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Letters   |    
Use of Coercion in Recovery-Oriented Care: Staying Vigilant: In Reply
Jeffrey L. Geller, M.D., M.P.H.
Psychiatric Services 2012; doi: 10.1176/appi.ps.2012p834a
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Copyright © 2012 by the American Psychiatric Association.

In Reply: I appreciate Davidson's taking the time to write a letter in response to my Open Forum, if for no other reason than that it underscores the points I was making.

Davidson indicates that advocates—and he himself, in fact—have addressed the role of coercion in psychiatric treatment. However, the only example he can give is the emergency response to a person incapable of making a decision in a situation of imminent serious harm. But why would we call this coercion at all? Do we call our treatment coercive when it is provided to a person who shows up in an emergency room bleeding out from esophageal varices, or with multiple head and skeletal injuries from a motorcycle accident, or after an overdose of a potentially deadly combination of drugs? No, we do not, and nor should we in the situation Davidson describes. The unaddressed coercion I refer to is of the everyday, sometimes subtle variety of coercion—for example, doing A to get B: “Purchase vegetables instead of junk food, and we'll increase the percentage of your SSI check you have for walking-around money.”

I am well aware that generations of persons with mental illness underwent unwarranted, prolonged confinement and involuntary treatment. In fact, generations of individuals without mental illness did so as well (1). Everyone should challenge the use of coercion when its use is neither necessary nor preferred by the person presumed to benefit from it. For example, should any of us deprive persons with mental illness of their choice to be in assisted outpatient treatment because they think they'll do better with it than without it, even if it is not “absolutely necessary”? And my clinical experience informs me that many do make such choices.

Davidson's argument that a 90% reduction in seclusion and restraint use in Connecticut over a four-year period tells us that in the year 2000 nine out of ten restraint or seclusion episodes were unnecessary is simply spurious. Davidson ignores all manner of other variables—for example, the increased use of second-generation antipsychotic medication; the significant influx of resources at the state's public psychiatric hospital, Connecticut Valley Hospital (CVH), as a result of threatened and then actual U.S. Department of Justice involvement; changes in the patient population and the hospital's staffing; the absorption of a closed Connecticut state hospital into the CVH census; and the poorly supervised use of restraints for persons once in CVH who are now in nursing homes (2).

Finally, I can find nowhere in my essay where I painted recovery advocates as “naïve.” The only individual I can think of whom I have occasionally labeled as naïve during his more than 30 years of advocating for recovery is myself.

Geller  JL;  Harris  M:  Women of the Asylum .  New York,  Anchor Books, 1994
 
Tinetti  ME;  Liu  WL;  Marottoli  RA  et al:  Mechanical restraint use among residents of skilled nursing facilities: prevalence, patterns, and predictors.  JAMA 265:468–471, 1991
[CrossRef] | [PubMed]
 
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References

Geller  JL;  Harris  M:  Women of the Asylum .  New York,  Anchor Books, 1994
 
Tinetti  ME;  Liu  WL;  Marottoli  RA  et al:  Mechanical restraint use among residents of skilled nursing facilities: prevalence, patterns, and predictors.  JAMA 265:468–471, 1991
[CrossRef] | [PubMed]
 
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