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.