Risk Management vs. Dignity of Risk


Risk Management vs. the Dignity of Risk

By Jonathan Dosick

Observing public policy trends here in Massachusetts, one thing I’m struck by is the lack of clarity around the concept of “risk.”

What does “risk” really mean? Is it something to be afraid of and avoided at all costs, or something to be embraced? Perhaps both? One thing is clear: the juggernaut of increased and often-duplicative ‘risk management’ continues to pick up speed. New policies, rules and regulations are constantly being proposed, in the guise of ensuring safety for staff and peer/survivors.

Seeking to prevent harmful situations is necessary in the world of health care. But when is it enough? When does ‘risk management’ – the attempt to stop all incidents of potential harm to self and/or others – become a hindrance to healing? While the preponderance of ‘risk management’ may assuage public and political fears in the present, it creates more danger in the long run.

Of course, we know that ‘risk management’ is geared towards ‘negative’ risk – i.e., harm to self or others. But there’s another way of looking at ‘risk’ – taking positive risk, even if not sanctioned by traditional care, is a necessary part of recovery, empowerment and wellness.

Unfortunately, awareness of productive risk-taking – so eloquently expressed by the term “dignity of risk” – is getting drowned out by ceaseless calls for increased ‘risk management.’ And I fear that these attempts are keeping people from realizing true freedom and wellness.

Lessons From a Tragedy?

A few years ago, a young woman working at a Department of Mental Health (DMH) – licensed group home near Boston was killed by a resident – unquestionably, a terrible tragedy. The ensuing media coverage of that event has been a major catalyst for providers, DMH and lawmakers to consider measures that are significantly changing the mental health care system; in many ways, making the system more and more restrictive.

It’s difficult to address these issues in the face of such tragedy without the appearance of disrespect for the victim and her family, which is absolutely unintentional. It’s understandable that there are calls for change. But at the same time, it’s alarming that what is widely understood as fact seems to get lost so easily in the public arena – that persons with mental health diagnoses pose no greater of a threat of violence towards selves or others than the general population, and in fact are more likely to be the victims of violence. The mainstream media must be called out for their complicity in selling the lie.

In the last several months, we have seen the following in Massachusetts:

  • More “official” mental health committees focused on safety and risk, with little or no peer/survivor involvement;
  • A vaguely-defined bill calling for all residential mental health employees to be equipped with a “panic button;”
  • ‘Advocacy’ confused with maintenance of ‘status quo.” Large “advocacy” groups, afraid to challenge mainstream thought, see ‘mental health advocacy’ as seeking more funding for inpatient beds, increased access to medication and involuntary treatment – rather than empowerment and rights.
  • A pronounced shift by labor unions away from idealistic support of human rights and toward “protect our worker members;” and
  • The ever-present threat of involuntary commitment laws.


Myself and other advocates have worked for eight years to make access to the outdoors a requirement at inpatient units and residential facilities – a simple concept that gets shot down every legislative session. Why? ‘Costs too much, too much risk.’ Efforts to improve human rights in the system stay on the back burner.

Quest for the Quick Fix

“In America we like solutions. We like solutions to problems. And there are so many companies that offer solutions. Companies with names like: The Pet Solution, The Hair Solution, The Debt Solution, The World Solution, the Sushi Solution.”

– Laurie Anderson, “Only an Expert”

Modern America: the land of buy now, pay later. We’re perpetually at war with the unknown. Every day, advertisements offer the false promises of permanent fixes: Take a pill! Call a lawyer! Lose weight without dieting! In today’s fast-paced, always-on, plugged-in culture, we yearn for quick fixes to anything that ails, disturbs, or inconveniences us.

I see an unmistakable parallel with the mental health system. New rules on safety and risk are the result of a system desperately seeking a ‘quick fix’ where there is none.

Risk as Growth

When I first heard the term “dignity of risk,” it was a startling moment of clarity. Must ‘risk’ always have a negative connotation? Taking risks is a crucial part of recovery and wellness; I know it firsthand.

For me, recovery began with acceptance of the unknown. Since my first psychiatric hospital stay in 1989, which I saw as a temporary “respite” from a troubled adolescence, being admitted to the hospital was my “quick fix.” There, I could surrender my pain and insecurity (or so I thought) to people who would pay attention to me, and find a sense of community with my peers. When I left, I’d be a new, “fixed” person. Only thing was, that never happened. I always felt just as lost at discharge as when I went in – in fact, there was the added burden of disappointment that I wasn’t healed.

Between 1989 and 2002, I went inpatient ten more times. During my second-to-last hospital stay, supported by the insight of an empathetic staff member, I finally realized: hospitals aren’t truly therapeutic places.

I was forced to realize the truth: yes, others could help me. But it was up to me alone to go through the pain of living and getting better. That was as close to a “fix” as possible! Over the next few years, I gradually became more independent. I found housing that wasn’t connected to mental health; obtained employment, and got off Social Security benefits. I’m not boasting here; my point is, if I had been prevented from taking these risks, I wouldn’t be living the kind of life I choose, wouldn’t be an adequate peer specialist or advocate. My self-esteem, while still not perfect now, would be very low or non-existent.

I see so many of my peers who, having been ‘in the system’ for so long, have absorbed and internalized “learned helplessness.” They believe they cannot make their own decisions. Years of ‘custodial’ care, infantilizing “privilege” systems, and other forms of inequality have extinguished independence and self-determination from their psyches.

REAL recovery and self-determination relies on than the ability to choose what’s best for oneself. Choices like:

  • Living on one’s own;
  • Obtaining employment;
  • Getting off benefits;
  • Beating addictions;
  • Managing one’s own money;
  • Expressing oneself freely; and
  • Choosing what kind of healing one truly wants.


The ‘system’ needs to get serious about this, moving beyond using the lingo of self-determination to actually implementing it. Only then can people truly recover.

“Risk Management” is based on a rigid, fear-based view of health care services – made possible by a health care system focused on profit, insurance and liability. When I hear more plans for “risk management” (a new, duplicative policy was just introduced a few weeks ago), I see a system creating future lives of stifling dependency. That’s not only tragic, but it makes no economic sense: without taking healthy risks, people will remain dependent, and utilize far more services (costs) in the long term.  

The Mass. Department of Mental Health deserves great commendation for introducing a peer specialist workforce, and there has been some real progress. Accepting “dignity of risk” is a process, which may be uncomfortable for the mental health system. Insurers will fight it. Liability issues will inevitably be cited. And of course, any act of violence that can possibly be linked to ‘mental illness’ will continue to be catapulted to the public’s attention. The involuntary commitment crowd will be glad to amplify the stereotypes and fear. But to me, risk is a key to moving forward.

Maybe we need to understand that no matter how hard we try to prevent them, tragedies will always happen. As a society, the more we strive toward total control, the less likely we will achieve it. What if we looked at it another way – acknowledging that in the long run, there would probably be far fewer tragedies of all kinds if the peer/survivor population was allowed MORE freedom?

We must revisit the idea of risk and be alert to the dangers that new “risk management” rules pose to our civil liberties. When the dignity of risk is respected, we can achieve true recovery and wellness.


Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.


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  1. Wonderful article! I work in occupational therapy, and we think about risk there, too. No one wants to see a patient fall, but if a patient doesn’t push themselves, they are never going to walk again. Growth involves risk. Healthcare systems and malpractice insurance policies fear risk.

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  2. Yes, Jonathan! The increasing CONTROL does not necessarily mean decreased risk. People cut themselves, get pregnant, are raped and abused, and kill themselves – all in locked inpatient wards! The attempt at increased control does not stop unwanted events, but it certainly kills any relationship that staff could have with people – those relationships that could and should be healing relationships. Staff people go home traumatized, injured and even disabled because they are told they must be jailers and people fight back to defend themselves from coercion. This increased control does not serve anyone at all but only harms ALL INVOLVED. When can we have institutions that care, listen, and support people in their healing journeys instead of punishing, restricting, restraining, and traumatizing them – again?

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  3. Oregon ‘mental health worker’ fatally stabbed on the ‘front lines’.

    Brent Redd, a man sentenced to be labeled and drugged by psychiatry for attempting to murder a family member in 2007, was being involuntarily paid a ‘home visit’ by a worker from the government paid to regularly turn up at his house and make sure he was still drugged. He stabbed this worker to death Sunday morning.


    What’s the world coming to when a ‘mental health service provider’ can’t go around to her involuntary ‘client’s’ home to force things (drugs) into someone’s body without getting things (knives) forced into their own body?

    This murderer, formerly an attempted murderer of somebody else, was 100% guaranteed to have been ‘taking his medication’ at the time.

    This is the statement the Oregon ‘service’ where the murdered woman worked released:

    “We are working closely with law enforcement and will also jointly launch a swift and thorough independent investigation to ensure the safety of our mental health workers who are on the front lines every day.”

    The ‘front lines’. You see the allusion there right? the ‘front lines’.

    Note the murderer, supposedly a brain diseased automaton, was personally the one who chose to pick up the phone and call police moments later to turn himself in and alert the authorities of his crime, immediately after he chose to stab the ‘worker’.

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  4. http://www.kval.com/news/local/Mental-health-worker-killed-in-St-Helens-152213315.html

    “Migchielsen (murdered worker’s boss)said Warren (the knife stabbing victim) had worked for Columbia Community Mental Health for a decade as a support worker who made sure clients had their medications…”.

    ‘made sure clients had their medications’.

    “Former employees of Columbia Community Mental Health that we talked to said they believe mental health workers should not be alone when checking on patients who are living in the community.

    “They should double them up,” said Jerome Fesler, whose wife was delivering medication to the suspect just a few weeks ago before she quit over concerns for her safety.”

    Nice to have luxury to ‘quit of over concerns for safety’. If their clients had ‘concerns over the safety’ of the drugs being forced into their bodies I’m sure those concerns would have been labeled a symptom of a ‘brain disease’.

    Needless to say, a big golf clap for the judge who sentenced the murderer to psychiatry (which is really just sentencing someone to psychiatric drugs) instead of prison, back when he was on trial for attempted murder of a family member.

    Did you know that the home of a ‘mental health client’ counts as the ‘front lines’?

    I wonder if someone should alert the postal workers that they setting foot on the ‘front line’ when they deliver the mail to these houses every day?

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  5. Note the Oregon Psychiatric Security Review Board has been run with iron fist for decades by the same woman who gave us the ‘front lines’ quote mentioned above.


    “A state investigation found that the executive director of the state Psychiatric Security Review Board verbally abused an Oregon State Hospital patient, who said the abuse left him feeling “like a piece of trash.”

    Mary Claire Buckley’s conduct was “coercing” and “disrespectful,” demonstrating “poor judgment,” according to an inquiry by the state Office of Investigations and Training.”

    “Buckley made abusive comments to a patient Jan. 19 as the person was jogging with a staff member on the OSH campus.

    At the time, Buckley was riding in a vehicle driven by a board staff member. Rolling down the window to speak to the patient, she reportedly took him to task for refusing to accept a board decision that called for him to enter a Secure Residential Treatment Facility, or STRF.

    As recounted by the patient and the attendant hospital staffer, Buckley made intimidating remarks, such as: “I’m really disappointed in you. You’d better go to (STRF). If you don’t, there’s going to be ramifications. You’d better take that (STRF) placement. This is your only option. There is no other option for you.”

    Hopefully this recent murder on Sunday is enough to get his coercive dinosaur forced out of her leadership role in the Oregon PSRB. She’s been there since the late 70s, on the ‘front lines’ as she would call it.

    I’d hate to be one of the people owned by her and the government. When she rolls down that car window to bark an order at you, you know what value your life has.

    Life has ALWAYS been cheap in coercive psychiatry.

    May the murdered woman rest in peace, and may the murderer finally be sent to prison where he belonged in the first place.

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  6. This is fine. I’m all for doing away with involuntary commitment. Most psychotic behavior is criminal, and therefore people exhibiting such behabior will end up (even more so) in jails and prisons. Congratualtions, I guess your cause would have succeeded then, eh?

    Take away all involuntary treatment, and it will let all psychiatrists off the proverbial hook…medico-legally speaking. If someone is brought into an emergency dept. in Anytown, USA, after a suicide attempt, they can simply refuse treatment and walk out the ER doors, and try to kill themselves again. Again, congratulations.

    The thing you people don’t understand is that most psychiatrists DETEST this part of the job. Admitting an involuntary patient is a painful, laborious process. The paperwork involved is immense. It would make our jobs a zillion times easier if the patient could just leave. But no…the reason psychiatrists lobby for involuntary committment is because we care about patients. No psychiatrist benefits from an involntary admission. Shrinks covering the ER are paid a salary. We get paid the same no matter what, so what reason would we have to WANT to admit someoe against his or her will (again, you can’t imagine the mounds of medico-legal paperwork such an admission is rife with). Same thing with the ward physicians. They’re paid a salary, too. Whether there’s 2 patients on the ward, or 20, same paycheck. There’s no incentive to fill the wards people (at least not for psychiatrists). In fact, involuntary patients, once on the ward, are a handful.

    It’s funny. I read this blog because I like to hear all sides, and I think psychiatry deserves some of its criticism, but there’s this underlying theme of paranoia here, almost implying that psychiatrists want to CONTROL patients. Again, nothing could be further from the truth. Involuntary patients are not pleasant to work with. I personally hate working on an inpatient ward for that reason. I went into medicine to help people. I’m a psychiatrist. You know what I bring to the table. If you want my help, I’m happy to be your doctor. If you don’t, then best of luck to you finding help elsewhere. Seriosuly…I hope you find what you’re looking for.

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    • Jonathan, thank you for raising this discussion about the false consciousness of “risk management,” and thanks to anonymous for the explication of the extent to which psychiatry is about control and containment, down to the military allusions. Kevin N’s comments horrify me, doubly so because he apparently works on inpatient units. Kevin, are you not listening to your own words? You claim that psychiatry doesn’t want to control people, then you complain that “involuntary patients are not pleasant to work with.” Of course they’re not pleasant to work with, because they have been dragged out of their homes against their will to be locked up in your psych unit TO BE CONTROLLED. What about this situation do you not understand as “control?”

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    • It is nice to hear a voice from the “other side” because it has all been to one-sided so far. One would think that psychiatrists are hiding in dark corners desperate to catch people, drug them and section them. One gets also the impression that psychiatrists never help anyone which is, of course, untrue. There is though something deeply wrong with the “system” psychiatrists are working in and it is this “system” that needs changing. It has to do with public fear, politics, the compensation culture and responsabilty and risk taking as it is so beautifully put here.

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    • Kevin N. sounds like a real piece of work.

      ‘unpleasant to work with’.

      I’ve got news for you, you’re not ‘working with’ them. You’re working ‘on’ them against their will.

      It’s clear you’re a real ‘caring’ physician by your comments.

      Now go about your paperwork. Don’t forget to lock the filing cabinet, oh, and the doors of the facility in which you house the people who you label ‘paranoid’ for even thinking you’re about controlling people at all.

      “but there’s this underlying theme of paranoia here, almost implying that psychiatrists want to CONTROL patients.”

      You are not the one who gets to call somebody you never wanted anything to do with you a ‘patient’. I don’t care whether you ‘want’ to control people or not, the fact is you DO, and that is all that matters.

      As far as what you ‘enjoy’ and what you find ‘annoying’ in terms of filling out paperwork, I don’t care what you enjoy or what annoys you. Unlike those bonded to you by said paperwork, you signed up for this job.

      In a decent world, it wouldn’t be some quack simply ‘filling out paperwork’ that took away somebody’s basic human rights. It would be a proper system of due process where the person could defend themselves legally from what the government sought to do to them.

      I bet the pen you use to fill out your detestable ‘paperwork’ has a Seroquel logo printed on it.

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    • Kevin,

      I am very impressed by the overall quality of the debate, first in the blogs themselves, but also in the comment sections (including your contribution). While I don’t think anybody has a perfect solution to offer in place of involuntary treatment, the dialogue with the opponents of involuntary treatment is useful to understand how to improve the system (in a way that requires less control and violence).

      I am myself convinced that they are combinations of behaviors/threats, and other emergencies where a democracy has to control and coerce to make sure safety and human rights are guaranteed as best as possible to everybody.

      Law officers choose their career to serve and protect the peace, rather than to control other people, but the latter is a part of their job they don’t hide from.

      Similarly, psychiatrists should be proud of their mission of trying to improve the well-being of society (even if they should try to be more humble with their patients about the power and maturity of their science, and its failings). But they should not shy away from the fact that in involuntary treatment, control and coercion is used, and they have a role in it. Instead they should make their case that their role in this control and coercion is legitimate (and be prepared for the fact that some current aspects of involuntary treatment might eventually look counter-productive or illegitimate in the future, but “serenity is giving up any hope of a better past”).

      In face of accusation of violence, psychiatrists should defend themselves by assuming the moderate violence they use, tell why they think it is proportionate, and remind everybody it is not only law-sanctioned, but also law-mandated. Psychiatrists are occasionally a part of the legitimate state monopoly on violence that is fundamental to a peaceful democracy, and there is no shame in that (maybe there is a little shame in bad science, but that’s a different topic).

      My reply to people who argue that jail should replace involuntary treatment is that if you break the law, you don’t choose what form of control is used to restore the rule of law. Now of course, you should have the full recourse and accountability provided by the courts, everybody agrees on that. And the law is a work in progress, there is elections and petitions, lobbying, the supreme court, peaceful protesting, the internet and madinamerica.com to make sure it doesn’t stop improving.

      I have no excessive love for psychiatrists, I originally came to madinamerica to see the scientific debate. It was enlightening to see the other aspects of psychiatry, including human rights, and social aspects. The only kind of comments I have trouble interpreting is those who argue that the law-sanctioned violence used by psychiatry is comparable to the one exercised on a victim of rape by a predator.

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      • “the dialogue with the opponents of involuntary treatment is useful to understand how to improve the system (in a way that requires less control and violence).”

        Good luck with that Stanley Holmes.

        You don’t like rape analogies? fine. In both forced drugging and rape, one party is inserting unwanted things into the other’s body by force. The date rapist who drugs his victims and violates both their body and consciousness, is a better comparison.

        You have trouble interpreting this? you’d rather I acknowledge that it is law sanctioned violence? Fine. Execution is killing, and murder by someone who is not an agent of the state is murder.

        I think you need to remember Stanley Holmes, this is law sanctioned violence against people who haven’t done any violence themselves.

        How can violence be ‘proportionate’ to nonviolence?

        I don’t think forced drugging is proportionate to anything.

        But you’ve never been subjected to forced drugging, so there’s that.

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      • Stanley Holmes “My reply to people who argue that jail should replace involuntary treatment is that if you break the law, you don’t choose what form of control is used to restore the rule of law.”

        Most people who get psychiatry forced on them have NOT broken the law.

        So don’t start with the breaking the law argument.

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        • Just to clarify:

          – I did not start the “law breaking argument”, it was first introduced in several comments by people against any kind of involuntarily psychiatric commitment. They were arguing that even in case where the law is broken, people should be able to choose jail rather than a psychiatric hospital.

          – I understand that a lot of commitments are not due to breaking the law, and I am sure some of those are abusive (for instance, because of pressure from family members that might be more delusional than the hospitalized “victim”, but some of those commitments might still be better than leaving the victim with the family).

          – I should admit I am curious on how we can get an estimate for the percentage of abusive involuntary commitments (where the coercion used was disproportionate). I can perfectly imagine that the vast majority of abuses are not even brought to court due to the fear of judges siding with psychiatrists. I can also imagine that even if overcoming that fear, suing a psychiatrist might be unsuccessful at the end. But just the act of trying would help the cause of preventing recurring abuse. Does anybody has ever tried suing for unjustified involuntarily commitment? The justice system has been good in at least some cases against big-pharma, I was wondering what was the track record for forced commitments?

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      • I know people who work in jails and prisons and most of what they do is dispense psychiatric drugs to the inmates.
        One is a nurse, she gives the shots. One is an MD who takes phone calls from the juvenile center and orders meds without meeting the juvenile. He is also allowed to give the OK to restrain a child.

        In Ohio, they have a “model” prison system wherein the inmates are regularly drugged until they die. Some of the inmates, upon release, commit another crime in order to get back into prison, because they feel safe in a drugged out haze.

        None of the inmates has been a murderer, and in the juvenile system, many of them are not even violent, just acting out in adolescent rebellion. Swimming in a pond on private property got a teenager drugged and put in solitary where he suffocated because the restraints were improperly adjusted.

        My point is who thinks jails and psych units are two separate things?

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      • Is it possible that both patients and psychiatrists hate involuntary commitment?

        Kevin N. has presented his point of view, can he be refuted or questioned without the personal attacks?

        This might mean thinking a bit before posting, editing out the insults.

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    • How is most “psychotic behavior” criminal? Psychosis was explained to me as a loss of contact with reality, possibly including delusions or hallucinations. Most people who experience this are hardly guilty of criminal behavior. “You know what I bring to the table.” Again, what in the world does this mean? Most of the patients who first meet you probably have no idea what you bring to the table, and won’t have the “best of luck” finding help elsewhere if they’re involuntary. “No psychiatrist benefits from an involuntary admission.” Mine certainly did, to the tune of thousands of dollars for practically no face time! I am talking about money paid directly to him. If you feel you can’t help them, and DETEST and hate working with them, why are you?

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    • There are a couple of studies which show that outpatient treatment orders don’t reduce re-admissions. So on merely practical grounds any service provider that wants to help people who are distressed need to look at this and seriously consider how to design services which are not coercive.

      Working with seriously distressed people is difficult. Seriously distressed people don’t trust a lot of people because in most cases the people who they thought they could trust have abused them. If you don’t feel anxious and confused but then stick in there, then you are probably not going to be much help to anyone.

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    • I’m really not interested in what you say or what lines of reasoning you contrive to fool yourself with, I am a student of what you do.

      I love that smug phrase, ‘nothing could be further from the truth’, almost as annoying as ‘if only things were that simple’, or, ‘I live in the real world’.

      As for the point about suicide, perhaps you need to take cognisance of the possibility that one of the reasons why people commit suicide on release from those carceral institutions that are labelled misleadingly ‘hospitals’, is because the residuum of hope the patient had when he/she was taken into ‘hospital’ dissipated in the course of his/her stay in those dens of iniquity.

      A man’s right to top himself is endowed to him by nature. He has no say in coming into a world prepossessed in favour of the ruthless, the wicked and the speciously beautiful, where the totalitarians, bullies and idiots in our midst always find a way of screwing things up for other people. Therefore, his right to kill himself is inalienable, and anything else is an act of usurpation, usually by someone labouring under the delusion that he is possessed of the cure for all existential ills.

      What are you gonna do, pump him full of drugs that will only augment the morbid ideation, as is common with psychiatric drugs? How oblivious you are to the paradox of your cruel compassion.

      You say that most psychiatrists detest this part of their job, yet obviously to not such a degree that it stopped them from pursuing a career where they are mandated to do this invidious task, something that is one of the paradigmatic practices of the institutional psychiatrist. That’s almost as absurd as a hangman saying that he DETESTS hanging people, even though he took the job of his own volition. If you detested something as much as you profess, you simply wouldn’t do it.

      You say the reason why psychiatrists lobby for involuntary committment is because you care. Barf city! Even if there is no discrepancy between your declared and actual intentions, the history of your profession superabundantly furnishes us with examples of why people must be safeguarded against your intentions, whether good or bad.

      I do not care whether or not you want to control them, that is what you do. If it reviled you as much as it would revile me, then you would give such an environment a wide berth. Are you trying to fool us or yourself, although the two pretty much amount to the same thing these days? I think there is an underlying theme of self-deception in your comment.

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  7. I like Jonathan’s writing style.

    This right here instantly caused my blood to boil:

    “It’s funny. I read this blog because I like to hear all sides, and I think psychiatry deserves some of its criticism, but there’s this underlying theme of paranoia here, almost implying that psychiatrists want to CONTROL patients. Again, nothing could be further from the truth. Involuntary patients are not pleasant to work with. I personally hate working on an inpatient ward for that reason. I went into medicine to help people. I’m a psychiatrist. You know what I bring to the table. If you want my help, I’m happy to be your doctor. If you don’t, then best of luck to you finding help elsewhere. Seriosuly…I hope you find what you’re looking for.”

    Now, I’ll break it down:

    Tell me you’re a mock! Tell me you’re not a REAL psychiatrist – you’re *pretending* to be! Haaa, and then call me “paranoid”. Too funny. It seems you’re getting your butt kicked, so I’ll be easy with the rest of my thoughts.

    “almost implying that psychiatrists want to CONTROL patients.” Nobody has implied, it is stated CLEARLY (and BOLDLY). Psychiatrists / psychiatry DOES control people – especially by telling them that they’re para-noid (which truly is ignorant) and if you’re able to “diagnose” someone as paranoid, you’re able to secure rights over that person. Securing rights is a form of control. You’re a spoke in a wheel of a system that serves *itself* before anything or anyone else. Where the system aims to control (secure rights), so do you.

    “Again, nothing could be further from the truth. ” YSOB. You’re a flamer!

    “Involuntary patients are not pleasant to work with.” I wouldn’t want to work with you. But do try working with people as people, instead of patients, and see what happens. Would you like a FREE crash course on how to co-labor with someone? CO-LABOR. As Jonathan PERFECTLY wrote: “During my second-to-last hospital stay, supported by the insight of an empathetic staff member, I finally realized: hospitals aren’t truly therapeutic places.”

    He’s correct, hospitals are NOT places to engage a therapeutic process. Hospitals are where we “learn the ropes” which means COMPLIANCE OR ELSE, and “else” means restraints, forced injections and possible restrictions and / or loss of what limited freedoms there are.

    “I personally hate working on an inpatient ward for that reason. I went into medicine to help people. I’m a psychiatrist. You know what I bring to the table. If you want my help, I’m happy to be your doctor. If you don’t, then best of luck to you finding help elsewhere. Seriosuly…I hope you find what you’re looking for.” You’re a mock! You HAVE to be a mock. NOT a very professional thing to say, publicly. You’ve GOT to be a fraud of some kind. I’m not gonna diagnose you. I won’t “thing” you, by telling you what I see. But I will tell you where to go, I’ll give you directions:


    training, and please do incorporate some spiritually based compassion in your “work”, which is to CO-LABOR with P-E-O-P-L-E. Remember: “doctor” very often means “ego”, so please do keep that in check. Your patients will be so honored.

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  8. Dear Jonathan,

    I think the resistance you are facing with your fresh air initiative indicates that what is really required is a total system redesign. What you need to propose is a complete acute care system that:

    1. Provides better comfort and treatment to patients than available in current hospital settings
    2. Has better outcomes than current treatment methods provided
    3. Can be provided at a cost lower than current cost of inpatient care

    My suggestion would be to get a team together of forward-thinking health care managers along with an architect and interior designer to work with your peer group to come up with what an alternative model would look like. Since you live in MA, this shouldn’t be hard to do, as our state has the best creative minds out there! 🙂

    The challenge with using risk minimization as the sole criteria for decisions, as you rightly noted, is that at some point, you get lower outcomes due to a lack of ability to innovate and try new approaches. As we say in the business world – no risk, no reward!

    Good luck with your initiative, and congratulations on your ongoing recovery.


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    • This is an excellent game plan for planting the idea and maybe seeing it happen. For people asking, what can I do — here’s an example.

      If you present a good case, you may not convince everyone immediately, but you make allies who can help carry the idea forward.

      Thanks, Alexa.

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      • It asks an important question: what would acute care look like in an ideal world? Take out the financial issues, the insurance companies, state regulations, and just ask the question. Once you have a vision, then begin to think about all these other issues and how to work with them, or around them. But the most important thing is to first be able to articulate what the vision is. The challenge of so much of advocacy is that all it does is articulate what is wrong with current models, without elaborating an alternative vision for what could be possible.

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  9. Much of what Jonathon says is true. As a mental health provider, I own the notion that in inpatient settings, which is where I have worked for 32 years, the goal is to control people until they control themselves. inpatient units are places where the pieces of a puzzle or mystery are identified and outpatient is the place where the long hard work of putting those pieces together occurs.

    A person taking a risk by moving forward in their life is not the same as a person being at risk to be assaulted or a person at risk to harm themselves. Should I as a mental health professional take a risk with your life or the life of a loved one by not responding or saying it is an acceptable risk to release a suicidal person into the community? It is not the fear of liability that drives my decision to be conservative. It is the fear of being wrong and having another human being end up dead, in what would have been a preventable death, becuase I made an error in judgment.

    I have lived experience with mental illness, having spent more than one year of my life hospitalized. I agree that my care was not optimal and that in retrospect many errors were made, the decision not to treat me with antidepressants, but instead to treat me with antipsychotics, in the absence of psychosis. I was unnecessarily hospitalized for much of that year, but I have to own the predicament that I put providers in. In my desperation for help, I would feel that my life was constantly on the line at my own hand. Priofessionals reasponded with the only help they knew how to give, which was to hospitalize me.

    Many things go wrong in the hospital. Many things go wrong most any where. many people who work in this field are hardened and more uncaring than they should be. Many others are good caring people trying to do their best to help with extremely limited resources. I agree that sometimes the best way to help a person is to get out of their way. As a provider, that is not always the easiest thing to do.

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    • “the goal is to control people until they control themselves”

      I don’t work at a psych “hospital”, never have, and never will. I work at a crisis center that is part of what in this country, Denmark, is called “social psychiatry”, and probably best, though not entirely, compares to “community mh ‘care’ ” in the U.S. At my work place I meet a lot of “patients” (we don’t call them that, they’re citizens, as is everybody who comes to the crisis center, labelled or not). None of them is capable of controlling themselves. They are controlled by the drugs, and everything the drugs can’t control for them, they come to us to take control over. More helpless than a newborn.

      Nobody has yet learned to take responsibility for themselves, and control their own life, by having others control them. If the goal is to put people into the position to take responsibility for themselves, and control their own lives, they should be given the opportunity to take responsibility for themselves, and control their own lives, while they are given all the guidance they ask for, and all the encouragement they need underway.

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  10. Reading the comments brings home your original point, Jon…what, exactly, is “risk.” Unfortunately, situations like the Stephanie Moulton murder lead to immediate, reflexive and exaggerated responses. Yet, often, when we look at the actual circumstances of the situation, there are factors at play that have little to do with a psychiatric diagnosis, as was the case in Massachusetts.

    The response is to redefine “risk” to include much, much more than imminent risk of ‘danger to self or others.’ I know in my own experience, I was hospitalized against my will many times for words and actions that were no where near “imminent” risk. (Oh, I’m sorry – these were voluntary. Given the option of signing a three-day or going before a judge, I opted for the former knowing I had no power in the court system because I was the one with the diagnosis.) Instead of the legal “imminent risk” standard, “risk” in our mental health system includes everything from a pattern of ‘refusing’ to ‘comply’ with treatment, not following the rules, making choices that others deem as ‘unrealistic’ or not healthy, or just not “having insight” into your ‘illness.’

    Similar to your thoughts, Jon, my question is always, “what makes ‘not risking’ risky?” Not to insult the psychiatrist, but the reality is that psychiatry is not science. Emotional distress is born of a unique combination of environment, social, spirit-ual and physiological factors that are not well understood. Healing similarly comes from filling the needs of the body, mind and spirit. What makes ‘not risking’ risky? It kills the mind and breaks the spirit. The body without a working, curious, problem-solving mind and without a spirit that believes in life and the future is just a shell.

    We need to separate true risk from imagined risk, or risk to the agency, the system, the psych profession or the pharmaceutical industry as a start. Perhaps if we worked more in partnership, collaboration and respect, the number of situations that arise to the true line of “imminent” would be greatly diminished.

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