Running head: PRACTITIONER SUGGESTED HOSPITALIZATION 1 Practitioner Suggested Voluntary Psychiatric Hospitalization from a Feminist Therapy Perspective Ashley Moseley University of Florida Faculty Advisor: Dr. Alyssa Zucker
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 2 Abstract This study explores "practitioner suggested voluntary psychiatric hospitaliz ation," or the gray area between voluntary and involuntary admission into psychiatric inpatient treatment where patients with voluntary status feel they have been persuaded into admission by practitioners with the authority to admit t hem involuntarily. Some scholars discuss this phenomenon in terms of power, indicating that what a practitioner views as a suggestion may be interpreted by a patient as coercion due to power imbalance within the psychiatric setting. However, research on ho w individuals with marginalized identities may be affected by practitioner suggested hospi talization is largely inconclusive. This study sought to address this gap by interviewing four feminist therapists, who focus on the intersections of social identitie s such as race, gender, and sexual orientation while promoting an egalitarian therapeutic relationship. The study discuss ed the experiences and opinions of feminist therapists, and analyz ed emerging themes Keywords: feminist therapy, psychiatric hospita lization, peer movement
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 3 Practitioner Suggested Voluntary Psychiatric Hospitalization from a Feminist Therapy Perspective I n 1860, Elizabeth Packard was committed to an asylum by her husband, a Calvinist pastor, for her exploration o f faith and her "unclean spirit, (Testa & West, 2010). Following her hospitalization, she devoted her life to advocacy, working to change hospitalization laws (Langsworthy). While activists have gained significant progress in reforming mental institutionalization, ev idence shows that coercive psychiatric practices still exist. In fact, a gray area between voluntary and involuntary hospitalization exists where individuals with a voluntary status feel they have been persuaded into admission by mental health professional s with the authority to involuntarily admit them. The goal of this stud y is to explore this phenomenon, which I will refer to as practitioner suggested voluntary psychiatric hospitalization through the lens of feminist therapy to further understand the ro le of power dynamics and the effects that hospitalization may have on people with marginalized identities. History Prior to the conception of mental asylums in the United States, individuals with mental illnesses were often relegated to prisons and homeles s shelters with the intention of ensuring safety for the community rather than providing treatment to people in distress (Testa & West, 2010). However, i n the early 19 th century, four privately funded asylums were established. Despite the benefits of havin g a designated space for individuals experiencing mental illness, the Victorian Era in which asylums emerged, marked by a "lower tolerance for disorder and deviance, and a sense of urgency about maintaining public safety and social order," blurred the distinction between "morality" and "sanity;" in fact, much of the cri teria that constituted "mental
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 4 illness" overlapped with what was considered immoral and socially abhorrent (Curtis, 200 1). Ambiguous hospitalization standards oftentimes led to their abuse through the unjust hospitalization of people who did not meet the r igid societal expectations of the era. Women, who held nominal civil rights that were rarely enforced, were particularly vulnerable to this phenomenon. In fact, women who did not adequately fulfill their duty of wife and mother were often d iagnosed as insa ne and subsequently relegated to a mental institution such as Elizabeth Packard (Testa & West, 2010). Involuntary and coerced psychiatric hospitalization persisted into the 20 th century with over 50,000 people residing in mental asylums in the 1950s (Te sta &West, 2010). However, s ubstantial reform to the system of mental institutionalization emerged dur ing the 1960s as individuals with marginalized identities fought for their fundamental rights. This spirit of activism and social justice infiltrated thr ough all aspects of life, as scholars, activists, and practitioners alike began to question the system of psychiatry and the fundamental definition of mental illness (Curtis, 2001) For example, radical psychiatrist Dr. Thomas Szasz argued that psychiatry was a form of social control that converted social constructions of deviance in to diagnoses, despite a lack of evidence regarding the cellular level disease processes of "mental illness." In fact, he viewed the psychiatric system as a "tacit contract existing between society as a whole and the class of psychiatrists, in which psychiatrists arrange to confine and control persons disturbing to society, in return for a social regard as member s of the medical profession," (Curtis, 2001). However, these progressive ideas did not gain enough credence to significantly change the laws and practices of psychiatric hospitalization ; though they aligned with the radical nature of the civil rights era, arguments of freedom and liberty remained more salient to America' s values Therefore arguments against involuntary or coerced psychiatric
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 5 hospitalization emerged based on the idea that "despite the existence of mental illness, and despite the fact that t he mentally ill might benefit from treatment, personal freedom is a higher order good than treatment," (Curtis, 2001). As a result, psychiatric care began to transition from the hospital to the co mmunity, leading the number of people in inpatient treatment to decline from 550,000 to 30,000 by the 1990s (Testa & West, 2010). From the deinstitutionalization era arose a new way of conceptualizing mental illness and psychiatric hospitalization shifting from a need for treatment model to a dangerousness model. In other words, to be hospitalized, an individual must demonstrate that they are at imminent risk of harm to self or others. The dangerous ness model rests on two principles regarding the state's responsibility to people exp eriencing mental health problems The first, paren s patriae, meaning "parent of the country," is the belief that the government must care for individuals who are unable to care for themselves. On the other hand, the state is guided by police power or the duty to protect the interest of all citizens. These guiding forces interact to form the dangerous ness model, creating a situation in which the state has the right to write statutes for the benefit of society at large, even when providing this benefit may come at the cost of restricting the l iberties of certain individuals," (Testa & West, 2010). While the deinstitutionalization era and the dangerousness model intended to provide protections to people experiencing mental illness, the idea that those in distress lacked the autonomy to make their own treatment decisions had unintended adverse effects. First, this model stigmatizes individuals with mental healt h problems by fueling a public fear regarding the supposed dangerousness of persons with mental illness. This is particularly detrimental as perpetrators of mass violence are often labeled as mentally ill in order to mask underlying systems of oppression that fuel hate crimes, such as misogyny and racism. Further, this stigma oftentimes results in the relegation of those experiencing mental
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 6 illness to societal margins such as the criminal justice system or homeless shelters, in order to protect society from their perceived burden (Testa & West, 2010). Coercion in "Voluntary" Hospitalization In theory, this mode l created clear distinctions between voluntary and involuntary hospitalization. However, a pioneering study by Gilboy and Schmidt (1971) challenged the assumption that voluntary admission into a mental hospital is conducive to an autonomous decision to see k treatment. Rather, in an observational study in a Chicago hospital, the scholars determined that individuals are often induced to voluntarily admit themselves by professionals who have the authority to involuntarily commit them, subsequently limiting the ir ability to leave the hospital upon request, regardless of their "voluntary" status (Gilboy & Schmidt, 1971). Several studies replicated this finding, indicating that coercion should be viewed as a continuum. For example, in a study of 412 voluntarily ad mitted patients, 44% did not regard t heir status as truly voluntary (Rogers, 1993) Though voluntary patients enter inpatient treatment under the assumption that their voluntary status affords them certain rights, they, oftentimes unknowingly without suffi cient information regarding their decisions, sacrifice the right to a court hearing that would have been available to them upon involuntary admission. Therefore, according to Gilboy and Schmidt, coerced "voluntary" commitment is not only a breach of civil liberties, but is also a direct violation of constitutional rights. In order words, "the involuntary commitment process, with its various safeguards, is a constitutionally required means of protecting citizens from the dangers of arbitrary civil commitment (Gilboy & Schmidt, 1971 p. 453 ). However other sc holars argue that what patients interpret as "coercion" by psychiatrists is no more than verbal persuas ion, or a description of how hospitalization could b enefit the patient In an observational study in a large hospital, L idz, Mulvey, Arnold, B ennett, and Kirsch
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 7 (1993) saw that while verbal persuasion by physicians and nurse clinicians was frequent, this persuasion generally lacked substantial pressures. However, in line with Gilboy and Schmidt, researchers indicated that this persuasion did not involve thorough information about t he hospitalization process or alternative options ; rather, physicians presented information in the form of "non negotiable" statements or already decided f acts ( Lidz et al. 1993). Therefore the authors argue that patients' perceptions of coercion are guided by power imbalances in a psychiatric setting, stating: W hen the attending says I think you need to come in' it appears to be a simple expression of o pinion. A simple attempt at persuasion. Yet we need to ask some questions about such judgments. Does it matter that a large safety officer is sitting outside the door? Does it mat t er that at any point the clinician can decide to commit the patient? Does it matter that the patient has been committed against his/her will before? How do these things affect the nature of the pressure? Indeed, clinicians sometimes use that some phrase (I think you need to come in') to mean we are going to commit you.' Can any statement made by a clinician be simply advice? (Lidz et al., 1993, p. 277). Discussi ons of power regarding psychiatric hospitalization call into question who is most affected, taking into account intersections of race, gender, class and other social identities. Given the historical unjust hospitalization of w omen one might argue that women are particularly susceptible. In fact, research demonstrates that women may be diagnosed as mentally ill according to more restrictive standards that are used as a method of reinforcing the ir subo rdinate social status. Discrimination against women has been largely ingrained within psychiatric theory as women have been historically defined by their anatomy and diagnosed as "hysterical" for not conforming to rigid gen der norms (Roth, 1974) This gendered bias within
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 8 theory permeates into practice, as men within the psychiatric profession are guided by gendered bias in their admission, treatment, and release of women in inpatient settings. Because women have historical ly been socialized to be submissive to male authority figures, it is argued that "the distinction between voluntary and involuntary admissions, already blurred by the existence of alternative coercive procedures, may be effectively eliminated," (Roth, 1974 p. 798). However, Holstein criticizes such findings for defining gender as a fixed characteristic of a patient, rather than dynamic and situational. Therefore he examines how patients perform their gender in civil commitment hearings, arguing that "gend er becomes relevant and influential only through these participants' specifically situated and motivated gender depictions. Thus, gender's relevance is not found in the candidate patient's gender per se, but rather in its rhetorical usage (Holstein, 1987 p. 143) In other words, because men and women are judged differently in psychiatric settings based on the social construction of gender, those who d isplay behavior not deemed as appropriate given their assigned sex may be pathologized. Holstein cites th e following example from a hospitalization court hearing : "Mr. Simms suffers from drastic mood swings. His affect is extremely labile. One minute he'll be in tears, the next he's just fine. He fluctuates. His affect may be flattened, then elevated. One moment he'll be telling you about his cleaning business, then he'll flip out and cry like a broken hearted schoolgirl over the most insignificant thing. Something that should never upset a grown man like Mr. Simms. During his periods of flattened affect, h e seems to lose all interest His passivity he's almost docile in a very sweet sort of way. He just smiles and lets everything pass. It's completely inappropriate for an adult male, (1987, p. 145).
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 9 In this example, the patient is not involuntarily commi tted because he is a man. Rather, he is pathologized for how he produces his gender by crying "like a broken hearted schoolgirl" in a manner that deviates from societal expectations of masculinity. Roth argues "the inherent vagueness of many of psychiatry' s diagnostic terms makes it easy for the clinician to conceal, even from himself, political and cultural preferences in the guise of neutral and detached judgments about objectively verifiable disease, (Roth, 1974, p. 798) Despite these findings, researc h on the demographics of coercion in mental health treatment has been unclear and oftentimes contradictory. While one study found correlations between increasing age and minority identity, implying that Black and ethnic minority identities make one at part icular risk of being coerced, two Nordic studies found no major correlations involving age and gender, and other studies found black and minority ethnicity to be a protective factor (Newton Holmes, 2010). In fact, scholars within the MacArthur Coercion Stu dy state that demographic factors do not affect the amount of coercion that a patient experiences in hospital admission. Rather, the researchers argue that coercion is related to the "procedural justice" of the admission process; patients who believe that they were treated respectfully and with genuine concern, and were afforded the opportunity to share their experiences, perceived less co ercion (Hoge et al., 2001). Such contradictory findings in regards to the demographics of psychiatric hospitalization in dicate the importance of further investigating nonconsensual psychiatric interventions and their ethical and multicultural implications. Physician perspectives regarding practitioner suggested voluntary psychiatric hospitalization are complex, as some vie w coercion as a "necessary evil" that is essential in aiding patients in distress. For example, in a Swedish study, fourteen psychiatric nurses stated that while they viewed coercion negatively and found it emotionally distressing, they were
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 10 unable to identify alternatives that would allow them to adequately provide care for their patients ( Olofsson et al. 1998). Appelbaum affirmed this view, stating that "m any ment al health professionals believe that in the absence of judicious (but not necessarily ju dicial) coercion patients will not receive needed care, their condition will deteriorate, and they will suffer psychological and perhaps physical distress," (Appelbaum, 1985). Whether this coercion has the benign intention of ensuring treatment to patients in distress, or whether, as indicated by Dr. Szasz' s theory, there is some level of social control involved, it is essential to consider the profound impacts that semi voluntary psychiatric hospitalization may have on patients. In a study of 18 involuntar ily admitted psychiatric patients, participants viewed their experiences of coercion in a negative manner. Further, they cited feeling "inferior as human beings," as one patient described "you become a nobody, they can do whatever they want with you, altho ugh maybe you are a very valuable person being in a crisis," (Oloffson, 2001). Given the detrimental effects that such coercion may have on patients, it is essential that practitioner suggested voluntary hospitalization is further explored. Peer Movement While research into coercion within psychiatric hospitalizat ion conducted by scholars and practitioners provides valuable information, the effects of nonconsensual psychiatric interventions are best understood through the voices of individuals who have experienced them. In the 1970s, the peer or ex patient s' movement formed from this notion, drawing upon ideals of the black, women's, and gay liberation movement s which i ndicated that individuals with privileged identities are unable to fully understand the lived experiences of individuals with marginalized identities. Similarly, ex patients found that "their own perceptions about mental illness' were diametrically opposed to those of the general public, and even more so to those of
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 11 mental health professionals ," leading them to form organizations consisting solely of people with lived experience of mental distress or psychiatric hospitalization otherwise known as "ex patients," "ex inmates," or "p eers" (Chamb erlin, 1990 ). Drawing upon consciousness raising groups which initially emerged during the women's movement, mental patients began to recognize commonalities and patterns of oppression among their experiences, indicating that their struggles w ere not solely internal and personal, but rather existed on a societal level (Chamberlin, 1990 ). From these consciousness raising groups emerged two primary goals of the peer movement: self help and empowerment, and advocacy. In the 1970s, self help grou ps began to emerge from the ex patient s' movement, generally consisting of individuals who were skeptical about the value and effectiveness of the psychiatric system. Members of such groups oftentimes expressed outrage towards the mental health system afte r experiencing injustices; rather than pathologizing this outrage, members of the ex patient s' movement viewed anger as a healthy reaction to the abuses they experienced within the psychiatric institution (Chamberlin, 1990 ). Activist and ex patient Judi C hamberlin, writing of her personal experiences with psychiatric hospitalization in her article Confessions of a Non Compliant Patient, described such outrage: Being a patient was the most devastating experience of my life. At a time when I was already fragile, already vulnerable, being labeled and treated only confirmed to me that I was worthless It was clear that my thoughts feelings, and opinions counted for little. I was presumed not to be able to take care of myself, not to be able to make decisio ns in my own best interest, and to need mental health professionals to run my life for me. For this total disregard of my wishes and feelings, I was expected to be appreciative and
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 12 grateful. In fact, anything less was tacked as a further symptom of my illn ess, as one more indication that I truly needed more of the same ( 1998). Self help groups allowed individuals such as Judi Chamberlin who felt abused and dehumanized by the psychiatric system to process their experiences outside of a medicalized environme nt. Despite recognizing the faults of the psychiatric system, many peers partake in professionally run services in combination with self help groups. For this reason, the movement also promotes empowerment among ex patients, allowing members to take a st ronger role in advocating for their own needs within the larger mental health system and reject the role of passive serv ice recipient, (Chamberlin, 1990 ). Whether they consist solely of ex patients, or whether they involve mental health professionals to some degree (including professionals who also identify themselves as peers), peer support groups take on a number of different forms. For example, experiential peer support allows participants to explore what would be considered by many as "extreme" state s, such as voices, visions, or hallucinations. While such groups acknowledge that difficulty coping with trauma and adversity often play a role in these "extreme" experiences, experiential peer support encourages people to explore their own beliefs be t hey spiritual, religious, paranormal, technologic al, cultural, counter cultural, philosophical, medical, and so on ," ( Dillon & Hornstein, 2013, p. 289). This philosophy operates in direct contrast with the psychiatric system, which defines such experiences as symptoms of an inherent disease that is often deemed "untreatable." In addition to experiential peer support, intentional peer support allows individuals to "work together to develop awareness of personal and relational patterns, to view life experiences from many angles, and to create new ways of seeing, thinking, and doing (Probert & Nash, 2015). For example, one of the core foundations of intentional peer support is that relationships are viewed as partnerships in which both
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 13 participants l earn and grow rather than one person helping the other (Intentional Peer Support) ; this mutuality exists in contrast to the relationships one might experience in a hospital setting, in which the psychiatrist is viewed as the expert and sole authority, whi le the patient is viewed as a passive recipient. Ultimat ely, while group members may still experience the emotional distress that le d to their psychiatric diagnoses, self help groups serve as a powerful confirmation that people, despite problems and disab ilities, can achieve more than others (or they themselves) may have ever thought possible," (Chamberlin, 1990 ). As important as self help is to the ex patients' movement, advocacy, or working for political change, is just as essential. In the words of ac tivist Judi Chamberlin: The basic principle of the movement is that all laws and practices which induce discrimination toward individuals who have been labeled "men tally ill" need to be changed, s o that a psychiatric diagnosis has no more impact on a person's citizenship rights and responsibilities than is a diagnosis of diabetes or heart disease. To that end, all commitment laws, forced treatment laws, insanity defenses, and other simila r practices should be abolished (1990 ). The long term goal of er adicating nonconsensual psychiatric interventions is backed by a number of other agencies. In fact, in 2017, the United Nations Special Rapporteur on the right to health called for a "sea of change" in mental health care: one that embraces a human rights a pproach rather than a biomedical approach, and one that acknowledges that crisis within the mental healthcare system is "not a crisis of chemical imbalances, but of power imbalances," ( United Nations Human Rights 2017 ). Further, in 2011, the National Coal ition for Mental Health Recovery, which aims to ensure that ex patients have a voice in the development and implementation of mental health care and policies, affirmed that nonconsensual psychiatric
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 14 interventions should never b e seen as treatment; rather, hospitalization should only be considered as a last resort option when all other methods have been exhausted (National Coalition for Mental Health Recovery, 2011). While a number of patient liberation groups have formed to undertake the overarching goal of eradicating nonconsensual psychiatric interventions, such as the National Association of Psychiatric Survivors, such activism may also take place on a more indivi dual level, as mental health practitioners advocate for their clients and employ human rights based and trauma oriented therapeutic practices ; these appr oaches acknowledge the profound role that trauma plays in human suffering by avoiding an exclusively bi omedical approach, and employ empathy and human connection in order to avoid taking away someone's rights through hospitalization (Probert, 2014). Feminist Therapy Given the inconclusive nature of r esearch into how practitioner suggested voluntary hospit alization affects people with marginalized identities this study seeks to explore the phenomenon through the lens of feminist therapy. During the second wave feminist movement, feminist therapy emerged from consciousness raising groups, as therapists bega n to apply feminist awareness into their therapeutic practice (Brown & Brodsky, 1992). Feminist therapy operates under three guiding principles: the personal is political, diversity, and an egalitarian therapeutic relationship (Enns, 2012) In the context of feminist therapy, t he personal is political refers to how both client and practitioner attend to the sociocultural context in which they live, reframing clients' distress as adaptive responses to oppression and helping clients to cultivate an active rol e in addressing inequalities (Enns, 2012). Feminist therapy also draws upon the idea of intersectionality, or how marginalized identities are intertwined and inseparable, leading to overlapping forms of oppression (Crenshaw, 1991). Finally, the third femin ist therapy facet an
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 15 egalitarian relationship is defined as one that views the client as their own expert, one that uses strategies to promote client's autonomy and power, one that encourages the expression of anger, and one that models appropriate behav ior for the client (Gilbert, 1980). While the literature on feminist therapy has significantly expanded since this initial research was conducted, the exercise of power by both clients and therapists is still arguably the most important factor that arises in discussions of feminist therapy (Rader and Gilbert, 2005). In fact, in a study conducted by Rader and Gilbert, practitioners who identified as feminist therapists were more likely to demonstrate power sharing behaviors, such as self disclosure; in turn, their clients were more likely to perceive such behaviors (Rader and Gilbert, 2005). Research Questions Because feminist therapy attends to sociocultural context while promoting an egalitarian therapeutic relationship, the professional opinions of femin ist therapists regarding practitioner suggested voluntary psychiatric hospitalizati on provide valuable insight. B y interviewing feminist t herapists, the study sought to answer the following research questions: 1. How do feminist therapists view the system of psychiatric hospitalization, specifically focusing on practitioner suggested or semi voluntary hospitalization? 2. How do feminist therapists interpret the role of power dynamics in psychiatric hospitalization? 3. According to the experiences and professional opinions of feminist th erapists how are individuals with marginalized identities (ex. minority status in terms of race, gender identity, sexual orientation, etc.) uniquely affected by psychiatric hospitalizati on?
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 16 This research is important because, as previously stated, the experience of coercion in mental health treatment can have detrimental effects on the patients involved, as many cite feeling dehumanized and inf erior (Oloffson, 2001). Further, people who have been hospitalized ar e at high suicide risk immediately following hospitalization, with one third of all suicides among patients occurring within 3 months of discharge (Olfson et al., 2016). This alarming statistic demonstrates the importance of furth er investigating non consensual psychiatric interventions and their effects on patients of all races, gender identities, socioeconomic statuses, etc. Methods Participants I recruited t herapists through online databases of mental health practitioners, pr ofessional references, and the Division 35 listserv of the American Psychological Association These recruitment methods resulted in a sample of four mental health professionals. Three participants identified explicitly as feminist therapists. While one practitioner did not formally identify as such, they incorporated feminist therapy practices into their work by focus ing on power dynamics an d the role of marginalized identities on mental health and adversity All practitioners were licensed psychologists at the doctoral level, and the number of years they had been practicing ranged from 11.5 to 45. Two participants worked in college mental health settings, while the other two participants worked in private practice. In terms of their social identities th ree participants were white, while one was of Latin American descent. A ll participants in the study identified as cisgender and heterosexual, three being cisgender women and one being a cisgender man (in order to further respect the confidentiality of part icipants the gender neutral pronouns they/them/theirs will be used for all participants). Three participants cited religious background as important facets of their identity as two identified as Jewish while one cited a
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 17 Catholic upbringing. Finally, one participant shared their identity as a peer, defined as an individual who self identifies as having lived experience of extreme mental distress or within the system of psychiatric hospitalization (Gainesville Peer Respite) Procedure After the study rece ived IRB approval, I conducted one hour, semi structured interview s with participants During the first segment of the interview, I asked participants questions about feminist therapy such as the feminist practices that they incorporate into their work. In addition, I asked participants h ow their own social identities affect their practices as feminist therapists. In the second section of the interview, participants were asked questions about their experiences with voluntary, involuntary, and practitione r suggested voluntary psychiatric hospitalization. Finally, participants were asked to discuss their general professional opinions on psychiatric hospitalization, the role that power dynamics play in hospitalization, and how individuals with marginalized i dentities may be uniquely affected by psychiatric hospitalization (see Appe ndix for full list of questions ) Following the interview process, participants were asked to fill out a brief demographic survey. The survey asked a number of professional quest ions, such as the participant's title and theoretical orientation, along with questions about their personal social identities. More specifically, participants were asked about their race/ethnicity, gender identity, sexual orientation, and any other aspect s of their identity they felt important to the purpose of the study. Finally I transcribed interviews and analyzed emerging themes Along with themes related to initial res earch questions, a number of other themes emerged and are further discussed in this study.
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 18 Results Main Themes Upon reviewing the interviews, the data analyst perceived the following themes in rela tion to the research questions: Psychiatric hospitalization as a last resort. Participants generally viewed psychiatric hospitalization as a final option only to be employed when the client is at high risk of suicide and is unable to adhere to alternative treatments A ll four participant s indicated that they had little to no experience with involuntary hospitalization; while some had experiences with practitioner suggested voluntary hospitalization, this was also rare, and only used when participants reached the point of questioning "Are [the clients] going to die if I don't do anything?" (Participant 4) In addition to an inability to adhere to alternative treatment plans participants cited several other factors that serve d as warning signs that the client may be at risk of suicide. Part icipant 2 began to consider hospitalization when they witnessed the deterioration of the client, or when the physical and mental state of the client became progressively worse Conversely, Participant 3 discussed the dangerousness of stagnation, or the sense that therapy sessions remain ed the same from week to week. According to Participant 3, stagnation can be alarming even if the sessions seem positive, as the therapy room can provide a sense of solace for clients; in other words "people do the most drastic things when they feel utterly alone on the planet, and they do not feel utterly alone in [the therapist's] office," (Participant 3) For some participants avoiding ps ychiatric hospitalization meant employing an "above and beyond" standard of care when working with clients in suicide danger, prioritizing them above other obligations in order to ensure their safety. In discussing their process of working with clients at suicide risk, Participant 4 stated "M y goal is at that moment to drop everything.
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 19 We're goin g to sit and it may take hours and I trust that almost every time if we sit with it and stick with it, we'll find some other way for them to get through it. One potential alternative treatment option used by participants is a safety plan, con sisting of activities that the person at risk of suicide can do to stay safe, along with personal and professional references within their support network (Participant 1 ). Participants also relied on peer respites as alternative treatment options, which ar e facilities run by staff members with lived experiences of extreme emotional distress, psychiatric hospitalization, or other mental health challenges. Such respites aim to provide sanctuary and support to individuals experiencing distress outside of the m edicalized environment of psychiatric hospit als by creating a community of "open dialogue, empowerment, self determination, recovery and wellness (Gainesville Peer Respite). Ultimately, while partici pants tended to view hospitalization in a negative manner, and took all possible measures to avoid it, some acknowledged it may be necessary in certain instances, even if this means severing therapeutic bonds. In the words of Participant 3 "they'll hate me for the rest of their life, but they'll have a re st of their life to hate me with." Power imbalance in psychiatric hospitalization. Participants prioritized alternative treatment methods over psychiatric hospitalization because they tended to view it as an abuse of power depriving patients of autonomy and authorship. This lack of autonomy stems from the fact that mental health professionals are given the power to make treatment decisions on behalf of clients, leaving th em without a sense of agency. While patients may encounter overtly coercive practices such as forced medication or restricted mobility, coercion may be more covert as patients lack authorship over their experiences. In other words, an individual that is hospitalized is often diagnosed in a manner that defines their experiences as symptom s of an inherent "illness," ignoring context and the role that adversity and marginalization play in human
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 20 suffering. Once the person is diagnosed, all actions are interpreted through that lens; for example, a patient crying because of their hospitalizatio n may have their behavior redefined as a symptom of depression (Participant 4). Because the patient must adhere to a particular worldview and self definition they lack a sense of authorship and the human right to understanding their own experiences in a manner that feels right to them (Participant 4 ). Two participants also discussed hierarchical power structures among mental health professionals themselves. Participants 2 and 3 indicated that power imbalance is present when you put your foot in the door of a psychiatric hospital, as psychiatrists generally take prece dence over nurses (Participant 3 ) Participant 2 discussed the gendered implications of these hierarchical power structures through t he i r experiences with both male and female psychi atrists. While female psychiatrists tended to be more collaborative and included the participant in their treatment decisions, male psychiatrists w ere generally more exclusionary. In fact, Participant 3 discussed two instances of when male psychiatrists in terfered with their clients without any notice or collaboration, with one psychiatrist going as far as using Electroconvulsive Therapy without consulting the therapist. These discussions align with existing literature suggesting that psychiatric theory is inherently guided by gendered biases. In order to offset power imbalances within the therapeutic relationship, participants in this study employed a numb er of power sharing techniques central to feminist therapy in order to foster a more egalitarian relat ionship. For example, Participant 3 only used their first name with patients in order to avoid power differentials caused by using formal titles Further, Participant 1 often engaged in an appropriate level of self disclosure when they felt it could benefit the client. By viewing the client as the expert of their own experiences, therapists in this study gave their clients a sense of agency and au tonomy.
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 21 Susceptibility of individuals with marginalized identities. According to par ticipants discussions of power are complicated by the fact that individuals with marginalized identities are oftentimes powerless in society as a result of systematic op pression, leading them to face unique obstac l e s in terms of psychiatric hospitalization. For example, Participant 4 argued that people with marginalized identities may be susceptible to psychiatric hospitalization because they are more likely to face adver sity, leading to emotional distress; when taken out of context, this distress may be diagnosed as mental illness, thereby leading to hospitalization. This perspective aligns significantly with the minority stress model, which argued that individuals with m inority identities are exposed to unique minority stressors, such as discrimination, which may lead them to develop mental health problems ( Meyer, 2003). Further, Participant 1 stated that individuals of minority status may be vulnerable to hospitalization as they lack affirmative mental health resources and knowledge of other options. Finally, Participant 3 discussed a situation reminiscent of the historical unjust hospitalization of women such as Elizabeth Packard, stating that "people can be involuntaril y hospitalized just for being different," aligning with Dr. Szasz's theory of psychiatry as social control. While they acknowledge this is not as prevalent in present day, they claim that it may still happen, as parents may push for a transgender adult to be hospitalized for not conforming to the gender binary. These viewpoints indicate that it is not necessarily the fact that these individuals have marginalized identities that makes them vulnerable to hospitalization; rather, it is the systematic oppressio n they experience outside of the hospital environment that increases their vulnerability. Another obstacle unique to individuals with marginalized identities is a distrust in the medical system (Participant 1) For example, d istrust in the medical institution is characteristic among African Americans, stemming from the ir historical exploitation dating back to the
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 22 antebellum period when slaves were often used as subjects for dissection and medical experimentation (Gamble, 1997) As described by participants in the study, this distrust is not only frequent among people of color, but also among individuals of gender and sexual minorities. For example, Participant 3 described a transgender client who had an intense fear of psychiat ric hospitalization due to a medical system that is often hostile towards people with non normative gender identities. Participants indicated this distrust is justified, as hospital environments may be hostile to individuals with minority identities. Acco rding to Participant 3 "hospitals reflect community standards. And if community standards are heteronormative, so is the hospital," creating a dangerous environment for individuals who do not adhere to societal standards However, discussions of how ps ychiatric hospitalization affects individuals of marginalized identities were not unanimous among the practitioners who participated in this study. For example, Participant 2 stated they did not notice gender differences among t he i r clients who had been ho spitalized. Further, Participant 3 discussed a transgender client whose experience in a psychiatric hospital was gender affirming. Such discrepancies among the participants are reflective of the inconclusive nature of the literature, indicating that furthe r research that centers the importance of social location in psychiatric hospitalization is essential. Additional Themes In addition to these themes addressing the initial research questions, the following additional themes emerged: Semi voluntary hospitalization as a dynamic spectrum. Participants demonstrated that psychiatric hospitalization cannot be viewed as dichotomous, with clear distinctions between voluntary and involuntary legal status. Rather, participants viewed hospitaliz ation as dynamic, as
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 23 voluntary admission had the potential to become in voluntary (Participant 4) In other words, if a voluntary patient requests to leave the hospit al, clinicians have the authority to change their status to involuntary if they deem that p atient to be dangerous, thereby preventing them from leaving the hospital Further, practitioner suggested voluntary psychiatric hospitalization took a number of forms. While some participants simply suggested hospitalization as a final treatment option w hen the client was unable to adhere to alternatives, other participants took additional steps to aid the process, such as offering to call the hospital on the patient's behalf (Participant 2) Sometimes practitioner suggested hospitalization took the form of "above and beyond" care, or extreme measures taken by therapists in order to ensure safety and security for their clients. Participant 3 described the case of a colleague who demonstrated feminis t therapy at its best and its most costl y for the practitioner" when working with a transgender client at high risk of suicide Because of th eir gender identity, the client's suicidal ideation was worsened by an intense fear of the medical system. However, the client was able to receive treatment when th eir therapist offered to accompany them to the ER, then cancelled her day, went to the psychiatric ER, sat with [the client] for 5 hours talked them through the process, [and] navigated gend er biases of the system with them," leading the client t o be admitted to a psychiatric hospital on a semi voluntary basis (Participant 3 ). Such situations, when practitioner suggested voluntary hospitalization takes the form of dedication to the client and determination to ensure safety, demonstrate that semi v oluntary hospitalization is nuanced and comp lex, and therefore cannot simply be labeled as coercive and ill intentioned without further examination. However, it is important to note that even when the practitioner has benign intentions, practitioner sugg ested voluntary hospitalization may still be interpreted by a client as coercive, potentially due to an unequal balance of power within the therapeutic relationship. For example,
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 24 Participant 4 details a situation in which a client decided to stop therapy b ecause the mere suggestion of hospitalization was interpreted as coercive, even though the therapist had all intentions of avoiding hospitalization and using other tr eatment methods. Hospitalization as trauma. In describing one of the primary reasons that feminist therapists tend to avoid psychiatric hospitalization, Participant 1 stated I do not feel comfortable, at all, that as a psychologist, I have the power of institutionalizing people. That feels that I could be perpet rating a trauma on someone else [by] really taking away their power to make decisions about their lives ." In other words, the lack of autonomy patients experience due to coercive measures such as restricted mobility and forced medication, as well as a lack of authorship caused by being told they must interpret their experiences through the lens of a mental "illness," can be distres sing to people who are hospitalized. Participant 4 discussed this lack of autonomy and authorship, not only as a mental health p ractitioner who has worked with many ex patients, but also as a "peer" having lived experience within the psychiatric hospitalization system. After a period of extreme distress due to trauma, they were diagnosed with severe mental illness and hospitalized in a manner th at violated their civil rights. Participant 4 internalized the idea that their experiences were caused by an inherent, incurable disease, leading them to question "who am I, a mental patient, to question all of these authorities and doctors a nd science?" ; lacking the ability to define their own experiences le d them to experience worsened distress Participant 4 indicated that these lived experiences now inform their therapy as they practice in a manner that focuses on the role that trauma, ad versity, and marginalization plays in human suffering. In addition to a deprivation of agency, patients may face a number of other traumatic factors, including exposure to law enforcement as patients who are hospitalized involuntarily
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 25 may be handcuffed a nd escorted by police. This is not only traumatic, particularly in a political climate in which significant tension exists between law enforcement and individuals with marginalized identities, but it also perpetuates stigma surrounding the supposed dangero usness of individuals with mental health problems. Further, many patients experience hospitalization as an overall dehumanizing environment. For example, Participant 2 discussed a client who was involuntarily hospitalized following a suicide attempt. The c lient described the hospital environment to be a "snake pit;" she was met by apathetic staff who only managed her symptoms through medication, rather than providing therapy and support. The patient stated that even the physical environment was distressing; the rooms were "dreary and gray" and the furniture was falling apart, serving as a physical manifestation of the lack of care that clinical staff held for patients (Participant 2). These viewpoints align with existing research of patients who felt coerced into mental health treatment, indicating that their treatment made them feel inferior or unworthy. Understanding the traumatic aspects of hospitalization indicate the importance of further investigating nonconsensual psychiatric interventions and their ef fects on patients. Hospital avoidance. Because inpatient treatment m ay be experienced as traumatic, psychiatric hospitalization oftentimes creates a situation in which individuals lie about their feelings and experiences in order to escape or avoid hospitalization and regain a sense of autonomy. In fact, Participant 3 described a patient who indicated they were okay in the therapi st's office, yet attempted suicide immediately after, leading to involuntary hospitalization. When the participant met t heir client in the hospital, the client said "I lied to you," indicating that her dishonesty stemmed from a fear of being involuntarily admitted (Participant 3). Participant 4 discussed hospital avoidance by linking it to the lack of authorship that stems from psychiatric hospitalizat ion, or the fact that patients are told they must interpret their experiences through the
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 26 lens of a mental "illness," even when underlying adversity or trauma has played a significant role in their suffering. In order to be released from t he hospital, they must comply with this worldview, leading them to stifle the feelings they are truly experiencing in order to regain autonomy. This is particularly detrimental when patients feel they must lie about the suicide risk they are facing, given that patients who have been hospitalized are at high risk of suicide immediately following their release from the hospital. Creating a situation in which patients must shut themselves down in order to avoid hospitalization may be detrimental to healing, calling into question the effectiveness and humanity of psychiatric hospitalization as a form of treatment (Participant 4) Discussion Participants' discussions of power align with existing literature indicating that coercive practices occur within psychiatric hospitalization. Furthermore, participants addressed ambiguities in the literature by demonstrating that while a minori ty identity does not inherently make one more susceptible to psychiatric hospitalization, the systematic oppression that individuals with marginalized identities experience may do so. Participants cited other factors unique to individuals with marginalized identities, such as distrust, a lack of affirmative resources, and a hostile hospital environment. These experiences indicate that further research on hospitalization should operate from an intersectional feminist perspective. While participants provided a wealth of knowledge, one limitation is that the small sample was not representative, as three of four participants were white, and all were cisgender and heterosexual. The lack of diversity within the sample was made particularly clear to me when intervi ewing Participant 1, who is of Latin American descent. When asked how their social identities impact their therapeutic practice, they described how the intersections of their privileged and marginalized
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 27 identities influenced their interactions with clients ; while their marginalized identities allowed them to empathize with others of minority status in race, gender, sexual orientation, etc., their privileged identities allowed them to "use the social power [they] have as a heterosexual person to speak out fo r injustices," (Participant 1). For example, Participant 1's office, which is decorated with various flags and representations of individuals of all races, classes, genders, and sexual orientations, served as a physical manifestation of the intersectionali ty that they infused in their therapy. While all four participants relied on feminist and social justice practices within their therapeutic practice, Participant 1 demonstrated a unique perspective as a person of color. In order for research to operate fro m a feminist standpoint, the voices of people with marginalized identities must be central; therefore, future research must be more inclusive in terms of race, gender ide ntity, sexual orientation, and other social identities. By discussing hospitalizatio n as trauma, participants demonstrated the central importance of this research. Practitioners indicated that many clients viewed hospitalization as a dehumanizing experience that hindered healing rather than fostering it. These discussions align with exist ing literature among psychiatric patients who perceived coercion, leading them to feel isolated and inferior. Because patients are at high suicide risk immediately following release, it is essential to explore the effects of non consensual psychiatric inte rventions. Further, because trauma and adversity play an immense role in human suffering and emotional distress, which may be diagnosed as mental illness, hospitalization as a traumatic event has the potential to worsen already existing traumas. For this r eason, mental health practitioners must implement trauma and recovery oriented therapy which "understands the depth of terror, rage, hopelessness, and powerlessness and the potential for escalation of suicide danger that can be evoked
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 28 within many distressed individuals by the threat of involuntary hospitalization and all that can go with it," (Probert, 2014). In addition, one of the most enlightening themes that emerged from this research project is that of "hospital avoidance," or the idea that p atients must repress their pain, suffering, and suicidal ideation in order to escape or avoid hospitalization. Hospital avoidance is epitomized in Judi Chamberlin's Confessions of a Non Compliant Patient, as she juxtaposes what it means to be a "good patie nt" and a "bad patient." A "bad patient" is one that seeks autonomy and empowerment, yet is met with coercive forces such as seclusion rooms or locked wards. A "good patient" is one that complies, that stifles negative emotions, that learns "to cry only at night, in [their] bed, under the covers without making a sound," (Chamberlin, 1998). In describing her experiences, Chamberlin states, I've been a good patient, and I've been a bad patient, and believe me, being a good patient helps to get you out of the hospital, but being a bad patient hel ps to get you back to real life," (1998). The "secret rebellion" she fueled within herself while in the hospital inspired her activism within the ex patient movement, promoting a message of recovery, empowerment, hope, and healing while encouraging patients to regain one's belief in themselves. Ultimately, the peer movement attempt s to give voice to individuals who have been assumed to be irrational to be out of their minds," (Chamberlin, 1990). While one participan t in this study identified as a peer, future iterations of this research should strive to further include individuals who have experienced coercive practices within psychiatric hospitalization in order to amplify voices that are often ignored.
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PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 33 Appendix Interview Questions Feminist Therapy 1. How long have you been a practicing therapist/counselor/psychologist? 2. How would you describe the theoretical orientation of your therapy? 3. How would you define feminist therapy? Do you identify with this definition? 4. How do you incorporate feminist practices into your therapy? 5. How would you describe the therapeutic relation ship that you maintain with clients (ex. egalitarian, authoritarian, etc.)? 6. How do you feel your social identities influence your practice as a feminist therapist? (ex. race, gender, etc.) Voluntary, Involuntary, and Practitioner Suggested Voluntary Hosp italization 1. Have you ever had a client who was involuntarily admitted into an inpatient psychiatric treatment? 2. If so, was this your treatment decision, or someone else's? For example, was it the decision of a psychiatrist or another practitioner? 3. What criteria do you use to determine whether or not someone should be involuntarily admitted into a psychiatric hospital? 4. Have you ever had a client who was voluntarily admitted to a psychiatric hospital? 5. If so, what role did you play in this treatment decision? 6. Have you ever suggested that a patient voluntarily admit themselves into inpatient treatment?
PRACTITIONER SUGGESTED VOLUNTARY PSYCHIATRIC HOSPITALIZATION 34 7. What criteria do you use to determine whether or not a client should voluntarily admit themselves into a psychiatric hospital? 8. What are your professi onal opinions regarding involuntary or practitioner suggested voluntary psychiatric hospitalization? 9. Do you believe that power dynamics in the therapeutic relationship affect the experience of psychiatric hospitalization? Why or why not? 10. In your experienc e, are particular individuals more likely to be involuntarily admitted into a psychiatric hospital? For example, do you believe that individuals of a particular race or gender identity are more likely to be involuntarily admitted? 11. In your experience, are there some individuals that are more likely to be encouraged to enter psychiatric hospitals voluntary? For example, do you believe that individuals of a particular race or gender identity are more likely to experience this? 12. Do you believe that particular communities are more susceptible to involuntary or practitioner suggested voluntary psychiatric hospitalization? Why or why not?