On Gratitude
Sylvia Caras, PhD
"Shortly after my last major episode, where I was hospitalised under the mental health act, I expressed 'gratitude' to those who had sectioned me. In retrospect, I feel I was grasping at the crumbs under the table. I had been so humiliated and demeaned, I no longer had any self-esteem evident, and felt I had to be grateful to the world for allowing me to exist in it. I can say, with the wisdom of hindsight and some time to buffer the pain, that there were in fact many options available, and few involved coercion of any description. My 'gratefulness' came from a deep sense of unworthiness which was exacerbated by forced treatment." (Hansen)
Introduction
Walking from our rooms at Beit College to the Royal College of Psychiatry on our way to
a London World Federation of Mental Health (WFMH) board meeting, John Copeland and I were
talking about forced psychiatric treatment. He, a psychiatrist, answered my objection by
describing to me an instance of the appreciation of his patient, that after involuntary
hospitalization he expressed gratitude.
A year later, at the Melbourne Convention Center, at the last meeting of my WFMH board
service, Leo de Graff and I had a similar conversation and he also spoke of patient
gratitude, in a way that firmly overrode any of my other objections to the practice of
coercive care.
The two conversations raised many questions. I knew that coercion is an ordinary feature
of psychiatric hospital practice, that psychiatry and psychology force treat. I thought
about the power needs of the professionals, about who is drawn self-righteously to
dominate in this way, and I wondered why value the authenticity of the statement of
gratitude? Why not treat it as delusional?
I decided I wanted to think about force and gratitude more systematically. The use of
coercion in public health and the range of objects and feelings of gratitude was far
beyond what I wanted to consider. I decided to look and only in a narrow way, at
involuntary mental health interventions and the relationship between the ones who order
them and the ones who are subject to them. I needed to clarify to myself my discomfort and
sense of confusion with accepting gratitude as a justification. Here is what I found, the
beginnings of an exploration.
I started by looking up gratitude in an online dictionary: 1. condition of being
grateful; a warm sense of appreciation of kindness received, involving a feeling of
goodwill towards the benefactor and a desire to do something in return; gratefulness.
(OED)
Then I began to talk a little with colleagues about gratitude, posted to an email list,
Googled a little, did some browsing in a few online journal indices available at UC Santa
Cruz, and read four articles that the Santa Cruz Public Library had photocopied for me by
ordering from the InterLibrary Loan service.
I had not expected to see the concept of gratefulness located in ethics, discussed by
philosophers who were considering duty, and obligation to appreciate the receipt of
beneficence, as well as the duty to give. But I saw very little about the desire to
receive, the feelings and expectations of the doer to be a recipient of gratitude
Ethics
Post-modern and feminist writers have more nuanced analyses, but around gratitude, in a
traditional way, Berger laid out the issues - the value of the benefit, the degree of
sacrifice, the voluntariness of the giver, the response of the receiver. He sums up,
"If I am the recipient of another's benevolence, his action indicates he cares about
me, he values me, he respects me. ... I am an object of his concern." He then
continues, "The practices involved in gratitude presuppose that the agents are
manifesting their mutual valuing of one another as ends in themselves; ... expectation of
concessions as a sign of gratitude can be an oppression." (Berger) Expectations of
concessions? Does this explain my discomfort? Expected gratitude taken as in-advance
permission for coercion?
Power
As I organized to write, I found myself frightened at the idea of questioning the
motivations of psychiatrists in a form that I intended to make public, to ask about their
need for praise. I am afraid to sound foolish, disrespectful. I was, and still am, afraid
that my ideas will be judged by being tucked into a DSM category.
"Historically, the powerful and privileged have imposed their guardianship upon the powerless and have felt the latter should be grateful for their 'care.' ... When the powerful are generous, it may be simply that they enjoy giving. It supports their own self-esteem; it demonstrates their wealth and power. Such generosity can be accompanied by insensitivity to others wishes' with regard to becoming obligated. The powerful can afford not to care whether others are obligated or not. ... Genuine benevolence is incompatible with disregarding others' willingness to become obligated. Those who lack such regard thereby lack respect. And willingness to become obligated to others despite their lack of respect raises the question, at least, whether one lacks of self-respect." (Card)
Physicians
Physicians are trained to believe they have a duty to help. It feels good to do that
duty. But if despite the patient's wishes, then to whom is the duty? How much is patient
recovery necessary to physician well-being? What about reciprocity? McConnell writes that
debts of gratitude require that the benefit be granted voluntarily, not be forced on the
beneficiary but be accepted, and that the grantor exercised non-routine effort (McConnell,
p 14).
Mental health professionals expect treatment compliance. I kept wondering about
physicians' expectations, and what happens when they are not met? Is an expectation of
gratitude an expectation of emotional compliance? Does an expectation of respect and
gratitude influence the interventions they select? When physicians coerce, do they think
"He's alive; he should be grateful?" Do they think "They'll thank me
later?" If gratitude is not received, does that disappointment turn to retaliation -
I'll treat you 'til you are grateful! ? Can gratitude serve as a foundation for a
healing/helping relationship?
"Receiving sincere expressions of gratitude can be a powerful experience, and may
lead the psychiatrist to a presumption of gratitude on the part of the patient. ...
However, these patients must be relatively rare in relation to the number of patients who
are committed." (Gardner)
There are many threads to think about while considering the expression of grateful
acceptance of coercion - ethics, morals, physician-patient power relationships, ...
Morals
"We define moral mandates as the specific attitude positions or stands that people
develop out of a moral conviction that something is right or wrong, moral or immoral.
Moral mandates share the characteristics of other strong attitudes -- that is extremity,
importance, and certainty -- but have an added motivational and action component, because
they are imbued with moral conviction. ... When people had a moral mandate, due process
was an irrelevant concern. Moral mandates appear to lead to the legitimization of any
procedure so long as the mandated end is achieved." (Skitka)
Love too can be used as a moral mandate to deny due process and to substitute judgment. ... The peculiar feature of power struggles in the family is that they occur in the name of love and demand from their targets willing compliance and even gratitude. (Kanter)
Coercion
"The process of perception of coercion may be incompatible with gratitude because
coercion undermines moral community." (Gardner)
When force is used, community belonging is undermined because the lock-up is a threat to
the already fragile self. The shame -- being transported by police, having possessions
explored removed, the indignities of intake - can lead to so much dissonance that the
person accepts the system's view that there is a perception of worthlessness. Admissions
procedures and intake may mimic familiar abusive relationships. Small kindnesses like
removing handcuffs create great appreciations. The requirement of permissions for the
simplest things, phones, showers, haircuts, maintain the medical staff's power. Patient
isolation is maintained within the unit where the perspectives are either that of the
system or that of the patients. Alternative nurturance like peer support is discouraged
and the points of view of other inpatients are discounted by staff as symptomatic.
Admission of disease is the way to discharge, claiming to now have insight, confessing
that non-compliance was a mistaken choice. Otherwise long-term holds and medications loom.
Inpatients become very aware of the needs of the treating staff. This coping strategy is
often charted as manipulation. The rage that, if not suppressed by self-control, is
medicated, later can turn to social activism or anti-social actions. After release, the
threat of further interventions continues to control: this can happen once; it will happen
again. The system insists it must substitute judgment because of the person's decisional
impairment: non-compliance and lack of gratitude are indicators of the need for treatment.
You may recognize these parallels to the expression of the Stockholm Syndrome in groups
held against their will in physical and symbolic/metaphorical/emotional/bondage.
Stockholm Syndrome
A characteristic of the Stockholm Syndrome is that the captives begin to identify with
their captors. They believe that the captor will not hurt them if they are cooperative and
even positively supportive. The Stockholm Syndrome was originally developed to explain the
phenomenon of hostages bonding with their captors. Researchers have concluded that this
seems to be a universal phenomenon which may be instinctive and thus play a survival
function for hostages who are victims of abuse.
This syndrome can occur where there is a perceived threat to survival, a perception by the
captive of some small kindness from the captor within the context of terror, isolation
from perspectives other than those of the captor, perceived inability to escape.
(Stockholm Syndrome)
Psychiatric captivity/treatment is justified by being in the best interest of the
community and the person.
However, Gardner concludes "Commitment is inherently demeaning, because the caregiver
must believe that the patient cannot order his or her affairs. Thus, the caregiver,
however benevolent, must demean the patient and, in this way, invalidate a condition for
the patient to be grateful."
"Imagine Dawn who feels grateful to her abusive father for the minimal aid he has given her and consequently obeys his every command. Dawn feels grateful toward her abusive father and expresses her gratitude by obeying his abusive demands. Dawn's expression of gratitude clearly fails to show the kind of self-respect that she deserves and is consequently morally problematic. Expressions of gratitude, therefore, can be a moral problem. This is one way that gratitude can go wrong - when expressions of gratitude serve to support a morally indefensible situation. ... When gratitude to others is coupled with a lack of self-respect there is a problem. ... The reasons for having gratitude, however, can easily be inappropriate. The expressions of gratitude can also be inappropriate." (Fitzgerald)
"Perhaps the point could be made here that gratitude, for some, can be a way of rescuing our dignity. If we state that someone has done us a favour, and that we need to be grateful, it rescues us from the shame and loss of dignity that coercive treatment incur." (Hansen)
Reciprocity
Reciprocity is an element of gratitude. There is a duty to be grateful for help and things
received. But the professional-patient relationship is unequal. What is the reciprocal
requirement expected of a patient? If reciprocity is seen as part of patient transference,
a boundary problem (Texas Medical Association) there is no opportunity for repayment and
attempts may be perceived as inappropriate.. A burden of debt remains, no way to honor the
expectations of social discourse, the inclination to return the favor. But does a patient
owe if someone is doing their job? Mere dollar payment, especially if there are insurance
benefits, may feel inadequate to discharge debt. Thus the inequality of the
professional-patient relationship is maintained and a permanent undischarged debt
retained. How does this imbalance color the gratitude that a patient gives?
Informed
There is considerable discussion about the capacity for informed consent, wondering
whether a person in a fearful and fragile state can understand and consent to
interventions. I wonder about informed gratitude. "Few committed patients are
retrospectively grateful for their care." (Gardner) If a patient is sufficiently
diminished in self-consideration, is servile, is self-deceiving, is compliance with the
medical expectation of gratefulness worthy gratitude? Does a decision to be grateful
demonstrate insight, or lack of insight?
Manipulation
Some people diagnosed with psychiatric disabilities are unusually sensitive to the moods
and needs of others. At the moment that gratitude for coercion is expressed, the patient
may be responding to the need, even guilt, of the physician. If the patient expects a
continuing relationship with the treating physician or hospital, the patient may be
expressing appreciation in a protective and defensive way, so that the medical record
reflects cooperation and insight and the treating relationship feels hopeful and safe. The
patient may know that a presumption of gratitude exists, and so complies.
Just Gratitude
Providers who dwell on gratitude as an excuse for coercion are receiving that gratitude at a certain point in time and subsequent reactions might be different.
I am not questioning the authenticity to the patient at the moment of expression of the patient's feeling of gratitude. I am exploring whether this feeling is more than fleeting, is worthy, informed, or, to use Bergers's term, deep. What is the feeling later, when the patient may be in a more self-determining situation?
Relatedness
Do treating professionals yearn for relatedness, identify with their patients, want an affirmation of their professional competence? Might they be using appreciative patients who acknowledge having been helped so they can feel selfless, devoted helpers, feel needed? Might they feel resentment when patients are ungrateful (Gabbard) and so don't provide that gratification? How self-serving is it if providers use the patient as an object to gratify their need by coercing the patient into treatment?
"The poor create an opportunity for members of the medical profession to define their working lives around helping the vulnerable. ... There can be no rescuer without someone to rescue, there can be no benefactor without a beneficiary. If giving to those in need enriches one's life, then one owes a debt of gratitude to those who needed the gift. The plight of poor patients gives the medical profession an opportunity - an opportunity to return the medical profession to a servant profession." (Fitzgerald)
"The picture that was held up of my life
without psychiatric intervention was bleak and short and painful and horrid and all
completely made up to terrorise me into compliance." I felt so bad and they told me I
was bad and I accepted their view and believed them when they said that they fixed me and
therefore "I was dutifully grateful. Of course I was totally without rights such as
review during this time. Now I understand what it all meant I am no longer grateful."
(Clarke)
Conclusion
Because it substitutes physician judgment for patient wishes, patient gratitude is an
inadequate defense for medical coercion. I've explored and learned a lot and clarified why
"but they are grateful" is superficial, and after all that it comes down to a
very old concept: with Winkler, restating the Golden Rule, "We should not determine
the needs of others by our own needs."
References
Berger, Fred, Gratitude, 1975.
Ethics:85, 298-309.
Card, Claudia, Gratitude and Obligation, April, 1988. American Philosophical
Quarterly 25:2, pp 1115 - 127.
Clarke, Sara, personal correspondence, 3 March 2003.
Fitzgerald, Patrick, Gratitude and Justice, October, 1998. Ethics, 109:1, pp 119 - 153.
Gardner, William and Charles Lidz, Gratitude
and coercion between physicians and patients, February 2001." Psychiatric annals
31:2, 125 - 129.
Hansen, Chris, personal correspondence, 12 Mar 2003.
Kanter, Rosabeth Moss, Intimate Oppression, 1974. The Sociological Quarterly,15: 2, Spr, 302-314.
Loxterkamp, David, MD, Border Crossings: On the Boundary of the Physician-Patient Relationship, Journal of the American Board of Family Practice
http://www.medscape.com/viewarticle/417827 .
McConnell, Terrance, Gratitude, 1993. Philadelphia: Temple University Press.
Minkowitz, Tina, personal communication, 30
April 2003
http://dictionary.oed.com/
Skitka and Mullen, The dark side of moral conviction, 2002. In Analyses of social
issues and public policy, 21, pp 35 - 41.
Stockholm Syndrome http://www.secasa.com.au/survivors/the_stockholm_syndrome_1.html
Texas Medical Association http://www.texmed.org/cme/phn/mpp/venues_boundaryproblems.asp
Winkler, Gershon and Lakme Batya Elior, The place where you are standing is holy, 1994.
New Jersey: Jason Aronson. p 78