Of unhoused minds and the ‘personality disorder’ fallacy

“So Koestler condemned himself to homelessness. All that remained were the ideas he dragged around with him like Job…Home finally was mind; home was homelessness; Koestler was the homeless mind.” David Cesarani, Arthur Koestler: The Homeless Mind (1998)

“The sufferer who frustrates a keen therapist by failing to improve is always in danger of meeting primitive human behaviour disguised as treatment” (Tom Main, 1957, ‘The Ailment’)

Recently, Barrelman gave a talk at the launch party of a book, in which he and a fellow Cynic have a chapter published. The book’s called Psychoanalytic Thinking on the Unhoused Mind. It’s put together by another comrade of ours – and a very fine volume it is too (this is the weblink if you’re interested).

Now, I get why the various chapters were collected under the rubric of ‘psychoanalytic’ and when I myself started off down this trail I admit that I hadn’t yet quite got over a lingering infection of Kleinitis that very briefly even threatened to develop into the rabid form of that ailment… However, as that other wandering Cynic once sang, ‘I’m younger than that now’ – and I find myself altogether more in the ‘psychosocial activism’ line these days.

Coming back to the main current of the whole ‘homelessness and ‘unhoused minds” project got me thinking about Cesarani’s famous rhetorical ending to his biography of Arthur Koestler – and also about another great twentieth century Central European Jewish author in the high literary tradition… Franz Kafka’s The Castle, as many of you may know, tells the story of K, whose profession ironically is that of land surveyor. K gets himself a gig in the eponymous castle – but no-one seems to know anything about it and he can never find the tradesmen’s entrance, nor can he find acceptance in the nearby village; and yet neither can he cannot go home.

As the following excerpt begins, K has been lying in wait, in the snow, in the yard outside the village Inn, to accost a fellow named Klamm: suspected to be a Castle official who could unravel K’s Gordian knot of longing, bewilderment and annihilation. K’s plan is derailed by a shaming encounter with a mysterious young gentleman (and accompanying flunkey) who orders him to move along and advises K that whether he waits or leaves, he will miss Klamm just the same…

“Then I’d rather miss him waiting’, K. said defiantly… K saw himself being left behind alone…both of them going very slowly, though, as if wishing to show K that it was still in his power to fetch them back.

Maybe he had that power, but it could have done him no good; fetching the sledge back meant banishing himself. So he stayed where he was, the only one standing his ground, but it was a victory that brought no joy…it seemed to K then as if all contact with him had been severed and he was now freer than ever before, no question about it, and might wait in this otherwise forbidden place for as long as he liked and had fought for and won this freedom as few others could have done and none might touch or banish him, barely even address him, but – this conviction was at least equally strong – as if at the same time there was nothing more futile, nothing more desperate than this freedom, this waiting, this invulnerability.”

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My ancient ancestor, that homeless, wandering, Cynical-with-a-capital-‘C’, manic street preacher of ancient times, Diogenes the Dog, was once found, (down on his dodgy knees) begging before a statue. The townspeople asked him what he was up to (for this is their more or less bemused role in all such stories: they are the Chorus). ‘Oi! Diogenes!’ they cried. ‘What on earth are you doing down there? You’re not going to get very far with that statue, now, are you?’ Diogenes replied: ‘Can’t you see? I’m practising disappointment’.

Now, for K, permanently displaced and snowbound, outwith the Castle walls, disappointment in the ordinary sense is a practice in which he will become very well versed. He can’t come in from the cold, in any direction. The more hopefully he travels, the more disappointedly he doesn’t arrive. But what I especially appreciate about the story is the hint of possession and constancy about K as he makes his stand and stakes out his resistance. It’s the only place he can stand – and in a moment of autonomy and self-possession, he comes to a realisation about this, however fleetingly. He could be understood as refusing the ride he is ambiguously and ambivalently offered by the mysterious stranger…the stranger certainly experiences him as having chosen not to take up the offer…but it now seems to me that, for K, it’s not a question of refusal. It’s more that the ride just does not compute. It’s a wagon he can’t imagine jumping onto.

When we started riffing off of the story of Diogenes and Alexander, we constructed Diogenes as refusing Alexander’s offer of accommodation, in an expression of what Zizek called Bartlebian politics – ‘I prefer not to’. According to this way of seeing things, K is saying: ‘I prefer not to catch a ride on any sledge commanded by you, Mister’. He ‘prefers not to’ cede any power or to banish himself – or to draw upon the example of Antigone, whose position in relation to Creon, the tyrant of Thebes, is very similar: ‘I decline to recognise your secular, public authority in any domain that pertains to my private and personal values and allegiances…’.

I celebrate anyone who can take and articulate such a stand but I now think that this reading is not quite right – that K’s resistance is more important than his refusal. I think where K takes his stand and stands his ground (K and Diogenes and Antigone and Bartleby and, say, Greta Thunberg) is in the only place he can stand. He resists the force that would drag him away from his moment of autonomy into what would in essence be someone else’s idea of how his narrative should read. The ‘Bartlebian’ moment is then the realisation of this – not the practice itself, but the reflexive consciousness of the power of the practice. Nobody can twist his arm into banishing himself.

The idea of ‘refusal’ remains significant – but its significance lies in the experience of the offerer, when he feels that the offer of accommodation is refused. It feels like refusal to the offerer, when his offer is not accepted. But the object of the offer may or may not have refused it. We know only this much: that the offer has not been taken up – at least, not on the terms in which it was made. The object of the offer isn’t ‘failing to improve’: it’s more like they’re resisting ‘improvement’.

One of the things that got me thinking about this was being part of a treatment team, being party to an offer that was constructed as having been refused. This was on an inpatient ward where the ‘objects’ of the offer were malnourished or starving people (mis?)constructed as or (mis?)understood to be suffering from ‘eating disorders’.

An entry would go on the progress notes: ‘food was refused’. Such was certainly the experience of the offerer – the nursing staff, for example, who have walked down the corridor with a tray in their hands and set it down beside the ‘patient’ – and then found themselves walking back down the corridor again, still carrying on their tray the untouched plates of food.

But I began to understand – and in fact, the ‘patients’ very patiently took my education in hand, in this regard – I began to understand that sometimes the sufferer, out of sheer terror, or bewildered and bewildering and circular rumination, hadn’t been able to come to a decision. The offer just did not compute. Like K in the snow, they had been able neither to move towards the offer or away from it. They had simply stood the only ground they knew how to stand upon in that moment. The offer – the offerer, even – had been resisted. It had not necessarily been refused.

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I think it does also behove us to resist. By ‘us’ I generally mean everyone, when it comes to pernicious discourses of any kind, but I particularly mean, for present purposes, those of ‘us’ who do the offering in such settings (or the writing about the offering). It may be, that as our practice develops, we may risk losing our compass – fluidity is our friend and rigidity our enemy, but fluidity is not the same as going with the flow.

For my part, as I get older (and older – or, remembering Bob Dylan again, do I mean younger?), I realise there’s stuff going round that I just can’t be doing with any longer. I don’t think that I mean this in self-deluded ‘heroic’ identification with some Wilsonian constructed outsider; but rather because it simply won’t wash and I decline to be aligned with it any longer. The lies and venality of our political classes, to give a pressing example: but the list is long, and I’m not here to have a rant. However, the one I particularly wanted to end by mentioning, by way of publicly correcting the record, is the deployment and weaponisation, within the system of care, of the contested diagnosis – the fallacious concept – of ‘personality disorder’.

Now the record needs correcting, because although those early papers were written in ‘critical’ mode, nonetheless, I’m sorry to say, the reader would possibly have come away imagining that there really was such a thing as ‘personality disorder’ and that all it needed was a spot of reframing. But it needs to be said very clearly that it just will no longer do to be telling people that the problem with ‘them’ is that ‘their’ personality is ‘disordered’, and that the remedy for this is a little more of that much-evoked and apocryphally ‘containing’ secular deity, Laura Norder. There is, in particular, and by logical extension, no such thing – no such illness entity – as ‘borderline personality disorder’. Note carefully that it therefore can’t be meaningfully researched, such as to test possible treatments for said non-existent ailment.

This is a blog and not a book (note to self: must write a book some time!) and so I can’t give you the whole lowdown as to why in the not so distant future the whole concept of personality disorder will only be found lurking in dusty box files in mildewed archives tagged ‘pseudo-scientific colonialist claptrap of the Industrial Age’. But a little history goes a very long way…

So next time someone uses the term ‘personality disorder’ about someone else, recall, if you will, Prichard’s 1835 definition of ‘moral insanity’, in which a diagnostic entity is inferred from a judgement on presenting behaviour and ‘the individual is found to be incapable…of conducting himself with decency and propriety in the business of life’ (this was before the present Conservative government was even a twinkle in the eye); and recollect that the formulation of ‘moral insanity’ was the medical ticket into expert witness status in the criminal justice system as psychiatry emerged as a distinct profession at the beginning of the nineteenth century (here I am greatly indebted to another fellow psychosocialist, David Jones, for illuminating some of this in his own comprehensive history of the development and deployment of the term…).. Remember the 1938 pronouncement of the psychoanalyst Adoph Stern that ‘it is well known that a large group of patients fit frankly neither into the psychotic nor into the psychoneurotic group, and that this border line group of patients is extremely difficult to handle effectively by any psychotherapeutic method’ – for this is the moment when the term ‘borderline’ came into the frame.

Fast forward then to 1980, amidst the tsunami surge of the neoliberal turn, when suddenly there was no such thing as society, the jobless we created were either ‘feckless’ or ‘on their bikes’ and only ‘hard-working families’ were beneficiaries of government policy: and the American Psychiatric Association published DSM-III with the caveat and proviso that its system was so imprecise that it should never be used for forensic or insurance purposes (and then fast forward to the sales figures for DSM-III, which very quickly persuaded those august gentleman of the APA that there might be mileage in more classifications and more disorders).

Pinch yourself on the cheek, therefore, next time you hear the term ‘borderline personality disorder’ and remember that it’s not yet forty years old and has been more or less discredited for at least half the duration of its (non-)existence. Remember Main’s warning about the risk of ‘primitive human behaviour’ being disguised as treatment. And ask yourself if this might not be a Bartlebian moment after all.

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I’ve stopped going along with the whole ‘there is such a thing’ discourse (as far as I can: I’m sure I can still be called out on this) and I’ve started actively resisting it. It’s kind of a liberating feeling (and I sincerely hope that it’s not only me that gets liberated, of course). You know how the way to negotiate the perilous web of a supermarket is consciously blinking, so that you don’t get stoned on the sounds, scents and settings spun by the marketing spiders as they pre-plot your purchases for you? It’s the same with all that stuff about borderline personality disorder. Once you start to resist, you’ll start to wonder how you ever got taken in. If there’s a single discursive practice we can pick out and say, well, no offence to Diogenes, but that old Dog has surely had its day, it’s what Edward Said in Orientalism called ‘othering’: by which he meant ‘disregarding, essentialising, denuding the humanity of another culture, people or geographical region’.

To which I would add the prefix: ‘toxic’.

Toxic othering: there’s much too much of it about. It’s like air pollution: you get so used to it, you don’t even know you’re dying. The only remedy is a zero emissions policy. When it comes to the homeless, the displaced, the dispossessed, let this new book, and maybe in some small way also this blog, be some part of the process, not so much of psychoanalytic reformulation, but of a psychosocietal process of resistance and realisation – I hope that a range of emergent practices may coalesce and cohere and crystallise (but not solidify) around it, as did K’s awareness in the snow – let’s all, indeed and after all, prefer not to go along with it a moment longer.

Janeway’s dilemma: coercive treatment and human rights in ‘eating disorders’ inpatient units

In 2017 the UN Human Rights Council published the “Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”. The secretariat prefaces the report by observing the Rapporteur’s call “for a shift in the paradigm, based on the recurrence of human rights violations in mental health settings, all too often affecting persons with intellectual, cognitive and psychosocial disabilities” (p.1).

The report goes on to say that “Informed consent is a core element of the right to health, both as a freedom and an integral safeguard to its enjoyment” (p.14). The right to consent to treatment includes the right to refuse treatment but “the proliferation of paternalistic mental health legislation and lack of alternatives has made medical coercion commonplace” (p.14). Justifications for using coercion based on risk and dangerousness and medical necessity are subjective and “exclusive to psychiatrists, who work in systems that lack the clinical tools to try non-coercive options” (p.14).

The report continues:

“Coercion in psychiatry perpetuates power imbalances in care relationships, causes mistrust, exacerbates stigma and discrimination and has made many turn away, fearful of seeking help within mainstream mental health services. Considering that the right to health is now understood within the framework of the Convention on the Rights of Persons with Disabilities [CRPD], immediate action is required to radically reduce medical coercion and facilitate the move towards an end to all forced psychiatric treatment and confinement. In that connection, States must not permit substitute decision-makers to provide consent on behalf of persons with disabilities on decisions that concern their physical or mental integrity; instead, support should be provided at all times for them to make decisions, including in emergency and crisis situations.” (p.15)

The report acknowledges the radical nature of these proposals and the concerns of stakeholders including medical practitioners and proceeds nonetheless to invite States to move towards an “absolute ban on all forms of non-consensual measures … Instead of using legal or ethical arguments to justify the status quo, concerted efforts are needed to abandon it. Failure to take immediate measures towards such a change is no longer acceptable” (p.15)

The implications of this report have been seized upon by service user and survivor groups (see for example Point 7 of the Executive Summary of the Kindred Minds BME Manifesto at https://www.nsun.org.uk/news/bme-mental-health-service-users-launch-manifesto) but mental health services are not perhaps falling over themselves in their haste to catch up.

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The reference to ‘psychosocial disabilities’ includes the contested diagnostic fields of ‘personality disorder’ and ‘eating disorder’ and my business in this blog is with the latter category. For more than fifteen years now I have been working as a psychotherapist on an inpatient ‘adult eating disorders’ unit and for the last seven or so of these years I’ve been leading the psychological therapies team there.

The ‘symptom’ being treated is starvation and the treatment being enforced is refeeding. Psychological therapies are understood to play a central role in supporting this process and/or in supporting the sufferer to undergo the intervention. In my role I am therefore unambiguously party to and implicated in this enforced treatment. This treatment is possibly often life-saving and life-restoring and yet is experienced as a terrifying intrusion, one to be resisted at times by any means possible, by many of the individuals who receive it – and now it has been proclaimed to be part of a widespread and endemic abuse of the human rights of those same individuals.

When I first arrived on that ward, more than fifteen years ago, coercive treatments under the Mental Health Act were very rare (I emphasise here that it is adults I am thinking of and the particular dynamics of adolescent units, although of course also covered by the Rapporteur’s findings, are outside my authority to comment upon). Adult patients in those days were on some psychological level ‘volunteering’ to undergo the intervention, in the hope of making a full medical recovery from malnutrition and from the distress that drove the troubled or troublesome food practices to begin with.

Nowadays 30-60% of patients at any one time are detained under MHA s.3 for compulsory treatment for their ‘disorder’ (specifically, anorexia nervosa, for other manifestations of eating distress are very rarely funded for this kind of unit). Coercion is therefore more explicitly medico-legal than it used to be, even though refeeding was always carried out across a power differential. And according to the Special Rapporteur, the coercive aspect of ‘eating disorder’ treatment is therefore more explicitly in contravention of international law.

In this blog I do not propose to argue for or against the findings and recommendations of the Special Rapporteur. I propose to treat them as a given and to look at the treatments I have been party to and the ethical issues they have always raised in this particular new light. Historic moments like the publication of the report to the Human Rights Council do and must give pause for thought and one question in particular has been niggling away at the back of my mind:

What can the fourth season of Star Trek: Voyager teach us about the ethical limits and excesses and the psychosocial dynamics of coercive treatment for ‘eating disorders’ on inpatient units?

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Well, I know you’ve been asking this very same question … and I don’t mean at all to be flippant about so deadly and deathly serious a subject. But sometimes material from literature and popular culture may serve as useful analogy or parable and I don’t want to blog about a ‘real life’ case study – for reasons I hope are self-evident.

So I hope you’ll bear with me, Trekkies and non-Trekkies alike, while we journey into the 24th century and the Delta Quadrant, 70,000 light years away from Earth, where we find the crew of the starship Voyager, under the command of the intrepid Captain Janeway, stranded far from home, making their way through unknown swathes of space and hostile predators, of whom the most significant for our purposes is The Borg, a hive of drone organisms who anthropophagically assimilate the technologies of alien species via enforced assimilation, turning enslaved individuals into cybernetically and surgically transformed fellow-drones within the Collective in pursuit of an idealised technological and socio-political perfection.

Now when I describe them thus, they don’t sound like a very sympathetic bunch, but you have to remember that the Borg drones have been subjected to coerced medical procedures in order to become Borg. They are already traumatised, colonised, subjected: made abject. They are victims-turned-predators, like a conscripted child army brainwashed into the massacre of alien villagers.

In their predatory and compassionless nature, they are very different indeed from the sufferers and survivors who pass through the door of the ward on which I work. But nonetheless I crave the reader’s indulgence not to be offended if I ask you (why? well, please bear with me a moment) to understand them not as the super-bad guys of the Star Trek mythology but as traumatised subjects with complex post-traumatic stress disorders; to imagine them as life forms with inalienable (although not conceptually individual) rights of their own – to see that they are fearfully perceived as ‘other’ in the sense of ‘belonging to an out-group’ – to see them as fiercely loyal to their sisterhood – in general to note that ‘their’ groupishness is different to ‘ours’ but that groupish they certainly are, chasing mirages of perfection together as one …

I ask you to allow, in short, for purposes of relating my parable, that this image might serve, in translation, as playful but respectful representation of the out-group in the Delta Quadrant of ‘severe and enduring’ eating distress …

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As our story begins, a drone has become isolated from the Borg Hive and taken into inpatient treatment in the Voyager Sickbay. The drone’s appellation is ‘Seven of Nine’. In our story there are no junior psychiatrists – but there is an Emergency Medical Hologram (EMH) (a long story!) and he is presenting a tricky case to the Captain/Consultant Janeway …

EMH: I’m afraid we have a decision to make. A difficult one. Her human immune system has reasserted itself with a vengeance. … Her life is in danger. I have little recourse but to remove the Borg technology.
JANEWAY: Which is the last thing Seven of Nine would want.
EMH: Hence the difficult decision. If a patient told me not to treat them, even if the situation were life-threatening, I would be ethically obligated to honour that request.
JANEWAY: This is no ordinary patient. She may have been raised by Borg, raised to think like a Borg, but she’s with us now. And underneath all that technology she is a human being, whether she’s ready to accept that or not. And until she is ready, someone has to make the decisions for her. Proceed with the surgery.

Here then is the central ethical dilemma. Seven of Nine is being held to ‘lack capacity’. Janeway is acting paternalistically, on behalf of the Federation, in what she feels is a construction of Seven of Nine’s best interests – even though the Voyager MDT is clear that Seven of Nine would not want this. Her junior doctor evokes the CRPD – ‘we must respect the wishes of the patient’ – but Janeway feels she has to ‘hold the hope’ of a full recovery for her captive/patient. Seven of Nine cannot be allowed to remain (cybernetically) disordered – she is at risk of organ failure – a radical intervention is mandated, whether or not in compliance with Intergalactic Law … [I hope by now it’s clearer why I pleaded with the reader to bear with me]

In post-operative recovery, Janeway does a bedside visit …

JANEWAY: I’ve met Borg who were freed from the Collective. It wasn’t easy for them to accept their individuality, but in time they did. You’re no different. Granted, you were assimilated at a very young age, and your transition may be more difficult, but it will happen.
SEVEN: If it does happen, we will become fully human?
JANEWAY: Yes, I hope so.
SEVEN: We will be autonomous. Independent.
JANEWAY: That’s what individuality is all about.
SEVEN: If at that time we choose to return to the Collective, will you permit it?
JANEWAY: I don’t think you’ll want to do that.
SEVEN: You would deny us the choice as you deny us now. You have imprisoned us in the name of humanity, yet you will not grant us your most cherished human right. To choose our own fate. You are hypocritical, manipulative. We do not want to be what you are. Return us to the Collective!
JANEWAY: You lost the capacity to make a rational choice the moment you were assimilated. They took that from you, and until I’m convinced you’ve gotten it back, I’m making the choice for you. You’re staying here.
SEVEN: Then you are no different than the Borg.

Janeway here is channeling Creon in Sophocles’ tragedy, seeking to persuade Antigone that she would be making the pro-social choice in choosing life and conformity over autonomy in death (I write about this a lot in other places). She tries to soothe Seven of Nine with the wisdom of her experience – she has seen others recover. Seven of Nine, from this particular perspective, is a serious case – the disorder took her over at a very young age – but in time she will learn that it’s worth coming in from the cold on Federation terms, even though she doesn’t see it that way right now.

But Seven of Nine, still using ‘we’ in her Borg identification with the Hive, has a perceptive question: if you get me better, so that I am then able to exercise my free will, will you allow me to return to the disordered out-group? Janeway is boxed in by the logic of her own position: she upholds the full recovery model and reasserts Seven of Nine’s lack of capacity. No change to the care plan, sorry, it’s all in your best interests, says Janeway … and Seven of Nine sees it clearly in the moment: I recognise you – you are my abuser.

A little later on, it’s time for Seven of Nine to start therapy – her body is restored somewhat towards a standard of normal functioning – her sense of panic has subsided – she is more compliant, although still held in seclusion – she has entered cautiously into a relationship with her treating team …

SEVEN: … I cannot function this way. Alone.
JANEWAY: You’re not alone. I’m willing to help you.
SEVEN: If that’s true, you won’t do this to me. Take me back to my own kind.
JANEWAY: You are with your own kind. Humans.
SEVEN: I don’t remember being human. I don’t know what it is to be human.
(Janeway picks up a [tablet] and lowers the forcefield.)
SEVEN: What are you doing?
JANEWAY: I’m coming in.
SEVEN: I’ll kill you.
JANEWAY: I don’t think you will.
(Janeway enters the cell, staying out of arm’s reach. She shows Seven the picture from the Personnel File [of Seven of Nine as a human girl] on the [tablet].)
JANEWAY:  Do you remember her? Her name was Annika Hansen … There’s still a lot we don’t know about her. Did she have any siblings? Who were her friends? Where did she go to school? What was her favourite colour?
(Seven looks at the picture for a while, then slaps it out of Janeway’s hand.)
SEVEN: Irrelevant! Take me back to the Borg.
JANEWAY: I can’t do that.
SEVEN: So quiet. One voice.
JANEWAY: One voice can be stronger than a thousand voices. Your mind is independent now, with its own unique identity.
SEVEN: You are forcing that identity upon me. It’s not mine.
JANEWAY: Oh yes, it is. I’m just giving you back what was stolen from you. The existence you were denied, the child who never had a chance. That life is yours to live now.

In a scene that seems to me to evoke forensic psychotherapy settings and seclusion facilities across many pathways, Janeway seeks, within a custodial frame, to engage Seven of Nine’s ambivalence and her repressed memories of her ‘pre-morbid’ condition before the trauma of assimilation by the Borg. Janeway is offering recovery but Seven of Nine not only can’t imagine what that might be like but is not at all sure there’s anything wrong with her that she needs to recover from. The emotional temperature goes up: Seven of Nine is aroused and agitated and distressed and confused but she can still clearly discern Janeway’s agenda, pressing upon her an identity that once was hers but with which she does not and cannot at present identify.

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There’s lots more where this comes from, as Seven of Nine’s ‘recovery journey’ continues and Janeway and her crew gradually increase her privileges and reward her progress with initially fearful and reluctant but gradually more trusting processes and mechanisms of social inclusion. As time goes on, Seven of Nine’s expertise by lived experience will come in handy, when Voyager comes across the Borg again …

But for now, it’s time to leave them to their travels and to come back to the Special Rapporteur and his recommendations. Where does this report leave the coercive framework for inpatient eating disorders treatment? The Rapporteur acknowledges the intense ‘stakeholder’ anxieties stirred by the prospect of radical change. Where would these units be, after all, without their medico-legal technologies?

I have seen people in Seven of Nine’s situation (by allegory and analogy) who, like her, came to feel grateful that their lives were saved by coercive interventions. I have seen others whose lives were saved in the strict (and short term) sense of the word but blighted at the emotional and existential level by the horror of the treatment they received ‘in their best interests’.

Obviously, I have no authority to make an ethical ruling here. The Rapporteur says that “instead of using legal or ethical arguments to justify the status quo, concerted efforts are needed to abandon it”. His position appeals to me and scares me in equal measure. But the point of this blog reduces to one question that inches its way into consciousness, in various different guises:

What if Janeway had wrestled a little deeper with the question of Seven of Nine’s fear of losing everything in treatment? Janeway makes a case for the ‘special patient’ – she pursues a justification for the excess of forced treatment by saying that Seven of Nine is ‘no ordinary patient’. But what if there are never ‘special’ reasons for using force? This is the axiom that we are being required here to accept.

The Rapporteur says we “lack the clinical tools to try non-coercive options”. What if the increasing power and potency and even sophistication of our medico-legal technologies (the Mental Health Act; the Mental Capacity Act; Community Treatment Orders; naso-gastric feeding; PEG feeding; pharmaceuticals and so forth) has deskilled us in some simpler forms of intervention? Suppose our coercive muscles are so well developed, that our engagement skills have become rather flaccid and feeble with disuse?

Suppose we invested in developing those skills in what Judith Herman called ‘existential engagement’, instead of falling back in relief, behind our coercive medico-legal redoubts, away from the stresses and strains of open debate? Suppose as many or even more lives might have been saved in creative ways, as have been lost to mishap or suicide under more coercive regimes?

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I don’t know; but I wonder …

 

References

Adlam, J. (2015) ‘Refusal and coercion in the treatment of severe Anorexia Nervosa: the Antigone paradigm’. Psychodynamic Practice, 21 (1), 19-35.                  https://www.researchgate.net/publication/265685587_Refusal_and_coercion_in_the_treatment_of_severe_Anorexia_Nervosa_The_Antigone_paradigm

Herman, J. (1997) Trauma and Recovery: The Aftermath of Violence – From Domestic Abuse to Political Terror. New York: Basic Books.

‘Star Trek: Voyager’ screenplays from http://www.chakoteya.net/Voyager/401.htm