Care through Coercion?: Reframing the Ethics Debate on Involuntary Mental Health Services

Background and Purpose

Contemporary mental health policy attempts to balance public interests of treating serious mental illness with the personal rights of individuals. To do so, services rely on dangerousness and grave disability criteria and, in recent decades, have expanded community-based involuntary treatment programs. However, drawing from sociological and ethical theories, critics argue that coercive programs produce psychological harm and are designed to produce behavioral conformity, often at the benefit of market economies. While a rich debate exists in the literature and public sphere on involuntary programs, little ethnographic work has been conducted that directly confronts how coercion operates in real-time, including how coercion is understood, morally rationalized, and experienced by frontline providers and their clients. Understanding the rationales for coercive practices in involuntary mental health services may help us illuminate the broader sociological discourses that motivate its use.

Methods

The primary author conducted a multi-year and interdisciplinary team-based ethnography of involuntary outpatient services (OPC) in a diverse metropolitan county. Data collection included direct participant-observations of treatment sessions and semi-structured interviews of clients, treatment providers, administrative staff, and client family members related to compliance to psychiatric treatment. Ethnographic notes and semi-structured interviews were iteratively analyzed to guide data collection until thematic saturation was reached on themes related to patient preferences, autonomy, and coercion.

Results

Involuntary services were sought by family members and providers due to their fears of an individual’s hyper-vulnerability to victimization, homelessness, and policing in their communities. Specifically, these referral sources described how previous services were unable to address their concerns and hoped that involuntary services would increase treatment compliance, deliver on basic resources, and protect clients from harm. Providers relied on coercive methods (i.e., use of threats) to gain compliance often as a last resort and, instead, used lesser forms of persuasion first (e.g., incentives) in hopes to cultivate patient-driven compliance. Regardless of the technique used, many clients felt involuntary programs undermined their autonomy, resulting in fractured relationships between them, providers, and family members. Issues of compliance were particularly focused on medications, which some clients preferred to decline due to their various adverse effects.

Conclusions and Implications

These results require social work to reflect critically on how its frontline practices may further alienate vulnerable individuals away from supportive services. Further, these results reframe coercion as not an instrument of state oppression, but rather emergent from a broader political landscape of social precarity and violence. Specifically, the emergence of involuntary services was justified to fill the gaps of a disjointed, and increasingly defunded, social welfare system that leaves individuals labeled with serious mental illness structurally vulnerable. Involuntary interventions identify these structural problems within individual actors, placing enormous burdens on clients, their providers, and communities to gain compliance in ways that create moral distress and burnout. Thus, re-envisioning a more ethical mental health system without a reliance on coercion will require acknowledging the relationship between frontline social work practice and the relationship of mental health to broader social welfare, criminal justice, and health policy.