Day 25: What is your opinion on forced/coercion in mental health treatment? Can be legal (law enforcement or psychiatric holds) or a “helping” friend/family member.
My initial reaction to this question/subject was, I have to be honest, the instant recognition that I personally had never experienced (as far as I can recall) any of these.
That is not to say that my kids have never ‘helped’ me. Of course they have. But not in the way in which I feel this question or topic implies.
Even in the very depths of my mental illnesses, even in the very worst of times, I shut off from all reality – disconnected from it. And so I simply felt ‘lost’ and ‘vulnerable’. Because of this I was (I think) fairly compliant. And thus the need for ‘force’ or ‘coercion’ was not present.
Of course I do recall occasions when my wife (and/or others) had wanted me to do something (or had wanted to bring about some form of change) which I did not want to do or did not feel able to do.
But, on those occasions, I either remained defiant in my position and nothing changed or she (or they) simply gently and patiently persuaded or convinced me. And thus, here again, no actual ‘force’ or ‘coercion’ (the action or practice of persuading someone to do something by using force or threats) had been present.
And the above statement does, I feel, bring two key issues into play when it comes to bringing about a change, or getting someone to do something against their will. These being…
a) The mental state (and thus the compliance or lack thereof) of the person being forced or coerced. and
b) The type and level of coercion or force applied.
And these are, I accept, often dependent on – or impacted by – the urgency or need for that change to take place.
And these are key factors because they are governed by ‘acceptable norms’.
We live, act and react, – do we not – within a set of ‘acceptable norms’. Standards of proper or acceptable behaviors or responses. And those ‘norms’ are governed by the circumstances and environments in which they exist.
For example: If we see a small boy going to put a knife in an electrical socket, the acceptable norm would be to quickly pull him away from said socket. Or even to smack his hand and tell him, “No!”
The objective of the adult, or parent or guardian, by stepping in, is to remove the danger and to educate the child in order to reduce or remove the potential for recurrence of that danger in the future.
And how quickly or dramatically we react to him going towards the electrical socket is directly dependent on how young he is and how close to the socket he is.
But either way, an ‘acceptable norm’ is not to sit and watch him do it, or to throw water over him in order to make the result more dramatic and the lesson more effective.
‘Acceptable norms’ are there as a guide and a reflection and as a measuring stick as to how we should treat each other. And surely ‘acceptable norms’ should also apply to the treatment of those who experience mental illness(es).
But who get’s to decide what is an ‘acceptable norm’?
Let me briefly return to my earlier statement…
“Even in the very depths of my mental illnesses, even in the very worst of times, I simply shut off from all reality – disconnected from it. And so I simply felt ‘lost’ and ‘vulnerable’. Because of this I was (I think) fairly compliant. And thus the need for ‘force’ or ‘coercion’ was not present.”
My compliance – it could be argued – kept me and my potential behaviors and responses within the ‘acceptable norms’.
But what if I had not simply shut off from reality? What if in my ‘disconnection’ my mind, presented me with an alternative (false) reality? One which told me that your reality (often the actual reality) was false? Even though I might still feel very ‘vulnerable’ would I (within my alternative, reality) still feel lost? Or could I, would I, instead simply feel threatened?
Because in that scenario – in the scenario of these two differing realities – your actions or reactions might well be ‘acceptable norms’ to you (and others in your reality) but they will possibly (even probably) be far from acceptable in the reality I am experiencing.
And that will not only have an impact on how I respond to your actions (or reactions) but also how I see and perceive your reality.
But our ‘acceptable norms’ are the ones accepted by society and thus are the ones that apply and therefore which matter.
Would, of course, be a logical argument put forward by the person (or persons) trying to bring about the change. But is this necessarily so? And indeed, does it always justify their actions and/or negate or remove my rights?
Does the fact that I am (at that time) living in – and perceiving things through – my alternative (even false) reality, negate or remove all my rights in your reality?
Let me, at this point, share Article One of the United Nations’ Universal Declaration of Human Rights…
All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood.
“All human beings“. Does my mental illness(es) somehow remove my ‘human being’ status? Of course the answer to this must be no!
“Are born free and equal in dignity and rights“. Does my mental illness somehow remove my dignity and rights? Here again surely the answer must be no? Of course I openly accept that my behaviors might effect said rights and indeed said dignity. But isn’t that true of everyone – regardless of the status of their mental health?
“Are endowed with reason and conscience.” Am I not – even with my mental illness(es) and even in my alternative reality) (except in very severe or extreme cases) endowed with some reason and a conscience? (And yes I accept that for some, reason and conscience might be seriously impaired or even seemingly absent, but I am not generally talking these extreme cases here.)
So the questions become – Should I (as a human being – albeit one with mental illness(es)) still not be afforded ‘dignity‘ and ‘rights‘ [even if, in my head, I have an alternative reality]? And should I (as a human being – albeit one with mental illness(es)) still not be afforded the chance to ‘reason‘ and apply my ‘conscience‘?
And together those effectively boil down to this one simple question…
‘Does my mental illness(es) affect these things or does my behavior?’ Because surely it has to be my behavior and not my mental illnesses. And here again, (it is worth pointing out) that this in fact true of everyone – regardless of the presence any mental illness?
So in fact,
We do must therefore ensure – when considering the use of force or coercion – that it is not the presence of any mental illness(es) that we are addressing, but is instead very clearly the needs arising from any resultant behaviors (or any very evident and real potential behaviors).
And likewise, we must ensure – when considering the use of coercion – that the basic human rights (some of which I have demonstrated and emphasized through the use of Article One of the UN’s “Universal Declaration of Human Rights” above) are respected at all times.
Because regardless of the presence of any mental illness, human rights are not optional.
So where does that leave us?
Well, the small boy in our earlier example was evidently incapable of reasoning – given his knowledge base to date – as to the danger of his actions. And so an adult or parent or guardian rightly had to step in.
And likewise, I fully accept that sometimes mental illness(es) or the state of a person’s mental health reduces their ability to reason properly or removes their ability to reason at all.
I therefore also accept that in those circumstances – just as the small boy was pulled away from the potential danger (even against his will) – the use of force or coercion might be necessary. BUT it should never be at the cost of someone’s basic human rights.
So let’s move towards the conclusion of this already too long a post (My apologies for that, but my mind is certainly not great today) by looking at the different situations stated within the question.
Family and Friends (‘Helping’)…
I need to be extremely clear here. The fact that a person is someone’s family member or a friend does not automatically ensure that they have person’s basic human rights – or indeed their welfare – at heart when applying force or coercion or when arranging for someone else to apply force or coercion?
All sorts of other motivations can come into play here. Perceived embarrassment or shame, perceived guilt, frustration, desperation, a lack of understanding, or a desire for a personal respite from it all, being just some of them.
Law Enforcement Agencies…
Often work with both limited resource and high levels of demand placed upon them. Consequently their objectives in any given situation are likely to be shaped by a desire to resolve the situation currently presented to them as quickly and as painlessly as possible.
And in this situation, whilst force or coercion might be necessary, the needs and wishes (and sadly sometimes even the basic human rights of a person with mental illness) could well be way down the list.
Emergency Medical Response Services…
Here again the above can apply although one would hope to a much lesser degree given the fact that they are at least in a more caring focused profession.
Can sometimes, or so it seems to me, lead to a need to placate or subdue a person with mental illness (or with mental health issues) not only for their own (and other patients) safety and welfare to be protected but also in order to stabilize them to such a point where ongoing treatment can be given. And, of course, in this scenario coercion or force may understandably be necessary.
But I think there is within such circumstances the potential (and indeed cases where this has happened) where such force or coercion has led to an impairment in that person’s reasoning ability and/or will power long after the initial crisis has been dealt with.
Ward or Institution Based Treatment…
Here again, I think that pressures placed on staff – coupled with limitations in resources – and a very real (possibly even acute) awareness of potential flash-points, can easily come into play. And that all of these can have a very real and possibly a negative influence on the rights of the individual.
Force and Coercion are not only present when actually applied, but also when implied. And we would do well to recognize, as individuals, and as a society (or collection of societies), that even circumstances and environments can imply the possible use of force or coercion to a vulnerable person.
Take a moment, if you will, to reconsider the five scenarios (Family and Friends through to Ward or Institution Based Treatment) and to picture them in your mind from the perspective of the person who is experiencing the/any force or coercion in those scenarios.
And having done so take a moment, if you will, to consider our ‘acceptable norms’ and how what is considered as ‘acceptable’ seems to change within each of those scenarios.
In every one of the scenarios which I have mentioned above. I have, whilst accepting that there could be a legitimate case for coercion or force to be applied, also, I believe, demonstrated how the potential exists for the needs and rights of a person with mental illness or poor mental health to be placed at risk or even ignored.
And whilst it is true that in some countries, checks and measures are in place to reduce the potential for this happening. It is, I think worth mentioning that a) those checks and measures aren’t always employed. b) sometimes local or state laws differ – thus removing some of these checks and measures and c) not every country employes said checks and measures.
I am therefore convinced that every state and every country therefore needs to establish and support independent mental health advocacy programs and services. So that..
a) the basic human rights of the individual experiencing mental illness or poor mental health are protected.
b) education in respect of mental illness and poor mental health is provided to all agencies and where the potential for said human rights of the individual to be threatened exists.
c) ‘acceptable norms’ in respect of the treatment of those who suffer from poor mental health or with mental illness(es) are regularly challenged in light of increased understanding of mental health and mental health related issues.
d) individuals experiencing mental illness or poor mental health and whose basic human rights have been ignored or discounted have the right to appeal and to recourse in law.
I am a person who suffers from mental illness.
One who – when my mental health is fairly good – has a fairly good understanding of mental health and a fairly good grasp on reality. The reality we all share.
But I am also, someone who knows that when my mental health is bad I can and do experience alternative realities which you cannot share.
And whilst I freely and openly accept that in some cases a person’s behavior (whether actual or evidently and realistically potential) could merit the use of force or coercion. In neither of those realities (the real one we share or the alternative ones my mind sometimes presents) can I find any excuse for the presence of mental illness alone to be justification for the removal of a person’s basic human rights.