Coercion or love?

In October I attended the 10th European congress in Violence in Clinical Psychiatry ( in Dublin. I have attended many of the earlier ones, and have always found these congresses most relevant from the point of view of getting new ideas for developing our adolescent forensic service. This time it was as good as always. I am particularly happy that our own workshop where we discussed aggression management in our unit was successful. Our point was to evaluate how our care philosophy has evolved since we opened the unit – almost 15 years ago! (15th anniversary jubilee seminar ahead in April – follow my updates!)

Justice was one of our big concerns in the beginning of the unit’s history. Adolescents easily challenge adults around them and blame them for injustice.  We then felt that justice means that everyone get the same. We focused particularly on negative consequences of problem behaviours. However, the society emphasizes all the time more patient autonomy and self-determination, and strict rules and structured consequences are increasingly seen as unnecessary coercion and wielding of power. On the other hand, our understanding of the mental disorders precipitating to violent outbursts, and research findings emphasizing the significance of positive approaches for enhancing behavior change have influenced our thinking and practices. From meeting all equally with same interventions we have moved to meeting each according to his/her needs, from consistent consequences of negative behaviours to rewarding positive behavior.

Risk of harm or dangerousness to self is widely accepted as a criterion for committing a person with mental illness / severe mental disorder (definitions vary across legislations) to involuntary care, and also for using coercion (such as forced medication, seclusion, physical or mechanical restraint) in the ward if the imminent self-harm cannot be avoided otherwise. On the other hand, use of coercion risks traumatizing the patient, and the possibility to use coercion risks creating an environment with misuse of power. It is of outmost importance to keep developing approaches that help a self-harming or suicidal patient to avoid self-harming, without using coercion. But what if all the therapeutic approaches fail? I have observed that this question is avoided by implying that if therapeutic approaches fail and the patient nevertheless self-harms or attempts suicide, the professionals have failed. Not only do they perhaps not have the right skills, an ultimate accuse I have heard is that they are only using skills and techniques – not putting all their love in it in a right way. So, if only the doctors / nurses / therapists loved the patient enough, self-harm and suicidality would dissolve?

Quite a demand! I doubt that symptom behaviour can be healed by loving and caring. Health care professional’s task is not to love but to use her/his professional skills to help the patient. I think it is lousy to take the discussion to implying lack of skills, not to mention love. In my opinion we need to talk about the ultimate: shall we intervene or not, when a patient seriously self-harms or attempts suicide?