Use of Coercion in Recovery-Oriented Care: Staying Vigilant

To the Editor: In an Open Forum in the May issue, Geller (1) states: “It is unfortunate that those who define and advocate for recovery either fail to acknowledge, or fail to address, the role of coercion.” As an example he cites a document published by the Substance Abuse and Mental Health Services Administration (2); however, this document addresses coercion explicitly and at length. As one of “those who define and advocate for recovery,” and having drafted the pages that Geller did and did not cite, I feel compelled to quote the following from the document:

“When a person is incapacitated by an acute episode of psychosis, is unable to make his or her own decisions, and poses a serious and imminent risk, the recovery-oriented practitioner is … obligated to intervene on the person's and the community's behalf. There is no need to view such interventions as conflicting with a recovery orientation if you consider the parallels to emergency medicine [where] … it is incumbent upon the medical professionals present to intervene on the person's behalf prior to securing his or her consent. … Recovery-oriented practice … is not contradictory to emergency intervention on the person's and community's behalf. What recovery-oriented practice requires is that such interventions be performed respectfully, in ways that ensure the dignity of the individual, with transparency, only for as long as is required by the emergent situation, and in ways that optimize the person's opportunities for exercising whatever degree of self-determination remains possible at the time.”

Geller is not alone in painting recovery advocates as naïve. But his argument—that coercion is also a part of life for people without mental illnesses—is one with which many recovery advocates agree. With rights to community membership also come responsibilities. What Geller misses in his suggestion that coercion occurs not “because of ‘psychiatric status’” but as “an intervention to address behavior” is that generations of persons with mental illnesses underwent involuntary treatments (including lobotomies) and prolonged confinement not for any illegal or dangerous behavior but simply for having a mental illness. Until we can rest assured that this can no longer happen—that persons will no longer be coerced because of their psychiatric status—recovery advocates will continue vigilantly to challenge the use of coercion to ensure that it is used only when, and only for as long as, it is absolutely necessary.

As a result of the 1999 passage of the Dodd-Lieberman Act that restricted use of restraints and seclusion to emergency situations, their use in Connecticut dropped by 50% within the first year and by 90% within four years, with no increase in staff injuries (3). Although this represents progress, recovery advocates suggest that it also means that as recently as 2000, restraints and seclusion were used nine times more often than they were actually needed. For every episode in which they might have been required, nine additional people were subjected to coercive measures unnecessarily. This is only one of the reasons why the U.S. Department of Justice has been conducting investigations of civil rights violations over the past decade in hospitals around the country. But unfortunately Geller appears to fail to acknowledge or to address this reality in his argument.