Showing posts with label involuntary treatment. Show all posts
Showing posts with label involuntary treatment. Show all posts

Friday, January 20, 2023

We Need A Model Terroristic Threat Statute

 


Over the past ten years of writing this blog, I hope that I have been clear about a few things. First, violence and aggression are complicated problems. Most of the political arguments out there today focus on peripheral issues like gun violence. In a country of gun extremists – there will always be excuses for why there is so much gun violence.  A common one is that there are mentally ill people with guns.  Some of the gun extremists have gone so far recently to suggest this is due to a crisis of untreated mental illness. Nothing is further from the truth.

Second, people with mental illness can be violent and aggressive. In political arguments where violence and aggression is being attributed to mental illness it is common to deny it. In a Community Psychiatry seminar 40 years ago – my position was “people with mental illness are no more violent than anyone else.”  My 40 years in the field has taught me that looking at violence across large groups is meaningless. In the acute care setting where I worked many if not most of the patients I treated were there for violence against others or self-directed violence.  Some were aggressive toward me and the staff I worked with – with some threats that persisted well after any hospitalization.

Third, violence and aggression can clearly be treated in many if not most cases, especially if it is a manifestation of acute psychiatric illness. Despite that being common knowledge in acute care settings – there is no effort to characterize it as a public health problem like suicide. There are no public service announcements about what to do if you have violent or aggressive thoughts. No hopeful messages that you do not have to act on any of those thoughts and that you can get help to restore your baseline thought patterns.

Fourth, violence and aggression are stigmatized in society. Most people at some point in their lives have been bullied or traumatized by other forms of aggression. In the US, incidents of extreme violence and aggression are commonplace in the daily news. There is a fascination with true crime television and documentaries about serial killers. The media seems preoccupied with discovering a “motive” for these crimes.  Apart from the usual sociopathic motives of intimidating and injuring people to get what one wants – motives are generally lacking. In fact, I would go so far to say that in the homicide cases broadcast on television the limiting factor was the availability of a firearm. In other words – no homicide would have occurred if a firearm was not present. The resulting stigma toward aggression, leads to biases toward patients with psychiatric illnesses who are violent because of those illnesses.

Fifth, there is a limited rational response to violence and aggression even if a public health response is ruled out. This occurs daily. There has been no clinic or hospital where I have worked where I have observed a well thought out plan to respond to these incidents even though aggression toward health care workers is a current epidemic. There are plenty of errors along the way whenever an incident occurs in the community. I have had patients who were in the cross hairs of a police sniper until somebody noticed they were pointing a toy gun at the police. Anyone in my field has had people who assaulted them, threatened them and their families, and in some cases that aggression has resulted in serious injury or death. The rate of intentional injury by another person is five times greater in the healthcare industry than all other industries and that rate is ten times greater in the psychiatric and substance use fields. With a healthcare system run by administrators rather than physicians – it is not clear why there are no functional approaches at the institutional level. In the case of the community and the hospital the usual approach is to send the person to the emergency department to see what they can do and if necessary, hospitalize them on a psychiatric unit.  By that time, it is common to see people who have been escalating for days or weeks and the necessary interventions are riskier than they would have been at an earlier point.

In thinking about a more functional response there are two problems – epidemiology and existing laws.  From an epidemiological standpoint there are many studies documenting specific forms of violence and how that individual may have been victimized in the past.  A joint Department of Justice (DOJ) and Centers for Disease Control (CDC) report from 2000 estimated that physical assault and stalking affected roughly 2.9 million women and 3.5 million men every year.  Intimate partner violence affected 1.3 million women and 835,000 men. Getting to the earliest point in that cycle of violence from an epidemiological standpoint seems to be missing.  At least I cannot locate any data.

From a legal standpoint, intervening before there is any physical danger is a highly problematic threshold. And if the necessary statutes exist, there is wide latitude in their interpretation by law enforcement and the judicial system. There has been some progress over the past 40 years but not much.  For example, in the past if a person was threatened – it was common for law enforcement to say they could not do anything because the threat has not been acted upon. That was clearly a suboptimal approach because threats involving lethal force often result in the precipitous application of lethal force. In many cases the lack of a firm limit on threatening behavior encouraged more of it. Contingency based systems also have the tendency to put the responsibility for action on people who have no relationship to the person making the threats.  Even though there has been substantial progress in domestic violence scenarios, it is common for the person being threatened to need to seek a court order for protection and convince a judge that threats or actual violence have occurred. In the case of threats by patients with known psychiatric illnesses, the Tarasoff decision has placed the treating professionals in the position of law enforcement with a duty to inform the person who is being threatened. A clear terroristic threat statute could address all of these issues and provide a path for early intervention.

Since most of my career was in the State of Minnesota, I will be referring to their statutes.  Preparing for this piece, I also read a paper from the University of Pennsylvania Law Review (2) highlighting some of the confusion in this area.  Minnesota, if a health care professional is threatened it is a good idea to inform the police about the threats and present them with any hard evidence (voice messages, emails, mailings, etc).  Laws enforcement who I have dealt with in these situations may refer to the threat as a “terroristic threat”. That is defined in Minnesota Statutes (3) as:

Threaten violence; intent to terrorize. Whoever threatens, directly or indirectly, to commit any crime of violence with purpose to terrorize another or to cause evacuation of a building, place of assembly, vehicle or facility of public transportation or otherwise to cause serious public inconvenience, or in a reckless disregard of the risk of causing such terror or inconvenience may be sentenced to imprisonment for not more than five years or to payment of a fine of not more than $10,000, or both.”

I have highlighted the relevant section of the statute. Minnesota legislation appears to cover both the individual case as well as larger scale incidents that would typically be equated with terrorism.  This statute allows law enforcement to exercise some judgment in dealing with threatening individuals.  For example, they can go to that person and say that if they persist, they will be arrested and charged with making terroristic threats. No other action is required by the person being threatened. In many cases that is a definitive intervention and no further action is required.

The paper by Flanders, et al looks at various scenarios that have occurred in the context of the current COVID-19 pandemic.  Their basic argument is that much of the mayhem created during the pandemic would not reach the legal standard of terroristic threats and if charges were required – they could occur under other statutes such as disorderly conduct or harassment. They are using a standard suggested by the American Law Institute Model Penal Code that includes the following:

A person is guilty of a terroristic threat if he threatens to commit any violent felony with the intent to cause evacuation of a building, place of assembly or facility of public transportation, or otherwise to cause serious public inconvenience, or in reckless disregard of the risk of causing such inconvenience.”  (2)

Note the difference with the Minnesota Statute – there is nothing about threatening with intent to terrorize another.  It is more about violent felonies that disrupt the public.  The authors in this case go on to specify the elements of terroristic threats in their “core case” model as consisting of a credible threat, use of a dangerous weapon, targeting the public or government, and the intention to create a panic or forced evacuation (p. 68).  They illustrate how this model statute has been modified and adapted in other states. I am not a legal scholar but to me – the model statute is missing one of the prime elements of terrorism – the intent to kill and injure people. The way it is written seems to make this implicit and secondary to disrupting the public. The public is disrupted because of their fear of being killed or injured. The Minnesota statute covers both cases by including the element of the individual being threatened.

Whether you are a health care professional or a member of the public, this is the level of protection from threats that is needed. Even then there is no guarantee that there will be a successful intervention by law enforcement. The person making the threats needs to be identified and the police need probable cause to intervene.  I have seen it work well even if no arrests or emergency holds are placed. Most importantly it creates clear boundaries between the police, the person being threatened, and the person who is threatening. The responsibility for action is no longer on the person being threatened.

There are also potential benefits in terms of earlier intervention in the case of psychiatric illnesses associated with threatening behavior.  There is a current awareness that crisis intervention services may be a better early option than the police and that may be a better early intervention.  The epidemiology of threats needs additional work.  My speculation is that there are tens of thousands of people who are trying to live every day with these kinds of threats.  They are a disenfranchised group whose needs have only partially been addressed by domestic violence and civil commitment laws.  A more functional terroristic threat statute like the one in Minnesota could result in early intervention and providing significant relief from that stress.

And finally early intervention can provide relief to many of the people I treated in inpatients settings for 22 years.  They were generally suffering from severe psychiatric disorders and substance use problems. I saw most of them recover to the point that they regretted the aggressive and violent behavior and were appreciative of the treatment they received to resolve that problem. It is easy in our society to view these folks as hopeless and as outcasts – but every acute care psychiatrist knows that is nonsense. The first step in making a societal change is to get the message out that violence and aggression can be treatable problems and earlier treatment generally leads to better outcomes.  More functional and comprehensive laws on aggressive behavior are a part of that.

 

George Dawson, MD, DFAPA

 

Supplementary 1:

A better terrorist threat standard also may also serve to improve the likelihood of early firearms interventions.  Just from news reports the main obstacles seem to be a combination of easy gun access, gun extremist rhetoric, the ability to avoid background checks, legal action to defeat any gun access legislation, and extraordinary efforts necessary by law enforcement to restrict gun access to individuals who are either at high risk or proven risk based on their recent behavior. If a person meets a statutory terroristic threat standard - that could trigger red flag laws or laws to block or remove gun access at the local level by statute.


References:

1:  Tjaden P, Thoennes N.  Prevalence, Incidence, and Consequences of Violence Against Women: Findings From the National Violence Against Women Survey, Research in Brief.  Washington, DC: U.S. Department of Justice, National Institute of Justice, 1998, NCJ 172837.

2:  Chad Flanders, Courtney Federico, Eric Harmon & Lucas

Klein, “Terroristic Threats” and COVID-19: A Guide for the Perplexed, 169 U. PA.

L. REV. ONLINE 63 (2020), http://www.pennlawreview.com/online/169-UPa-

L-Rev-Online-63.pdf

 

3:  Various MN Statutes:

 

609.713 THREATS OF VIOLENCE.

https://www.revisor.mn.gov/statutes/cite/609.713

 

609.79 OBSCENE OR HARASSING TELEPHONE CALLS

https://www.revisor.mn.gov/statutes/cite/609.79

 

609.795 LETTER, TELEGRAM, OR PACKAGE; OPENING; HARASSMENT

https://www.revisor.mn.gov/statutes/cite/609.795

 

609.749 HARASSMENT; STALKING; PENALTIES

https://www.revisor.mn.gov/statutes/2022/cite/609.749

 

Graphics Credit:  Tim McAteer, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons.  Page URL:  https://commons.wikimedia.org/wiki/File:SWAT_team.jpg


Saturday, December 31, 2022

The Rights Versus Treatment Debate

 


Just yesterday I coauthored a brief opinion piece on the issue of civil commitment and the issue of rights versus treatment (2). My co-author Mark L. Ruffalo had the great idea to initiate our commentary based on a letter from the late Darold A. Treffert, MD who was then the Superintendent of Winnebago State Hospital in Wisconsin. Dr. Treffert was also an expert on autism and savant syndrome.  I heard him speak on that topic about 15 years ago at the Door County Summer Institute.  His letter (2) was both a statement about the need for legal intervention and a call to action. In the final line, he attempted to solicit negative experiences from other physicians about a civil commitment process that erred on the side of rights rather than recognition of severe problems and treatment and the resulting problems.

Historically this letter came around the time that antipsychiatry forces were building and one of their main talking points was that there was no such thing as a mental illness.  People simply had “problems in living” and therefore no medical or legal intervention was necessary.  Certainly not a legal intervention that resulted in the deprivation of civil liberty.  The antipsychiatrists and liberty advocates failed to recognize the problem of severe mental illness and the associated lack of problem recognition and impaired decision making.  Those impairments greatly compromise any person’s ability to negotiate the world safely and take care of their self. The usual examples include suicidal or aggressive thoughts and behavior.  They can also extend to routine medical care and activities of daily living.  As an example – a person with severe mental illness may no longer see the need to take insulin for diabetes, or blood pressure medications, or anticonvulsants. That can precipitate a medical emergency in addition to any existing psychiatric emergency.

In Dr. Treffert’s letter, he mentions that the Wisconsin Supreme Court set a new commitment standard of “extreme likelihood that if the person is not confined he will do immediate harm to himself or others.”  Imminent likelihood became an impossible standard in many cases. Even if a patient had attempted suicide or assaulted someone, at any point during a one or two week court process – they could make the argument that the imminent danger had resolved – even if they were refusing treatment and continued to have severely impaired judgment. In that case what frequently happened was that courts experimented with rapid dismissals of commitment petitions – until there is a catastrophic outcome.  At that point they become as cautious as the physicians involved in assessing and treating the patient.

The dangerousness standard for commitment has additional unintended consequences. It functions as a de facto hospitalization standard. It is common that managed care companies deny payment for admissions or even continued stays in the hospital based on the imminent danger statute even in patients being treated on a voluntary basis. The applicable standard in this case should be an adequate treatment standard – also a quality standard.  It is highly likely that any patient admitted after a suicide attempt or episode of severe aggression will continue to have that problem if they are discharged without adequate treatment. Adequate psychiatric treatment generally takes much longer than typical 2-to-3-day crisis hospitalizations. As a de facto standard in the managed care era, it is also easy to discharge a patient who is uncooperative with care by documenting the resolution of the imminent crisis and discharging them rather than working on relationship building and a plan based on a therapeutic alliance. The adversarial legal standard becomes an adversarial medical process. 

Imminent danger standards also fail to recognize forensic populations, the subgroup of people with severe mental illness who have a pattern of violent crimes and have a chronic risk of violent and aggressive behavior. This group of patients often cannot be treated in the same setting as other patients with severe mental illness, and require treatment in forensic settings with adequate staffing and protections for both patients and staff. That segregation can also occur at the community hospital level, where just a few hospitals have psychiatric units and fewer have units that are designed to contain aggressive behavior. Aggression and violence in psychiatric settings is so stigmatized that its existence is commonly denied unless someone is trying to make a political argument that involves blaming societal violence on psychiatric patients.  Even then there are counterarguments that it does not exist. I have been advocating the position that violence and aggression secondary to mental illness are public health problems that should be addressed at that level for at least 20 years.  During that time, I have not seen a single public service announcement with that message.  Instead, the political and legal system continues to ignore that approach by flooding the country with firearms, closing many if not most community mental health centers, closing supported housing, and failing to provide affordable housing.

The response from journalists is not much better – ranging from overt misinformation about psychiatry and mental illness to the occasional human-interest story. The people who know the most about the problem – psychiatrists, social workers, and case managers are left out of the loop in favor of the most convenient critic. Journalists seem unaware of conflict of interest of many of their recruited experts and do not apply the same standard that they would for a psychiatrist.  Journalists and politicians also promote widespread cannabis use and in some cases legalization of many drugs that all pose serious health risks to psychiatric populations.  It is as if saying that out loud is bad for business and tax revenues.  

The humane aspects of involuntary treatment are often turned on their head in the rights versus treatment debate.  Is it more humane to keep persons with mental illness circulating between short term hospital with minimal to no treatment, jails, and homelessness because they do not recognize the problems they are having and fail to come up with solutions, or is it more humane to offer involuntary treatment?  Context is very important.  In my experience, during involuntary treatment – therapeutic alliances occur as it becomes evident that the treatment providers are helping the patient survive better. People with impaired insight and judgment require evidence that they are being helped and that is generally a turning point in the process. If a person is homeless, the evidence has to be provided right where they are – on the street.  That requires active outreach by treatment teams. Ideally that can happen before any crisis occurs that may lead to civil commitment and involuntary treatment. But even if the patient is committed active intervention to support them outside of institutional settings is possible.  This method of community psychiatry and community support has been around since it was invented by Len Stein, MD and Mary Ann Test, MSW in the 1970s. I was fortunate enough to have been supervised by Dr. Stein during residency and one of the key concepts was “the money has to follow the patient.”  In other words, the money used to finance extended state hospital stays had to be used to treat people in the community and provide them with their own housing.  This was a model to maintain people disabled by severe mental illnesses in their own housing.  The other elements included active outreach and 24/7 availability of staff to help them resolve any crises. That basic model has been around for 50 years and it is rarely implemented and only recently discussed in mainstream medical journals.

The primary reason we have a problem with both homelessness and untreated chronic mental illness in the United States is economic. The managed care model of health care administration showed how easy it was to deny and ration psychiatric care to make money.  That model was sold based on increased efficiency and cost containment – but at this point it is obvious that it does neither. It does reroute funds to pay for a massive increase in the number of administrators at both the private and public levels.  These administrators are largely focused on enforcing the rationing of care instead of providing quality care. In fact, the real onset of managed care heralded the total disappearance of quality metrics in medical care. Quality was no longer monitored by external agencies.  It was internalized in managed care organizations. The focus went from adequate treatment of a problem to how quickly a person could be discharged to maintain profitability under an unrealistic reimbursement system.  That approach is a disaster for acute care psychiatry, community psychiatry, and it makes involuntary treatment more likely from the resulting chronicity. It has also been a major frustration for outpatient psychiatrists trying to get hospital access for their patients in crisis. But the economics are generally swept under the rug or discussed at a superficial level by the critics.

At the community level, rather than active outreach by trained mental health staff most communities end up using law enforcement or other first responders with minimal to no mental health training. In most communities they are the only staff available on a 24/7 basis and that is also a funding issue. There are situations where the police do need to be involved in a mental health crisis, but that is far less common than the need for mental health intervention.

What are the solutions? I have written about many on this blog over the years. At the top of my lost today is just moving past the rights versus treatment debate. It has been a stalemate for 50 years while the entire system of care has collapsed due to rationing. The rights have been adequately safeguarded for decades and arguments about abuses before that time are irrelevant. What do I mean about adequate safeguards? In the state where I worked, there was a prepetition screener, a prepetition screening team (to discuss the merits of commitment and whether the patient met statutory requirements), 2 court appointed examiners, a defense attorney, a country attorney, a probate court judge, and if necessary, a substance use assessor.  That is about 7-10 people independent of the treating staff and any one of who could disagree with the commitment process.  I am not aware of any legal process that provides more safeguards.

On the treatment side, there is a legal concept called least restrictive treatment. That simply means a treatment setting where the person is free to come and go as they please rather than being in a facility where they either can’t leave or have to ask for permission.  The goal of the Stein and Test model was to maintain people in their own apartment – the least restrictive of all. That is a goal that any functional system should aspire to.  When we hear about the homeless problem only a fraction of those folks have severe mental illnesses.  Another fraction has substance abuse problems. The obvious solution is a housing first option that may include social support or in the case of mental illness case management services with active community psychiatry outreach.  The first step is not transport to emergency departments and admission to psychiatric units.   

Another unmentioned dimension on the treatment side is well trained and motivated staff.  Police officers do not choose a career in law enforcement because they are interested in communicating with and treating people with severe mental illnesses. Mental health staff do.  Communication and relationship building goes a long way toward defusing a crisis and preventing involuntary treatment.

Addressing the dilapidated psychiatric infrastructure is the final step. The issue of psychiatric beds is a chronic problem with the ongoing political rhetoric that no more are needed compared with needs analyses based on bringing the length of stay (LOS) of psychiatric patients in the emergency department to the same LOS as medical and surgical patients. On that basis – there are very few places in the US with adequate psychiatric beds.

By far – the single most detrimental factor has been the managed care model of rationing in health care systems and by the states. Denying care will always be more cost effective than providing care.  It is also a good model for generating profits. Much of that early profit was made by shifting the cost of effective care for serious mental illnesses away from subscriber-based health care systems to state funded systems – at least until the states adopted the model for themselves. Any serious discussion of the rights versus treatment debate needs to start at that point. Involuntary treatment and civil commitment will never be a solution to the problem of homelessness or the revolving door of people with severe mental illnesses getting inadequate treatment.

I wish that I could end the year on a more positive note but things seem very grim out there. We are still in the midst of a pandemic that has showcased how susceptible the public is to misinformation and political manipulation.  I can't help thinking that this has been the state of affairs in psychiatry for the past 50 years and this post is some of that evidence.  I am hoping that we can see the rise of some leaders in psychiatry to counter these trends - just as we have seen experts in virology and engineering counter the coronavirus misinformation.  But it seems like it will take a lot more than that.

Here is hoping for a better year in 2023 and beyond!

 

George Dawson, MD, DFAPA

 

References:

1:  Ruffalo ML, Dawson G.  Still Dying With Their Rights On, 50 Years Later.  Psychology Today December 30, 2022 Link

2:  Treffert DA. "Dying with their rights on". Am J Psychiatry. 1973 Sep;130(9):1041. doi: 10.1176/ajp.130.9.1041. PMID: 4727765.


Photo Credit:

Eduardo Colon, MD with thanks.


Additional Posts Relevant To This Topic:

 1:  The Problem With Inpatient Units:  Link

 2:   Are There Any Good Jobs Left for Psychiatrists?  Link

 3:  The Bureaucratic Takeover of American Psychiatry: Link

 4:  There Is No Identity Crisis In Psychiatry  Link

 5:  Holding Tank or Psychiatric Unit?  Link

 6:  Medical Care of the Seriously Mentally Ill - The Way It Should Be Provided Link

 7:  Governments and Psychiatric Beds  Link

 8:  The New York Times Steers The Mental Health Conversation in the Wrong Direction  Link

 9:  Bedless Psychiatry and  Recipe for Remaining Bedless  Link

10:  The New York Times Article on Why Mental Health Can't Stop Mass Shooters  Link

11:  My Opinion on Community Mental Health from 1989  Link

12:  Minnesota's Abandonment of the Severely Mentally Ill - Nearly Complete  Link

13:  Treatment setting Mismatches - The Implications  Link

14:  Why There Are No Bipartisan Solutions to Exorbitant Health Care Costs in the USA  Link

15:  A Circular Ethical Argument About Psychiatric Services  Link

16:  The EMTALA Paradox  Link  June 11, 2017

17:  Managed for Mediocrity - Corporate Medicine in the 21st Century  Link

18:  Remission Before Discharge?  An Un-American Concept  Link

19:  Do Businessmen Dream of Medicine Without Doctors?  Link

20:  Americans Can't Do Basic Health Care Arithmetic  Link

21:  The Largest Psychiatric Hospitals in the USA Link

22:  Hospitalists...  Link

23:  A Better Analysis of the Psychiatrist "Shortage"  Link

24:  Just When You Thought American Healthcare Could Not Get Any Worse  Link

25:  Newsflash from the StarTribune - Psychiatric Patients Have Nowhere to Go  Link

26:  Medicine to Psychiatry to Parking Lot:  The Evolution of Detox Over the Past 30 years  Link

27:  Admission, Discharge, and Readmission Policies: No Better Example of Business Driven Pseudoscience  Link

28:  How To Ruin You Life Without Being Dangerous  Link

29:  How the Ruling Class Impacts Your Health Care and Why They Need to be Stopped  Link

30:  Trauma In Psychiatric Hospitalizations  Link



Friday, February 18, 2022

Coercion versus something else?

 


My motivation for writing this post comes from recent activity on Twitter about “coercive care” in psychiatry and an opinion posted there by a psychiatrist suggesting that psychiatrists need to be aware of their role as an agent of the state when they are engaged in involuntary treatment. After seeing this I checked the literature and there were papers published on the subject – so I thought I would write a post about the issue – specifically whether coercion is an appropriate word to use and how it compares to involuntary treatment as a description and a concept.

I don’t consider the issue lightly.  For most of my career I have been in acute care settings that required knowledge and skill in negotiating involuntary care scenarios – specifically emergency holds, probate court holds, civil commitments, conservatorships, and guardianships. That involved hundreds of court appearances in 7 counties and 2 different states.  I also testified as an expert on the issue of prolonged state hospital stays for a patient advocacy organization and testified in both malpractice cases and a criminal responsibility case.  I have personally seen how local politics can affect the civil commitment and conservatorship laws to the point that they are actively ignored for various reasons. In that unstable landscape, the staff responsible for treating the patient needs to be very flexible and innovative to provide the necessary care.  The following graphics show what that care generally looks like.  It is a diagram of how involuntary treatment gets initiated and carried out.

The commonest path is that there is an incident in the community, emergency medical services are activated, and the patient is placed on a hold and transported to the emergency department (ED).  While there an ED physician and mental health clinician (typically a social worker) makes and assessment of the patient and determines if they can be discharged, admitted on a voluntary basis, or admitted on an emergency hold. 

Following the admission, the inpatient staff makes their respective assessments and typically discuss their findings and the plan in team meetings. If the patient was admitted on a timed hold (72 or 96 hours) and a determination is made that the patient cannot be treated on a voluntary basis prepetition screeners are contacted.  They come in and see the patient and collect more collateral information than the inpatient team has access to.  They compile this in a prepetition screening document and in a team meeting separate from the hospital staff (they are typically county employees) make a determination that the hold will be cancelled or they will refer the patient for further court intervention.  If they determine to not support the emergency hold, the patient is typically discharged and it is illegal for a physician to immediately place them on another emergency hold. If they are referred to the court a probable cause hearing is held.  At that point the judge can release the patient or refer for a final hearing.  Before any final hearing, 2 court appointed examiners (typically a psychiatrists or psychologists employed by the county) will see and assess the patient. They will testify in court and give specific treatment recommendations to the court – independent of the hospital staff charged with treating the patient. At the final hearing the patient can again be released with no court intervention based on a judge’s decision. They can also be court ordered to follow treatment recommendations including further hospitalization and medications.  Courts can also accept a stay of commitment – meaning that the patient is not formally ordered to accept treatment for a duration of time but they can accept treatment and follow up and if everything is going well at 6 months any involvement with the court self dismisses.  There is a similar intervention for persons who have been formally committed called a provisional discharge. In that case, the person is discharged with a plan to report back on outpatient progress. The structure of this process highlights the fact that no single person or discipline makes a decision about involuntary treatment. In addition, the statutory requirements for mental illness or substance abuse do not specify any particular diagnosis but depend on whether there is behavior that is self-endangering, harmful to others, or significantly affects the person’s ability to function in their own interest at the most basic level (adequate self-care in terms of food, housing, and addressing significant medical problems).

The question critical to this post is how is this process coercive rather than involuntary?  And is there a difference between those terms?   Just looking at standard definitions coercion is clearly more insidious and it implies malignant intent. The Webster’s definition is “to compel by force or intimidation; to bring about by force; to dominate or control esp. by exploiting fear, anxiety, etc.”  Using the same source, the definition of involuntary is “not voluntary, independent of one’s will.”  At this level, coercion is nothing medical staff are ever trained to do and in fact would constitute a violation of professional ethics.  In psychiatry, the training is focused on helping psychiatrists overcome standard biases that people experience when interacting with others who have clear problems with severe psychiatric disorders.  The entire focus of psychiatric training is developing a cooperative and helpful relationship.

What about legal definitions and statutes pertaining to coercion?  The legal definition of coercion is essentially the same as the dictionary definition:  Verbal and/or physical threats and other forms of intimidation in order to force someone to do something/not do something that they are otherwise legally allowed/not allowed to do.  Laws against coercion in federal statues range from the obvious forms like sex trafficking to threats of retaliation for political activity or exercising rights at work. In all of these cases, the victims of coercion are generally going to be capable of making decisions in their best interest but are unable to make willful decisions due to coercion.

It turns out that an entirely different level of analysis has been applied to the issue of coercion and psychiatric patients. That level of analysis is done by philosophers using thoughts about coercion from previous works on ethics.  For example, Schramme (2) expands arguments from Frankfurt’s work to discuss specific examples of coercion. He begins with the informed consent model.  I consider Gutheil and Appelbaum to be authoritative in this area and they discuss three elements of informed consent: information, voluntariness, and competence (3).  The adequate information is discussed from the perspective of a professional level of disclosure and also a “reasonable person” or the level of information that most people would expect. The expected information varies from state-to-state and in some cases for psychiatry there is a written information standard. For example, in the State of Minnesota, antipsychotic medication consent requires a signed consent form about those potential side effects.  Voluntariness means consent is freely given. It is often assumed that since psychiatric patients are generally considered to be vulnerable adults who may be dependent on institutions that this is a form of situational coercion. Gutheil and Appelbaum point out that this would in effect not recognize the decisions made by large numbers of people in institutions just because of the place they reside. They describe more clearcut and explicit forms of coercion such as threatening the loss of food or clothing if the patient does not follow recommended treatment. Competence means that the patient has mental capacity to understand the information presented and may a make a reasonable decision in order to give informed consent.  Psychiatric disorders can affect all three elements of informed consent.

The philosophical look at coercion is a bit more complex and it is selectively applied to the case of psychiatric care. Just looking at the demographics raises some questions.  There are 1.3 million people in the US under guardianship or conservatorship. At the same time there are 6.96 million people with dementia, 500,000 people with moderate to severe intellectual impairment, 36.25 million with subjective cognitive impairment, and an undetermined number of people with cognitive impairment and impaired capacity secondary to severe psychiatric disorders. Those numbers suggest that there are not nearly enough guardianships in place to provide substituted consent for people during medical emergencies.  In many jurisdictions guardianships and conservatorships have to be pursued by family and that often creates an undue financial burden. In the jurisdictions that actively ignore conservatorships and guardianships – persons needing them often incur unnecessary medical risk because treating physicians realize that they cannot accept their consent to procedures involving risk – like surgeries.

Schramme has analyzed the issue of coercion in the following ways. He breaks coercion down to threats and offers.  For the purpose of his discussion, he states that he is exclusively focused on autonomous choices that are contrary to the will of the patient.  These choices cannot be made under the influence of threats but he outlines 3 scenarios where informed consent is lacking:

1.  A patient is not able to give informed consent – I think he makes a critical mistake here by stating that most psychiatric patients are able to give consent and their capacity is not globally impaired.  It clearly depends on illness severity and the stage of treatment. Most forensic hospitals are charged with the task of restoring competency to mentally ill offenders so that they can proceed to trial.

2.  A patient disagrees with treatment and makes that known but he is forced to accept treatment anyway. The example given is a patient who if forced to take medication because he is potentially dangerous to others. Schramme depicts this as “a conflict between the patient’s will and the opinion of the doctor”.  But where does the dangerousness come in? Why is the patient unable to see that he is at risk from an extremely adverse outcome (aggression and long-term incarceration or injury and possible death due to a confrontation with the police) and not incorporate that into his refusal?

3. A patient passively complies with a treatment recommendation and does not make an overt decision. Schramme states that although this would not typically be considered as coercive treatment – it all depends on whether the consent is given freely or not. The implication is that passive consent is not necessarily informed consent.  Schramme invents the term “interactive coercion” to suggest that psychiatric patients can be coerced by the interpersonal relationship beyond what is typical of medical paternalism. That presupposes that either nonpsychiatric physicians do not have relationships with their patients, psychiatrists are masters at manipulating people, or some combination.

From that point he goes on to provide 3 examples of interactive coercion  

Case 1:  The psychiatrist predicts that “damage or harm” will occur if the patient does not follow certain course of action. This may or may not be coercion. Schramme gives the example of taking away the patient’s cigarettes or writing them a suboptimal report (the damage or harm) unless they comply with the prescribed course of action.  He acknowledges that harm can be predicted due to non-compliance and it may not be a threat but a natural consequence of untreated illness. Prediction of future causal events is a warning and not a threat hence no coercion (p. 360).  On the other hand, he suggests an “unusual” prediction such as electroconvulsive therapy (ECT) if the patient had no previous experience either it would constitute a threat.  The two necessary features for predicted harm to be a threat/coercion would be that it needs to be intentional and unusual.

Case 2: The psychiatrist proposes a “detrimental unusual consequence if the patient does not comply an example of effective threats as coercion. In this case, if the threats are ineffective, they are inconsequential, lead to no coerced decision. Schramme points out that “there is no rigid line between a threat and a warning”. He gives an example of a patient interpreting an action as a threat that may have had more to do with the social roles of patients and nurses on the ward.

Case 3: The psychiatrist offers a beneficial unusual consequence if the patient complies with a specific task. In this case there may be intermediate conditionals. For example, the patient may not be motivated or feel like socializing but forces themselves to do it anyway to get the offer.

Schramme introduces the idea of irresistible threats and offers at this point. An offer becomes irresistible when there is no other real alternative.  In this case even if the choice is voluntary, it can still be against one’s will.  The best example is substance use disorders where the person may not want to take the drug but acts on the drug as an irresistible offer rather than a preferred motivation to remain abstinent. This is an example of an offer that is irresistible and therefore coercive in that it they are against the will of the person.  This is not a hard rule and Schramme emphasizes that all offers are not bad and they depend on the subjective preferences of the patient.  He goes on to develop the idea that “manipulation and coercion – at least in psychiatric hospitals – do not only stem from predicted consequences which bring people to do A, namely that they to prevent bad things from happening.” (p. 367). Instead, he defines it as “an influence on the autonomous will of the patient and not on the welfare of a person”.  He closes by pointing out that institutional and interpersonal dependencies can also result in irresistible offers to psychiatric patients.  He cites some examples that today are irrelevant or exaggerated. For example – giving a patient cigarettes if they take a medication or the offer of a “good report” for group attendance.  I have not observed either of these happening on inpatient units over the course of my career even when smoking was allowed on inpatient units.  Even so, Schramme concludes that these coercive offers are not necessarily morally wrong because “it might be good to sacrifice the freedom of the patient for the sake of his well-being.” (p. 368).  That is more than a trivial distinction and I would argue is the basis of both civil commitment and guardianship or conservatorship.

Szmukler and Appelbaum (4) reviewed the coercion literature to date and described their own approach to the issue of coercion. Their first step was noting that coercion was a loaded term and describing a graduated systems of treatment pressures including:

(1) persuasion

(2) interpersonal leverage

(3) inducements

(4) threats

(5) compulsory treatment (in the community or as an inpatient).

They provide an example of a community psychiatric nurse following a patient in the community and how each of these pressures may work. They develop models based on paternalism and capacity/best interests.  Their definition of paternalism based on previous research is given as:

“…a person is acting paternalistically towards another if his action benefits the other; his action involves violating a moral rule with regard to the other; his action does not have the other's past, present, or immediately forthcoming consent, and the person believes he or she can make his or her own decision on the matter. A paternalistic act requires justification because it involves the violation of a moral rule but with the intention of preventing a harm to the person.” (p. 240)

A series of questions is provided to answer whether or not a paternalistic intervention is indicted.  Answering those questions for a typical emergency admission to an inpatient setting is typically balancing the deprivation of personal liberty against death and disability.  More subtle tradeoffs don’t end up as admissions to inpatient units.

A capacity/best interest analysis is just the way it sounds.  The patient has impaired decision making and is not able to make decisions in their best interest. Best interest has a degree of subjectivity but the authors describe some general guidelines based on previous work. The authors suggest that clinicians need a consistent ethical framework for approaching these problems that is as rigorous as the typical technical frameworks they use in practice.  

“Protection of others” is described as a more difficult problem for Szmukler and Appelbaum largely because of the subjectivity involved. They discuss for example the low percentages of patients with mental illness who are aggressive and the impossibility of prediction. They do not mention that a number of features (acute care settings, acute threats, history of violence/aggression, psychosis, pooling of cases, access to weapons) may greatly increase risk but they are writing from the perspective of community rather than inpatient care. They make an interesting comment: “Mental health professionals may accept an obligation to notify appropriate authorities if there is a serious risk of harm to others, but what is serious and who should instigate or implement coercive responses is a matter for debate.”  (p. 242). My understanding is that there is a duty to warn in every state and the clinician not only needs to make a good faith effort to contact the potential victim and take what other steps may be necessary (eg. calling the police) to protect that person.

With that review, what assures that the term coercion is not just another term used to inappropriately criticize monolithic psychiatry?  The standard dictionary definitions implying malignant intent is certainly consistent with inappropriate criticism.  Schramme acknowledges that there are situations where informed consent cannot occur due to a lack of capacity but goes on to elaborate on treatment refusal where there is probably lack of capacity and consent where the patient interactively coerced by institutional or interpersonal scenarios.  There is a high degree of subjectivity involved in the interactive coercion scenarios.  Schramme seems to approach the problem hypothetically rather than interactively. For example, as a clinical psychiatrist why would I ask if the patient was perceiving a warning or a threat – I would just ask them. In many cases agitated and paranoid patients are spontaneously accusing staff of threats and malignant intent before any assessment or conversation has occurred.

The best way I can think of how to proceed is to post a vignette – in the standard way that they are posted these days – a composite of features noted over the course of 25 years and not any specific patient:

 

Case Vignette

 28-year-old man with schizophrenia and Diabetes Mellitus Type 1 since age 8. He stopped treatment for schizophrenia a year ago. Since then, he has been hospitalized for recurrent diabetic ketoacidosis (DKA) four times and the consult-liaison (C-L) team has noticed progressive cognitive problems. He is discovered by the police in a park at night. The air temp is -5°F/-20°C and he was not wearing adequate clothing (no jacket, caps or gloves). In the ED he is noted to have a frostbite injury of his feet and hands. He requests immediate discharge and states that he will follow up with medical and surgical care on an outpatient basis. He refuses to consider psychiatric care. He denies any hallucinations or delusions.  He is admitted to the burn unit on a 72 hour hold by the ED physician.  Is this coercion?

He is seen the next day by the C-L team. He has some mild cognitive impairment and memory problems.  He is detached and not saying much about why he was hospitalized. His affect is restricted but he does not appear to be depressed. He is requesting discharge but has no clear plan of what he will do when he leaves.  When asked about the diabetes mellitus diagnosis he replies: “I can’t have it because I don’t have a pancreas.”  The C-L team recommends referral to inpatient psychiatry and proceeding with a probate court referral.  The team speaks to a family member there who talks at length about the family’s concern for the patient’s safety and their relief that he is hospitalized. Is this coercion?

This is a realistic description of how patients are admitted to acute care hospitals. The police officers in this case call EMS and the patient is assessed by paramedics. The patient is taken to a local emergency department where he is seen by a physician and a social worker and admitted. In this case an involuntary hold is initiated by the police or by the ED physician. A psychiatric diagnosis per se is not required since the statutory definitions of mental illness are based on impaired judgement that endanger the person or their health.  Independently 6 people (none of whom were psychiatrists) agreed those conditions existed.

He is seen and treated by surgery staff. He passively goes along with treatment but there are obvious concerns about his capacity. Is this a case of “interactive coercion” by surgical staff per Schramme’s formulation? He is non-disclosing with psychiatry staff but the key observation is that he no longer believes he has diabetes because he no longer has a pancreas.  This is not a basis for adequate medical decision making or self-care and that is further documented by his 4 episodes of diabetic ketoacidosis, continued inability to manage this condition and the question of cognitive impairment after episodes of coma. This patient is referred for civil commitment and will be seen by pre-petition screeners (typically one screener but a team of 4-5 people make the decision), a defense attorney, 2 court appointed examiners, and a probate court judge.  A total of about 9 people are involved in a process to determine if the patient meets statutory requirements for civil commitment and whether treatment should be court ordered.

Looking at the formulations of both Schramme and Szmukler and Appelbaum is instructive.  The probate court proceeding that I describe is clearly a safeguarded capacity/best interest scenario. The patient clearly lacks the capacity to make an informed decision and consent on the basis that he no longer recognizes that he has diabetes or that it needs to be treated despite life threatening consequences. It is very clear that he would not get adequate treatment of diabetes or the frostbite injuries if he was not hospitalized, observed, and actively treated. By their formulation they would say that maximum treatment pressure is exerted by compulsory treatment. In the final analysis, the ethical issue is that the patient is being deprived of his right to continue to wander the streets without adequate clothing or medical treatment for the compulsory treatment.  Apart from a magical immediate restoration of capacity is there a better short-term solution that is better designed to protect his rights? I don’t see any.

An additional consideration is the issue of agency on the part of the inpatient psychiatrist.  That psychiatrist has a fiduciary responsibility to the patient. That involves discussing all relevant aspects of diagnosis and treatment with the patient, including the concerns about his ability to care for himself. Is that psychiatrist and agent of the state or as some philosophers like to put it – the will of the state is being enacted though that psychiatrist? Definitely not and here is why – the will of the state is transacted through the commitment court and all of those personnel.  The treating psychiatrist is unnecessary for the commitment proceeding and the court is focused on what their examiners conclude.  Psychiatrists have no personal stake in whether somebody is detained in a hospital by a court order. In fact, without a court order it is an unlawful detention subject to both criminal and civil penalties.  Over the years I have had to discharge many people because the court did not produce a timely court order or decided to release the patient.  Further, in the actual hearing the opinions of the court examiners are the ones the judges depend on. The only interest of the inpatient psychiatrist is making an accurate assessment, making sure all of the patient’s medical problems are treated, and making the optimal recommendations for medical and psychiatric care. The inpatient psychiatrist is also talking with the patient on a daily basis assessing progress and attempting to establish a good working relationship with the patient whether or not a court hold is in place or not. That working relationship is possible when the patient recognizes that there is no adversarial relationship with the inpatient psychiatrist. In fact, the treatment of patients on court holds should be indistinguishable from voluntary patients.

By Schramme’s formulation that patient is not a competent consenter. As noted about his passive cooperation with the burn surgeons, endocrinology, and the inpatient psychiatrist might be construed as interactive coercion. There is also a chance that it might not be according to these definitions because the psychiatrist is discussing adverse outcome with the patient but the discussion is based on what has happened many times already.  Even with compromised cognitive capacity the patient is able to acknowledge this and the fact that he does not want to end up in a coma in the ICU gain. Another important aspect of these discussions is the psychiatrist is very neutral and not reactive or blaming. They are a sincere expression of concern given everything that is going on an what has happened to the patient.

A final consideration here is that both philosophical and legal approaches to involuntary treatment probably do not capture what is really happening. For example the will  or the autonomous will is the focus of both the coercion and the involuntary treatment discussion.  Reading though any paper on the will, illustrates that it is a vague, changeable, and completely subjective concept.  It is also not constant over time. When philosophers like Schramme write about it – the are typically referring to an individual and not a class of people. It makes more sense to talk about a person’s conscious state rather than an isolated will.  Conscious states are complex and multidimensional (6).  Even though they cannot be accurately measured at this point – on a clinical basis it can easily be observed that conscious states can change from being adept at self-care and day to day living to states where inadequate self-care becomes self-endangering. It makes very little sense to think that the will or autonomous will of a person experiencing a major psychiatric illness is constant over time. The goal of treatment ideally is to restore the autonomous will and assist the patient with getting back to their baseline.  I have had that confirmed many times by people who benefitted from that process.

 

George Dawson, MD, DFAPA  

 

References:

1:  Bureau of Labor Statistics. Occupational Employment and Wages, May 2020 29-1223 Psychiatrists https://www.bls.gov/oes/current/oes291223.htm

2:  Schramme T.  Coercive threats and offers in psychiatry. In. Schramme T, Thome J (eds). Philosophy and Psychiatry. Walter de Gruyter; New York; 2004: 357-369.

3:  Gutheil TG, Appelbaum PS.  Clinical Handbook of Psychiatry and the Law, 3rd edition. Lippincott, Williams, and Wilkins, New York; 2000; p. 153-162.

4:  Szmukler G, Appelbaum PS. Treatment pressures, leverage, coercion, and compulsion in mental health care, Journal of Mental Health. 2000 17:3, 233-244, DOI: 10.1080/09638230802052203

5:  Walter J. Consciousness as a multidimensional phenomenon: implications for the assessment of disorders of consciousness. Neurosci Conscious. 2021 Dec 30;2021(2):niab047. doi: 10.1093/nc/niab047. PMID: 34992792; PMCID: PMC8716840.

 

Supplementary 1:  Workforce exposed to involuntary treatment scenarios:

There are an estimate 30,451 working psychiatrists in the United States. According to the Bureau of Labor Statistics 25,540 are employed and the rest are self-employed.  Since it is very likely that acute care psychiatrists are employed by hospitals 4,160 are in General Medical and Surgical Hospitals and 3,550 are in Psychiatric and Substance Use Hospitals. There are currently 37,400 members in the American Psychiatric Association and that number may reflect researchers and the retired.  The total pool of psychiatrists who might be involved at some level in involuntary treatment is about 7,710 from the acute care setting but that is likely a gross overestimate for several reasons. First, not all acute care settings treat people on an involuntary basis. In any metro area emergency medical services (EMS) generally brings the patients to only those hospitals who can provide the full array of emergency services. Second, even among psychiatrists employed in hospitals only a small percentage of them will provide direct care to patients who are there on an involuntary basis. Third, there are very few free-standing psychiatric hospitals or substance use facilities that accept anyone on an involuntary basis. It is very likely that less than 10% of the psychiatric workforce ever provides treatment to people on an involuntary basis.   

Supplementary 2: Graphic modification to show the emergency hold and probate court hold





Supplementary 3:  Historical note

Although the patient is clearly safeguarded in the above process - some people might ask themselves: "Why don't we just abolish involuntary treatment and let things revert back to the way it was?"  It would certainly make things a lot easier for psychiatrists. The short answer is that it is inhumane to people with severe mental illness and their families.  The families are typically omitted from any discussion of involuntary treatment but historically they were charged with trying to contain a family member with severe problems.  Patients in those situations often had catastrophic outcomes and even if they did not entire generations of family members were adversely affected by single family members with severe mental illness.  That history is out there but it is difficult to find probably because of the stigma associated with those disclosures.

   






Monday, October 3, 2016

Psychosis Idealized





I thought I would provide a counterpoint to the New York Times editorial entitled "Medicating A Prophet" written by Psychiatrist Irene Hurford (1).  The opinion piece is available free online and I encourage anyone interested in the topic to read the article rather than accepting my summary here as adequate.  I will say from the outset that I am not a stranger to any of the issues that Dr. Hurford discusses either clinically or personally.  The bulk of my career was spent treating people with severe mental illnesses and addictions.  Once you have worked in that setting, it is clear that many people who are severely ill need involuntary treatment and that is one of the decision points that she addresses.

In her essay, Dr. Hurford describes an early call experience during her residency.  She was asked to assess a man in the emergency department (ED) who had been delusional for 30 years.  The delusions were religious and grandiose in nature.  He was a college graduate but was homeless living on the street in Philadelphia.  He also had AIDS and the complication Kaposi sarcoma.  His reason for being in the ED was "to preach".  Dr. Hurford encourages him to come in for voluntary treatment but he refuses.  At that point she ponders involuntary treatment but in the essay decides to discuss the patient's right to psychosis. Later we learn that she made the decision but has decided to analyze that decision in retrospect based on factors that she has encountered since.

One of those factors was the influence of a professional colleague who based on her own experience with psychosis and that colleague's mother's experience suggested that thoughts about living "in psychosis" and outside of psychosis need to be challenged.  She basically states that the problem may be within the beholder rather than the identified patient. Following that logic, it makes sense to show up in an ED to preach while ignoring serious health problems.  It also makes sense to make decisions about the person's "in psychosis" experience knowing so little about them.  In my experience, nobody in the ED calls the parents or family of a 50 year old street person, to get a clear picture of how the psychosis has truly affected him.  When I have treated these people on an inpatient unit and made those calls, I have never heard that the patient was well served by the psychosis.  Not a single time.  In many cases, family members were surprised to hear that person was still alive.

Dr. Hurford advances a number of other arguments that I call into question.  She uses a very loose definition of insight as a "failure to accept an alternative view of reality".  She turns this around to suggest that anyone who does not accept this premise (implicitly the treating physician) also lacks insight.  I don't think that you can practice psychiatry and not be comfortable with alternative realities.  I would suggest a more appropriate definition of insight as a decision-making process.  Can I accurately assess how I am doing in the world?  Am I making decisions in my best interest?  Are those decisions consistent with my ability to survive?  If I realize that I am not doing well can I get help?  Pretty basic decisions.  Not a question of lifestyle choices.  To have a lifestyle you have to live.  That is the kind of insight that I am used to dealing with.

Dr. Hurford discusses a case of a young patient with a psychotic disorder who stopped taking his medications and started using cannabis on  daily basis.  He dropped out of college and became progressively incoherent and then mute.  She is concerned about traumatizing the patient by "enforcing" treatment even though he cannot "eat, sleep, and talk."  I don't follow the logic that some treatment intervention - even basic detoxification from cannabis is somehow more traumatic than not eating, sleeping, or being able to communicate.  How is that a preferred alternative existence?

At that point she digresses to a very brief overview of the usual comments about mental illness being only peripherally associated with violence and the lack of evidence that forced treatment led to fewer hospitalizations, arrests, or a better quality of life.  She cites a meta-analysis of three randomized-controlled studies of more than 700 people.  There are a lot of reasons why meta-analyses are not superior to the actual trial data.  There are also a lot of reasons why truly clinical samples with these problems cannot be ethically randomized or included in the studies.  There are also reasons why I would expect the entry points into these studies to be highly variable as well as the treatment resources that are involved.  In Minnesota, we have 87 counties and the rule is that there are 87 interpretations of the commitment act for involuntary treatment.  There are two corollaries operating here.  The first is that the courts will be very liberal in terms of dropping commitments until something bad happens.  At that point the pendulum swings back in the direction of more frequent commitment.  The second is that only the wealthiest counties in the state can afford to provide adequate resources to treat the severely mentally ill.  Even then there is no assurance that the counties that can afford it will actually provide the care.  Some currently function like managed care companies and ration the care.  They can end up rationing care and commitments in order to save the county money.  The lack of evidence that forced care does anything may be more of an indictment of the lack of quality or consistency in delivering care and interpreting the law  and rationing care more than anything.  I have personally treated many times the number of people with forced treatment than in the meta-analysis and there is no doubt that the outcomes were better than with no treatment.

The outcome variables cited by Dr. Hurford are also dreadfully lacking compared with what can be seen routinely in clinical settings.  They include very adverse outcomes in encounters with the police including getting shot, dying from a treatable illness, suicide, loss of relationships with spouses and children, loss of a job and income, and acute loss of life due to poor insight and judgment.  In Minnesota, all that takes is going outside in the winter time without adequate protective clothing and you are dead or in the Burn Unit with frostbite.
     
Right now we are in the midst of a sweeping cultural change that idealizes psychosis and suggests that hallucinogens and cannabis are therapeutic drugs.  That will put the next generation or two of people with psychoses, mood disorders, and substance use disorders at risk for chronicity and every possible negative outcome.  A point that should not be lost on anyone is how no care for psychosis is "cost-effective" care when the total impact on the patient is ignored.  My point in writing this rebuttal is really advice for the people in these generations.  Ask any psychiatrist treating you or your family member where they stand on this issue.  

Especially if you value psychotic symptoms a lot less than your psychiatrist does.



George Dawson, MD, DFAPA





References:

1.  Irene Hurford.  Medicating A Prophet.  New York Times.  October 1, 2016.