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Med Humanit. 2019 Jul 30. pii: medhum-2018-011521. doi: 10.1136/medhum-2018-011521. [Epub ahead of print]

Estranged relations: coercion and care in narratives of supported decision-making in mental healthcare.

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Social and Global Studies Centre, School of Global, Urban and Social Studies, RMIT University, Melbourne, Victoria, Australia.
Royal Hospital for Women, Sydney, NSW, Australia.
Hunter New England Local Health District, Tamworth, NSW, Australia.
Social and Global Studies Centre, School of Global, Urban and Social Studies, RMIT University, Melbourne, Victoria, Australia
Adjunct, Monash Centre for Health Research and Implementation (MCHRI), Monash Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia.
Department of Psychosocial Studies, Birkbeck, University of London, London, UK.
Centre for Social Research in Health, UNSW Arts and Social Sciences, University of New South Wales, Sydney, New South Wales, Australia.


Supported decision-making has become popular among policymakers and mental health advocates as a means of reducing coercion in mental healthcare. Nevertheless, users of psychiatric services often seem equivocal about the value of supported decision-making initiatives. In this paper we explore why such initiatives might be rejected or ignored by the would-be beneficiaries, and we reflect on broader implications for care and coercion. We take a critical medical humanities approach, particularly through the lens of entanglement. We analyse the narratives of 29 people diagnosed with mental illness, and 29 self-identified carers speaking of their experiences of an Australian mental healthcare system and of their views of supported decision-making. As a scaffolding for our critique we consider two supported decision-making instruments in the 2014 Victorian Mental Health Act: the advance statement and the nominated person. These instruments presuppose that patients and carers endorse a particular set of relationships between the agentic self and illness, as well as between patient, carer and the healthcare system. Our participant narratives instead conveyed 'entangled' relations, which we explore in three sections. In the first we show how ideas about fault and illness often coexisted, which corresponded with shifting views on the need for more versus less agency for patients. In the second section, we illustrate how family carers struggled to embody the supported decision-making ideal of the independent yet altruistic nominated person, and in the final section we suggest that both care and coercion were narrated as existing across informal/formal care divisions. We conclude by reflecting on how these dynamic relations complicate supported decision-making projects, and prompt a rethink of how care and coercion unfold in contemporary mental healthcare.


medical anthropology; medical humanities; patient narratives; psychiatry; sociology


Conflict of interest statement

Competing interests: None declared.

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