In this paper, we discuss how the COVID-19 pandemic offers a particularly salient moment in which to identify and reflect on shifts in psychiatric carcerality in highly concrete ways. Drawing from our own professional and practical experience as in-patient (acute-care) psychiatrists implementing changes in ward policies in light of infection control concerns and linking this experience with insights and tensions between Mad Studies, Critical Prison Studies, and the psychiatric writings of Franz Fanon, we focus on specific ways that therapeutic value is undermined within these complicated and complex settings. Using Repo's metaphor of “carceral layers,” our analysis considers how particular infection control policies and practices, institutional approaches to pandemic management, and larger ideologies of risk have worked together to produce spatio-temporal aspects of carcerality in a psychiatric acute-care setting in Toronto, Canada.
In contrast to the overlap between carceral spaces and involuntary admission to closed inpatient wards, inpatient psychiatry units are also considered “new” spaces of care, with greater aspects of permeability and transition between hospital and community life (see Curtis et al., 2009).
To further position ourselves within this analysis: as authors, each of us identifies as white settlers and as cis women who generally live without significant ongoing disability. We each spend some of our clinical work in acute psychiatric settings (e.g. the inpatient unit, the emergency department), but also have additional areas of focus – for instance, LM and KS also work in the area of medical psychiatry. We are also researchers with a diverse set of interests, from quality and safety (KS), to functional movement disorders (LM), to feminist philosophy of science/science and technology studies (SB). One important positionality that we do not hold or endeavour to represent is the position of psychiatry service users themselves. This is clearly a perspective that would add important complexity to the issues we raise in this paper.
Appendix 1 describes the restraint algorithm created at our institution for contending with COVID-19 related infection risks within acute-care psychiatric spaces. The algorithm is a two-page document beginning with a red diamond labelled “COVID SCREEN” and negative versus positive as options from this point. Negative screen leads to treatment as usual. Positive screen leads to a decision box titled “NP Swab” (nasopharyngeal swab). Choices are then detailed from the NP Swab decision box, including determining whether an individual can self-isolate or not. Assessments are required for need for detention in hospital, and the next decision point identified as to how they are being detained (i.e. under the Mental Health Act or not). The decision tree continues to ask whether the individual is capable with respect to refusing a swab, and which additional legislative Acts would justify the use of restraints for the purposes of isolation if a capable individual with symptoms continues to refuse an NP swab. Isolation via environmental restraints would be potentially applied for up to 14 days in the absence of an NP swab. Text boxes also outline additional steps that should be taken, including education regarding the importance of swabs, language-specific signage for the individual's room, offering activities and as-needed medication to manage boredom or agitation, and steps for managing exit-seeking from one's room if the individual is isolated. The second page of the algorithm outlines the algorithm rationale as well as legal information and considerations from hospital bioethics. See https://www.clpsychiatry.org/wp-content/uploads/University-Health-Network-Covid-Screening-and-Isolation-Algorithm-041620.pdf 4. Femi Eromosele offers a thorough discussion of the tensions between Fanon and Mad Studies, additionally identifying that Fanon's observations on psychiatry and the formation of subjectivity signal a contradiction or ambiguity surrounding the relationships between madness, subjectivity, and freedom that leads his work to diverge from the arguments that subtend Mad activism. (See Eromosele, 2020.)