Discussing a psychiatrist’s objections to mandated treatment.
To the Editor:
Recent tragic events have linked mental illness and violence. Some people — I, for one — consider this link dangerously stigmatizing. People with mental illness are far more likely to be victims of violence than perpetrators. Moreover, psychiatrists have limited capacity to reliably predict violence. Nonetheless, these events increase pressure to identify people who might conceivably commit violent acts, and to mandate treatment with antipsychotic medications.
For a tiny minority of patients who have committed serious crimes, mandated treatment can be effective, particularly as an alternative to incarceration. But for most patients experiencing psychotic states, mandated treatment may create more problems than it solves.
For many medical conditions, better outcomes occur when patients share in treatment design and disease management. Imposed treatments tend to engender resistance and resentment. This is also true for psychiatric conditions.
Patients with psychotic symptoms often feel that their own experience is dismissed as meaningless, like the ravings of an intoxicated or delirious person. Decisions to decline antipsychotic medications are often regarded mainly as a manifestation of illness — an illness the person is too sick to recognize — even though many people might reject antipsychotics because of metabolic and other toxicities.
When a clearly troubled person firmly believes that he or she needs no help, there are no simple answers. These situations are particularly agonizing for families. Safety is paramount — and at times can be elusive. Still, if psychiatrists humbly try to understand the person on his or her own terms, do not dismiss the person’s experience as meaningless and truly respect the person’s choices about treatment, sometimes this opens the way to an effective treatment relationship. For some suffering and alienated people — certainly not all — feeling respectfully understood can be a critical step toward recovery.
Mandated treatment is a blunt instrument that may drive more people away from seeking care than it compels into care.
Framingham, Mass., Jan. 28, 2013
The writer is a psychiatrist and an associate clinical professor of psychiatry at Harvard Medical School.