control (“Autonomy Granting” to “Control”). Each point in cir- cumplex space reflects a weighted combination of these two di- mensions and can be used to map the therapeutic relationship (see Freedman et al., 1951; Gurtman, 1992; Kiesler, 1983; Leary, 1957). For example, prototypic therapist behaviors that combine moderate affiliation with moderate control are mapped as “Pro- tect,” whereas those that combine moderate affiliation with mod- erate autonomy granting are mapped as “Affirm.” Beyond describ- ing relationships, the circumplex model also allows for prediction. Specifically, according to the principle of complementarity, one person’s behavior evokes a class of behavior from the other person that is similar on the affiliation axis (e.g., therapist hostility invites client hostility) and reciprocal on the control axis (e.g., therapist control invites either client submission or client autonomy taking; Benjamin, 2000).

According to both the structure of the interpersonal circumplex (see Figure 1) and the principle of complementarity, therapist control alone will not influence the degree of affiliation in the therapeutic relationship. Given that the control axis is orthogonal to the affiliation axis, therapist behavior can be purely controlling (and neutral in affiliation). Theoretically, control will come at the expense of affiliation only if control tends to be combined with hostility. Specifically, hostile control from a therapist (i.e., “Blame,” Figure 1) would elicit hostile submission (“Sulk”) or hostile autonomy taking (“Wall Off”) from a client.

Two relevant findings have emerged from studies of volun- tary psychotherapy that apply Benjamin’s circumplex mea- sures: the observer-rated Structural Analysis of Social Behavior (SASB: Benjamin, 1996), or the self-report INTREX (Benja- min, 2000). First, therapists rarely exercise pure control or hostile control and (perhaps for that reason) clients rarely respond in a manner that is disaffiliative or distancing. Instead, voluntary treatment relationships are predominantly character- ized by therapist “Affirm” and “Protect” (i.e., affiliative autonomy-granting and control) and corresponding client “Dis- close” and “Trust” (i.e., affiliative autonomy-taking and sub- mission; Critchfield et al., 2007). Even among patients with poor outcomes, therapist pure control (M � 5.3) and patient pure submission (M � 4.2) are quite low, relative to therapist “Affirm” (M � 35) and “Protect” (M � 20) and patient “Trust” (M � 17) and “Disclose” (M � 101; Henry et al., 1990; see also Harrist et al., 1994; Shearin & Linehan, 1992; K. Critchfield, personal communication, June, 2011; Tables 1 and 2).

Second, when therapists do exercise pure or hostile control, patients tend to behave in a manner that is disaffiliative and often experience poor clinical outcomes. INTREX ratings of high therapist control are associated with disaffiliative re- sponses from the client (e.g., “Sulk” and “Wall off”; see K. Critchfield, personal communication, June, 2011; Harrist et al., 1994; Table 2). Similarly, therapist “Watch/Control” early in therapy is associated with poorer overall therapist-rated alliance (Coady & Marziali, 1994). Moreover, having a therapist with low “Affirm” and high “Control” is predictive of longer hos-

Figure 1. Simplified One-Word Cluster Model (Benjamin, 1996) with Corresponding Angular Displacement Added. Therapist transitive scores in bold; client intransitive scores underlined.

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48 MANCHAK, SKEEM, AND ROOK

pital stays and less symptom improvement for clients (Najavits & Strupp, 1994).

In summary, research on voluntary treatment relationships sug- gests that therapists rarely express “pure” or hostile control, but when they do, it tends to promote disaffiliation, distancing, and poor outcomes. The extent to which these findings generalize from voluntary to involuntary treatment contexts is unknown. In invol- untary contexts, therapists may be pulled toward more controlling behavior, and clients may feel coerced to take part in treatment. Patients who feel coerced may respond with (a) anger and resis- tance to treatment goals or (b) a sense of helplessness and de- creased therapeutic engagement (see Monahan et al., 1995).

There is indirect evidence for such propositions. Specifically, patients in mandated civil psychiatric treatment perceive greater coercion to take part in treatment than voluntary patients (Shee- han & Burns, 2011; Swartz, Wager, Swanson, Hiday, & Burns, 2002). In turn, perceived coercion is inversely associated with patient ratings of the therapeutic alliance (Sheehan & Burns, 2011), which emphasize affiliation. Similarly, in correctional

treatment, rehabilitative probation officers’ use of hostile con- trol (i.e., “toughness”) is associated with decreased caring, fairness, and trust in the officer–probationer relationship (Skeem, Eno Louden, Polaschek, & Camp, 2007).

The extent to which mandated treatment relationships involve greater amounts of therapist control than voluntary treatment relationship is unknown. Even more, it is unclear whether pronounced control (which is rare in voluntary relationships, but may be common in mandated relationships) comes at the expense of affiliation. Because the quality of the client-provider relationship may play a crucial role in behavior change, it is necessary to properly operationalize the construct to study its effects on client outcomes. Ratings of the therapeutic alliance (i.e., affiliation) may not fully capture therapist– client relation- ship quality in mandated treatment, where control may play a prominent role. It is necessary to first empirically test whether it is the case that mandated treatment relationships are higher in control and explore how control and affiliation are related in mandated treatment.

Table 1 Therapist Transitive INTREX Cluster Score Predictions and Preexisting Voluntary Data Findings

Cluster Predictiona Critchfieldb Shearin & Linehan (1992) Harrist et al. (1994) Grand M (used as distilled data)

Affiliation clusters Affirm/Understand���1 Highest 95.4 (6.8) 85.0 (14.5) 74.4 (15.9) 78.4 (14.3) Love/Approachc���2,3 High 75.0 (33.4) 82.1 (12.0) 40.5 (18.0) 65.9 (21.1) Nurture/Protectc���4 Highest 83.0 (25.3) 89.1 (11.4) 57.3 (17.5) 76.5 (18.0)

Attack clusters Belittle/Blame Lowest 0.3 (1.3) 5.4 (6.6) 3.1 (6.9) 2.7 (5.9) Attack/Reject Lowest 0.0 (0.0) 5.8 (10.5) 2.5 (5.6) 2.2 (4.9) Ignore/Neglect Lowest 0.3 (1.3) 9.8 (14.5) 4.5 (9.3) 4.0 (8.2)

Control dimension Free/Forget Moderate 43.0 (40.1) 44.6 (28.4) 44.2 (17.3) 44.0 (21.6) Watch/Control Low 18.3 (21.2) 34.1 (32.1) 12.9 (12.8) 14.8 (15.1)

Note. Values are means with standard deviation in parentheses. A Bonferroni correction was applied to the Attachment and Attack Clusters and Control Dimension. Any flagged significant effects in these clusters are � � .02. a High � M � 75; moderate � M 26 –74; low � M � 25. b K. Critchfield, personal communication, June, 2011. c Unweighted grand M was used. ��� p � .001, F test for comparing sample means; 1 Critchfield vs. Harrist t(df � 83) � 5.0, p � .001; Cohen’s d � 1.1;

2 Critchfield vs. Harrist t(df � 83) � 5.7, p � .001; Cohen’s d � 1.3; 3 Shearin & Linehan vs. Harrist t(df � 72) � 4.6, p � .001; Cohen’s d � 1.1;

4 Critchfield vs. Harrist t(df � 83) � 4.7, p � .001; Cohen’s d � 1.0.

Table 2 Client Intransitive INTREX Cluster Score Predictions and Preexisting Voluntary Data Findings

Cluster Predictiona Critchfieldb Shearin & Linehan (1992) Harrist et al. (1994) Grand M (used as distilled data)

Affiliation clusters Disclose/Express Highest 75.0 (23.7) N/A 78.6 (13.9) 78.0 (15.6) Joyfully Connectc���1 High 65.7 (34.5) N/A 47.5 (15.4) 56.6 (25.0) Trust/Relyc���2 Highest 82.0 (19.7) N/A 65.2 (14.7) 73.6 (17.2)

Attack clusters Sulk/Scurry Lowest 16.0 (28.8) N/A 9.6 (11.3) 10.7 (14.4) Protest/Recoil Lowest 7.0 (16.2) N/A 4.9 (8.3) 5.3 (9.7) Wall-off/Distance���3 Lowest 24.3 (23.3) N/A 9.8 (12.3) 12.4 (14.2)

Control dimension Assert/Separate���4 Moderate 32.0 (34.2) N/A 62.3 (11.9) 57.0 (15.8) Defer/Submit Low 18.7 (29.6) N/A 12.4 (12.4) 13.5 (15.4)

Note. Values are means with standard deviation in parentheses. N/A � not available. A Bonferroni correction was applied to the Attachment and Attack Clusters and Control Dimension. Any flagged significant effects in these clusters are � � .02. a High � M � 75; moderate � M 26 –74; low � M � 25. b K. Critchfield, personal communication, June, 2011. c Unweighted grand M was used. ��� p � .001; t test for comparing sample means; 1 t(df � 83) � 3.6, p � .001; Cohen’s d � .79;

2 t(df � 83) � 3.8, p � .001; Cohen’s d � .83; 3 t(df � 83) � 3.5, p � .001; Cohen’s d � .77;

4 t(df � 83) � �6.0, p � .001; Cohen’s d � 1.3.

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49CHARACTERIZING MANDATED TREATMENT RELATIONSHIPS

Present Study

Based on a sample of individuals with serious mental illness mandated to mental health treatment through the criminal justice system, we addressed two aims in this study. First, we seek to determine how more frequent control is present in mandated treatment relationships than voluntary treatment relationships. Sec- ond, we determine whether increased therapist control in mandated treatment is associated with decreased client–therapist affiliation. We articulate our hypotheses and the procedures to test these hypotheses below.

To address our first aim, we provide not only a descriptive summary of our mandated sample, but we also seek to place our findings in context. To do so, we compare ratings of control and affiliation from our mandated sample to those found in prior studies of voluntary clients. We use this approach for two primary reasons. First, it is difficult—perhaps infeasible—to randomly assign offenders to voluntary versus mandated treatment. As noted by Parhar, Wormith, Derkzen, and Beauregard (2008, p. 1111), “[t]rue voluntary participation [in correctional treatment] does not exist in the criminal justice system because there is always some degree of external pressure.” A judge is unlikely to mandate treatment arbitrarily for some people with serious mental illness but not others. Second, absent any comparison or context, it is often difficult to interpret purely descriptive findings. Having a group against which to compare new data can place research findings in context.

Such practices are used both in the interpersonal circumplex (Excel Circumplex Calculator, A. Pincus, personal communica- tion, April 25, 2011; Wright, Pincus, Conroy, & Hilsenroth, 2009) and the psychological assessment literatures. For example Morgan, Fisher, Duan, Mandracchia, and Murray (2010) examined the criminal thinking styles of prison inmates with serious mental illness in light of scores obtained from nonoffender psychiatric patients and nonmentally ill offenders. More formally, Bornstein, Gottdiener, and Winarick (2009) used existing validation data on interpersonal dependency from nonclinical college samples as a benchmark against which to statistically compare their newly obtained data from a clinical substance-abusing sample.

Given the precedent to use existing data as a point of compar- ison when providing descriptive information about a sample for which there is not direct comparison group, we use published and nonpublished patient-rated, self-report INTREX data to which we compare our mandated sample data (K. Critchfield, personal com- munication, June, 2011; Harrist et al., 1994; Shearin & Linehan, 1992). Based on previous research (Angell, 2006; Monahan et al., 2005; Neale & Rosenheck, 2000) and consistent with the princi- ples of complementarity in interpersonal theory (i.e., behavior toward a person will elicit a complementary response; e.g., control and submission; see Benjamin, 2000), we hypothesize that man- dated treatment relationships involve greater therapist control and corresponding greater client submission than voluntary treatment relationships.

To address our second aim—to examine the relationship be- tween affiliation and control, we focus exclusively on the man- dated treatment sample and use several different indices com- monly used in interpersonal research in general (e.g., structural summary analyses to characterize the predominant interpersonal pattern in the client–therapist relationship) and with SASB/INTREX

technology, specifically (e.g., use of cluster score correlations and pattern coefficients, described below). Given that observer-rated and self-report studies of voluntary treatment relationships suggest that when control is present, it may adversely affect the relation- ship, we hypothesize that higher levels of control in mandated treatment will be associated with reduced client–therapist affilia- tion.

Method

We interviewed 125 mental health court participants about their relationship with their primary treatment provider and rated this relationship on the INTREX (Benjamin, 2000). We then compared data from this sample to published and unpublished data on pa- tients in voluntary treatment and used several interpersonal circumplex- specific statistical techniques and indices to examine the quality of mandated treatment relationships.

Procedure

Participants were recruited either at a courthouse or mandated treatment facility. Research assistants (RAs) made brief announce- ments to groups of prospective participants to describe the study (e.g., eligibility requirements, interview nature, confidentiality protections, and compensation of $30) and invited them to partic- ipate. RAs screened interested participants for eligibility and scheduled an interview for eligible persons at a time and location of their convenience. At the scheduled time, RAs completed the informed consent process and a 2-hr interview with participants, which included verbal administration of the INTREX and several other measures not central to the present study aims. The study protocol was approved by relevant Institutional Review Boards.

Participants

Participants were English-speaking adults who (1) were current participants in one of four mental health courts, (2) had completed at least one mandated treatment session with a therapist, case manager, or counselor, and (3) had a remaining mental health court term of approximately 4 months. Participants’ average age was 37 years (SD � 11.4); 54% were women, and 67.2% were White (16% Hispanic, 10.4% African American, 3.2% Native American, 3.2% Asian). Although 87% were currently unemployed, 70% of participants had received high school diploma/GED or greater education. Participants’ self-reported (and chart-verified) primary diagnosis was for a mood disorder (bipolar disorder � 54%; major depression � 19%; mood NOS � 2%); 23% had a diagnosis of schizophrenia, schizoaffective disorder, or other psychotic disor- der; and 2% had another Axis I mental disorder (e.g., anxiety, ADHD). Participants’ index offense was for drug (50%), property (32%), minor (11%), and person (6%) crimes (as defined by Monahan et al., 2001).

The average participation rate across the four courts, defined as the total number of people enrolled in the study divided by the total number of people enrolled in the mental health court during the year in which the study was conducted, was 32% (range � 25%– 40%). As shown in Table 3, enrolled participants did not differ from the court populations from which they were drawn in term

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