Monday, October 02, 2006

On A Short Leash

Dinah posted yesterday about the issue of mandatory therapy for children of divorce. Dr. A made the observation that "If the person is brought kicking and screaming to the doctor or counselor, then it may not be a good idea for that person."

Compelled treatment is more my domain than Dinah's, I guess, since many forensic patients end up in that predicament. Does compelled treatment work?

Yup. That's kind of the point of having mental health courts and outpatient commitment (or what opponents characterize as 'leash laws').

Eventually. Maybe not the first time, but eventually. Eventually when they figure out that dropping out of treatment leads to relapse and relapse leads to incarceration. Or in the case of insanity acquittees, return to the psychiatric hospital. People who work in substance abuse programs now welcome dual intervention with court supervision because they know the court-ordered patients are more likely to show up and to return.

It isn't easy initially, and sometimes you have to help the person realize that staying well does need to be a priority over moving into your own apartment with a girlfriend so your mother can't remind you to take your medicine or go to your twelve-step group. It takes time to change behavior and sometimes one learning experience just isn't enough.

Coercion can take many forms separate from the criminal justice system---pressure from family members or employers, having a payee to answer to or living in a supervised housing situation that requires participation in a day program. Staying well becomes a priority if your friends and relatives are tired of living with your symptoms, or if being sick means you lose your living situation.

I've mentioned this in the past, but some of the best research on mandated treatment is being done by the MacArthur Foundation. The interesting this about this work is that it showed that leveraged treatment is not necessarily perceived as coercive by the patient if the patient is given a chance to participate in the process---ie. to participate in a mental health status conference with a judge or to discuss how money will be spent with a payee. While outcomes studies are still being done, there is evidence that use of leverage reduces likelihood of rehospitalization and reduces length of stay.

A better way of dealing with things is the psychiatric advance directive. Analogous to a living will, patients can give notice what treatment they want if the need arises and they are incompetent to give consent. (Read the FAQ's on the link to find information about how to make an advance directive. The Bazelon Center web site has a sample form, but you need to follow the laws of your particular state.)


On a more pleasant note, I thought I'd post my Quote of the Day from an inmate given a twelve year sentence for robbery:
"That judge was prejudiced. He was prejudiced by all those theft charges on my record."
And they wonder why I love working with these guys.


Sarebear said...

Nice quote!

My husband finally said he'd go to therapy, but we had alot of fights about it. He feels therapy is only for "sick" people . . . gee, thanks . . .

So if/when he goes, I suspect there'll be alot of resistance because A)it's something I'd like, and B)he really doesn't want to.

he actually IS one of those "sick" people as caring for me has given him bouts of depression . . . lol (at the fact that he's one of "those" people, not at the fact that he has depression).

Anyway. If/when I get the SSDI, then we can pay off all our debt and have plenty left over, as well as alot of extra money each month from not being in debt, and we can then afford therapy for both of us . . .

Dr. A said...

Interesting post. I may have to take back some of what I said yesterday. I was talking with some teacher friends today who work with tough inner city kids.

I don't want to get into the whole nature/nuture thing. But, suffice to say that these kids learning disabilities and/or mental health issues were not brought on by the kids themselves.

Why am I talking about this again? Well, some of these kids end up in the care of the children's service board (CSB) and end up in the court system -- and may end up having "compelled" treatment -- which these teachers told me today, does help some of these kids. Sorry for my rambling.

Finally, the psychiatric advanced directive is going to be the law of the land in my state come next year. Hospitals around here are trying to figure out the best way to educate the community to get the word out.

MT said...

That guy should be a philosopher. If Hume were a convicted burglar he might make the same accusation.

Anonymous said...

“Therapy is a really risky proposition. You don’t usually get a competent therapist the first time. Therapists can do a lot of damage before you find someone who can help you in a way you can use. They can increase your sense of self-doubt at a time when you need to be able to trust yourself. So I never recommend it to anyone who isn’t desperate. It’s just not worth the risk.”

Note: I figure anyone in prison is by definition desperate! Still, we are talking about a significant measure of self-determination here. Prison inmates can opt out (subject of a previous post). And people not in prison are in a position to experiment to determine for themselves whether therapy or imprisonment is the lesser of two evils (subject of present post).

This worked quite well with my brother. He really hated being in jail, so when presented with the alternatives of either checking himself into a hospital or going to jail, he chose to check himself into a hospital. And then... he got to work with a team led by an excellent psychiatrist who enjoyed working with him and who he liked and respected. Previous hospital experiences had been much less productive, partly because the option of jail was not there and partly because the psychiatrists were simply not interested.

The time hospitalisation worked, my parents had done their research, had identified the hospital they wanted, had made contact with the team, and were able to arrange that my brother would check into that hospital and not the usual one that police took people from their mental health units. (The one he had been in before where the personnel had not evaluated him but had stated that they would not attempt to help.)*

Really, “therapy” is not some homogenous thing that is standardised and dispensed in exactly the same way at pharmacies everywhere. Far from it. There’s a lot of luck, a lot of chance, and a huge variability in quality.

*Sound implausible? Detail, then. My brother used marijuana. He is black. At the age of 20 he left home to live on the street. The homeless shelter he turned to immediately moved him to their mental health unit. The shelter tried to get treatment for him. He was seen by a psychiatrist who tried to persuade him to take medication. Ultimately he was hospitalised for his own protection by court order. At the hospital he was immediately given a large injection of Haldol to sedate him, at which point he passed out for 12 hours. The next morning, the psychiatrist on the ward announced that they would not offer him psychiatric care because his problem was drug use, not schizophrenia. Nobody at the hospital had been able to evaluate him because he had been unconscious since he arrived. The psychiatrist presumably arrived at his conclusion based on the combination of black skin and history of marijuana use. (Refusal to treat a schizophrenic who consumes stuff is bizarre: schizophrenics consume stuff! They are notorious for it!) My brother no longer uses marijuana, but he is still schizophrenic. He really likes his meds and his mental health worker. He lives independently and is starting to work. So yeah, with these details the hospital’s refusal to treat a schizophrenic patient without evaluating him becomes plausible. But that doesn’t make it good care. And it didn’t help him get off the street.

It’s one thing to mandate treatment. It’s quite another to offer adequate treatment. Yes, my brother eventually got adequate treatment because my parents were educated and involved. But how many psychiatric patients are able to provide that kind of advocacy for themselves? They are very vulnerable. And they routinely get very bad care. Really.

Dinah said...

My advance directives: If I am incompetant to make decisions due to an acute psychiatric illness, I would like my sundaes to be made as follows: vanilla, extra hot fudge, whipped cream (but not whipped topping), no nuts or cherry. crumbled kitkat would be a nice little addition, if availabe.

ClinkShrink said...

Anonymous, thank you for your comment and I'm glad things worked out well eventually for your brother. That was a terrific illustration of what I was talking about. Jail is a low point for people and certainly could be a crucial time to intervene and start turning somebody's life around. Ideally this wouldn't be just because the jail was a bad place, but eventually (maybe someday?) because they meet someone there who can take them seriously, get them started in treatment, give them the basic illness education they need to get started, and get them on the road to being responsible for their own illness. This is very difficult to do in a jail setting because of the relatively short length of stay (2-3 months avg) but I have seen this get accomplished in the prison setting with inmates who are open to it. Getting through the trust issue is the biggest challenge.

ClinkShrink said...

Dinah, I will follow your directives to the letter. I promise. Unfortunately, you will be NPO for your scheduled ECT but Roy and I will see that the sundaes are put to good use.

Anonymous said...


Note that my brother was not treated in prison. Even on the outside, finding a psychiatric team willing to treat him - and getting my brother and the psychiatric team to encounter one another - took the concerted efforts of his parents, an advocacy organisation that could supply a knowledgable lawyer, a crisis intervention team, a homeless shelter and the legal system.

And they had to do it all twice, because the first time the psychiatric team was unhelpful. The first time the psychiatric intervention was just as mandated as the second time: he was taken to the hospital in handcuffs.

It didn't help.

ClinkShrink said...

Anonymous, you said:
"He really hated being in jail, so when presented with the alternatives of either checking himself into a hospital or going to jail, he chose to check himself into a hospital."

So, you agree with me that mandated treatment can help people. It can make them willing to participate in treatment. That was my point. I agree that is not the whole picture---you have to have people in free society who are willing to treat forensic patients. I agree with you on that.

My next comment was that we should take the process one step further "up stream" and work to get treatment started as soon as possible---at the door of the correctional facility.

Jassy said...

I got a great deal out of this post. While I no longer work with people who are required, either by protective services or the courts, to attend therapy, I spent a few years as a marriage and family therapist doing both therapeutic home visits AND on-site clinic visits. Getting over the "They made me come!" place to the point where we could actually get some good work done was hard, very hard. But after the initial "I hate you and I don't want to be here" weeks, having people tell you at the end of the therapy hour that it had been worth it, made all the difference to how I felt about doing the work. (However, please note that I am now in private practice and ONLY work with folks who want to be in therapy - no accident there!)

Anonymous said...

Okay, I admit to getting sidetracked. I went off on my usual rant that the problem of finding an accessible therapist willing and able to help is a greater barrier than most mental health workers seem willing to admit publicly. Sorry.

Back to my original point that while jucidial pressure may be useful, the examples given of its usefulness were in contexts where people had some measure of self-determination. And by "people," I mean both the patient and the treatment team.

My brother was actually taken to hospital in handcuffs twice, now that I review events. The first time the psychiatrist announced that the problem was marijuana abuse and that the hospital would not have any part of a treatment plan. My brother was kept sedated with injections of haldol for the three legally-mandated days and then sent back to the homeless shelter without follow-up. The second time the psychiatrist interviewed him, determined that there was nothing wrong with him, and sent him back to the homeless shelter immediately. (My father, who had sought the second court order, while initially frustrated with the hospital for not assuming their responsibilities, soon got a greater kick out of picturing his 21-year old high-school dropout schizophrenic son successfully snowing a psychiatrist. Hee hee!)

Both times my brother had no stake in cooperating with the hospital and every motivation to appear competent to leave. Both times the psychiatrists were asked to hospitalise a patient based on an evaluation performed by the judicial system, not the medical system. Neither my brother nor the psychiatrists cooperated.

The third time, my brother was given a choice between cooperating with the psychiatric system or being hospitalised by the judicial system. He was told that if he checked himself in for treatment that the judge was likely to suspend his sentence for [bad things that led to his arrest]. This time the hospital was asked to evaluate him and to admit him on their own terms. Both my brother and the admitting psychiatrist were presented with choices, and both cooperated.

No, I am not saying that mandated treatment is not useful. What I am saying is not to underestimate the rôle of self-determination and choice even under conditions of judicial pressure. That it's not either-or: it may need to be both.

ClinkShrink said...

Very well said.