Madness versus badness: the ethical tension between the recovery movement and forensic psychiatry

Abstract

The mental health recovery movement promotes patient self-determination and opposes coercive psychiatric treatment. While it has made great strides towards these ends, its rhetoric impairs its political efficacy. We illustrate how psychiatry can share recovery values and yet appear to violate them. In certain criminal proceedings, for example, forensic psychiatrists routinely argue that persons with mental illness who have committed crimes are not full moral agents. Such arguments align with the recovery movement's aim of providing appropriate treatment and services for people with severe mental illness, but contradict its fundamental principle of self-determination. We suggest that this contradiction should be addressed with some urgency, and we recommend a multidisciplinary collaborative effort involving ethics, law, psychiatry, and social policy to address this and other ethical questions that arise as the United States strives to implement recovery-oriented programs.

A tale of two cultures: examining patient-centered care in a forensic mental health hospital

“…Much of the research literature regarding patient-centered care and related constructs has been built on the foundation of shared decision-making between service providers and patients, the latter of which are assumed to be self-determining agents (Pouncey & Lukens, 2010). In a forensic mental health hospital, this principle must be balanced with a myriad of opposing priorities that relate to safety and security, as well as the fact that some patients are unable to realize their own treatment needs.…”

“…In a forensic mental health hospital, this principle must be balanced with a myriad of opposing priorities that relate to safety and security, as well as the fact that some patients are unable to realize their own treatment needs. Forensic mental health services predominantly have been professionally driven and organized according to principles of a bio-medical paradigm, which often is oriented toward impairment, biological reductionism, and physician-led treatment decision-making (Borrell-Carrio, Suchman, & Epstein, 2004; Ghaemi, 2006; Pouncey & Lukens, 2010). For the aforementioned reasons, patient-centered care historically has not been prioritized in forensic mental health services.…”

“…Such people in many societies, including Canada, are treated with greater compassion and humanity by diverting them toward treatment and away from traditional criminal justice processing which includes punitive sentences. This presents a quagmire for philosophies of care that prioritize self-determination and rational choice: as is articulated by Pouncey and Lukens (2010): ‘how can we advocate treating persons with mental illness as full moral agents for the purpose of providing social goods, while simultaneously treating them as compromised moral agents when the same illness earns them social sanction?’ (p. 102). Additionally, individuals are typically under the jurisdiction of a forensic mental health system because an untreated or ineffectively treated mental illness led to the commission of a criminal act.…”

Beyond Easy Answers: Facing the Entanglements of Violence and Psychosis

“…This disabling potential is often more impactful when experienced in isolation and fear by individuals for the first time and/or who have had no chance or opportunity to engage with effective, compassionate professional, family and/or peer services and supports (cf. Perlin, 1997;Pouncey & Lukens, 2010). If we consider further contributing factors, such as social rejection and misunderstanding, to such experiences as commanding or threatening voices and intense fears of persecution or death, as well as the influence of popular entertainment venues and news media that regularly romanticize and normalize aggression, war and bloodshed (Anderson et al, 2010;Griffin, 2010;Kahlor & Eastin, 2011), absolutist, individualizing judgments regarding culpability become even more suspect.…”

Hoping Against Hope: The Prison-to-Community Transition Experience of Men With Co-Occurring Severe Mental Illness and Substance Use Disorder

“…However, the broader literature that explores the phenomena of recovery with people who have committed offences is slowly emerging (Doyle, Logan, Ludlow, & Holloway, 2012;Mezey & Eastman, 2009;Mezey, Kavuma, Turton, Demetriou, & Wright, 2010;Pouncey, 2010;Turton et al, 2011). One of the core concepts in the recovery literature is "hope".…”