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Patient and advocate Joseph Rogers still seethes when he recalls being bound in four-point restraints for three days and defecating on himself because he was not permitted to use the toilet, he said at a roundtable on coercion at APA's annual meeting in Toronto this June.
Although his account seems extreme, coercion remains "the issue in the consumer movement," said Rogers, executive director of the National Mental Health Consumers Self-Help Clearinghouse. When groups of mental health consumers meet, they "can't even get past" the issue of coerced treatment, he noted. This is true both of those who are pro-psychiatry and anti-psychiatry, he added.
Robert Michels, M.D., the Walsh McDermott University Professor of Psychiatry and University Professor of Psychiatry at Cornell Medical College, moderated the roundtable, which featured a panel of psychiatrists, National Alliance on Mental Illness Executive Director Laurie Flynn, and Rogers.
Many patients do deeply resent coerced treatment, said panelist Lewis Opler, M.D., medical director for the New York City region of the New York State Office of Mental Health. He has seen patients suffering from post-traumatic stress disorder as a consequence of their coercive treatment, he said.
Opler said that although he favors "coercive means of getting people into the hospital" when there is danger to self or others, there is a glaring need to do this in better ways than is now the norm and to preserve the patient's dignity. But he added that "there is compelling evidence that not to treat [for example, a person experiencing] an acute schizophrenic episode" is likely to worsen prognosis for that person.
"What you're saying is that somebody with a serious mental illness really has a right to be involuntarily treated with the best available treatment" to help him or her recover, Michels commented. But Michels reminded Opler that at the New York State Psychiatric Institute, where Opler now has an office, that same rationale had once been used to justify studies supporting lobotomy.
"When it was done, it was considered by professional leaders to be the best treatment available for schizophrenic patients who didn't have the judgment to consent to it, and [the rationale was that] therefore at times it might have to be embarked upon for their good, involuntarily. That's exactly the argument you just used, isn't it?"
Psychiatrists have a responsibility to "look at their own interactions with patients" and admit that they may find it easier to be coercive than to engage patients, Flynn asserted. "I don't think psychiatrists do a very good job or take very seriously the need to really engage their patients effectively in an ongoing way with respect for their individuality," she added. Patients need help to understand their need for treatment, and their need for "continuing to take responsibility for being a partner in their care."
Studies have shown that giving patients the right to refuse treatment creates an incentive for the psychiatrist to engage the patient, but also drives up the cost of treatment, observed Michels. Most patients who initially invoke their right to refuse eventually agree to accept treatment after speaking with a psychiatrist. The extra time required, however, has the effect of depriving other patients of psychiatric care, he observed.
But the bottom line is no rationale for substituting coercion for engagement, said Flynn. Society has a moral obligation to find adequate resources so that coercion is minimized.
"I come from this from a very personal angle" as someone who himself was coerced in his relationship with psychiatry, remarked Rogers, who said he suffers from bipolar disorder and psychotic episodes.
The problem of severely disturbed people acting out in public should first be addressed by trying to involve family members or friends, rather than immediately resorting to coercion, several panelists remarked. But a corollary of this is that homeless people estranged from their families are more likely to be coerced, said Michels.
The real-world outcome of lack of family and community ties is more often abandonment than coercion, said Rogers. "Coercive psychiatry, in terms of a continuum of care, is care." For some people, jail with "three hots and a cot" might be better than total abandonment and being left to sleep and die under a railroad trestle.
Michels paraphrased Rogers, commenting that "coercion is a form of care-the worst form of care-but better than no care at all." Rogers agreed, noting that "coercion is when society, for whatever reason, wants to continue to pay attention to you as an individual. And usually it's related to society's interests and not the individual's interest. But still, for some reason, you're on the radar screen." The great majority of the seriously mentally ill simply "fall off the radar screen," said Rogers.
One partial way to avoid coercion is the use of the Odysseus Contract, in which the patient, while rational, puts in writing what should be done in the event of a future psychotic break, said Opler, who has employed such contracts with success. One practical problem is that a patient likely to need such a contract is unlikely to have a copy on hand when needed. It is possible to set up a database that identifies whether a chronic patient has such a contract and give outreach workers ready access to that information, Rogers said. Patient advocates are working on developing such a system in Philadelphia, he said.
Outlawing all coercion "would be somewhat scary," Rogers commented. But coercion of the mentally ill results because we, as a society "failed them so far down the track that by the time we're coercing them that may seem to be the only alternative . . . . For me the way we get rid of coercion is to take mental illness very seriously and respond very seriously and create the kinds of support and systems in response to that so a person doesn't end up" in a psychotic state.
The National Mental Health Consumers Self-Help Clearinghouse Web site is