Abstract
Based on extensive ethnographic research in psychiatric custody for adolescents, this article uses the creation of, implementation of, and resistance to a treatment model to reveal issues of constraint in American psychiatric treatment. The treatment model is called Counter Response. As a model Counter Response shifts the treatment focus in a total institution for mentally ill youth from the youth themselves to the staff response to the youth. This article uses Counter Response as a case study to illustrate the close ties between constraint and autonomy in psychiatry. It also shows how models like Counter Response reflect the power of unregulated treatment paradigms in American adolescent institutional psychiatric intervention. Finally, the article demonstrates that resistance to Counter Response reveals a tension American practitioners have with psychiatry’s constraining power.
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Notes
All names are pseudonyms.
This assumption was based on anthropological research on psychiatry including Rebecca J. Lester’s (2007) “Critical Therapeutics: Cultural Politics and Clinical Realities in Two Eating Disorder Treatment Centers” and (2009) “Brokering Authenticity: Borderline Personality Disorder and the Ethics of Care in an American Eating Disorder Clinic,” T.M. Luhrmann’s (2000) Of Two Minds, Lorna A. Rhodes’s (1991) Emptying Beds.
These phrases come from a local historical text on Havenwood. I do not cite the document because it uses the original name of the institution.
Havenwood identifies the youth that live there as “troubled” and the goal of the institution to make them “productive citizens.” The concept of “troubled youth” is pervasive in the field of residential treatment as is the framework of “at risk” youth. See for example Larry Brendtro and Mary Shahbazian (2004) Troubled Children & Youth: Turning Problems into Opportunities, Larry K. Brendtro, Martin Brokenleg, and Steve Van Bocken’s Reclaiming Youth at-Risk: Our Hope for the Future, and Nicholas J. Long, Mary M. Wood, and Frank A. Fecser’s Life Space Crisis Intervention: Talking with Students in Conflict.
Restraints often do not follow the choreographed procedure and they are considered rather violent aspects of treatment. See Hejtmanek 2010 for more information.
Of course what counts for dangerous behavior is subjective. According to a Vice President of Havenwood and the TCI training dangerous behavior is when a youth becomes violent against him/herself or others. Destruction of property does not count in this definition.
African American linguistic and cultural practices were not only common in the milieu but elsewhere I argue become the way to communicate treatment progress (Hejtmanek 2010, in press).
These goals were shared in written and presentation format. I, and everyone at Havenwood, was trained in Counter Response. Written materials produced by the creators of the model were shared. I am quoting from the PowerPoint presentation and the written document. However, I do not cite them due to author confidentiality.
The lead author and clinician of Counter Response did not work directly with the residential population or on the units at Havenwood. And in over twenty years at the institution she never worked with a residential client in individual therapy; all of her patients were out-patient clients.
I do not have space to go into here but restraints did become, for many, a part of the job. In fact, part of the socialization process for staff members was to discuss the difficulties of restraining and then to get used to the fact one had to restrain. I observed the New Staff Support Group that repeatedly discussed this process—honoring and accepting the challenge of performing restraints so that one could do one’s job. I am not surprised that James’ statement is that he didn’t feel anything about it, he just did his job. He is articulating the local standard framework for dealing with the difficult job of restraining youth.
I interviewed the lead psychologist about her work at Havenwood. She reiterated the Counter Response information I had learned in trainings and by reading the papers she had co-authored. However, I realized how inquiries into the theoretical and evidenced based perspectives of Counter Response could be negatively interpreted or appear as a challenge to authority. Therefore, I use the formal representation of Counter Response and workers’ discussions and responses to it as my primary sources of data. I am less interested in arguing for or against Counter Response and more interested in showing how a model, its implementation, and the resistance to it are meaningful in terms of psychiatry’s power to constrain.
Briefly, most youth lamented the fact that they were wards of the state or under their parent’s supervision and, therefore, legally powerless in their treatment prescription. Many of the youth at Havenwood did not believe they, nor others, were “bad enough” to be in residential treatment. Nonetheless, most went about their treatment process, learning to share in therapy, to not act out and need restrained, and to “make better choices” in a variety of ways, the desired autonomous result of psychiatric constraint (Velpry 2008). They also learned to “do you” and to “take their consequences” which integrates hip-hop logic into psychiatric treatment practice (Hejtmanek, in press). I argue that due to this integration a particular institutionalized autonomous subject emerges, challenging what we know about institutional psychiatric power (Foucault 1988/1965, 1995/1977; Goffman 1961; Rhodes 2000, 2004; Waldram 2012).
James is emblematic of how line staff members came to talk about Counter Response. I’m “not in treatment” became a ubiquitous statement when staff members would informally talk about the implementation of Counter Response and their feelings, which were overwhelmingly against the model. Participant observation in the cottages allowed me to learn about these perspectives and to collect this kind of contextual information.
See Foltz 2004 for a detailed description of the psychiatric diagnostic procedures for residential clients. See Hasci (1997) for a discussion of the empirical basis for foster homes versus institutions for foster youth. Lee et al. 2011 provides a detailed comparative literature review of which studies focus on outcome measures of “group care.” Lee et al. (2011) conclusion is that “unfortunately, the literature on group care is relatively unsophisticated, requiring social workers and others to rely on scant evidence to make decisions that may impact family stability, social and psychological functioning, and child and community safety” (186). They call for continued and expanded research; Lee and Curtis McMillan (2007) focuses on quality of care in treatment rather that outcomes of individuals post treatment. Quality measures are thought to be linked to outcomes therefore is quality within institutions can be measured then the focus will be there and the outcomes will improve as does quality.
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Hejtmanek, K. Practicing and Resisting Constraint: Ethnography of “Counter Response” in American Adolescent Psychiatric Custody. Cult Med Psychiatry 38, 578–596 (2014). https://doi.org/10.1007/s11013-014-9403-x
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DOI: https://doi.org/10.1007/s11013-014-9403-x