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Assertwe_communiry beahnnt (ACT) i.s a uid.rE
hropa.gated tean
aryoach to .omnunit, /nental health care thar ,assediu;bi engagesa
subgraup oJ individutlh uith severenenk l ittness uho;onh;u"ous1t
disngagc hom nantal health sen)ices.It inrotues a nunhtt of intttestk
Poxies - including climts, care$, clinicians and manaser, E;ch oberates
according to peruttuedethical printipbs retatedto thtiialws, nries and,
pnnciqles.ACT candeuesa .Jilzmmathat is eomnnnin bs.,)chiatm. ACT
ptulln' ,o,iol ryntnl uhil\t \tnutto\?ouh hol4ing rhnapeuti,
aspiration. Thc clients' pospectiue aI this Aitemma uis studied in
xntotiaxs uith 12 clients using the .groundedtheory' a\proach. Rzsultt
suggestthat clients' disengagenznt 6 us nuch a histu/ricaland cultural
ph.nonrn^! a\ a rault oJ k,h oJ tn,tght. Ma\,ttatt hnd,xpaim,.d
ryatlan.oJ ?a ) h?lpw?kin{ b'ha!,our and aI had b,m,uble,r ro
caefttueinter<rentiotli. Thesecoer.iueintslientions uere experimcei as an
attach on id.entiry. AA feh that their uoiu had. not becn liltened to in
fntou\ .nt"ra.ti.n\ utrh p\v hiat* \nvir^. Con,cquntinIJ rh" f hnts
hadan n 'as"d h"l oI a,ou\atanundi\u?,ot po1tt. uhnh NaL, la
iryfp-!*n uh.en exanining the ethi.s of tonmuniq prchiatry.
nationsof the dilftrAu betu,een
persuasionaia' ciercnn'
tn exMtlz - naf n zA tu beadaptedfot thi client group. R"jutts are
.onpar?du" pe\ph hup. we ronrtudz tint tht pctpe, riue,
n n" dinmtrons.SuLhan hnpiiut approu to pxamnng
p\).ntamt ?thhs
na) nsur" tha! u' in,npoftt? thp ,ubi".trL, i"\ of
ua,ious intercst?ai pailizs in thz cknical drcision nakine ltricess.

Community psychiatly - a.sevolved since the advent of deinsri_

tutionalisation - involves dranaric alterations to psychiatric

€ Blalrqel ruuiNhe6 LLd 2m2, lo! cowrey Road, onord ox{ lJr, L,K
dd 1t0 Main src.t, Malden, I'tA 02t,t8. Usa

From the standpoint of a doctor in an emergency room, it is rot

helpfirl ro divide suicides into radonal and irrational ones and
then to feat them differendy. Sometimes so-called ir.rational
suicides require us ro aid death. The more details we know aboul
any panicular case,the better we can reat the patienc effecrively.
But beyond this, philosophical platitudes should be eschewed,
particularlv those that concern life, dignilv, and sanity.

Vakrie Cna! Hard.mstlz

Scimce and. I'echnokgl StudiesProgram/
Dqanwn of PhiksophJ
Vtuginia Tech
vA 24061-0227

Rrsabn Walkff Stunail

Depatlnznt of Intemal Medicine
LhiftniiE oI TexasMediml Branch Cah)eston
'r'x 77555
. usA

Dinner discussions with Jim Benton and Matt Stewart greatl]'
impr o\ed rhe ( onrenr of r} is e.sar.We rhanl rhem bnrh toi l}leir
help. An earlier version of this essavwas presented to the Schooi
ofPhilosophy and Bioethics a. Monash Universiqv.The audience
patiendv and in great detail explained what was wrong with our
essay.We appreciate their effort. Research for rhis articie war
supported in paft by a generous graDt liom rhe McDonnell

pracrice. These include changes ro rhe locus of care, as weli as

llearmcnr ep-pror.hesrnd runding re,ourtes. lr ]ims ro providc
InF mngc ol seru, c5 onre provided wi$in $e arvlum in Lhe
communicy. These include accommodation, social supporq
reatment monitoring and vocacional support. However edrical
changes in community psvchiatrv har,e bejn generally ignored.t


De-institutionalisarion has occurred simultaneously rith a
mnvemenl rorvdrd5 .onsumerism a,rd empuhermenr in
psychiary. The empowerment movement focusei on increasing
rhe auonomy ofclients. One kev chanqe has been the theoreticai
change from paremalistic models of th1 therapeuric relationship
('Doctor knows best') to a otore collabor-ativeielationship where
diens are ar epred Jl e\peru rbour rheir owr illnesspror es..:
Cun(ulT.nd\. rere polirl develupmenrj hare , an
Inr r eise rn rhe \e ul .oer.r\c p^wcr\ wi$;n lhe .ommunirr._ tol
e \ a m p l er o m m u n i n r r e r r m e n o r r d . ^ w h e f ec h e n t 5a r e t o r i e d l o
compl,ywith medication in rhe community. In rhe UI! manvsuch
policy d€veloprnenl5 hirve eme.ged from rare bur much reported
cases of homicide involving ps,vchiatric clients. These liad to
pronouncemenLs that 'care in rhe communiw has failed'.3 Such
casesproduce a climare ofblame for clinicians where the locus of
risk moves ftom the client to the clinician, thus producing false
Posrtlve assessmenbof risk. A false posrLrveassessfitenrls ,vhen
isk is overestimared so that clients ire restdcred unnecessa lv.
For example berhFen 1989dnd I993 Lhe number ol i omD,rhon
admissions increased bv 27% in the UKo As Harrison'noteJ,
may be drawn inro ,upervisionprogram. hrviDg .l
. u \ r o d i a la n d . i e r i ! e L h e r d p e u r ri (o ,u s . . . . T h e r e " i . a . i g n i 6 , i n r
risk that mental health professionalswi resort to inpati;nr care,
or over'-rcstrir Live'ry]esot rherapeuLiccare. be, ause ol risks nor
ro rheir clienll bur ro rhem.elresstruuld\o,nelhinq qo llnnne..
Thc case manrgemenr approach has been adopied ro ensire

'-.G psvch\^tty.
_ _SmulEr 1999.Elhicsin CommDniq
ed S Bloch,P. ChodotrandS.A.cre€n,eds.Oxford.Okord Unilersiq,pres:
r P.Chddo{.Paretualism p9.nur)
12'a61983j 8: 520.
3 F@t Dob"on (Heald
' Szmulzer, Secferarr).House or coinmons, LrL 1999.
op.dr. nore 1.
" H. Hriion.
Risk a$e$ment in a .limare of titigation.
Pr.hiatry 1997t \70: 37-37

ci Bh':kyen Publth.E Ltd' 2002


continuit! of care and c(H)rdinate service Provision. Various

models ;f'case management' have been proposed to manalie
indiriduats withiD the communiry-o Key functions include:
assessment, developmem of a care plan, monitoring, and
'Standard care nlanagement
eva.luatingprogress aDd follow-up.
is not very effective,' leading to the developmenl of seveEl
intensive case management approaches.
ACT was developed in the early 1970s in Madison, Wisconsin,
to rreat difficult-ro-engage clients who have a historv ofa so{alled
'revohing door'
rycle of adrnissiondisengagement-readmission."
Recendy ACT has been adopted as a treatment model across the
industrialised world, and rc;lication studies are bormtiful.e ACI
has been described as the mosr e*rnined -non-pharnacological
inteflention for clients wift schizophrenia.'" It may be seen as a
panacea for governments wonied about the safety of'care in the
communiw'. ACT aims to proride a complete care package. This
includes treaunent within the community (Ether than statutory
offices), a high le!€l ofstaffsupport, a high stafl-to client utio, an
emphasis on practical activities of daily living, and a team
approach to cale management so that clielts have access to a
number of statf. ACT is reported to reduce *re number of days in
hospital lor clients, though the effect on other outcomes is less ,qc.f mav be applied either as a comPonent of Seneric
communiw menral health leams or in sPecific teams focusing
solely on administering ACT lbr a small grouP of clients with
severe mental illness. Assertive Outreach Teams are an examPle
of the latter-
An example - the case of Mr. B, whose case is g?ical of dre
participants interviewed - may help illustrate the e.hical
implications of ACT:
Nlr. B is a 3l-year old gentleman of African-Caribbean origin
with a diagnosis of pamnoid schizophrenia and a history of
minor forensic offences. He has had around 20 admissions to

" n'I. u'.'.r. G.R. Bond, R.E. Drake md S.G. Resnick Modelsof
community .de for severe enral illn€s: a review or resed.h on c4€
m Das.emen| S.hizarb%ia Bu etin 1998t 24: 31 11
? M. Ma6hdt, A. Gray, A. Lockwood 2nd R. Green Czs€ mdagement for
selere nental disord€N. The Cubnne Librar.t 1991, 5
' Ibid.
e BJ. Bums md A.A. Santos.Aserdve Community T.eatment an uPdate of
mndomised .onrolled dzls. Pr.hiatric 5nn61,995i 46i 609-675
I. Sblell. Is dsertive communiry reattren! ethical care? Hma l Ra
Pstchiatt 2001t 9: 1391-43.
M MaFhall, et. al.,4. 'ir. note 7.

hospital all under rious statutory sections of the Mentai

Health Acq and does not attend outprrienr uppoirrrm.rrrs.
he-hasbeen manaqedrhroughdepoi L.a,,",i.",
wni|.n ne detaulLson shonlv after leavingho.piral.14r B
hi. kev p,obiemsas gambtingand ha. manv
oeol\. lhe \Lt team mdnage\ his moner .o lhat Vr. B Re|s
regura. mcome each week. Mr. B is satisfied with
arrangement but does not want to have any more intenentions
from ACT. He describes a time - several years ugo - *l,er 1r;
tried, ro engagerllh ps\.hieLn. .erviee. rJrrougi hi, Cp anj
rhe q.crde-nrand Emerqend Dcparrmenr ot r hi lq al Leneral
nosprtal. Mr. tJ \rdres Lhdr professiunalsrold him rhere \""1
nothrng wrong with him. Alier severalyears,he became acuaely
ill and wds secrioned and restrained by the potice. Mr. B
olfindine ps\chiarn , oer.ive. and ulks wirh n..ralei, ol bei;;
d popular and charismari. leader rr ichool.
The. Af"l 4o6.1 iondcnses a pdradox ia,ed in .ummunia
ps\.hrarn. lhe model rhe $e|?pFuti, arpiralion of
rn.reasrngperronal autonom\. \Fl rhe proFam aims ro engaqe
peopre aeuon, exemplifo rhar fiev do nor ,znr ro ir.
Involreo 'vlur psv.brdrri( se|1i(es. fhi, paradox ir presenr
r]rroughour .ommunirv psvchiarrt. bur is tar more
a,ure in
\L I wnere $e ctlentJarc bv dcfinirion diefi,ulr raerrgage.Thi.
r a i s e sd n u m b e ' o t e r h i . a l q u e , L i o n 5l o
. rerdmple if .liinsare
nol d dangcr Lo rhemsel\es or orher\ _ rhe rrirgrien 1.,.
compulsol detention in the UK - do we have che right ro force
a 'thempeuric' inteEction? Are the restricrions of-the asvlum
bcing tmnrponed ro rlre (ommunir) wi$nur the \uturorr
'.unuols? ACT rlinician, do, nor generallr .onrider rheir hork
ro oe elnr.aln .hdllengrng anri few arrieleehdre bcen wTir(en
dbout rhf erhicrl implirarions ot rhe dpprod,-h.Tellingty. user.
perspecrjves on ACf ha\e rarety been ,iudied, and rr i, r.rnrlear
how they experience ACT_
T h o u g h r h e r ei s n o u n i l o c a l( o n ( e p t o l , o e r . i o n r h e , o , c p l
rerersto a mnge ol pressuresused _ rmplt.idv o, explirirly _ io
garn a pauent . compliance wirh trearmenr. fhe
relanonship benveen clini.ian and patienl tends lo be more
lnrensein ACT given lhc clini.ran is,nsihletor d larie$ of
generic needs - for example social ;kils rehabilitation' in

t: R-J.Diuond and
D.r. WiHer. 1985.Eth,catproblemsin communitv
b eahcn I ot d'nc.hrun .aliv menult lt, tn t,o, ii , mnun,\ tiutz q;i .
.,' \.w Dir-hon,jo; vdnb'
ff"j;'{j#:l;'.i !;:iJ...}'j,*.

s Bl!.kven PublBhe^ Lrd 2002


addirion ro m€dication. Persuasion is an appeal ro reason.

However rhr intense relariorrship mav afford bpportunities ibr
other exerdoN of power. Leveruse is a qpe of intetpersonal
pressure, which can be exerted b..uuse "i the inteditv of a
relationship - there may be an emotional bond that produces an
internal pressure ro comply. Werrheimer has argued lucidly rhar
the dilference berween threars and offers can bi defined in the
following manner: a coercive proposal is one where refusal would
leave the clienr wol.seofftharrat a .moral baseline,.rslfan offer is
not accepred, rhe clienr will be no .$'orseoff compared to this
bi$eline. Though this is a useful heuristic, clients with paranoid
schizophrenia rend to have a low threshold for experieniing both
anxiety and paranoia. This mq, srem from aspeits of the iitness
proces,.from hrsron(dl e\perienceswiLhinpslchialric,enr. es.or
nom .urtumt erperien, es _ for example lhe historirJl
expenence of association between psychiafiy and the criminal
justice sysremfor British African-Cadbbean individuals. Thus
mav benefit by examining their intrapsychic experience of
pressure phenomenologically.

Can medical ethics help us address such questions? To counrer
rhe claim,that medical ethics are charaaterised by ine.r,itable
generalin.'" an anr}ropologitaJ approa(h mjy be used ro
,rdore\s\?nous subiecli\ariesin rhe debare aboul *re erhi.5 of
communitl. psychiaoy. Such empirical work can be used ro
examine ethics fiom lhe narure of irll interesred parties in
, omrnunin p\, hiert - rhese inr lude rLni, ians, manaeeri.
clienr rhe general publi.. and tamilies.'-'Such an iporoactr
dlio\. Ie\els ot mo-ral explandtionso r}lar neirher provid'ernor
.licnr is fir\oured.'' Fu her. rhe dpproa,h correspondswirh rhF
nas.enr emergeo,e of rhe posr,modem perspe,rire wirhin
p\!.nrJIn - \uch a per\perrivejrguc. rhJl rhere rre no uni\?rsdl

A . A w p , r l e i m c , q p h i l G u p t - i . J. \ i m i i a r o n o t c o r r . . u n t o ! m F n l l l
t r J l r h i s r u c q8 " i u ,r @ , a tr , r m , / ,a n d . , , rt"z u t g q j ; . 2 3 9 _ 5 E ,
' B HuflD$,c,
t o q l . C d e d r n o g m p h ) , ^ eL \ e t i r Fo r n c d i r , t e l h r s ? t n
4 R?adn L.R. wiakler andJ.R (:oorn,. eds. ouo.d. Brirkwrlt:
'5 AA.A.
Alrez How ndonat should bioerhicsbe?The ralue of empincal
approaches.Bidntr 2001i l5: 501_519.
"l& vj
,I ' t i n a t t n 4 d tB n t hY:'|:'-^_D':.:S In Bioerlrs r./ra. Jtumat uJ ^sLn aM
i \ l o 9 5 : i : 8 ) . D . L , r a u H n r o! i m e .H 4 d C h n r c s B r d l r r i ,
199519: 192-206.

truths of llealth and iilness, or capaciqv to be acultunl or

Central ro scientfic research are the core philosophies that
guide researchers' choice of methodolog). Qualirative research
recognises the social world is constructed fiom nuhiple dvnamic

Participants were recruired through care co-ordinaton of an

Assertive Outreach Team in an impoverished inner-ciw area of
l o n d o n . l h e . d m p l . . o n , i s r e do l e i g h r m e n a n d f o u r h o m e n
with an avenge age of 38. Nine of the participants were Bitish
African-Caribbean, one was British Asian, and two were white
Bdtish. The majo qvof pafticipants lived atone (n = g), and were
single (n=9). All the participanB had been compulsorily
detained in hospital within the i:st year, and all had a'primary
ICD-I0 diagnosis of schizophrenia.l3 The mean "rt-t "r oi
ps,vchiatricadmissions rlar seven.
The broad aims of the study were explained to all rhe
participanb and written informed consent for participation was
obtained including pemission ro publish and io quoie. Erhicat
appro\.al was obtained from rhe local research ethics commirree.
Participants were assured of the anonyrnity and confidentiality of
infomation they provided.

A qualirative grornded rhcorv approa(h har uted meaning rh.rl

rheorv i. q|ounded in rheme\ emergenr trom parri,rpans
spontaneous conve$ations rather rhan a priori
This method uses the 'constant comparison' technique so rhar
themes which emerge liom initial open-ended interviews are
.ompared ro later inrerviersro allou lhe dc\clopmFnLofa model
bdsed solelv on dara from parLieipanr,.-"During Lhe iniLial

r7 R l2ugharne.
tuMne in
MmtalH.abhCan.S.Pnebeand M. Slade,eds.BtunnerRoudedge:
'" Th. ICD|1
Classficahm af Matal a"d R.hutiturdt Disodi, j992. Ctinic.J
Desciptiors md Diagnosri. cuidetines. rorh Edn. C€n@. World Health
'" B.G.Glaer &d AI-.
Sri^nss\967. m. dn.dtry aflatund.d theq: strategiz,
ld Wtitdt)l. ta?dnh.Ch\.aln ilthne.
- . e \ b L r yp a r i . .
A . 5 u d s " I . r o r b r n .t v q o B d \ i , . . t q L r l i u u \ rr F . e J k hN
CA Sage;B.c. clser, ,{.L- Stnus. 1967.The discoveryof gounded iheory.

o Black en PubrishenLd 2002



intei'{,jews,participants were sinply asked: 'could you tell me

about your experiences with mental health seivices' with non-
value iaden probes used to conli ue lhe conversation. Interviews
took place undl saluraLion' was achieved i.e. further inrcrviews
did nor feld or chall€nge any cabgories. All intenie$r were
audio taped. Coding :rnd the identificatioD of categories took
place manuaily throughout data collecnon b ensure constanr
comp:rison and theoretic:rl sampling. The research group
ex:llnined the tnnscripts ro assess inter-mter reliabilitl of

The results were conrrasred wich ethical issues discussed in the
psvchiatric ethics literature, and arising from the authors'
ethnoglaphic experiences in ACT teams across London.
To present the inteffiew results, il may be useful to provide a
participant's view of the psycholic siate. Psychosis can be
characterised by a basic disturbance of the trust
... the constant presumption that experience will conlinue to
unlbld according to some constitutive sq'le.'r The personat
impact of these pslchotic statesr€r evident fiom the inteniews.
One participant recalled: 'I had my benefit book, which was due,
and I didn't know. ... I w"-i looking at it the {'rong wav, I w:|s
walking around broke, and my book became ba|tered and tom,
and I lost quite a bir of monel ihen ... and I thought it was
another month.' Anxieties pertaining |o chis fundamental experi-
ence frame both participanls' and providen' perceptions of the
ethics of intenentions. As ihe conc€ms are direct and indirect
respectively, so both parties have d;fferent phenomenological
experiences of whaais acceptable.

Early help-seeking behaviour

Manv of the participants inteffiewed had lost significant others,
including family members, partners and key clinicians early in
their psychiatdc career. For exarnple: 'I staned voices, I
started ta.lking to myself, she coDldn'l take it an)(nore, the
relationship broke up ... and I ended up on my o!!n'. Many
initial attempLs at obtaining help for the psychological distress

't E. HuserL. Cncd in L- Bingddrye. 19a7. MeLlncoti,,t naria (R. Lsinte.,

lnnt. Paris. P.e$es UniveBitaires de F ..ce: 22. Ttuslated in E. Corin and G.
lnuzon. From Simprom to Phenomena: the ardculation oi experlence in
schizophrcnia. Jaumat of r\thok)g 1994:2i: u.

c Black*enPuLrishcDLL,r ?00r
'It took two years before anvone listened
were mel\rith rejection:
to me and admitted me. So two yeatx I lvas trying to be admitted
bur nobody would have me because they kept telling me I lvas
fine, but two yearswithout no treatmenl, no medication, nothing,
dnd I pfern wvlt flipped ... af(er n o real\ | wa\ so far gnne Lhdl
r h e y h a d r o d d r n ; rm e . l r d i d n r h a r e t o , n r n e r h i s l a r . f h e
literature on chronic illnesses,such as cancer and arthritis, sholv
Lhdl the o\eruhelnring imPlicarions ol illncsr .on idenrin i'
miriq.rled bl dfllrmation irom signiti.anr othe|s." Bt the ame
.ervires inren"ned, Ihe .lienr had olren given up on help
necessitating a cisis intenendon. For example, Mr. B felt anger
that he was subject to police restraint as a result of having his
requestfor help for his Psychotic qmptoms ignored yeal.searlier.
Ntr. B is thus prone to expenence selvlces :rs aggresslve,coercrve
and pircm.rlislic and h.r. ambiralente Iohards engaeemenr
despiie benefiting liom qo,ial helP Vo.r of 'he paniciPant
expiessed relief at being Biven the opPortunity to discuss their
privious experiences of coercion and lhe images were verv !1vid:
iWhen you are on the ward, you get slaffthat think i.'s a
Prison or
something. And that you've done something and they rry and
bossyou iround. Control you, control you It has been suggested
rhar r}le e\perienc. of being se(rioned ma\ in it-seuProduce Po't
raumaric Stres. Dr$rder.7' This would obviouslyrnctcar Ihe
baseline for anxiety around issues of power making the line
between penuasion and coercion e\€n more sensitlve for this
client group. Possibly such anxiery may be experienced more
acutely bv clients liom sPecific cullural grouPs for example
British African Caribbean men due to historical disPaities of

Mosi of the participants described the Psychiatric s)ljtem and the
labelling ofdiagnosis as an attack on their identiw. For examPle:
'I get sick, I get cncked up, and this is mv life l can't keep
I fighting against it and trying to be someone else.As a young boy'
growing up at school, a lot ofPeoPle u'!ed to come lbr protection

" adjNtment
J.L. Johnson.lggl. Letuoing to liv€ again: the Process of
rolo;ng; hean ritact(.lnJ.M. MoBe, J.L. Joh nson, e<ts Th? Itn5r L'pn nP
Newbtrt Parr, O{ SiSe: l3-99r EJ. Spccdting ]gaz Hean atta.h: th. JMit!
-1s at HoN an.l in th. 116rtat Ns YorL' Tavislocl
S. Priebe, M. Broker, S. Gunkel. Involun€'-y adnissio. and Posttiaumatic
stres disorder qmpioms in s.htophr€nia p2tients A'apr Pychiatl 1994: 39:

O Blr.[rcI rublisheF L'd ?00:


to me. I had people fiat could depend on me. I liked inde-

pendence, I liked to do my own thing, ),ou know: To lead,;md I
am not ill a position to lead no more.'
Idendty dilemmas fie common in many chronic illnesses and
m a r p r ' o d u , en o ' l ' - u m p l i r n ( ew i r h m e d r , J l i o n . .R a l e so t n o n -
compliance are eqrilalent in che general medical and psvchiatric
populations. This suggests rhe processes of adaptation to an
illness are no! necessarilydissimilar to that ofothei populations,
for example men with cancer,
The idea of appearing strong and in control is evidenr in ahe
overrepresentation ol men in ACT. Men's iden.iqv dilemma.srend
to evolve around certain binary opposirions, such :is: risking
a.rivin \\ Ioned passivin:remainrnSindepen.ienrr. bceoming
d e p e n d e n tm
: a i n t a i n i n ed o m i n d n r er . . h e c o m r n g. u b o r d r n a r e . i a
T h c i m p o r t a n c eo t r h e r c o p p o s i L i o n i\ s . u h u r e - p e r f i . w i r h
ri.Ung d, uvin a fearurefor men in .ultures ol fuii(an Ldribbean
origin: '\4/hen you're coming from as a psychiatric parient is a big
difference. lt doesn't seem like a tot, bur irs rhe whole oi youi
morality and freedom that goes when you hare to, a life where
you re lull ofeneryy and zest and doing your own rhing alJ ofthe
trme to tly to come to terms with being a um, find (.)
)rztsetf in
the si.kness'
Does nonrompliance conespond with the consruct of
insight? Man) parricipantr used biomedicat language or concepts
Io de., ribe speciJi. siluduon. Paru(rpanLsdc,epted aspe.Lsot
ps\.hnsi.. \u.h as hcarine roi,es. jnd r.outd u.e rhe rerm
of himself or herself - 'I diagnosed myself as
schizophrenic' - bur would nor accept being tre;Gd as a patient.
Is rhis resistance related to a hc[ of inaighr associatid with
psychosis?lltrilst .10%of outpariencswith schizophrenia are non
compliant,. so are about 50% of all panicipanrr in general
nrcdrcine.' Thu. tornpliance rnol nor be i"nt"una."a *i,t,
in.rght.'" I( appe,rr.inrurLi\ei\probablc rhrr rhere mal be a lo!\
threshold for anxielv and paranoia even when a client has
re.o\ered liom rJrroughmedicarion.Thi. ma) rausc e
.lrenr to cxperien(e intenle inrerndl pressure from leverage

^ g g.lyja"j .!"1q.,- dilenmd of chronicalyi| m.D. rhe so.iotsitut
Qzarsr| 19951
" L.H. Epsreinmd P-{. Clus. A
behaeioumlmedi.ire peNpecrive on
"* "- / co,rd,u8orcti^].atpr'abs ts82l
?d R. Mccab., E.
euyk, -{. Beirne aDd M. Duue. ls rhe.e a role rbr
, . o m p i i r n . ei n r } F a \ c , \ n . n r o t i n . ' 8 h . i n . h r u n x \ h t o p t , r e n r d . p i : y . n o b & .
th^Lh A Malntu 20OO:a:113-178.

tacticl based or the clinician-client relationship.

Ho!\,ever the
aeriolog1 ol rjln mar he a. murh a resuh
oi rhe hrsroriral
expenenrcs ot ps\i hiarri, \ervjce\ and $, idl e\,lusion
f,om ,he
.omrnunrl\ al d ,unscquen,e of che illnes!
pro.ess. Suih
ola.nroni( rrgun,ent5 mu,r be ,on\rdered uhen ue
rne ernr(sot (omnrunit\ pb\chirLlv.
The reaction to an inreruentiori direcrly corresponderi
. to rhe
locus of rhe intervention in relation i" tfr.
ir,av. Cert in
i n r e n e n L i n n sw e ' e e \ p c r i e n L c d a s m o r e r h r e d r e n i n u
to rhe
roenurv. lhrs was e\pccialtv 'rue Inr depul _
rni.".rable _
meor.auon l\hr.h wasqcneraltvde..ribed br irronq
viiuat imaees
o r n o e , e d e c b : ,1 p r F l c r i r / o r a l m e d i ( d r i o n ,r o t l l e
d c p o t .. ; o r
wnen I n-eru-\ecr ro gr!e mc rhe depor ther rrsedro injer r ine and
p,"p.1. Mv reg:tlerebucktrng.
mr hip, rere...
::-,1.i I 1."0,
rren.lhev lonk mF oll of $F inie, rion. | .ropped hearine roices
Dur tnc srcteettects bere .o bdd I d preter ro hear rh""roites
_ such a, otrnzapirre and
:"1-1, i*p'," .anrFp{rhori,s
nspendonc- p'o.iu' e ,ignifi.anrl) fehe, side eBe,
E Iha|| otder
npr, rl anu-ps\rhori.s. Howerer Lhe:c medi.jr,uns ean
onlr be
ralen o-rdlh.Wh.n
lroviders are ,oncerned .r,ou, ..*pf;n*.
rne\. olen pre{nbe depor _ injeeLable _ medi,auon. lhn
racrDrares montronng of .ornpliJn.e.
l n c o n t r a s t .l n r e n e n r i o n \ l o c u s i n g o n m n r c
dijLrl jnter_
\ e n l r o n \ , l o r p a r r i p d n ! 5 .s u ,h a 5 h o u s i , r g
a n d h r . n e f i s ,. r e
oernDed .N sarjsfa.ron: ,a .ocial worler; wJj rl,e
bc,r one
ro,reallvplnush $rouqh mv probte,ns.Huusins
:::i':l-: !..*.d
ocnerrtsand e\e|1,lhing.He d conre b1..orr ii our, r,ork
rut rh!
ra||n. dnd pur it lorlr?rd lo mc. prru,ipanr.
,eemed ro
appreciate the .ationale of such inrenendo;s
when stable _
even when they described having fek under p.ess.r.e
to co_pty.
The thenpeutic retationship
de\ripriuns drise from di5rru,, in rherrpeu,i,
rcra onsnrprbir5cd.onpreuous cxp.rien, es In
previou. reiarion_
snrp\. the approach toeu,ed on medi.d,ion Reta,ion.hip\
seen ds impe'\nral and, au,e of,hon
m e n l | | m e sd n d t r r q u e n l( u m o r e ro f s r a Bw h o d i d
norhari mu.h
ume ro \ee rhe , trenr: ,[ had lJldr wi$ mv so.irl hortFr
Lur.\. She wdi ... ,omc$inq etse fhar ume I !!R!
tery. \cn \iLl
and_t.wa\rJ-r4ng Lo rell hef mv siruarionand ,he rard I loo( rerv
conrjclen(.\ou should be ablc ro eope wirh rhis you
,hhrr\ . know whdt I
rhjn,kins wong wirh rhir larll 1 nn., .1,.
T:jll, lTT I need help?
unoersund l he dddirionatresour,-e\in ACI a o\

o Bla.Lw€urublrshe!! r_td.200.,1

an opportunitv to remodel the relationship becween pronder

and client.
Visits to participanb may continue even llhen a client explicidv
asks lbr them to be stopped. Often the more a client tries to
disengage, the more a team will artempt contact- This noiion of
bereficial coercion often conflicls with the principie of personal
auronomv: Just trying to work out how I can stop them seeing me
now. I don't haye a choice, the)'just come- They don't listen
someum€s. They'll change some appointments but thel" won't
change them all ...'. Though the service cannot bc descnbed as
\'oluntary, the aspecLsof coercion are not legallv decreed, and
therefore pardcipanls do not hold legal righlr to appeal.
In ACT, the team approach means participants are ketlvorked
bv manv menbers of the team collectively. Al1 workers have a
genenc role in addition to thet specialist role, so a psychologist
or social worker has multiple roles such :rs counsellor, advocate
and medication manager. This role diflision may lead to
boun.lan ddtu.ion espe,ialh gi!cn rlrni,ians meet prrtiripdnLr
within their own environ rents.
Maybe as a result of rhe earlv loss of caregive$, manv
pariicipanls expressed difficulties with dre boundaries between
client and clinicians. Seveml participants mentioned that the.e
11?slittle point in fomring a relationship wich clinicians a.5they
rvould alwrys leave, or have roo little tinle, a.! if it was favoumble
to keep some psychological distance rather than risk another
rejection: clients don't know that boundary well enough,
they don'r kno how to handle that distarce properh. Thev start
thinking he and she is alwals talking to me, and they're very
nice to me', so they keep pushing and pushing and pushing. And
ultimatelv, you know, hhat you are facing is rejectiorr. They will
have to reject you'. The ACT tean approach cm therefore be an
advantage: a good thing because they've got to leave anwvay,
they only stay for about two or drree yea6 so, you don't get
altached to drem'. One client succincdy explained: 'iCs all about
dependency, isn't it? It's a iine line'. Panicipan6 may be aware
ihat infomation they transmit to one member is shared amongst
fie uhole team, and indeed the wider semce.
Participants described critical ingredients in becoming
engaged with ACT as revolving around social interventions.
The posirive therapeutic relationships reported were charac-
rcrised by an emphasis oo reducing anxiety *rrough co-
ordinating the wider social environment, for example through
help with housing or benefits or providing social contact: 'There
are lots of outings to the cinema. That stops the isolation ...

a Bracbdl PubhsheF t_rd 2002


keeps up communication,_
.i ^,rli;:ffii:T;Ail5if:,X
own worldview: the help of people like u.., d; ;;;;

jli .J'T,T:H:
*'' th"m'
l"i',ilj,Il' i,
"'t" ' r i n i ( d r p o p u r a u o r r's' ' i i' p.u'h;rn'

Ifpardcipantsregrin rrusiin rhe rher

problemsand paternalism.
rn. "^,r'r1'ffi3";"",t"',:t::5$:
arouno seerngengagemFnras a goal wirhin
irselt. rarher rh.rn

no:ff t' ff :' il'';,,:;:il robeviiied
lili'ft".1,*f':;':i;:';lf 'o'" or';;
,T;::ff-';il.^*hi#rrk "i":ilil:, :::"ll-.'l:;;
mFan'ne.rien,i. rererened
,od, om-:T,i:l""Xtl;::;fi::'j
i;T.l'H',:*1'",1T,*.,Xi'#n-i*H^1.* i:;:...'ff
pnJll:J:lrlron emlnr ro di.Fnqaserronr.erujee,jg3;j.

comes a responsibiliry to know whar ,mental
health, looks like
or peoPre
we""'i'; i;;;;
Thc parirdoxot ACT is dre dispdrirl berween
ourr omer asoiredro
l; i,,.T"',",:1,1,?:::,
on reducingadmissions
ana t.epi.,g Nr,. it ;o opposed
ro dnri_p,)choric..
At,.#"U,"fr. Ui
D \ . o r n m l n r r v m r g h rs e e km o r e . n o r m r t \ o e i a l

c B|JJF||} 'b|rlhcn 1 ,002


as not responding to auditon hallucinations in the street lt is

nor obvious r'lio has moral status within philosophi'al
aooroaches to bioethics,2Tand $'hether rhe participants' or the
ciiiriclu.r"' tiew carry equ:rl t'eight. How can rve descnbe the
differences ber\{een the providers' and parients' penPecdves?

Diachronic ve$us qnchronic assessment

ParticiD:Lntsand provrden can be seen a'i communicating in tivo
diflFrenr tne. ol redsoninq S!1l.hroni, redsoningis .uncemed
wirh e\en6 e\isring in t limirrd time period and ignores
historical antecedents. By contmst, diachronic reasonirg relates
t o p h e n o m e n at . u , h a s l a n g u a q eo r c u l l u r e r a r l h e v n t ( u r o l
chirnqe o\er a pe|iod ol tirni Tt'*e.on,ePb mdt be us'cl to
erplaln rhe dr-Blringtu, u" nl r}le clients dnd providea
The itrre*iews s;gges( rhat the reasons for disentragement
arise - at lext partl - from clients' Previous experiences-of
mental health senices and rejecrion in their pri\ale lives This
history must be acknowledged when deciding lvhat we can
categorise as beneficent coeicion For example, Mr' B har a
histon ofbeine lbrcibly admitied to hospital and does not accePt
a paft;m of ev;nts necessarilyleading uP to these admissions Mr'
B'states be is happy that the A(If team manages his money, but
feels he is forcid to take depot medication to continue this
relalionship. Mr. B sa)s he respecLsdre ACT team, and thac they
a r e a n i m ; r o ' e m e n r ' ( o m p a r a dt o p r e v i o u sl r a m s b u l l n o u l d
D r r L e r ( o b el e f t a l o n . r o , . n r i n u e r v i r } l h i s l i l e . [ 1 r . B I " t o g n i ' e '
i1.61uqri.nr6s psr,, bur kould prcief ro li\' \viLhrhe voi'es
s i \ e n r h e i o o s e q u e n , e so i t a t i n g m i d i c a r i o no ' r h i s ' o ' i a l a n d
iexual life. Given Mr. B's previous forensic histor,v,the pro\iders
are most concerned with medication whiist Mr. B would like
more help wirh his social circumstances. We believe tha! the
eviden.e iueeess drsengagenrenr is nur simph a , on'equen' e of
a la.k .r ii'ighr' Y"'. I ?lient ma\ ha\e heiehren'd le!els of
anxiety as a iesult of paranoid schizophrenia Hol{eve^r this
apped|sro bc.oupled wirh hi"rurical dnre'edent5 rtr rhe lite and
experien,e. t,t rhi individual. Disengage'nenr mav Ihus be seen
solutron to avoid an impasse - and
as a racional choice. The onlY
one afforded by the ACi model - is to model a more
collaborative iherapeutic relationship. There is Pressure to keep

tr E.R Xanriannm the Riseed Fall

of ParadismTheoryin Bioethics ln ,{r?Li'dE nnri A ?}dl' E R WinHer md
l.R. Coo;bs, edr. Oxiord. Blaclq'etl:343-365

s Bhckrel Pul'lisheu Ld 200:


individuals out of hospital because of rhe resolrrce dminage.

It Gmpting to use coercive strategies ro keep peopG on
medication and in the communiqT. However in thi long'run
ma\ be morc.orr ehts.ri\ero ri\k rhis possibitiNdnd give-etienrs
l l ' e n g h r l o , r \ ' n L ' w h i l s li n . r e a r r n er h e i r s o ,i a l w e l r r r F .
Though there is a need for risk asiessment \,rirhin communiw
care, the currenr climate of blame mav bias fhtse posiri;
as\essmcnb.For exdmplc. r ,linr.ian ma) llor ri.l , hansins r
( Iienl lrom inie.uble 'nedi.arjon ro oral medr drion - su, h
the case of M.. B - because it is more difEcult to monitor
compliance in this case.1'here may be a sptemic overemphajis of
the chances of a clienr defaulring-on medication, and frirther of
ttre consequences of such an occunencc.
Funlcr rmininq idenuMne dnd rrearinA
n9l:C'_.' rarhef Lhdn re,ognirrng rnd developing menrai
nearul . L\pFnmenrs hdvectcmonclraLed *rdl ir people ar. in dn
environmenr wherd fie\ .11s elpecred ro he seirizoDhreni..
p a r h o l o g w : l l b e t u u n d e \ e n i n n u r m a t p " o p t e . r 3C t i e i , r l , u . h
as Mr. B, who have a forensic histow, wili ahays come out as a
high risk on objective risk assessmentmeasures. Given mental
health professio[als are nor trained to recogdise mental .health,,
tlris negaFs Mr. B's chance of leading an independenr life _
unless he disengagesfiom serices. In the narional healch care
system ofrhe UX, the blame culture is particularly pre.lalent since
the government is uldmarell responsibte for rhe qualir,v of the
$stem. Thus, any failure and uncoward incident in heilth care
can_becomea polirical issue,which other political parries and rhe
media are likely to exploir. This creates a clinate for
accountabilir,v,which may lead to scapegoadng and blame.

Proximal vemus distal intervendons

The locus ofinrerventioD -Iiom those direcrlv affecring the bodv
to those focusing orl the wider social environment _ appears to
be critic2l in difterenriaring which intenentions are expdrienced
a^scoercive. This can be conceprualty defined as foltows. proxjmal
rnrervenuons - such as medication _ directlv irtedere rvith the
body. Distal intervenrions - such as housing and benefits _ are
siruared,aravtrom Lhepoinr or origio. espe;ialtvof lhe bod). In
s L d n d d r d . a r ec l r e n b . o m p t v i n gw i r h p r o x i m a li n r e l a . n r i o n r, r e
des.nbe.l ds engagedwirh 'ewi(e' dnd may Lhenbe offered more
distal interventions focusing on rhe social context such ar aid

?3D. Rosenhan.
On beingsde in insbe rs./3:\7g.250-2b8.

6 Rrr.k,cr Pubtishd^L'd ?002

with benefits and housing. However, lhe clients inrenrieued
described a pattern where non-compliance with proximal
inteflenlions was confounded by clinicians with non-compliance
with distal inteNentions provoking non-engagement. The
participanti interviewed described fe€ling more coerced when
interventions were proximal - for example being restnined,
medicated, or compulsorily deL1ined. When interventions were
more distal. pressure or iererage was recognised but the
participanLs could recognise the \'?lue of these inteF/emions.
The ad ntage of ACT is that the additional resources in the
model - for example the increased staff: client ratio - can afford
the oppoftunilv to lbcus on distal inteFentions as a leverage to
engagement. These may be used to monitor clienb with sr.rtutory
- rather than implicit - coercion needed if the isks dictate this.
Huuerer to allow t]ri.. serucesnerd to rerugniseenga8emenras
a goal within itself. Further our research reveals a qstematic flaw
namel)' the aisumption by ofier sewices that non{ompliance
r,,ith proximal intenentions means non-engagement with seNices
per se. This appears to reflect an imposition of a positivist view of
what is 'good rreatment' for individuiJs wi*r psychosis.

The 'lived experiences' of participanrs embed ethics within a past
and a future. Clients' narrativesprovoke questions about the ethics
ofthe thenpeutic relationship, the locus ofcoercive intenentions,
and the porendality for recovery within community psychiatn.
.A.lthoughthe participants' accoun6 ofthe diachronic implicadons
ofbeneficent coercion differ from the providers' more s).nchronic
approach, common dremesare apparena In ou. opinion, an act of
coe.cion leill be experienc€d - and should be examined dilferendy
- for an individual without a history of ps,vchiatricsenices who is
subj€ct to inte.vention' treatment, and a clientwho has been
shown to disengagecontinuouslv.
Phenomenologi,.rl inallsis e\dmines 'Lhe glnunded e\peri-
en,es of .ick per.onr. familier. and healer. in conrer,ts.--
Ue hope to have shown that such approaches are necessaryto
examine different peNpectives in the ethics of community
psychiaty by,.recognising that rhere may be levels ot moml
explanation."" The complexity of community psychiatrv
necessitatesattempts at the dialectical integntion of diachronic

'e Hormaster, ,4. dt. nor 14.

- Yesley,
Gracia,ar. .tl. note16.

o Bli.r*n FubrishcELLd 2002