Discussing a psychiatrist’s objections to mandated treatment.
To the Editor:
Recent tragic events have linked mental illness and violence. Some people—I, for one—consider this link dangerously stigmatizing. People with mental illness are far more likely to be victims of violence than perpetrators. Moreover, psychiatrists have limited capacity to reliably predict violence. Nonetheless, these events increase pressure to identify people who might conceivably commit violent acts, and to mandate treatment with antipsychotic medications.
For a tiny minority of patients who have committed serious crimes, mandated treatment can be effective, particularly as an alternative to incarceration. But for most patients experiencing psychotic states, mandated treatment may create more problems than it solves.
For many medical conditions, better outcomes occur when patients share in treatment design and disease management. Imposed treatments tend to engender resistance and resentment. This is also true for psychiatric conditions.
Patients with psychotic symptoms often feel that their own experience is dismissed as meaningless, like the ravings of an intoxicated or delirious person. Decisions to decline antipsychotic medications are often regarded mainly as a manifestation of illness—an illness the person is too sick to recognize—even though many people might reject antipsychotics because of metabolic and other toxicities.
When a clearly troubled person firmly believes that he or she needs no help, there are no simple answers. These situations are particularly agonizing for families. Safety is paramount—and at times can be elusive. Still, if psychiatrists humbly try to understand the person on his or her own terms, do not dismiss the person’s experience as meaningless and truly respect the person’s choices about treatment, sometimes this opens the way to an effective treatment relationship. For some suffering and alienated people—certainly not all—feeling respectfully understood can be a critical step toward recovery.
Mandated treatment is a blunt instrument that may drive more people away from seeking care than it compels into care.
Framingham, Mass., Jan. 28, 2013
The writer is a psychiatrist and an associate clinical professor of psychiatry at Harvard Medical School.
After decades of relentless psychosis, forced treatment was the only way that my mother was able to begin her path to recovery. As a psychiatrist and a family member of a loved one with schizophrenia, I know well the challenges of caring for individuals who firmly and consistently refuse help.
For me, the dilemma of forced treatment is an issue of access to care, and should be based on whether an individual is able to fully understand the nature, risks, benefits and alternatives of treatment, or of refusing that treatment. Because of a phenomenon known as anosognosia, certain psychotic and manic individuals do not recognize their symptoms. Without compelling treatment for this population, they rarely voluntarily seek the care that they desperately need and deserve, often leading to heartbreaking outcomes such as homelessness and incarceration.
For my mother, and for hundreds of thousands of others with severe mental illness, declining treatment is not about providers not listening, side effects of medications or stubborn denial. She fundamentally does not believe she needs help, despite a wealth of reality-based evidence to the contrary.
While mandated treatment involves complex considerations and should be an approach of last resort, for individuals with a clear history of serious mental illness who are unable to make reasonable medical decisions, it is at times the difference between empowering the person with the illness, rather than empowering the illness itself.
San Francisco, Jan. 31, 2013
The problem with our mental health system is it prioritizes improving mental health over treating serious mental illness. Less than 9 percent of Americans have serious mental illnesses like schizophrenia. Another 25 to 40 percent have poor mental health. The “psychotic killer” headlines are the result of cutting services for the seriously ill to pay for services for all others.
We used to have enough psychiatric hospitals for the most seriously ill. Today, we spend more on mental health but are short 95,000 psychiatric beds. Three times as many mentally ill will spend tonight incarcerated rather than hospitalized largely as a result of our new spending priorities.
Are people with mental illness more violent than others? The 25 to 40 percent are not. Those in the 5 to 9 percent who go untreated are.
Court-ordered assisted outpatient treatment helps these most seriously ill individuals get treatment and reduces violence, dangerous behavior, suicide and incarceration. Such treatment programs go largely unfunded while programs for newly minted mental health issues like bullying are showered with dollars. To reduce episodes of violence, we have to target the population most likely to be involved in it. We have to send the most seriously ill to the front of the line for services.
D. J. JAFFE
Mental Illness Policy Org.
New York, Jan. 30, 2013
I am the parent of a 15-year-old boy who suffers from severe mental illness. My son has been violent. He has tried to strangle me, he held a baby sitter at knifepoint when he was 5, and he continues to be a danger to himself and others. My son is not a monster, and he is not evil. He is loving, kind, smart and polite. And he is severely mentally ill.
With all due respect to Dr. Gordon, I could not disagree with his views more. As a parent who lives in a state of crisis every day, I am sure that in this case, the patient’s rights would be better preserved by offering him a safe and therapeutic environment. A severely mentally ill individual is incapable of knowing what is in his or her best interest. For the small percentage of people who are severely mentally ill, involuntary treatment is the only solution. The alternative is the streets or prison.
If my son had cancer or any other illness or disability, he would receive the necessary treatment for his success and well-being. Unfortunately, because his disability is severe mental illness, and because of doctors and lawmakers who think like Dr. Gordon, my son will likely die on the streets or in jail.
That is an outrage.
Torrance, Calif., Jan. 30, 2013
I was hospitalized against my will and forcibly given electroshock and damaging medication. After three brutalizing years in the broken mental health system, the best help for me finally came from a kind and gentle doctor who listened to me, believed in my many strengths and encouraged me back into college and a full life.
Dr. Gordon is correct. Kindness is the best medicine of all.
DOROTHY W. DUNDAS
Newton, Mass., Jan. 30, 2013
Dr. Gordon’s preference for mandating psychiatric treatment only for those mentally ill individuals who have committed serious crimes is admirable—unless you are one of the victims of that serious crime.
As a state prosecutor in Maine for more than 20 years, I have had a front-row seat as the mental health community has abdicated responsibility for untreated, and obviously unbalanced, individuals until they have committed a crime. As a result, thousands of mentally ill defendants are crowded into county jails awaiting trial. But there are worse fates for these individuals.
Sometimes they become engaged in lethal police encounters, when law enforcement officers are forced to use deadly force to protect themselves or others. In Maine, more than 40 percent of individuals shot by police officers in the last 12 years had mental health problems.
Sometimes they kill family members. The 2010 Report of the Maine Domestic Abuse Homicide Review Panel found, “More than ever before the panel has reviewed cases involving intrafamilial homicide; a significant number of these cases involved perpetrators who have mental illness and are not medication compliant.”
As one newspaper commentator recently observed about Maine’s mentally ill, “We are killing them, and they are killing us.”
My colleagues and I regularly encounter family members of mentally ill defendants who plead with us to somehow get treatment for their loved one before they do something unthinkable.
I sometimes wonder if Adam Lanza’s mother faced this same predicament.
Farmington, Me., Jan. 30, 2013
I am a mental health counselor and an advocate in the child welfare system, and I see the effects of enforced treatment on a daily basis. In my observation, receiving mental health treatment does not necessarily reduce violence, and can sometimes even make people more violent than they would otherwise be. While some people do just fine on medication, psychiatric drugs can sometimes induce or exacerbate violent behavior. Prozac was initially banned for sale in Germany in the late 1980s for this very reason.
Many of those responsible for mass shootings in the last 20 years actually were receiving or had received psychiatric drug treatment before they went on their sprees. Given the known side effects, it is likely that these drugs caused or contributed to a large number of these incidents. At the least, we can say that giving these people psychiatric treatment, even voluntarily, did nothing to prevent them from going on a shooting rampage.
Rather than blaming the victims, mental health professionals need to keep a close eye on those who are prescribed psychiatric drugs, and make sure that they are taken off such drugs if they show any signs of instability, violence or self-harm. Counting on enforced psychiatric treatment to reduce or prevent violent shooting sprees is at best ineffective and may, in fact, be making things worse.
STEPHEN T. McCREA
Portland, Ore., Jan. 30, 2013
Thank you, Dr. Gordon, for arguing against mandated treatment. As a mental health counselor, I am often appalled at how we have seemingly lost our way in our treatment of people experiencing psychotic symptoms. Rather than looking for alternative, more humane solutions, we have convinced this population that there are few options apart from psychotropic sedation.
We would be better off looking to other countries that are finding success with models such as “open dialogue,” a family and social network approach originating in Finland and now starting to be used in the United States.
New York, Jan. 30, 2013
The Writer Responds
I do not deny that people suffering from mental illness commit acts of violence. I know that caring for a loved one who ragefully rejects help can be agonizing and that families often bear the burden of this violence. My heart goes out to Ms. Stoufer and her son.
Dr. Tsai powerfully captures the conundrum of an extreme case, in which his mother’s judgment was so impaired that compulsory care was necessary. However, anosognosia is a slippery slope.
It’s just too easy—unless we doctors are scrupulously humble—to mistake disagreement for disease, and inadvertently dismiss the legitimate preferences of people with mental illness. What applies to extreme situations must be very carefully generalized.
Mr. Jaffe highlights mandated outpatient treatment. For some, this intervention is helpful. But the research is unsettled. It’s unclear whether it’s the mandate or the availability of more treatment that helps people. It is clear that the more people experience their care as fair and noncoercive, the more helpful it is.
I believe we need more services that are inviting, build on strengths, offer peer and family partner supports, and include real choice about medications. In my view, we rely too much on medications—and inducing or forcing people to take them—rather than appreciating the complexity of the problems people face and providing services that people want.
Our fragmented, underfunded system has been disastrous for many. Jails crowded with people with mental illness testify to that.
Respecting the rights of our fellow citizens with mental illness requires reserving mandated treatment to conditions of adjudicated incompetence or imminent dangerousness, or as an alternative to incarceration.
Coercion is sometimes necessary, but we should be clear about its cost: trust and collaboration are largely incompatible with force. Genuine partnership can be a balm for many hurts, and open the way for some people to real and lasting growth.
Framingham, Mass., Feb. 1, 2013