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This collection of essays about coercive treatment in psychiatry is timely, for two reasons. First, coercive practices are increasingly the subject of public criticism, as the authors note in their introduction. Often and forcefully voiced by those who speak from personal experience, these practices are portrayed as of serious moral concern in recent policy documents, as well. (For example, coercive treatment seems to be in violation of rights proclaimed by the UN Convention on the Rights of Persons with Disabilities (2006).) In addition, coercive practices have also changed since deinstitutionalization. Community treatment orders, outpatient commitment and other mandated forms of treatment outside the clinic have been added to, or even replaced, the seclusion, mechanical restraint and forced medication that comprised coercive measures before the last decades of the twentieth century.
The volume is organized around five sections, beginning with aspects of coercive treatment that are clinical and conceptual, legal, and ethical, and then followed by users' views; a final section is focused on coercion and undue influence in decisions to participate in psychiatric research. With this structure, there is some repetition and overlap; and the separation between ethical and legal particularly, is little more than a matter of emphasis, here rather arbitrarily assigned. Nonetheless, each discussion adds to the whole in a valuable way.
The editors, as well as many of the authors, are distinguished researchers of long standing in this field, and they draw on data and practices from an impressive range of countries beyond the US, and UK, including Germany, Sweden, Egypt, New Zealand, Israel and Hungary. This widely representative approach, and the introduction of international comparisons and contrasts, is one of the work's greatest strengths. Another is its serious effort to include thought by service users. This kind of recognition for the unique perspective provided by personal experience is an today found in many works about psychiatric practice, but it is nowhere more valuable than here, where these authors can speak with authority of the immediate psychic effects of coercive practices. One of these essays is Dorothea Buck-Zerchin's "Seventy years of coercion in psychiatric institutions, experienced and witnessed" – a ninety something woman who's forced treatment (and sterilization) began before she was twenty, and went on intermittently for the rest of her life. The personal detail, breadth of historical knowledge and sheer sanity of Ms Buck-Zerchin's chapter are a shameful reminder of how unwarranted and mistaken coercive treatment has often been. Other chapters by users introduce helpful examples and analyses that provide detail and depth, and show a sophisticated assessment of research methodology and an encouraging emphasis not only on how treatment has been in the past and what was wrong with it, but on how the situation might be realistically improved.
Much here is familiar. Central questions about coercive treatment find there way into one or several of these discussions: how to define coercion; what circumstance may make it at times unavoidable in the psychiatry setting; whether in our embrace of autonomy we have lost sight of more paternalistic principles that might serve to justify such treatment; the ingredients of true informed consent; the cultural ideas linking coercion to stigma and other negative consequences, and the possibility that a person-centered approach stressing partnership and trust can reduce the need for, and baleful effects of, coercive treatment. The unfortunate history of the worst abuses to which enforced treatment has led is also rehearsed. Less familiar ideas raised in these chapters include a practice-oriented preventive strategy for avoiding the escalating situations where coercion is a response of last resort, and a review of the forms of leverage employed in the community treatment setting that bring their own, new coerciveness in this post-asylum era.
In a far-reaching policy proposal Szmukler and Dawson take on the relationship between dangerousness and capacity, traits often wrongly and misleadingly linked, as they point out. These authors' elaborate new legal structures that would eliminate the (in their view) discriminatory difference of treatment for mental and physical conditions found in current law and policy – what they entitle mental disorder exceptionalism. Instead, they favor fusing civil commitment statutes with capacity tests in comprehensively revised legislation based on decision-making capacity that would cover everyone with reduced capacity, regardless of cause. A person without deficits of capacity cannot be detained, according to this revision, even if he has been given a diagnosis of mental disorder. Addressing as it does the time honored and hard-fought protections traditionally accorded the mentally ill in law, this discussion shows the privileging of the principle of autonomy over that of beneficence at its most extreme, and illustrates the depth and importance of the philosophical issues at stake in this arena.
The person who binds himself in advance to accept some treatment is acting as an autonomous and free agent, and another important set of ideas raised in several of these discussions points to advance care directives as a preferable alternative to coercive treatment – as they are. Despite their obvious ethical appeal, their widespread and for the most part effective use in general medicine, and the fact that in the small body of empirical research undertaken they have been shown to reduce the use of coercive interventions, psychiatric advance care directives seem thus far to have provided more problems than solutions. Research on attitudes towards them, for instance, show practitioners reluctant to follow those directives permitting the patient to refuse treatment; concern is also expressed over their usefulness in crisis situations (to which must be added the obvious point that they will not help with unanticipated first episodes of disorder). Issues of personal identity may complicate the use of such directives with disorders that result in deep personal change, or reoccurring personalities. But even before we get to these, the difficulties expressed by authors in this book seem to doom psychiatric advance care directives. Unfortunately, as in almost all the other areas around coercive treatment and its effects, there is a dearth of adequate research or empirical data. Yet, to the extent that coercive treatment is increasingly recognized to jeopardize human rights, improvements and innovations such as these must be given a chance and subject to more thorough, empirical study.
Summing up then, this is a rich and valuable collection. It comes at a time when ideas about both coercion and treatment are being revised, and in addition to raising more practical and policy-related challenges, it demonstrates important philosophical issues requiring further attention.
© 2013 Jennifer Radden
Jennifer Radden, University of Massachusetts, Boston