What, pray tell, does it mean to be normal? How does one define normal? Normal strikes as bearing a sense of purity. Of consistency. And of synchrony. All highly coordinated, unwavering, and undifferentiated.

An argument may be made for normalcy to be synonymous with homogeneity. Two individuals who think alike, talk similarly, act alike, are inclined to react similarly and make the same decisions. All within a minuscule standard deviation. The question that begs is whether such a phenomenon exists or is liable to exist in the pristine standards it is enforced with.

The truth is that no two individuals think, speak, or act alike to identical proportions. There has yet to be determined purely similar patterns of behavior between various individuals. If being normal is behaving completely alike, then no one fits the bill of being normal. The only argument that can be made is that normalcy is relative, and that deviations in thought, word, speech, and behavior are not only rampant but are the order of the day.

Does it follow then that individuals with mental illness are abnormal. What does it mean to fall three standard deviations beyond the mean? We could elect to ascribe to some manner of psychosocial decorum, but decorum is by its nature a consensus. Neuropsychologically speaking, mental illness symptoms are not necessarily perversions of character. Objectively examined, they are different patterns of behavior. And psychosocial decorum springs heavily from sociocultural norms which are ever changing. Consider such examples as the atheism and LGBQT+ movements, previously shunned but currently accorded their due respect.

Individuals with mental illness are not abnormal by any stretch. To think as such is to eschew from the true meaning of normalcy and confuse it with the truly valid concept at play, homogeneity.

People with mental illness aren’t normal. It is not a laurel any of them desire. Would you rather be normal, or would you prefer to be unique?

“Barbara has been forcefully sedated, multiple times within hours of each other, because her affliction, her brain, cannot be placated by standard doses. She’s been brusquely manhandled by brawny, belligerent orderlies with very little bedside manner. My empathy is of little consequence to her. My inaction abets with the orderlies’ treatment. I must make her story known.”

Testimonials of Coercion

However, despite these reforms, inhumane treatment continues, perhaps not appreciably in Europe, but in parts of the United States and some of the developing world. Barbara is living proof. She has bled from struggling with her restraints. She’s been forcefully sedated, multiple times within hours because her affliction, her brain, cannot be placated by standard doses. She’s been brusquely manhandled by brawny, belligerent orderlies with very little bedside manner. My empathy is of little consequence to her. My inaction abets with the orderlies’ treatment. I must make her story known.

Elyn Saks, a professor of law at USC, who suffers from schizophrenia, recalls in her memoir The Center Cannot Hold: My Journey Through Madness her commitment at the Warneford Hospital in New Haven, Connecticut: “No single hallucination, no threat of demonic forces or impulses I couldn’t control had ever held me hostage like this. […] no one who loved me, knew that I was here, tied to a bed with a net over my body. I was alone in the night, with evil coming at me both from with myself and from without…For hours, […], I yanked against the restraints, and I sang my heart out.” In a sobering tone, she concludes, “At that point, I’d been restrained for six hours. My muscles ached and my skin was chafed from struggling.”

Saks mentions separately that most states permit clinical personnel to restrain patients even when there is no considerable risk of harm and without demonstrating the restraints’ effectiveness. As such, coercion can be enforced liberally without a value judgment. Any uncooperative mental health patient is at the mercy of the preying staff member. The internment only ceases when the patient folds or complies; this stage is usually marked by exhaustion. The time to being spent, however, is the metric that matters. Depending on the illness and the state, it could take more than a day.

Several studies have shown that coercion does not serve any remedial or corrective purpose. In one such study on attitudes towards coercion, 730 mental health professionals largely responded that coercion infringed on fundamental civil liberties and its effectiveness lacked adequate scientific evidence. That said, most of them thought that it was a “necessary evil” to be used to bring about compliance. Contrarily, it is a brutal means of enforcing compliance in patients, people whose ability to recognize its merits is impeded. Except in instances of imminent, inevitable peril (which is objectively difficult to determine), coercion has a high cost-to-benefit ratio and is tenuous as a psychiatric intervention. Xenia Kersting and colleagues of the University of Bonn in Germany conducted a review of 67 studies drawn from institutions around the world. They found that coercion resulted in deaths by “strangulation in 9 studies, chest compression in 14 studies, and pulmonary embolism in 8 studies.” The same review found injury in 0.8 to 4 percent of total cases studied. Yet the law is ambiguous on the subject, and coercion remains an option for dealing with people with psychiatric conditions, even those who manifest an iota of unwelcome behavior. As Saks reports, the law does not expressly forbid states from infringing on the civil liberties of mental health patients, allowing it where a patient is deemed to be a substantial threat to self or to others (often a highly subjective assessment). She mentions that most states permit hospital staff to apply mechanical restraints to patients even if a serious threat of injury is not present and without demonstrating that restraints improve the patient’s behavior.

The good news is that there are alternatives to coercion that have proven efficacious. Damián Fernández-Costa and colleagues, based in Spain and Ecuador, reported in a systematic review of 21 studies conducted at various facilities around the globe that staff in 9 of those studies trained in “verbal de-escalation techniques” were able to mollify frantic patients. The use of padded isolated rooms without any other form of restraints help to placate patients by reducing sensory overload and social stimulation. Also, for the long-term, use of medication like benzodiazepines and antipsychotics like clozapine tend to preserve an air of calm, decreasing near incidences of agitation. Perhaps because of these alternatives, the use of coercive measures has started to decline. The National Association of State Mental Health Program Directors (NASMHPD) reports that between the years 2000 and 2004, as per data obtained from more than 200 facilities, the number of patients restrained decreased by 16 percent.

In Europe, mental health practitioners have demonstrated that humane treatment improves mental health outcomes. The United States and the rest of the world could stand to borrow a page from this approach. Straitjackets and enclosed padded rooms are antiquated. Mechanical restraints offer no therapeutic potential or repose. Individuals who are bound and deprived of freedom may find it difficult to find clarity and healthfulness; perhaps in rare circumstances but does the benefit then outweigh the cost? Lax, ambiguous statutes require clarification, or even an overhaul. Coercion as a psychiatric intervention, though a necessary pressured alternative sometimes, serves us ill as a society.

Barbara knows how futile it is to stave off what will almost certainly recur. As is the case with all chronic illnesses, she is liable to become manic again. We touch on the topic sometimes. Antipsychotics and mood stabilizers haven’t yet afforded her the peace of mind they seem to grant many other individuals who share the illness. At the very least, this evasive peace she cherishes is sporadic and fleeting. The saving grace, if optimism dares to be gleaned in this case, is that she will likely be too delirious to consciously experience the manhandling, the tying of her hands and feet to the metallic bed posts and maybe even the forced sedation. The memories will come back piecewise when she’s lucid, like a bad hangover. But I remain hopeful that someday soon modern medicine will bestow upon her the dignity she deserves when she is in the throes of an episode.

https://medium.com/@urizeniczoa/bound-for-insanitys-sake-a109d2b7ece3

There is no Normal.

Nobody is Normal,

Normalcy does not Exist………..

A History of Coercion in Psychiatry

Coercion in psychiatry has been practiced as a doctrine for several hundred years since the advent of the mental asylum. As the name suggests, it is enforced despite the patient’s wishes and without their consent. Coercion intervention measures include physical restraints, secluding patients in isolated rooms and forcefully administering medicines.

Before the seventeenth century, mental illness was treated in the home in much of Europe; severe cases were referred to “private madhouses.” Public lunacy asylums came to the fore in the seventeenth century. In these asylums, most patients were free to roam, but those considered dangerous were chained and secluded. In England, the Bethlem Royal Hospital was opened in 1247 while the Bethel in Norwich and Guy’s Hospital were opened between the seventeenth and eighteenth centuries. In America, the Pennsylvania Hospital was opened in 1751.

Historians such as Akihito Suzuki have described how public mental health facilities came to be run and what manner of treatment was assessed in them. In psychiatric wards, patients were sequestered and restricted in movement to part of the asylums’ grounds at most. They were treated impersonally and harshly as they were largely considered to be mentally subpar. Any lack of cooperation was met with forcefulness. The most bellicose patients were chained to walls. Mechanical restraints that were employed against hostile patients included metal handcuffs, leather wrist braces and cloth bridles. Composing chairs were used for violent and unrelenting patients. These sturdy chairs were firmly attached to the floor; the motion of a patient confined to them was severely restricted with leather straps, and confinement could last an entire day or however long it took the patient to concede. Straitjackets originally restricted the entire body heavily, from the patient’s neck to their ankles and bound their arms very close to their torso. There was extremely limited range of motion. Finally, in about 1812, hydrotherapy replaced some of the above stringent methods of reigning in mentally ill patients. One method involved tying patients to a chair and ducking them multiply into a tub of cold water. Another involved wrapping distressed patients in cold, soaked sheets. This was thought to restrict movement by lowering body energy and desensitizing the patient, overcoming the stimulus that had previously energized the patient. With these controlling impositions, they were coerced to act as instructed.

Towards the end of the eighteenth century, during the Enlightenment, mental health reform introduced more humane considerations at mental asylums in much of Europe and in some of the U.S. as well. According to William A. White, who was the superintendent of St. Elizabeth’s Hospital in Washington D.C., circa 1920, and psychology scholar Paul Laffey, psychiatric practitioners and staff embraced moralist attitudes in treating mentally ill individuals. Asylums did away with chaining and physically punishing patients. Providers stressed attitudes of compassion and kindliness when treating them, leading to improved outcomes in patients’ mental and associated physical health. For instance, in 1839 in England, John Conolly—who assumed the office of superintendent of the Middlesex County Lunatic Asylum, the largest in Britain at the time—did away with the use of straitjackets, hand manacles, leg-locks, and all 40 composing chairs. In their place and towards a humanist approach, Conolly favored manual restraint of frenetic patients by the institution’s attendants. This was meant to immobilize them rather than overpower them, preventing self-harm while gauging the patient’s status in real time. Conolly also devised the padded seclusion room for patients too violent to be manually restrained. These considerate treatment methods replaced measures involving restraints in the asylums. Patients were little exposed to external stress, if at all. The moralist treatment approach affirmed that patients were human beings albeit suffering from mental illness, but not lesser because of it. While actual treatment lagged because of the times—medical care, specifically pharmacological interventions, did not effectively treat mental illnesses—quality of life of the patients in these asylums improved substantially. These improvements in patients’ lives could be attributed to new views on the morality of mental illness.

Barbara the Resilient