On Gratitude
Sylvia Caras, PhD

"Shortly after my last major episode, where I was hospitalised under the mental health act, I expressed 'gratitude' to those who had sectioned me. In retrospect, I feel I was grasping at the crumbs under the table. I had been so humiliated and demeaned, I no longer had any self-esteem evident, and felt I had to be grateful to the world for allowing me to exist in it. I can say, with the wisdom of hindsight and some time to buffer the pain, that there were in fact many options available, and few involved coercion of any description. My 'gratefulness' came from a deep sense of unworthiness which was exacerbated by forced treatment." (Hansen)

Introduction

Walking from our rooms at Beit College to the Royal College of Psychiatry on our way to a London World Federation of Mental Health (WFMH) board meeting, John Copeland and I were talking about forced psychiatric treatment. He, a psychiatrist, answered my objection by describing to me an instance of the appreciation of his patient, that after involuntary hospitalization he expressed gratitude.

A year later, at the Melbourne Convention Center, at the last meeting of my WFMH board service, Leo de Graff and I had a similar conversation and he also spoke of patient gratitude, in a way that firmly overrode any of my other objections to the practice of coercive care.

The two conversations raised many questions. I knew that coercion is an ordinary feature of psychiatric hospital practice, that psychiatry and psychology force treat. I thought about the power needs of the professionals, about who is drawn self-righteously to dominate in this way, and I wondered why value the authenticity of the statement of gratitude? Why not treat it as delusional?

I decided I wanted to think about force and gratitude more systematically. The use of coercion in public health and the range of objects and feelings of gratitude was far beyond what I wanted to consider. I decided to look and only in a narrow way, at involuntary mental health interventions and the relationship between the ones who order them and the ones who are subject to them. I needed to clarify to myself my discomfort and sense of confusion with accepting gratitude as a justification. Here is what I found, the beginnings of an exploration.

I started by looking up gratitude in an online dictionary: 1. condition of being grateful; a warm sense of appreciation of kindness received, involving a feeling of goodwill towards the benefactor and a desire to do something in return; gratefulness. (OED)

Then I began to talk a little with colleagues about gratitude, posted to an email list, Googled a little, did some browsing in a few online journal indices available at UC Santa Cruz, and read four articles that the Santa Cruz Public Library had photocopied for me by ordering from the InterLibrary Loan service.

I had not expected to see the concept of gratefulness located in ethics, discussed by philosophers who were considering duty, and obligation to appreciate the receipt of beneficence, as well as the duty to give. But I saw very little about the desire to receive, the feelings and expectations of the doer to be a recipient of gratitude

Ethics

Post-modern and feminist writers have more nuanced analyses, but around gratitude, in a traditional way, Berger laid out the issues - the value of the benefit, the degree of sacrifice, the voluntariness of the giver, the response of the receiver. He sums up, "If I am the recipient of another's benevolence, his action indicates he cares about me, he values me, he respects me. ... I am an object of his concern." He then continues, "The practices involved in gratitude presuppose that the agents are manifesting their mutual valuing of one another as ends in themselves; ... expectation of concessions as a sign of gratitude can be an oppression." (Berger) Expectations of concessions? Does this explain my discomfort? Expected gratitude taken as in-advance permission for coercion?

Power

As I organized to write, I found myself frightened at the idea of questioning the motivations of psychiatrists in a form that I intended to make public, to ask about their need for praise. I am afraid to sound foolish, disrespectful. I was, and still am, afraid that my ideas will be judged by being tucked into a DSM category.

"Historically, the powerful and privileged have imposed their guardianship upon the powerless and have felt the latter should be grateful for their 'care.' ... When the powerful are generous, it may be simply that they enjoy giving. It supports their own self-esteem; it demonstrates their wealth and power. Such generosity can be accompanied by insensitivity to others wishes' with regard to becoming obligated. The powerful can afford not to care whether others are obligated or not. ... Genuine benevolence is incompatible with disregarding others' willingness to become obligated. Those who lack such regard thereby lack respect. And willingness to become obligated to others despite their lack of respect raises the question, at least, whether one lacks of self-respect." (Card)

Physicians

Physicians are trained to believe they have a duty to help. It feels good to do that duty. But if despite the patient's wishes, then to whom is the duty? How much is patient recovery necessary to physician well-being? What about reciprocity? McConnell writes that debts of gratitude require that the benefit be granted voluntarily, not be forced on the beneficiary but be accepted, and that the grantor exercised non-routine effort (McConnell, p 14).

Mental health professionals expect treatment compliance.  I kept wondering about physicians' expectations, and what happens when they are not met? Is an expectation of gratitude an expectation of emotional compliance? Does an expectation of respect and gratitude influence the interventions they select? When physicians coerce, do they think "He's alive; he should be grateful?" Do they think "They'll thank me later?" If gratitude is not received, does that disappointment turn to retaliation - I'll treat you 'til you are grateful! ? Can gratitude serve as a foundation for a healing/helping relationship?

"Receiving sincere expressions of gratitude can be a powerful experience, and may lead the psychiatrist to a presumption of gratitude on the part of the patient. ... However, these patients must be relatively rare in relation to the number of patients who are committed." (Gardner)

There are many threads to think about while considering the expression of grateful acceptance of coercion - ethics, morals, physician-patient power relationships, ...

Morals

"We define moral mandates as the specific attitude positions or stands that people develop out of a moral conviction that something is right or wrong, moral or immoral. Moral mandates share the characteristics of other strong attitudes -- that is extremity, importance, and certainty -- but have an added motivational and action component, because they are imbued with moral conviction. ... When people had a moral mandate, due process was an irrelevant concern. Moral mandates appear to lead to the legitimization of any procedure so long as the mandated end is achieved." (Skitka)

Love too can be used as a moral mandate to deny due process and to substitute judgment. ... The peculiar feature of power struggles in the family is that they occur in the name of love and demand from their targets willing compliance and even gratitude. (Kanter)

Coercion

"The process of perception of coercion may be incompatible with gratitude because coercion undermines moral community." (Gardner)

When force is used, community belonging is undermined because the lock-up is a threat to the already fragile self. The shame -- being transported by police, having possessions explored removed, the indignities of intake - can lead to so much dissonance that the person accepts the system's view that there is a perception of worthlessness. Admissions procedures and intake may mimic familiar abusive relationships. Small kindnesses like removing handcuffs create great appreciations. The requirement of permissions for the simplest things, phones, showers, haircuts, maintain the medical staff's power. Patient isolation is maintained within the unit where the perspectives are either that of the system or that of the patients. Alternative nurturance like peer support is discouraged and the points of view of other inpatients are discounted by staff as symptomatic. Admission of disease is the way to discharge, claiming to now have insight, confessing that non-compliance was a mistaken choice. Otherwise long-term holds and medications loom. Inpatients become very aware of the needs of the treating staff. This coping strategy is often charted as manipulation. The rage that, if not suppressed by self-control, is medicated, later can turn to social activism or anti-social actions. After release, the threat of further interventions continues to control: this can happen once; it will happen again. The system insists it must substitute judgment because of the person's decisional impairment: non-compliance and lack of gratitude are indicators of the need for treatment.

You may recognize these parallels to the expression of the Stockholm Syndrome in groups held against their will in physical and symbolic/metaphorical/emotional/bondage.

Stockholm Syndrome

A characteristic of the Stockholm Syndrome is that the captives begin to identify with their captors. They believe that the captor will not hurt them if they are cooperative and even positively supportive. The Stockholm Syndrome was originally developed to explain the phenomenon of hostages bonding with their captors. Researchers have concluded that this seems to be a universal phenomenon which may be instinctive and thus play a survival function for hostages who are victims of abuse.

This syndrome can occur where there is a perceived threat to survival, a perception by the captive of some small kindness from the captor within the context of terror, isolation from perspectives other than those of the captor, perceived inability to escape. (Stockholm Syndrome)

Psychiatric captivity/treatment is justified by being in the best interest of the community and the person.

However, Gardner concludes "Commitment is inherently demeaning, because the caregiver must believe that the patient cannot order his or her affairs. Thus, the caregiver, however benevolent, must demean the patient and, in this way, invalidate a condition for the patient to be grateful."

"Imagine Dawn who feels grateful to her abusive father for the minimal aid he has given her and consequently obeys his every command. Dawn feels grateful toward her abusive father and expresses her gratitude by obeying his abusive demands. Dawn's expression of gratitude clearly fails to show the kind of self-respect that she deserves and is consequently morally problematic. Expressions of gratitude, therefore, can be a moral problem. This is one way that gratitude can go wrong - when expressions of gratitude serve to support a morally indefensible situation. ... When gratitude to others is coupled with a lack of self-respect there is a problem. ... The reasons for having gratitude, however, can easily be inappropriate. The expressions of gratitude can also be inappropriate." (Fitzgerald)

"Perhaps the point could be made here that gratitude, for some, can be a way of rescuing our dignity. If we state that someone has done us a favour, and that we need to be grateful, it rescues us from the shame and loss of dignity that coercive treatment incur." (Hansen)

Reciprocity

Reciprocity is an element of gratitude. There is a duty to be grateful for help and things received. But the professional-patient relationship is unequal. What is the reciprocal requirement expected of a patient? If reciprocity is seen as part of patient transference, a boundary problem (Texas Medical Association) there is no opportunity for repayment and attempts may be perceived as inappropriate.. A burden of debt remains, no way to honor the expectations of social discourse, the inclination to return the favor. But does a patient owe if someone is doing their job? Mere dollar payment, especially if there are insurance benefits, may feel inadequate to discharge debt. Thus the inequality of the professional-patient relationship is maintained and a permanent undischarged debt retained. How does this imbalance color the gratitude that a patient gives?

Informed

There is considerable discussion about the capacity for informed consent, wondering whether a person in a fearful and fragile state can understand and consent to interventions. I wonder about informed gratitude. "Few committed patients are retrospectively grateful for their care." (Gardner) If a patient is sufficiently diminished in self-consideration, is servile, is self-deceiving, is compliance with the medical expectation of gratefulness worthy gratitude? Does a decision to be grateful demonstrate insight, or lack of insight?

Manipulation

Some people diagnosed with psychiatric disabilities are unusually sensitive to the moods and needs of others. At the moment that gratitude for coercion is expressed, the patient may be responding to the need, even guilt, of the physician. If the patient expects a continuing relationship with the treating physician or hospital, the patient may be expressing appreciation in a protective and defensive way, so that the medical record reflects cooperation and insight and the treating relationship feels hopeful and safe. The patient may know that a presumption of gratitude exists, and so complies.

Just Gratitude

Providers who dwell on gratitude as an excuse for coercion are receiving that gratitude at a certain point in time and subsequent reactions might be different.

I am not questioning the authenticity to the patient at the moment of expression of the patient's feeling of gratitude. I am exploring whether this feeling is more than fleeting, is worthy, informed, or, to use Bergers's term, deep. What is the feeling later, when the patient may be in a more self-determining situation?

Relatedness

Do treating professionals yearn for relatedness, identify with their patients, want an affirmation of their professional competence? Might they be using appreciative patients who acknowledge having been helped so they can feel selfless, devoted helpers, feel needed? Might they feel resentment when patients are ungrateful (Gabbard) and so don't provide that gratification? How self-serving is it if providers use the patient as an object to gratify their need by coercing the patient into treatment?

"The poor create an opportunity for members of the medical profession to define their working lives around helping the vulnerable. ... There can be no rescuer without someone to rescue, there can be no benefactor without a beneficiary. If giving to those in need enriches one's life, then one owes a debt of gratitude to those who needed the gift. The plight of poor patients gives the medical profession an opportunity - an opportunity to return the medical profession to a servant profession." (Fitzgerald)

"The picture that was held up of my life without psychiatric intervention was bleak and short and painful and horrid and all completely made up to terrorise me into compliance." I felt so bad and they told me I was bad and I accepted their view and believed them when they said that they fixed me and therefore "I was dutifully grateful. Of course I was totally without rights such as review during this time. Now I understand what it all meant I am no longer grateful." (Clarke)

Conclusion


Because it substitutes physician judgment for patient wishes, patient gratitude is an inadequate defense for medical coercion. I've explored and learned a lot and clarified why "but they are grateful" is superficial, and after all that it comes down to a very old concept: with Winkler, restating the Golden Rule, "We should not determine the needs of others by our own needs."


References

Berger, Fred, Gratitude, 1975. Ethics:85, 298-309.

Card, Claudia, Gratitude and Obligation, April, 1988. American Philosophical Quarterly 25:2, pp 1115 - 127.

Clarke, Sara, personal correspondence, 3 March 2003.

Fitzgerald, Patrick, Gratitude and Justice, October, 1998. Ethics, 109:1, pp 119 - 153.

Gardner, William and Charles Lidz, Gratitude and coercion between physicians and patients, February 2001." Psychiatric annals 31:2, 125 - 129.

Hansen, Chris, personal correspondence, 12 Mar 2003.

Kanter, Rosabeth Moss, Intimate Oppression, 1974. The Sociological Quarterly,15: 2, Spr, 302-314.

Loxterkamp, David, MD, Border Crossings: On the Boundary of the Physician-Patient Relationship, Journal of the American Board of Family Practice

http://www.medscape.com/viewarticle/417827 .

McConnell, Terrance, Gratitude, 1993. Philadelphia: Temple University Press.

Minkowitz, Tina, personal communication, 30 April 2003

http://dictionary.oed.com/

Skitka and Mullen, The dark side of moral conviction, 2002. In Analyses of social issues and public policy, 21, pp 35 - 41.

Stockholm Syndrome http://www.secasa.com.au/survivors/the_stockholm_syndrome_1.html

Texas Medical Association http://www.texmed.org/cme/phn/mpp/venues_boundaryproblems.asp

Winkler, Gershon and Lakme Batya Elior, The place where you are standing is holy, 1994. New Jersey: Jason Aronson. p 78

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