In Reply: I thank Dr. Lefley and Ms. Wasow for their kind personal words and for giving me an opportunity to clarify and reinforce the intent of the article. As Lefley states, force is only needed "if all else fails." We are kidding ourselves if we think "all else" is routinely tried. Force has become the easy alternative to expert helping. I am certainly not surprised by the recitation of reasons for the use of force. I have heard or seen most all of them.
I think the "massive dishonesty" and "unconscionable indifference" that Lefley notes with respect to not acknowledging the conditions that generate forced treatment are easily trumped by our seeming indifference to the massive use of force in the mental health culture. I wonder how many people refuse treatment because of their brain function, as Wasow suggests, and how many refuse treatment because of how the mental health system functions (1). And the oft-quoted phrase about treatment refusal—"Free to die with their rights on"—does have a contrasting phrase in my vocabulary. Because of our harsh practices, how many people with severe mental illnesses are "forced to live with their dreams turned off"?
The point is that we need to redouble our efforts to practice alternatives to forced treatment (2). Lefley is correct that the rationale for the use of force should be acknowledged. However, it our use of force based on this rationale that can cause great harm to the person ostensibly being helped. Rather than acknowledging this rationale for the use of force as a given, we need to challenge it with helpful alternatives. Who would have thought that we could have a goal of eliminating seclusion and physical restraint from state institutions? But we can (3). In what other creative ways can we eliminate force from our field? Lefley has provided us examples of such alternatives.
The debate about force is not about questionable ideology but about questionable practices. As Lefley implies, it is easy to admire a philosophy based on the rejection of force. The test is to make practice congruent with such a philosophy in instances in which force has traditionally been the practice of choice? I repeat my challenge to myself and to my colleagues. Let us commit to figuring out how to stop our mindless use of force. Let us use our best minds, such as those of Dr. Lefley and Ms. Wasow, to find ways to extricate our field from being society's purveyor of force. We need leaders to champion, develop, and demonstrate effective alternatives to force and then to permeate the field with these practices. We cannot and must not accept the use of force that pervades our field.
Also, I want to clarify for Ms. Wasow and for others who may not be familiar with the effects of this disease—MS does indeed damage the brain. Furthermore, along with myriad other difficulties, cognitive problems and depression are common symptoms of MS.
Campbell J, Schraiber R: The Well-Being Project. Sacramento, California Network of Mental Health Clients, 1987
Fisher, D: Recovery from schizophrenia: from seclusion to empowerment, Mar 2006. Available at www.medscape.com/viewprogram/5097
Smith G, Davis RF, Bixler EO, et al: Pennsylvania state hospital system's seclusion and restraint reduction program. Psychiatric Services 56:1115-1122, 2005