A Perspective in Opposition to

Mental Health Courts

A Compilation of Writings

Addressing the Issue of Mental Health Courts,

Coercion, and Recovery Approaches

2007

Contents

ˇ  Mental Health Courts by Pat Risser

ˇ  National Mental Health Association position on Mental Health Courts

ˇ  Quote from William A. Anthony, Ph.D.

ˇ  Additional Thoughts from Pat Risser

ˇ  Mental Health and Human Rights by Sylvia Caras, Ph.D.

ˇ  Blood Pressure Court (Satire)

ˇ  A Fairy Tale by Coni Kalinowski, M.D.

Mental Health Courts

(compiled and written by Pat Risser)

In advocating for mental health courts, Rusty Selix, the executive director of the Mental Health Association in California, wrote, "Unfortunately, across the United States, people with mental illnesses are overrepresented in prisons and jails. In California alone, it is estimated that between 20 percent and 25 percent of all California prisoners are afflicted with serious mental health problems such as schizophrenia and bipolar disorder." (http://www.nctimes.com/articles/2007/07/15/perspective/20_15_047_14_07.txt)

Mental illness is a concept subject to debate. There are no biochemical markers, no biological tests, no hard evidence at all, to "prove" the existence of "mental illness." Proof = demonstrate a reliable association between a clearly specified pattern of observables and other reliably measurable event(s) which operate as antecedents. (This is same level of proof used for TB, cancer, diabetes, etc.) In addition, I don't believe that our thoughts, moods, feelings or emotions are a disease, disorder or illness.

It is claimed by some that mental health courts will provide a stopgap to prevent mentally ill offenders from becoming part of the prison system. Part of my problem is that while we're allegedly seeking equality, we're also seeking "special" treatment. So SB 851 provides a stopgap for "mentally ill" offenders. What's next? A stopgap for offenders with blond hair and blue eyes? How about offenders who can wiggle their ears? Why should any "offender" be treated differently? Allegedly, mental health courts will offer alternatives to defendants with "mental illness." Isn't that everyone? Hasn't the DSM just about reached the point where we're all in there somewhere? Most legislation for mental health courts claim that they will, when appropriate, offer defendants an opportunity to participate in court-supervised, community-based treatment in place of typical criminal sanctions. What is "community-based" treatment and is it anything but forced drugs administered by the decree of psychiatrists? It's a shame to surrender the criminal justice system to psychiatry. I believe our criminal justice system belongs and should remain the purview of those who have been trained in the law. Lawyers, judges and other legal advocates have a much greater awareness of peoples' rights and their obligation to defend those rights.

Setting aside the "mental illness" debate for a moment, there are at least two other obvious solutions. First, law enforcement can choose to not arrest folks. There would be fewer problems if they turned an unseeing eye toward minor offenses. The other solution is that people (not just those labeled "mentally ill") should not break laws. Fewer broken laws equals fewer arrests equals fewer in jails and prisons. If people choose to break laws, perhaps they should heed the saying, "if you can't do the time, don't do the crime."

Mr. Selix states that, " Effective mental health treatment is the missing element of corrections reform." The "system" has been working at getting better and more "effective" for many, many years. If their efforts are tied to the increase in prison population then I guess they haven't done a good job. The only folks I'm seeing get much better are those who are connected to solid peer supports and services. It seems a shame to refer people (or rather "sentence" them) to a system that the President's New Freedom Commission said is, "in a shambles." Of course, folks in California (like Mr. Selix) should be aware of that since Steve Mayberg (Mental Health Director of California) was on that Commission. 

Mental health courts are segregationist apartheid. (I first heard this term used by Judi Chamberlin.)  Any time we take one group and set them apart from everyone else, we are practicing discrimination. What's next?  Separate drinking fountains and bathrooms and eating areas and then moving people into ghettos and then labor camps from which they are never heard from again?  All done with the approval and acceptance of the law and respecting our 'rights.'  What's needed is something where the treatment system is the one ordered to provide real supports to people to help them to live and thrive successfully in the community of their choice.  (Federal definition of 'recovery' is, "a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.")

Mental health court should be the court of the mental health system and not the court of people being forced or coerced into treatment that doesn't work.  It should not be the court of 'compliance.'  Imagine jailing a diabetic for having dessert or incarcerating a person having chronic bronchitis for lighting up a cigarette or forgetting his/her inhaler. No one would find such a solution to public health problems acceptable because it violates people's right to choose their lifestyles and medical treatment.  In virtually all other medical concerns, we have upheld individuals' rights in this regard irrespective of the possible risks to self or others. It is absurd to imagine jailing (or threatening to jail) someone for non-compliance with medical treatment. We wouldn't jail someone for not adhering to a diet and eating fast food. We don't treat people "for their own good" over their objections.

Mental health courts are courts of force and coercion are indicative of treatment failure and should not be used.  Force isn't treatment.  A therapeutic alliance is impossible in the face of force/coercion.  Force and coercion are abuse.  MH Courts are solely designed to "force" medication "compliance." Sure, they claim to only be helping people to comply with "treatment" but in this day and age, "treatment" more and more consists solely of medication.  People are just plain contrary and generally non-compliant.  Most people don't take the full ten days of antibiotics as prescribed.  They stop when they feel better.  There are endless other examples.  However, compliance is the major concern of the mental illness system and families who expect those in the mental illness system to uphold a standard of compliance higher than everyone else.

While complying with 'treatment' consisting of medications, it's good to remember two particularly damning recent research studies. One found that mental patients in the United States are now living an average of 25 years less than those who escape notice by the psychiatric system. The other study by the World Health Organization found that third-world countries that practice far less 'western medicine' actually have far higher 'recovery' rates. Perhaps less invasive 'treatments' should be emphasized. Perhaps mental health courts should consider that they might be sentencing people to a death sentence of a shortened life span. 

Mental health courts create another 'in' door to the system yet the system is chronically overcrowded and without enough 'exit' doors.  It is not the job of the legal system to adjudicate 'treatment.'  The legal system lacks the knowledge and expertise to dictate terms of 'treatment' for people and the legal system incorrectly relies upon the medical model of psychiatric care to help people.  The medical model of psychiatric care is a failure.  Mental health courts are a wasteful diversion of people and resources from the mental health system to a criminal justice system that also lacks resources and connections to the community. And, what about the people who, because they are difficult to treat, will get labeled as 'treatment resistant' or 'non-compliant' and it is due to the inadequacies of the mental health provider or the treatment program.  It is claimed that mental health courts are necessary to stop the revolving door of the mental health system and the criminal justice system. Yet, there are no studies to indicate that using the coercion or force of a court system does anything to reduce recidivism. There is no proof that forcing people into "treatment" either reduces recidivism in the mental health system or the prison population.

Mental health courts are typically funded by mental health funds. How did that happen?Was it put to a vote? And, does the mental health system have any obligation to the criminal justice system or should the funds of the criminal justice system cover their own? The mental health system is for those who are psychiatrically labeled and the criminal jus tice system is for those incarcerated for breaking the law. The two aren't the same and certainly aren't funded the same. Do we want the funds of the mental health system diverted to criminal justice? Doesn't the criminal justice system have lots and lots of their own funds? Besides, there really isn't any mental health system. There's only a mental illness system. People are labeled as mentally ill, treated as mentally ill and given mental illness drugs. As a result, we die an average of over 25 years sooner but hey, aren't we mentally "healthier?"

Mental health courts need to assure that they don't blame the person for the failures of the mental health system.  Instead of creating courts to force medication compliance, we should spend our valuable time, energy and resources creating true alternatives that work to divert people into proven successful self-help programs (that they will desire and therefore automatically 'comply' with).  How do we get people 'out' from under the thumb of the mental health courts once they are in?  In Oregon, people can remain under the PSRB system for far longer than necessary.  People who are no longer considered a danger to themselves or others are often forced to continue to comply with 'treatment' (forced drugs) despite the known dangers of these drugs. 

Most people who have been labeled with psychiatric disabilities have experienced abuse, neglect and trauma – it is wrong to label the result of those experiences as sickness or illness.   It is also wrong in a similar way to label the control of the natural thoughts, feelings and emotions that result from abuse, neglect and trauma as: healing, recovery or wellness and it is even worse to drug or shock those thoughts, feelings and emotions into control or submission.  This IS the medical model and 'treatment' at it's worst.  Mental health courts that force people into medication compliance do not consider the whole person and their background, history and other factors.  Forcing someone into submission may cause him or her to no longer be a public nuisance, but there is no consideration of how miserable or incapacitated it may make him or her.  There is likewise no consideration of how toxic his or her environment may be.  Drugs do not help poverty, joblessness, homelessness, abuse and other social ills that contribute to the emotional distresses that cause people to come to the attention of the mental illness system.

The mental illness system deludes, diminishes, discounts and distorts the reality of consumer/survivors by diverting attention from abuse, neglect and trauma and victims' natural reactions.  The mental health system shifts the focus to sickness/healing rather than remediation of injustice.  While our children are locked in psychiatric units, the parents and other adults who abused, neglected and otherwise mistreated them are continuing their lives free of any consequences.  While adults languish in hospitals or drug induced stupors in 'treatment' programs, those who originally abused, neglected or otherwise mistreated them are continuing their lives free of any consequences.

The system blames the victim instead of seeking remediation and providing validation.  The system often fails to acknowledge that the people it serves have usually been victims.  The system 'treats' these victims by blaming them in the form of labeling them as 'mentally ill.'  The system invalidates our experiences and us through the use of its language.  Not only are the labels invalidating, so is much of the language.  For example, the term 'side-effects' minimizes and trivializes the impact of the very real effects of medication and makes it easier to blame the person for non-compliance. Statements like, "Oh, it's just a side-effect," gloss over our very real suffering and refocus on coercing our compliance.  It's tragic how often psychiatrists will dismiss tremors and other uncomfortable and even more serious maladies as "just a side-effect."  Sometimes, even death is a "side-effect."  In any other social structure, the use of seclusion and restraints would be considered torture and locking people up against their will would be called incarceration and not 'treatment.'

POSITION OF MENTAL HEALTH AMERICA (FORMERLY THE NATIONAL MENTAL HEALTH ASSOCIATION) ON MENTAL HEALTH COURTS:

"Mental health courts, and all other courts dealing with mental health treatment issues, need to be vigilant to minimize the use of coercion to compel treatment.  The danger is that in the hope of improving access to scarce treatment resources, mental health courts will, in the end, increase coercion and stigma.  There is also the risk that they will fail to effectively triage available treatment resources to achieve the best overall public health outcomes.  The basic problem is that the courts cannot run the mental health system from their limited vantage point and cannot provide the resources needed to fill the gaps.  Therefore, mental health courts risk inappropriate intervention of the criminal justice system, with no real improvement in treatment outcomes.  At best, they may effectively determine individual needs and advocate for good individual treatment.  At worst, they risk further criminalizing people with mental illnesses and fragmenting the mental health and criminal justice systems."

http://www1.nmha.org/position/mentalhealthcourts.cfm

Drugs are not solutions.  Psychiatric drugs need to be used with more caution and restraint.  Underlying causes of people's distress needs to be addressed.  We can't solve homelessness, poverty, joblessness, abuse and other social issues with a prescription pad.  Drugs don't solve poverty issues and they don't heal emotional wounds.  People who have poverty issues ought not have to be labeled mentally ill to get housing, meaningful employment, social opportunities, etc.  Staff have been mis-trained to equate subduing a person with treatment; a quiet client who causes no community disturbance is deemed 'improved' no matter how miserable or incapacitated that person may feel as a result of the 'treatment.' Someone may go for years and years to a day treatment program where they live from cigarette to cigarette or from Big Gulp to Big Gulp (a 7-11 soft drink) but they have no life. They are essentially 'soul dead' but as long as they stay out of the hospital and comply with taking their drugs, they are considered a success. We need to define success differently!  Mental health courts contribute to the distress of people by becoming a 'compliance enforcement' branch of psychiatry.  Mental health courts know little to nothing about how psychiatry contributes to peoples' misery.  Re-traumatization is common.

Mental Health Courts don't really solve the criminalization of psychiatric disability. In many places, they are a well-meaning response to the discrimination and stigma of the regular court system, the lack of mental health care in the jails, and the tendency of police to arrest people with psychiatric disabilities in order to get them off the street. A better, although more difficult, solution is to educate judges and ensure that they do not treat people with psychiatric disabilities with contempt; make sure that jails provide adequate mental health care, and make clear to police that it is not their function to clear the streets of idiosyncratic people who make shopkeepers nervous. In other words, mental health courts don't solve the root problem.  Part of the problem with the mental health system is that there is a lack of clarity regarding the product, goals, mission and purpose.  It is unclear whether the primary task is to produce 'Medicaid billable units of service' or treatment hours or tenure in the community for the clients or cost savings for the agency.  It is unclear for whom the clinicians work, whether it's on behalf of the clients or the agency or the system and whether their task is to help people improve their quality of life (as defined by the clients) with successful living in the community of their choice or whether it's to improve company profits.

Mental health courts are usually only for misdemeanors, and minor ones at that. They basically use 'crimes' like loitering or shoplifting less than $5.00 worth of goods to sweep people into a treatment system.  Some objections to mental health courts might be muted if they were only used for major (i.e. death penalty or life imprisonment) felonies.

People don't usually exercise much in the way of informed consent over whether they will go to a mental health court or regular court.  Additionally, mental health clients are not given the right to make mistakes (fail) without it being judged negatively.  Thus, they are deprived of the growth opportunities that everyone else experiences through trial and error.  People don't know when they 'consent' to mental health court that they may be caught in a web of force and coercion lasting many years longer than if they just dealt with the offense that brought them to the attention of the system. In addition, they may not realize that they might essentially be sentenced to a shorter life span by taking medications that can result in that shortened life span being filled with misery, pain and suffering.

The jurisdiction of mental health courts can go on much longer than a person would have served for the misdemeanor for which he or she was arrested. If the court requires that a person be involved in mental health treatment for anytime longer than the time required for jail and probation /parole, then the court is participating in 'unnecessary' coercive treatment. Mental health treatment should be a choice. Just as some people choose to be treated or not treated for certain medical problems, they should have the same choice regarding mental health treatment. It is a fairness in sentencing issue (although it is at the opposite end of what is usually presented as fairness in sentencing). I do believe that people with mental health issues involved in the justice system should be able to access treatment if they so desire.  There is no 'treatment alliance' (that which psychiatrists claim contributes to 'success' in the mental illness system) in the court system.

Having worked in community mental health programs and having been a client of community mental health programs, I am also concerned about the people who because they are difficult to treat will get labeled as 'treatment resistant' or 'non-compliant' due to the inadequacies of the mental health provider or the treatment program. A program that 'fails' the client will result in blame and 'punishment' directed toward the client. A provider who 'fails' in their job will be ignored while the client will be chastised, penalized or sentenced.

In Florida, the judge in the mental health court got state appropriations for specific mental health treatment units to which she sent people who came before her court. Legally that violates separation of powers doctrine. While many praised this judge for her kindness and creativity, there is no guarantee that other judges will be as kind or creative in their efforts.

The system needs to be completely revamped. Clients are trained to be "mentally ill" and not mentally healthy. Efforts are focused on disability instead of strengths and abilities. Dependency is maintained under the guise of good care. The system is staff-oriented as opposed to client-oriented. The system is still heavily biased in favor of institutional based containment rather than community based supports.

Criminal records keep people from getting housing in the community, employment, interfere with parental rights, and can seriously affect eligibility for many social programs. Rather than operating as diversion from the criminal justice system, the mental health system is increasingly serving as the gateway into the criminal justice system. More and more as seclusion and restraints are reduced on inpatient units, mental health staff call upon the police to arrest and control patients. Outpatient systems call upon police for everything from "welfare checks" to enforcement of outpatient commitment orders.

Compliance is an issue of control, not treatment.  People in general don't 'comply.'  Many who were prescribed 10 days of antibiotics stop after a few days when they feel better.  Few actually 'comply' with diets.  We're just generally ornery and contrary and to expect compliance is to deny our basic humanness.

Three Faulty Medication Compliance Assumptions:

1. Psychotropic medications are effective (not true for many)

2. Psychotropic medications are safe (tardive dyskinesia and other harmful effects are all too common)

3. People stop taking psychotropic medications for inap propriate reasons (as you know, this is nonsense)

There are serious concerns about the checks and balances of the system. Where are they? An attorney may represent the person in their defense, and if they determine the program is not beneficial for their client, they may not recommend it. However, for those people who do agree to the program, what happens if they later disagree with the treatment, or if they have a grievance? What rights do they have to disagree with their treatment protocol? To whom do they voice their concerns? What are the treatment options? Is it solely medication? Is therapy included? Will consumer-run and peer services be considered to be treatment or part of the treatment?  Is there room for alternative forms of 'treatment?'

There are no biochemical markers, no biological tests, no hard evidence at all, to 'prove' the existence of 'mental illness.'  'Proof' means to demonstrate a reliable association between a clearly specified pattern of observables and other reliably measurable event(s) that operate as antecedents. (This is same level of proof used for TB, cancer, diabetes, etc.)  Yet, the courts rely upon the opinions of voodoo practitioners (psychiatrists) who claim to be experts on 'mental illness.'

There are many ways to interact with people.  We can treat them as 'patients' or we can try to understand and see their world through their eyes.  We can weigh the 99+% of the positive or we can look only at the less than 1% negative.  Using mental health courts enforces the view of the person as 'patient' and negates the person.  People should not be defined by a system that labels them as 'illness', 'disease' or 'disorder.'  Courts that are part of the psychiatric system don't ask: What happened to this person? What is this person's hopes and dreams?  What are this person's loves?  Who are the people (good and bad) with whom this person has interacted?  What experiences (positive and negative) has this person had?  Why did this person end up following one path rather than another?  What motivates this person?  Who are this person's role models?  What drives this person to get out of bed every day and proceed through the day?  What defines this person's 'spirit?'

Characteristic assumptions of the Disease Model are:

o A primary focus on biological dysfunction, denying the consumer control over his or her disability;

o A belief that recovery from severe mental disorders is highly unlikely or impossible;

o Symptom reduction and remission are the best possible outcomes;

o Inflexible, time-limited services designed for provider convenience rather than consumer needs;

o A belief that the doctor or therapist is primarily responsible for the healing process;

o Lack of proactive outreach and ongoing support for consumers and family members.

Fundamental assertions of the Recovery Model are:

o  A paradigm shift to a holistic (i.e., biological, psychological, social, and spiritual) view of mental illness;

o Recovery from severe psychiatric disabilities is achievable;

o  Recovery can occur even though symptoms may reoccur;

o  Recovery is not a single event or linear process--it involves periods of growth and setbacks, rapid change or little change;

o Individual responsibility for the solution, not the problem;

o  Recovery is not a function of one's theory about the causes of mental illness;

o  Recovery requires a well-organized support system;

o  Consumer rights advocacy and social change;

o  Flexibility to issues of human diversity.

&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

An Elephant in the Room

Editorial in Psychiatric Rehabilitation Journal,

by William A. Anthony, Ph.D., Winter 2006

The idiom that there is an elephant in the room is used to indicate that some issue, which is perfectly obvious to some people, is rarely talked about. Furthermore, the use of the expression refers to an issue that can't be avoided, much like an elephant in the room, but often is. This phrase implies a value judgment that the issue should be discussed openly.

I sense the elephant in the room whenever we talk about the importance and beauty of the recovery vision while accepting the incompatibility and ugliness of the use of force in a recovery oriented system. The danger in not openly discussing this incompatibility is that eliminating the use of force will never be critically examined as a necessary goal in a recovery oriented system. As a matter of fact phrases such as outpatient commitment and forced medication oftentimes are seemingly paired in a na‘ve and incongruous way with the pursuit of recovery-oriented systems.

I am not offering a single strategy as to how to get force out of the system. I don't know the most effective and efficient way to go about it. What I am proposing is that if we do not redouble our efforts to focus seriously on the incompatibility of force and recovery, we will never figure out ways of eliminating force from recovery oriented systems. Force elimination is both a necessary and reasonable goal as we move further down the path of recovery. Let us use our most creative minds to discuss this elephant in the room, rather than spend time trying to regulate or reduce the use of force in the hopes of making env ironments that use force more "humane". This incompatibility must see the light of day. There is no such thing as "forced recovery".

                                               -- William A. Anthony, Ph.D.

Additional Thoughts From Pat Risser:

In 2002, Dan Fisher was serving on President Bush's New Freedom Commission on Mental Health and he was a member of the subcommittee on "Rights and Engagement" with a focus on coercive treatment. He invited me to represent the consumers/survivors side of the issue and provide testimony to the subcommittee.

I went to Washington to provide 'expert' testimony. Dan knew that I felt passionately about our rights and that I'd been to law school, was formerly director of Patients' Rights in a county in California and was President of NARPA (National Association for Rights Protection and Advocacy). The other members of the subcommittee were Ginger Lerner-Wren (Judge from the first Mental Health Court in the Country in Broward County Florida) and Henry Harbin, M.D. (Psychiatrist, CEO Magellan Behavioral Health and former Commissioner of Mental Health in Maryland). Providing testimony for the opposing viewpoint (in favor of "compassionate coercion") was Steve Sharfstein, M.D. who was the incoming Vice-President of the American Psychiatric Association.

Much of the original draft of this document opposing mental health courts was developed in preparation for providing my testimony. I knew I couldn't just come out in opposition with Judge Lerner-Wren but what I'd noticed was that she held the system accountable. Rather than 'sentence' people to the treatment that was available from the system, she determined what would help the person and 'ordered' the system to provide for those needs even if they had to create something that would work. She was also very understanding and compassionate. Essentially, she 'sentenced' the system to meet the needs of the person. 

When I gave testimony, I credited her as the reason why Broward County Mental Health Court works. However I also pointed out that she could not be duplicated elsewhere so there was no way to assure that other mental health courts would be successful. At that point, Steve Sharfstein poo-poohed with his typical psychiatric arrogance and claimed I didn't know what I was talking about. Then, Judge Lerner-Wren proceeded to chew him out royally and stated I was right! It was quite a show.

In any case, there are a number of reasons why the mental illness system does not work. By extension, a court system that forces people into a broken system that the New Freedom Commission declared is in disarray, would be akin to asking people to drive safely in a broken car. It just doesn't make sense.

Some of the reasons why the system is broken are:

ˇ  Clients are trained to be "mentally ill" and not mentally healthy

ˇ   Efforts are focused on "disability" instead of strengths and abilities

ˇ   Dependency is maintained under the guise of good care

ˇ   The system creates a suffocating "safety net"

ˇ   Clients are not given the right to make mistakes (fail) without it being judged negatively

ˇ   The system is deaf, dumb and blind to research and ignores it's implications in practice

ˇ   The system is staff-oriented as opposed to client-oriented

ˇ   School-based inculcation is so strong as to be nearly totally immutable (people get stuck and stay stuck in what they learned from 20-year

out-of-date textbooks)

ˇ   "Mental Illness" is perceived by staff to be an intractable condition (recovery not possible) for at least 75% of the clients

ˇ   Severe and persistent disabilities associated with "mental illness" are grounds for assuming clients are incapable of choice

ˇ   Pervasive belief that "treatment" (symptom control) must precede substantive rehabilitation efforts

ˇ   Belief that impairment in one life area affects all abilities

ˇ   Absence of clarity as to the product (what it is that the system is supposed to provide) precludes evaluation and effective management

* There is confusion about mission, purpose and goals; What is the desired product?

-Treatment hours?

-Tenure in the community?

-Quality of life? (as defined by whom?)

-Normalization? (as defined by whom?)

-Recovery? (as defined by whom?)

ˇ   Pay is too highly correlated with credentials that are not indicative of the skills required to do the job (academic degrees don't necessarily correlate to "people skills")

ˇ   Public dollars continue to subsidize the education and preparation of practitioners for the private sector with no pay back to the public sector despite some fairly massive workforce shortages

ˇ   Notable major advances are accomplished by rebels yet the system rewards conformity and punishes non-conformity

ˇ   The system subcomponents are underfunded and non-integrated

ˇ   The governor has minimal interest in mental health aside from cost-containment

ˇ   People argue about causes and attempt to make clients "compliant" instead of teaching them coping skills regardless of causes and in spite of them

ˇ   Legislators are na‘ve and pay more attention to providers' and family members' wants than to consumers' needs

ˇ   Provider Boards of Directors are inadequately trained to do their jobs. What little training they receive is generally done by staff within the agencies creating inbreeding that is not beneficial

(adapted from a presentation by Paul Sherman, Ph.D. in 1994 at the California Case Management Conference in Asilomar, California)

Mental Health and Human Rights 

(written by Sylvia Caras, Ph. D.)

There is no conflict between a position that generates the greatest good and at the same time does the least harm. Coercion does the least good, the most harm, and is disrespectful to human dignity.

Coercion deals with a social problem by punishing the victims.

By creating a sub-class, coercion readies the public mind for prejudice and discrimination.

Interventions without consent may ignore the problems of living that cause distress.

Disagreement with medical authority is not incapacity.

Self-management and personal responsibility save public money.

Governments have a responsibility to protect all their citizens. The way to do this is by strengthening self-definition and autonomy so we each define useful assistance and accommodation for ourselves.

Determining the needs of others by one's own needs is oppressive. The value "caring coercion" puts another's idea of what is good for me over what I would like for myself, whitewashes the violation of my personal integrity, dishonors my experience of my life.

The mental health system is a violent system, using force to impose its will, bullying patients by withholding privileges and threaten ing charting and isolation, subduing its subjects with leather and chemical restraints, and in general setting a harsh example of how humans should treat one another. What is needed is to overhaul a dishonest system.

Prompted by Sharfstein's title: Case for Caring Coercion, APHA 2006, Boston, and informed by internet exchanges with members of the WNUSP board and subscribers to ActMad.

Sylvia Caras, Ph.D., http://www.peoplewho.org

Blood Pressure Court proposed (satire)

Doctors have noted that many of their patients with high blood pressure fail to take their prescribed medications. Some complain of side effects, some of the expense, some just do not have the insight to foresee the consequences of their failure to take their meds. This has serious consequences for high blood pressure patients, their families and for society. Patients can have strokes or kidney failure as a result of their non-compliance with treatment and the burden is left on their families and society to take care of them when these tragedies are easily preventable if high blood pressure patients would just comply with their doctors' instructions.

Our nursing homes and Emergency Rooms are becoming more and more crowded with these non-compliant high blood pressure patients, putting a burden and a danger on all of the rest of us. On the road, non-compliant high blood pressure patients are even more dangerous to themselves and others as they may have a stroke and pass out at the wheel, killing or injuring themselves and/or innocent other drivers and passengers. E. Fullofit Whig has estimated that there are 1,000 preventable deaths by car accidents caused by non-compliant blood pressure patients each year. When will society put an end to this plague?

Researcher Hookeruser Votrehan has studied this tragic and difficult problem and come up with a solution that will be helpful to the non-compliant patient, their families and society. He has proposed High Blood Pressure Courts, similar to Drug Courts for substance abusers but with an emphasis on getting patients to take their blood pressure medications rather than on getting drug users to stop using illegal substances. Patients who persist in being non-compliant could be taken to court by their doctors or family members or even roommates or landlords who are aware of their lack of insight and a judge would order them to take their medication and submit to random blood pressure screenings to ensure that they are in fact complying with the judge's order. Patients found to be out of compliance will be admitted to a nursing home for a short stay to help them gain insight into what awaits them if they do not become compliant with their treatment. Further lack of compliance could result in being involuntarily committed to an inpatient facility where means exist to assure compliance for the patient's own good.

Commentary: Unlike drug courts designed to force people to stop using drugs, there are mental health courts designed to force people to use drugs. Imagine courts for all sorts of non-compliant behavior. Perhaps there will be a "diet" court to punish those who eat fast food and are overweight. Perhaps there could be a "sunblock" court for those who tan too much and risk skin cancer. These examples may be absurd but we need to be wary of any and all forms of social control and the intrusion into our private lives and civil rights.

A FAIRY TALE

By Coni Kalinowski, M.D.

Once upon a time in a land by the ocean, people lived in comfort and prosperity. Over time, they came to notice that some of the people among them had unusual experiences. Some heard voices, others saw things that other people couldn't see, others became very agitated or very sad, some became confused. At times these experiences caused people much pain, and they suffered and their families suffered with them.

The families went to the leaders of the people and cried, "Our sons and daughters are suffering. You must help us." and the leaders of the people saw the truth in what they said and undertook to find a cure for these ills. Whereupon they commanded wise and compassionate doctors and profitable pharmaceutical companies to bring before them new treatments - wondrous drugs that would heal people if taken regularly. 

And so the drugs were administered to the sons and daughters who had these unusual experiences. But apparently an evil spell had been cast upon the medications, for they were far less effective and far more injurious than promised. Many sons and daughters were crippled by their effects. Many feared the medicine had been turned to poison. "This drug doesn't help me at all....it makes me too tired....it makes my muscles stiff...it makes me too jumpy...I gained 50 pounds on it...it makes me feel like a zombie," they were heard to say. The sons and daughters were frightened and disappointed, and they threw down the pills and returned to their unusual lives and unusual experiences.

Their families were enraged and returned to the leaders and the doctors. "You must help us," they said, "Our sons and daughters do not see how wonderful these medications are, and they will not take them." 

"Never fear," said the leaders, "we will create a law that will compel your children to take the drugs they need, for it is clear that they do not have the insight and judgment to make this decision on their own."

And so a proclamation went throughout the land requiring people who were afflicted by visions and voices, mood swings and confusion to appear for their required medications. Thousands upon thousands of sons and daughters were forcibly, but compassionately injected and, Lo, they began to heal. Unburdened by their symptoms, the sons and daughters were able to keep their medication appointments and attend day treatment regularly.

And they all lived happily ever after, with minimal residual disability and fewer side effects than placebo. 

The end.

Like I said....it's a fairy tale.