1.5.3 Coercion in Psychiatric Rehabilitation
Abraham Rudnick, MD, PhD, FRCPC
Updated December 1, 2013
- To appreciate the ethical problems of using coercion in psychiatric rehabilitation
- To recognize an alternative to coercion in psychiatric rehabilitation and its grounds
Mr. Smith is a 38-year-old single, unemployed man who lives on his own in subsidized housing. He has been an outpatient of yours for the last year or so, and he also has a community case manager who has known him for the last decade or so. He has been diagnosed with schizophrenia, paranoid type, since he was 19 years old, and he has also been diagnosed with cannabis abuse since he was 25 and with non-insulin-dependent diabetes mellitus for the last two years (with no history of hypo/hyperglycemic coma). He is treated with oral antipsychotic medication and a low-sugar diet and has declined other treatment suggestions such as depot (injectable) antipsychotic medication and oral hypoglycemics. He is considered capable of consenting to treatment but not of managing his finances, for which the public guardian and trustee is the substitute decision-maker. Lately he has had an exacerbation of auditory hallucinations and related death wishes without suicidal intent. The identified trigger to this exacerbation is an increase in his cannabis intake due to peer pressure. The identified trigger for many of his previous psychiatric exacerbations, some of which have led to hospital admissions, is non-adherence to antipsychotic medication. Mr. Smith does not have a history of physical aggression or suicidal acts. Although Mr. Smith insists on maintaining his subsidized housing as he likes his independence, his case manager approaches you with the request to collaborate with her in creating and implementing a plan to coerce Mr. Smith into moving to a group home, where his adherence, substance use and diabetes can be monitored closely and addressed. She states that, with your support, the public guardian and trustee could be convinced to discontinue Mr. Smith's payment for subsidized housing and to divert it to group home payment.
- Should Mr. Smith be supported in maintaining his subsidized housing, and if so, on what grounds?
- If Mr. Smith should be supported in maintaining his subsidized housing, to what extent, if at all, is that qualified by potential benefits for him of living in a supervised setting such as a group home?
- What is the characterization of the notion of therapeutic coercion, and to what extent, if at all, is it compatible with psychiatric rehabilitation?
- What may be a sound alternative to the case manager’s approach, and what may be the grounds for such an alternative?
Coercion is not usually compatible with psychiatric rehabilitation. When safety is at serious risk — such as a likely risk of death — due to a person's mental illness, coercion and use of physical force may be acceptable. Otherwise, a mentally ill person's goals should be respected as much as possible in clinical decision-making. When these goals are considered unreasonable, engagement in dialogue with that person regarding his or her goals is recommended, as reflected in the process of rehabilitation readiness assessment and development. The above requires prudent clinical and ethical decision-making that is contextualized and conducted in an accountable manner, as is true for all medical decision-making.
Generally, mental health challenges are complex and related outcomes are commonly determined in part by social factors such as poverty and discrimination.8 As part of that, mental health services require an interprofessional approach and call for person-centered care even for the most seriously mentally ill individuals.9 Recovery is now recognized as the ultimate goal of mental health care, although it sometimes raises challenging ethical questions.10 Physicians and others providing care to people with mental illness can benefit from identifying and addressing ethical issues pertaining to their involvement with these individuals.
- Anthony WA, Cohen M, Farkas M, Gagne C. Psychiatric rehabilitation. 2nd ed. Boston: Center for Psychiatric Rehabilitation; 2002.
- Bloch S, Green SA. An ethical framework for psychiatry. British Journal of Psychiatry 2006; 188: 7-12.
- Rudnick A. The goals of psychiatric rehabilitation: an ethical analysis. Psychiatric Rehabilitation Journal 2002; 25: 310-3.
- Hawkins JS, Emanuel EJ. Clarifying confusions about coercion. Hastings Center Report 2005; 35: 16-9.
- Walton DN. The new dialectic: conversational contexts of argument. Toronto: University of Toronto; 1998.
- Cohen MR, Anthony WA, Farkas MD. Assessing and developing readiness for psychiatric rehabilitation. Psychiatric Services 1997; 48: 644-6.
- Rudnick A. The ground of dialogical bioethics. Health Care Analysis 2002; 10: 391-402.
- Callard F, Sartorius N, Florez-Arboleda J, Bartlett P, Helmchen H, Stuart H, Taborda J, Thornicfroft G. Mental illness, discrimination and the law: fighting for social justice. Chichester, West Sussex, UK: Wiley-Blackwell; 2012.
- Rudnick A, Roe D (eds). Serious mental illness: person-centered approaches. London: Radcliffe; 2011.
- Rudnick A (ed). Recovery of people with mental illness: philosophical and related perspectives. Oxford: Oxford University Press; 2012.