Monday, October 02, 2006

On A Short Leash

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

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

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

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

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

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

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

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

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