(WITHDRAWN) Psychiatric Drugs in a Declining Welfare State: An Ethnography of Coercion in Mental Health Services

Background and Purpose:

A central ethical dilemma in mental health services concerns personal autonomy related to psychiatric drugs. Providers and clients must work together to interpret and adjust drugs based on their perceived effects on behaviors, subjective experiences, and quality of life. Yet, providers may rely on a range of coercive and influential techniques to ensure consumption among clients who decline drugs. This has raised serious ethical questions due to the propensity of antipsychotics to produce adverse effects. Further, coercive techniques may damage how clients relate to their providers and sense of agency in services. Little is known how clients and providers navigate these dynamics, particularly in involuntary outpatient programs. Thus, the primary focus of this study was to explore the relationship between interpretations of drug effects and psychiatric drug decision-making between clients and provides in involuntary outpatient services.

Methods:

The primary method was ethnographic observations (< 1000 hours), including semi-structured interviews and participant observations. Data was collected as a part of a contracted quality improvement evaluation of Los Angeles County’s involuntary outpatient treatment (OPC) program. A team of ethnographers conducted observations of community outreach services, court hearings, and treatment delivery beginning in October 2016. Semi-structured interviews were conducted with 24 outreach workers and treatment providers, 20 clients, and 12 family members. For the analysis, thematic codes were developed in an interdisciplinary research team to capture the emergent processes and themes in the notes. All coded data related to psychiatric drugs in outpatient services were extracted. Next, the data were compared to identify prominent patterns in relation to providers’ and clients’ perceptions of and experiences with drug use.

Results:

Providers believed that psychiatric drugs would reduce clients’ risks of violence perpetration and victimization, hospitalizations, arrests, and homelessness. Providers relied on progressively more intense forms of influential techniques with non-compliant clients to ensure drug consumption. Clients who preferred to decline drugs expressed feeling powerless and often complied to avoid perceived negative consequences, which ranged from social disapproval to court-orders.

Negative drug effects challenged the relationships between providers and clients. Clients worried that the negative effects would result in increased social stigma and irreversible physical harm, and prevent them from pursuing life goals. Further, clients reported that their concerns were regularly disregarded by providers, which fostered mistrust. In contrast, providers were concerned when negative effects interfered with the treatment process (e.g., drowsiness during case management); yet, both sets of concerns were outweighed by providers’ beliefs that drug effects protected clients and their communities from harm. In order to compel drug consumption and maintain client rapport, providers relied on court officials or family members to influence clients to comply with drug treatment.

Conclusions and Implications:

Psychiatric drugs were believed to reduce the vulnerabilities of clients and their communities. This served as a moral justification to compel drug consumption, even when it interfered with therapeutic rapport. Our results suggest that the reduction of the welfare state has perpetuated a reliance on psychiatric drugs to protect clients and eroded client personal autonomy in services.