Ethiek en deontologie van het pedagogisch handelen laatste deel.pdf

# Introduction to mental healthcare and its historical evolution Mental healthcare is a broad field encompassing the study and application of knowledge to prevent, improve, or restore mental health. ### 1.1 Definition and applications of mental healthcare Mental healthcare is defined as a broad term for the research and application of knowledge aimed at preventing, improving, or restoring individuals' mental health. This field has various applications and settings [1](#page=1): * **Residential care:** This includes admissions to psychiatric hospitals or psychiatric departments within general hospitals [1](#page=1). * **Outpatient care:** This involves services offered in community mental health centers, private practices, day centers, and meeting houses [1](#page=1). * **Residential facilities:** These are places like sheltered housing and psychiatric nursing homes [1](#page=1). ### 1.2 Disciplines involved in mental healthcare A multidisciplinary approach is fundamental to mental healthcare, involving a range of professionals such as pedagogues, psychologists, psychiatrists, therapists, nurses, and support staff [1](#page=1). ### 1.3 Historical evolution of psychiatry The history of psychiatry is marked by a significant shift from confinement and harsh treatment to a more humanized approach, though debates about restraint and coercion continue [2](#page=2). #### 1.3.1 Early practices and the emergence of humanization * **1793:** Philippe Pinel is a pivotal figure who, in 1793, freed individuals from chains in dungeons and psychiatric hospitals. Prior to this, people deemed "insane" were often confined in chains and exhibited like animals [1](#page=1). * **Shift to medical treatment:** The move was towards medical treatment rather than mere confinement. Psychiatric hospitals began to be established to house individuals, with the dual aim of healing (medically) and disciplining them through structure and work [1](#page=1). * **19th-century developments:** The 19th century saw an increase in the number of psychiatric institutions [1](#page=1). * **Dr. Guislain:** In Flanders, Dr. Guislain was a pioneer, establishing the "Psychiatric Hospital Dr. Guislain" in 1857. This period also involved discussions about the ethics of confinement and the use of isolation cells [1](#page=1). * **Focus on humanization:** From this point forward, efforts focused on how to limit the use of coercion. Guislain and Pinel advocated that individuals with lived experience of psychiatric admission could be the most effective caregivers because they understood the patient's perspective [1](#page=1). #### 1.3.2 Psychiatry in Flanders: current landscape and challenges * **Prevalence of institutions:** Flanders has a substantial number of psychiatric hospitals [2](#page=2). * **Reasons for admission:** Admissions occur for various reasons, including psychosis, substance abuse, uncontrollable aggression, depression, and unprocessed trauma [2](#page=2). * **Therapeutic offerings and integration:** Psychiatric hospitals offer a range of therapies and environments for patients to find peace. They are closely integrated with other mental healthcare services like meeting houses and sheltered housing [2](#page=2). #### 1.3.3 The efficacy and controversies of modern psychiatry * **Necessity and benefits:** Modern psychiatry is considered essential for many, acting as a means to prevent total breakdown or to make life manageable for both the individual and their environment, especially in regions lacking community support. Many projects in psychiatry aim to help people recover by providing a safe space from overwhelming internal and external worlds [2](#page=2). * **Ongoing concerns:** Despite advancements, there are testimonies of coercion, exclusion, physical restraint (fixation, binding), and power imbalances. Examples include experiences of being locked up, denied requested help, or being treated like a child [2](#page=2). * **Focus on reducing coercion:** The guest lecture aims to foster a better understanding of coercion and explore ways to minimize its use in psychiatry [2](#page=2). #### 1.3.4 The concepts of coercion and power The past decade has seen increased criticism regarding coercion and power dynamics in various care sectors [2](#page=2). * **Testimonies and reports:** Testimonies from youth institutions describe harsh experiences, from painful restraint to sleeping on concrete blocks. Leaked reports on conditions in closed institutions in Flanders have also generated significant discussion. In educational settings, particularly special needs education, students are sometimes placed in isolation rooms inappropriately [2](#page=2). * **Historical context of criticism:** Criticism of coercion and power is not new; the history of caregiving is a narrative oscillating between humanization and coercion. This critique spans across different sectors, including psychiatry, special youth care, disability care, and education [2](#page=2). > **Tip:** The historical evolution of mental healthcare highlights a continuous tension between the need for control and the imperative of humane treatment. Understanding this history is crucial for contemporary practice. > **Example:** Philippe Pinel's action in 1793 is a landmark example of the shift towards humanization, moving away from treating individuals with mental illness as animals in cages towards a medical and structured approach [1](#page=1). --- # Understanding coercion and power dynamics in mental healthcare This section examines the multifaceted nature of coercion and power within mental healthcare, focusing on patient experiences and theoretical underpinnings. ### 2.1 Defining coercion and power Coercion and power dynamics are critical elements that have historically been present in the field of mental healthcare and other care sectors, existing on a spectrum between humanization and coercion. This is not a new phenomenon but has been a subject of critique for the past decade, particularly highlighted by testimonies from youth institutions and concerning reports on closed psychiatric facilities. This critique extends to various sectors including psychiatry, special youth care, disability care, education, and elderly care [2](#page=2) [3](#page=3). #### 2.1.1 Formal coercion Formal coercion, often referred to as "hard coercion," includes interventions that are legally regulated and involve direct actions such as isolation, physical restraint (fixation), involuntary admission, and forced medication. The guiding principle is to apply these measures as minimally as possible [3](#page=3). **Isolation cell:** An isolation cell is a room designed to be low in stimulation and involves solitary confinement. Its use can be excessive and not solely for safety reasons, but also for perceived therapeutic benefits, as a form of punishment, out of habit (even when legally impermissible), or as a misguided attempt to achieve internal peace. Research indicates that isolation does not enhance safety, can be traumatizing, exacerbate psychosis, and is detrimental to the therapeutic relationship [3](#page=3). > **Example:** A patient recounts being placed in an isolation cell immediately upon arrival following an escape attempt. Despite expressing how traumatizing the experience was and hoping to discuss the reasons for the escape, they remained restrained for 26 hours and then confined to the isolation cell for four additional days [3](#page=3). #### 2.1.2 Informal coercion Informal coercion, or "soft coercion," encompasses all measures not explicitly regulated by law. This can include rigid rules, punishments, imposed structure, and threats. Examples include not having a choice in what to eat, being forced to go to bed, or being prohibited from contacting loved ones or a suicide hotline. This concept is often described as being only "the tip of the iceberg" of coercion, as its impact can be as negative as formal coercion, yet it is frequently difficult for healthcare professionals to recognize [3](#page=3). #### 2.1.3 Exclusion Exclusion occurs when individuals who desire care are denied access to it. This can happen to patients with complex or "severe" problems deemed too aggressive for treatment, or those perceived as repeatedly relapsing, suggesting that treatment is futile. Patients may also be excluded if they are not considered motivated enough to attend certain therapies, or face the threat of treatment cessation if they do not cooperate. The more complex a person's issues, the harder it is to find help, creating a risk that mental healthcare becomes a "place of excellence" rather than fulfilling its social function [4](#page=4). #### 2.1.4 Understanding coercion Defining coercion is not straightforward and cannot be reduced to a simple list of techniques. It is more accurately understood within a "coercive context" (Sjöström, 2006), where the focus shifts from the techniques themselves to the relationships and circumstances that lead to an experience of coercion. Different forms of coercion can reinforce each other; for instance, strict rules might provoke aggression, leading to increased isolation and exclusion [4](#page=4). * **Coercion** refers to specific interventions. * **Power** refers to the practice and context in which coercion takes place. #### 2.1.5 Power (Foucault) Drawing on Foucault, power is not a brute application of force but is interwoven into relationships, being mobile and unstable. The focus in understanding power is on social and unconscious power structures, rather than solely on individuals or narratives perceived as "wrong". The central question is: what power relations unfold between people? This perspective encourages listening to individuals who have experienced these dynamics [4](#page=4). ### 2.2 Patient experiences of coercion and power Research, such as the study by Verbeke et al. involving interviews with former patients, consistently found that almost all participants experienced coercion in various forms. A specific dynamic emerged across different coercive techniques: desubjectification [4](#page=4). #### 2.2.1 Desubjectification Desubjectification occurs when, within a coercive context, individuals are approached one-dimensionally as a "patient," overshadowing their unique life stories, personal struggles, and other social roles. For example, behaviors like singing might be interpreted as mania, or criticism as indicative of borderline personality disorder, limiting the individual's ability to express themselves freely as it gets linked to their diagnosis. This process legitimizes coercion and imbues interventions with a coercive quality, as it can be perceived as important for the caregiver to apply these measures. Coercion profoundly impacts an individual's core subjectivity; many enter treatment because their subjectivity has been affected, only to have it further pressured by coercion when they are solely viewed through the lens of their illness [5](#page=5). > **Example:** A patient recounts being told they were experiencing psychosis and imagining a situation after having an argument at work, despite seeking therapy to address it practically. This invalidation was deeply distressing. Another patient describes being told they were "too busy" and not allowed to go home for the weekend, with their entire behavior being attributed to their illness once admitted to psychiatry [5](#page=5). #### 2.2.2 Broken contact Desubjectification leads to "broken contact," making it difficult to establish a bond of trust once this rupture occurs. This prevents the development of a therapeutic relationship, as coercion often operates within a context that bypasses authentic relationships, with healthcare professionals enforcing rules and patients passively receiving them. Singular differences between individuals are lost, and what is important to the patient is often no longer seen as significant [5](#page=5). > **Example:** A patient suggests that more communication with patients would significantly reduce power abuse. They describe a perceived separation between nursing staff and patients, with patients merely circulating and attending therapy. More ordinary conversations, they believe, would foster mutual trust [5](#page=5). #### 2.2.3 What constitutes good care? All participants in the Verbeke et al. study also recalled instances of good care, characterized by a lack of coercion or where boundaries felt non-coercive. This involved building a bond and being recognized for one's unique existence, rather than being treated as a mere part of a category or diagnosis. Research by Larsen & Terkelsen indicates that caregivers who have a strong bond with their patients are more likely to perceive them as unique individuals and thus use less coercion [6](#page=6). > **Example:** A patient states that when they felt caregivers believed in them, they believed in themselves more. Conversely, when they felt compelled to just follow rules, they felt like an object, not a human being. They found those who approached them humanely to be the most helpful [6](#page=6). ### 2.3 Power relations and coercion No single technique, such as isolation or rules, is inherently coercive. Something becomes coercive when it is embedded within a power relationship that results in desubjectification. This creates a coercive context, where viewing someone solely as a "patient" makes coercion appear logical and continually widens the distance between the patient and the healthcare provider [6](#page=6). #### 2.3.1 The single story Drawing on Adichie, the danger lies in becoming fixed in a singular narrative. Without realizing it, people can be confined to a "single story," leaving them with no room for maneuver [6](#page=6). #### 2.3.2 Power and identity Power can fixate individuals into specific identities, such as "patient," "psychotic," "disabled," or "borderliner". This can lead to a state of powerlessness, akin to an actress trapped in a poorly written script. Psychoanalysis suggests that subjectivity is not singular, and no one is fully reducible to a single identity. Clinical work should therefore be attentive to this fragmentation, recognizing that areas of doubt and where things do not work are more important than rigidly adhering to a fixed identity [6](#page=6). --- # Ethical considerations and alternative approaches in mental healthcare This topic explores the ethical complexities inherent in mental healthcare, distinguishing between morality and ethics, and presents alternative methods to reduce coercion by addressing underlying attitudes and fostering a more humane approach [10](#page=10) [7](#page=7). ### 3.1 The prevalence and roots of coercion in mental healthcare Despite evidence that coercion is counterproductive in mental healthcare, its widespread use stems from a combination of ignorance and, more significantly, fear and powerlessness experienced by healthcare providers [7](#page=7). #### 3.1.1 Fear and powerlessness as drivers of coercion * Fear and powerlessness arise when healthcare providers feel ineffective in their interventions with patients [7](#page=7). * Anxiety, according to Lacan, signals that something is occurring and requires interpretation [7](#page=7). * The therapeutic relationship is an integral part of treatment, and healthcare providers can be profoundly affected by their work [7](#page=7). * Psychological suffering can evoke surprise, disbelief, and fear, confronting providers with their own vulnerabilities and the anxieties associated with the "strange" or "mad" that they may carry within themselves [7](#page=7). * The inability to bear this anxiety often leads to the development of "social defense mechanisms," which are ways to avoid confronting fear [7](#page=7). * Coercion and exclusion are common mechanisms employed to manage or eliminate this anxiety [7](#page=7). * Increased feelings of insecurity lead to a greater desire for control [7](#page=7). * The problem is not the presence of fear itself, but rather the denial and projection of this fear onto patients [7](#page=7). #### 3.1.2 Justifying coercion * When providers react in ways that feel alien to them due to fear and powerlessness, they may attempt to justify their actions [8](#page=8). * Instead of self-reflection and team-based problem-solving to find alternative approaches, providers might rationalize their coercive behavior [8](#page=8). * This rationalization is termed "non-implicated violence" [8](#page=8). ##### 3.1.2.1 Non-implicated violence * Rationalizing coercion involves justifying it with seemingly logical explanations, such as claiming isolation provides "calm" for a young person, which is often nonsensical [8](#page=8). * It also involves systematizing coercion, for example, by implementing a rule that all young people must be in their rooms from 5 PM onwards [8](#page=8). * These subtle mechanisms can come to dictate care, leading to a feeling of detachment from one's work, performing actions "because they must" rather than through genuine engagement [8](#page=8). * This can result in becoming stuck in rigid rules and protocols [8](#page=8). * An example is Chris Chapman's experience in a facility where children with disabilities were frequently restrained. A stark difference existed between day and night shifts; during the day, immediate restraint was common, while at night, children were held on laps. Chapman had forgotten that a frightened child could be comforted by being held, thus avoiding immediate confinement. This illustrates how practitioners can stop reflecting on their actions [8](#page=8). #### 3.1.3 Consequences of non-implicated violence * It conceals the underlying fear and powerlessness within the work [8](#page=8). * It stifles ethical and creative thinking, as noted by Hannah Arendt [8](#page=8). * The therapeutic bond deteriorates [8](#page=8). * It leads to desubjectification and a coercive environment [8](#page=8). ### 3.2 Alternative working methods and visions Reducing coercion requires a shift in perspective and the implementation of alternative approaches that prioritize humane interaction and understanding over control [7](#page=7). #### 3.2.1 Specific alternative techniques A wide array of techniques and interventions exist for managing aggression, psychosis, and suicidal ideation, recognizing that there is no one-size-fits-all solution. The choice of intervention depends on the target group, the skills of the providers, the history of the case, and the architectural possibilities of the setting [9](#page=9). * **Seclusion area:** This is not solitary confinement but rather a space that is home-like, with continuous presence and significant proximity from staff. This approach has resulted in reduced aggression and fewer instances of isolation, demonstrating that containment can be achieved through different means [9](#page=9). * **Open Dialogue:** Developed by Jaakko Seikkula in Finland, this approach emphasizes connecting through speech during psychosis. It involves open conversations where participants can express anything, without a specific agenda. By enabling dialogue within the patient's context, many crises can be resolved or diminished. The core idea is that psychotic symptoms are expressions of a crisis, not a deficit. This method has led to a significant decrease in forced admissions, medication, and coercion [9](#page=9). * **Life Space Crisis Intervention (LSCI):** This method involves talking with young people in crisis to de-escalate situations. The underlying principle is that problematic behavior communicates something, and the crisis can be transformed into a learning opportunity, teaching young people how to talk about their issues [9](#page=9). #### 3.2.2 The limitations of techniques alone Techniques, in isolation, are insufficient and can themselves become new tools of coercion. For example, a padded isolation room, while a technique, can still be used coercively. As Foucault stated, "Nothing is bad, everything is dangerous". Therefore, techniques are only effective when embedded within ethical thinking [9](#page=9). ### 3.3 Understanding ethics and morality in mental healthcare #### 3.3.1 Ethics and morality distinguished * **Morality** refers to a system of social rules and moral codes that define what is considered good, wrong, or normal. It attempts to answer precarious and uncertain matters with clear rules, sometimes referred to as "quantifying ethics" [10](#page=10). * **Ethics**, conversely, goes beyond regulations. It involves reflecting on behavior without prescriptive rules, placing the question mark at the center of precarious and uncertain situations [10](#page=10). #### 3.3.2 Ethics and responsibility Jacques Derrida posits that ethics exists precisely because there are no rules; it arises from the necessity of inventing rules. Responsibility only emerges when one does not know what to do. Ethics, therefore, is about how one engages with a situation and handles responsibility in the absence of pre-defined answers [10](#page=10). #### 3.3.3 Morality and power The problem with coercion and power lies in responding to precarious human experiences with rigid rules, a process known as moralization. An example is how to handle sexual relationships between patients: either prohibit them outright or assess each case individually. Psychiatry often exaggerates normality, leading to punishment for minor infractions, such as being late [10](#page=10). #### 3.3.4 Psychoanalytic perspective on ethics From a psychoanalytic viewpoint, ethical questions arise in healthcare settings due to individuals seeking help, but healthcare providers should not answer these questions for their patients. This is because imposing one's own values is ideological. The human psyche inherently works against the good; even well-intentioned actions can clash with internal drives and unfamiliar aspects of oneself [11](#page=11). * The absence of a fixed answer does not imply a void; rather, everyone must find their own way to navigate life and interact with others [11](#page=11). * While providers cannot provide definitive answers to patients' ethical dilemmas, they can open up questioning around these issues [11](#page=11). * Ethics is an infinite process, not static, requiring constant re-evaluation of established norms, as described by Calum Neill [11](#page=11). * Healthcare providers should operate from a position of not knowing, which facilitates a collaborative search for solutions [11](#page=11). * Ethics aims to dismantle what power has attempted to solidify [11](#page=11). #### 3.3.5 Ethics and uncertainty in psychiatry Healthcare providers must embrace uncertainty and doubt, starting from the premise of not knowing and being unable to know everything in advance. For instance, while exploring alternative techniques for seclusion, each crisis necessitates finding a new compass. Knowledge and technical skills do not eliminate doubt and uncertainty, as seen in the prenatal detection of mental disabilities. Doubt and uncertainty must remain central, allowing for a "void" to exist [11](#page=11). * The concept of the "broken institution," as described by Maud Mannoni, suggests that institutions do not always need to have all the answers and should allow for the possibility of things going wrong. An institution is not a place where everything is known or managed [11](#page=11). * Opening up thinking, as advocated by Hannah Arendt, serves as a constant remedy against the unthinking application of coercion [11](#page=11). #### 3.3.6 Allowing uncertainty in practice * This involves not trying to control everything and being willing to take risks [12](#page=12). * It means tolerating powerlessness, for example, during relapses [12](#page=12). * Exclusion is avoided by not pre-determining what individuals should do or how they should be [12](#page=12). * Reflective thinking should be continuously fostered through a culture of open communication, taking time for reflection, and engaging external perspectives to introduce new impulses and prevent stagnation [12](#page=12). * Presenting cases to external professionals, while time-consuming, is highly beneficial for allowing uncertainty [12](#page=12). * The documentary "Le Courtil" illustrates how guidance involves a constant process of tolerating what is unbearable for the children, not necessarily "limiting the children," but limiting "that which is difficult for that specific child" when necessary. This is achieved through flexibility in rules and the absence of isolation cells, made possible by the ability to tolerate and bear [12](#page=12). * This approach is only feasible because ethics is central to the practice [12](#page=12). #### 3.3.7 Ethics and the therapeutic bond Ethics is both singular and relational; it exists in relation to others. In healthcare, individuals seek help with ethical issues, necessitating investment in the therapeutic bond. Analyses show that coercion diminishes when investment is made in the therapeutic bond, a principle that is both simple and profoundly difficult to implement [12](#page=12). ##### 3.3.7.1 Investing in the therapeutic bond * This involves not abandoning individuals during crises (e.g., in a seclusion area) and not giving up on them during relapses or difficult behavior [12](#page=12). * It means seeing the person beyond their diagnosis [12](#page=12). * Problematic behavior and symptoms should be viewed as solutions rather than mere "difficulties" [12](#page=12). * Individuals are not straightforwardly intentional beings; case discussions are a valuable method for fostering this understanding [12](#page=12). * Building a connection to both people and places is crucial. Places should be welcoming, allowing individuals to "be," and offer continuity of care. Through this bond, containment becomes possible [12](#page=12). ### 3.4 Illustrative case studies #### 3.4.1 Case: Theft T., aged 22, exhibits compulsive stealing behavior. * **Initial team approach:** Daily checks, punishments with room arrest or isolation, and forced confessions were ineffective [13](#page=13). * **Case construction:** It was revealed that T. had been compelled to steal as a child to fund his mother's heroin addiction, and he struggled to detach from this identification [13](#page=13). * **New approach:** Money was confiscated without punishment or condemnation. The focus shifted to fostering other identifications, such as "the cook." T. was no longer viewed as a thief [13](#page=13). * **Outcome:** This led to greater mental peace and reduced aggression [13](#page=13). #### 3.4.2 Case: Substance abuse L., aged 29, was admitted involuntarily following a history of dealing and using drugs. * **Team statements:** Comments like "it's always the same with these junkies" and "he doesn't think I'm afraid" revealed desubjectification driven by fear [13](#page=13). * **Patient's provocation:** The patient stated, "I love the war between me and the staff" [13](#page=13). * **Navigating the situation:** There are no fixed parameters for dealing with such cases, posing a risk of exclusion and control [13](#page=13). * **Case construction:** The focus was on understanding the individual's unique history and the story their behavior told. Drugs and challenging behavior were interpreted as forms of escape [13](#page=13). * **Building a bond:** Establishing a connection through humor and trust was prioritized. Discussions around substance abuse were facilitated with an external supervisor [13](#page=13). ### 3.5 Visionary change and its impact #### 3.5.1 The importance of vision and culture Techniques alone are insufficient to reduce coercion; reduction is only possible when embedded within a broader vision of problematic behavior and mental suffering, and when the organizational culture shifts [14](#page=14). * This shift involves allowing uncertainty, opening up thinking, and fostering the therapeutic bond, creating a broad ethical foundation from which to develop a vision [14](#page=14). * It requires making space for the powerlessness and anxiety inherent in the work [14](#page=14). * This, in turn, changes human relationships and impacts desubjectification [14](#page=14). #### 3.5.2 Examples of visionary change * **Villa Voortman:** This meeting house for individuals with dual diagnoses has a distinctive vision of addiction, psychosis, and care. It avoids isolation cells and forced treatment, actively opposing exclusion [14](#page=14). * **Meander:** This department for individuals with mental disabilities and psychiatric problems adopted a new vision focusing on individual perspectives, recognizing that problematic behavior expresses something, and listening beyond the disability. This resulted in a significant reduction in aggression and isolation and a drastic decrease in rules [14](#page=14). * **La Borde:** This institution strongly emphasizes "institutional psychotherapy." The core idea is that the hospital itself is "sick" and needs care. This is achieved through free circulation, heterogeneity, and nurturing the collective. The purpose is to prevent the institution from reinforcing illness and instead to become a place where new possibilities can emerge [14](#page=14). #### 3.5.3 Responsibility for visionary change * The question arises as to who should drive this visionary change. It is crucial to avoid attributing responsibility solely to others [15](#page=15). * Everyone, in their own way, influences the system. As Arendt stated, "even if you are part of a system, you must always be held accountable for what you personally do (or do not do)" [15](#page=15). * Educators have a unique opportunity to make teams aware of power dynamics and to promote alternative visions [15](#page=15). --- ## Common mistakes to avoid - Review all topics thoroughly before exams - Pay attention to formulas and key definitions - Practice with examples provided in each section - Don't memorize without understanding the underlying concepts

| Term | Definition | |------|------------| | Mental Healthcare | A broad term encompassing the research and application of knowledge to prevent, improve, or restore the mental health of individuals. | | Residential Care | Involves inpatient treatment within psychiatric hospitals or specialized psychiatric departments of general hospitals, providing a structured environment for intensive care. | | Outpatient Care | Services offered outside of a hospital setting, including mental health centers, private practices, day centers, and community meeting houses, allowing individuals to receive support while living at home. | | Supportive Housing | Refers to living arrangements such as sheltered housing or psychiatric nursing homes that provide a secure and supervised environment for individuals with mental health conditions. | | Psychiatry | The medical discipline focused on the diagnosis, treatment, and prevention of mental illnesses, evolving from custodial care to a more medically-oriented approach. | | Humanization (in mental healthcare) | The historical shift in the approach to individuals with mental health conditions, moving away from confinement and mistreatment towards more compassionate and medically-informed care, emphasizing dignity and respect. | | Coercion (in mental healthcare) | The use of force or constraint in mental healthcare settings, a practice that has historically been debated and is increasingly being critically examined to find ways to minimize its application. | | Discipline (in historical psychiatry) | In the early history of psychiatry, this referred to the establishment of fixed structures, routines, and work for patients as a form of treatment and behavioral management. | | Isolation Cell | A room used for the confinement of individuals, often in a psychiatric or correctional setting, typically characterized by minimal stimuli and restricted contact, and a subject of controversy regarding its use. | | Specialized Youth Care | A sector within the broader field of social services that provides care and support for young people with complex needs, often involving behavioral or developmental challenges. | | Care for People with Disabilities | Services and support systems designed to assist individuals with physical, intellectual, or developmental disabilities, aiming to improve their quality of life and promote independence. | | Formal Coercion | Refers to overt forms of coercion that are regulated by law, including isolation, physical restraint, forced hospitalization, and involuntary medication administration. The aim is generally to use these measures as little as possible. | | Informal Coercion | Encompasses subtle forms of pressure not explicitly codified in law, such as rigid rules, punishments, imposed structures, and threats. This can include restrictions on personal choices or communication. | | Exclusion | The denial of care to individuals who desire it but are unable to access services, often due to perceived "heavy" problems, repeated relapses, or perceived lack of motivation, creating barriers to seeking help. | | Coercive Context | A situation where interventions are experienced as coercive, not due to the techniques themselves, but due to the surrounding circumstances and relationships, leading to a feeling of being controlled or pressured. | | Power | In the context of mental healthcare, power is not a simple application of force but is intricately woven into relationships, being mobile and unstable. It involves understanding social and unconscious power structures. | | Desubjectification | The process by which individuals in a coercive mental healthcare setting are primarily viewed and treated as a diagnosis or "patient," overshadowing their unique life stories, individual struggles, and other social roles. | | Broken Contact | A consequence of desubjectification, where the patient-provider relationship deteriorates, making it difficult to establish trust and a therapeutic bond, as authentic relationships are avoided. | | Single Story | The risk of being confined to a fixed narrative or perception, preventing individuals from having agency or room for maneuver, as described by Adichie, where people are "locked up" in a singular perspective. | | Power and Identity | Power can be used to solidify an individual's identity into a specific category (e.g., "patient," "psychotic"), leading to a sense of powerlessness, akin to being trapped in a poorly written script. | | Dwang (Coercion) | Refers to the use of force or other pressures to compel individuals to comply with treatment or rules, often seen as counterproductive to care and stemming from fear and powerlessness within mental healthcare settings. | | Angst en onmacht (Fear and powerlessness) | These are identified as root causes for the pervasive use of coercion in mental healthcare, where healthcare providers may feel unable to help patients, leading to reactive and often detrimental interventions. | | Niet-geïmpliceerd geweld (Un-implicated violence) | A subtle form of violence that arises when healthcare professionals act out of duty rather than genuine involvement, leading to routinized practices, adherence to rules and protocols, and a detachment from the human aspect of care, effectively masking underlying fear and powerlessness. | | Seclusion Area | A designated space for individuals experiencing distress that is designed to be homely and inclusive, with constant presence of staff, aiming to reduce aggression and the need for isolation through proximity and a comforting environment. | | Open Dialogue | A therapeutic approach originating in Finland that emphasizes connective communication during psychosis, allowing for open expression without predefined goals, aiming to alleviate crisis by providing context and a space for individuals to find words for their experiences, leading to reduced hospitalizations and medication use. | | Ethiek (Ethics) | The philosophical reflection on precarious and uncertain human matters where clear-cut answers are absent, involving questioning behavior without prescriptive rules, and centralizing the "question mark" in complex situations, distinct from morality which relies on established social rules. | | Moraliteit (Morality) | A system of social rules and moral codes that defines what is considered good, wrong, or normal, often used to provide clear answers to complex human experiences, which can be problematic when applied rigidly in mental healthcare. | | Therapeutische band (Therapeutic alliance) | The relationship of trust and connection between a healthcare provider and a patient, which is crucial for effective mental healthcare and is seen as a means to reduce coercion by fostering understanding and support. | | Visieverandering (Vision change) | A fundamental shift in perspective and culture within mental healthcare settings, moving beyond techniques to a broader understanding of problematic behavior and mental suffering, which is essential for reducing coercion and fostering a more ethical and supportive environment. |