Open Excellence Podcast host Rudy Caseres explores alternatives to coercion and forced psychiatric treatment for youth and how families can best support their children in distress.
Rudy: Today we are talking about alternatives to coercion when supporting family members in distress. I think this is a great supplement to our last episode on what forced treatment is like. Personally, I’ve never wanted my family to be involved in making healthcare decisions on my behalf. And I certainly never wanted to be coerced into treatment, but I am just one person. Now to be clear, there are many parents and guardians who truly want to support their loved ones when they are at their most distressed, but the resources on how to do so in a way that honors personal agency and liberty are not always easily available.
Furthermore, there are plenty of resources and organizations that actually recommend coercion and forced treatment as a solution, which is not good at all and can ultimately prove harmful for the person needing support. So for this episode, I made it my mission to research alternatives that can actually make a positive difference. I will be interviewing two advocates, Mark Henick and Sheryl Boswell, who provide their own input on bettering our current system.
Sheryl: I’m Sheryl Boswell. I’m the executive director of youth mental health Canada. I’m an educator I’ve taught elementary, secondary post-secondary and adult education, and I’m a suicide loss survivor, and I’m a child and youth mental health expert with years of experience.
Rudy: I’ve known Sheryl for several years and I can definitely trust what she has to say on youth mental health. Our talk together lasted two hours so it was incredibly tough to edit it down, for the sake of brevity. But here we go.
Now, have you had experiences where you were dealing with a youth who was under great distress, where it resulted in that person being involuntary hospitalized?
Sheryl: I’ve worked with hundreds of youth and heard stories of this experience where the police came and people being admitted to a psychiatric ward and experiencing horrendous conditions. There is that kind of lack of response, lack of support, lack of understanding, or this sort of extreme response of forcing hospitalization and the consequences for that are tremendous. Informed people know that coercion doesn’t work and that it’s gonna damage the relationship in the family.
Mark: My name is Mark Henick. I’m a mental health advocate, strategist, author. My new book will be coming out this January about my personal lived experience, recovering from mental illness and ideally, helping other people to do that too.
Rudy: Mark is a little shy, but he forgot to mention that he’s a really big deal in Canada and has been featured in various TV news outlets and print publications. His TED Talk, “Why We Choose Suicide,” has been viewed nearly 7 million times on YouTube. So when he speaks up about mental health, youth or otherwise, people tend to listen.
Mark: I think it’s important to consider the mental health of family caregivers of loved ones. The struggles of family members are hard on everybody. I think family members want to help, in some cases, especially where suicide might be of a concern, for example, as it often is in these kinds of cases of involuntary admission. Family members obviously don’t want to see that happen. That’s the worst possible outcome.
So their motivation then to get that person help sometimes overrides that person’s rights or at least their consideration of that person’s rights. I think part of the unconscious reasoning or sometimes even the conscious reasoning is they might not like me. It might be taking away their rights, but at least it’ll be keeping them alive.
Now, unfortunately, of course, there are some problems with that, that in my own personal experience and in the experience of people that I’ve worked with, not many people really recover at least fully anyway in hospital. Maybe it’ll keep them safe for a short period of time, but it doesn’t really seem to be the key that family members often think that it is.
I can say with a fair amount of personal authority, I don’t know how much external authority I have, but I do have a considerable amount of authority over my own story and over my own experiences, and what I can say is that. Over the more than half dozen times that I was involuntarily hospitalized, it didn’t help.
And I don’t think that my personal struggle would have been either as difficult or as prolonged had there been non-hospital based interventions that were accessible to me earlier on. So that’s why I’m passionate about this issue. I think while as a clinician, I see the necessity of it. And in some small limited cases, there is a necessity for hospitalization.
In the vast majority of cases, we need to be moving intervention much further upstream. Not only for human rights cases, I should say. I don’t even approach this from that perspective necessarily but rather that it doesn’t work. The research shows that, sure, somebody might want to involuntarily hospitalize somebody in hopes of getting them better. It doesn’t get them better. The evidence doesn’t support that. So why don’t we do evidence based practice that actually does help get people better, especially earlier on?
Rudy: So if coercion doesn’t work why is it often the first thing that families resort to when their son or daughter are experiencing a mental health crisis? According to a BMC Health Services Research study, a worse relationship between patient and parent significantly predicted higher experience of coercion.
28% of the total sample of patients reported a lack of confidence and trust both in parents and staff. One could easily surmise a link between the two. And although coercion and youth mental health care is fairly common there is actually very little research done on the subject, much less the efficacy of it. And to be clear, coercion can include such practices as chemical inducements, interpersonal leverage, show of force, including restraints, threats, and unnecessarily strict house rules.
Furthermore adolescents are usually materially, financially, and emotionally dependent on parents or guardians so that control and pressure may relate to care, trust, and family loyalty. There is also a risk that some adolescent patients lack or lose trust in parents and staff during hospitalization and consequently feel isolated in the ward. In the BMJ article I cited a minute ago.
It says that coercion is often accompanied or followed by feeling rejected, aggrieved, punished. This empowered or terrified some prospective studies have connected, experienced coercion to lower quality of life and worse alliance and follow up care. The study concludes: given frequent use of formal coercion the potential for informal pressure or coercion and the vulnerable adolescent years experienced caution in adolescents should be an important research topic.
And yet it isn’t. And in fact, the little research we have shows that it is ineffective at best. And extremely harmful at its worse. Keep in mind that the justification for coercion by mental health clinicians and parents is that it is for the patient/child’s own good in the pursuit of improving that person’s mental health and even saving their lives. But I definitely don’t want to make it sound like I am laying all the blame on the families because oftentimes they feel coerced themselves to well… well… use coercion.
Sheryl: There’s a lot of legal issues and ethics around coercion. So if you’re concerned about the individual harm, the individual’s going to cause harm to themselves or potentially to other people then society feels that they have a right to take away the rights of, of an individual with mental illness. But around youth this issue of forced treatment, it’s often not talked about. So, the fact that all those kinds of issues under 18, where the parent can, might be pressured to take action that is forcing or involved in coercion of some kind of treatment.
We don’t look at the rights of young people because they’re under parental rights and supervision. And this is seen as the role of the parents that they should be doing this. The systems are putting pressure on parents to respond this way and a child just who has intense anxiety phobia about getting to school and feeling very socially anxious because they’ve missed school and because their peers are talking about them and being forced by their parents into the school. It’s just deepening the level of trauma and that way of responding and reactions that happen.
Rudy: So you see, it is just a bad situation all around, but what are some tips for parents to avoid ever having to get to a place where coercion is seen as an option? And also what can school teachers who have a great influence over youth that often goes underappreciated do to offer support as well?
Sheryl: If you focus on what motivates a young person, so one is going to motivate a young person to get out of bed. What is going to motivate them to get out of their house to get into a school building when they have intense anxiety? Why don’t you look at what motivates people? What is their passion? What are their interests? Who are they? What works for them?
There’s two international best practice stories. One from Canada, one from the U S. And in both instances, the young person knew exactly what their motivators were, knew, what they loved doing, knew what their passions were and both knew what kind of schooling would work for them. And it did. It got them out of their mental health crisis and their history of non-attendance at school and back into school. And unfortunately in Canada, the systems did not recognize the needs of the student, but in the United States, they did. So real different responses to the same kind of situation.
And I think that’s where very clearly that there are models that could work and not looking beyond what we already have, because it’s the only way and because this is the funding and whatever, and looking at well, how do we best serve individuals? It’s not a one size fits all, not all the schooling, the type of the educational model that we have, it doesn’t work for all people. And if it doesn’t work for all people, that means we’re not supporting the human rights of all young people. And under the United nations and under human rights and disability legislation, it says that all students have human rights have the right to an education. Well, if they do, why don’t we do something about it to support students?
It seems basic to me to go beyond status quo, that’s clearly not working and really looking at other kinds of support options. These kinds of short term support options could be respite centers that are really positive, short term kinds of taking a break from just dealing with all the pressures of life, looking at community based models, looking at greater peer support or looking at creating, you know, that you’re not just a teacher, your role is not just a teacher providing content, but your role in a school system for example, is to be a champion and to be an advocate for all the students. And there’s some students who need a lot more support than others recognize that and do something about it.
Rudy: Mark Henick, speaking from his past experience as a youth and as a father right now, offers his own feedback.
Mark: All the time it happens where a parent will come to me and ask how they can get their kid help. And I almost always talk to them about developing their relationship with their child in a better way. And that’s often difficult because parents don’t want to accept or don’t even see that there might be problems in their relationship.
But what I can say, and I still remember this very keenly being a kid who was struggling and feeling like everybody only talked to me when they wanted to fix me. Like I was a broken down car on the side of the road and that included my parents. The only thing we ever talked about were my problems.
I wanted to talk about the things that I was passionate about, the things that I was interested in. The stuff that I found funny, cause you can still find stuff funny when you’re depressed, it turns out. But I felt like I had become an object that I had been objectified and then it was just a project for people to figure out what was wrong with Mark. And the problem with that approach of course, was that it didn’t help to figure out what was actually wrong with me, because it was so dehumanizing and so objectifying in so many ways that just embedded my issues further.
So when parents talk to me about that, I ask them about the nature of their relationship with their kids and it’s often difficult or acrimonious. And part of that is just, especially if the kid’s a teenager it is normal but then I ask them how long often they tell their kid, they love them, how often they do things that are not related to their illness, just for relationship building, just for connection building?
Sometimes parents feel that their kid is just seeking attention. That they’re just doing these things for whether it’s threatening suicide or self-harming that they’re just doing it for attention. And I always correct that, “No, that that kid has a need for connection that is not being fulfilled in some way.” And that’s not a parent’s fault.
I think we walk on eggshells around parents all the time because we don’t want to insult them or make them feel badly about their parenting. This has nothing to do with their parenting per se, in the majority of cases. But also, we as parents need to recognize, maybe we can do better. Maybe we can actually learn how to be better parents than our parents were very often.
Andrew Solomon writes about this. We parent vertically, we just pass down our values from the top, from our parents and down into our kids on the bottom. I think we can do better than that. We can learn from the past. We can pay attention. We can parent more mindfully. Pay attention to what’s working and what’s not. And if we have deficits in our parenting, if we have gaps, we can learn new skills to deal with that. Namely teaching our kids how to name and label their emotions early on, and then giving them skills to manage those emotions.
The reason why most parents don’t do this, and I can say this honestly as a parent of three myself now, because we don’t know either. And we don’t want to hold ourselves out to our kids as somebody who doesn’t know something, that’s one of the scariest things in the world, I think. But we need to be more humble with our kids. We need to be able to recognize where, you know, “Hey, maybe I just don’t have the skills to deal with this right now, but I can learn.”
That’s what a good mindful parent, an open-minded parent I think does. So I always had as parents to keep an open mind, to keep a learner’s mindset or a beginner’s mindset. That maybe they’ve never done this before. Maybe they haven’t dealt with a kid with a mental illness like this before, and that’s okay. It’s a hard thing to deal with. But fortunately there are skills that you can learn. There are people you can talk to. And I think that it’s key that parents have support in this as well. That it’s taxing, it’s draining on parent’s mental health to deal with the kid’s emotional needs to deal with anybody’s emotional needs. So parents need to take care of themselves as well.
Rudy: So we talked about youth, from when they are children all the way through high school age, but what about when they turn 18? Oftentimes, when someone is considered to be “gravely disabled” the parents can still have control over their son or daughter, even if that now adult wants to live independently. And with the use of legal conservatorships that person may have very little rights at all.
When someone turns 18, they become an adult of course, and that gives them legal rights. I hear from parents saying that if someone is quote unquote gravely disabled, with their mental illness, that they should be allowed to have conservatorship over their loved one, their son, their daughter indefinitely. Do you agree with that or not?
Sheryl: I’m quite familiar with the people who are advocating for that. I think it’s a real challenge for a parent seeing your child suffer whatever age they are. That goes without saying. The challenge is that systems after 18, the parent doesn’t have a right to be involved. Beyond that it is a real challenge what the parent’s involvement is.
I just think that we need to recognize societal responsibility for we’re taking care of each other so that you don’t make a line about , “Oh, you’re the parent and this is an adult and we can’t give you information.” So, getting to points where you have an adult child and forcing treatment that’s something very different. I’ve never experienced something like schizophrenia or psychotic kind of behavior where you’re really concerned about the health and life of your child. I’m not going to make any judgements because I just think it’s a hard place to be and having real concern for your child and trying to do the best it needs to involve people working together to support and some kind of support team is needed.
So, I just think our responses in every aspect of mental health lack compassion, lack involvement of people with lived experience. And so rather than getting to a point where, “Oh, some parents are advocating that they have the right to force treatment.” I don’t want to go to that extreme. I would say all parents want compassionate responses to their child, whatever age they are. That would be my focus is like a lot needs to change.
Rudy: What say you, Mark Henick?
Mark: As long as an individual is of the age of majority. And as long as professionally speaking, they meet the criteria of being able to make decisions on their own it doesn’t matter what anybody else thinks. This issue around kids reaching the age of majority and then becoming adults and then even well into adulthood, having parents in particular who want to maintain control over their lives, it’s most obvious when they turn 21 or 18 or 16 or whatever the age is and the jurisdiction for privacy in particular, where a kid will speak to a doctor and then the parent wants to know what they said to the doctor.
But they’re not a kid anymore because they passed the age of majority. This is entirely I think a problem of parents that they need to learn to let go. And this has been an age old conversation the parents have have been having, I think, as long as parents have been having kids, they’ve been needing to learn how to let go at some point. And that’s incredibly difficult to do, especially with a kid who has high needs and who may be not functioning as well as that parent wants them to function. The reality, however, is though that when they reach the age of majority, they have their own rights.
They are their own person under the law. And that means that they are their own person and allowed to make their own mistakes. They’re allowed to suffer. And that is the worst possible thing, I think, for a parent to think. But we can’t inject recovery into people. We can’t do recovery for them.
We can support them the best that we can and parents need to continue to support their adult children throughout their difficulties. But if that child, who is no longer a child anymore, if that adult, is going to refuse to take their medication, if they’re not going to shower for days on end, if they’re not going to feed themselves properly, as long as they’re not a danger to themselves or others in a real, tangible way, and I think parents always find ways of framing that creatively to show that they are a danger, but as long as their objectively not a danger to anyone else, even if their quality of life isn’t great and even if everybody around them sees that their quality of life isn’t great, there’s nothing that that parent can do about it.
So what then needs to happen is that that parent needs to be able to do some appropriate self care in terms of accepting that that they can help as much as they can and they can offer all the help and all the support and all the love in the world, but they also need to grieve to a certain extent their loss of control over their child’s life. And that, in fact, they might be powerless in those circumstances beyond reasonable limits.
And that’s where I think a qualified mental health professional can help that parent to deal with that really difficult realization that there might be nothing they can do here. That they may have reached their boundary of the boundary between them and their child’s rights. And they might need some support in working through that. So that’s an area where parents need a considerable amount of support in letting their children be their own person but also continue to offer warm, loving support whenever and wherever that adult child might need it.
Rudy: So we’ve covered what is wrong with our current systems of so-called care. But what can we do about the near future? What realistically, can we hope for and advocate to change for the better?
Sheryl: I just feel like, gosh, I mean, in Canada we don’t have a lived experience movement, so, as people say, we don’t have a seat at the table, we’re not actively involved. That really works against young people in their families. And you know, nobody shares anything. No one ever works together. There’s no coordinated effort. And that kind of mean spiritedness happens.
What I would like to see is that we all start to challenge what we have and have a greater strength and confidence to say, “we expect better. We expect more. We expect integrity. We expect humility. We expect our voices to be heard. We expect lived experience to be the leaders in everything that we do. We don’t want these token, oh, we need a youth advisory group because we look like we, you know…
So all of our approaches need to be questioned. A lot of people don’t like questioning what we have and think that’s somehow complaining or critical when we should be happy for what we have. And I say, no, I want to go beyond begging, beyond acceptance. And I want to get into something that shakes things up and says, okay we will do what is necessary to show that we value young people and we are going to create education, support teams that really, you know, like people working together and with respect and consideration and compassion and, it all sounds great, but it’s so challenging.
It would make a huge difference if we started to listen to young people. What do you need? What optimally would make a difference for you supporting you to access an education, to get back on track, to get back into healthy functioning? And we don’t ask those questions and that’s just wrong. It’s wrong.
The systems should be transparent. All these organizations say, reach out, reach out for what? Where? Who? When? What do they do? What’s the difference? What’s the difference between a social worker and a psychologist or a child and youth worker or an attendance counselor? Nobody knows. So we’re doing such a disservice to young people when we don’t even really look at what we’re doing and how we’re doing it. Can we do better?
And of course we can do better and we need to do better because right now we’re not really doing a great job of providing quality care, quality respect and compassion for people and a lot needs to change. And I think the extreme of it forced or coerced treatment models, they don’t work. You don’t put people who are not well in together and then say, “well, you know, um, you’re here for one week or two weeks. Okay. Now you have to go back and there’s no followup.” I mean, what kind of coordinated response is that? So I just think we could look at really healthy responses that don’t criminalize, don’t penalize, don’t punish. But that we respond in much, much more compassionate ways.
Rudy: Any other final thoughts before we wrap up?
Sheryl: Wind me up. (laughs) No, no. I just feel really passionate about all of this. There’s a lot to say about this and we need to say it a lot more in society.
Mark: Well I think it’s important to always to remember not to write anybody off regardless of how old they are and or how long they’ve been struggling with a mental health problem or illness. The reality is that according to all of the data, recovery is not only possible from even severe and persistent mental health problems and illnesses, but recovery is expected. Recovery is likely when people get the help that they need.
The problem is that people aren’t getting the help that they need and that’s partly because we don’t always know what kind of help that they need. Therefore I think we need to focus our efforts on reforming the mental health care system. Or actually I should say rebuilding the mental health care system. It’s not fair to say that the mental health care system is broken because it was never built right to begin with.
So we need to dedicate our passionate advocacy efforts toward restructuring, rebuilding a system that actually helps to intervene early before we find ourselves in these tragedies where people seem to be unhelpable. Though, even in those cases, I would encourage everybody to approach every person they meet who might be struggling with the idea that this person too not only is capable of but deserves a good life. They deserve to recover. And I think that that’s true for every single person who lives with a mental health problem or illness of any degree.
Rudy: That’s gonna do it for this week. I hope you all learned just a little bit more about alternatives to coercion in the youth mental health care system as well as just being a more compassionate human being. Special thanks to my guests, Mark Henick and Sheryl Boswell. I’ll leave some links in the show notes so you can support their work.
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