The new paternalism: Supervision is the essential part of caring coercion.

American Public Health Association

Boston, November 2006

I arrived in Boston from Athens were I had attended the Internet Governance Forum. I picked an inexpensive hotel and while it is clean and friendly and convenient, there are constant fan noises from the ventilation system. I’ve been wearing my earplugs and keeping the television on.

I walked some and slept some and woke this morning to a cool fall day, overcast in the morning, clear by the afternoon. I ate at Finagle a Bagel, then took public transportation, two changes, elevators at both ends but stairs in the middle - I asked someone to help me get the wheeled tote bag down the stairs.

There are 15000 registered, the space seems fully accessible though it has a strong plastic smell, my picture is displayed at the Mental Health Section booth as this year’s section award winner. Ron Manderscheid was in the exhibit hall and we had a nice chance to chat.

IT and Human Rights - 4 panelists, 2 in audience, the other a UC Davis librarian - LeaderNet - proprietary software based on Cold Fusion - any group welcome to create a community there. Http://


Slide of blog looked complex, appreciative inquiry a training technique. Library science has always valued free knowledge for all, but does allow fees for speedy service.

There’s free WiFi at my hotel and at the at the conference center.

The Mental Health Section social hour was well attended and pleasant. I was named as the annual section awardee, given an impressive wall plaque and a book by Norman Sartorius. I feel gratitude for having the chance to use the skills that led to receiving this award. In accepting, I said:

I appreciate the recognition that this award conveys and it’s especially nice to receive it here in Boston, where I spent the first half of my life.

It’s been hard to interest consumers in this work and I’m glad to see that the section keeps trying.

I felt respected and included here and more than a diagnosis. Through you, and our work, I learned about a perspective that goes beyond individuals to look at population health.

Today most attention is directed downstream at treatment and rehabilitation. But rescue medicine is not enough. We can use primary prevention to reduce the number of people upstream, the number coming into the system and wanting services. Healthy lifestyles in healthy
communities can reduce the impact of risk factors and create local peer support.

You know this.

I’d like to use this chance to focus on a foundation of health, ... to wonder out loud when hitting one’s partner or having sex with one’s kids became an American tradition, a behavior to not be questioned until it is glaring. I think the mission of this section could be to start with social violence, to end the permission to mistreat each other, just as long as it’s at home.

Studies consistently confirm a very high rate of sexual and physical
abuse among persons who later get diagnosed with mental illness. If this kind of trauma were reduced, I anticipate a significant parallel reduction in the rates of suicide attempts, psychological distress, and long-term trauma based illness.

An aspirational value of public health must be the opportunity for each person to have a safe and valued place in order to achieve their own promise.

Thank you

I spoke to a woman who will be presenting on the social construction of autism and I thought about the social construction of disease and illness and how this serves society.

It was late and I took a taxi to my hotel, had a fascinating conversation about politics with the driver, here 18 years from Nigeria, and a citizen planning to vote.


I’m up at 3 AM again - I’m glad the hotel has WiFi.

I met my sister and cousin for a delightful breakfast and took the conference bus, 35 minutes, to the site and am attending an Information Technology meeting. They insist on talking at the nuts and bolts level, and resist the philosophical and moral implications. There are no databases about providers.

Then I attended the ‘Human Rights and Mental Health’ session. The first presentation is titled ‘Case for Caring Coercion’. I sputtered so in reading the title that I prepared a one-pager. I didn’t trust myself to speak compellingly.


Sharfstein: psychiatry is called upon to manage social control, a power that requires great care and sensitivity, and is opposed by civil libertarian laws. He’s skillful, sets up well laying out what opposition arguments will be, even noting ‘caring coercion’ is an oxymoron like airline food. I felt trivialized hearing the joke. He quoted Isaiah Berlin - what is freedom to those who can’t make use of it and said Jefferson got the order right, a hierarchy of rights - first life, then liberty and then the pursuit of happiness. Typhoid Mary imprisoned on an island, was expendable. The price of liberty is good behavior. Individualize supervision in a culturally sensitive way. Supervision is the essential part of caring coercion. Probation even though no criminal activity. The new paternalism. Overuse of the criminal justice system, and underutilization of supervision and community treatment. Proactive prevention supervision. Clients are held accountable.

He is so sure of his wisdom to supervise. I feel unsure of what to reply. It’s quite frightening. He gave an example of how he ‘supervised’ by punishing outbreaks of crazy behavior with shots of thorazine and the patient finally got the message. Caring coercion is right wing in that it seeks order but also left wing in that it relies on government. The brain is compromised.

Rosenhecht: cites Moe Armstrong, values peer support, gives cases

Eisenberg: mental patients suffer more, die younger and more frequently

This whole session could have been organized by the most conservative segment of NAMI!

I did make a statement and passed around the handout. The rebutter gave me a what-would-you-do-if . I said you’ll win any argument with a worst case scenario, and that there needed to be an high level moral policy and there would be harms regardless. A woman from the audience self-identified as a consumer, said that "The quality of life is far more important than life itself." Question of criminalizing. Suggested that Kendra’s law should be named Andrew’s law because he was refused care. A woman from NIMH suggested that there be on ongoing coercion/ethics discussion at APHA. After I had a chance to think things over, I think I should have objected more strongly to the Typhoid Mary example, and not bought into their vocabulary that it is ‘libertarian’ to be against force. I did say it was a human rights violation, but could have better appealed to the utility-justice ethical continuum.

There were several hundred people lined up for the shuttle busses back to the hotels. One full bus pulled away, another didn’t come, a rumor began of an accident and total downtown gridlock, and with a woman standing next to me, took public transportation back, got to my hotel at 7:30 and watched a little of the election news coverage.

There’s another coercion presentation today and it’s raining, windy and mild. I’m working hard to motivate myself to keep controlled and pass out more of my handouts!

And it’s November 8 and I’m enjoying the headlines!

It’s raining, I walked for a while, realized I hadn’t lost my jaywalking skills, had tea at Starbucks, took the conference bus (45 minutes), and am a session on coercion, particularly Kendra’s law. Several people spoke to me in advance, thanking me for speaking out yesterday. One woman said that she’d gone back to her hotel and told her colleagues "You won’t believe what happened at my session ... " and we were then interrupted and I didn’t find out just what it was I did that was so startling, maybe just disagreeing with the speakers right to speak for us. That emboldened me to speak more today, and I put my handout on the table and see that many have picked it up. Bruce Link compared outpatient commitment and assertive community treatment. He made distinctions; of course one has a court order, but I don’t see much difference.

I objected to the use of ‘stigma’, he rebutted, I insisted, he said he’d written a paper, I said so had I, we agreed to exchange papers. He needs to preserve the isolating language!

I said users/survivors would lie on surveys if it were in our self-interest, he said he thought people would tell him the truth, I thought but didn’t say that lots of professionals think they have uniquely trusted relationships with us.

I guess I’ve made a difference by being at these sessions and speaking out, but it surely takes its toll. I’m feeling very sad, don’t like adversarial conversations, I don’t like winning or losing! I said twice out loud I’m moving on, towards human rights and the internet, and away from mental health. It felt good to disengaging in a public way.

I’m meeting my sister for supper after the conference close tonight and then flying home.

United charges $2 per bag for curbside check-in and the porter reminded me that the money went straight to United and doesn't include any gratuity.  It costs $3 for a SmartCarte.  The flight was full,  uneventful, they ran out of bottled water after the first 90 minutes, we landed early - I read, and watched The Devil Wears Prada.  My transfer home was an hour late picking me up.  I'm home and half unpacked.