The root of the problem, for Kant, is time. But the past is out of his control now, in the present. Even if he could control those past events in the past, he cannot control them now. But in fact past events were not in his control in the past either if they too were determined by events in the more distant past, because eventually the causal antecedents of his action stretch back before his birth, and obviously events that occurred before his birth were not in his control.
In that case, it would be a mistake to hold him morally responsible for it. Compatibilism, as Kant understands it, therefore locates the issue in the wrong place. Even if the cause of my action is internal to me, if it is in the past — for example, if my action today is determined by a decision I made yesterday, or from the character I developed in childhood — then it is not within my control now.
The real issue is not whether the cause of my action is internal or external to me, but whether it is in my control now. For Kant, however, the cause of my action can be within my control now only if it is not in time. This is why Kant thinks that transcendental idealism is the only way to make sense of the kind of freedom that morality requires.
For transcendental idealism allows that the cause of my action may be a thing in itself outside of time: My noumenal self is an uncaused cause outside of time, which therefore is not subject to the deterministic laws of nature in accordance with which our understanding constructs experience. Many puzzles arise on this picture that Kant does not resolve.
For example, if my understanding constructs all appearances in my experience of nature, not only appearances of my own actions, then why am I responsible only for my own actions but not for everything that happens in the natural world? Moreover, if I am not alone in the world but there are many noumenal selves acting freely and incorporating their free actions into the experience they construct, then how do multiple transcendentally free agents interact?
How do you integrate my free actions into the experience that your understanding constructs? Finally, since Kant invokes transcendental idealism to make sense of freedom, interpreting his thinking about freedom leads us back to disputes between the two-objects and two-aspects interpretations of transcendental idealism.
But applying the two-objects interpretation to freedom raises problems of its own, since it involves making a distinction between noumenal and phenomenal selves that does not arise on the two-aspects view. If only my noumenal self is free, and freedom is required for moral responsibility, then my phenomenal self is not morally responsible. But how are my noumenal and phenomenal selves related, and why is punishment inflicted on phenomenal selves? Can we know that we are free in this transcendental sense?
We do not have theoretical knowledge that we are free or about anything beyond the limits of possible experience, but we are morally justified in believing that we are free in this sense. On the other hand, Kant also uses stronger language than this when discussing freedom. Our practical knowledge of freedom is based instead on the moral law. So, on his view, the fact of reason is the practical basis for our belief or practical knowledge that we are free.
Every human being has a conscience, a common sense grasp of morality, and a firm conviction that he or she is morally accountable. We may arrive at different conclusions about what morality requires in specific situations. And we may violate our own sense of duty. But we all have a conscience, and an unshakeable belief that morality applies to us.
It is just a ground-level fact about human beings that we hold ourselves morally accountable. But Kant is making a normative claim here as well: Kant holds that philosophy should be in the business of defending this common sense moral belief, and that in any case it could never prove or disprove it 4: Kant may hold that the fact of reason, or our consciousness of moral obligation, implies that we are free on the grounds that ought implies can.
In other words, Kant may believe that it follows from the fact that we ought morally to do something that we can or are able to do it. This is a hypothetical example of an action not yet carried out.
In both the Groundwork of the Metaphysics of Morals and the Critique of Practical Reason, Kant also gives a more detailed argument for the conclusion that morality and freedom reciprocally imply one another, which is sometimes called the reciprocity thesis Allison On this view, to act morally is to exercise freedom, and the only way to fully exercise freedom is to act morally.
First, it follows from the basic idea of having a will that to act at all is to act on some principle, or what Kant calls a maxim. A maxim is a subjective rule or policy of action: We may be unaware of our maxims, we may not act consistently on the same maxims, and our maxims may not be consistent with one another.
But Kant holds that since we are rational beings our actions always aim at some sort of end or goal, which our maxim expresses. The goal of an action may be something as basic as gratifying a desire, or it may be something more complex such as becoming a doctor or a lawyer.
If I act to gratify some desire, then I choose to act on a maxim that specifies the gratification of that desire as the goal of my action. For example, if I desire some coffee, then I may act on the maxim to go to a cafe and buy some coffee in order to gratify that desire.
Second, Kant distinguishes between two basic kinds of principles or rules that we can act on: To act in order to satisfy some desire, as when I act on the maxim to go for coffee at a cafe, is to act on a material principle 5: Here the desire for coffee fixes the goal, which Kant calls the object or matter of the action, and the principle says how to achieve that goal go to a cafe.
A hypothetical imperative is a principle of rationality that says that I should act in a certain way if I choose to satisfy some desire. If maxims in general are rules that describe how one does act, then imperatives in general prescribe how one should act.
An imperative is hypothetical if it says how I should act only if I choose to pursue some goal in order to gratify a desire 5: This, for example, is a hypothetical imperative: This hypothetical imperative applies to you only if you desire coffee and choose to gratify that desire.
In contrast to material principles, formal principles describe how one acts without making reference to any desires. This is easiest to understand through the corresponding kind of imperative, which Kant calls a categorical imperative. A categorical imperative commands unconditionally that I should act in some way. So while hypothetical imperatives apply to me only on the condition that I have and set the goal of satisfying the desires that they tell me how to satisfy, categorical imperatives apply to me no matter what my goals and desires may be.
Kant regards moral laws as categorical imperatives, which apply to everyone unconditionally. For example, the moral requirement to help others in need does not apply to me only if I desire to help others in need, and the duty not to steal is not suspended if I have some desire that I could satisfy by stealing.
Moral laws do not have such conditions but rather apply unconditionally. That is why they apply to everyone in the same way. Third, insofar as I act only on material principles or hypothetical imperatives, I do not act freely, but rather I act only to satisfy some desire s that I have, and what I desire is not ultimately within my control.
To some limited extent we are capable of rationally shaping our desires, but insofar as we choose to act in order to satisfy desires we are choosing to let nature govern us rather than governing ourselves 5: We are always free in the sense that we always have the capacity to govern ourselves rationally instead of letting our desires set our ends for us. But we may freely fail to exercise that capacity.
Moreover, since Kant holds that desires never cause us to act, but rather we always choose to act on a maxim even when that maxim specifies the satisfaction of a desire as the goal of our action, it also follows that we are always free in the sense that we freely choose our maxims. Nevertheless, our actions are not free in the sense of being autonomous if we choose to act only on material principles, because in that case we do not give the law to ourselves, but instead we choose to allow nature in us our desires to determine the law for our actions.
Finally, the only way to act freely in the full sense of exercising autonomy is therefore to act on formal principles or categorical imperatives, which is also to act morally. Kant does not mean that acting autonomously requires that we take no account of our desires, because that would be impossible 5: This immediate consciousness of the moral law takes the following form:.
In other words, to assess the moral permissibility of my maxim, I ask whether everyone could act on it, or whether it could be willed as a universal law. The issue is not whether it would be good if everyone acted on my maxim, or whether I would like it, but only whether it would be possible for my maxim to be willed as a universal law.
This gets at the form, not the matter or content, of the maxim. A maxim has morally permissible form, for Kant, only if it could be willed as a universal law. If my maxim fails this test, as this one does, then it is morally impermissible for me to act on it.
If my maxim passes the universal law test, then it is morally permissible for me to act on it, but I fully exercise my autonomy only if my fundamental reason for acting on this maxim is that it is morally permissible or required that I do so. Imagine that I am moved by a feeling of sympathy to formulate the maxim to help someone in need. In this case, my original reason for formulating this maxim is that a certain feeling moved me. Such feelings are not entirely within my control and may not be present when someone actually needs my help.
So it would not be wrong to act on this maxim when the feeling of sympathy so moves me. But helping others in need would not fully exercise my autonomy unless my fundamental reason for doing so is not that I have some feeling or desire, but rather that it would be right or at least permissible to do so.
Only when such a purely formal principle supplies the fundamental motive for my action do I act autonomously. Even when my maxims are originally suggested by my feelings and desires, if I act only on morally permissible or required maxims because they are morally permissible or required , then my actions will be autonomous.
And the reverse is true as well: Kant holds that reason unavoidably produces not only consciousness of the moral law but also the idea of a world in which there is both complete virtue and complete happiness, which he calls the highest good.
Furthermore, we can believe that the highest good is possible only if we also believe in the immortality of the soul and the existence of God, according to Kant. On this basis, he claims that it is morally necessary to believe in the immortality of the soul and the existence of God, which he calls postulates of pure practical reason.
Moreover, our fundamental reason for choosing to act on such maxims should be that they have this lawgiving form, rather than that acting on them would achieve some end or goal that would satisfy a desire 5: For example, I should help others in need not, at bottom, because doing so would make me feel good, even if it would, but rather because it is right; and it is right or permissible to help others in need because this maxim can be willed as a universal law.
But although Kant holds that the morality of an action depends on the form of its maxim rather than its end or goal, he nevertheless claims both that every human action has an end and that we are unavoidably concerned with the consequences of our actions 4: This is not a moral requirement but simply part of what it means to be a rational being.
Moreover, Kant also holds the stronger view that it is an unavoidable feature of human reason that we form ideas not only about the immediate and near-term consequences of our actions, but also about ultimate consequences.
But neither of these ideas by itself expresses our unconditionally complete end, as human reason demands in its practical use. And happiness by itself would not be unconditionally good, because moral virtue is a condition of worthiness to be happy 5: So our unconditionally complete end must combine both virtue and happiness.
It is this ideal world combining complete virtue with complete happiness that Kant normally has in mind when he discusses the highest good.
Kant says that we have a duty to promote the highest good, taken in this sense 5: He does not mean, however, to be identifying some new duty that is not derived from the moral law, in addition to all the particular duties we have that are derived from the moral law. Rather, as we have seen, Kant holds that it is an unavoidable feature of human reasoning, instead of a moral requirement, that we represent all particular duties as leading toward the promotion of the highest good.
Nor does Kant mean that anyone has a duty to realize or actually bring about the highest good through their own power, although his language sometimes suggests this 5: Finally, according to Kant we must conceive of the highest good as a possible state of affairs in order to fulfill our duty to promote it. Here Kant does not mean that we unavoidably represent the highest good as possible, since his view is that we must represent it as possible only if we are to do our duty of promoting it, and yet we may fail at doing our duty.
Rather, we have a choice about whether to conceive of the highest good as possible, to regard it as impossible, or to remain noncommittal 5: But we can fulfill our duty of promoting the highest good only by choosing to conceive of the highest good as possible, because we cannot promote any end without believing that it is possible to achieve that end 5: Kant argues that we can comply with our duty to promote the highest good only if we believe in the immortality of the soul and the existence of God.
This is because to comply with that duty we must believe that the highest good is possible, and yet to believe that the highest good is possible we must believe that the soul is immortal and that God exists, according to Kant.
The highest good, as we have seen, would be a world of complete morality and happiness. This does not mean that we can substitute endless progress toward complete conformity with the moral law for holiness in the concept of the highest good, but rather that we must represent that complete conformity as an infinite progress toward the limit of holiness. Rather, his view is that we must represent holiness as continual progress toward complete conformity of our dispositions with the moral law that begins in this life and extends into infinity.
Kant holds that virtue and happiness are not just combined but necessarily combined in the idea of the highest good, because only possessing virtue makes one worthy of happiness — a claim that Kant seems to regard as part of the content of the moral law 4: But we can represent virtue and happiness as necessarily combined only by representing virtue as the efficient cause of happiness.
This means that we must represent the highest good not simply as a state of affairs in which everyone is both happy and virtuous, but rather as one in which everyone is happy because they are virtuous 5: However, it is beyond the power of human beings, both individually and collectively, to guarantee that happiness results from virtue, and we do not know any law of nature that guarantees this either.
This cause of nature would have to be God since it must have both understanding and will. Kant probably does not conceive of God as the efficient cause of a happiness that is rewarded in a future life to those who are virtuous in this one. Both of these arguments are subjective in the sense that, rather than attempting to show how the world must be constituted objectively in order for the highest good to be possible, they purport to show only how we must conceive of the highest good in order to be subjectively capable both of representing it as possible and of fulfilling our duty to promote it.
But Kant also claims that both arguments have an objective basis: So while it is not, strictly speaking, a duty to believe in God or immortality, we must believe both in order to fulfill our duty to promote the highest good, given the subjective character of human reason.
To see why, consider what would happen if we did not believe in God or immortality, according to Kant. But Kant later rejects this view 8: His mature view is that our reason would be in conflict with itself if we did not believe in God and immortality, because pure practical reason would represent the moral law as authoritative for us and so present us with an incentive that is sufficient to determine our will; but pure theoretical i.
This final section briefly discusses how Kant attempts to unify the theoretical and practical parts of his philosophical system in the Critique of the Power of Judgment. Reason legislates a priori for freedom and its own causality, as the supersensible in the subject, for an unconditioned practical cognition.
One way to understand the problem Kant is articulating here is to consider it once again in terms of the crisis of the Enlightenment. But the transcendental idealist framework within which Kant develops this response seems to purchase the consistency of these interests at the price of sacrificing a unified view of the world and our place in it.
It is important to Kant that a third faculty independent of both understanding and reason provides this mediating perspective, because he holds that we do not have adequate theoretical grounds for attributing objective teleology to nature itself, and yet regarding nature as teleological solely on moral grounds would only heighten the disconnect between our scientific and moral ways of viewing the world.
That is why his theoretical philosophy licenses us only in attributing mechanical causation to nature itself. In this respect, Kant is sympathetic to the dominant strain in modern philosophy that banishes final causes from nature and instead treats nature as nothing but matter in motion, which can be fully described mathematically. But Kant wants somehow to reconcile this mechanistic view of nature with a conception of human agency that is essentially teleological. For as we saw in the previous section, Kant holds that every human action has an end and that the sum of all moral duties is to promote the highest good.
This harmony can be orchestrated only from an independent standpoint, from which we do not judge how nature is constituted objectively that is the job of understanding or how the world ought to be the job of reason , but from which we merely regulate or reflect on our cognition in a way that enables us to regard it as systematically unified.
In the Critique of the Power of Judgment, Kant discusses four main ways in which reflecting judgment leads us to regard nature as purposive: First, reflecting judgment enables us to discover empirical laws of nature by leading us to regard nature as if it were the product of intelligent design 5: We do not need reflecting judgment to grasp the a priori laws of nature based on our categories, such as that every event has a cause.
But in addition to these a priori laws nature is also governed by particular, empirical laws, such as that fire causes smoke, which we cannot know without consulting experience. To discover these laws, we must form hypotheses and devise experiments on the assumption that nature is governed by empirical laws that we can grasp Bxiii—xiv. Reflecting judgment makes this assumption through its principle to regard nature as purposive for our understanding, which leads us to treat nature as if its empirical laws were designed to be understood by us 5: Since this principle only regulates our cognition but is not constitutive of nature itself, this does not amount to assuming that nature really is the product of intelligent design, which according to Kant we are not justified in believing on theoretical grounds.
Rather, it amounts only to approaching nature in the practice of science as if it were designed to be understood by us. We are justified in doing this because it enables us to discover empirical laws of nature. But it is only a regulative principle of reflecting judgment, not genuine theoretical knowledge, that nature is purposive in this way.
Second, Kant thinks that aesthetic judgments about both beauty and sublimity involve a kind of purposiveness, and that the beauty of nature in particular suggests to us that nature is hospitable to our ends. So beauty is not a property of objects, but a relation between their form and the way our cognitive faculties work.
Yet we make aesthetic judgments that claim intersubjective validity because we assume that there is a common sense that enables all human beings to communicate aesthetic feeling 5: Beautiful art is intentionally created to stimulate this universally communicable aesthetic pleasure, although it is effective only when it seems unintentional 5: Natural beauty, however, is unintentional: In both cases, then, beautiful objects appear purposive to us because they give us aesthetic pleasure in the free play of our faculties, but they also do not appear purposive because they either do not or do not seem to do this intentionally.
Although it is only subjective, the purposiveness exhibited by natural beauty in particular may be interpreted as a sign that nature is hospitable to our moral interests 5: Moreover, Kant also interprets the experience of sublimity in nature as involving purposiveness. Third, Kant argues that reflecting judgment enables us to regard living organisms as objectively purposive, but only as a regulative principle that compensates for our inability to understand them mechanistically, which reflects the limitations of our cognitive faculties rather than any intrinsic teleology in nature.
The parts of a watch are also possible only through their relation to the whole, but that is because the watch is designed and produced by some rational being. An organism, by contrast, produces and sustains itself, which is inexplicable to us unless we attribute to organisms purposes by analogy with human art 5: Specifically, we cannot understand how a whole can be the cause of its own parts because we depend on sensible intuition for the content of our thoughts and therefore must think the particular intuition first by subsuming it under the general a concept.
To see that this is just a limitation of the human, discursive intellect, imagine a being with an intuitive understanding whose thought does not depend, as ours does, on receiving sensory information passively, but rather creates the content of its thought in the act of thinking it.
Such a divine being could understand how a whole can be the cause of its parts, since it could grasp a whole immediately without first thinking particulars and then combining them into a whole 5: Therefore, since we have a discursive intellect and cannot know how things would appear to a being with an intuitive intellect, and yet we can only think of organisms teleologically, which excludes mechanism, Kant now says that we must think of both mechanism and teleology only as regulative principles that we need to explain nature, rather than as constitutive principles that describe how nature is intrinsically constituted 5: Fourth, Kant concludes the Critique of the Power of Judgment with a long appendix arguing that reflecting judgment supports morality by leading us to think about the final end of nature, which we can only understand in moral terms, and that conversely morality reinforces a teleological conception of nature.
Once it is granted on theoretical grounds that we must understand certain parts of nature organisms teleologically, although only as a regulative principle of reflecting judgment, Kant says we may go further and regard the whole of nature as a teleological system 5: But we can regard the whole of nature as a teleological system only by employing the idea of God, again only regulatively, as its intelligent designer.
This would be to attribute what Kant calls external purposiveness to nature — that is, to attribute purposes to God in creating nature 5: According to Kant, the final end of nature must be human beings, but only as moral beings 5: This is because only human beings use reason to set and pursue ends, using the rest of nature as means to their ends 5: Moreover, Kant claims that human happiness cannot be the final end of nature, because as we have seen he holds that happiness is not unconditionally valuable 5: Rather, human life has value not because of what we passively enjoy, but only because of what we actively do 5: We can be fully active and autonomous, however, only by acting morally, which implies that God created the world so that human beings could exercise moral autonomy.
Since we also need happiness, this too may be admitted as a conditioned and consequent end, so that reflecting judgment eventually leads us to the highest good 5: Thus Kant argues that although theoretical and practical philosophy proceed from separate and irreducible starting points — self-consciousness as the highest principle for our cognition of nature, and the moral law as the basis for our knowledge of freedom — reflecting judgment unifies them into a single, teleological worldview that assigns preeminent value to human autonomy.
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Some were obviously intellectually gifted. Several had advanced degrees and had been proficient in their fields prior to their involvement with the mental health system. Only one person was currently employed. Another was planning to go back to college. All of the participants had been involved with the mental health system for many years. The shortest time was two years and the longest more than 25 years. People had a general sense of despair and resignation about their lives.
This affected their motivation. In discussing possibilities like recovery education and peer support, although some said these initiatives might be helpful, there was little genuine enthusiasm about anything that was suggested, and no belief that anything positive was going to happen.
Each person had a tumultuous and trauma-filled history that often included severe loss. Although most of this occurred prior to their involvement with the mental health system, some severe trauma and loss occurred within the mental health system and was related to mental health treatment e. With several notable exceptions, the physical health of the interviewees was poor. People were overweight, had various movement disabilities, and had serious chronic illnesses like heart disease and diabetes.
Although they knew they had these conditions, they had little information about anything they could do to help themselves other than medical interventions. Only one person talked about trying to maintain a healthy diet and work on weight loss. The study participants had little insight or knowledge about the possible causes of mental health difficulties and knew little about their own treatment, alternative treatments, and self-help strategies for addressing mental health difficulties.
They were accustomed to having things done to them rather than taking the initiative to help themselves. People also had notably limited systems of connection. Others had only several supportive people in their lives. Some could only name care providers as people in their circle of support.
Most had lost connection with family members and did not feel part of any community. All of the people interviewed had a history of being perceived as dangerous, either to themselves, family members, or the community.
The researchers were warned in advance that the interviewees were potentially dangerous. Prior to the interviews, the researchers expressed some anxiety about safety. Consultants from Vermont Protection and Advocacy taught them how to deescalate difficult situations and how to quickly leave a situation that had the potential to be dangerous.
However, the researchers did not experience any situations in which they felt they were in danger. The interviewees were interviewed by either the principal investigator or the coresearcher in one-hour interviews.
The researchers worked with the interviewee to arrange a place for the interview that was most comfortable and convenient for the interviewee. Before beginning the interviews, the researchers, using data gathered in the focus group meetings, developed an interview guide.
The interview guide is prepared to ensure that the same basic lines of inquiry are pursued with each person interviewed. It will provide topic or subject areas within which the interviewer is free to explore, probe, and ask questions that will elucidate and illuminate that particular subject.
Thus, the interviewer remains free to build a conversation within particular subject areas, to word questions spontaneously, and to establish a conversational style but with the focus on a particular subject that has been predetermined Patton, , p.
Qualitative inquiry, strategically, philosophically, and therefore methodologically, aims to minimize the imposition of predetermined responses when gathering data. It follows that questions should be asked in a truly open-ended fashion so people can respond in their own words Patton, , p. Open-ended questions were designed to avoid predetermined responses. The researchers noted that after the first few questions, they tended to follow tangents addressed by the interviewee that they felt might lead them to the most helpful information.
Why do you like being with them? Why do you think that is? Is that something that you want to change in your life? What sorts of things are you doing and with whom? If so, what has been your experience with Peer Support? If so, what has been your experience with it? How long were you on? How did you feel about being on it? If so, how was that helpful? A flexible approach was used in the interviews, adapting styles and strategies to best meet the needs of the study participants and to facilitate collection of pertinent data.
Although this guide was far too extensive for most of the one-hour interviews, it provided a helpful structure. In retrospect, it might have been preferable to interview each person several times. In subsequent interviews, participants might have been more trusting, and more open to sharing at a deeper level. In spite of their initial distrust, after the interviewees learned about the interviewer and the focus of the study, they opened up, some slowly, others more quickly, often escalating into an unexpected intensity.
They seemed to relax when they understood that the interviewer was not part of the mental health system, but a person like them who had mental difficulties for many years and had attained a level of recovery. They were openly surprised that anyone would want to spend time with them, to hear what they had to say, and that anything they had to say might be useful.
The time passed quickly. Both researchers reported that they wished for more time and further connection. They left the interviews with mixed feelings, frustration at not being able to spend more time and delve more deeply, and satisfaction that they had ventured into territory that few have been privileged to enter.
In addition, using an informal narrative interview process, the researchers talked to Vermont State Hospital personnel, court officials, community mental health center administrators and care providers, law enforcement officials, and other community members who have experience with or an interest in this issue. These people were not directly connected to the people that were interviewed, nor did they or anyone know who was interviewed.
The researchers recorded information from these interviews with field notes. These interviews were not as helpful as had been anticipated. Those that were most helpful were interviews with people who work directly with individuals who have orders of involuntary commitment, including program administrators and case managers.
They talked of their frustration with inadequate funding to provide needed supports and resources that would allow for a recovery-oriented focus.
They supported the possible implementation of a program that would include a system of mentors. Because court personnel did not personally know the people who have involuntary commitment orders, they seemed to be unable to consider other options for people.
Family members, many of whom had little or no contact with the person who has the involuntary commitment order, held views that seemed inflexible. If the study time period had been longer, the researchers would have tried to reach out to more people in the community to see if they could find some with helpful insight. This chapter provided an in-depth description of the process that was used to gather the data to use in program development, including the methodology, the Institutional Review Board process, project administration, publicity, advisory boards, informational meetings and focus groups, recruitment of respondents, and interviews.
The next chapter will describe the process of analyzing the data from this study. In addition to the literature review, the data from the field notes of the focus groups and informal interviews with stakeholders, along with the hundreds of pages of transcriptions from the interviews with people who have had involuntary commitments, were analyzed to find out what strategies should be included in a program or project that would be helpful and useful to people who have orders of involuntary commitment.
Finding answers to questions posed by Vermont state mental health officials also informed the learning process. It was not the intention of the project to analyze the individual interviewees, but rather to hear them and learn from their experiences.
The researchers began the analysis process by reading and rereading the field notes and transcripts. From the initial readings, the researchers developed a list of 27 domains. These domains were entered into the software program HyperResearch. In addition, one of the researchers had used this program successfully on other projects. To facilitate the analysis process, the researchers developed a list of codes that they felt would most effectively meet the needs of studying the data.
Significant phrases, statements, and sections of each transcript were coded and entered into the software program. This coding was an intensive, extensive, and powerful process. It required on-going revision as the researchers discussed the data and discovered new meaning. The close scrutiny of this potent information was frustrating, draining, and exhilarating: As the data were being analyzed, the researchers continually referred to the literature studied in developing the research proposal, in designing the project, and as the project proceeded.
A sense of hopelessness and disenfranchisement seemed to permeate the data, making it often feel heavy, dark, and incredibly sad. Were it not for the occasional words of wisdom that allowed a glimpse into a different way of knowing, a glimpse that showed the brilliance, the creativity, and the courage of many of these people, the data analysis would have been a dreary task.
After careful consideration, continued review, and discussion of the data, patterns emerged and the codes were collapsed into each other. The resulting themes were:. Again, the researchers read and reread the transcripts and the theme reports from the Moving Ahead project.
They studied the field notes on the focus groups and the informal interviews. They had meetings, phone calls, and strings of e-mails. They discussed the theme reports and shared various ideas with both of the advisory boards and project consultants.
They talked again with some of the people who had orders that were interviewed. Although they continually referred back to the literature, field notes, transcripts, and theme reports, compiling the following summary of each theme helped the researchers clarify possible core elements of the pilot project. Interviewees as a group reported negative experiences with the involuntary commitment process.
Key problems that people had with these orders was lack of understanding of why they have the order, what constitutes a violation of the order, the stigma of being on the order, the lack of choice, feeling like it is a punishment, and the lack of consistency about protocol for getting the order rescinded. They said orders dictated things like where you can live, what you do with your time, and the specifics of your treatment including medications.
They contend that these issues increase frustration and stress levels that make their lives even more difficult and make it more likely that they would have difficult times and continue to need the order. This involuntary commitment order that Dr.
He was punishing me. So, why are you on an order of involuntary commitment? Am I supposed to be a dangerous man? Am I supposed to have done something terribly wrong? Why do you think you have this order of involuntary commitment? Am I supposed to be a danger? Am I supposed to—? No threatening behavior, it says. Did I ever threaten anybody? And I was never drunk. So, how could it be you have an order of involuntary commitment?
I pretty much do what I want as far as the order of involuntary commitment goes. The only part of it that I have to go into is I go in for meetings once every three months, and my injection, once every three weeks. Aside from that, I pretty much ignore it, because just reading it makes me upset.
My opinion is you were in the hospital to get better supposedly. In effect they were using the order as a safety net. In addition, it helped people understand how they can deal with or avoid crisis situations. Certainly, the Vermont Project Chittick et al. People reported that they have difficulty meeting the challenges in their lives, especially those that are unique to their circumstances.
Some of the most common challenges reported by the interviewees included:. They sometimes just make me feel like I should just be in the hospital. People spoke of feeling controlled by others including their psychiatrist, the courts, specific family members, and the mental health system.
Intrusive symptoms over which they felt they had little or no control increased their feelings of impotence. I feel like a baby again. I have to live with them, because they are my guardians. They have all my money. Joking around and socializing is hard. In the pilot, people were assisted and supported as they worked to meet these challenges in their lives.
Identifying these challenges and having them validated in a peer relationship was often a first step Mead, Then a peer or mentor supported them and worked with them to address and relieve these issues, and introduced them to skills that would assist them in addressing life challenges in the future.
Programs that focus on one-on-one mentoring like ComPeer and Peer Bridger see Chapter II are respected for their success in helping people to address their life challenges and move forward with their lives. The Vermont Project Chittick et al. Some of their methods, which included practice and role modeling, were included in this project. All those who were interviewed reported multiple traumas and losses in their lives.
They spoke of loss from:. I had another baby after I left the hospital. Parental custody was removed for all my children and they were adopted. And she kicked me out of the house when I was I was on the streets for a year? Then I got sent to this Camp for troubled teenagers. Their approach was totally drugs. No therapy, no nothing. Before I left there, I tried suicide just a couple times, but nothing real serious.
When I was up there at … Camp, I went over to … and took a bunch of wooden chairs and paper towels and all that stuff and put it in a circle and tried to kill myself. Set them all on fire. The only thing that saved me is one of the handymen there saw the smoke, and pulled me out of it. So I tried to get a hold of my wife.
Clearly the pilot program needed to validate the loss and trauma people have experienced, give them opportunities to talk about it, and discuss the role of trauma in their mental health difficulties. People involved in the project as mentors or peers needed to receive instruction in trauma-informed methods and use them to guide their relationships with people who have orders of involuntary commitment Mead, A few people found diagnosis to be minimally helpful. Others did not and often found it to be harmful.
Many people did not understand what the diagnosis meant. It was clear from these responses that the pilot project, in order to be most inclusive and to be respectful of all views, needed to avoid a diagnosis basis.
This meant that, in order to take part in this program, a person did not have to be specifically diagnosed with an illness like schizophrenia or bipolar disorder, or accept that they have a mental illness, but rather it was a program for people who have mental health difficulties, have an order of involuntary commitment, and wanted to work toward their recovery and independence.
However, activities in the pilot helped people to understand any diagnosis they have been given and to make decisions regarding what role they want that diagnosis to play in their recovery and their life. The program was clearly and intentionally complementary to medical treatment and not designed to take the place of medical treatment. They hardly knew enough about recovery even to dream of it. They seemed almost afraid to dream of any positive change in their lives.
In responding to questions regarding their hopes and dreams, they said they were told what their hopes and dreams should be, and were not supported in having hopes and dreams of their own. Most said they had given up on or forgotten their dreams and had little or no hope. With further interviewing, they shared hopes and dreams that included things like independence and recovering parts of their previous lives that they had lost, like their home life, custody of their children, and certain relationships.
They talked about helping others, going back to school, having a family, making enough money to live comfortably, pursuing a career, regaining their health, and doing normal things in the community like shopping and going to the movies.
The literature clearly shows that people who live with even the most severe mental health difficulties can get well, stay well, and successfully do the things they want to do with their lives Desisto et al. People shared a multitude of strengths, abilities, and interests. However, many of them noted that they no longer have opportunities to use their strengths and do the things they can and like to do.
It seemed obvious that creating opportunities for people to pursue their interests and strengths might renew their passion for life, enhance their quality of life, and help them to feel better Rapp, Some people found it hard to identify interests and strengths.
When asked what their strengths and interests are they responded with statements like the following quote from a study participant: It could also lead them to discover new interests as well as explore things they used to enjoy and try them again Copeland, Among the interviewees, there was a general sense of despair around the conditions of their lives. They made little connection between their life circumstances and the various life traumas they had experienced or specific actions they had taken.
This clearly affected their self-perception. The pilot project included activities that help people develop self-esteem, learn how to self-advocate, and practice self-advocacy Copeland, As they developed these skills and felt better about themselves, they felt more ambitious and motivated and began to take on recovery-related tasks.
The common thread that ran through much of the data was that people wanted to feel close to others, to have relationships, and to feel connected to their natural community. Most also thought that they would benefit from peer support and recovery education in their efforts to reach that goal. People want connection with others and a strong sense of community outside of the mental health system.
In analyzing the data, it became clear that in all kinds of relationships peer, family, intimate, mental health system, and community , the qualities that people felt would be most helpful in others included many that are the same as for peer support Mead, People said their relationships with family were not good and that they want them to be good. They craved strong connection with their own children, many of whom had been taken from them long ago.
They spoke of abusive spouses and parents, but did not mention any possible connections between this abuse and their mental health difficulties. Almost all of the interviewees spoke of their lack of intimate relationships and their wish for intimacy in their lives.
And many emphasized a strong desire to be in close connection with their community. Some of the words and phrases that they used to define close relationships that guided pilot project relationships include: Although it was expected that people would want more connection with their peers in the mental health system, that was not a finding of this study. Rather people said they want to know how to sustain close relationships with the people in their lives, meet and become friends with people outside of the mental health system, and be involved in their community.
Therefore the pilot program helped people develop interpersonal skills, create opportunities to meet potential friends, and feel more closely connected to their community. People shared extensive lists of things they know they can do to stay as well as possible and that help when they are having a hard time. People said it would help them to recover and get off the involuntary commitment order to: Other important ideas included:. These lists are similar to the lists that people put forth when they develop the Wellness Tools section of a Wellness Recovery Action Plan Copeland, b.
In the pilot project, people had an opportunity to develop long lists of tools and develop plans that would guide them in using these tools. People eschewed the following values, which would not be a part of the pilot project, were not helpful, and were often harmful: People in this group seemed to have little knowledge about their medications.
In several cases people reported that they willfully stopped taking their medications to get back into the hospital, as their living circumstances had become intolerable, such as living on the street in winter, being forced to share living space with people who treat them badly, or not having enough money to buy food. People who facilitated the pilot project did not have the expertise to advise people about medications the project did not have enough funds to hire such a person. However, a part of recovery education and the peer relationship, when it seemed necessary and appropriate, was to learn together about the medications and medication management, and help people find the information they need to make medication decisions.
People who took part in this program as mentors were told that they could not and must not advise people about taking or not taking medications, but could suggest the person talk with their doctor when these issues arise. They were advised of the liability issues related to advocating that a person stop taking their medications. This was an interesting finding given that the Vermont State Department of Mental Health through Vermont Psychiatric Survivors supports an exemplary peer-run program that sets up peer support groups across the state and offers on-going, free recovery education and Wellness Recovery Action Planning seminars that are open to anyone.
It seems that information on the availability of these initiatives is not reaching people who have involuntary commitments, or they are not willing to participate in these activities.
Several people said that they thought these programs would be useful to them. By incorporating these approaches in the pilot, this project had the potential for demonstrating how these initiatives would work for people who have or have had involuntary commitments. The interviews show that these initiatives needed to be modified to best meet the needs of people in this group, be easily accessible, and voluntary. As an end goal, the people who were interviewed felt that becoming fully integrated into the community was more important than peer support.
Peer support might allow people to practice skills they needed to become more fully integrated into their community.
In developing the pilot project, it was useful to look at the common experiences that the interviewees shared. Each person had, at some time, been hospitalized at the Vermont State Hospital. Several were currently patients in that facility.
The following quotes from people who were interviewed in the study describe what they found to be helpful about the hospital experience. Being around people, caretakers, workers, who care about you. Good change of pace from sitting there alone, feeling depressed, feeling rather desperate about a situation. The pilot project did what it could to emulate the positive aspects of the hospital experience that were noted by these study participants.
Although several people reported there was plenty to do, things like going to the canteen, woodworking, groups, crafts, and spending time in the gym, others complained that there were long periods of time when there was nothing to do, especially on the weekends. Weekends are really, really slow.
I listen to my walkman, watch a little TV, exercise. The pilot project introduced people to activities that they can engage in either alone or with others when they are living in the community Copeland, Usually, it will take me about a year to recover from the hospitalization. Cooped up like this is horrible. The air is stagnant. I think the hospitalization, in large part, represents the sadism of the human character. I think the staff there was really horrible.
At least one in particular was very disrespectful, and sexually inappropriate. When people who were very sick would do strange things he would laugh. The emphasis was on disciplining people and not really on helping them. I was also being treated lousy. People complained about a lack of transitioning from the hospital to the community. For instance, one person said:.
They just sent you to court and if you got out, you got out. They should have had a psychologist there working with you, talking to you about adjusting to your new environment, which is a shocker when you get out. How to adjust and giving you ideas and really laying the groundwork for you. I had to adjust on my own. It was a highly sophisticated transitioning program that could easily be replicated by the hospital at this time.
As happened in the Vermont project, the pilot project included mentors who could go into the hospital as people were preparing to leave and work with them on developing plans for how they could manage when they got out. This person could also be an advocate and could provide education, support, and companionship while introducing the person to a variety of activities and community resources.
Study participants were not accustomed to being asked for recommendations. However, when they realized that their ideas would be heard and validated, they were willing to talk about their ideas. Most of these ideas are incorporated in the other theme summaries.
However, several people suggested the option of trained peer mentors, people who would listen and provide a bridge back into the community. These would be people who could be trusted and who would help people make choices and who might serve as a role model. They could attend events and share activities. These nonjudgmental, caring people would be like natural friends and would have nothing to do with mental illness. The data analysis process was further enhanced by responding to the questions posed by the Vermont State Department of Mental Health in their request for proposals.
How are people who have involuntary commitments currently interacting with professional and peer organizations and the community? Very few people had a sense of, or connection to, their larger community. Many people felt isolated due to their lack of transportation, limits on personal freedom, stigma, and the loss of old friends. It was also not uncommon for people to identify their residential program or even the state hospital as their community. When people had internalized the message that they are different from others they often felt shame just walking around in the community, felt that people judged them unfairly, or were worried that they might have an embarrassing incident while in the community.
Many people identified recovery as having friends outside the mental health field. Because of this lack of connection, mental health workers were often cited as either sole supporters or as controlling parental figures.
When people had had good experiences with mental health professionals, the qualities they cited as helpful were: Many people were anxious to break off their connection with mental health services. They spoke about the over-controlling nature of the relationships, the lack of collaboration around medications, and the perceived use of orders of involuntary commitment as punishment. It was also quite clear that some of the incidents resulting in hospitalization were perceived differently by mental health workers and the recipient.
What are the treatment and support needs of people who have orders of involuntary commitment that are not being provided by the current professional and peer support systems? Participants had many treatment and support needs that went beyond the scope of their current services or connections with peer support. For example, many people felt that they had little connection with the larger community, that friends were hard to make, and there were few places where people could get together.
Although some people used the local clubhouse, most did not find it particularly stimulating; and no one identified it as a place to build connections.
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