Recovery model vs. forced treatment
May 13, 2006
I have been off-line for a time since my wife Julie Kipp and I just moved to our new home (backbreaking & exhausting work-but well worth the efforts).
I thought I would contribute to the discussion (recovery & forced treatment) on the complexities of the disorders we call schizophrenia & bipolar disorder by a recent example from my practice.
I have been seeing a young man off and on for many years whose family manages to get him hospitalized against his will plus placed on AOT (assisted outpatient treatment-aka Kendra's Law) even though he is definitely not a danger to himself or others (no history or even reported ideation of violence against self or others-and he can take care of his needs except he used to rely on his family for financial support). He was forced to take second generation antipsychotics even though his delusions had already ceased. He is no longer delusional and is less socially isolated. He is able to speak of his delusions and OCD symptoms asmeaningful and serving functions for himself. He wishes his family would see his delusions as something not to be too anxious about-his mother's intense anxieties (she is a first generation Holocaust survivor-at the age of 4 she had to be hid in the woods with a strange family & separated from her family) make him more anxious. He has a mentally ill father with whom he is in good contact-often taking care of his needs (he is the only one in his family who has contact with his mentally ill father-the mother's utter avoidance of him-I think may increase my patient's anxieties-if one has mental problems one can be thrown out of the fold so to speak-as Post-Kleinian psychiatrist Roger Money-Kyrle believed-the mentally ill person can become the container for the madness of the society and family -- exportation to the state hospital can sometimes be a situation of 'out of sight-out of mind'-one's own madness is externalized and then one is in a better position to avoid contact with such madness).
He secretly stopped his meds as soon as he got out of hospital and for the next 6 months he had to report to an AOT team who monitored his compliance with the meds. He was never able to tell them that he discontinued the meds as soon as he was discharged out of fear of being taken to the ER for an evaluation. The usual take on this "noncompliance" is that it is lack of insight due to the illness (what I would like to know is who is the one
who lacks insight? aren't we providers also lacking insight? especially if we do not take the time to get to know our patients at a deeper level than "How are you doing?" "Any side effects from the meds?" "Are you showering and eating right?"- these are good questions and can convey the message that someone actually cares-but this work requires deeper forms of personal involvement-the AOT team never really got to know him-it's hard to open up to persons who have such significant power over oneself-I remember RD Laing saying that on the ward it's important to realize that you hold the key to the door-not the patient-that fact speaks a thousand words). When my patient would go for his weekly 'check-in,' he would be told "see how the meds are working-you are no longer delusional." He was afraid to tell them that he was not taking the meds. After the six month period expired, he was discharged from AOT, but placed on a more informal monitorring intervention, in which he had to check in with a case worker on a weekly basis and a psychiatrist on a monthly basis.
He and I believe that his civil rights have been violated without due cause. It would have been a different situation had the AOT team been open to other forms of intervention.
Another of my patients has a family member in the mental health field who is quite controlling-to the point where any odd symptoms are reason for the psychiatric alarm to go off-a trip to the ER to see if he needs adjustments in his meds or hospitalization. There clearly is a power struggle going on between him and this immediate family member. The latter sees his symptoms as residing within the patient-a 'one-body' approach, rather than seeing the relational aspects of these symptoms (which are quite significant-involving passive-aggressiveness and identification with the aggressor). This individual has developed Type II diabetes as a result of chronic use of second generation antipsychotics (as have patients with whom I worked at a state hospital-I wonder if the latter are represented in the lawsuits against the pharmaceutical companies-poor, marginalized patients often do not have access to the information and support they need to ensure their civil rights and secure reparation to harm done to them-harm that was accidental-but harm nevertheless).
Acutely, meds may prove very helpful to many individuals, but not to others. The question of maintenance medication has never been scientifically resolved. There are conflicting research findings on this issue. There are many who believe chronic exposure of antipsychotics may actually make the person more vulnerable to repeated psychotic episodes due to the up-regulation of dopaminergic neurons in the mesolimbic pathways (and many other iatrogenic changes)-sometimes referred to as supersensitivity or rebound psychosis. We simply do not have the research base to justify making all of our patients chronically ingest chemicals that may actually be harmful to them-there certainly are cases where the treatments may prove to be worse than the disorder itself. Recent research reported from the University of Illinois Medical School (20 year follow-up study) showed that the patients who came off their meds were the very patients who did better. I believe this was Manfred Bleuler's observations as well-a finding I believe also reported in the Vermont Longitudinal Study. The WHO studies demonstrating better outcomes in Africa, India, and South America (by an almost 50% margin) than in Western Europe & America are also suggestive of psychosocial factors as being key to recovery. I will soon post an updated summary of the world literature on recovery rates (data which is a good antidote to therapeutic nihilism).
Brian Koehler
Postdoctoral Faculty
New York University
