Six months ago, I was just starting in a position called “Treatment Team Coordinator” at a secure residential treatment facility. In my home state, such facilities are referred to by the mental health system as “SRTF” and are part of the system for persons psychiatrically committed, either civilly under the jurisdiction of the county commitment investigator or criminally under the jurisdiction of the state’s Psychiatric Security Review Board (or PRSB.)
Prior to that I worked as lead counselor at a crisis respite program for persons experiencing an acute mental or emotional crisis. This program provides room and board for up to nineteen adult individuals in crisis for a period of 7-10 days. Admission to the program was entirely voluntary, and individuals were free to leave if they chose to do so. While at the program, individuals would have the opportunity to receive immediate crisis counseling and case management services to assist in establishing long term counseling, medical services and connecting to housing programs, outpatient substance recovery programs, etc.
This former job turns out to be far more in keeping with my own values and sense of personal ethics. But at the time I felt that I had to move on. I have a deep passion to serve other human beings with my work. Yet I have always felt that my greatest gifts were in seeing the bigger picture, empowering teams of people, advocating for change and shaping the vision of an organization in the community. The treatment team coordinator position was described as a position that, in addition to clinical case management duties, included supervisory, leadership, and program development opportunities. This seemed to be the opportunity I was looking for: to grow within the agency into positions of leadership that could allow me to be a voice for change. I felt like I had to pursue it.
Looking back now, I see that my decision to accept the position of treatment team coordinator was both short-sighted and representative of tunnel vision. My agency holds as its core values of service a “person-centered” model in which the rights and autonomy of those we serve are respected, in which service is focused on empowerment and collaborative partnership rather than coercion, and where trauma-informed practice is a cornerstone of our work. Thus, when I accepted the position at one of its secure residential treatment programs, I told myself that people in the program must really “need” to be there, and that they would be treated in accordance with these values the agency holds dear.
I have just completed six months in this position. What I have discovered instead is that despite good people sincerely attempting to uphold the values and vision as stated by the agency, there is an irreconcilable disconnect between those values and a secure residential treatment facility. I have come to understand that the word “secure” is just a euphemism for involuntary, “residential” is just a euphemism for prison, and “treatment” is just a euphemism for behavior corrections. I work in an involuntary psychiatric correctional facility.
Correction, Compliance, Conformity
I now realize that I overlooked many important questions when making the decision to accept this role. At the time, I minimized the importance of questioning whether working as part of a program that incarcerates persons against their will on psychiatric grounds was something that could reconcile with my own values and beliefs. I had never worked in a program that was “secure” or that had psychiatrists on site pushing drugs. I had never worked for a program that was so deeply embedded in the state system of mental health with its own expectations and agenda. In other words, I had never really come face to face with the medical and authoritarian model of treatment from the inside. Despite being slightly “forward-thinking” when it comes to mental health, I still assumed that residents of this facility were persons who:
(a) absolutely needed to be there for basic safety and that all other less invasive options had been thoroughly exhausted,
(b) would receive deep empathetic and compassionate counseling with the goal of understanding the lived experience of the individual, helping the individual connect with the underlying meanings and recognize the deep feelings associated with extreme emotional states as the primary support offered, and
(c) would receive support focused on helping individuals accomplish their own goals and develop effective assertiveness and self-advocacy sufficient to navigate society without surrendering their autonomy and individuality to it.
Each one of these assumptions was categorically incorrect.
First, there is almost never a situation in which all other less invasive options other than involuntary psychiatric incarceration are exhausted. Instead, for a wide variety of reasons, other less invasive alternatives are not considered. One reason is the structure of the system itself, and the intersection of extreme financial, political and power reasons that cause the ultimate goal of “mental health” services to be conformity to social “norms” and the development of an “authority-compliant” personality in “problem” individuals.
Since I started my position as treatment team coordinator, I have been confronted over and over again by individuals who have been committed for little more than being financially and behaviorally “annoying” to persons in positions of authority. When an individual experiences an extreme or emotional state, and engages in behaviors such as taking some of his/her clothes off in public, being verbally “aggressive” (not physically violent) toward an authority figure such as a police officer or a hospital psychiatrist, or temporarily acting as a danger to himself/herself or others, these behaviors can and regularly do lead to the individual’s basic rights being stripped away.
Yelling at people, “agitation,” or verbal hostility should not be enough to justify involuntary commitment and the forced drugging that inevitably comes with it. Yet people frequently experience psychiatric incarceration because they are inconvenient to a system that does not and will not provide empowering, listening, understanding relational care.
Second, the state system of mental health (our program’s sole source of funding) sets the standard and expectations for the kind of “treatment” we provide to psychiatric inmates. The primary driving value underneath all the rhetoric of state mental “health” is coercion – compelling people to be compliant to an authoritarian society, to “get with the program,” to adapt to “social norms,” and to “behave” in ways persons in authority define as “appropriate,” which too frequently just means not inconvenient to the system.
This is why the predominant modality of “treatment” is some variant of a very dated and simplistic behaviorism. For the life of me I cannot believe that there is anyone left in the world who still thinks that one can elicit lasting behavioral changes in another person through a series of external sanctions and rewards completely apart from any serious attempt to understand the underlying emotional experiences that elicit behaviors.
I am not suggesting that there are no instances in which professionals and individuals can work together toward lasting behavioral changes, or when “problem behaviors” are identified by an individual who desires change. What I am suggesting is that the mental health system is overwhelmingly focused on correcting “problem” behaviors with the hopes that people will better conform and adapt to social norms and thus be less of a problem to the rest of us.
It is also why it has not been at all uncommon for me to attend training or lectures or read books in which the expert says things such as “I don’t care about your past, and I don’t need to know how you feel. All I need to do is identify what I determine to be your problem behaviors and find the right combination of positive or negative incentives to get you to behave differently.” Success is measured by whether or not someone becomes more compliant with an “authority’s” expectations, not whether or not someone experiences emotional and personal healing. For most people I work with who are incarcerated for psychiatric reasons, their happiness or own assessment of their quality of life is not an issue that informs treatment planning; whether or not they are behaving most certainly is.
Drugging: First, Frequent and Forever
Forced drugging serves these behavioral compliance goals. Where I work it is often said that we do not force people to take medications. What is meant by that is that we are (thankfully) not a restraint or seclusion facility, which means if someone refuses to take medications, we cannot force them down and inject them. And I must point out that at one point in time, our program was licensed for seclusion and restraint. The program changed because the agency came to realize how inconsistent seclusion and restraint was with the values of trauma-informed, empowering care. The agency also received a lot of guff for making this decision from external partners in the mental health system. I respect the agency’s willingness to make this commitment.
But sadly, I contend that forced drugging is still a living reality in my facility. Our psychiatrists and psychiatric mental health nurse practitioners (working at our agency by contract from a separate medical group) start from the operating assumption that people “need” powerful anti-psychotics, mood stabilizers, and benzodiazepines on an ongoing and permanent basis, and often times “need” combinations of two or even three anti-psychotics at once.
If a client dares to talk about wanting to stop taking medications or wanting to look for alternative means to experience healing, this works against his/her chance of being released, and greatly increases the likelihood that our facility will seek to recommit the individual for even more psychiatric incarceration. If a person stops taking his/her medications while in our facility, two discussions begin among the professionals:
The first discussion is, how do we convince the person to take medications when they do not wish it? I define that as coercion, no matter how gently the coercion is applied. The second discussion is, if we fail to do the former, when can we remove him/her from our facility and into an even more secure level of care (typically where medications can be physically forced against a person’s will?)
In my time in the facility, there has been less discussion about understanding what an individuals’ needs might be, why they do not wish to take medications, what they are feeling and experiencing, and how we might be able to partner with them in alternative, more empowering, and less intrusive ways. Given the constraints of the mental health system and the requirements placed on our program by that system, it seems to me that my colleagues simply do not know how to provide alternative options.
From Counselors to Corrections Officers
The state mental health system and our program speak of the provision of “clinical treatment services.” In my opinion, we provide minimal clinical treatment services. I feel as though I am surrounded by colleagues who want nothing more than to engage in meaningful, empowering, therapeutic dialogue with the people we serve., but the very nature of our program and its place within the system of mental health prevents this from happening in most cases.
My experience with the state mental health system has made it clear to me that its primary focus is on behavioral correction, with little to no concern for identifying underlying emotions or understanding the meaning behind extreme emotional states. In fact, our county changed its name from “Mental Health” to “Behavioral Health.” I don’t even know what behavioral “health” means.
As a result, we are not allowed to be mental “health” clinicians. We are corrections officers. Providing genuine clinical support services would require us to engage in actual counseling and therapy. I mean “therapy” in the now arcane sense, in which people discuss feelings and emotions and program staff seek to understand the meaning behind the lived experiences of the people they serve.
In the eyes of this social worker, that is clinical work. Behavioral modification is not clinical work, but rather the work of correction officers. The obsession with corrections through the form of behavioral “interventions” leads to excessively paternalistic and condescending attitudes towards those we serve, even if a person really has no conscious desire to hold these attitudes. Sadly, many people do desire to hold these attitudes yet say without flinching, “We know best.”
That’s not to say that there might be no place engaging in meaningful work with an individual that might lead to self-selected changes in their behavior. But those changes are lasting only when they emanate from within the person, not when they are the product of attempts to incentivize from without.
Meaningful behavioral changes come last, not first. And if they come at all, they come only when the individual begins to make sense of the meaning behind his/her own lived experience, and from that foundation, finds the internal resources to fuel change. The clinical task is to support the individual process of self-awareness and self-understanding as the vehicle for recovery.
We are not doing that.
Six months ago I had a dim awareness of the conflicts I’d be faced with as I assumed this position. It was my hope that despite these obstacles, I would feel a sense that powerful and important work could be done. To this day I continue to believe that the people I work with are good and decent people; many of them really do want to be a healing force in the lives of others. But I think that many people have come to accept that the system is “just the way it is,” and that they must try to “do their best” within it rather than openly resisting it. I cannot do this.
I believe our agency is experiencing a crisis of contradiction. The agency really has taken many steps in keeping with its stated values of compassion and empowerment. Many other agency programs throughout the county are voluntary and address acute emotional crisis as well as basic needs such as stable housing and community supports. Many programs effectively utilize peer advocates, and respect for their vital role is growing.
But despite all this, I see one major glaring problem: if the agency truly wants to serve its stated values and vision with consistency and without contradiction, it will be required to remove itself completely from the psychiatric incarceration business.
I believe that operating a locked facility to serve the interests of a fatally flawed state mental health system is contrary to a sanctuary model, to trauma-informed care, to client-centered and empowering practice, and to a mission of fostering healing partnerships in support of recovery.
My personal question is this: what do I do now?
I will readily admit that I am confused and anxious as I question what happens next for me. Tomorrow, it will be time for me to start another work day. If I simply hand in my resignation, I will be closing the door on an agency that I believe still has many positives and that I hope may be open to change and progress. I would also likely lose my apartment and have no money for food to eat within two weeks. Financial well-being was never a promise when I committed to this field of work, and I presently live essentially hand to mouth, with massive student loans looming over my head nearing default.
So I prepare to return to a job that is at odds with my heart while I attempt to figure out how I can find a place, whether within my agency or outside of it, that will afford me the greatest opportunity to advocate for therapeutic relationships, demand human rights for persons labeled by the system as “mentally ill,” provide leadership creatively and collaboratively in partnership with professionals and peers, and pursue a vision of both individual and social healing.
Wish me luck.
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.
I have tremendous respect for your decision to speak publicly about this professional and personal crisis you find yourself in. I think you are far from the only “provider” who’s awakened to this dilemma, and I believe that more and more are joining you in this place of confusion, sadness, betrayal, and whatever other emotions may come with the realization that the system that employs you and surrounds you is founded upon deep, systemic oppression and injustice. I hope that your story will inspire others in similar positions to speak out about their own internal dilemmas, and that you can all come together to create a sea change from the inside.
Oneo f the things you talk about in your post is a serious problem all over the field of mental health. Even DJ Jaffe contends that outpatient commitment doesn’t “force” anybody to have to take psychiatric drugs. If you asked any one of the many people who work over people forced to take psych drugs, the overwhelming majority will say that they do no such thing and may even argue that we need better laws to allow it but then there’s the question: Why on Earth are they taking the drugs then if they don’t want to be? Obviously, they are being forced. There should be no side stepping around the issue.
But even worse is the fact that it doesn’t take much to get forced. In the spirit of the law a person is supposed to be so out of control that they would otherwise have to be in restraints 24/7 to keep from thrashing about and hurting people. But in reality, like you said, it’s simply just agitation or verbal hostility. The people working in the mental health fields are simply misevaluating a persons dangerousness to get to the convenient conclusion that they “need” drugs and should be forced to take them. If most people who have supported the laws for forced drugging over the years knew that it was being applied to people for simple agitation, I like to believe that they would no longer support such laws.
Verbal hostility? You mean like the day I insulted a doctor by stripping her of TWO of her identifications? Instead of calling her DOCTOR Borha, I called her Mr. Borha. She heard me and summonsed the attack team – the call of duty. All other inmates are gathered up in the lobby area, the door is shut and when the team of attackers have isolated their target, they move in for the DOMINANCE & SUBMISSION session. They warn you to “make it easy on yourself”.
I got strapped and force drugged as a result of insulting the woman in charge of the house (there was no other “behavior” that caused it). After strapped (4-point, I’ve had 5 point AND straight jackets) and drugged, every few minutes they sent someone in to see if I was sleeping. “You sleeping yet?” NOPE, I yelled loudly. I fought that drug, and I won. All the while I had a female employee who sat by my side who said that she would feed me my dinner (it was dinner time, I asked when I would be allowed to eat). I told her if she put her hand near my mouth, I would bite her.
She did not feed my dinner to me, because she was a very smart woman.
LIKE I SAID: PSYCHIATRY IS NOT A BRANCH OF MEDICINE. IT IS A BRANCH OF GOVERNMENT. I’ll say it forever until it gets deep into the minds of EVERYBODY. I also say that psychiatry is the anti-christ. There is no other entity on Earth I can think of that matches the description.
What do you do now?
Draft. You’ll need to design the particular construct that you think is most appropriate for care. Maybe you have some people who’d like to take on the project with you. People with a shared vision. When it is done (could take many months or over a year), you can take the next step. Creation. Development. Establishment. Finally, a living reality. Maybe you can start a GoFundMe project. Don’t lose your vision. Create it. Produce it.
What does it look like? What sort of people would you help? What sort of problems do they have? HOW do you help them? Do you believe that people can permanently exit the trauma-centered life and go on to live a healthy, functional life of well-being and personal fulfillment? What does that look like? Can you see that far, into your vision? Can you see what the successfully “helped” person actually looks like?
Tap into your resources. Find the ones near you (if you believe in Divinity, they are either already in your life or can be easily called to you) and see what you’re capable of.
It helps a whole lot to have faith and belief in yourself, Andrew. Confidence.
Andrew is a good name. It anagrams to “warden” and means “man of strength” or “man of power”. Andrew is the name I gave to my son.
If you don’t want to be the warden, Andrew – what will you be?
Many suitable categories, for potential creation and development of a sanctuary model of care. http://www.gofundme.com/
You are an honest man, and for that you have an opportunity to help combat the worst offense against liberty and human dignity since the abolition of chattel slavery in America.
I have spent my 12 years as an attorney working in Illinois state psychiatric institutions on behalf of every individual’s absolute right to refuse psychiatry.
Everything you have written is true, in spades. I hope you will stay where you are, and find ways to fight for abolition from inside the system. I would like to help you if I can.
I wish you the best of luck — as well as peace. You deserve it.
Very familiar. My observation of the practices in Mental Health Units here in Australia is well expressed by your article.
Thanks everyone for the kind words and feedback. It’s all very appreciated as I struggle to find my place in this very big mess of a system.
As a peer worker in a state hospital I experience many of the same contradictions in the system that you’ve pointed out here. Know that you are not alone in the struggle. Thanks you for speaking openly about your situation. If more people would speak out it would begin to expose the system for what it really is and what it really does. Like you I find individual staff people who want to do the right things for the people locked in the units but the psychiatrists have such a strangle hold on the system here that to question anything leads to grave problems. People just go with the flow since this is the way it’s always been here.
Andrew, I admire your strenght and courage for sharing your plight. I too work in the community of the SRTF and you articulated my inner struggle respectfully and wisely. Thank you for relating your insight about the “forced treatment” and behavioral modification training that occurs in the Secure Residential Treatment Facilities. I am on this journey with you Andrew, and I hold on hope that our values will guide us to the places where we can facilitate the most change in the psychiatric system and in our community.
Andrew there in lies the rub. Thanks for your transparency. There are good people in these corrupt coercive systems. The cultural forces are so strong they either conform to survive, do the best they can under very difficult circumstance protecting the vulnerable to the best of their ability or they leave.
Myself and another nurse started a private mental illness recovery company in Canada in 1997. We survived for five years on the bleeding edge. We knew we had to create something totally new and totally different. We were effective because we had skill but we were credible to individuals and family members because we had lived experience both personally and as family members. We made a full recovery and reclaimed our lives. Before we sat down at the kitchen table with them they believed because they were told by the ‘experts’ that it was life long they would never recover, would have to stay on medication the rest of their lives etc.
So between having the nerve to disclose we were mental patients and use it as a strength point and a private health company in Canada we were not embraced by the establishment and discredited by mainstream psychiatry and mental health although we did have some quiet champions in these areas. We had an evaluation of our services and all clients surveyed would invest the money again. In spite of numerous attempts to get government to meet with us we could not ever get any real consideration for our recovery model of accessible timely service. Too much money is flowing out to big pharma and coersive care systems. We did manage to get a meeting with a Ministerial Assistant but he told us there was not a dime to be had. We then found out he was on a 6,000 dollar a month retainer in case his phone rang and he had something interesting to say. In my opinion probably not money well spent. Although he was a nice enoug guy.
I am a Healthcare Leader currently. I know the large amounts of money that runs through a health unit and a health facility budget. Redirecting the money to consumer run services is now my focus. I am the Founder of Joshua’s Tree; the search for innovation in psychosis recovery. My goal is the creation of an Altered States Research, Recovery and Learning Community in Saskatchewan Canada. It will tip. It is just a matter of when. Thank you again for ‘fighting the Good fight’.
Interesting to read your comment Wendy and it’s drawn my attention to the post which I’ll have a read through (as an MIA writer I can see the dashboard of all comments).
I agree with you that the tipping point is near although not sure how near and what the result will be after the tip. But change I think is always welcome. And consumer/user run services are the way to go, it makes sense. Chrys
Thank you Andrew for your Honesty. There are many of us who work in places that contradict our core values, and if we went now, away from the place of our work, perhaps the only compassionate voice would be removed. My reading of recovery narratives is that it is often one good person, an OT or support worker for example, who leads the person suffering from mental distress to a better place, or is, at least, the catalyst for recovery. Being in a position of leadership you are also best placed to try an effect change, be it through example, education or speaking truth to power. I stay because I want the system to change and I want to be part of that change. Me not being there won’t stop this happening. Of course your life and mental health and mental health is also important, so if you do decide to stay you will need to find some allies at work and external support.
Your situation is one to which I have given a lot thought over the last few months. I was, until quite recently, a prisoner at New Hampshire Hospital in Concord, N.H., and the role and the feelings of the “mental health workers” and the nurses and even some of the psychiatrists was something that used to bother me. Obviously, you don’t get into those sorts of professions unless you start off with the belief on some level (1) that you care about people and (2) that you might be able to help in some way. Yet, when I looked around at what was, quite blatantly, a model based on nothing more than coercion and incarceration, and one where I was forced to take drugs and where I was taken down into restraints and isolated when I didn’t comply with whoever might be in charge, I couldn’t help but wonder what sorts of feelings were being felt by those people ass they manhandled me and forced a needle into my ass.
In particular, there was a small group of nurses and “mental health workers” who obviously went out of their way to be compassionate and responsive “caregivers”. Yet, when it came right down to it, they would respond in line with the goals of the very same force of coercion (going in to care for or watch a restrained “patient”, etc.) that I was doing my utmost to resist, and though they did so looking unhappy about it, they did it nonetheless.
I can see that not everyone, like some of the people I saw there, was a complete sellout who just wanted to uphold the system as it was then in operation. When I saw your comment about wondering what exactly “behavioral health” might be, I had to laugh, because I have wondered the exact same thing in the exact same words, and the only conclusion I could come to is that I just have no idea what “behavioral health” might be, unless one were to turn it into some kind of sick joke about not crashing your car through barriers on the highway and not having sex with someone who has a venereal disease. Seriously: what the hell is “behavioral health”? Can anyone answer that question without resorting to some circular explanation about “not harming yourself” or any of the other nonsense that is used as an excuse to forcibly drug people to “prevent harm”, especially when “harm” is usually the last thing that is being threatened? I have heard more rationalizations for brutality based on the excuse of “safety” than I could ever have imagined would be possible.
I salute your courage in openly stating your problems with your institution and in openly admitting what is going on there and how you feel about it. Unless others also question their consciences, nothing can change. On the other hand, I have a fear centered on when all the compassionate “caregivers” abandon the system: after all, who will be left behind to run them? How much worse will it get without people like you there, or without all the people I saw myself who wanted to genuinely help? In the end, the whole system will be run by willing and eager collaborators in oppression. I don’t suggest that you stay, because to do so is to be a collaborator, and yet one can understand the argument for trying to stick around and mitigate the harm being done. It’s a terrible conundrum, and I can only say that I admire your willingness to risk exposure and to speak up publicly about this terrible conflict. I wish you the best, and I mean that sincerely, even as someone who so recently had to put up with the very kind of coercion you’re talking about, even when it came from people who I could tell were very like you in their deepest beliefs. Good luck.
In my humble opinion ‘behavioral health” is nothing more than behavior medication. It is an attempt to force people to think, feel, believe, and act in one particular way. You are to be compliant and this means taking the toxic drugs and you are to be quiet and you are to behave and not cause any problems. It is coercive and authoritarian in all respects. Behavioral health is creating learned helplessness in people so that they always look to the “experts” for the answers that they need in their own lives. Behavioral health is teaching people how to be good sheeple, plain and simple.
On a related note, the phrase, “behavioral sleep medicine” exists in the sleep medicine industry. I absolutely despise it as I feel it is essentially blaming the patients for their difficulties.