Therapeutic Alliances With Patients Who Are Being Treated Involuntarily Can Be Improved

Rob Wipond
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Empathic approaches, open-minded conversations and other strategies can help re-build positive therapeutic relationships with patients who are being treated involuntarily, according to a study by Australian researchers in the Journal of Mental Health Nursing.

The researchers conducted interviews with twenty-five involuntary psychiatric patients about their experiences, and then looked for common themes and issues of concern.

“There is increasing evidence that an involuntary hospital admission and treatment can undermine the therapeutic relationship,” the researchers wrote. “While good relationships with staff are important factors influencing long-term recovery, there is little information on how people experience their relationships with staff while under an involuntary treatment order.”

Participants described involuntary treatment as “daunting and frightening,” and said that staff behaviors and attitudes towards them were fundamental to shaping their experiences in hospital. The patients emphasized the “importance of staff listening to their concerns” and being able to “look beyond their illness and diagnosis.” They also highlighted the “importance of having a space to make sense of their experiences” while feeling like they were “working in partnership” with their caregivers.

“These findings highlight that when using recovery principles, such as an empathic engagement with the patients’ lived experience, forging partnerships with patients in treatment decision-making to enhance agency, an involuntary treatment order does not have to limit the ability to establish positive relationships,” concluded the researchers.

Wyder, Marianne, Robert Bland, Andrew Blythe, Beth Matarasso, and David Crompton. “Therapeutic Relationships and Involuntary Treatment Orders: Service Users’ Interactions with Health-Care Professionals on the Ward.” International Journal of Mental Health Nursing, 2015, n/a – n/a. doi:10.1111/inm.12121. (Abstract)

29 COMMENTS

  1. “These findings highlight that when using recovery principles, such as an empathic engagement with the patients’ lived experience, forging partnerships with patients in treatment decision-making to enhance agency, an involuntary treatment order does not have to limit the ability to establish positive relationships,” concluded the researchers

    I think the researchers are delusional and need to be hospitalized against their will and forcibly treated with meds. All sarcasm aside, this is an admirable ideal but not very realistic. Kind of like saying one can form therapeutic relationships with jailors.

    • I agree. What my forced treatment, plus my years of research into medicine, taught me was to never trust any doctor ever again. I, of course, am polite to my new doctor, but make it quite clear that I do not need a paternalist doctor who is misinformed by pharmaceutical industry biased medical journals. Information is power, and now that we have the internet, patients can actually be more well informed than the doctors. I do find it sad, however, that the mainstream doctors are still exposing belief in the DSM disorders and standing in support of the psychiatrists’ right to force treat people, because this is destroying the credibility and trustworthiness of the entire medical community.

      • I agree with you both. This is a constantly stated ideal that never even comes close to coming to fruition. In this case, talk is cheap, and amounts to pretty words and wasted time, energy, and resources to state the obvious, and still not be able to embody it. Too much pressure on everyone to conform to the corruption.

        I’ve also lost faith in the current medical establishment, completely, which is why I made it a point to learn integral self-healing. That was a life-changer, because I am no longer dependent whatsoever on this kind of western medicine. My journey through the psychiatric world enlightened me to how toxic western medicine can be, from greed, arrogance, and utter lack of empathy, no matter how hard they try–at best, it’s patronizing and not authentic. More like a script.

        My healing support is no longer at all within this precarious health institution, because it is too dishonest and profit-driven, and extremely limited in its scope of information regarding healing. Plus, everyone seems way to stressed out to be focused and present, that’s really my biggest concern. That can never work to the advantage of a patient–or anyone, really–despite the integrity of a few enlightened individuals from within. Time for radical change.

      • SE,

        Wow, I can’t imagine being exposed to forced treatment. I had a doctor who tried to bully me into seeing a psychiatrist and I found that very intimidating and traumatizing.

        Additionally, the issue isn’t just about meds. Many doctors don’t like fully informed patients as they feel because they have MD by their name, you shouldn’t question anything they say. I am finding this out as one who is considering minor surgery and am still looking for the right surgeon.

    • Agreed.
      The very nature of involuntary treatment precludes the possibility of a relationship, therapeutic or otherwise, as relationship, for me, infers some degree of mutuality.

      It’s like asking a rape victim how their rapist might make the experience of being raped better for them…the only answer is, “DON’T DO IT!”

      All you can expect from involuntary patients is apparent compliance, apparent politeness, apparent submission. … maybe. But a healthy and or therapeutic relationship is no more possible than a healthy loving relationship between the rapist and their victim.

      To suggest otherwise is totally disingenuous or severely deluded.

      • “It’s like asking a rape victim how their rapist might make the experience of being raped better for them”

        Well put !

        People who have never stared down the barrel of a loaded needle behind a locked door with no place to run just don’t get it.

        I was given the choice of taking this overdose of pills I KNEW was extremely dangerous to my health and life or be given ” injectable form “.

        I continued to refuse the dangerous handful of pills out of self preservation not simply defiance and luckily for everyone involved I was not raped with a needle as they had threatened.

        It was so horrible what they did to me , I had decided if they did inject me by force (rape) I was going to sneak up on them outside the hospital and break there knee caps with a heavy pipe or crow bar when it was all over and that the jail time would be worth it.

        All I needed was to get back on my feet after that alcohol binge but instead I got the weeks long nightmare UHS dishes out to keep its profits at like a billion (thousand million) dollars a year.

        They lied all over my medical records (suicidal). I don’t do suicidal. “Speech is rapid”, You just threatened me with a needle you POS, should I speak really really slow now ?

        I donate my time to this website and human rights in mental health for a reason. Psychiatry in its current form is a crime against humanity.

        • “It was so horrible what they did to me , I had decided if they did inject me by force (rape) I was going to sneak up on them outside the hospital and break there knee caps with a heavy pipe or crow bar when it was all over and that the jail time would be worth it. ”
          I have promised myself that if they ever try to do this again I’ll defend myself as in any way possible to me and yes I’ll go after them because I know there will never be any justice. The sad irony of it is that it will be used as an excuse to say I needed the abuse in the first place. Sick, horrible, abusive system.

        • It used to be well known that the “pressured speech” of a manic episode was so intense that the best actors couldn’t replicate it. Now, most of the people in New York city have symptoms of mania. Any excuse to go with bipolar, I guess. It must pay better than other conditions, or it’s trendy.

      • It’s like asking a rape victim how their rapist might make the experience of being raped better for them…the only answer is, “DON’T DO IT!”
        Yeah… I agree 100%.
        “All you can expect from involuntary patients is apparent compliance, apparent politeness, apparent submission. … maybe. But a healthy and or therapeutic relationship is no more possible than a healthy loving relationship between the rapist and their victim.”
        Yes, exactly, thank you for stating that so clearly.

        • Speaking to a psychiatrist on a ward as an equal makes him very angry, in my experience. Failure to submit got me threats of being held for a 180 days. Telling him “threat to self or others, you can’t hold me for 180 days for disagreeing with you” made him furious. Childish people are the last thing that someone in crisis needs, especially after the crisis has passed. It’s been five years since my one involuntary commitment and I’m still amazed at the personal problems of some of the staff.

          • “Speaking to a psychiatrist on a ward as an equal makes him very angry, in my experience.”

            I found this to be true, also, in general. Childish, yes, that’s exactly how I perceive it, like arrested adolescents. It’s the most tragic irony, mind-boggling. I envision a role reversal, here.

    • “I think the researchers are delusional and need to be hospitalized against their will and forcibly treated with meds.”
      I think that would actually be an experiment which would provide the said researchers with valuable insights into the issue. The only problem is that we would not receive a pass from the ethics committee (and rightly so).
      I wonder what is the next thing they are going to study? Whether the people whom you punch in the face are more likely to punch you back and avoid any contact with you going further until you apologize to them and be nice and polite from that moment on? This is ***ing ridiculous.

  2. The Stanford prison experiment (SPE) was a study of the psychological effects of becoming a prisoner or prison guard.
    http://www.google.com/search?q=stanford+prison+experiment

    “Undermine the therapeutic relationship” Just a little right.

    No mention of the intake forced strip search “hospitals” do in this article.
    No mention of the injection threats to coerce drugs like Haldol.
    No mention of them coming to your room to make threats to wake you up for blood pressure check at 6 AM.

    A fun part is getting a bill for this when it’s all over. I walked in voluntary to the ER after making myself sick drowning my sorrows with Vodka for a week looking for detoxification. My mistake. I was sober but really hurting. I got transported to a Universal Health services psychiatric facility where I lived the inpatient nightmare. Lockup, strip search then threats and coercion.

    This site is dedicated to all the people who were harmed or killed in UHS facilities. They speak for those who have no voice, to protect others from experiencing the pain they endured.

    https://watchinguhs.wordpress.com/about/

  3. Gotta give a hand to psychiatry here, please people, since the institution is only trying – desperately so, mind you – to “treat and correct” the problems that it created in the first place. Nuttin wrong with that, is there?

    Britta

    p.s.
    Quote from ‘V for Vendetta’, the movie:
    I have not come for what you hoped to do, I have come for what you did.

      • They don’t even understand leverage, not at all.

        I had plenty of leverage when I went to EEOC against a social service agency, which is why I won a settlement. Although in mediation, the settlement amounts to a tiny fraction of what really would be owed, and in mediation, you’re made to sign a waver of responsibility, so really, they’re still not taking responsibility, but they are paying out. This isn’t justice, but it’s the legal option given.

        In addition, the mediator, knowing that I was royally screwed–but the payout has limitations in mediation–did say that I could go further, but that they would make life hell for me. She knew this from having done the negotiations with them, which took several hours because they were really STUBBORN and kept trying to interpret very reasonable emails I had sent requesting dialogue (as per ADA), as demented or threating or something. They really made fools of themselves trying to stigmatize me, because they were so obviously out in left field, and the mediator and attorney could see this.

        Still, I really had no protection against their aggression, and that’s what court can be all about in these instances–character annihilation, not necessarily truth, even as a person recovering from mental disability. So that’s a double bind right there–if you fight for your rights, you’ll be re-triggered into abuse trauma. Great.

        Getting up to the mediation itself took a year after filing with the help of an attorney, who, thankfully, was non-profit, so it cost me nothing. She was the one bright light in all of this, that was fortuitous for me. But they canceled and postponed it three times, and then by the time we finally got there, the CEO had resigned. The president, whom I named as an ‘abuser,’ fled the state before I even filed, and the program director resigned after I had been terminated (wrongfully).

        I was still healing, not really in great mental clarity, nor in great self-confidence, when all this occurred. But I sure do know abuse and discrimination when it hits me, and this woke me up but good. That was actually the beginning of my recovery, on a very practical level.

        I was actually very calm when they fired me–although the did it in a panel of three against just me, and even tried to get away without giving me an explanation or evidence of why I was being terminated. (This was a social service agency, mind you). They were seriously delusional, and thought I would explode. I’ve never exploded at work, I’m always totally professional, have been for the 20 years or so I’ve worked. But they were stigmatizing me, totally, as a ‘violent mentally disabled’ person, when that’s never been an issue for me, not in the slightest. The only violence I’ve ever shown is toward myself.

        Instead, I called my partner who came right over and stood guard while I collected my things. I was very calm, and went kind of slow, asked to see my file to make sure it was in order (it was not, it was missing a response I had written to an unjust reprimand, which was later found on my supervisors desk, buried under paperwork and files), and the pres got so pissed, and I was told to leave immediately. They were so trying to intimidate me! Fools.

        I was already so drained, and there was absolutely no mental health advocacy for me in San Francisco, so it was just me and my partner and my attorney. Had I gone further under those circumstances, I would have backslid a great deal in my health, it was precarious as it was by the time I got to the end.

        But I did fine, took my small settlement and at least the satisfaction that I was believed and that my reality was, indeed, the clearest and most reasonable, but it did not feel complete, and they continued business as usual. I did not feel good about this, but I had to get on with my own life and build my practice, etc. Still, it gnawed at me.

        About 6 months after the mediation was settled, I got an email, as did everyone who had ever been associated with this organization, that their hard drive with all the confidential files had been stolen.

        Then, several years later, I participated in a speaker bureau and griped around town a lot about the system and made my film about it, passed it around the city, within the system, and next thing I knew, about a year later, this agency lost its funding and closed. I can’t say for certain what went down, but I’d like to think that between mediation and the film, I helped to create positive change, away from stigma and discrimination.

        When I found this out, I felt a bit like I had done the David vs. Goliath thing, which felt good and satisfying, finally complete with all that, but it was seriously and truly exhausting, because they really will not take responsibility, no matter what.

        There’s got to be a better way.

        • Btw, if you really want to piss off anyone in the mental health and social service system, outshine them. Every single person in this agency, outside the management oligarchy, knew that I was succeeding wildly with clients, which I was. I was transitioning them quickly into work, and they were doing great. I was the only clinician in a sea of business majors as social workers, at this agency. My peers, however, recommended that I steer clear of management when possible. They were all so intimidated by them. One colleague even used the word ‘vicious’ to describe one of the top brass in this organization. It was scary.

          I was still not feeling myself and was really just starting to recover from feeling disabled, so I was quite humble, but all it took was my success with clients to spoil their party. That’s why is was an open and shut case. I got accolades from outside partners, for my work with clients. After being there for three months, they started fabricating excuses to get rid of me. After 6 months, they had created all sorts of fantasies about me, and created a reason to fire me. I had done absolutely nothing wrong, always followed protocol, but whenever I turned to an in-house advocate and said, “I feel as though I am being discriminated against,” his response would be. “You have to stop using words like that around here!” True story.

          I know I’m off topic, here, but these dynamics are so pervasive throughout the whole system, I felt this might be relevant information. I just like for people to be aware of as much as possible in this system, so that they can make wiser decision for themselves than I made! I was really programmed for a while, there, to think the system was there to help me. I could not have been more naïve and mistaken.

  4. “”There is increasing evidence that an involuntary hospital admission and treatment can undermine the therapeutic relationship,””
    No sh*t Sherlock. Do you need to study that? I think that patients’ resistance to this kind of torture is a true evidence of their sanity and strength not the other way around.

  5. In big capital red letters BUYER BEWARE! You’ve got all sorts of people trying to suggest that the patient is helped by forced treatment. They want a positive interaction, like, wow, isn’t this a nice prison way out here in the sticks, and don’t you enjoy your mind-rape and slavery. Aren’t the slave-drivers fetching and gentle. Yessah, Massah Hospital Director Sah, I’se a good little Wierd Uncle Tom O’Bedlam for ya, sah. They have gone so far as to suggest that the patient who resists actually wants the treatment that patient is resisting. Excuse me if I refrain from shrugging off the increased mortality, but I know better than listen to bunk. Deductive reasoning tells me I will live much longer by keeping away from psychiatry and psychiatrists. I know it hasn’t gotten through to some of you folks out there, but psychiatry kills.

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