Sederer Urges 'Solutions that Avoid the Use of Coercion'

NYAPRS Note: The following excerpt comes from a recent Psychology Today blog from Dr. Lloyd Sederer, entitled “Involuntary Psychiatric Hospitalization: A life saving yet often aversive intervention.” Following several accounts of instances where involuntary treatment was used, Dr. Sederer offers the following thoughts. See the piece in its entirety at  


….There are countless other stories like this. They are unsettling because there is no good answer when a person becomes potentially dangerous – to self or others – the condition legally needed to employ involuntary commitment. An intervention may be necessary but it may not be helpful - for more than the moment. People who are subject to loss of liberty, to the deeply unsettling experience of having the police intervene, of being transported in restraints, and of being put behind a locked hospital door never forget the experience. Some come to terms with it and a few even come to understand (even if they don’t forgive). But this is a traumatic experience and a normal response to it is to not want to put yourself back into an environment, like a mental health clinic or hospital, where that could happen again.


“Would I do what I did again should circumstances reach crisis and life threatening proportions? I don’t know what other responsible thing there would be to do. Thus, good answers seem to lie with solutions that avoid the use of coercion and loss of liberty, whenever possible. These are solutions, I believe, that require that mental health interventions be made more humane while we also work to reengineer services to intervene earlier and more effectively in the course of a person’s illness.


We owe people with mental illness what has been called ‘patient centered-care – not as a slogan but as a standard of practice. What this would look like would include open access to an appointment where instead of waiting for days or weeks people in crisis could come to a clinic the same day they want to be seen. There would be the ability for clinicians to meet with patients (and families) outside the four walls of a clinic, in settings more natural and less stigmatizing (this is particularly necessary for younger people). Special attention needs to be paid to what is needed to keep youth in school and adults in work, or on a path to work.


Shared decision-making where patients are made partners in their care is an important way to engage and retain people in treatment. The use of medications needs to be highly judicious and attentive to managing the side effects that frequently discourage patients from taking them. We need to enlist the help of families who can serve as an early warning system for problems in their loved ones. Most often (though not always) families are the most important and enduring source of support for a person with a medical illness, including mental disorders (Opening Closed Doors What I describe here is not new but it calls for changes that will take leadership and relentless persistence since change is hard, even when clearly needed.


We also owe people with mental illness and our communities an alternative to the demoralizing experience of a condition advancing to a severe, persistent and even dangerous state that makes involuntary commitment almost inescapable. This requires giving people with mental illness, their families and communities, and our mental health system the means to identify problems early, typically in adolescence, and new methods of engaging people with illness in effective treatments that also support their families. Some ways to change are described above and others that have seen success in other countries are being introduced in this country (Lieberman, Dixon, Goldman, Early Detection and Intervention in Schizophrenia: A New Therapeutic Model; JAMA August 21, 2013 Volume 310, Number 7). This is the kind of overhaul the mental health system needs. This is the kind of overhaul that could provide more effective care with dignity and probably save lives and money.


Humane, patient centered services and early intervention are paths out of coercion. Imagine their impact on people with mental illness, their families and communities, and doctors who may not need to find themselves in situations such as I have described. Achieving these goals would be something to be proud of.”