COERCION AND CARE



Sylvia Caras, Article Organizer

Articulate former objects of coercive psychiatry who advocate for system change are often discounted as not representative of the population who are involuntarily treated. To avoid this exceptionalization, when I was encouraged to develop this article I publicized the request electronically to 75 people. This essay incorporates quotes from several advocates who responded to your request to discuss involuntary psychiatric treatment. Because the themes keep intersecting, the headings below are not mutually exclusive.

Legal Questions

La Fond lays out the legal questions. "States may use police power to enact laws empowering public officials to forcibly confine any citizen considered mentally ill and dangerous to others or to himself. In modern times this special system of social control, which amounts to 'preventive detention,' has generally been applied almost exclusively to the mentally ill. The criminal justice system assumes a citizen is innocent until proven guilty and generally will only incarcerate an individual who is convicted of a crime or to ensure an accused's presence at trial. In sharp contrast, the coercive mental health system confines a mentally ill person because a mental health expert predicts that, unless restrained, the mentally ill person will commit a dangerous act--such as committing suicide or assaulting an innocent person--sometime in the future." (La Fond, 25)

"Here in the United States it's supposed to take two physicians to get you involuntarily committed. But I have yet to encounter a case where one doctor said admit and the other one didn't" (Ventura)

Other Social and Ethical Questions

"As a cultural anthropologist and activist I have personal and legal objections to involuntary treatment and commitment as well as a cultural critique. Institutions by which and in which persons free of criminal convictions are deprived of rights guaranteed to citizens of the United States are extraordinary indeed and must (for the sake of all of us) be looked upon as aberrations to be challenged in a free society. That the challenge to involuntary 'treatments' or 'commitments' comes largely from consumers, survivors, and ex-patients simply demonstrates to what extent the society has permitted these outrageous practices to become naturalized in the language and behavior associated with 'mental health' bureaucracies. This language (for example, the term 'treatment') inoculates freedom depriving practices with culturally acceptable curds of meaning. But there is nothing natural about these practices. There is nothing necessary about these practices. And there is nothing historically and culturally to suggest that human beings must be protected from themselves and from each other in the ways bureaucracies in the United States have found to be most expedient." (De Danaan)

"Involuntary commitment, forced treatment, and psychiatric control over decision-making are really not complicated issues, despite the efforts to make them seem so. The fundamental question is this: why do we take one group of people, those labeled "mentally disabled," and deny them the basic rights all other American citizens take for granted? We hear talk about "special needs," "vulnerabilities," "at-risk populations," and lots of other terms designed to obscure this fundamental question: is it ethically justifiable to confine people against their will, to subject them to procedures against their will, or to overrule their life choices on the basis of an ostensibly medical diagnosis? I believe that until we frame this question properly, as a human rights question, we will continue to make the simple complicated." (Chamberlin, b)

Paternalism and Self-Determination

"The laws authorizing _parens patriae_ intervention assume mental illness so interferes with patients' rational decision-making abilities that someone else must make treatment decisions for them. Paternalism is the core justification." (La Fond, 26)

The patient's sphere of self-determination has been made very small.

"The ethical system (if I can call it that) that drives the involuntary treatment system is paternalism, the idea that one group (the one in power, not oddly) "knows" what is best for another group (which lacks power). The history of our civilization is, in part, the struggle against paternalism and for self-determination. People in power are always saying that they know what is best for those they rule over, even if those poor unfortunate individuals think they know best what they want. The powerful seldom cast their own motives in anything but benevolent terms. The struggle for freedom has always been seen by the powerful as a denial of the obvious truth of the superiority of the rulers." (Chamberlin, b)

"Those who would overrule, on the basis of "incompetence," the dreams of others, are usually concerned with safety issues, with little regard to happiness. If we are truly concerned with protecting people we may deem to be incompetent, surely we must zealously protect their right to pursue happiness as well as their right to be safe." (Chamberlin, b)

"Reason is _not_ the exclusive property of a class of experts whose training and credentials certify the possession of a special endowment. Reason is a more humble, more universal, more democratic gift." (Yankelovich, p 240)

Need

Policy makers use the language of higher power, authority, and the passive voice to mandate needed services, needed treatments. The very language makes it sound as if the result desired by the intervener is based in a natural order, on natural law as compelling cause. Using the language of imperative distances the policy maker from involvement with particular people and specific situations. Using a word like need as a basis for justifying action hides that this is a personal judgment. Need ignores that there is an object, a value, a goal that is the professional's goal (unstated) or society's goal (unstated), but perhaps not the stated goal of the individual. (Caras)

Danger, Control, and Rehabilitation

"'Prevention of harm' and 'need for treatment' justify enlisting the expertise of 'science' in the armamentarium of social control. 'Cure' is no longer voluntary; instead, it is a coercive technique for controlling the behavior of out- of-control people." (La Fond, 25)

Locked hospital wards exist so that the outside world can maintain itself. There are many other forms of power; why is this goal only reachable through coercion? Many of the people who are subjects of coercive psychiatry already have been subject to trauma. Involuntary psychiatry exacerbates their post-traumatic stress, and may in and of itself create that syndrome. "If psychiatrists want to be like other doctors, I believe they should do as other doctors do: wait for patients to come to them, and treat those patients as free agents." (Chamberlin, b)

"As Karl Menninger wrote in his 1968 book The Crime of Punishment: 'The scientists and penologists I know take it for granted that rehabilitation--not punishment, not vengeance in disguise--is the modern principle of control.'" (La Fond, 30)

Because in involuntary psychiatry, the patient is not placed first, users of mental health services may resent the relief from social responsibilities that today's rehabilitative practices offer.

Fear of punishment is the fundamental intervention that affects outcomes. Fear could enhance regimen compliance and make a regimen look effective. Fear could diminish stability and make it appear that there was more need for even more coercive measures.

"We should never get sidetracked into defining better or more human ways of doing restraint or seclusion. By doing so we continue the myth that it is a legitimate form of treatment." (Chamberlin, a)

Alternatives

As Chamberlin points out, it is the task of the persecuted to reveal their oppression; it should not also be their task to develop alternatives. (Chamberlin, b)

Even so, consumers, survivors and ex-patients have been developing alternatives like talking some one down in a safe setting (without the fear of locks and meds), using personal assistant care as does the rest of the disability community, creating consumer controlled drop-in centers, and involving themselves in any way possible to reduce psychiatrogenic disabilities. "(A record of involuntary intervention) stigmatizes and oppresses. Once one has been categorized ... , one loses most of the power to determine one's future and control over one's identity and destiny. "(U)ltimately, self-realization requires the power to shape one's future, to control one's destiny, to choose from a variety of alternatives." (Bosmajian, 142)

The Ad Hoc Survivor and Consumer Committee for Health Care Reform has endorsed the position that "No forced or coercive treatment should by paid for by any measures enacted during health care reform."

Conclusion

An issue for deliberation is the ethical considerations around forcing citizens to be treated in locked facilities. When practicing involuntary psychiatry, physicians are an implementing arm of law. They restrain the liberty of same for the social benefit of many. There is an inherent tension here between beneficence and autonomy. But the medical value of "patient first" is not functioning. The individual is conformed; to say there is benefit is to impose standards which are not made explicit, and may not be medical.

Of course harm to others and community disruption must be subdued, in the legal ways to which a society has agreed, through the criminal justice system, not through emergency psychiatric practice.

Clay acknowledges the distinction between the sometime necessity for a controlled environment and retaining the right to informed consent. (Clay) Thompson argues that a genuine right to refuse treatment is fundamental. (Thompson)

"Psychiatric diagnosis is, in part, a process of decontextualization, of denying the real meaning that supposedly dysfunctional behavior has to the individual. What is really helpful is contextualization, helping the person to understand that thoughts, feelings, and emotions do have meaning within the context of that person's own life and experiences. Unlike involuntary psychiatric treatment, this kind of real, individualized help is impossible without the active participation of the individual being helped." (Chamberlin, b)

"The language of need is the language of paternalism. It makes room for beneficence and its cost is passivity and dependency. Instead, policy could use language that develops agency and personal power that enables and emancipates, language that minimizes medical and legal paternalism. Policy could look from the point of view of the individual's own life plan and purpose to provide a multiplicity of means for user productivity and user community participation." (Caras)

Medicine could restrict its reach, diagnosis more narrowly, refuse to collude; society better could tolerate eccentricity.

"It isn't strange that those persons who insist on defining themselves, who insist on this elemental privilege of self- naming, self-definition, and self-identity encounter vigorous resistance. Predictably, the resistance usually comes from the oppressor or would-be oppressor and is a result of the fact that he or she does not want to relinquish the power which comes from the ability to define others." (Bosmajian, 9)

"In my 13 years experience as a peer advocate, what I see is it is the people who take responsibility for their own recovery who are the ones who get well. Choice is very important." (Clay)

Contributors:

Sylvia Caras is the owner of Madness, an electronic information and advocacy list for people who experience mood swings, fear, voices and visions.

Judi Chamberlin is an Associate of the National Empowerment Center, a technical assistance center federally funded to serve the needs of the consumer/survivor/ex-patient movement nationally. She is an author, serves on many boards, and speaks internationally.

Sally Clay is President, Support Coalition International, a coalition of advocacy and support groups for people with "mental disability" labels.

LLyn De Danaan, Ph.D., is an anthropologist, activist, researcher, and faculty member, Evergreen State College, Washington State.

Ron Thompson is a Washington DC area attorney who argues relentlessly against the principle of forced treatment.

Rosemarie Ventura is a consumer with 19 years experience.

Please direct comments and further discussion to

sylviac@netcom.com This article is available through anonymous ftp to 129.32.32.98 cd /pub/psych

Submitted by Sylvia Caras, 146-5 Chrystal Ter, Santa Cruz CA 95060-3654.

Sources

Ad Hoc Survivor and Consumer Committee for Health Care Reform, c/o Bazelon Center for Mental Health Law.

Bosmajian, Haig, _The Language of Oppression_, Lanham, MD, University Press of America, 1983.

Caras, Sylvia, "Need."

Chamberlin, Judi, a, ThisIsCrazy e mail July 28, 1994.

Chamberlin, Judi, b, Choice and Responsibility: Legal and Ethical Dilemmas in Serving Persons with Mental Disabilities, Albany, New York, June 21-22, 1994.

Clay, Sally, ThisIsCrazy e mail July 26, 1994.

De Danaan, LLyn, private e mail July 29, 1994.

La Fond, John Q and Mary L Durham, _Back to the Asylum: The Future of Mental Health Law and Policy in the United States_, Oxford University Press, 1992.

Thompson, Ron, "Comments of a departing Trustee of the Bazelon Center for Mental Health Law," 1994.

Ventura, Rosemarie, ThisIsCrazy e mail July 28, 1994.

Yankelovich, Daniel, _Coming to Public Judgment_, Syracuse University Press, 1991.