While I've suffered overt coercion in the mental health system and clearly it's evil...the fact is for many of us it is indeed clear. And it's easy to point it out...it may not be easy to fight it as there are so many proponents of it, but at least everyone knows what we're talking about whether it's agreed upon or not.

What is much more insidious is the subtle coercion that so many people are blind to. Most people are blind to....that is what truly frightens me...it's the seemingly kind, but manipulative doctors who don't tell you the truth about the drugs they are pushing and the paradigm they prop up that is so very damaging to all of society. And of course, it's the "gateway" to more overt coercive treatment.

Very thought provoking post. I'll give my 2 cents. I think the subtle coercion in mental health care is what happens most often. It's the comments like, "You have a chronic illness & you must take medication for the remainder of your life." or "We have tried everything, the only thing left is ECT." Those are powerful statements to a patient who is already depressed. What could be more depressing than to hear crap like that? So, it keeps some patients feeling even more helpless and accepting even more drugs when in fact what they may need is to get away from their crazy psychiatrist or their crazy therapist or off the drugs or whatever.

Then, there are the more blatant coercive forms. This would be like threatening patients with some form of unpleasant action if they don't do this, that, or the other. Example, Kendra's Law. "If you don't come in to get your big shot of haldol in the ass, then we'll have no choice but to put you in the psych hospital." Some choice, right? I also think the more blatant coercive forms occur in the psych hospital even if you entered voluntarily. I was encouraged to go inpatient (subtle coercion) but once I was there was told that if I didn't do what they said I wasn't going home (I think that would certainly qualify as the more blatant form of coercion).

But, I do think the voluntary model does exist. I was in therapy following my most unpleasant experiences with Crazy Therapist # 1 & Jackass Psychiatrist. Maybe it feels voluntary because I actually improved, got a job, and didn't need her anymore. I didn't stay mired in therapy for years, getting worse and worse (which I think would be more of the subtle coercion). The therapist built me up, instead of tearing me down. That's what I would like to see more of.

No good ideas on how to parse terms here, but it is worth thinking about how much about psychiatric care can be truly "voluntary" when non-drug options are not offered or readily available.

I have the same question about what counts as coercion in the mental health system. But I won't jump the gun - I'm interested to see what others have to say first.

As someone who has found Lamictal to be very effective for me personally with few side effects, I'm also certain that the withdrawal will be hell when and if I go off it, unless and maybe even if I manage it very, very carefully. I'm prepared to take that risk; but I agree the potential for withdrawal problems is an under-scrutinized and under-publicized hitch in its reputation as a wonder med.

I don’t think that enough attention has been paid, in general, to what you point to here as “the subtle coercion of the mental health system,” not just in the more obvious ways in which patient responses to doctors and families are being blended (as you put it so well), but also the ways in which the medical model has seeped into culture in general to shore up the idea that life is a illness that can be cured through the transformative powers of medicine. The kind of medical model in which the healer holds all the cards of health and is separate from the person suffering, and who is defined as the patient.

I don’t want to take up too much space or time here, but let me just give a small example of what I mean by this: a boy, barely past his 18th birthday, goes off to college, after having lived most of his life in the shelter of suburbs, with plenty of toys and distractions, and, because he happens to have a quick mind, to start with, he never had to spend much time studying, let alone ever read for pleasure, when there so many video games and such to quell the desire for stories . In college, away from home, the boy, faced with life as he had never know it before and himself in it, immediately labels his condition as “manic depressive,” because that’s what his seen in movies, and heard the grown-up talk about at parties while growing up, or googled on the web…. You get the point. So he goes to a psychiatrist, because where he grew up, most people have therapists, as well as a nice selection of pills to go with various mental conditions, the way they have merlots or cabernets, or chardonnays to go with dinner… Anyway, because the boy is not used to talking, he opts for his first rite of passage in the world of pills and thinks his problems are solved. But, as fate would have it, the boy develops an allergy to the pill, and by this time, he also manages to develop a rudimentary relationship with the psychiatrist, as well as he has spent more time away from home, discovering, well, the world, in all its complex glory.

I promised not to hog space here, but I have failed, so let me sum it up from the angle of one who has watched the younger generation grow up in a world where not only is there no time to forge an emotional life, but also in which this life has been increasingly presented to them as just another branch of modern medicine – or better yet a consumer for a new market. Then again, it’s nothing new that I am saying (and yes, I am reading Charles Barber’s book)

"subtle coercion of the mental health system, blending a voluntary patient response to doctors and families pressing people into compliance and treatment."-Dawdy

This exists.

It exists as a subtle,yet non-legal/non-court ordered treatment plan required for clients residing in residential care/group home facilities in Washington State.Though the lifestyle has freedom, one then questions the ultimate definition of it.Sometimes, it is necessary for the individual, to remain outside of an unlocked institution. I know this because I know about 40 people living this way. One man recently told me he remembered me visiting at Western State (Institution)Hospital. I told him I was so glad he was not there anymore. He looked at me, and said, "This, this is freedom." He spoke a 1000 words with his smile. Another woman remembers me visiting at another psychiatric hospital.She talks to me daily and she takes the bus to restaurants and is happy. Another woman just arrived from Western State that I also knew from inside a psych hospital and she hugged me and as I told her I was so happy she wasn't in a hospital, she cried, and had the biggest smile.

They are voluntarily leading successful lives outside of a locked down state institution.

This is a reason why subtle coercion is needed and it works with good outcome.

Some may differ that subtle medication coercion is needed/warranted/right, but all I know is there are a group of people I see every single day that would be locked up without it.I see them riding the bus, going shopping, and having a life.

It might not be a life others understand reading here, but then again these were severely ill and at times violent patients.There are extreme cases, where yes, "running into traffic" as Philip wrote when he discussed this briefly, or "can't wipe their own butt".

There is a sense of freedom when one is alive.

That's the bottom line, they are alive and I think it shouldn't be underestimated, it's a life they may not have had otherwise.

I'm glad you're feeling better!

Mathmatically I can think of six types of people.
Two groups.
First group volantary seeking help.
1) patient gets drugs, is happy, success
2) patient gets drugs, is not satisfied, failure.
3) patient gets drugs, is happy for a significant amount of time, but drugs don't continue to work,withdrawl and addiction , possible perminant brain/central nervous system damage.

Second group
Second group INvoluntarily get psychiatric treatment. Family-friends or court order forces treatment.
4)patient gets drugs, is happy, success and thanks psychiatry for saving them.
5)patient gets drugs, is angry, anger only proves they are ill, more drugs given to heal the chemically imbalanced brain (sarc. joke)
6)patient gets drugs, limited to no improvement, life in hospital-prison plus life on psychiatric drugs to speed death/physical disease. May in fact be autistic/aspergers, who cares?

People then can throw in criminal and drug abusers/addicts, but I think these are initially choices(stupidity?) that people get trapped into, so don't count as mental illness.

On the issue of "subtle coercion," it's important not to slip into stereotypes. I think too many people do blindly trust doctors - not just in mental health care, but in general. (Just an aside: how is psychiatry radically different from the rest of medicine in its lack of accountability, its involvement with big pharma, its arrogance towards patients, and its vulnerability to fads based in half-baked science? I'm curious what people have to say.)

On the other hand, there are those stubborn, suspicious types who question the process at every step and refuse to take their psychiatrist's word for anything. (Personally I hate taking pills or seeing doctors of any kind, and I know full well it is a mine field out there - which is why it really ticks me off when people assume I take meds out of blind faith or ignorance.) And I'm sure there are a whole range of responses in between.

Granted there is always some level of imbalance in any doctor-patient relationship; but at least for someone in outpatient psychiatric care, there is always the option of just walking away, flushing their pills down the toilet, and not coming back. And I don't think you can underestimate how many people who are suffering from situational depression or some other transient ill, even in the Prozac era, do exactly that.

I think the biggest difference between psychiatry and what I cal "legitimate" medicine is that psychiatry and psychiatric treatment is not based on empirical, testable, objective evidence or tests. Psychiatry is also not falsifiable in a sense since denying your malady is deemed proof of illness.

I was a "blind faith" guy who implicitly trusted my doctors and their judgment. Now I treat them the same way I do a Realtor. I've come to learn that I am primarily responsible for my health, knowing about medicines and procedures, their risk/benefit ratios, and to always get 2nd and third opinions when necessary. This isn't easy, and I'm not certain to what extent my approach is viable in a general sense.

re: outpatient
There is voluntary and involuntary outpatient. I suspect involuntary probably forces you to make your meds in the presence of staff. We don't have that option here in CT which how I avoided a potential lengthly hospital incarceration (no lesser option to the court...)

One of the problems with the psychiatry/psychology thing is if these problems aren't chronic mental health practitioners don't make any money, unlike real medical professionals. If you go to your general practitioner with a sore throat, he can treat it and know you'll be back when your back hurts or you start sneezing. He has no incentive to tell you that your throat will always be sore, it's a chronic condition, and you're going to have to be on medication for the rest of your life that will never stop your throat from being sore but instead will have such serious side effects that you need to see him regularly forever.

The coercion starts with telling a customer that their condition is chronic. Ironically psychiatry is the only branch of medicine that regularly does this and the only one with no proof that such a thing is true. So first the patient is robbed of hope and then told they have to take medication that won't correct their problems forever. That's what bugs me about folks who talk all of these drugs, these people always have a laundry list of the mental problems they still have while on 5 different meds.

If doctors were honest, it wouldn't be so bad. Oh and the chemical imbalance myth that folks are sold as if it's a proven fact....If a pshrink told a patient, "I understand that you are unhappy because your wife died, your cat is sick, we have no idea why, whatever, but we do have these drugs that will change your mood - we're not sure why - they usually will work for six months or so and after that you may spend the rest of your life physically unable to get off of them even though you have ever increasing emotional problems, or you might not. And the sales rep is a really hot ex cheerleader from the University of Texas. Want a prescription?" I'd have little problem with the drugs, it's the lies, the you have a chemical imbalance and must take drugs forever crap that is coercion, dishonest, detrimental."

I think the coercive model is just involuntary commitment and forced medication in jail, things like that, where clearly the patient has no say (medicating kids actually comes under this I would say). The problem with the so called voluntary model is that it is based on brainwashing and propaganda. I'm not sure we can even call it subtle coercion since that implies the person doing the coercing is aware of what they're doing (doesn't it?). The problem in psychiatry is that a whole system has been built up on false premises -- both in diagnosis and in treatment. And everyone -- professionals and patients -- have false beliefs that end up serving obscure purposes that are not readily apparent. There are many well meaning psychiatrists out there who really think they are doing the right thing but it's all based on a house of cards (in my book). Anyway not sure if this helps you sort out your terms or not but it's certainly something to think about.

The Last Psychiatrist's most recent two posts address the issue of labeling. http://thelastpsychiatrist.com/2008/05/oh_please_what_do_europeans_kn.html

It's the labeling that makes people think they are sick not being sick that makes people think they need labels (yes that's a little szasz). And I know there will be the posts like "well if you'd ever spent three days in bed" or "got out of the car and started screaming in traffic" but still the sleeping thing is pretty normal in some cultures and classes as is being assertive in a disruptive way.

My experience with the mental health system has been that it is often like a one-way door. You can enter voluntarily seeking help with some kind of mental distress that seems overwhelming at the time, but if you decide to leave (because there is nothing helpful about the treatment offered) they may not let you. The door that opened so easily going in may not work at all if pushed from the other side. You just have to wait until your captors - who you had been misled into thinking might provide healing - decide it is in their best interest to let you out. This can involve waiting a few days or weeks until some kind of "temporary hold" runs out, or it can require waiting much longer if there is some kind of court-ordered committment involved.

Of course, the same thing could happen with outpatient drugging, too. That which you originally volunteered for can become mandatory if you try to make it stop - your treatment is voluntary only so long as you don't try to end it. Though you might not have ever been forcibly "treated" if you didn't volunteer for it first, once they have you in their clutches you no longer have an option. "Subtle coercion" seems like too mild a term for that - it's more like a choice that you can't take back (though you may be misled into thinking that they will always let you change your mind).

I think it might be accurately described as kind of like a bait-and-switch type of thing. People who are caught up in it are likely to be already in a pretty bad state, so their resistance to abusive or damaging treatment is less than it would've been otherwise.

I'd like to add that I'm glad you're not feeling so bad as you were. I think that the dark wintertime weather has a negative effect on many people, though more so for some than for others.

When I think of the wonders of "objective", "legitimate" medicine, I think of my grandmother, who was more or less killed by doctors who were too busy reading data on charts to pay attention to an old lady complaining about pain in her stomach. I also think of a close friend, who was told by two different "specialists" that her chronic wrist pain could only be solved by an invasive surgical operation and who sneered at the idea of massage therapy. She never went back; instead she stuck with the massage, and it worked. If she had followed their advice, I wonder how many follow-on surgeries would have been necessary just to correct the complications from the first one. How is this so different from the nonsense that goes on all the time in psychiatry?

So criticize psychiatry all you want, but please don't pretend that the rest of medicine isn't fucked up for most of the same reasons. The practice of medicine in general is in a terrible state right now; the basic science may be improving, but overall treatment and care-giving are not, and it is a huge mistake to idealize it for the sake of better bashing psychiatry.

Legitimate medicine, as with other disciplines, is fallible and full of the human factors: greed, envy, ignorance, ego, competency, etc...

Objective tests are observer independent. An x-ray might be subjectively interpreted, but the image does not change based on WHO views it. An x-ray won't show a compound fracture if you don't have one and vice versa. Yes, mistakes can be made in the measurement and analysis process, and tests have limitations. However, no such objective tests exist for psychiatry.

The difference is that psychiatry is being sold as a biological disease. A biological disease has a specific etiology that distinguishes it. It can subjected to objective laboratory tests. Mental disorders/disease are classified on the basis of non-specific symptoms not objective tests. This may seem as somantics, but it is critical since psychiatry is making unsubstantiated claims that elevate and equate symptoms to disease.

Psychiatric diseases have no biochemical, anatomical, or functional signs that can be measured that reliably distinguish that the brains in question are in fact from mental patients. There is significant overlap between what people call normal and diseased brains. There are no external validating criteria for diagnosing psychiatric disorders. Diagnoses are solely based on a psychiatrist's idea of how a person should be. Evil spirits explain mental illness as well as chemical imbalance. Objective tests exist for neither.

Part of problem is managing expectations. We often remark that even aspirin could not get approved in today's environment, yet people happily take it for all sorts of reasons. Quite a few people die each year from bleeding ulcers directly related to aspirin. Most have some sort of compromising factor, but the aspirin is the culprit. Pharmaceuticals are deemed "safe" based on population statistics, so naturally some people are going to die, or get get sick in due course. It comes down to how well you understand the risk/benefit and whether you have a choice to take a drug or undergo a procedure freely knowing the risks. I'd argue a psychiatric patient is in the worst position to make that decision because of the systemic coercion and intellectual and emotional blunting from the drugs.

The difference is that your grandmother's chronic wrist pain can be evaluated to see if there is an infection, a mechanical issue, soft tissue inflammation, arthritic, spine related, etc... These are all measurable, quantifiable, and falsifiable. The fact that the docs were not overly holistic in their practice does not undermine the fact that "legitimate" medicine has validated tools to identify (not that it's always right, we know that's not correct) a probable cause and thus a treatment (if one exists) for her pain. I note she wasn't held or treated against her will for choosing a different path - try that in psychiatry. Kent's description above is spot on in my experience.

The difference is that the underlying foundation of "legitimate" medicine withstands scrutiny. Psychiatry's does not when you insist on the same standards of logic and proof.

I guess, in the end, if all you have is a hammer everything looks like a nail...

Garth,
You are absolutely right that this nonsense is hardly limited to psychiatry. There are lots of excellent books on the issue of how the field of medicine is focused on selling sickness, rather than promoting health: Selling Sickness by Alan Casselss and Ray Moynihan, Overtreatment by Shannon Brownlee and of course the old classic Limits to Medicine by Ivan Illich. There there's one called The Last Well Person which is how I feel when I go to the dentist and they ask what meds I'm on and I say none -- you can hear the jaws dropping to the floor. It's almost unheard of these days not to be on something. Staying away from the doctor is almost a full time occupation of mine. It takes a lot of work actually. I had to learn the hard way by observing others lose their life or their health to the medical profession. And frankly our whole country will go down the tubes if we don't change the driving force in treatment to promoting wellness rather than selling sickness. Unfortunately it doesn't look like the trends are in the right direction.

"What is the coercive model of the mental health system?"
It is any and all state intervention relating to the mental health system. That some state-administered psychiatry appears to be voluntary is besides the point, since laws exist giving agents of the state (psychiatrists, social workers, etc) powers to detain, drug, and otherwise control the lives of innocent persons.. Without special mental health laws, any and all unwanted psychiatric interventions would be treated just as any unwanted medical interventions would - as assault and battery.

Note that this bypasses all debate about how illness and mental illness are defined. Indeed, those who argue that mental illness is just like any other illness must squarely face the fact that medical treatment is premised on consent, while psychiatry is not.

There are many forms of psychiatric coercion, but I agree that it helps to define terms on this matter. Coercion is a political concept (involving more than one person), and despite some minor disagreements/confusions between libertarian writers, the idea itself is pretty simple.

The other side of the coin is that psychiatry not only wrongly condemns the innocent, but it excuses the guilty (paradigm case: insanity defense, but as with coercion, comes in many distinct forms, too numerous to mention here).

Thank you for the recommendations, Sara.

Paul, until fairly recently the etiology was unknown and there were no "objective" tests for many, if not most non-mental ailments. That didn't prevent doctors from identifying many of them correctly as specific, biological disorders and attempting to treat them based on external symptoms. The germ theory of disease was the subject of debate for many years before bacteria were identified in the 19th century. Who saved the most patients, the ones who bought into the theory based on incomplete evidence, or the many others who dug in their heels until the existence of unseen "germs" was proven? By your standards of "logic and proof", it should have been the latter, but it wasn't.

Many diagnoses of physical ailments are still not "falsifiable," with x-rays or blood tests or anything else. If the doctors had operated on my friend's wrist and the pain had failed to go away, would that have falsified their diagnosis? Not at all: there are plenty of other reasons they might use to explain why the operation failed. Yet orthopedics is supposedly as objective and scientific as medicine gets.

Yes, psychiatry should be held to the same standards as the rest of medicine, and many of its current theories may be completely wrong - but the standards you are imposing are based on an unrealistic vision of what medicine should be, not what it is. By the way, it was my friend who had the injured wrist. It was my grandmother who died because the physicians around her ignored her reports of pain, which apparently were not "objective" enough to figure in their assessment of her condition.

Garth:
"psychiatry should be held to the same standards as the rest of medicine"
If this were true, there would be no justification for any coercive psychiatry.

You make several reasonable points, but one must look at the past century of psychiatric brain research, and conclude that no physical basis for any of what are now called mental disorders have been identified. Even if it were to be the case some time in the future (ignoring, for the sake of argument, all of the accompanying reasons for psychiatric diagnoses), it would fail to provide an excuse to coerce people into treatment, or to excuse wrongdoing.

Garth "Yes, psychiatry should be held to the same standards as the rest of medicine"

I came up with 6 possible variations, Kent reminded me of the one way voluntary entry. "The door that opened so easily going in may not work at all if pushed from the other side"

We must never forget psychiatry is not just medicine. (if you can believe it is medicine)

from wikipedia Thomas Szasz “ The collaboration between government and psychiatry results in what Szasz calls the "therapeutic state," a system in which disapproved thoughts, emotions, and actions are repressed ("cured") through pseudomedical interventions.[53]

Wait/ you mean psychiatry is not a medical field? this explains a lot. This explains lack of health coverage and arrogant doctors, make that psychiatrists who generally do not accept insurance, and claim to not make as much money as medical doctors.

The details of care, coercive or not, remain barbaric. I've seen people not locked up and on meds vs. locked up on meds and this is the ONLY choice we have now unless the people being sufficiently battled into taking meds for freedom can do anything else for themselves.

So in this case in my opinion, speaking for the 44 people I know I'd rather see them where I do, in a free living situation than where I saw many of them, in a locked up psych ward from hell, called an institution for long term care.

Of course, I would rather not see them drugged up but fucking hell they are living a better life than the alternative and that's all I can say.

At least they do not have a court order. Sometimes within this system you have to take the shit until SOMEONE CHANGES THE WAY IT IS NOW WORKING.

Bitch and moan all you want but until the changes happen we are all just letters typed on this blog whining.

Another huge problem is that psychiatrists are not held accountable in the same way other doctors are because there's no clear cut diagnostic procedure. In other fields misdiagnoses is malpractice. If you had a seizure and the doctor diagnosed epilepsy and treated you for epilepsy and you dropped dead because it turn out you had a brain tumor, you can sue. In psychiatry, your doc can change your diagnosis every month and no one will give a damn.

I just found this as I was wandering around the net. It's a Szasz quote: "Mental disease is fictitious disease. Psychiatric diagnosis is disguised disdain. Psychiatric treatment is coercion concealed as care, typically carried out in prisons called "hospitals." Formerly, the social function of psychiatry was more apparent than it is now. The asylum inmate was incarcerated against his will. Insanity was synonymous with unfitness for liberty. Toward the end of the nineteenth century, a new type of psychiatric relationship entered the medical scene: persons experiencing so-called "nervous symptoms" began to seek medical help, typically from the family physician or a specialist in "nervous disorders." This led psychiatrists to distinguish between two kinds of mental diseases, neuroses and psychoses. Persons who complained of their own behavior were classified as neurotic, whereas persons about whose behavior others complained were classified as psychotic. The legal, medical, psychiatric, and social denial of this simple distinction and its far-reaching implications undergirds the house of cards that is modern psychiatry." http://www.szasz.com/freeman21.html

Hey, I wasn't suggesting that there weren't serious problems specific to psychiatry or practices that need reform. I was arguing against the mistaken idea that psychiatry is some huge deviation from modern medicine in general. If anything, many of the problems in psychiatry stem from its relentless attempt to conform to modern medical ideology - which, again, is failing in its supposed mission of healing for many, many people.

The idea that psychiatry exists mainly to repressed officially "disapproved" thoughts, emotions, and behaviors is both limited and limiting. I understand the appeal for those who have been through coercive treatment, but it has nothing to say to the majority of people who actively seek treatment for themselves because they are suffering from problems that THEY define as impairing their own functioning or even ruining their lives. Furthermore, the government is nowhere present in the vast majority of these interactions (insofar as it is failing to regulate psychiatric drug testing and marketing, it is probably not present enough). I'm sorry to be so blunt, but that is why Szacz's views seem tired and old to me, and completely inadequate to deal with the current situation except in a minority of cases.

Garth"majority of people who actively seek treatment for themselves because they are suffering from problems"

All the children diagnosed with mental illness's are seeking treatment? right.

People who actively seek treatment also believe in the brain chemical imbalance that Pharma Co. has a solution for.

I Want A New Drug
"I want a new drug
One that wont make me sick
One that wont make me crash my car
Or make me feel three feet thick"