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Coercion and pressure in mental healthcare raise moral questions. This article focuses on moral questions raised by the everyday practice of pressure and coercion in the care for the mentally ill. In view of an example from literature—the story of Ulysses and the Sirens—several ethical issues surrounding this practice of care are discussed. Care giver and patient should be able to express feelings such as frustration, fear and powerlessness, and attention must be paid to those feelings. In order to be able to evaluate the intervention, one has to be aware of the variety of goals the intervention can aim at. One also has to be aware of the variety of methods of intervention, each with its own benefits and drawbacks. Finally, an intervention requires a context of care and responsibility, along with good communication and fair treatment before, during and after the use of coercion and pressure.
Mentally ill patients may be subjected to various kinds of coercive interventions. The use of coercion and pressure in mental healthcare raises serious moral questions. Much attention traditionally has been paid to the moral justification of compulsory commitment and treatment, to the conditions that should be met and to the limits of interventions used against the will of the mentally ill patient.1,2,3,4 More recently, the debate also encompasses compulsory and assertive community treatment.5,6 The focus is on the ethical justification of coercive interventions in psychiatry. Important as this issue is, it is only part of the story. Just as important are moral questions raised by the everyday practice of pressure and coercion in the care for the mentally ill, and the process of care in which this takes place.
In order to explore what issues stakeholders consider morally relevant in the daily practice of using pressure and coercion, we conducted a study in six mental health institutions in the Netherlands.7 Individual and focus group interviews took place with mental health workers, patients and relatives. Moreover, we organised a national focus group with representatives from the different institutions. The moral aspects of pressure and coercion were investigated on the basis of case discussions and experiences of daily dilemmas and problems arising in practice.
This resulted in eight quality standards over which a consensus was reached. These standards primarily address mental healthcare workers and other professionals. Their aim is to stimulate reflection and debate about the use of pressure and coercion in mental healthcare. In what follows, a number of these standards are explored in more depth.
As the acceptance and use of informed consent has increased, coercion and pressure in mental healthcare have become more and more ethically problematic.8,9,10,11,12,13 Nobody likes to be in a seclusion room, tied or knocked out by sedatives. Coercive interventions may be experienced as traumatic and as an attack on identity.14,15 Professionals who put coercion or pressure into practice are also burdened by this.16 Yet restriction of the freedom of movement and forced medication can sometimes be unavoidable. Care givers and care receivers are aware of that.15,16 Professionals are caught between using coercion against unwilling patients and abandoning their commitment to providing the care they believe is necessary.17
We will discuss several ethical issues around coercion and pressure, using the example of the story of Ulysses and the Sirens from Homer's Odysseia. Ulysses, sailing his ship past the Sirens, orders his shipmates to plug their ears with wax and to tie him to the mast so he can hear the singing of the Sirens without endangering himself and his men. The goddess Circe had advised him to do so. The shipmates carry out the orders. The moment Ulysses hears the Sirens sing, he implores his men to untie him, but they tie him up to the mast even tighter. By means of coercion, they sail safely round the rock of the Sirens.
This story is a metaphor, and the typical situations in mental healthcare in which coercion and pressure are used are certainly not completely analogous. (The metaphor of Ulysses and the Sirens is generally applied to so‐called Ulysses or self‐binding contracts.18 We hope to show that the story has broader relevance.) Ulysses is not mentally ill. His life is fairly under control. The shipmates do not act as care givers; they are men who carry out orders. Nevertheless, we think that the story, from an ethical point of view, can clarify several important aspects of using coercion and pressure in mental healthcare. On the one hand, the example of Ulysses is interesting because it shows that coercion is problematic, even in relatively clear‐cut and controlled situations. On the other hand, the story of Ulysses reveals several ethical aspects and conditions that have relevance in more difficult and less clear‐cut situations.
As the story shows, the use of coercion involves emotions. A disaster seems to be imminent, which makes Ulysses and his men anxious. The intervention itself is emotionally charged, for it is not self‐evident to tie someone up or be tied up. When Ulysses starts to resist, he gets angry and utters threats and reproaches. The shipmates have to intervene even more forcefully. As a result, tension builds up inevitably, in the course of which both Ulysses and the ship's company feel irritated and powerless. In spite of the apparently simple order to ignore any resistance whatsoever, the use of coercion leads to an emotional situation.
When coercion and pressure have to be used, tragic situations occur. Characteristic of a tragedy is that evil is involved regardless of the action taken.7 Agamemnon's dilemma is classic.19 Fortune‐tellers predict that his fleet will not reach Troy unless he sacrifices his daughter. If he sides with his men, she will have to die. If he sides with her, he will lose the war. A similar situation comes up when coercion is used. When people are coerced, they are deprived of the opportunity to follow their own course of action. When it is decided not to use coercion, people are left free but it is also clear that the resulting damage cannot be averted.
In tragic situations, a choice has to be made. Faced with the dilemma, Agamemnon chose to sacrifice his daughter. According to Nussbaum,19 it is not wrong in itself that Agamemnon made that choice. The culture prevailing in those days hardly left him another option. However, Nussbaum says it can be held against Agamemnon that he sacrificed his daughter without any sense of doubt or guilt. Emotions such as remorse and regret would have been appropriate in such a situation. The same goes for the use of coercion. Given the current legal and cultural context, there is sometimes only one course to follow. Nevertheless, one should be aware of the options that are left out; emotions that are appropriate should not be pushed aside.
Coercion and pressure evoke emotions. From an ethical perspective, it is the absence of emotions in such situations that should arouse suspicion. The thought that patients need to understand the necessity of the intervention imposed on them or that staff have to follow a professional course of action and should be immune to emotions is problematic. With regard to coercion and pressure, a professional course of action means that one is willing to face ambivalent feelings and recognize such feelings in others. Coercion and pressure must never be put into practice automatically, without second thoughts and doubts.
The emotions involved make it necessary to be attentive to each other's feelings. The intervention should be effective, and it should also be applied with consideration and respect. When the shipmates feel compelled to tighten the ropes, they need to continue treating Ulysses like a fellow man, talking to him and reassuring him. They need to stand by each other and keep their spirits up. After the venture, they will have to look back at it together and show their relief at their safe arrival. Emotions should occupy an important place in handling coercion and pressure, and it is a major concern to find ways to talk about and reflect upon them.
From a legal perspective, averting danger resulting from mental illness is the only goal that justifies the use of coercion in psychiatry. Coercion means a violation of a person's freedom. This conflicts with the right to self‐determination. The basic idea is that people should decide for themselves what they think is right, without the interference of others. This view is based on negative freedom.20
Negative freedom is defined as freedom from interference by others and can be described as a right to be left alone (“freedom from”). It does not say anything about how this freedom is exercised by the individual. Dutch law acknowledges other goals of coercion. In the law regulating rights and duties of doctors and patients with regard to medical treatment (provisions regarding the medical treatment contract in the Civil Code), coercion is placed within the context of being a good care giver. Instead of danger, health is at the centre. The idea behind this is that patients are sometimes not able to decide by themselves what is best. This is expressed in the concept of incompetence.8 Incompetent persons cannot make a choice that shows insight into the situation. One could say that such persons are not free in their choices. In this context, freedom is considered to be a positive freedom: it is not “freedom from”, but “freedom to”. Persons are free in a positive sense if they show insight into and control of the situation they find themselves in. Self‐realisation is emphasised instead of self‐determination.20
In Ulysses' story, both concepts of freedom are at stake. Ulysses gives up his right to self‐determination by asking his men to tie him to the mast and not to untie him, much as he would like them to do so later. He gives up his negative freedom, which shows insight into the situation. Ulysses knows he will not be able to control himself when the Sirens come within earshot. This makes his request an expression of positive freedom. If Ulysses asked his men to comply with his orders at the moment the Sirens come into sight, he would retain negative freedom, but his positive freedom would vanish. He would be carried away by the temptations and lose control.
Coercion can be used to prevent either expected or present danger, but in many cases it is also bound to positive goals. When care givers try to motivate depressed patients to get out of bed in the morning, they are not avoiding danger, but trying to enable the patients to spend the day in a meaningful way. If patients are allowed to stay in bed because they want to, they are completely free in a negative way, but if they get out of bed they can do things that add meaning to their life.
From a perspective of negative freedom, interventions are a priori problematic. The moment other people interfere, freedom is limited. Even when people themselves want the intervention to be imposed on them, it still does not mean that this is justified. When people cannot revoke their request (like Ulysses), their freedom is restricted. Positive freedom does not exclude a priori intervention by others. Self‐realisation is impossible without the help of others. From the perspective of positive freedom, the intervention is not problematic, but leaving the other alone is. This does not mean that every intervention is permissible. Interventions need to be evaluated thoroughly and to be justified. Moreover, one should take into consideration whether the intervention actually enhances the person's self‐realisation. Here a slippery slope is possible. The notion of proportionality is necessary to define where the limits should be set. Above that, it is important to recognise that mental illness does not necessarily imply incompetence to refuse an intervention.
Interventions can be performed in several ways. In applying coercive measures, one can seclude patients, tie them or put them to rest by medication. Every method has both positive and negative effects. Secluding and tying patients have a more rapid effect than administering medication. Medication acts on the biological background of patients' behaviour. From the perspective of negative freedom, the choice of a method of intervention is decided according to which method is most radical. In legal terms, an invasion of the body is a severe intervention. From that point of view, administering medication is a more extreme method than seclusion. From the perspective of positive freedom, it is important whether the method contributes to the control that patients have over their life. As a result, one can prefer medication (if it can help to improve the symptoms while seclusion and tying do not).
An approach in terms of negative or positive freedom influences the method of intervention that is decided upon. Yet it remains to be seen whether the general connections that have just been sketched are tenable. Is it true that interventions that affect the body (such as medication) are always more radical than other methods (such as seclusion)? From a psychological perspective, seclusion can be extremely burdensome and harmful. The standard approach does not take into account the way in which individual patients experience different interventions. Jamison, a psychiatrist who has manic depression, realises she needs medication but feels the use of it interferes with her work and private life because of the numbing effects. Not until she cuts back on medication does her life return to more or less normal. This makes it clear that self‐realisation takes more than administering the medically most effective drug dosage.21 It is, again, the patient's experiences that are of overriding importance when evaluating the intervention used.
Ulysses' story shows the same problems as Jamison's. The method Ulysses chooses is not the most effective, for he would suffer less emotional torment if he had his ears plugged. In that case, he would not be exposed to the enticement of the Sirens. Yet it is understandable that Ulysses chooses to be tied up. This way he can hear the sweet singing, which, according to Homer, entrances everyone. Jamison makes the same choice. After having cut down on medication, she describes her experiences as enriching, but happiness is not all that it brings about: “I had become more susceptible to beauty, but also to sadness.”21
Not only with regard to methods of coercion a choice has to be made. The same goes for the use of pressure. Moody22 distinguishes four different methods of intervention when a patient refuses to cooperate. They include advocacy, in which the care situation is changed; encouragement and persuasion, in which the patient is urged to cooperate; and overruling. Moody assumes that these interventions represent a continuum. Changing a person's environment is less radical than encouragement; encouragement in turn is less drastic than persuasion or taking over the decision. No matter how plausible this might be, one still has to find out what the patient thinks. Changing the environment can sometimes cause more burden than backing someone up a little. Even the assumption that coercion is always more radical than pressure can be disputed. Pressure can look like apparent freedom of choice and because of this can be even more harmful than coercion. Manipulation can be worse than overt coercion.
Ulysses' story is characterised by the faith Ulysses and his shipmates put in each other. The men trust him even when they get an unusual order, without knowing exactly why. Ulysses trusts them to carry out his order and not to listen to him, no matter how much he begs them. Trust is put under pressure during the use of coercion, but it does not get lost fundamentally. Coercion is used within the context of a joint venture, in which each party assumes responsibilities.
In psychiatry, a care giver using coercion does so in a context of commitment and responsibility. This distinguishes a care giver from a police officer or a warder. However great the conflict between patient and care giver and however great the feelings of irritation, frustration, fear or insecurity, there is always a mutual commitment within the framework of a care process, which is characterised by a specific goal, namely preserving the shared life of the community.23
In a context of commitment and care, communication is pivotal, whether before, during or after the use of coercion or pressure. Agreements must be made beforehand. When coercion or pressure is used, the care giver and the patient have to keep in touch with each other. Interventions should be evaluated afterwards. This evaluation needs to address the question to what extent the intervention is suited to the context of care. Did the intervention take place too early or too late? Was it too drastic or too lenient? How can one learn from experience in order to anticipate future situations in which the use of coercion or pressure may be necessary? This looking back aims at improving future actions, and it also intends to rebuild the relationship, which has been put under pressure, and to restore respect.
Ulysses knew what to ask his men because he was informed about the risk. Circe had told him all about it. She warned him about the Sirens and also advised him to have himself tied to the mast. In ancient Greece, it was the gods who told people what to expect and what to do. In our society, the care process is guided by other sources of knowledge. Patients and care givers can learn from each other about the threats they face and about ways to stand up to those threats. That knowledge can be explored, elaborated on in consultative bodies and laid down in guidelines. Such guidelines do not exclude commitment and care; they demand a context of mutual involvement and responsibility, both during the drawing up of guidelines and when they are put into practice. In order to handle coercion and pressure adequately, an organisation needs to work actively to build mutual commitment and responsibility.
Life without coercion and pressure is impossible. Situations exist in which an intervention is required to avert danger and to preserve or improve the prospects of a safe voyage. However much coercion and pressure are necessary, they should never become routine. Care giver and patient should be able to express feelings such as frustration, fear and powerlessness, and attention must be paid to those feelings. In order to be able to evaluate the method of intervention, one has to be aware of the variety of goals aimed at. One also has to be aware of the variety of methods of intervention, each with its own benefits and drawbacks. The pros and cons of a method are to be decided by the individual experiences of a patient. Finally, an intervention requires a context of care and responsibility, along with good communication and fair treatment, before, during and after the use of coercion and pressure. These requirements are specified in more detail in the quality standards regarding the use of coercion and pressure.7
No matter how willing we are to be attentive to emotions, to think about goals and methods and to build the care process together in the light of commitment and responsibility, handling coercion and pressure properly cannot be commanded. Whether an intervention succeeds is also a matter of luck. We must hope that luck will be on our side, as it was with Ulysses and his men when they managed to pass the rock of the Sirens.
Competing interests: None declared