The standards of care of the modern mental health system all but insist that a therapist use force in working with clients diagnosed with severe psychiatric problems—especially those labeled with schizophrenia or bipolar disorder.  The mental health practitioner is taught to be skeptical of their judgment, their self-control, and thus their wishes.

1. Therapy Without Force: A
Treatment Model for Severe
Psychiatric Problems
Presented by : Dr. Daniel Mackler
Licensed Clinical Social Worker | LCSW.

2. Introduction
•The standards of care of the modern mental health system all
but insist that a therapist use force in working with clients
diagnosed with severe psychiatric problems—especially those
labeled with schizophrenia or bipolar disorder. The mental
health practitioner is taught to be skeptical of their judgment,
their self-control, and thus their wishes.

3. •When we trump a person’s right to make autonomous
decisions we send him the message that he is incompetent.
We teach him not to trust himself. We teach him that his
experience is a pathology rather than an opportunity for self-
study and growth. We teach him that his “symptoms” or
“defenses” are a problem rather than a window into a world
of deeper meaning and history. We teach him that life’s
answers are outside of him, that the truth is not within him,
and that his best bet is not to look within for guidance. How is
this so different from the message that “mental illness” is a
genetic, biological aberration and that the only hope for
salvation is psychiatric drugs for life?

4. Types of Coercion
•1.Forced Medication
•2.Forced withdrawal from medication
•3.Forced Hospitalization
•4.Forced Therapy
5.Force used to prevent suicide (and harm to others(.

5. 1.Forced Medication
•The first and perhaps most common type of coercion faced by
consumers labeled with severe psychiatric disorders is forced
medication. (Here I also include other forms of forced biological
treatment, such as forced electroconvulsive therapy.) This can take
many forms—both overt and covert. The overt forms include
forcing someone to take antipsychotics in order to get or keep his
housing or other benefits, forcing someone to take antipsychotics in
order to continue his participation in a work or mental health
program (or in therapy itself), forcing someone to take
antipsychotics in order to be granted release from a mental
hospital, forcing someone to take medications, including injectible
antipsychotics, under threat of being re-hospitalized (e.g.
Involuntary Outpatient Commitment), and, in a hospital setting,
physically restraining someone and injecting him against his will.

6. •Although these forms of overt coercion vary in their intensity, they
all share a common thread of denying a client his right of choice.
Likewise, the coercion in these “treatments” squelch his self-respect
and undermine his sense of self in a way that is metaphorically
comparable to the bodily side effects of the drugs themselves.
[Note: For more on the toxic side effects of psychiatric drugs, see
psychiatrist Grace Jackson’s two books in the reference section.[
•Likewise, any therapist who participates in overtly forcing a person
to take medication deals a crippling blow to the therapeutic alliance
—if there was one to begin with. Similarly, any family member or
friend who uses force to pressure someone to take medication
strikes a blow at the foundation of trust in the relationship. If
someone wishes to take psychiatric drugs on his or her own, and
has fully informed consent about the drugs’ potential risks versus
benefits, then it is his business to decide his own course of action.
But if he (or she) wishes to avoid medications, then that too is his
full right as a human being. It is no one else’s right to question him.

7. •Meanwhile, covert forms of forced medication are, in many cases,
similarly pernicious. A primary one involves the therapist pressuring
the client to take antipsychotics in order to keep in the therapist’s
good graces. Many people underestimate, or outright ignore, the
psychological intensity of this. Clients, especially those who are
vulnerable, lonely, isolated, and desperate for connection—which is
not uncommon in people diagnosed with severe mental problems—
may be so attached to their therapist that they will do almost
anything to win his favor. Rejection by their therapist may be
unthinkable to them—even provoking suicidal feelings in some—
especially if they have a repeated history of abandonment by
parental-like figures. [Of note: John Read et al. (2008) note that
people diagnosed with psychotic disorders have, in general,
compared to people not diagnosed with mental disorders,
experienced many more adverse or traumatic childhood
experiences within their families of origin.] This affords the
therapist massive power to throw around his weight in the most
subtle of ways—and apply coercive force simply with a withheld
smile or a grumbled reply.

8. •Another covert type of force involves the use of societal stigma—
and unscientifically-based social mores. A person labeled with a
psychotic disorder who refuses medication can meet all types of
emotional resistance from friends, family members, peers, and even
the television and newspaper. [I ask this, though: how many of
these social norms are based on the work of “scientists” who are on
the payroll of major pharmaceutical companies?] Together they can
form a covert wall of force, psychologically pressuring the client to
“do the right thing,” “face reality,” and “take your meds.” When the
therapist gives any credence to these social norms—and does not
overtly challenge the inappropriateness of those who preach its
message—he subtly joins the norm himself. For this reason I am
hesitant to support family therapies that place pro-medication
family members on equal therapeutic footing with anti-medication
consumers. So much coercive damage can be done to a client in the
name of “respecting alternate points of view.” Isn’t it more
appropriate for the therapist to side first and foremost with the
client, and to respect his autonomy and boundaries no matter
what?

9. 2.Forced withdrawal from
medication
•This is the flip side of the previous form of coercion. In this
scenario the seemingly “progressive” therapist uses the power
of his role to pressure the client to stop taking his
medications. Perhaps the therapist is even skilled and
experienced at helping clients withdraw—and has successfully
guided many through the process. His skill, however, is
tainted if the decision to withdraw or taper does not come
solely from the client. The therapist’s job is to present the
potential pros and cons of medication—assuming, that is, that
the client is interested in hearing them—and then to back off
and let the client decide for himself.

10. •I recently heard a story of a Scientologist who pressured a
“resistant” mental health consumer to withdraw from her
psychiatric medication. Although the woman had no intention
of withdrawing, the coercion caused her to feel undermined,
and thus emotionally damaged, as a person. And she did not
even have a close relationship with the Scientologist! How
much worse is it, then, when a trusted therapist uses the
nurtured intimacy of the therapy hour to meet his own
treatment ideals?

11. 3.Forced Hospitalization
•
•I consider forced hospitalization to be downright vicious, if
only for the iatrogenic damages—damages caused by the
treatment—of hospitalization itself. Although some credit
hospitalization as a life-safer, too often I have seen clients
choose to enter the hospital entirely on their own, free of
coercion, and come out far less centered and happy than
before they even went in. And how much worse is it when
they are hospitalized against their will? The wealth of
psychiatric survivor literature on this subject is enough to tell
that tale.

12. •So often a therapeutic relationship cannot stand the violation
inherent in the therapist forcibly hospitalizing the client. It is a basic
attack on the person’s freedom, on par with getting someone
unfairly arrested, or, in the words of so many clients, metaphorical
for being raped. (And that doesn’t even address the subject of the
number of consumers who actually do get raped or physically
assaulted during involuntary mental hospitalizations.(
•On the flip side, many outpatient therapists lack the skill, training, or
insight—or collegial support—to know how to remain therapeutic in
the face of a “psychotic” or “acting out” client. But I argue that
limitations in the ability of the therapist do not excuse the use of
coercion. Ideally, the therapist’s limitations should place pressure
on the therapist to find ways to become more therapeutic (a subject
I will address later in the paper), though of course many therapists
and many therapeutic systems fall short of the ideal. Instead they
adopt treatment models based on coercion—or simply refuse to
work with clients who are “too severely disturbed.” Likewise, other
treatment providers stigmatize, criticize, or marginalize therapists
who have the skills they lack. This stigmatization is convenient: it is
much easier to pathologize the competence of a fellow clinician
than to study and outgrow one’s own professional limitations.
Denial, projection, and rationalization are by no means limited to
one side of the couch.

13. 4.Forced Therapy
•All too often people are mandated to therapy. Mandates are an
overt form of coercion, because choice has been removed from the
equation. Although some people do benefit from mandated
therapy, in the few beneficial cases I have observed the benefit
came only once the client’s motivation for therapy eclipsed the
intensity of the mandate, thus, in essence, negating it. Early in my
therapeutic career I worked in various outpatient therapy clinics in
New York City and was forced, as part of my job duties, to work with
mandated clients, some of whom were deemed “psychotic.” These
clients were mandated to work with me by a variety of sources,
including mental health programs, psychiatrists, family members
(who threatened to kick the client out of the house if he didn’t go to
therapy), parole or probation officers (who threatened prison and
demanded attendance records), housing programs (who threatened
to kick the clients onto the street if they didn’t attend “therapeutic
treatment”), and sometimes even by my own clinic itself, which
would refuse to allow the client access to his psychiatrist (that is,
psychopharmacologist) until he concurrently attended therapy.

14. •This mandate almost assuredly rendered the therapy untherapeutic
from the start, and incidentally, such clients, despite the mandate,
generally had a much lower show-rate for sessions than my non-
mandated clients. And should I be surprised? I myself personally hate
being mandated to do anything, especially if I'm supposed to talk about
my most personal issues with a complete stranger who is in the power
position. (I was mandated to two sessions of psychotherapy at age
thirteen and I still resent that therapist, twenty-five years later.(
•Meanwhile, the way I helped mandated clients find value in the therapy
was that I told them that the only goal I felt that was reasonable for the
therapy was to help them get their mandate revoked, and I devoted all
my energy to this end. I wrote letters for them—which I let them edit—
detailing why they did not “need” therapy and why revoking the
mandate would be the most therapeutic course. I told my mandated
clients that I believed that if there were any hope of them getting
anything useful out of the therapy it could only come from their
choosing to attend on their own volition. Many appreciated this—and
many, with my full support, dropped out of therapy the day their
mandate was revoked. I invariably considered this a success, though I
admit to having felt a much greater sense of satisfaction when they
continued to come to therapy voluntarily following the revocation of
the mandate. That was where the real therapy began.

15. •In this vein, I am generally hesitant to work with children, as
so many are initially resistant to coming to therapy. Children
lack the ability to give consent to be able to vote, to be able to
drink alcohol, to have sex, to serve in the military, to be able
to choose where they live, and in most cases to work. Thus I
also question if children, in most cases, also lack the
psychological ability to give consent to come to therapy. Are
they not often, at some subliminal level—and sometimes a
not-so-subliminal level—being coerced to come to therapy by
someone, somehow?
•At this point, being in private practice, I refuse to work with
mandated clients. I only agree to work with people who come
by choice—and not based on fear of even the most minimal
external punishment. By agreeing to work with mandated
clients I have come to realize that I cannot avoid being part of
the coercive power structure. And my self-esteem cannot
tolerate that.

16. 5.Force used to prevent suicide
(and harm to others(
•This type of force is particularly complex. The standards of care of
the mental health field insist that we therapists do all within our
power to prevent our clients from committing suicide. Our licenses
and our jobs rest on our commitment to stop clients from harming
themselves (and others), at all costs. In some cases we have the
“right” and even “responsibility” to pressure them to take
medication or be locked up in the hospital. In other cases we have
the “right” and “responsibility” to break therapeutic confidentiality
and call their friends and family members and other treatment
providers—who in turn might hospitalize them or have them
arrested—even if we never got a signed release of information. We
have the “right” and “responsibility” to call the police on them, to
get them dragged away in handcuffs and straightjackets, to have
their freedoms stripped away, and to treat them as objects—objects
to save—not subjects. And we do this in the name of love and
caring and therapeutic insight and professionalism.

17. •Although at times our interventions might be loving and
caring, at other times they are not—and are instead a chance
for the therapist to act out his power. I personally wish to
avoid using this power at all costs. In my ten years of being a
therapist, and working with countless suicidal people, I have
not yet hospitalized one—or broken his or her confidentiality.
(And I have never had a client commit suicide—for which I am
thankful.) Instead I deal with his or her suicidality—and
struggle to find ways to try to alleviate it. I also begin with the
basic assumption, which I often share with the client, that a
person coming to therapy does not fully want to kill himself,
because if he was so fully committed to killing himself he
wouldn’t come to talk about it. He would simply do it. In this
regard, I discuss his options, and place the onus of
responsibility on him, which in and of itself can help to
alleviate suicidality.

18. •Although the practical reality of this is rarely so easy as the
last half-paragraph might suggest, it is not impossible. It just
requires creativity—and perhaps most of all it requires that
the therapist be able to tolerate a huge amount of anxiety and
uncertainty. Many therapists cannot or do not wish to do this,
and in many cases I can understand why—because I often do
not feel up to the task myself. The pressure on a therapist can
be intolerable, not just because it is terrifying to ponder one’s
emotional reaction to a client potentially murdering himself,
but also terrifying to consider the legal and professional
ramifications for a therapist who did not take forcible action
to prevent it. For that reason I at times have serious doubts
about the ultimate legitimacy of the whole mental health
field. How can a therapist be expected to work
therapeutically in a field that requires that when the going
gets rough he become a coercive agent of the state?

19. •Similarly, therapists are pressured to prevent clients from harming
others. We are expected in many cases to use coercive force, which
risks placing us in a double bind. Clients come to us vulnerable and
desperate for help, and we do as we are taught in encouraging them
to be open and honest about their actions, thoughts, and motives,
yet at times we might be expected to hospitalize them or even
indirectly have them arrested (such as through breaking
confidentiality in warning a potential victim of theirs) if they become
too honest and admit to certain unsavory thoughts or illegal actions.
And if we don’t practice coercion, however subtle or justified this
coercion might appear, and they do harm or kill someone else, then
we may be held culpable—both by the state, the licensing boards,
and our own ambivalent consciences. This can be hell on a therapist
—and pressure those of us who eschew coercion to become
therapeutic supermen and superwomen who push the envelope of
the standards of care, racing therapeutically against time and
ancient trauma to “undo” violent impulses. But might not this
pressured race—which a client much surely sense, if only
unconsciously—also be a form of coercion?

20. •I understand and respect that therapists have to follow the
laws of their state to prevent clients from harming others, and
I am not arguing that we disregard these laws, but I do ask
this: where do we draw the line in warning victims? And
what constitutes a real danger to others, much less an
imminent danger to others? And most importantly, I ask this:
what else might we do to prevent a client harming others?
This whole subject matter, which I have only dealt with
minimally, is rife with complexity and frustration, and leads
into the next subsection.