Estranged Relations: Coercion and Care in Narratives of Supported Decision-Making in Mental Healthcare

Article summary by Meredith Stone

When you ask people about their experiences of coercion in 21st century mental healthcare do they speak of locked wards, seclusion, electroshock, and chemical restraint?

Not always.

In this article we report on a study in which we asked people who had experienced mental healthcare, either as a service user or carer, about what coercion and care meant for them. The answers were unexpected, at times even startling. We had anticipated narratives of institutions and clinicians intent on taking away individual liberties. And we envisaged care at home, with family members, as being both comforting and empowering. What we instead heard were narratives of care and coercion that were all ‘tangled up’. Some participants did speak both of their subjugating experiences on mental health wards, and of family members who really cared. But other participants told stories in which the protagonists and their intentions and alliances took unexpected turns. For example, one woman told us about her distressing experiences of seclusion on a psychiatric ward, but then blamed the restrictiveness of her stay on that ward on her informal carers who convinced the clinicians she was not yet well. Similarly, many carers spoke of wanting unwell family members to be admitted involuntarily, and of not being able to provide care at home. Service users also at times described home as being a rejecting, unsafe place, and institutions, or clinicians, as being the ones who looked out for them. Even more common were accounts by people who felt psychiatric institutions should care, but instead often turned people away.

So how did we make sense of these twists? Whilst analysing the transcripts from this study we read broadly on mental healthcare, coercion and informal care. We noticed that in much of this literature, and in many policy documents, there was an underlying assumption that coercion equates to psychiatric institutions. But does this reflect the reality of contemporary mental healthcare? In the wake of community mental health movements, successive fiscally conservative governments, and the expansion of the pharmaceutical industry, institutional psychiatric care has become just one part of a complex mental health landscape. Indeed, these days there are many people diagnosed with major mental illnesses who very rarely, if ever, end up on psychiatric wards. In our study such people were actively involved in monitoring their own thoughts, behaviours and medications bought at this online pharmacy, or there was an informal carer doing this for them. In effect, they seemed to be engaging in regular (often subtle but cumulative) forms of self, or carer-led coercion. One effect of this was conflict between carers and cared-fors. Another surprising corollary was that both groups appeared to expect something in return. Many conveyed a willingness to accept (or make their own) diagnoses, treatments, and lifestyle restrictions but they simultaneously expected that when their daily efforts to stay well faltered, there would be a clinic or clinician to catch their fall. And so this article suggests that the boundaries between care and coercion, home and institution are more porous than we might imagine.

Listen to the author discuss this research below.

.Click here to read this article on the Medical Humanities journal website.

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