Is coercion inevitable??

Much of the current debate about mental health reform is about coercion.   On the national level most discussion is about Rep Tim Murphys bill which basically says coercion is inevitable and needed and indeed that the most needed reform is to make coercion easier and more likely to implement.  His view is that the biggest problem in the mental health  system is the lack of cooperation of those who need its help.   His answer is stop asking them … Make em.

He thinks we know what to do to people and their lack of cooperation is not a choice but a symptom of their “illness.”

A different view says it is not what you do to people that matters but what you do with people and their choice matters. 

Most states buy into the inevitability of coercion and when it doesn’t work normally tries to solve it with more  coercion.  They may talk about the value of empowerment and similar notions but largely don’t believe that the  “mentally ill”  are likely to make good choices about their lives.   They don’t put their money where their mouth is.

Tennessee is one of very states that does not have an AOT program. The TAC came into the state several years ago and lost. The report written about AOT by the Dept of Mental Health is still one of the best analysis of AOT I have ever read. A lot of advocates spoke and spoke loudly. As part of a political compromise the next year a pilot AOT program was started. After serving one person in two years that pilot was disbanded. The consensus was clear. There were better options. AOT is dead in Tennessee.

Coercion is not a guiding value in Tennessee. I have heard leaders in the Dept of Mental Health talk about the trauma of commitment and their worries about the long term consequences of coercion. They are aware that whatever value may be seen in crisis stabilization there is little evidence of long term benefits. People are often hurt. Too often the same people keep coming back.

They are pioneers in trying to find options. Several years ago one state hospital was shut down and that money by legislative act was committed back that area and invested in community based programs.

Tennessee has also put a lot of effort into developing crisis stabilization units. A crisis stabilization unit (CSU) is a small voluntary facility in many Tennessee communities which is exactly what it says… a place where people who believe they are in or moving towards crisis can come for help in stabilizing themselves and their lives. Length of stay is a maximum of 3 days. You can leave at any point before that if you want. The emphasis is on providing a safe place and support, introducing people to the idea of recovery and recovery tools and helping to tie people to community resources if they want additional help. This past year the most amazing thing happened. For the first time as many people were admitted to CSU’s as to state psychiatric hospitals. Many of the people who used CSU’s would have been hospitalized I’m the past.

State psychiatric hospitals serve about 7600 people a year. Within the last couple of weeks a major new initiative has been announced. As a result of a Samhsa grant (ironic considering the Murphy debate) the Dept of Mental Health in cooperation with the Tennessee Mental Health Consumers Asociation (TMHCA) is getting ready to implement a peer run Peer Engagement Project which could change the way psychiatric hospitalization is done in Tennessee forever. Under the direction of the Tmhca the plan includes the following :

1. 1000 hospital staff per year will be trained in trauma informed care.
2. At least 5000 patients a year will be served through support groups, recovery skills classes and peer bridger services. All these services will be provided by people with lived experience of their own.
3. There will be both peer and family voices on the board of trustees of the state psychiatric hospitals. In addition a peer led review committee will be set up for the psychiatric hospitals.

There are other provisions but these are key ones.

Tennessee continues to try to find options to psychiatric hospitalization. The peer engagement project seeks to change the experience of hospitalization. It says more coercion is not the only answer to the failure of coercion. The answer to the lack of effectiveness of psychiatric hospitals is not to make it easier to hospitalize people or keep them longer but to develop alternatives to hospitalization and to try to make it more unlikely those hospitalized will return.

What Tennessee is doing may not be the answer everywhere. It does show there are other answers and that no coercion is not inevitable. The best way to change the mental health system is not to give more control over what we do to people but change what we do with them.


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