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Annual Conference

SF14 Session 2: Harbouring Doubts: Creating safe spaces to sit with uncertainty

By February 20, 2014 No Comments

Cath Roper gave a thought provoking presentation regarding the trauma associated with involuntary care through mental health legislation. Cath is consumer academic at the Centre for Psychiatric Nursing, University of Melbourne. She held one of the first consumer consultation positions in Melbourne from 1995-1999 before she became the first to occupy a consumer academic role in the Melbourne research centre. Cath experienced trauma through annual involuntary admissions to hospital over a 30 year period and has dedicated life to thinking about this topic, and how a community has settled with separate legislation for people with mental health issues that supports involuntary treatment. In particular, she is interested in working with staff on practices that support self-determination of people subject to mental health orders, and reducing restrictive practices. 

Cath began her presentation by explaining that she was using a different and somewhat provocative lens on the issue of trauma and safety. She explained her belief that mental health legislation is itself a form of structural violence and that there are both negative ethical and ‘real world’ consequences that affect both patients and providers. She argued that ‘safe spaces’ are needed in order to count these consequences, do the work of ‘regretting’, and find an ethic that shows respect for all persons. This structural violence involves a number of factors including discrimination, the ‘hidden category’ of people who are under mental health legislation and creating non-autonomous beings by deciding that a person is incompetent and unable to make their own decisions. These are not trivial issues and it is critical that spaces be created to pay attention to them. 

Cath continued to argue that the creation of the non-autonomous patient is ethically perilous. A decision is made that a person is at risk of not accepting treatment and a psychiatrist begins to act on their behalf using a medically driven standard that does not always take personal preferences into account. The patient is unable to refuse these decisions and there are no clear steps around how to get personal autonomy back. This is very concerning from an ethical perspective, particularly where in many cases involuntary treatment is lifelong. 

A range of critical factors associated with respect for personhood were identified including citizenship, dignity, human rights, bodily integrity, empowerment, self-determination, choice and voice. However, these are the very things that mental health legislation interferes with and are real life, felt and embodied costs and losses that deserve consideration. Consequences of real world violence includes the loss of freedom of movement, erosion of personal responsibility, bodily integrity being violated, difficulty securing one’s own treatment preferences, and acceptance of treatment being given violently. Further, if you are saying that a person doesn’t have competence, there is a danger of de-humanisation. 

Cath argues that these negative consequences aren’t often visible to us. Often, the standard coneptualisation of involuntary treatment is that ‘the ends justify the means’. That is, a person at risk combined with a duty of care and the ‘best interests’ of the person in mind justifies the short term action taken. However, while the intention might be to keep a person safe or protect their reputation, this action also costs a person their autonomy. 

Cath provided an analogy of ethical tensions associated with mental health legislation by asking a question on whether the ends justify the means: Is it right for the officer to torture the terrorist in order to find the location of a bomb endangering hundreds of innocent lives? (Walzer’s 1973 example in Stocker 1990). This is a ‘dirty hands’ situation where whichever way you act, there is a wrong that occurs which has an ethical cost. According to this idea, while both courses of action can be ethically justified, dirty aspects of either act stain both the act itself, and the actor. Thus the dis-value doesn’t just disappear and must be counted. Mental health legislation also creates a dirty hands situation where a patient’s “autonomy and selfhood” is violated, and therefore is a great moral moment and a cause for regret. While the legislation permits these circumstances for the benefit of the person, the point remains that the ‘benefit’ does not remove the moral need to also count and regret the violation. So, Cath argues, we should not move to a justification before we stop to count the costs.

Cath argued that currently while there is a ‘double wrong’ occurring it is not often viewed this way and most providers would find it difficult to identify ethical problems associated with their actions because interfering with autonomy is seen as necessary. So what does this mean for providers? Cath argues that working under mental health legislation places a provider in a dirty hands situation which sets up immoral circumstances which forces clinicians to act in (unethical?) ways – they are stained and must engage in morally compromising acts. Therefore there is moral work to do: those working under the mental health legislation might regard their treatment and decisions as morally justifiable, but also must attend to, count and regret the moral wrongs engendered by their acts. 

Cath suggests that currently there are few spaces in clinical work for these issues to be worked through. Ways forward include creating spaces for sitting with uncertainty; counting and regretting the costs to personhood when involuntary treatment is necessary; negotiating consent and seeking to preserve bodily integrity; agonising, trepidation, transparency around decision making; awareness of what is ethically at stake for people and being dedicated to demonstrating respect for persons. Finally, a way needs to be found to provide a path back to autonomy for scheduled persons. 

The presentation concluded with a question for consideration: “How do I demonstrate respect for this person at this time”?