“Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive”
- C.S. Lewis
Warning: Heavy use of ’quotes’ ahead.
Force in ‘mental health’ care has been a popular topic for decades now, yet it’s scary how similar the conversation remains. ( For example, see the ‘Declaration of Principles‘ published in 1982 in Phoenix Rising or the ‘Insane Liberation Front Manifesto‘ as documented by Tom Wittick.) Jonathan Keyes’s recent blog certainly generated quite a bit of commentary caught between conflict and assimilation, and the very mention of the infamous Treatment Advocacy Center (no, I will not link to them!) gets many of us boiling over.
Yet, the conversation has also seemingly lost its way. Theres a vastness between what we think we are demanding and what is actually being conveyed that can sometimes feel impenetrable. Often, I’m not sure we’re really even engaged in the same conversation, as much as we superficially may appear to be.
One perspective that I particularly appreciate originates with Jim Gottstein and the Law Project for Psychiatric Rights. Jim so often speaks of the Transformation Triangle which incorporates multiple points and aspects involved in systems change including creating new choices, changing attitudes and changing laws. This approach does a great job of recognizing that there can be many parts to the process of transformation.
Perhaps the gaps in our arguments can largely be explained by the fact that often we’re coming from different (but nonetheless valid) angles of the triangle without fully recognizing and articulating that point. But, even that is a bit of a leap from where we seem to typically be most stuck. Prior to diving into how we make the change we want, we need to better define what it is that were seeking.
Coming to greater clarity on whether or not we think force is okay raises many issues all on its own, and leaves us teetering on the edge of one of the biggest gaps of all: What happens to all the people who we don’t want to see forced but for whom the alternatives that exist simply aren’t a fit or aren’t accessible?
Our movement (the one with which I most clearly identify, anyway) is well known for its embattled cries for the abolition of all force. We’re also known for the promotion of alternatives like Soteria, Open Dialogue (ad nauseum), ‘peer’ respites and the like. But what happens when someone is in serious distress but seems not quite a fit for one of these highly praised alternatives either for lack of their own interest or inability to participate in the defined process? What if they aren’t able or willing to hold the values of a mutually based environment at the local respite or simply have no interest in checking out a Soteria house? (Never mind that these alternatives are generally either under represented or outright unavailable in most areas.) Any of us would be fools to pretend that there aren’t situations where someone is altered in a way that puts them or others in real danger in the absence of any truly satisfying answer as to how to support them through.
Our movement also does itself a great disservice by insisting that the cure all to this particular gap is nothing more than love, being present, talking with, listening to, and so on (as much as all that may be the answer more often than most realize). We offer ourselves up to be all too easily painted as a naïve group throwing a no force tantrum while stubbornly turning away from some of the harshest realities. In those moments, we also bare our throats to those enemies of the state (of humanity) such as E. Fuller Torrey who are ever poised to dig in their claws with their own battle cries of anosognosia and fear mongering parades of Grimm nightmare tales.
If we are a movement that is ever to fully mature, we need to be willing to answer (or at least talk with) the well-meaning clinician who asks, ‘But really, what am I supposed to do? Am I just supposed to walk away?’ And, we need to come up with much clearer answers to the seemingly unanswerable than we’ve tended to offer thus far.
While any sort of real, concrete answer to addressing the gap has not fully shown itself in the face of the complexities of so many human experiences and competing needs bouncing off one another, consideration of a series of points seems to have moved many of us toward at least a much less cavernous chasm.
So, are we trying to change the system or disband it entirely? Or are we trying to disband it by improving it until what was… simply is no more? And, are we trying to reduce force to only those times when it is absolutely needed? Or are we fighting to eliminate it altogether? Or are we trying to reduce it by virtue of aiming to eliminate? And what about those people with whom we simply cannot connect and who are teetering on an edge of their own? And where to even begin (again)?
Force is a Force, Of Course, Of Course:
This conversation gets even more confusing when we don’t bother to stop and clarify what sort of force we’re talking about. In the broadest of senses, I have to imagine that we ALL agree with SOME sort of force .
For example, if someone was to physically assault you, I assume you (whoever ‘you’ are) would be okay with the police (or anyone else in the vicinity) forcing them to stop. Most would also say that the person who is getting assaulted who then defends themselves using reasonable force is also in the right.
So, for starters, to be clear, when I am writing and talking about force here, I am talking specifically about systematized force in the ‘mental health’ system.
Given that, what follows is not a singular answer, but a number of points strung together because they have arisen for me through dialogue on-line and in person. I offer them because I believe that consideration of each point has the potential to lessen the apparent gap and move us toward increasing clarity and change:
A Pig By Any Other Name…
…Is still a pig. In fact, it could be even more dangerous, because maybe… just maybe… that pig will be able to convince you it’s a swan (or fairy, or whatever treads on the happier end of your fantasy worlds) for long enough to lure you in, leaving you not only trapped but outright lied to as well. So, let’s take a quick(ish) look at language.
Some years ago, I visited a so-called ‘peer’ respite in Arizona that was attached to a crisis services center. (Mind you, this is not a model that I support for these sorts of respites in the first place.) A group of us sat with administrators on the crisis services side, and listened while they boasted about having recorded no restraints in the past year. That sounded good, until we asked more questions and learned that if someone was held down for under 15 minutes in order to be forcibly medicated, the administrators simply didn’t count it as restraint.
In reality, the dishonesty and lack of transparency that often gets intertwined with so-called ’mental health’ services feels traumatizing all on its own. After hearing about the re-definition of restraint by the Arizona group, I recall cancelling my evening plans and huddling in my hotel for the night because I felt so disturbed at the idea that these administrators had such power to prettify something so ugly. Sadly, it’s nothing new.
However, in order to have a conversation about force in any sort of productive way, we need to do away with the prettification. Somewhere along the way, people got confused about language. They seem to think that because so many of us argue against diagnostic and systemized language in general, that we’re into words that are either vacuous or a downright lie. It’s quite the opposite, really.
To hell with ’Assisted Outpatient Treatment,’ ‘temporary holds,’ and the like. As a friend recently remarked, ’temporary hold’ sounds as if one is simply waiting on the line for the next available customer services representative at the power company while, at worst, suffering some particularly bad muzak. And, few people who have experienced the utter loss of power of being locked somewhere they don’t want to be for even twenty-four hours would say a three day hold isn’t force. So, simply put: Let’s begin by just naming it.
Lest anyone continue to be confused, a few more clarifications:
- If, as a part of treatment, you hold someone down for any reason for any length of time… it’s still force.
- If you name yourself a ’Recovery Center,’ but people can get involuntarily committed to your definition of ‘recovery’… it’s still force.
- If you leave the doors unlocked, but no one is actually allowed to leave without being chased and brought back whether they like it or not… it’s still force.
- If you say you’re ‘assisting’ someone, but the direction you’re assisting them in is the exact opposite of where they want to go… it’s still force.
- If someone is compliant with their psychiatric drug regimen only because you administer it by mandatory order in a syringe once a month… it’s still force.
- If ‘choosing’ not to follow through with recommended treatments results in someone being picked up and incarcerated… it’s still force.
- If you have someone involuntarily hospitalized because you’re really, really worried about them and genuinely think they are unable to make decisions that will keep them safe, and it’s really, really the best, most justified instance of involuntary hospitalization ever … It’s. Still. Force.
Calling it what it is is not the same as deeming it right or wrong. So, please, lets quit the verbal Febreeze and move on.
Answers Do Not Come to Those Who Wait:
A wise woman (aka Chris Hansen of Intentional Peer Support fame) recently reminded me that when slavery was abolished there was no grand plan for all the men, women and children who were abruptly released into freedom. There was no promise of housing, income or much of anything else. People suffered. People died.
And yet, it was the right thing to do. Lack of alternatives and well-thought-out plans could not be justification for the continued enslavement of human beings. Perhaps even more importantly, answers are generally born out of necessity, not some far off possibility of change once we figure things out somewhere down the road.
I do not think, for example, it was any sort of coincidence that Soteria Vermont got its funding around the same time that their hospital was washed away in a storm. We should all bear this in mind as we are asked to tread slowly in our demands for an end to human rights violations and incarceration based on projection and subjective assessment.
A Time to Grieve:
So much of this conversation gets lost in anger and defensiveness. And, it all makes sense. It makes sense that people who have been hurt or lost loved ones to abuses in the system are angry. It makes sense that people who were doing what they thought was right out of desperation to help a family member, or via careers that their livelihoods are staked in, feel defensive. And yet, that continuous loop doesn’t particularly move us toward progress.
We speak often about healing spaces for people who have been hurt. But what of people in provider roles? Or family and friends? Sure many of us have met the cold-hearted provider who seems to hold more wealth in power than compassion, or who has been so beaten down by life that they just don’t seem to care… but most want to do what’s right. Yes, there are truly terrible family members who have no good intentions… but most are trying to help.
Thus, it seems critical to find times and places for people to come together - those hurt and those part of the system (directly or indirectly) that hurt them – and acknowledge the harm done. I’m not particularly attached to a twelve-step approach, but I’d say that, ‘the first step is acknowledging there is a problem,’ feels about right here. Imagine the power of hearing out those who have been hurt without argument or justification, owning at least a piece of the harm that has been done, apologizing and genuinely trying to understand how to move forward to something different. Imagine how we could all be changed by such a process.
In fact, a woman stood up at the very, very end of this year’s Alternatives conference, took the microphone in the grand ballroom and – in front of hundreds of people – said that she’d come to realize (as a result of the many voices at the event) that she had done things that hurt people. (Sandy Steingard’s recent piece in the Washington Post doesn’t go quite so far as this… saying one was ‘wrong’ is different than acknowledging one actually caused ‘harm’ even if the latter is implicit, but it starts to get there and is also worth a read.) She wanted to say it out loud and own it. It took courage to say that in front of so many people who are still nursing the many wounds of the ‘treatment’ that was supposed to help them, and I can only hope she’ll hold onto that courage, take those words home with her and make real change. However, courage aside, I generally find that those who have been hurt are much more receptive to statements such as that, than to who are simply offering an explanation and asking for a pass. So, why is that one of the first times I’ve ever heard those words spoken in such a public setting?
If nothing else, this sort of admission seems a necessary step toward getting to a point where everyone can begin to hear the rest of these arguments.
When we hire at the Western Mass Recovery Learning Community, the most important questions we ask during the interview are the ones designed to determine just how much someone has to UNlearn. We offer up scenarios on hearing voices, self-injury, suicide and more not so much looking for the right answer as we are looking to better understand just how ingrained the good ol’ typical societal beliefs may be in that particular individual.
Why? We’re looking for people who know that hearing voices doesn’t have to be a bad thing; that self-injury is a way of coping and isn’t the worst thing in the world; that suicidal thoughts are largely an existential issue best addressed by giving someone space to talk things through. However, we live in a culture that is (‘Mental Health First’) aiding more and more people into believing that these and other understandable human experiences generally require major intervention and panic-button-pushing responses that all too often involve force of some sort or another.
There are many unlearning campaigns (such as Hearing Voices and Alternatives to Suicide) already afoot. However, strengthening our efforts in that department would provide a rather automatic reduction in the perception of the need for force, and as we all know, perception is incredibly powerful when it comes to something as intangible as mental health.
Business as Unusual:
People in provider roles inevitably feel overwhelmed when they are attacked for using force, as it often comes with little to no suggestions as to what to do instead. We talk about meeting someone who is in distress ’where they are at,’ but we rarely do that for people in provider roles who have been indoctrinated into particular ways of thinking and being, sometimes for decades. While I agree that we can’t exactly be patient about demanding change while people are dying, asking providers to jump from A to Z without support just isn’t realistic.
Perhaps one of the smartest things we can do to move people toward change is to ask them to practice business as unusual. That is to say: We know that when people go about their daily routine uninterrupted, it’s unrealistic to expect change. However, when we ask them to make even small changes to how they think about or do things, it can have a profound effect.
For example, one organization in Massachusetts has reported a dramatic decrease in the practice of forcibly hospitalizing people simply by requiring that all incidences of such force be tracked. They record the date, the reason, and so on and have seen such a dramatic reduction that their funder is asking them to identify the details of their process for purposes of replication.
Chris Hansen also suggests that organizations consider making any use of force a critical incident that requires an investigation including an interview with the person who experienced the force. (This is a protocol we’d implemented at our respite house, Afiya, before ever hearing Chris’s recommendations, although we’ve never had to use it because we’ve never actually reached the point of calling the police or emergency services at the house.)
Perhaps if such policies were implemented in all ‘mental health’ settings, things would at least begin to shift in the right direction.
A new law was recently passed designating assault on a healthcare worker as a felony. At one point, many people seemed to be advocating that the law be written with an exception for those with psychiatric diagnoses. I couldn’t disagree more. We can’t argue that people with psychiatric diagnoses are not dangerous whilst at the same time saying, ”but please give us a pass when we hurt you, because we just can’t help ourselves!”
However, here’s an argument I could get behind wholeheartedly: Let’s put an exception into that law for anyone undergoing any sort of force.
Restraint. Forced hospitalization. Forced drugging. What-have-you. When you force something on someone’s personal being, they may quite rightfully deem their actions to be self-defense. So, when you decide someone’s dangerous and thusly treat them with force in some manner, ’dangerous’ just became far more likely.
Add to that the fact that the person arriving before you very likely already experienced force, humiliation and/or loss of control in the immediate past with Emergency Responders (never mind a whole world of historical trauma that they may have experienced) and it becomes increasingly difficult to imagine how a person might manage to contain themselves. Yet, all too often, the provider who feels they have no other choice but to use force is putting the locus of control and responsibility on that person for becoming violent.
If we want people to stop acting violently, perhaps we need to stop treating them violently. When people who have historically been treated violently act violently, perhaps we need to share in some of the responsibility of how they learned to walk in that way through this world.
So funny how words - such as violence and dangerousness, for instance - ultimately find their definitions in the hands of those who are in power.
AND, MOST IMPORTANTLY…
It Works Until It Doesn’t Work:
On October 22nd, 2013, I traveled with many others from the Western Massachusetts Recovery Learning Community (RLC), to testify at a hearing on Forced Outpatient Commitment (aka ‘AOT,’ ‘IOC,’ and whatever other word or acronym you wish to throw at it). I said many things during my time at the podium, but I concluded with the following statement: “If you’re going to force it, you better make sure that what you’re forcing works.”
The facts of the matter are (and this doesn’t get said nearly enough in these sorts of conversations) that forced treatment – and particularly forced drugging – simply doesn’t work. In actuality, evidence of every kind suggests that it makes the situation worse for most people in the long run (and there’s no way to tell who the minority might be until it’s far too late). Numerous studies have now demonstrated contrarily pesky sorts of results such as the following:
- Psychiatric drugs seem to lead to worsening outcomes (both in that people on them tend to work less and lead less full lives overall, AND in that they appear to experience worsening ’symptoms’ over the long term INCLUDING those about which the general public expresses the most fear) and potentially permanent damage (e.g., El-Mallakh, R. ‘Tardive dysphoria: The role of long-term antidepressant use in inducing chronic depression.’ Medical Hypotheses 76 (2011): 769-773; Harrow M. ’Do all schizophrenia patients need antipsychotic treatment continuously throughout their lifetime? A 20-year longitudinal study.’ Psychological Medicine, (2012):1-11)
- Forced ‘treatment’ (such as forced outpatient commitment orders) does not appear to reduce difficulties in community (such as those that lead to re-hospitalizations) (e.g., Dawson, J and Rugkasa, R. ’Community Treatment Orders: Current Evidence and the Implications.’ British Journal of Psychiatry,(2013) 203: 406-408.)
- Suicide rates for people just released from hospitals (to prevent suicide attempts) seems to be awfully high (e.g., Crawford, Mike J. ‘Suicide Following Discharge from In-Patient Psychiatric Care.’ Advances in Psychiatric Treatment (2004) 10: 434-438.
Sure, force may prevent someone from doing something undesirable in a singular moment, but then what? What if stopping them via force actually increases the risk of that undesirable outcome down the road? If someone’s most likely to kill themselves after they’ve been hospitalized for attempting or stating they want to kill themselves, do we just never let them out? Quite the quandary, it would seem … except, not really. Force begets force begets force begets harm begets force. Repeat. The pattern has to end somewhere, and in our conversations about force (particularly with legislative bodies) we need to be much clearer to point this out as we move forward.
An Abolitionist State of Mind:
Last spring, I attended a meeting in the DC area on the topic of ’mental health,’ ‘recovery’ and ‘prevention’ (all quite intentionally in quotes as I am never quite sure what most of us mean by them). During the introductory remarks, one individual stood before us and declared, ”There will always be forced treatment.” This remark would have been unacceptable coming from anyone, but was particularly so because the person speaking those words had himself experienced involuntary hospitalization and was now seen as being in a position to represent our movement.
The dichotomy of force/no force is overly simplistic and ultimately false. However, the truth is that nothing but an abolitionist perspective should be tolerated. Any protocol that lists force as a viable option (even if only as last resort) will inevitably lead to more frequent justifications. Any individual who acknowledges the necessity of force in the same breath as saying it is fundamentally wrong, diminishes our values to the point of irrelevancy. The moment we accept our values in a compromised form and ourselves willingly start portraying them as such, they become something else entirely and are no longer ours to hold.
We Have To Because We Can:
As much as I would still argue for an abolitionist state of mind, many continue to point out the gradations of wrong when it comes to concepts of force, and they are right. In a conversation on this very topic, one person recently noted to me: After over 20 seasons of Cops, not a single person that they have apprehended has been sedated with a needle. Now, granted, the police have other methods that we’d likely not recommend, including tasers and guns, but its a thought provoking statement nonetheless.
Truthfully, the most valuable direction to take this conversation is not to a comparison between the merits of the preferred tools of our various systems, but one that explores how people tend to look only within the tool box that they are given and use some tools not necessarily because they absolutely need to, but because they can or because it’s all that they know to do.
However we may feel about other methods that are used to subdue people who seem dangerously out of control, the argument that a particular measure was used because there was categorically no other choice simply falls flat when we take a look around not just within our own culture, but within all those around us as well as back into our history. Unless we believe that people in past eras or other cultures where this does not happen (sometimes simply for lack of access to the same tools) are from an alien species, our understanding that there is absolutely no other choice than forced drugging continues to disintegrate.
Reality Check: Forced drugging is several steps more invasive than detainment in a hospital or even restraint. It is violently invasive and many would aptly compare it to rape. Just because it looks more peaceful, doesn’t make it so (though it may mean that the people using the force get to feel better about having done so simply because of said surface appearances).
The same goes for Electroconvulsive therapy (ECT). Like forced drugging, it can have permanent physical implications for one’s body and brain, and can leave one unable to even try to refuse. In his anti-ECT literature, Peter Breggin makes some interesting statements about ECT never being fully voluntary because one of its primary effects is to render someone substantially more docile and ultimately unable to refuse further ECT. I would suggest this argument could also be applied to many psychiatric drugs.
Wrong Because It’s Wrong Because It’s Wrong Which Makes It Wrong. So, There.:
The truth is that people will be lost, and there’s nothing we can do to fully control who, when, where or how. That notion is frightening and it makes sense that people fight against it. It forces us to stare down our own mortality and that of others around us.
Yes, there may be some instances where force might keep someone alive (in the moment). There are certainly even people who claim that force has saved their or other peoples’ lives. However, what of the hundreds of thousands of peoples who have been killed or died decades early because of the ‘treatments’ into which they were forced? What of the people who have killed themselves specifically because of the demoralization they experienced when hospitalized against their will? Has anyone done an analysis of all those years lost and lined it up against lives lost in the various well-publicized tragedies we all wish we could prevent? I’d be willing to bet big dollars on which tower would stand taller.
But, lets say for a moment that 99% of people forced suddenly started saying that force helped them. (And most do NOT say that, no matter what the Treatment Advocacy Center drones would have you believe.) Would even that justify the continued use of force in the system?
No, people generally are not able to sign away rights just because they think the lack of them might be of some benefit. Employees cannot agree to work 80 hours without overtime, because of labor laws, even if they would come out ahead financially. A baby cannot be sold, even if to a much more stable and loving family. The applicability of rights are not and cannot be based on a cost/benefit analysis.
Hence, the retrospective opinion that forced ’mental health treatment’ was for the best is meaningless and should be considered wholly irrelevant to this conversation. In actuality, any process that suggests that rights should somehow be curtailed or differently applied to one particular group of people because of some particular label must be seen as incredibly dangerous.
If someone is hurting you, you can use force by self defense. If someone has done something illegal, you can use force via the police and the legal system. But why should force be considered a viable option because you are deemed a risk to do something and also happen to have a psychiatric diagnosis? Certainly we could take a look around our world and find many people at risk of doing serious harm, but who we’d never suggest be arrested as a preventative measure, lest we find ourselves in the worst kind of police state imaginable. A young male with gang associations? An individual who has been drinking at home and has a history of spousal abuse? Et cetera.
Although by all statistical indications, these individuals are much more likely to actually do something that will harm someone else, they have rights and the law requires those rights to be respected. Why should that also not be true for people who have been given psychiatric labels, and what are the full implications of not demanding equality in that way? (Hint: The implications are huge, and every time you hear a story of someone losing parental rights, being hospitalized when they maybe weren’t so obviously dangerous, being forced to continue taking psychiatric drugs that are visibly destroying their body, and so on, please be reminded of that.)
All this said, I hear from desperate parents, friends and other family on a fairly regular basis and it’s hard to fault them for turning to the system and asking for forceful intervention when desperation looms. Its hard for me to imagine that I wouldn’t lose all objectivity and contradict myself in a matter of seconds if it were my own child. Or husband. Or close friend.
We’re human and we get to have human reactions. But our human reactions shouldn’t necessarily be called ‘treatment’ and can’t be used as a justification for force and the violation of human rights of thousands of people. Our fear and desperation cannot be the reason it’s okay to force ’treatments’ on people that they do not want (and that research shows tend to make the problem worse in the long run) just so we can feel like we’re doing something in the moment, future be damned. Recognition that the legal system also has many failings cannot legitimatize power abuses in the ’mental health’ system. And, when we do go there we need to recognize it not as proof that force is necessary, but as proof that we were at a loss and all (not just those working in the system) have far more work to do.
Someone also recently suggested to me that perhaps everyone with the power to initiate, use or legislate force in the ‘mental health’ system should be trained to consider:
- Would you do what you are recommending with your own hands?
- Would you do what you are recommending with that person’s mother watching?
- And my own addition to that: Would you do what you are recommending with YOUR mother watching?
Where do we go from here? I’m not entirely sure, but, when faced with questions of force, perhaps we should also consider the brilliantly simple words of Duane Sherry: ”You first.”
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.