In Defense of Coercion

I know that I addressed this issue in an earlier post on involuntary hospitalization, and this post may be redundant.  Still, I have been reading more posts complaining about the use of coercion in mental health treatment and especially by psychiatrists.  In these posts, and in the comments on my previous post on involuntary hospitalization, it seems that many of the comments by many (though not all) of the writers are addressing particular misuses of coercion rather than a general consideration of whether coercion has a legitimate place in the role of a mental health provider.

To begin with, I acknowledge that there is clear potential for misuse of coercive methods in all forms of health care but particularly in mental health care.  Therefore, an important question is whether it is so dangerous as to be eliminated from use.  Next, if one agrees that there is some role for coercion, we would need to decide what circumstances would permit it.  We would also need to consider what methods would be appropriate if coercion were allowed and if the situation permitted it.

First, please let me restate that I HATE coercion.  I have used it, but only reluctantly and after I have exhausted all other options I could identify.  I will not claim to be perfect, but I will say that I have never used coercion lightly or thoughtlessly.  I also will not hold myself up as an example for all mental health professionals.  I believe that people can sincerely, honestly, intelligently, and morally disagree with me, though I am willing to defend my views and decisions and test them against the strengths and weaknesses of other views.

Second, I will try not to overgeneralize and claim to know what “all” mental health care providers believe and what “all” patients want.  If you catch me doing this, you have my permission to correct me vociferously.  I would only encourage you to join me in resisting overgeneralization.

O.K.  Now to the defense.  I do believe that there is a place for coercion in mental health care, though I believe that its role should be very small and that procedures should be in place to minimize the frequency and duration of its use.  With regard to its place in mental health care, I believe that it should never  be punitive, it should never be used before all other available options have been considered, and it should always be subject to judicial scrutiny.

Why do I believe that coercion has a role in mental health?  Because I believe that there are circumstances when people’s behavior (not mere thought or attitude) put them at a risk of causing irreversible damage to their lives that they would not consent to if they were not in their current state of mental illness.  Let me unpack this long statement.  First, in my view, the behaviors I am talking about are suicidality and homicidality.  Outside of death, most effects of behavior are at least potentially reversible.  Things can be replaced.  Relationships can be repaired.  New jobs can be found.  I am not happy that people suffer loss of such things, and if invited to help them address their mental illness and solve their problems, I would gladly do so.  But if people can keep themselves alive and not put the lives of others at risk, our society allows them to risk other aspects of their lives as they wish.  Second, I do not hospitalize patients against their will for mere thoughts and attitudes.  Thoughts and attitudes alone have never killed a patient or anyone else.  If theses suicidal or homicidal thoughts have been put into action or if there is compelling reason to believe that they will be put into action, then hospitalization may be required.  Third, I have seen many patients who were suicidal or homicidal during an acute exacerbation of a mental illness and who later were thankful that they did not harm themselves or others during their illness.  This of course does not mean that they were all hospitalized or that the ones who were hospitalized were happy about it.  It also does not mean that everyone in that situation will be happy they were prevented from harming themselves or others.  What it does mean to me is that everyone deserves to be protected from irreparable effects of behaviors motivated by disordered perception, thought, and emotion.  If they continue to desire to pursue suicide or homicide/assault after normal perception, thought, and emotion are restored, then this becomes an issue for bioethics and police.  We are no longer in the realm of mental health.  Fourth,  we have the issue of whether mental illness exists.  This argument will not be settled here.  Please simply note that my defense assumes that there are illnesses/diseases that affect the working of the brain and the normal functioning of the mind and that lead to frequently reversible alterations in perception, understanding, judgement, emotion, and/or behavior that do not represent the usual worldview, goals, and values of the patient.

Why do I believe that the role of coercion should be very small and that procedures should be in place to minimize the frequency and duration of its use?  Primarily out of concerns for autonomy.  While I do not believe that personal autonomy is absolute, I hold it as the highest ethical principle.  I believe that there are many assaults on personal autonomy by family, society, “physical” illness, “mental” illness, government, nature, etc.  The truth is that we cannot do whatever we want to do.  Some limitations are unavoidable and generally acknowledged.  Others are rather arbitrary.  The word “autonomous” literally means “a law unto oneself.”  If this law were constant and rational, it would be easy to let autonomy be absolute.  When we realize that our “self law” is vacillating, inconstant, and at times self-contradictory we see the need for self-restraint (or at least the willingness to accept the consequences of our behavior).  When the “self law” assumes a form that is foreign to what an individual previously desired and valued, especially when this alteration entails suicide/homicide and might be attributable to a mental illness, I see the need to prevent or delay the action and attempt to return the patient to his former “self law.”  Still, most variations in self determination are not of major consequence (i.e. are not “life an death”).  Coerced hospitalization or other treatment should be reserved for the rarer “life and death” situations and should only be used long enough to ensure a return to the patient’s own normal perception, thought, and emotion.  As I said above, if behavior remains a problem after this, it is up to the ethicists and police to deal with that.  It has left the realm of mental health.

Why do I believe that coercion should never be punitive, and can one be coercive without being punitive?  These are questions that will undoubtedly be controversial and which may marshal strong arguments on both sides.  I believe that coerced treatment can be non-punitive but that there is great danger in it being seen as punitive when it is not or in it being used punitively inappropriately.  The only ethical principle I know of for coercive treatment is beneficence.  Generally, I hold autonomy above beneficence, but if I have compelling reason to believe that autonomy has been dangerously affected by mental illness, I consider it an ethical duty to restore the patient’s autonomy to its normal state.  While this may be viewed as punitive, there is no punishment in it (if thoughtfully and properly done).  I am not trying to deliver an aversive stimulus, though psychiatric hospitalization is aversive to most people.  I am not trying to use an aversive stimulus as a reinforcing stimulus, though it might serve that function unintentionally.  One might certainly question my motives and ask to make sure that I was not using hospitalization punitively.  On what I think is serious and honest reflection, I believe that I have not used coercion punitively.

The reason why I believe that all other available options should be considered prior to coercion should be obvious.  If not, please ask.  The reason why I believe that coercion should always be subject to judicial scrutiny is that I know that all mental health professionals are not perfect.  Some are far from it.  In a disagreement between mental health professionals and patients, a neutral, fair judge should be available to make sure that all rights are protected and that sound judgements being made.  This, of course, means that there should be a means of advocacy for patients so that their voices and points of view can be heard.

I try to work with my patients to make sure that they are able to assert their rights and maintain autonomy in their lives.  I would be very happy if none of them ever had to go into a hospital again and if they never felt compelled to take a medication against their will.  Still, I hope that there are good, moral, wise, and caring people available if they ever need either but are unable to ask.