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Mental health reporting laws: A false answer to gun violence
The tragic Feb. 14 massacre at Marjory Stoneman Douglas High School in Parkland, Fla., which left 17 people dead and 15 hospitalized, was the 34th1 U.S. mass shooting of 2018. Last year was a record year, with 346 mass shootings.2 In response to these tragedies, mental health providers are being looked at to help solve the problem. In fact, the day after the Florida shooting, President Trump tweeted: “So many signs that the Florida shooter was mentally disturbed ... Must always report such instances to authorities, again and again!”3
This response is reminiscent of how the state of New York reacted to the 2012 Sandy Hook massacre in Newtown, Conn. One month after the shooting, the NY SAFE (New York Secure Ammunition and Firearms Enforcement) Act was passed, which, among its measures, requires mental health providers to report individuals “likely” to engage in harm.4 The act represented an attempt to empower mental health providers to report high-risk, potentially violent individuals to the appropriate authorities.
However, we must acknowledge that some practical difficulties arise with such mandates. First is the reality that the overwhelming majority of patients in therapy who endorse violent impulses do not go on to commit harm toward themselves or others, nor do they break the law. Up to 25% of teenagers have thoughts of killing themselves6; 41% of depressed mothers have experienced thoughts of harming their children7; and up to 68% of individuals have homicidal fantasies.8 It would be difficult to argue that we would be doing our due diligence in reporting all patients who share such thoughts. Even if we agree that we ought to report only those who are at high risk for potential future violence, few guidelines are useful in stratifying risk for future violence outside of forensic settings. Prognostication is particularly difficult in cases where there is no history of previous criminal activity, as was the case with the confessed9 gunman in the Florida case. We also must acknowledge that evidence is scant suggesting that mental health treatment as a whole can reduce the incidence of mass murders. Evidence does suggest, however, that patients with serious mental illness are not involved in a majority of cases.10
Second, these types of mandates can perpetuate stigma in mental health, both potentially driving away patients who could benefit from therapy, and straining the relationships between patient and provider for those in treatment. Given the high degree of effort it takes for some populations to engage in mental health services, Indeed, it has been demonstrated many times that nothing matters more to the outcome of mental health treatment than the relationship between the providers and their patients,11 an effect that is true even for medication management.12 Being more wary of one’s treating provider may, therefore, limit the effect of treatment from the patient’s perspective. In the same vein, some therapists may rightly pause to consider whether they should be more vigilant and dutifully extract statements confirming a nonviolent mindset at every meeting, much in the way we perform suicide risk assessment to assess safety. Or, therapists could hesitate to probe for violent themes out of an underlying wish to avoid discovering something that they would have to report. Such tensions created within the therapist also may lend to suboptimal treatment.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Joshi is a research track psychiatry resident at the University of California, San Diego. His current research focuses on developing novel therapeutic strategies to target cognitive impairment in schizophrenia. His interests include graduate medical education and applied bioethics.
References
1. Gun Violence Archive http://www.gunviolencearchive.org/reports/mass-shooting
2. https://www.abc15.com/news/data/mass-shootings-in-the-us-when-where-they-have-occurred-in-2018
3. https://twitter.com/realDonaldTrump/status/964110212885106689
4. http://www.nyspsych.org/index.php?option=com_content&view=article&id=73
5. https://www.politico.com/states/new-york/albany/story/2018/02/15/after-florida-school-shooting-cuomo-again-touts-safe-act-256104
6. MMWR 2004;53(2):1-96
7. J Affect Disord. 1999 Jul;54(1-2):21-8
8. Ethol Sociobiol. 1993;14(4):231-48
9. http://www.dcf.state.fl.us/newsroom/publicdocuments/Headquarters/Records20180219/Petition%20to%20Publically%20Release%20DCF%20Records.pdf
10. Ann Rev Clin Psychol. 2017 May 8;13:445-69
11. Psychotherapy Theory Res Prac. 2001;38(4):357-61
12. J Affect Disord. 2006 Jun;92(2-3):287-90
The tragic Feb. 14 massacre at Marjory Stoneman Douglas High School in Parkland, Fla., which left 17 people dead and 15 hospitalized, was the 34th1 U.S. mass shooting of 2018. Last year was a record year, with 346 mass shootings.2 In response to these tragedies, mental health providers are being looked at to help solve the problem. In fact, the day after the Florida shooting, President Trump tweeted: “So many signs that the Florida shooter was mentally disturbed ... Must always report such instances to authorities, again and again!”3
This response is reminiscent of how the state of New York reacted to the 2012 Sandy Hook massacre in Newtown, Conn. One month after the shooting, the NY SAFE (New York Secure Ammunition and Firearms Enforcement) Act was passed, which, among its measures, requires mental health providers to report individuals “likely” to engage in harm.4 The act represented an attempt to empower mental health providers to report high-risk, potentially violent individuals to the appropriate authorities.
However, we must acknowledge that some practical difficulties arise with such mandates. First is the reality that the overwhelming majority of patients in therapy who endorse violent impulses do not go on to commit harm toward themselves or others, nor do they break the law. Up to 25% of teenagers have thoughts of killing themselves6; 41% of depressed mothers have experienced thoughts of harming their children7; and up to 68% of individuals have homicidal fantasies.8 It would be difficult to argue that we would be doing our due diligence in reporting all patients who share such thoughts. Even if we agree that we ought to report only those who are at high risk for potential future violence, few guidelines are useful in stratifying risk for future violence outside of forensic settings. Prognostication is particularly difficult in cases where there is no history of previous criminal activity, as was the case with the confessed9 gunman in the Florida case. We also must acknowledge that evidence is scant suggesting that mental health treatment as a whole can reduce the incidence of mass murders. Evidence does suggest, however, that patients with serious mental illness are not involved in a majority of cases.10
Second, these types of mandates can perpetuate stigma in mental health, both potentially driving away patients who could benefit from therapy, and straining the relationships between patient and provider for those in treatment. Given the high degree of effort it takes for some populations to engage in mental health services, Indeed, it has been demonstrated many times that nothing matters more to the outcome of mental health treatment than the relationship between the providers and their patients,11 an effect that is true even for medication management.12 Being more wary of one’s treating provider may, therefore, limit the effect of treatment from the patient’s perspective. In the same vein, some therapists may rightly pause to consider whether they should be more vigilant and dutifully extract statements confirming a nonviolent mindset at every meeting, much in the way we perform suicide risk assessment to assess safety. Or, therapists could hesitate to probe for violent themes out of an underlying wish to avoid discovering something that they would have to report. Such tensions created within the therapist also may lend to suboptimal treatment.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Joshi is a research track psychiatry resident at the University of California, San Diego. His current research focuses on developing novel therapeutic strategies to target cognitive impairment in schizophrenia. His interests include graduate medical education and applied bioethics.
References
1. Gun Violence Archive http://www.gunviolencearchive.org/reports/mass-shooting
2. https://www.abc15.com/news/data/mass-shootings-in-the-us-when-where-they-have-occurred-in-2018
3. https://twitter.com/realDonaldTrump/status/964110212885106689
4. http://www.nyspsych.org/index.php?option=com_content&view=article&id=73
5. https://www.politico.com/states/new-york/albany/story/2018/02/15/after-florida-school-shooting-cuomo-again-touts-safe-act-256104
6. MMWR 2004;53(2):1-96
7. J Affect Disord. 1999 Jul;54(1-2):21-8
8. Ethol Sociobiol. 1993;14(4):231-48
9. http://www.dcf.state.fl.us/newsroom/publicdocuments/Headquarters/Records20180219/Petition%20to%20Publically%20Release%20DCF%20Records.pdf
10. Ann Rev Clin Psychol. 2017 May 8;13:445-69
11. Psychotherapy Theory Res Prac. 2001;38(4):357-61
12. J Affect Disord. 2006 Jun;92(2-3):287-90
The tragic Feb. 14 massacre at Marjory Stoneman Douglas High School in Parkland, Fla., which left 17 people dead and 15 hospitalized, was the 34th1 U.S. mass shooting of 2018. Last year was a record year, with 346 mass shootings.2 In response to these tragedies, mental health providers are being looked at to help solve the problem. In fact, the day after the Florida shooting, President Trump tweeted: “So many signs that the Florida shooter was mentally disturbed ... Must always report such instances to authorities, again and again!”3
This response is reminiscent of how the state of New York reacted to the 2012 Sandy Hook massacre in Newtown, Conn. One month after the shooting, the NY SAFE (New York Secure Ammunition and Firearms Enforcement) Act was passed, which, among its measures, requires mental health providers to report individuals “likely” to engage in harm.4 The act represented an attempt to empower mental health providers to report high-risk, potentially violent individuals to the appropriate authorities.
However, we must acknowledge that some practical difficulties arise with such mandates. First is the reality that the overwhelming majority of patients in therapy who endorse violent impulses do not go on to commit harm toward themselves or others, nor do they break the law. Up to 25% of teenagers have thoughts of killing themselves6; 41% of depressed mothers have experienced thoughts of harming their children7; and up to 68% of individuals have homicidal fantasies.8 It would be difficult to argue that we would be doing our due diligence in reporting all patients who share such thoughts. Even if we agree that we ought to report only those who are at high risk for potential future violence, few guidelines are useful in stratifying risk for future violence outside of forensic settings. Prognostication is particularly difficult in cases where there is no history of previous criminal activity, as was the case with the confessed9 gunman in the Florida case. We also must acknowledge that evidence is scant suggesting that mental health treatment as a whole can reduce the incidence of mass murders. Evidence does suggest, however, that patients with serious mental illness are not involved in a majority of cases.10
Second, these types of mandates can perpetuate stigma in mental health, both potentially driving away patients who could benefit from therapy, and straining the relationships between patient and provider for those in treatment. Given the high degree of effort it takes for some populations to engage in mental health services, Indeed, it has been demonstrated many times that nothing matters more to the outcome of mental health treatment than the relationship between the providers and their patients,11 an effect that is true even for medication management.12 Being more wary of one’s treating provider may, therefore, limit the effect of treatment from the patient’s perspective. In the same vein, some therapists may rightly pause to consider whether they should be more vigilant and dutifully extract statements confirming a nonviolent mindset at every meeting, much in the way we perform suicide risk assessment to assess safety. Or, therapists could hesitate to probe for violent themes out of an underlying wish to avoid discovering something that they would have to report. Such tensions created within the therapist also may lend to suboptimal treatment.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Joshi is a research track psychiatry resident at the University of California, San Diego. His current research focuses on developing novel therapeutic strategies to target cognitive impairment in schizophrenia. His interests include graduate medical education and applied bioethics.
References
1. Gun Violence Archive http://www.gunviolencearchive.org/reports/mass-shooting
2. https://www.abc15.com/news/data/mass-shootings-in-the-us-when-where-they-have-occurred-in-2018
3. https://twitter.com/realDonaldTrump/status/964110212885106689
4. http://www.nyspsych.org/index.php?option=com_content&view=article&id=73
5. https://www.politico.com/states/new-york/albany/story/2018/02/15/after-florida-school-shooting-cuomo-again-touts-safe-act-256104
6. MMWR 2004;53(2):1-96
7. J Affect Disord. 1999 Jul;54(1-2):21-8
8. Ethol Sociobiol. 1993;14(4):231-48
9. http://www.dcf.state.fl.us/newsroom/publicdocuments/Headquarters/Records20180219/Petition%20to%20Publically%20Release%20DCF%20Records.pdf
10. Ann Rev Clin Psychol. 2017 May 8;13:445-69
11. Psychotherapy Theory Res Prac. 2001;38(4):357-61
12. J Affect Disord. 2006 Jun;92(2-3):287-90
Our fascination with medication compliance
As a forensic psychiatrist, I follow news relating to mental illness and crime. Like many of the judges and lawyers with whom I work, the media appear to have an obsession with medication compliance in those with mental illness. Being “off medications” has become a threatening term suggestive of unbridled impulsivity and violence – a term that can explain any behavior, implying that without medication, humans are routinely capable of all things without warning.
The year 2018 already has provided two stark examples of this phenomenon. During the first week of the year, two articles with the following headlines were published: “ ‘He was off his meds’: Son charged in mother’s murder”1 and “A man lost his life in the subway after telling a teen off of his medication to ‘get away.’ ”2 Those two articles describe awful events that, as the headlines suggest, are best explained by a lack of compliance with a psychotropic medication regimen.
“A man lost his life in the subway after telling a teen off of his medication to ‘get away’ ” reports on a 65-year-old man who was pushed onto New York’s subway tracks after interacting with an 18-year-old who “did not take medication that day for his mental illness.” This article provides some limited details on the state of mind of the defendant, indicating that he had been “talking to himself.” However, to reinforce the message, the article informs the reader that he had been prescribed three psychotropics – insinuating a multiplier effect for the role of noncompliance. Furthermore, the article implies that missing a single day of psychotropics is an explanation for the incident.
The media routinely use this bias in favor of the medication explanation in its analysis – or lack thereof – of violent behavior in people with mental illness. Recent stories include a man killing his nephew3 and a man killing his girlfriend4, and both were incidents apparently best explained by medication noncompliance. Another story reports of police officers who were charged with assault after an altercation with a patient with mental illness led to the patient’s death. In the latter case, the article suggests that the simple fact that the victim had been acting erratically warrants the comment that he was “likely was off his medications.”
My work in the jail system also has been tainted by this overreliance on the unquestioned dogma of medication compliance. Discussions pertaining to punishment and privileges of inmates with mental illness often would lead to the question: “Is he taking his meds?” I have witnessed countless times when crucial decisions about placement in solitary confinement were predicated on questions of medication compliance. My answer was always the same: “Why does it matter? If the inmate is following the rules and behaving respectfully, how does taking a pill provide more important information?”
What was once thought to be a predictor of relapse risk, despite limited evidence, has become the outcome itself. As a society, we have falsely equated mental illness with violence; we have furthermore falsely equated remission and safety with medication compliance. The consequences of those beliefs are severe as we have limited attention, and our focus on medications blinds us to much clearer risk factors. 5
The court system is equally riveted with this question. Judges and lawyers associate medication compliance with legal competency, safety in probation or parole, and general well-being. I have witnessed agitated patients being reprimanded for their lack of medication adherence, leaving me to remind lawyers that the patient has been compliant. Conversely, patients are congratulated for their medication adherence when appearing well, until I remind the lawyers that the patient missed his last two visits for long-acting injectables.
As our field is reconciling new evidence questioning the long-term role of antipsychotics in schizophrenia, I am questioning whether society has accepted their value as a foregone conclusion. Lex Wunderink, MD, PhD, and his associates challenged accepted dogma when conducting a long-term, randomized trial of antipsychotics, in which patients on a dose reduction and discontinuation arm did better at 7 years than the patients on the continuation arm.6 The then National Institute of Mental Health director, Thomas Insel, MD, wrote in his blog that for some schizophrenia patients, “remaining on medication long term might impede a full return to wellness.”7
A Cochrane review of the literature found that, over time, antipsychotics had a diminishing effect on relapse prevention. After 2 years, the effect approached zero.8 In 2016, Nancy L. Sohler, PhD, and her colleagues looked at the literature on antipsychotic use in longer trials. The data were of poor quality and inconclusive.9 However, stories in the popular press suggest that the best explanation for violent behavior in the mentally ill population is medication noncompliance.
Inextricably bound up with this dogma regarding noncompliance is the incorporation of the pharmaceutical industry into mainstream psychiatry. The promise of psychopharmacology to treat mental illness was adopted in a wholesale manner for financial and practical reasons as well as a desperate optimism to relieve seemingly intractable problems. Sadly, the failure of psychopharmacology to produce on said promises has not produced a backlash. Instead, there is a doubling down on this belief, which can be seen, for example, in the creation of Abilify MyCite – with its promise to keep clinicians informed about their patients’ medication compliance.10 The alternative to this prescribing culture would be an attentive reckoning of the ongoing limitations inherent in the treatment of those with mental illness. If noncompliance cannot explain violence in people with mental illness, we are left with the same complex and subtle issues surrounding violence that frustrate easy journalistic explanations, and relatively cheap and easy interventions for the care of this population. It feels better and is more cost effective to blame the patients for not fitting our biological models by being drug nonresponders or noncompliant.
Blaming pills is facile. It is tangible and easier to measure than looking into someone’s mind. Psychiatrists have promoted this idea by teaching the public about chemical imbalances and by focusing on medication management. However, when the consequences are as severe as placing people in solitary confinement or explaining murder, the evidence needs to be equally solid as the severity of the punishment. This must start with psychiatrists reeducating the public on the role, the power, and the limitations of psychotropics.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre mentors residents on projects, including reduction in the use of solitary confinement of patients with mental illness and examination of the mentally ill offender. Dr. Badre can be reached at Badremd.com.
References
1. Worcester Patch. Jan. 2, 2018.
2. Rare News. Jan. 4, 2018.
3. WTSP.com. Dec. 31, 2017.
4. Wavy.com, Dec. 20, 2017.
5. U.S. Attorney General. 2016. U.S. Department of Justice Report and Recommendations Concerning the Use of Restrictive Housing.
6. JAMA Psychiatry. 2013 Sep;70(9):913-20.
7. Blogpost, by Thomas Insel, MD. Aug. 28, 2013.
8. Cochrane Database Syst Rev. 2012 May 16. doi: 10.1002/14651858.CD008016.pub2.
9. Am J Orthopsychiatry. 2016;86(5):477-85.
10. New York Times. Nov. 13, 2017.
As a forensic psychiatrist, I follow news relating to mental illness and crime. Like many of the judges and lawyers with whom I work, the media appear to have an obsession with medication compliance in those with mental illness. Being “off medications” has become a threatening term suggestive of unbridled impulsivity and violence – a term that can explain any behavior, implying that without medication, humans are routinely capable of all things without warning.
The year 2018 already has provided two stark examples of this phenomenon. During the first week of the year, two articles with the following headlines were published: “ ‘He was off his meds’: Son charged in mother’s murder”1 and “A man lost his life in the subway after telling a teen off of his medication to ‘get away.’ ”2 Those two articles describe awful events that, as the headlines suggest, are best explained by a lack of compliance with a psychotropic medication regimen.
“A man lost his life in the subway after telling a teen off of his medication to ‘get away’ ” reports on a 65-year-old man who was pushed onto New York’s subway tracks after interacting with an 18-year-old who “did not take medication that day for his mental illness.” This article provides some limited details on the state of mind of the defendant, indicating that he had been “talking to himself.” However, to reinforce the message, the article informs the reader that he had been prescribed three psychotropics – insinuating a multiplier effect for the role of noncompliance. Furthermore, the article implies that missing a single day of psychotropics is an explanation for the incident.
The media routinely use this bias in favor of the medication explanation in its analysis – or lack thereof – of violent behavior in people with mental illness. Recent stories include a man killing his nephew3 and a man killing his girlfriend4, and both were incidents apparently best explained by medication noncompliance. Another story reports of police officers who were charged with assault after an altercation with a patient with mental illness led to the patient’s death. In the latter case, the article suggests that the simple fact that the victim had been acting erratically warrants the comment that he was “likely was off his medications.”
My work in the jail system also has been tainted by this overreliance on the unquestioned dogma of medication compliance. Discussions pertaining to punishment and privileges of inmates with mental illness often would lead to the question: “Is he taking his meds?” I have witnessed countless times when crucial decisions about placement in solitary confinement were predicated on questions of medication compliance. My answer was always the same: “Why does it matter? If the inmate is following the rules and behaving respectfully, how does taking a pill provide more important information?”
What was once thought to be a predictor of relapse risk, despite limited evidence, has become the outcome itself. As a society, we have falsely equated mental illness with violence; we have furthermore falsely equated remission and safety with medication compliance. The consequences of those beliefs are severe as we have limited attention, and our focus on medications blinds us to much clearer risk factors. 5
The court system is equally riveted with this question. Judges and lawyers associate medication compliance with legal competency, safety in probation or parole, and general well-being. I have witnessed agitated patients being reprimanded for their lack of medication adherence, leaving me to remind lawyers that the patient has been compliant. Conversely, patients are congratulated for their medication adherence when appearing well, until I remind the lawyers that the patient missed his last two visits for long-acting injectables.
As our field is reconciling new evidence questioning the long-term role of antipsychotics in schizophrenia, I am questioning whether society has accepted their value as a foregone conclusion. Lex Wunderink, MD, PhD, and his associates challenged accepted dogma when conducting a long-term, randomized trial of antipsychotics, in which patients on a dose reduction and discontinuation arm did better at 7 years than the patients on the continuation arm.6 The then National Institute of Mental Health director, Thomas Insel, MD, wrote in his blog that for some schizophrenia patients, “remaining on medication long term might impede a full return to wellness.”7
A Cochrane review of the literature found that, over time, antipsychotics had a diminishing effect on relapse prevention. After 2 years, the effect approached zero.8 In 2016, Nancy L. Sohler, PhD, and her colleagues looked at the literature on antipsychotic use in longer trials. The data were of poor quality and inconclusive.9 However, stories in the popular press suggest that the best explanation for violent behavior in the mentally ill population is medication noncompliance.
Inextricably bound up with this dogma regarding noncompliance is the incorporation of the pharmaceutical industry into mainstream psychiatry. The promise of psychopharmacology to treat mental illness was adopted in a wholesale manner for financial and practical reasons as well as a desperate optimism to relieve seemingly intractable problems. Sadly, the failure of psychopharmacology to produce on said promises has not produced a backlash. Instead, there is a doubling down on this belief, which can be seen, for example, in the creation of Abilify MyCite – with its promise to keep clinicians informed about their patients’ medication compliance.10 The alternative to this prescribing culture would be an attentive reckoning of the ongoing limitations inherent in the treatment of those with mental illness. If noncompliance cannot explain violence in people with mental illness, we are left with the same complex and subtle issues surrounding violence that frustrate easy journalistic explanations, and relatively cheap and easy interventions for the care of this population. It feels better and is more cost effective to blame the patients for not fitting our biological models by being drug nonresponders or noncompliant.
Blaming pills is facile. It is tangible and easier to measure than looking into someone’s mind. Psychiatrists have promoted this idea by teaching the public about chemical imbalances and by focusing on medication management. However, when the consequences are as severe as placing people in solitary confinement or explaining murder, the evidence needs to be equally solid as the severity of the punishment. This must start with psychiatrists reeducating the public on the role, the power, and the limitations of psychotropics.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre mentors residents on projects, including reduction in the use of solitary confinement of patients with mental illness and examination of the mentally ill offender. Dr. Badre can be reached at Badremd.com.
References
1. Worcester Patch. Jan. 2, 2018.
2. Rare News. Jan. 4, 2018.
3. WTSP.com. Dec. 31, 2017.
4. Wavy.com, Dec. 20, 2017.
5. U.S. Attorney General. 2016. U.S. Department of Justice Report and Recommendations Concerning the Use of Restrictive Housing.
6. JAMA Psychiatry. 2013 Sep;70(9):913-20.
7. Blogpost, by Thomas Insel, MD. Aug. 28, 2013.
8. Cochrane Database Syst Rev. 2012 May 16. doi: 10.1002/14651858.CD008016.pub2.
9. Am J Orthopsychiatry. 2016;86(5):477-85.
10. New York Times. Nov. 13, 2017.
As a forensic psychiatrist, I follow news relating to mental illness and crime. Like many of the judges and lawyers with whom I work, the media appear to have an obsession with medication compliance in those with mental illness. Being “off medications” has become a threatening term suggestive of unbridled impulsivity and violence – a term that can explain any behavior, implying that without medication, humans are routinely capable of all things without warning.
The year 2018 already has provided two stark examples of this phenomenon. During the first week of the year, two articles with the following headlines were published: “ ‘He was off his meds’: Son charged in mother’s murder”1 and “A man lost his life in the subway after telling a teen off of his medication to ‘get away.’ ”2 Those two articles describe awful events that, as the headlines suggest, are best explained by a lack of compliance with a psychotropic medication regimen.
“A man lost his life in the subway after telling a teen off of his medication to ‘get away’ ” reports on a 65-year-old man who was pushed onto New York’s subway tracks after interacting with an 18-year-old who “did not take medication that day for his mental illness.” This article provides some limited details on the state of mind of the defendant, indicating that he had been “talking to himself.” However, to reinforce the message, the article informs the reader that he had been prescribed three psychotropics – insinuating a multiplier effect for the role of noncompliance. Furthermore, the article implies that missing a single day of psychotropics is an explanation for the incident.
The media routinely use this bias in favor of the medication explanation in its analysis – or lack thereof – of violent behavior in people with mental illness. Recent stories include a man killing his nephew3 and a man killing his girlfriend4, and both were incidents apparently best explained by medication noncompliance. Another story reports of police officers who were charged with assault after an altercation with a patient with mental illness led to the patient’s death. In the latter case, the article suggests that the simple fact that the victim had been acting erratically warrants the comment that he was “likely was off his medications.”
My work in the jail system also has been tainted by this overreliance on the unquestioned dogma of medication compliance. Discussions pertaining to punishment and privileges of inmates with mental illness often would lead to the question: “Is he taking his meds?” I have witnessed countless times when crucial decisions about placement in solitary confinement were predicated on questions of medication compliance. My answer was always the same: “Why does it matter? If the inmate is following the rules and behaving respectfully, how does taking a pill provide more important information?”
What was once thought to be a predictor of relapse risk, despite limited evidence, has become the outcome itself. As a society, we have falsely equated mental illness with violence; we have furthermore falsely equated remission and safety with medication compliance. The consequences of those beliefs are severe as we have limited attention, and our focus on medications blinds us to much clearer risk factors. 5
The court system is equally riveted with this question. Judges and lawyers associate medication compliance with legal competency, safety in probation or parole, and general well-being. I have witnessed agitated patients being reprimanded for their lack of medication adherence, leaving me to remind lawyers that the patient has been compliant. Conversely, patients are congratulated for their medication adherence when appearing well, until I remind the lawyers that the patient missed his last two visits for long-acting injectables.
As our field is reconciling new evidence questioning the long-term role of antipsychotics in schizophrenia, I am questioning whether society has accepted their value as a foregone conclusion. Lex Wunderink, MD, PhD, and his associates challenged accepted dogma when conducting a long-term, randomized trial of antipsychotics, in which patients on a dose reduction and discontinuation arm did better at 7 years than the patients on the continuation arm.6 The then National Institute of Mental Health director, Thomas Insel, MD, wrote in his blog that for some schizophrenia patients, “remaining on medication long term might impede a full return to wellness.”7
A Cochrane review of the literature found that, over time, antipsychotics had a diminishing effect on relapse prevention. After 2 years, the effect approached zero.8 In 2016, Nancy L. Sohler, PhD, and her colleagues looked at the literature on antipsychotic use in longer trials. The data were of poor quality and inconclusive.9 However, stories in the popular press suggest that the best explanation for violent behavior in the mentally ill population is medication noncompliance.
Inextricably bound up with this dogma regarding noncompliance is the incorporation of the pharmaceutical industry into mainstream psychiatry. The promise of psychopharmacology to treat mental illness was adopted in a wholesale manner for financial and practical reasons as well as a desperate optimism to relieve seemingly intractable problems. Sadly, the failure of psychopharmacology to produce on said promises has not produced a backlash. Instead, there is a doubling down on this belief, which can be seen, for example, in the creation of Abilify MyCite – with its promise to keep clinicians informed about their patients’ medication compliance.10 The alternative to this prescribing culture would be an attentive reckoning of the ongoing limitations inherent in the treatment of those with mental illness. If noncompliance cannot explain violence in people with mental illness, we are left with the same complex and subtle issues surrounding violence that frustrate easy journalistic explanations, and relatively cheap and easy interventions for the care of this population. It feels better and is more cost effective to blame the patients for not fitting our biological models by being drug nonresponders or noncompliant.
Blaming pills is facile. It is tangible and easier to measure than looking into someone’s mind. Psychiatrists have promoted this idea by teaching the public about chemical imbalances and by focusing on medication management. However, when the consequences are as severe as placing people in solitary confinement or explaining murder, the evidence needs to be equally solid as the severity of the punishment. This must start with psychiatrists reeducating the public on the role, the power, and the limitations of psychotropics.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre mentors residents on projects, including reduction in the use of solitary confinement of patients with mental illness and examination of the mentally ill offender. Dr. Badre can be reached at Badremd.com.
References
1. Worcester Patch. Jan. 2, 2018.
2. Rare News. Jan. 4, 2018.
3. WTSP.com. Dec. 31, 2017.
4. Wavy.com, Dec. 20, 2017.
5. U.S. Attorney General. 2016. U.S. Department of Justice Report and Recommendations Concerning the Use of Restrictive Housing.
6. JAMA Psychiatry. 2013 Sep;70(9):913-20.
7. Blogpost, by Thomas Insel, MD. Aug. 28, 2013.
8. Cochrane Database Syst Rev. 2012 May 16. doi: 10.1002/14651858.CD008016.pub2.
9. Am J Orthopsychiatry. 2016;86(5):477-85.
10. New York Times. Nov. 13, 2017.
Personality disorders and the court system
As forensic psychiatrists, one of our main roles is to apply the Dusky standard to assess competency. In this regard, multiple times a week, we see pretrial defendants who wait weeks, sometimes months, in jail, for their competency evaluations. Will they be permitted to attend court and continue with their legal proceedings, or will a judge remand them into an involuntary treatment unit to restore their competency? The number of defendants referred for competency evaluation is formally not measured, but estimates suggest it almost doubled from 19731 till 2000.2
The intent of ensuring the competency of the accused is fundamentally fair. While all would agree that only those who are convicted of committing crimes be found guilty, not every culture has paid attention to the question of whether those found guilty understand how and why that happened.
The Dusky standards come from the landmark U.S. Supreme Court case of Dusky v. United States in 1960. Milton Dusky faced charges of kidnapping an underage female across state lines and raping her. Despite psychiatric testimony that the defendant could not “properly assist” his counsel because of a delusion that he was framed, the court found him competent and convicted him to a 45-year sentence. The case was appealed all the way to the Supreme Court, which held that the fact that Dusky was oriented and remembered the events was not enough to establish competency. The Supreme Court stated that the test for competency was the ability to consult with a lawyer with “a reasonable degree of rational understanding” and a “factual as well as rational understanding of the proceedings.” The Dusky ruling did not comment on what conditions may make a person incompetent to stand trial.3
With the increase in referrals for competency, we have noted an expansion in the kind of referrals we receive. In a hospital setting, physicians often comment that referrals for capacity evaluations stem from the patient’s disagreement with her/his attending physician about treatment, not a lack of understanding of the treatment options. Similarly, many referrals we receive for evaluation of competency to stand trial seem generated by interpersonal difficulties rather than insufficient rational and factual knowledge. In this article, we will review a case seen in our clinic five times over a period of 7 years. Over that time frame, the defendant was incarcerated 10 times and referred 5 times for a competency evaluation. We have changed key facts about the defendant and his case to protect his confidentiality.
Defendant’s background
The defendant is a 40-something-year-old man who vacillates between homelessness and living with friends who partake in his penchant for alcohol. He has committed various crimes, including thefts, disorderly conduct, and possession of controlled substances. He went to prison once for selling narcotics but quickly retorts: “I don’t sell … . This [expletive] cop came and asked if I had any. She was hot. What did you want me to say? It was entrapment.”
However, to get this defendant to have a conversation is no simple task. On his way to the professional visit area, he was livid with a deputy about not receiving an entire breakfast tray earlier in the morning. When he sat down for the interview, he initially yelled for 10 minutes without interruption. His speech was full of profanities and demeaning comments about our ethnic background, education, and expertise. After about 15 minutes and numerous attempts at inserting a question or a comment, I said: “I do not think that you have evidenced a lack of competency, and you are not engaging with me. I am leaving. Thank you for your time.” He shouted two more times, then stopped, smiled, and said: “I was just testing you. Relax, doc.” He subsequently answered all of my questions with his usual jokes and a calm demeanor.
Once he engaged in the interview, he was able to provide a factual and rational description of his charge, which was, “criminal threat.” “I was at the bus station with my knife; I was playing with it; I was not threatening anyone. Then this [racial expletive] cop comes and tells me that I am under arrest.”
Challenging behavior continues
During the course of the interview, he was able to demonstrate that he understands the meaning of making a threat, of committing a crime, and of the roles of the different courtroom personnel. However, the stress of court highlights his interpersonal problems. In this particular case, he recounts: “Court had not yet started; I was talking to my lawyer, and the judge interrupted me, so I answered: Wait your turn [expletive] … not my greatest idea.” When asked about his past referral for competency, he mentions it was in response to trying to fire a public defender because “she was Mexican. I don’t work with those.”
Given his behavior, it is unclear how else a judge or a lawyer could have acted. One could argue that it would be a mistake not to refer this defendant for a competency evaluation, considering his outbursts. On the other hand, he had been evaluated many times before, and the opinion of well-respected forensic psychiatrists was that he did not have a mental illness.
While we reflect on our experience with this defendant, we are unsure of the lessons to be learned. We ponder whether psychiatry does a disservice when not being clearer about what constitutes a serious mental illness. We wonder if we exacerbated the confusion by the removal of “Axis II” categories from the DSM, implying that severe personality disorders are no longer different from, say, schizophrenia and bipolar disorder. Rarely do we hear psychiatrists point out that unusual behaviors do not equal mental illness. We are often too pleased in advocating for more resources by saying that all crimes, all substance misuses, and all annoying behaviors are forms of mental illness when, in reality, the criminal4, the addictive5, and the less common6 are not always biologically based mental disorders or even the real problem, for that matter.
This defendant is difficult. He argues, he yells, he provokes, and he hurts others physically as well as emotionally. While many psychiatrists have decided to codify this pattern of behavior within the B cluster of personality traits, have we misled the public into thinking that patients with personality disorders require the same attention and care as patients with other forms of mental illness, like schizophrenia? Often, we see patients with schizophrenia, bipolar depression, or major depression, who even at their best, are too impaired to file their taxes, apply for an identity card, or understand the complexity of the legal system.
Psychiatry’s difficulty in verbalizing the difference between those disorders harms the public perception of mental disorders. As a result, we have a forensic system similar to the rest of the community health care system – with an abundance of individuals with severe mental illness not referred for treatment or evaluation, and several patients with personality disorders bogging down a system with very limited resources. It is our responsibility not only to educate the public on how to manage and contain the emotions that patients with personality disorders engender in us, but also to educate the public on how to recognize patients with profound mentally ill patients who are quietly suffering.
Dr. Badre is affiliated with the county of San Diego, the University of California at San Diego, and the University of San Diego. Dr. Rao is a San Diego–based board-certified psychiatrist with expertise in forensic psychiatry, correctional psychiatry, telepsychiatry, and inpatient psychiatry.
References
1. Competency to Stand Trial and Mental Illness: Final Report. Rockville, Md.: National Institute of Mental Health, 1973.
2. Youth on Trial: A Developmental Perspective on Juvenile Justice. Chicago: University of Chicago Press, 2000.
3. J Am Acad Psychiatry Law. 2007;35(4 Suppl):S3-72.
4. Clin Psychiatry News. 2017;45(8):5.
5. Law and Philosophy. 1999;18(6):589-610.
6. Am J Psychiatry. 1981 Feb;138(2):210-5.
As forensic psychiatrists, one of our main roles is to apply the Dusky standard to assess competency. In this regard, multiple times a week, we see pretrial defendants who wait weeks, sometimes months, in jail, for their competency evaluations. Will they be permitted to attend court and continue with their legal proceedings, or will a judge remand them into an involuntary treatment unit to restore their competency? The number of defendants referred for competency evaluation is formally not measured, but estimates suggest it almost doubled from 19731 till 2000.2
The intent of ensuring the competency of the accused is fundamentally fair. While all would agree that only those who are convicted of committing crimes be found guilty, not every culture has paid attention to the question of whether those found guilty understand how and why that happened.
The Dusky standards come from the landmark U.S. Supreme Court case of Dusky v. United States in 1960. Milton Dusky faced charges of kidnapping an underage female across state lines and raping her. Despite psychiatric testimony that the defendant could not “properly assist” his counsel because of a delusion that he was framed, the court found him competent and convicted him to a 45-year sentence. The case was appealed all the way to the Supreme Court, which held that the fact that Dusky was oriented and remembered the events was not enough to establish competency. The Supreme Court stated that the test for competency was the ability to consult with a lawyer with “a reasonable degree of rational understanding” and a “factual as well as rational understanding of the proceedings.” The Dusky ruling did not comment on what conditions may make a person incompetent to stand trial.3
With the increase in referrals for competency, we have noted an expansion in the kind of referrals we receive. In a hospital setting, physicians often comment that referrals for capacity evaluations stem from the patient’s disagreement with her/his attending physician about treatment, not a lack of understanding of the treatment options. Similarly, many referrals we receive for evaluation of competency to stand trial seem generated by interpersonal difficulties rather than insufficient rational and factual knowledge. In this article, we will review a case seen in our clinic five times over a period of 7 years. Over that time frame, the defendant was incarcerated 10 times and referred 5 times for a competency evaluation. We have changed key facts about the defendant and his case to protect his confidentiality.
Defendant’s background
The defendant is a 40-something-year-old man who vacillates between homelessness and living with friends who partake in his penchant for alcohol. He has committed various crimes, including thefts, disorderly conduct, and possession of controlled substances. He went to prison once for selling narcotics but quickly retorts: “I don’t sell … . This [expletive] cop came and asked if I had any. She was hot. What did you want me to say? It was entrapment.”
However, to get this defendant to have a conversation is no simple task. On his way to the professional visit area, he was livid with a deputy about not receiving an entire breakfast tray earlier in the morning. When he sat down for the interview, he initially yelled for 10 minutes without interruption. His speech was full of profanities and demeaning comments about our ethnic background, education, and expertise. After about 15 minutes and numerous attempts at inserting a question or a comment, I said: “I do not think that you have evidenced a lack of competency, and you are not engaging with me. I am leaving. Thank you for your time.” He shouted two more times, then stopped, smiled, and said: “I was just testing you. Relax, doc.” He subsequently answered all of my questions with his usual jokes and a calm demeanor.
Once he engaged in the interview, he was able to provide a factual and rational description of his charge, which was, “criminal threat.” “I was at the bus station with my knife; I was playing with it; I was not threatening anyone. Then this [racial expletive] cop comes and tells me that I am under arrest.”
Challenging behavior continues
During the course of the interview, he was able to demonstrate that he understands the meaning of making a threat, of committing a crime, and of the roles of the different courtroom personnel. However, the stress of court highlights his interpersonal problems. In this particular case, he recounts: “Court had not yet started; I was talking to my lawyer, and the judge interrupted me, so I answered: Wait your turn [expletive] … not my greatest idea.” When asked about his past referral for competency, he mentions it was in response to trying to fire a public defender because “she was Mexican. I don’t work with those.”
Given his behavior, it is unclear how else a judge or a lawyer could have acted. One could argue that it would be a mistake not to refer this defendant for a competency evaluation, considering his outbursts. On the other hand, he had been evaluated many times before, and the opinion of well-respected forensic psychiatrists was that he did not have a mental illness.
While we reflect on our experience with this defendant, we are unsure of the lessons to be learned. We ponder whether psychiatry does a disservice when not being clearer about what constitutes a serious mental illness. We wonder if we exacerbated the confusion by the removal of “Axis II” categories from the DSM, implying that severe personality disorders are no longer different from, say, schizophrenia and bipolar disorder. Rarely do we hear psychiatrists point out that unusual behaviors do not equal mental illness. We are often too pleased in advocating for more resources by saying that all crimes, all substance misuses, and all annoying behaviors are forms of mental illness when, in reality, the criminal4, the addictive5, and the less common6 are not always biologically based mental disorders or even the real problem, for that matter.
This defendant is difficult. He argues, he yells, he provokes, and he hurts others physically as well as emotionally. While many psychiatrists have decided to codify this pattern of behavior within the B cluster of personality traits, have we misled the public into thinking that patients with personality disorders require the same attention and care as patients with other forms of mental illness, like schizophrenia? Often, we see patients with schizophrenia, bipolar depression, or major depression, who even at their best, are too impaired to file their taxes, apply for an identity card, or understand the complexity of the legal system.
Psychiatry’s difficulty in verbalizing the difference between those disorders harms the public perception of mental disorders. As a result, we have a forensic system similar to the rest of the community health care system – with an abundance of individuals with severe mental illness not referred for treatment or evaluation, and several patients with personality disorders bogging down a system with very limited resources. It is our responsibility not only to educate the public on how to manage and contain the emotions that patients with personality disorders engender in us, but also to educate the public on how to recognize patients with profound mentally ill patients who are quietly suffering.
Dr. Badre is affiliated with the county of San Diego, the University of California at San Diego, and the University of San Diego. Dr. Rao is a San Diego–based board-certified psychiatrist with expertise in forensic psychiatry, correctional psychiatry, telepsychiatry, and inpatient psychiatry.
References
1. Competency to Stand Trial and Mental Illness: Final Report. Rockville, Md.: National Institute of Mental Health, 1973.
2. Youth on Trial: A Developmental Perspective on Juvenile Justice. Chicago: University of Chicago Press, 2000.
3. J Am Acad Psychiatry Law. 2007;35(4 Suppl):S3-72.
4. Clin Psychiatry News. 2017;45(8):5.
5. Law and Philosophy. 1999;18(6):589-610.
6. Am J Psychiatry. 1981 Feb;138(2):210-5.
As forensic psychiatrists, one of our main roles is to apply the Dusky standard to assess competency. In this regard, multiple times a week, we see pretrial defendants who wait weeks, sometimes months, in jail, for their competency evaluations. Will they be permitted to attend court and continue with their legal proceedings, or will a judge remand them into an involuntary treatment unit to restore their competency? The number of defendants referred for competency evaluation is formally not measured, but estimates suggest it almost doubled from 19731 till 2000.2
The intent of ensuring the competency of the accused is fundamentally fair. While all would agree that only those who are convicted of committing crimes be found guilty, not every culture has paid attention to the question of whether those found guilty understand how and why that happened.
The Dusky standards come from the landmark U.S. Supreme Court case of Dusky v. United States in 1960. Milton Dusky faced charges of kidnapping an underage female across state lines and raping her. Despite psychiatric testimony that the defendant could not “properly assist” his counsel because of a delusion that he was framed, the court found him competent and convicted him to a 45-year sentence. The case was appealed all the way to the Supreme Court, which held that the fact that Dusky was oriented and remembered the events was not enough to establish competency. The Supreme Court stated that the test for competency was the ability to consult with a lawyer with “a reasonable degree of rational understanding” and a “factual as well as rational understanding of the proceedings.” The Dusky ruling did not comment on what conditions may make a person incompetent to stand trial.3
With the increase in referrals for competency, we have noted an expansion in the kind of referrals we receive. In a hospital setting, physicians often comment that referrals for capacity evaluations stem from the patient’s disagreement with her/his attending physician about treatment, not a lack of understanding of the treatment options. Similarly, many referrals we receive for evaluation of competency to stand trial seem generated by interpersonal difficulties rather than insufficient rational and factual knowledge. In this article, we will review a case seen in our clinic five times over a period of 7 years. Over that time frame, the defendant was incarcerated 10 times and referred 5 times for a competency evaluation. We have changed key facts about the defendant and his case to protect his confidentiality.
Defendant’s background
The defendant is a 40-something-year-old man who vacillates between homelessness and living with friends who partake in his penchant for alcohol. He has committed various crimes, including thefts, disorderly conduct, and possession of controlled substances. He went to prison once for selling narcotics but quickly retorts: “I don’t sell … . This [expletive] cop came and asked if I had any. She was hot. What did you want me to say? It was entrapment.”
However, to get this defendant to have a conversation is no simple task. On his way to the professional visit area, he was livid with a deputy about not receiving an entire breakfast tray earlier in the morning. When he sat down for the interview, he initially yelled for 10 minutes without interruption. His speech was full of profanities and demeaning comments about our ethnic background, education, and expertise. After about 15 minutes and numerous attempts at inserting a question or a comment, I said: “I do not think that you have evidenced a lack of competency, and you are not engaging with me. I am leaving. Thank you for your time.” He shouted two more times, then stopped, smiled, and said: “I was just testing you. Relax, doc.” He subsequently answered all of my questions with his usual jokes and a calm demeanor.
Once he engaged in the interview, he was able to provide a factual and rational description of his charge, which was, “criminal threat.” “I was at the bus station with my knife; I was playing with it; I was not threatening anyone. Then this [racial expletive] cop comes and tells me that I am under arrest.”
Challenging behavior continues
During the course of the interview, he was able to demonstrate that he understands the meaning of making a threat, of committing a crime, and of the roles of the different courtroom personnel. However, the stress of court highlights his interpersonal problems. In this particular case, he recounts: “Court had not yet started; I was talking to my lawyer, and the judge interrupted me, so I answered: Wait your turn [expletive] … not my greatest idea.” When asked about his past referral for competency, he mentions it was in response to trying to fire a public defender because “she was Mexican. I don’t work with those.”
Given his behavior, it is unclear how else a judge or a lawyer could have acted. One could argue that it would be a mistake not to refer this defendant for a competency evaluation, considering his outbursts. On the other hand, he had been evaluated many times before, and the opinion of well-respected forensic psychiatrists was that he did not have a mental illness.
While we reflect on our experience with this defendant, we are unsure of the lessons to be learned. We ponder whether psychiatry does a disservice when not being clearer about what constitutes a serious mental illness. We wonder if we exacerbated the confusion by the removal of “Axis II” categories from the DSM, implying that severe personality disorders are no longer different from, say, schizophrenia and bipolar disorder. Rarely do we hear psychiatrists point out that unusual behaviors do not equal mental illness. We are often too pleased in advocating for more resources by saying that all crimes, all substance misuses, and all annoying behaviors are forms of mental illness when, in reality, the criminal4, the addictive5, and the less common6 are not always biologically based mental disorders or even the real problem, for that matter.
This defendant is difficult. He argues, he yells, he provokes, and he hurts others physically as well as emotionally. While many psychiatrists have decided to codify this pattern of behavior within the B cluster of personality traits, have we misled the public into thinking that patients with personality disorders require the same attention and care as patients with other forms of mental illness, like schizophrenia? Often, we see patients with schizophrenia, bipolar depression, or major depression, who even at their best, are too impaired to file their taxes, apply for an identity card, or understand the complexity of the legal system.
Psychiatry’s difficulty in verbalizing the difference between those disorders harms the public perception of mental disorders. As a result, we have a forensic system similar to the rest of the community health care system – with an abundance of individuals with severe mental illness not referred for treatment or evaluation, and several patients with personality disorders bogging down a system with very limited resources. It is our responsibility not only to educate the public on how to manage and contain the emotions that patients with personality disorders engender in us, but also to educate the public on how to recognize patients with profound mentally ill patients who are quietly suffering.
Dr. Badre is affiliated with the county of San Diego, the University of California at San Diego, and the University of San Diego. Dr. Rao is a San Diego–based board-certified psychiatrist with expertise in forensic psychiatry, correctional psychiatry, telepsychiatry, and inpatient psychiatry.
References
1. Competency to Stand Trial and Mental Illness: Final Report. Rockville, Md.: National Institute of Mental Health, 1973.
2. Youth on Trial: A Developmental Perspective on Juvenile Justice. Chicago: University of Chicago Press, 2000.
3. J Am Acad Psychiatry Law. 2007;35(4 Suppl):S3-72.
4. Clin Psychiatry News. 2017;45(8):5.
5. Law and Philosophy. 1999;18(6):589-610.
6. Am J Psychiatry. 1981 Feb;138(2):210-5.
Ethics in compulsory treatment of patients with severe mental illness
“Ethics is knowing the difference between what you have a right to do and what is right to do.”
– Potter Stewart, U.S. Supreme Court Justice
An understanding of the difference between what is allowed or even recommended and what is ethical often is contemplated in the treatment of mental illness. Mental illnesses can impair judgment in patients confronted with complex decisions about their treatment. A provider, therefore, has to make a decision between respecting autonomy and/or engaging in what may be considered beneficent. While the line separating beneficent care and the respect for the autonomy of a patient may not be present, the question often arises – especially in inpatient care of patients with severe mental illness.
In the inpatient units, I was taught to justify and be mindful of any removal of someone’s right. I learned the responsibility of stripping someone’s freedom. Not only would I find myself preventing someone from going where they wanted or from talking to whomever they wanted, but frequently, we involuntary injected patients with neuroactive chemicals. Those measures are used only in extreme circumstances: In most states, one has to be unable to provide themselves with food, clothing, or shelter secondary to mental illness to be subjected to such aggressive treatment.
Currently, the United States is seeing an increase in the focus on providing more treatment: an emphasis on beneficence over autonomy. This change can be witnessed in the passage of compulsory outpatient treatment laws. Those rulings, such as Laura’s Law in California and Kendra’s Law in New York, have been promoted in response to an increased concern over the consequences of untreated mental illness in crime. In this commentary, I present a case where I felt that despite being given the right and expectation to involuntary treat someone, I did not feel that it was ethical to involuntarily medicate him. (I have made appropriate changes to the patient’s case to maintain confidentiality.)
Our facility
The Psychiatric Stabilization Unit (PSU) of the San Diego Jails is a 30-bed acute psychiatric unit. We serve the 4,500 male inmates and one of the largest mental health systems in the county. The vast majority (from 70% to 90% at any one time) of patients suffer from a psychotic illness, and more than 50% have a comorbid substance use disorder. Contrary to most inpatient units, we do not have pressure from insurance or utilization review to regularly change dosages or medications, and we do not have significant pressure to discharge patients within a certain time frame. The unit serves very disenfranchised patients with most being homeless prior to their arrest and many having no emergency contact or social support of any sort. The unit is staffed by one attending psychiatrist and two therapists. We are subjected to the same involuntary commitment and involuntary medication laws as are community psychiatric hospitals, but we get a significant number of patients under court orders.
The patient presented in this case came under such court order for restoration of his competency to stand trial. In the United States, one cannot stand trial unless competent. Competency is defined as one’s ability to take a meaningful or active part in a trial, the capacity to understand laws, the capacity to understand personal responsibility, the ability to express a plea, and the capability to instruct legal counsel. When patients are found incompetent, they commonly get court ordered to an unit like the PSU with a court order that they cannot understand the risk, benefits, and alternatives of psychotropic treatment and thus can be involuntarily medicated. Often, including in this case, the court order will mention that the patient will not become competent without treatment, including involuntary antipsychotics.
Overview of the case
George is a 50-year-old white male without psychiatric history. He had never been hospitalized psychiatrically voluntarily or involuntarily. He has never engaged in outpatient psychiatric care, has never taken psychotropic medication, and has never been diagnosed with mental illness. He mentions no prior episode of self-harm, suicidality, or suicide attempt. He occasionally drinks alcohol and has smoked marijuana on a few occasions. He despises other drugs, saying that they are “dangerous.” He mentions that his parents had “difficult personalities” but denies any knowledge of them having formal mental illness.
He was born in rural Louisiana to a British mother and an American father. His parents divorced while he was in preschool. His mother remarried, to a salesman, which required them to move frequently to different states for his work. He mentions having performed moderately in school, but poor grades were secondary to his “boredom.” He graduated high school and went to vocational school in technological manufacturing but was unable to graduate. He has since held a series of low-level jobs in retail and janitorial services. He mentions having been in romantic relationships, but when asked to elaborate, he is unable to name any past girlfriends or describe any past relationships. Nonetheless, he describes a wide array of social supports with many friends, though it must be noted that all of his friends have some form of mental illness or intellectual disability.
At this time, he lives with his friend Harry. Harry has a moderate form of autism. George helps him with everything from grocery shopping to financial matters to assistance in personal hygiene. In exchange, Harry provides him with housing that he inherited and financial assistance from his disability benefits. They have lived in the same home for 2 years, since Harry asked George to move in because of concern that he would lose his home over the unsanitary conditions that were present at that time.
George had never been arrested prior to this incarceration. The circumstances of his arrest are unusual. After a neighbor had made complaints that Harry and George were illegally lodging in Harry’s home, the city investigated the matter. George’s report was that Harry was unable to fill out the forms appropriately and was asked to present himself in court. George came along for moral support but became extremely upset when lawyers and judges asked his friend to answer questions he did not have the cognitive ability to answer. Without second thought, George voiced his anger but was asked to remain quiet while not on the stand. He was asked to remain seated and was demanded to follow orders. A few moments later, George was arrested for contempt of court and obstruction to an officer.
Once incarcerated, he declined having any mental illness or needing any treatment during the customary triage visit. He had no problem as an inmate and was never referred to psychiatric services. However, when meeting with his public defender, George derailed into delusions. He talked about how the cops had been conspiring against him all of his life, with his current incarceration as a culmination. He mentioned how the judge was purposely trying to get them evicted so that he could own the house himself. He asked his lawyer to countersue the judge for a violation of his rights. The public defender filed for a competency evaluation of his client.
The forensic psychiatrist evaluated the patient and had a similar interpretation. This was a patient who had delusions and was perseverating on them to the point of being unable to engage in meaningful work with his attorney. The psychiatrist recommended involuntary treatment with an antipsychotic after diagnosing the patient with a psychotic illness.
My interactions with George
George is a loud and bucolic man with an usual mix of Southern idioms, a slightly British accent, and East Coast humor. He insisted on telling me why he wanted the staff to refer to him by his Native American nickname prior to the start our interview. He then asked me to listen to his life story to understand why Harry meant so much to him. Despite recounting their truly meaningful relationship, his affect was odd with poor reactivity; he had an incongruent and somewhat ungenuine joyfulness.
Once I heard his account of their friendship, I asked him about his charges and the incident in the courtroom. His answer was a long diatribe about the wrongs that had been done to him, but most of his speech was a series of illogical delusions. I informed him of my thoughts about his fixed and false beliefs, but he was not able to understand my comments. Nonetheless, I felt that he related to me well and that we had established good rapport.
As I was informing him about the antipsychotic I had chosen for his involuntary treatment, he asked me to hold off. He asked me to consider working with him for some time without medications. After all, he did not believe that he had a mental illness and wanted to attempt to engage in the competency training with our therapist without being medicated.
My conceptualization of him
George is a peculiar case. Practically all patients who are committed to my unit for competency restoration are psychotic, and their psychosis prevents their engagement with their attorneys. They have poor insight into their illness, which leads to their commitment. On admission, I confirm the assessment of the forensic psychiatrist and start the ordered involuntary treatment on patients. Many of them are gravely disabled – making the ethical dilemma easier to navigate. For other patients, the idea that they will be kept incarcerated until found competent also makes the forced treatment a simpler decision.
George was different – his impeccable grooming, his dislike of jail food, and his request for appropriately fitting jail clothes were far from disorganized. More importantly, however, he had adequate shelter outside of jail, income for assisting Harry, and a rich network of friends. Despite being riddled with delusions, his thought process was linear, and he was redirectable – even when discussing his delusions. I conceptualized the ethical conflict as such: Not treating him might lead to a longer period of incompetence and a longer incarceration; treating him would go against his desire to remain untreated.
After contacting Harry, I was fairly certain that George had suffered from his delusions for at least a significant part of his adult life, if not in its entirety. However, Harry was infinitely thankful for George’s assistance and felt that George had a good life. This added another fundamental question: Would forcing George to engage in formal mental health treatment lead him to have a better life? He was happy, had meaningful relationships, and contributed to his life as well as his friends’ lives in a deep way.
I diagnosed him as having an unspecified psychotic disorder, likely schizophrenia; he had delusions and negative symptoms, like his impaired affect. Despite this diagnosis, I decided to hold off from using involuntary treatment. I met with him daily for more than 2 weeks, and we discussed his story, his feelings, and his beliefs. On occasion, it was hard to separate the delusions from justifiable anger at the system. He had felt that he and Harry had been wronged, when society should have protected their vulnerability. He learned to trust me, and his therapist taught him competency training. Despite a possible 1-year commitment, we declared him competent to stand trial in 2 weeks. He had learned and excelled in all facets of the training.
George still had delusions, but he understood his charges, that he had acted inappropriately in the courtroom, and how to discuss his case with his legal counsel. Harry found George to be at his baseline during visits. George acted appropriately; he followed the complex rules set on inmates and engaged in all groups that are held on the unit.
Discussion
I certainly do not question the value of involuntary psychiatric treatment for many patients with grave disabilities, violent tendencies, or incompetence. However, George’s case makes me wonder if many people living with schizophrenia can have rich and meaningful lives without ever being in contact with a mental health provider. I wonder if our almost-obsessive attention to antipsychotics makes us lose sight. Our biological reductionism may lead us to see patients such as George as someone with overactive dopaminergic pathways in need of antidopaminergic antipsychotic. Unfortunately for many, biological reductionism often is based on unsubstantiated evidence.
George reminds me that life, including schizophrenia, is more interesting and complicated than a set of genes, pathways, neurons, or neurotransmitters. Our patients’ lives may be convoluted with delusions, often stemming from truth or impaired affects, which are nonetheless genuine. I don’t know what will happen to George, but his past 50 years suggest that he will continue to have friends, and he will continue to live without being impaired by his delusions. Strangely, I worry less about him than many of my other patients.
Many mental health providers have advocated for a wider and easier access to involuntarily medicate our patients. I think that there is a misguided belief that involuntary antipsychotic treatment will lead to a rise in their use. However, if Carl Rogers, PhD, and others were right in stating that our relationship with our patients was the ultimate factor in their recovery, at what cost are we willing to jeopardize this? My fear is that this cost will be the loss of trust, which is so necessary in treatment. I hope that my short relationship with George did not scare him from ever seeing a psychiatrist again. In some ways, I suspect that by simply listening to George and withholding forced treatment, he will be more inclined to seek treatment in the future.
Take-home points
- Certain patients with psychosis have fairly high functioning.
- Milieu therapy is, in certain cases, able to assuage some symptoms of psychosis.
- Compulsory antipsychotic administration may not be ethical in certain cases of acute psychosis.
- Biological reductionism may undermine a complete ethical understanding of psychosis.
- Psychiatric disorders are etiologically complex and multifactorial.
- Involuntary treatment may provide short-term gains, but prevent long-term trust between patient and provider.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre also mentors several residents on projects, including reduction in the use of solitary confinement of patients with mental illness, reduction in the use of involuntary treatment of the mentally ill, and examination of the mentally ill offender.
“Ethics is knowing the difference between what you have a right to do and what is right to do.”
– Potter Stewart, U.S. Supreme Court Justice
An understanding of the difference between what is allowed or even recommended and what is ethical often is contemplated in the treatment of mental illness. Mental illnesses can impair judgment in patients confronted with complex decisions about their treatment. A provider, therefore, has to make a decision between respecting autonomy and/or engaging in what may be considered beneficent. While the line separating beneficent care and the respect for the autonomy of a patient may not be present, the question often arises – especially in inpatient care of patients with severe mental illness.
In the inpatient units, I was taught to justify and be mindful of any removal of someone’s right. I learned the responsibility of stripping someone’s freedom. Not only would I find myself preventing someone from going where they wanted or from talking to whomever they wanted, but frequently, we involuntary injected patients with neuroactive chemicals. Those measures are used only in extreme circumstances: In most states, one has to be unable to provide themselves with food, clothing, or shelter secondary to mental illness to be subjected to such aggressive treatment.
Currently, the United States is seeing an increase in the focus on providing more treatment: an emphasis on beneficence over autonomy. This change can be witnessed in the passage of compulsory outpatient treatment laws. Those rulings, such as Laura’s Law in California and Kendra’s Law in New York, have been promoted in response to an increased concern over the consequences of untreated mental illness in crime. In this commentary, I present a case where I felt that despite being given the right and expectation to involuntary treat someone, I did not feel that it was ethical to involuntarily medicate him. (I have made appropriate changes to the patient’s case to maintain confidentiality.)
Our facility
The Psychiatric Stabilization Unit (PSU) of the San Diego Jails is a 30-bed acute psychiatric unit. We serve the 4,500 male inmates and one of the largest mental health systems in the county. The vast majority (from 70% to 90% at any one time) of patients suffer from a psychotic illness, and more than 50% have a comorbid substance use disorder. Contrary to most inpatient units, we do not have pressure from insurance or utilization review to regularly change dosages or medications, and we do not have significant pressure to discharge patients within a certain time frame. The unit serves very disenfranchised patients with most being homeless prior to their arrest and many having no emergency contact or social support of any sort. The unit is staffed by one attending psychiatrist and two therapists. We are subjected to the same involuntary commitment and involuntary medication laws as are community psychiatric hospitals, but we get a significant number of patients under court orders.
The patient presented in this case came under such court order for restoration of his competency to stand trial. In the United States, one cannot stand trial unless competent. Competency is defined as one’s ability to take a meaningful or active part in a trial, the capacity to understand laws, the capacity to understand personal responsibility, the ability to express a plea, and the capability to instruct legal counsel. When patients are found incompetent, they commonly get court ordered to an unit like the PSU with a court order that they cannot understand the risk, benefits, and alternatives of psychotropic treatment and thus can be involuntarily medicated. Often, including in this case, the court order will mention that the patient will not become competent without treatment, including involuntary antipsychotics.
Overview of the case
George is a 50-year-old white male without psychiatric history. He had never been hospitalized psychiatrically voluntarily or involuntarily. He has never engaged in outpatient psychiatric care, has never taken psychotropic medication, and has never been diagnosed with mental illness. He mentions no prior episode of self-harm, suicidality, or suicide attempt. He occasionally drinks alcohol and has smoked marijuana on a few occasions. He despises other drugs, saying that they are “dangerous.” He mentions that his parents had “difficult personalities” but denies any knowledge of them having formal mental illness.
He was born in rural Louisiana to a British mother and an American father. His parents divorced while he was in preschool. His mother remarried, to a salesman, which required them to move frequently to different states for his work. He mentions having performed moderately in school, but poor grades were secondary to his “boredom.” He graduated high school and went to vocational school in technological manufacturing but was unable to graduate. He has since held a series of low-level jobs in retail and janitorial services. He mentions having been in romantic relationships, but when asked to elaborate, he is unable to name any past girlfriends or describe any past relationships. Nonetheless, he describes a wide array of social supports with many friends, though it must be noted that all of his friends have some form of mental illness or intellectual disability.
At this time, he lives with his friend Harry. Harry has a moderate form of autism. George helps him with everything from grocery shopping to financial matters to assistance in personal hygiene. In exchange, Harry provides him with housing that he inherited and financial assistance from his disability benefits. They have lived in the same home for 2 years, since Harry asked George to move in because of concern that he would lose his home over the unsanitary conditions that were present at that time.
George had never been arrested prior to this incarceration. The circumstances of his arrest are unusual. After a neighbor had made complaints that Harry and George were illegally lodging in Harry’s home, the city investigated the matter. George’s report was that Harry was unable to fill out the forms appropriately and was asked to present himself in court. George came along for moral support but became extremely upset when lawyers and judges asked his friend to answer questions he did not have the cognitive ability to answer. Without second thought, George voiced his anger but was asked to remain quiet while not on the stand. He was asked to remain seated and was demanded to follow orders. A few moments later, George was arrested for contempt of court and obstruction to an officer.
Once incarcerated, he declined having any mental illness or needing any treatment during the customary triage visit. He had no problem as an inmate and was never referred to psychiatric services. However, when meeting with his public defender, George derailed into delusions. He talked about how the cops had been conspiring against him all of his life, with his current incarceration as a culmination. He mentioned how the judge was purposely trying to get them evicted so that he could own the house himself. He asked his lawyer to countersue the judge for a violation of his rights. The public defender filed for a competency evaluation of his client.
The forensic psychiatrist evaluated the patient and had a similar interpretation. This was a patient who had delusions and was perseverating on them to the point of being unable to engage in meaningful work with his attorney. The psychiatrist recommended involuntary treatment with an antipsychotic after diagnosing the patient with a psychotic illness.
My interactions with George
George is a loud and bucolic man with an usual mix of Southern idioms, a slightly British accent, and East Coast humor. He insisted on telling me why he wanted the staff to refer to him by his Native American nickname prior to the start our interview. He then asked me to listen to his life story to understand why Harry meant so much to him. Despite recounting their truly meaningful relationship, his affect was odd with poor reactivity; he had an incongruent and somewhat ungenuine joyfulness.
Once I heard his account of their friendship, I asked him about his charges and the incident in the courtroom. His answer was a long diatribe about the wrongs that had been done to him, but most of his speech was a series of illogical delusions. I informed him of my thoughts about his fixed and false beliefs, but he was not able to understand my comments. Nonetheless, I felt that he related to me well and that we had established good rapport.
As I was informing him about the antipsychotic I had chosen for his involuntary treatment, he asked me to hold off. He asked me to consider working with him for some time without medications. After all, he did not believe that he had a mental illness and wanted to attempt to engage in the competency training with our therapist without being medicated.
My conceptualization of him
George is a peculiar case. Practically all patients who are committed to my unit for competency restoration are psychotic, and their psychosis prevents their engagement with their attorneys. They have poor insight into their illness, which leads to their commitment. On admission, I confirm the assessment of the forensic psychiatrist and start the ordered involuntary treatment on patients. Many of them are gravely disabled – making the ethical dilemma easier to navigate. For other patients, the idea that they will be kept incarcerated until found competent also makes the forced treatment a simpler decision.
George was different – his impeccable grooming, his dislike of jail food, and his request for appropriately fitting jail clothes were far from disorganized. More importantly, however, he had adequate shelter outside of jail, income for assisting Harry, and a rich network of friends. Despite being riddled with delusions, his thought process was linear, and he was redirectable – even when discussing his delusions. I conceptualized the ethical conflict as such: Not treating him might lead to a longer period of incompetence and a longer incarceration; treating him would go against his desire to remain untreated.
After contacting Harry, I was fairly certain that George had suffered from his delusions for at least a significant part of his adult life, if not in its entirety. However, Harry was infinitely thankful for George’s assistance and felt that George had a good life. This added another fundamental question: Would forcing George to engage in formal mental health treatment lead him to have a better life? He was happy, had meaningful relationships, and contributed to his life as well as his friends’ lives in a deep way.
I diagnosed him as having an unspecified psychotic disorder, likely schizophrenia; he had delusions and negative symptoms, like his impaired affect. Despite this diagnosis, I decided to hold off from using involuntary treatment. I met with him daily for more than 2 weeks, and we discussed his story, his feelings, and his beliefs. On occasion, it was hard to separate the delusions from justifiable anger at the system. He had felt that he and Harry had been wronged, when society should have protected their vulnerability. He learned to trust me, and his therapist taught him competency training. Despite a possible 1-year commitment, we declared him competent to stand trial in 2 weeks. He had learned and excelled in all facets of the training.
George still had delusions, but he understood his charges, that he had acted inappropriately in the courtroom, and how to discuss his case with his legal counsel. Harry found George to be at his baseline during visits. George acted appropriately; he followed the complex rules set on inmates and engaged in all groups that are held on the unit.
Discussion
I certainly do not question the value of involuntary psychiatric treatment for many patients with grave disabilities, violent tendencies, or incompetence. However, George’s case makes me wonder if many people living with schizophrenia can have rich and meaningful lives without ever being in contact with a mental health provider. I wonder if our almost-obsessive attention to antipsychotics makes us lose sight. Our biological reductionism may lead us to see patients such as George as someone with overactive dopaminergic pathways in need of antidopaminergic antipsychotic. Unfortunately for many, biological reductionism often is based on unsubstantiated evidence.
George reminds me that life, including schizophrenia, is more interesting and complicated than a set of genes, pathways, neurons, or neurotransmitters. Our patients’ lives may be convoluted with delusions, often stemming from truth or impaired affects, which are nonetheless genuine. I don’t know what will happen to George, but his past 50 years suggest that he will continue to have friends, and he will continue to live without being impaired by his delusions. Strangely, I worry less about him than many of my other patients.
Many mental health providers have advocated for a wider and easier access to involuntarily medicate our patients. I think that there is a misguided belief that involuntary antipsychotic treatment will lead to a rise in their use. However, if Carl Rogers, PhD, and others were right in stating that our relationship with our patients was the ultimate factor in their recovery, at what cost are we willing to jeopardize this? My fear is that this cost will be the loss of trust, which is so necessary in treatment. I hope that my short relationship with George did not scare him from ever seeing a psychiatrist again. In some ways, I suspect that by simply listening to George and withholding forced treatment, he will be more inclined to seek treatment in the future.
Take-home points
- Certain patients with psychosis have fairly high functioning.
- Milieu therapy is, in certain cases, able to assuage some symptoms of psychosis.
- Compulsory antipsychotic administration may not be ethical in certain cases of acute psychosis.
- Biological reductionism may undermine a complete ethical understanding of psychosis.
- Psychiatric disorders are etiologically complex and multifactorial.
- Involuntary treatment may provide short-term gains, but prevent long-term trust between patient and provider.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre also mentors several residents on projects, including reduction in the use of solitary confinement of patients with mental illness, reduction in the use of involuntary treatment of the mentally ill, and examination of the mentally ill offender.
“Ethics is knowing the difference between what you have a right to do and what is right to do.”
– Potter Stewart, U.S. Supreme Court Justice
An understanding of the difference between what is allowed or even recommended and what is ethical often is contemplated in the treatment of mental illness. Mental illnesses can impair judgment in patients confronted with complex decisions about their treatment. A provider, therefore, has to make a decision between respecting autonomy and/or engaging in what may be considered beneficent. While the line separating beneficent care and the respect for the autonomy of a patient may not be present, the question often arises – especially in inpatient care of patients with severe mental illness.
In the inpatient units, I was taught to justify and be mindful of any removal of someone’s right. I learned the responsibility of stripping someone’s freedom. Not only would I find myself preventing someone from going where they wanted or from talking to whomever they wanted, but frequently, we involuntary injected patients with neuroactive chemicals. Those measures are used only in extreme circumstances: In most states, one has to be unable to provide themselves with food, clothing, or shelter secondary to mental illness to be subjected to such aggressive treatment.
Currently, the United States is seeing an increase in the focus on providing more treatment: an emphasis on beneficence over autonomy. This change can be witnessed in the passage of compulsory outpatient treatment laws. Those rulings, such as Laura’s Law in California and Kendra’s Law in New York, have been promoted in response to an increased concern over the consequences of untreated mental illness in crime. In this commentary, I present a case where I felt that despite being given the right and expectation to involuntary treat someone, I did not feel that it was ethical to involuntarily medicate him. (I have made appropriate changes to the patient’s case to maintain confidentiality.)
Our facility
The Psychiatric Stabilization Unit (PSU) of the San Diego Jails is a 30-bed acute psychiatric unit. We serve the 4,500 male inmates and one of the largest mental health systems in the county. The vast majority (from 70% to 90% at any one time) of patients suffer from a psychotic illness, and more than 50% have a comorbid substance use disorder. Contrary to most inpatient units, we do not have pressure from insurance or utilization review to regularly change dosages or medications, and we do not have significant pressure to discharge patients within a certain time frame. The unit serves very disenfranchised patients with most being homeless prior to their arrest and many having no emergency contact or social support of any sort. The unit is staffed by one attending psychiatrist and two therapists. We are subjected to the same involuntary commitment and involuntary medication laws as are community psychiatric hospitals, but we get a significant number of patients under court orders.
The patient presented in this case came under such court order for restoration of his competency to stand trial. In the United States, one cannot stand trial unless competent. Competency is defined as one’s ability to take a meaningful or active part in a trial, the capacity to understand laws, the capacity to understand personal responsibility, the ability to express a plea, and the capability to instruct legal counsel. When patients are found incompetent, they commonly get court ordered to an unit like the PSU with a court order that they cannot understand the risk, benefits, and alternatives of psychotropic treatment and thus can be involuntarily medicated. Often, including in this case, the court order will mention that the patient will not become competent without treatment, including involuntary antipsychotics.
Overview of the case
George is a 50-year-old white male without psychiatric history. He had never been hospitalized psychiatrically voluntarily or involuntarily. He has never engaged in outpatient psychiatric care, has never taken psychotropic medication, and has never been diagnosed with mental illness. He mentions no prior episode of self-harm, suicidality, or suicide attempt. He occasionally drinks alcohol and has smoked marijuana on a few occasions. He despises other drugs, saying that they are “dangerous.” He mentions that his parents had “difficult personalities” but denies any knowledge of them having formal mental illness.
He was born in rural Louisiana to a British mother and an American father. His parents divorced while he was in preschool. His mother remarried, to a salesman, which required them to move frequently to different states for his work. He mentions having performed moderately in school, but poor grades were secondary to his “boredom.” He graduated high school and went to vocational school in technological manufacturing but was unable to graduate. He has since held a series of low-level jobs in retail and janitorial services. He mentions having been in romantic relationships, but when asked to elaborate, he is unable to name any past girlfriends or describe any past relationships. Nonetheless, he describes a wide array of social supports with many friends, though it must be noted that all of his friends have some form of mental illness or intellectual disability.
At this time, he lives with his friend Harry. Harry has a moderate form of autism. George helps him with everything from grocery shopping to financial matters to assistance in personal hygiene. In exchange, Harry provides him with housing that he inherited and financial assistance from his disability benefits. They have lived in the same home for 2 years, since Harry asked George to move in because of concern that he would lose his home over the unsanitary conditions that were present at that time.
George had never been arrested prior to this incarceration. The circumstances of his arrest are unusual. After a neighbor had made complaints that Harry and George were illegally lodging in Harry’s home, the city investigated the matter. George’s report was that Harry was unable to fill out the forms appropriately and was asked to present himself in court. George came along for moral support but became extremely upset when lawyers and judges asked his friend to answer questions he did not have the cognitive ability to answer. Without second thought, George voiced his anger but was asked to remain quiet while not on the stand. He was asked to remain seated and was demanded to follow orders. A few moments later, George was arrested for contempt of court and obstruction to an officer.
Once incarcerated, he declined having any mental illness or needing any treatment during the customary triage visit. He had no problem as an inmate and was never referred to psychiatric services. However, when meeting with his public defender, George derailed into delusions. He talked about how the cops had been conspiring against him all of his life, with his current incarceration as a culmination. He mentioned how the judge was purposely trying to get them evicted so that he could own the house himself. He asked his lawyer to countersue the judge for a violation of his rights. The public defender filed for a competency evaluation of his client.
The forensic psychiatrist evaluated the patient and had a similar interpretation. This was a patient who had delusions and was perseverating on them to the point of being unable to engage in meaningful work with his attorney. The psychiatrist recommended involuntary treatment with an antipsychotic after diagnosing the patient with a psychotic illness.
My interactions with George
George is a loud and bucolic man with an usual mix of Southern idioms, a slightly British accent, and East Coast humor. He insisted on telling me why he wanted the staff to refer to him by his Native American nickname prior to the start our interview. He then asked me to listen to his life story to understand why Harry meant so much to him. Despite recounting their truly meaningful relationship, his affect was odd with poor reactivity; he had an incongruent and somewhat ungenuine joyfulness.
Once I heard his account of their friendship, I asked him about his charges and the incident in the courtroom. His answer was a long diatribe about the wrongs that had been done to him, but most of his speech was a series of illogical delusions. I informed him of my thoughts about his fixed and false beliefs, but he was not able to understand my comments. Nonetheless, I felt that he related to me well and that we had established good rapport.
As I was informing him about the antipsychotic I had chosen for his involuntary treatment, he asked me to hold off. He asked me to consider working with him for some time without medications. After all, he did not believe that he had a mental illness and wanted to attempt to engage in the competency training with our therapist without being medicated.
My conceptualization of him
George is a peculiar case. Practically all patients who are committed to my unit for competency restoration are psychotic, and their psychosis prevents their engagement with their attorneys. They have poor insight into their illness, which leads to their commitment. On admission, I confirm the assessment of the forensic psychiatrist and start the ordered involuntary treatment on patients. Many of them are gravely disabled – making the ethical dilemma easier to navigate. For other patients, the idea that they will be kept incarcerated until found competent also makes the forced treatment a simpler decision.
George was different – his impeccable grooming, his dislike of jail food, and his request for appropriately fitting jail clothes were far from disorganized. More importantly, however, he had adequate shelter outside of jail, income for assisting Harry, and a rich network of friends. Despite being riddled with delusions, his thought process was linear, and he was redirectable – even when discussing his delusions. I conceptualized the ethical conflict as such: Not treating him might lead to a longer period of incompetence and a longer incarceration; treating him would go against his desire to remain untreated.
After contacting Harry, I was fairly certain that George had suffered from his delusions for at least a significant part of his adult life, if not in its entirety. However, Harry was infinitely thankful for George’s assistance and felt that George had a good life. This added another fundamental question: Would forcing George to engage in formal mental health treatment lead him to have a better life? He was happy, had meaningful relationships, and contributed to his life as well as his friends’ lives in a deep way.
I diagnosed him as having an unspecified psychotic disorder, likely schizophrenia; he had delusions and negative symptoms, like his impaired affect. Despite this diagnosis, I decided to hold off from using involuntary treatment. I met with him daily for more than 2 weeks, and we discussed his story, his feelings, and his beliefs. On occasion, it was hard to separate the delusions from justifiable anger at the system. He had felt that he and Harry had been wronged, when society should have protected their vulnerability. He learned to trust me, and his therapist taught him competency training. Despite a possible 1-year commitment, we declared him competent to stand trial in 2 weeks. He had learned and excelled in all facets of the training.
George still had delusions, but he understood his charges, that he had acted inappropriately in the courtroom, and how to discuss his case with his legal counsel. Harry found George to be at his baseline during visits. George acted appropriately; he followed the complex rules set on inmates and engaged in all groups that are held on the unit.
Discussion
I certainly do not question the value of involuntary psychiatric treatment for many patients with grave disabilities, violent tendencies, or incompetence. However, George’s case makes me wonder if many people living with schizophrenia can have rich and meaningful lives without ever being in contact with a mental health provider. I wonder if our almost-obsessive attention to antipsychotics makes us lose sight. Our biological reductionism may lead us to see patients such as George as someone with overactive dopaminergic pathways in need of antidopaminergic antipsychotic. Unfortunately for many, biological reductionism often is based on unsubstantiated evidence.
George reminds me that life, including schizophrenia, is more interesting and complicated than a set of genes, pathways, neurons, or neurotransmitters. Our patients’ lives may be convoluted with delusions, often stemming from truth or impaired affects, which are nonetheless genuine. I don’t know what will happen to George, but his past 50 years suggest that he will continue to have friends, and he will continue to live without being impaired by his delusions. Strangely, I worry less about him than many of my other patients.
Many mental health providers have advocated for a wider and easier access to involuntarily medicate our patients. I think that there is a misguided belief that involuntary antipsychotic treatment will lead to a rise in their use. However, if Carl Rogers, PhD, and others were right in stating that our relationship with our patients was the ultimate factor in their recovery, at what cost are we willing to jeopardize this? My fear is that this cost will be the loss of trust, which is so necessary in treatment. I hope that my short relationship with George did not scare him from ever seeing a psychiatrist again. In some ways, I suspect that by simply listening to George and withholding forced treatment, he will be more inclined to seek treatment in the future.
Take-home points
- Certain patients with psychosis have fairly high functioning.
- Milieu therapy is, in certain cases, able to assuage some symptoms of psychosis.
- Compulsory antipsychotic administration may not be ethical in certain cases of acute psychosis.
- Biological reductionism may undermine a complete ethical understanding of psychosis.
- Psychiatric disorders are etiologically complex and multifactorial.
- Involuntary treatment may provide short-term gains, but prevent long-term trust between patient and provider.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre also mentors several residents on projects, including reduction in the use of solitary confinement of patients with mental illness, reduction in the use of involuntary treatment of the mentally ill, and examination of the mentally ill offender.
Debunking false claims about mental illness and violence
On July 27, 2015, Lai Hang shot and killed her son, George, at the Valley Hotel in Rosemead, Calif. Ms. Hang had been diagnosed with terminal cancer a few months prior and was concerned about the future of her son. George was almost 18 and diagnosed with schizophrenia.
In thinking about why Ms. Hang chose this act, I can’t help but wonder about our role in perpetuating the myth that mental illness and violence go hand in hand.
Loss and tough adjustment
George had been born to Lai and Peter Hang, who moved to the United States in 1992 from the southeast Asian country of Laos to open a printing shop and pursue the “American dream.” In 2012, Peter Hang was diagnosed with metastatic cancer and died, a development that was a severe stressor for George.
Over a period of months, George reportedly started withdrawing from friends and acting differently. He destroyed things around the house, including a garden he had planted with a family friend. His grades slipped in school; he was getting report cards full of Fs. He subsequently was diagnosed with schizophrenia. Ms. Hang grew increasingly concerned about him in the context of the multiple highly publicized mass shootings attributed to patients with mental illness.
When George became more interested in Adolf Hitler after a school project on World War II, Ms. Hang’s fear intensified. Her concerns grew even more in the wake of reports of killings by James Holmes in Aurora, Colo.; Adam Lanza in Newtown, Conn.; and Elliot Rodger in the Santa Barbara County, Calif., town of Isla Vista. After the Charleston, S.C., church shootings of June 2015, George Hang reportedly became fixated on Dylann Roof. With increasing distress over her son, Ms. Hang wondered whether anything could have been done to stop those shooters.1
Politicians long have perpetrated the belief that patients with mental illness cause violence. Former President Barack Obama often linked mental illness to gun violence. For example, in a 2016 statement, he said: “While individuals with mental illness are more likely to be victims of violence than perpetrators, incidents of violence continue to highlight a crisis in America’s mental health system.”2
The recent election also was a prime example, with quotes such as: “This isn’t a gun problem; it’s a mental health problem ... these are sick people,” by now-President Donald Trump, and “We are not making sure that someone who is mentally ill can’t get access to a gun”3 by Ohio Gov. John Kasich.
The media also have promoted this view with headlines such as “Get the violent crazies off our streets,” and “They threaten, seethe and unhinge, then kill in quantity.” In one article, the writer contended: “In our newfound complacency, we had forgotten a particular kind of violence to which we are still prey … violence of the mentally ill.”4
How the evidence stacks up
Nonetheless, the scientific evidence contradicts those views. Most reviews on the topic come to conclusions similar to those of Debra A. Pinals, MD, and Lisa Anacker, MD, who recently wrote: “Despite media accounts to the contrary, persons with mental illness account for only a small percentage of persons who commit acts of violence ...”5
Jeffrey W. Swanson, PhD, who has spent his career examining these issues, studied more than 10,000 people with and without mental illness over 1 year, and found that serious mental illness was found in only 4% of the cases of violence. He found three factors that do predict the occurrence of violence: whether the perpetrator was male, poor, or abusing drugs.6 “That study debunked two myths,” Dr. Swanson, professor in the department of psychiatry and behavioral sciences at Duke University, Durham, N.C., reportedly said. “One: people with mental illness are all dangerous. Well, the vast majority are not. And the other myth: that there’s no connection at all. There is one. It’s quite small, but it’s not completely nonexistent.”7
Despite the consistent research on this topic, the voice of psychiatry has been muddled. Many have promoted this intuitive yet wrong narrative. In particular, this approach has been embraced by the Treatment Advocacy Center (TAC), a large nonprofit organization “dedicated to eliminating barriers to the timely and effective treatment of severe mental illness.”
In 2013, E. Fuller Torrey, MD, the executive director of TAC, contended in an interview “about half of … mass killings are being done by people with severe mental illness.” His solution is explicit: “The U.S. would have fewer mass killings if individuals with severe mental illnesses received proper treatment.”8 In a fact that implies tacit approval of Dr. Torrey’s problematic positions, three past presidents of the American Psychiatric Association currently serve on TAC’s board: Jeffrey A. Lieberman, MD; Steven S. Sharfstein, MD; and John A. Talbott, MD.
It is worrying that some psychiatrists have started sounding false alarms again when advocating for laws that support assisted outpatient treatment (AOT). In AOT, an individual meeting specified criteria for mental illness and potentially asserted to have a risk for violence is compelled by court order to comply with outpatient psychiatric treatment as a condition of remaining in the community.9 Some psychiatrists contend that “the relationship between deinstitutionalization and the increasing episodes of violent behavior by individuals with serious mental illness who are not being treated has been firmly established. Until we address the treatment issue and use proven remedies, such as assisted outpatient treatment … we should expect these episodes of violent behavior to continue,” they conclude.10
I am concerned about this issue, not only because of the stigma faced by our patients. I want to prevent our patients from realizing that behind their backs, outside of the office, we speak of them as dangerous and in need of involuntary confinement. I am concerned that patients will no longer trust psychiatrists if we describe them in such scary fashions without even the backing of science. If nonmaleficence is at the cornerstone of medical ethics, maybe as psychiatrists we could start by not falsely accusing our patients of being dangerous.
As Irvin D. Yalom, MD, famously said: “It’s the relationship that heals.” I cannot think of anything more important to my practice than cultivating genuine and meaningful relationships. I work as a psychiatrist with patients who have severe mental illness. They are dehumanized by the system, disenfranchised from society, and feared by the media. My role is to create a relationship that helps them overcome those obstacles.
References
1 Los Angeles Times. May 22, 2017
2 Obama White House Archives, Jan. 4, 2016
3 TheTrace.org. Sept. 1, 2015
4 The Guardian. Oct. 2, 2015
5 Psychiatr Clin N Am. 2016;39:611-21
6 Ann Epidemiol. 2015 May;25(5):366-76
7 The New Yorker. Nov. 19, 2014
8 60 Minutes. Sept. 27, 2013
9 Psychiatr Serv. 2016 Jul 1;67(7):784-6
10 CNS Spectr. 2015 Jun;20(3):207-14
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego; and the University of San Diego. He teaches on medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre also mentors several residents on projects, including reduction in the use of solitary confinement of patients with mental illness, reduction in the use of involuntary treatment of the mentally ill, and examination of the mentally ill offender.
On July 27, 2015, Lai Hang shot and killed her son, George, at the Valley Hotel in Rosemead, Calif. Ms. Hang had been diagnosed with terminal cancer a few months prior and was concerned about the future of her son. George was almost 18 and diagnosed with schizophrenia.
In thinking about why Ms. Hang chose this act, I can’t help but wonder about our role in perpetuating the myth that mental illness and violence go hand in hand.
Loss and tough adjustment
George had been born to Lai and Peter Hang, who moved to the United States in 1992 from the southeast Asian country of Laos to open a printing shop and pursue the “American dream.” In 2012, Peter Hang was diagnosed with metastatic cancer and died, a development that was a severe stressor for George.
Over a period of months, George reportedly started withdrawing from friends and acting differently. He destroyed things around the house, including a garden he had planted with a family friend. His grades slipped in school; he was getting report cards full of Fs. He subsequently was diagnosed with schizophrenia. Ms. Hang grew increasingly concerned about him in the context of the multiple highly publicized mass shootings attributed to patients with mental illness.
When George became more interested in Adolf Hitler after a school project on World War II, Ms. Hang’s fear intensified. Her concerns grew even more in the wake of reports of killings by James Holmes in Aurora, Colo.; Adam Lanza in Newtown, Conn.; and Elliot Rodger in the Santa Barbara County, Calif., town of Isla Vista. After the Charleston, S.C., church shootings of June 2015, George Hang reportedly became fixated on Dylann Roof. With increasing distress over her son, Ms. Hang wondered whether anything could have been done to stop those shooters.1
Politicians long have perpetrated the belief that patients with mental illness cause violence. Former President Barack Obama often linked mental illness to gun violence. For example, in a 2016 statement, he said: “While individuals with mental illness are more likely to be victims of violence than perpetrators, incidents of violence continue to highlight a crisis in America’s mental health system.”2
The recent election also was a prime example, with quotes such as: “This isn’t a gun problem; it’s a mental health problem ... these are sick people,” by now-President Donald Trump, and “We are not making sure that someone who is mentally ill can’t get access to a gun”3 by Ohio Gov. John Kasich.
The media also have promoted this view with headlines such as “Get the violent crazies off our streets,” and “They threaten, seethe and unhinge, then kill in quantity.” In one article, the writer contended: “In our newfound complacency, we had forgotten a particular kind of violence to which we are still prey … violence of the mentally ill.”4
How the evidence stacks up
Nonetheless, the scientific evidence contradicts those views. Most reviews on the topic come to conclusions similar to those of Debra A. Pinals, MD, and Lisa Anacker, MD, who recently wrote: “Despite media accounts to the contrary, persons with mental illness account for only a small percentage of persons who commit acts of violence ...”5
Jeffrey W. Swanson, PhD, who has spent his career examining these issues, studied more than 10,000 people with and without mental illness over 1 year, and found that serious mental illness was found in only 4% of the cases of violence. He found three factors that do predict the occurrence of violence: whether the perpetrator was male, poor, or abusing drugs.6 “That study debunked two myths,” Dr. Swanson, professor in the department of psychiatry and behavioral sciences at Duke University, Durham, N.C., reportedly said. “One: people with mental illness are all dangerous. Well, the vast majority are not. And the other myth: that there’s no connection at all. There is one. It’s quite small, but it’s not completely nonexistent.”7
Despite the consistent research on this topic, the voice of psychiatry has been muddled. Many have promoted this intuitive yet wrong narrative. In particular, this approach has been embraced by the Treatment Advocacy Center (TAC), a large nonprofit organization “dedicated to eliminating barriers to the timely and effective treatment of severe mental illness.”
In 2013, E. Fuller Torrey, MD, the executive director of TAC, contended in an interview “about half of … mass killings are being done by people with severe mental illness.” His solution is explicit: “The U.S. would have fewer mass killings if individuals with severe mental illnesses received proper treatment.”8 In a fact that implies tacit approval of Dr. Torrey’s problematic positions, three past presidents of the American Psychiatric Association currently serve on TAC’s board: Jeffrey A. Lieberman, MD; Steven S. Sharfstein, MD; and John A. Talbott, MD.
It is worrying that some psychiatrists have started sounding false alarms again when advocating for laws that support assisted outpatient treatment (AOT). In AOT, an individual meeting specified criteria for mental illness and potentially asserted to have a risk for violence is compelled by court order to comply with outpatient psychiatric treatment as a condition of remaining in the community.9 Some psychiatrists contend that “the relationship between deinstitutionalization and the increasing episodes of violent behavior by individuals with serious mental illness who are not being treated has been firmly established. Until we address the treatment issue and use proven remedies, such as assisted outpatient treatment … we should expect these episodes of violent behavior to continue,” they conclude.10
I am concerned about this issue, not only because of the stigma faced by our patients. I want to prevent our patients from realizing that behind their backs, outside of the office, we speak of them as dangerous and in need of involuntary confinement. I am concerned that patients will no longer trust psychiatrists if we describe them in such scary fashions without even the backing of science. If nonmaleficence is at the cornerstone of medical ethics, maybe as psychiatrists we could start by not falsely accusing our patients of being dangerous.
As Irvin D. Yalom, MD, famously said: “It’s the relationship that heals.” I cannot think of anything more important to my practice than cultivating genuine and meaningful relationships. I work as a psychiatrist with patients who have severe mental illness. They are dehumanized by the system, disenfranchised from society, and feared by the media. My role is to create a relationship that helps them overcome those obstacles.
References
1 Los Angeles Times. May 22, 2017
2 Obama White House Archives, Jan. 4, 2016
3 TheTrace.org. Sept. 1, 2015
4 The Guardian. Oct. 2, 2015
5 Psychiatr Clin N Am. 2016;39:611-21
6 Ann Epidemiol. 2015 May;25(5):366-76
7 The New Yorker. Nov. 19, 2014
8 60 Minutes. Sept. 27, 2013
9 Psychiatr Serv. 2016 Jul 1;67(7):784-6
10 CNS Spectr. 2015 Jun;20(3):207-14
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego; and the University of San Diego. He teaches on medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre also mentors several residents on projects, including reduction in the use of solitary confinement of patients with mental illness, reduction in the use of involuntary treatment of the mentally ill, and examination of the mentally ill offender.
On July 27, 2015, Lai Hang shot and killed her son, George, at the Valley Hotel in Rosemead, Calif. Ms. Hang had been diagnosed with terminal cancer a few months prior and was concerned about the future of her son. George was almost 18 and diagnosed with schizophrenia.
In thinking about why Ms. Hang chose this act, I can’t help but wonder about our role in perpetuating the myth that mental illness and violence go hand in hand.
Loss and tough adjustment
George had been born to Lai and Peter Hang, who moved to the United States in 1992 from the southeast Asian country of Laos to open a printing shop and pursue the “American dream.” In 2012, Peter Hang was diagnosed with metastatic cancer and died, a development that was a severe stressor for George.
Over a period of months, George reportedly started withdrawing from friends and acting differently. He destroyed things around the house, including a garden he had planted with a family friend. His grades slipped in school; he was getting report cards full of Fs. He subsequently was diagnosed with schizophrenia. Ms. Hang grew increasingly concerned about him in the context of the multiple highly publicized mass shootings attributed to patients with mental illness.
When George became more interested in Adolf Hitler after a school project on World War II, Ms. Hang’s fear intensified. Her concerns grew even more in the wake of reports of killings by James Holmes in Aurora, Colo.; Adam Lanza in Newtown, Conn.; and Elliot Rodger in the Santa Barbara County, Calif., town of Isla Vista. After the Charleston, S.C., church shootings of June 2015, George Hang reportedly became fixated on Dylann Roof. With increasing distress over her son, Ms. Hang wondered whether anything could have been done to stop those shooters.1
Politicians long have perpetrated the belief that patients with mental illness cause violence. Former President Barack Obama often linked mental illness to gun violence. For example, in a 2016 statement, he said: “While individuals with mental illness are more likely to be victims of violence than perpetrators, incidents of violence continue to highlight a crisis in America’s mental health system.”2
The recent election also was a prime example, with quotes such as: “This isn’t a gun problem; it’s a mental health problem ... these are sick people,” by now-President Donald Trump, and “We are not making sure that someone who is mentally ill can’t get access to a gun”3 by Ohio Gov. John Kasich.
The media also have promoted this view with headlines such as “Get the violent crazies off our streets,” and “They threaten, seethe and unhinge, then kill in quantity.” In one article, the writer contended: “In our newfound complacency, we had forgotten a particular kind of violence to which we are still prey … violence of the mentally ill.”4
How the evidence stacks up
Nonetheless, the scientific evidence contradicts those views. Most reviews on the topic come to conclusions similar to those of Debra A. Pinals, MD, and Lisa Anacker, MD, who recently wrote: “Despite media accounts to the contrary, persons with mental illness account for only a small percentage of persons who commit acts of violence ...”5
Jeffrey W. Swanson, PhD, who has spent his career examining these issues, studied more than 10,000 people with and without mental illness over 1 year, and found that serious mental illness was found in only 4% of the cases of violence. He found three factors that do predict the occurrence of violence: whether the perpetrator was male, poor, or abusing drugs.6 “That study debunked two myths,” Dr. Swanson, professor in the department of psychiatry and behavioral sciences at Duke University, Durham, N.C., reportedly said. “One: people with mental illness are all dangerous. Well, the vast majority are not. And the other myth: that there’s no connection at all. There is one. It’s quite small, but it’s not completely nonexistent.”7
Despite the consistent research on this topic, the voice of psychiatry has been muddled. Many have promoted this intuitive yet wrong narrative. In particular, this approach has been embraced by the Treatment Advocacy Center (TAC), a large nonprofit organization “dedicated to eliminating barriers to the timely and effective treatment of severe mental illness.”
In 2013, E. Fuller Torrey, MD, the executive director of TAC, contended in an interview “about half of … mass killings are being done by people with severe mental illness.” His solution is explicit: “The U.S. would have fewer mass killings if individuals with severe mental illnesses received proper treatment.”8 In a fact that implies tacit approval of Dr. Torrey’s problematic positions, three past presidents of the American Psychiatric Association currently serve on TAC’s board: Jeffrey A. Lieberman, MD; Steven S. Sharfstein, MD; and John A. Talbott, MD.
It is worrying that some psychiatrists have started sounding false alarms again when advocating for laws that support assisted outpatient treatment (AOT). In AOT, an individual meeting specified criteria for mental illness and potentially asserted to have a risk for violence is compelled by court order to comply with outpatient psychiatric treatment as a condition of remaining in the community.9 Some psychiatrists contend that “the relationship between deinstitutionalization and the increasing episodes of violent behavior by individuals with serious mental illness who are not being treated has been firmly established. Until we address the treatment issue and use proven remedies, such as assisted outpatient treatment … we should expect these episodes of violent behavior to continue,” they conclude.10
I am concerned about this issue, not only because of the stigma faced by our patients. I want to prevent our patients from realizing that behind their backs, outside of the office, we speak of them as dangerous and in need of involuntary confinement. I am concerned that patients will no longer trust psychiatrists if we describe them in such scary fashions without even the backing of science. If nonmaleficence is at the cornerstone of medical ethics, maybe as psychiatrists we could start by not falsely accusing our patients of being dangerous.
As Irvin D. Yalom, MD, famously said: “It’s the relationship that heals.” I cannot think of anything more important to my practice than cultivating genuine and meaningful relationships. I work as a psychiatrist with patients who have severe mental illness. They are dehumanized by the system, disenfranchised from society, and feared by the media. My role is to create a relationship that helps them overcome those obstacles.
References
1 Los Angeles Times. May 22, 2017
2 Obama White House Archives, Jan. 4, 2016
3 TheTrace.org. Sept. 1, 2015
4 The Guardian. Oct. 2, 2015
5 Psychiatr Clin N Am. 2016;39:611-21
6 Ann Epidemiol. 2015 May;25(5):366-76
7 The New Yorker. Nov. 19, 2014
8 60 Minutes. Sept. 27, 2013
9 Psychiatr Serv. 2016 Jul 1;67(7):784-6
10 CNS Spectr. 2015 Jun;20(3):207-14
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego; and the University of San Diego. He teaches on medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre also mentors several residents on projects, including reduction in the use of solitary confinement of patients with mental illness, reduction in the use of involuntary treatment of the mentally ill, and examination of the mentally ill offender.
French psychiatrist condemned for society’s deficiency
On Dec. 14, 2016, a French psychiatrist was sentenced to an 18-month suspended prison sentence. Lekhraj Gujadhur, MD, was the supervisor of unit 101 at the Psychiatric Hospital Center of Saint-Egrève in France. In November 2008, he had approved the nonsupervised release of a schizophrenia patient, Jean-Pierre Guillaud, to outside of his unit but within the hospital facility. Mr. Guillaud, while outside supervision, escaped. He subsequently purchased a large knife and murdered a 26-year-old student, Luc Meunier, Le Monde reported.1
This is reminiscent of a similar case in 2012 in Marseille, where a psychiatrist received a suspended prison sentence after his patient committed murder. That prior case was later dismissed in appellate court. In my opinion, both trials point to a failure in psychiatry’s responsibility to educate the public in our limitations and roles. They also highlight the necessary discourse that society should have on the role of mental illness when it comes to crime.
Although I appreciate society’s concern about such crimes, I think that displacement of our anger onto Dr. Gujadhur is misguided, and instead, allows us to forget to look at our own poor judgment. Dr. Gujadhur, other psychiatrists, and mental hospitals do not have the responsibility to enact sentences for crimes; the legal system does. Law enforcement and prosecutors had numerous opportunities to charge and commit Mr. Guillaud over the years but chose not to do so, instead permitting him to stay within society under the care of the mental health system.
Asking Dr. Gujadhur to primarily focus on becoming an agent of the law, instead of treating his patient, is unfair. Schizophrenia, and in particular paranoia, are greatly worsened by social isolation. Confining Mr. Guillaud would be countertherapeutic and possibly lead to his suicide. Would Dr. Gujadhur have been responsible for the suicide? Mental health providers have to understand and support the psychological functioning of their patients. Creating a dual agency blurs and effaces the doctor-patient relationship, already so fragile in the treatment of paranoid patients.
The publicity of such cases, and of Mr. Guillaud’s mental illness, seems to go against current mental health research. Recent work has suggested that mental illness is not a significant risk factor for violence but rather a risk factor for being the victim of violence. Certainly, some patients with mental illness commit acts of violence, but studies suggest that this is mostly independent of their mental illness (Law Hum Behav. 2014 Oct;38[5];439-49).2 Our overemphasis on the mental status of criminals belittles their crimes and suggests that psychiatrists are responsible for the failings of our legal system.
As a supervising psychiatrist at one of the largest jail systems in America, I am familiar with the challenges in such cases. All of my patients are facing legal charges, and many suffer from severe mental illness like schizophrenia. As their treating psychiatrist, I am not asked to also sentence them for the charges they are facing. Simply working for the sheriff makes my ability to gain the trust of my patients much more difficult. Conspiring with the city or district attorney in an attempt to protect society would obliterate any chance at rapport building.
Working in corrections, I am deeply familiar with the current debate on the solitary confinement of our mentally ill offenders. Ironically, in that context, society has blamed the legal system for socially isolating our mentally ill offenders, especially ones with severe mental illness.3 In our jail, we meet regularly and discuss in an interdisciplinary fashion the role and consequences of social isolation. During our weekly sessions, a case involving stabbing someone 2 years prior would not have justified the punishment of social isolation and constant monitoring.
As a field, psychiatry must educate society on its ability to create a therapeutic environment and its ability to provide risk assessment of violence. We must also remind others of the impossibility of doing both simultaneously. Decisions on removing patients’ right to freedom can be informed by the mental health perspective but should be left to the courts. Society’s need to find a target after such tragedies is understandable, but blaming the treating psychiatrists will not help past or future victims.
References
1. Le psychiatre d’un schizophrène meurtrier condamné pour homicide involontaire, Le Monde, Dec. 14, 2016.
2. How often and how consistently do symptoms directly precede criminal behavior among offenders with mental illness? (Law Hum Behav. 2014 Oct;38[5]:439-49).
3. How to fix solitary confinement in American prisons, Los Angeles Times, Oct. 17, 2016.
Dr. Badre is a supervising psychiatric contractor at the San Diego Central Jail. He also holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches on medical education, psychopharmacology, ethics in psychiatry, and correctional care. He mentors several residents on projects, including reduction in the use of solitary confinement of patients with mental illness, reduction in the use of involuntary treatment of the mentally ill, and examination of the mentally ill offender.
On Dec. 14, 2016, a French psychiatrist was sentenced to an 18-month suspended prison sentence. Lekhraj Gujadhur, MD, was the supervisor of unit 101 at the Psychiatric Hospital Center of Saint-Egrève in France. In November 2008, he had approved the nonsupervised release of a schizophrenia patient, Jean-Pierre Guillaud, to outside of his unit but within the hospital facility. Mr. Guillaud, while outside supervision, escaped. He subsequently purchased a large knife and murdered a 26-year-old student, Luc Meunier, Le Monde reported.1
This is reminiscent of a similar case in 2012 in Marseille, where a psychiatrist received a suspended prison sentence after his patient committed murder. That prior case was later dismissed in appellate court. In my opinion, both trials point to a failure in psychiatry’s responsibility to educate the public in our limitations and roles. They also highlight the necessary discourse that society should have on the role of mental illness when it comes to crime.
Although I appreciate society’s concern about such crimes, I think that displacement of our anger onto Dr. Gujadhur is misguided, and instead, allows us to forget to look at our own poor judgment. Dr. Gujadhur, other psychiatrists, and mental hospitals do not have the responsibility to enact sentences for crimes; the legal system does. Law enforcement and prosecutors had numerous opportunities to charge and commit Mr. Guillaud over the years but chose not to do so, instead permitting him to stay within society under the care of the mental health system.
Asking Dr. Gujadhur to primarily focus on becoming an agent of the law, instead of treating his patient, is unfair. Schizophrenia, and in particular paranoia, are greatly worsened by social isolation. Confining Mr. Guillaud would be countertherapeutic and possibly lead to his suicide. Would Dr. Gujadhur have been responsible for the suicide? Mental health providers have to understand and support the psychological functioning of their patients. Creating a dual agency blurs and effaces the doctor-patient relationship, already so fragile in the treatment of paranoid patients.
The publicity of such cases, and of Mr. Guillaud’s mental illness, seems to go against current mental health research. Recent work has suggested that mental illness is not a significant risk factor for violence but rather a risk factor for being the victim of violence. Certainly, some patients with mental illness commit acts of violence, but studies suggest that this is mostly independent of their mental illness (Law Hum Behav. 2014 Oct;38[5];439-49).2 Our overemphasis on the mental status of criminals belittles their crimes and suggests that psychiatrists are responsible for the failings of our legal system.
As a supervising psychiatrist at one of the largest jail systems in America, I am familiar with the challenges in such cases. All of my patients are facing legal charges, and many suffer from severe mental illness like schizophrenia. As their treating psychiatrist, I am not asked to also sentence them for the charges they are facing. Simply working for the sheriff makes my ability to gain the trust of my patients much more difficult. Conspiring with the city or district attorney in an attempt to protect society would obliterate any chance at rapport building.
Working in corrections, I am deeply familiar with the current debate on the solitary confinement of our mentally ill offenders. Ironically, in that context, society has blamed the legal system for socially isolating our mentally ill offenders, especially ones with severe mental illness.3 In our jail, we meet regularly and discuss in an interdisciplinary fashion the role and consequences of social isolation. During our weekly sessions, a case involving stabbing someone 2 years prior would not have justified the punishment of social isolation and constant monitoring.
As a field, psychiatry must educate society on its ability to create a therapeutic environment and its ability to provide risk assessment of violence. We must also remind others of the impossibility of doing both simultaneously. Decisions on removing patients’ right to freedom can be informed by the mental health perspective but should be left to the courts. Society’s need to find a target after such tragedies is understandable, but blaming the treating psychiatrists will not help past or future victims.
References
1. Le psychiatre d’un schizophrène meurtrier condamné pour homicide involontaire, Le Monde, Dec. 14, 2016.
2. How often and how consistently do symptoms directly precede criminal behavior among offenders with mental illness? (Law Hum Behav. 2014 Oct;38[5]:439-49).
3. How to fix solitary confinement in American prisons, Los Angeles Times, Oct. 17, 2016.
Dr. Badre is a supervising psychiatric contractor at the San Diego Central Jail. He also holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches on medical education, psychopharmacology, ethics in psychiatry, and correctional care. He mentors several residents on projects, including reduction in the use of solitary confinement of patients with mental illness, reduction in the use of involuntary treatment of the mentally ill, and examination of the mentally ill offender.
On Dec. 14, 2016, a French psychiatrist was sentenced to an 18-month suspended prison sentence. Lekhraj Gujadhur, MD, was the supervisor of unit 101 at the Psychiatric Hospital Center of Saint-Egrève in France. In November 2008, he had approved the nonsupervised release of a schizophrenia patient, Jean-Pierre Guillaud, to outside of his unit but within the hospital facility. Mr. Guillaud, while outside supervision, escaped. He subsequently purchased a large knife and murdered a 26-year-old student, Luc Meunier, Le Monde reported.1
This is reminiscent of a similar case in 2012 in Marseille, where a psychiatrist received a suspended prison sentence after his patient committed murder. That prior case was later dismissed in appellate court. In my opinion, both trials point to a failure in psychiatry’s responsibility to educate the public in our limitations and roles. They also highlight the necessary discourse that society should have on the role of mental illness when it comes to crime.
Although I appreciate society’s concern about such crimes, I think that displacement of our anger onto Dr. Gujadhur is misguided, and instead, allows us to forget to look at our own poor judgment. Dr. Gujadhur, other psychiatrists, and mental hospitals do not have the responsibility to enact sentences for crimes; the legal system does. Law enforcement and prosecutors had numerous opportunities to charge and commit Mr. Guillaud over the years but chose not to do so, instead permitting him to stay within society under the care of the mental health system.
Asking Dr. Gujadhur to primarily focus on becoming an agent of the law, instead of treating his patient, is unfair. Schizophrenia, and in particular paranoia, are greatly worsened by social isolation. Confining Mr. Guillaud would be countertherapeutic and possibly lead to his suicide. Would Dr. Gujadhur have been responsible for the suicide? Mental health providers have to understand and support the psychological functioning of their patients. Creating a dual agency blurs and effaces the doctor-patient relationship, already so fragile in the treatment of paranoid patients.
The publicity of such cases, and of Mr. Guillaud’s mental illness, seems to go against current mental health research. Recent work has suggested that mental illness is not a significant risk factor for violence but rather a risk factor for being the victim of violence. Certainly, some patients with mental illness commit acts of violence, but studies suggest that this is mostly independent of their mental illness (Law Hum Behav. 2014 Oct;38[5];439-49).2 Our overemphasis on the mental status of criminals belittles their crimes and suggests that psychiatrists are responsible for the failings of our legal system.
As a supervising psychiatrist at one of the largest jail systems in America, I am familiar with the challenges in such cases. All of my patients are facing legal charges, and many suffer from severe mental illness like schizophrenia. As their treating psychiatrist, I am not asked to also sentence them for the charges they are facing. Simply working for the sheriff makes my ability to gain the trust of my patients much more difficult. Conspiring with the city or district attorney in an attempt to protect society would obliterate any chance at rapport building.
Working in corrections, I am deeply familiar with the current debate on the solitary confinement of our mentally ill offenders. Ironically, in that context, society has blamed the legal system for socially isolating our mentally ill offenders, especially ones with severe mental illness.3 In our jail, we meet regularly and discuss in an interdisciplinary fashion the role and consequences of social isolation. During our weekly sessions, a case involving stabbing someone 2 years prior would not have justified the punishment of social isolation and constant monitoring.
As a field, psychiatry must educate society on its ability to create a therapeutic environment and its ability to provide risk assessment of violence. We must also remind others of the impossibility of doing both simultaneously. Decisions on removing patients’ right to freedom can be informed by the mental health perspective but should be left to the courts. Society’s need to find a target after such tragedies is understandable, but blaming the treating psychiatrists will not help past or future victims.
References
1. Le psychiatre d’un schizophrène meurtrier condamné pour homicide involontaire, Le Monde, Dec. 14, 2016.
2. How often and how consistently do symptoms directly precede criminal behavior among offenders with mental illness? (Law Hum Behav. 2014 Oct;38[5]:439-49).
3. How to fix solitary confinement in American prisons, Los Angeles Times, Oct. 17, 2016.
Dr. Badre is a supervising psychiatric contractor at the San Diego Central Jail. He also holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches on medical education, psychopharmacology, ethics in psychiatry, and correctional care. He mentors several residents on projects, including reduction in the use of solitary confinement of patients with mental illness, reduction in the use of involuntary treatment of the mentally ill, and examination of the mentally ill offender.