Coercion in Treatment: Researchers' Perspectives: In Reply

I agree with Dr. Roskes: coercion is a complex phenomenon with multiple dimensions. The question that he poses in his letter has three parts, which I address below.

Is research conducted by nonconsumers who have not experienced coercion flawed? Yes. Work in the area of emancipatory research has shed more light on the inherent power imbalance between those who conduct social inquiry and those who experience it (1). In addition, measurement bias, instrument bias, and interviewer bias are all basic challenges in conducting research (2). Research design is compromised when the construction of tools does not include the input of consumers with direct experience of coercion. Moreover, the research process itself can have an impact on outcomes. This is confirmed by the Hawthorne effect—or its corollary in physics, the Heisenberg effect—where observation affects the object of study (3). Fundamentally, all research is flawed (4).

Is research by nonconsumers of less value? No. Studies by consumers and nonconsumers are both valued.

Is research conducted by consumers unbiased? Yes and no. Consumers who have experienced coercion bring an unassailable veracity and credibility to any study. Each person's unique experience cannot be regarded as “bias” when it is first-hand knowledge of coercion. Jonathan Delman, a leading consumer advocate and consultant, recounted, “I would compare my experience of coerciontotorture, with medication changes that have left me in a zombie-like state; coercion causes a sane person to feel insane or akin to a criminal” (personal communication, June 1, 2011). However, consistent with the Rashomon effect (5), individual experience is not uniform, standardized, or universal. Each person's perception is different, which makes the study of coercion challenging.

More important than debating who should claim the high ground in coercion research is appreciating the damaging effects of coercion on individuals who receive care. These effects have been well articulated and should be taken as the sentinel call to recognizing that coercive practices thwart the purpose of mental health services—to facilitate recovery by improving a person's mental health condition and functioning—and have no place in a treatment paradigm. It is also important to recognize an inherent flaw in service system design, a flaw based on exploitation of a power imbalance. Tom Lane, a nationally recognized consumer leader who has experienced seclusion and restraint, summed it up well, “To suggest that ‘patients’ who have had coercive experiences are merely ‘unlucky’ or ‘unfortunate’ is a grave misrepresentation of what is, in fact, a gross injustice. It is not a matter of luck or fortune, like winning the lottery or not. It is a further reflection of the lack of understanding of a failed framework of those mental health systems which see coercive practices as treatment or acceptable ‘interventions’” (personal communication, June 5, 2011).