Coercion of Voluntary Patients in an Open Hospital

Abstract

Author's Note (1982) "Coercion of Voluntary Patients in an Open Hospital" was written twenty years ago when I was training as an intern in a small psychiatric hospital. The article was a first in the literature -an analysis of the oppression and control of psychiatric patients in an allegedly open, humanistically oriented psychiatric hospital. Unhappily, the article remains a Hrst. I know of no other similar analysis in the official psychiatric literature over the subsequent twenty years.Psychiatry remains as reluctant as ever to recognize the devastating impact of its treatments upon the minds and brains of its patients. The personal, subjective response of the patient is almost wholly ignored in the psychiatric literature. Meanwhile, in private practice, as well as in clinics and hospitals, the psychiatric patient is subjected to a variety of threats and controls, from the simple authority of the physician to the more concrete menace of involunillry drugging, electroshock, and incarceration. Despite many legal attempts to increase the civil liberties of mental patients, it remains true today that even the ostensibly voluntary mental patient has almost no protection against assault with the psychiatric armamentorium.For those psychiatric patients who experience the relatively benign and sometimes helpful experience of psychotherapy in private practice, the threat of psychiatric oppression may seem remote. But should this same patient become "irrational," "self-destructive," "dangerous," "mentally ill," or even "in

Respect in mental health

“…Coercion, according to Breggin, 53 is any action or threat of actions, which compels the patient to behave in a manner inconsistent with his own wishes. More recently, Patterson 54 reminds us that coercion exists on a continuum of overt to covert forms.…”

The gap between voluntary admission and detention in mental health units: Table 1

“…Similarly, a mental health nurse may correctly perceive that a very disturbed patient would probably be detained if she tried to leave, and be motivated to impart this information to avert subsequent misunderstanding or, indeed, greater duress. Breggin described ‘prophylactic coercion’, motivated by desire to avoid transferring patients to a more restrictive environment 1. Is there an ethical difference between the imparting of correct information in these instances?…”

“…Clearly some individuals will not feel threatened, but rather reassured, by seeing the healthcare team take responsibility for their safety. Noting the diversity of individual's responses to possibly coercive situations, Breggin himself emphasised patients' experiences in determining whether or not coercion took place: “Coercion may be considered the experience of an unusually constraining or intimidating alternative, so that the individual feels his freedom of choice is pre-empted.”1 The same situation, then, may be coercive or not depending on subtle effects on the individual.…”

“…Where detention is possible, after all, being or feeling threatened with detention is possible; equally insidious ‘warnings’ about the probability and circumstances of detention are unlikely to be fully avoidable under the present system. Locked doors or ‘managed exits’ in some units, the presence of others who are formally detained, ‘observations’ confirming patients' whereabouts or restricting time outdoors, and the terminology of ‘absconsion’ as opposed to self-discharge all contribute to an atmosphere in which, as Breggin wrote, “the threat is so pervasive that it hardly needs to be mentioned by the therapist.”1…”

Compulsory community treatment: ethical considerations

“…Sherwin (1992) asserts that in the ethical evaluation of certain medical practices, feminism demands that we consider every intervention in regard to its potential for oppression. If we believe Breggin (1997), who labels institutional psychiatry as ‘psychiatric oppression’ (p. 423) and ‘political totalitarianism’ (p. 424), compulsory community treatment would seem to be a form of oppression that feminists would renounce. It is not that simple.…”