Consensual vs. coercive treatment: new manifestations of an old dilemma

Abstract

The 1960s and 1970s were a time of substantial changes in approaches to involuntary hospitalization and treatment in the United States, a process that was also reflected elsewhere in the world. Objections to the use of coercion in psychiatry became widespread, rooted in concerns about the reality of mental illnesses, the effects of institutional treatment, financial considerations, and growing attention to patients' rights. This movement led to narrowed criteria for civil commitment (from criteria based on need for treatment to dangerousness-based criteria), along with increased procedural protections. Committed patients were given unprecedented rights to refuse treatment in many jurisdictions. Advocates envisioned steady progress towards a community-based, essentially consensual system of care. In the early 21st century, however, it has become apparent that, even as coercive treatment in institutions has diminished, new forms of coercion have developed to enforce treatment in the community. These include mental health courts, probation and parole requirements, outpatient commitment, and use of informal leverage over patients' money, housing, parenting rights, and the like. Coercive treatment in psychiatry has not disappeared, and may not even have diminished. Rather it has moved from the institution to the community. This presentation will describe this evolution and consider the lessons that may be drawn regarding the future of psychiatric treatment and systems of care.