Involuntary Psychiatric Treatment

I had a thought of rummaging through all my posts on psychiatric topics over the years and linking to the best of them, but there are over a hundred, and I don’t like reading my own work all that much sometimes. I narrowed it to a single topic and picked three recent posts that are connected. The psychiatrist Scott Alexander over at Slate Star Codex reviewed the book My Brother Ron, and I discussed and rediscussed on it at my own site. I got good comments as well.

My Brother Ron
Update on My Brother Ron
Update II

A fourth post is on the closely-related topic of guardianship over psychiatric patients. Guardianship and the Behavior of Nations.

I may also post on my Underground DSM, Wyman’s Oppositional Treatment, and other fun things in the future.

8 thoughts on “Involuntary Psychiatric Treatment”

  1. Good review.

    I am interested in why you might be generally opposed to commitment. If I have this backward, and you are actually in favor of more commitment, I will only point out that hospital care is already a large part of state budgets, and we would need 10 times the hospitals. It is labor intensive.

  2. Mike K…”He taught me to talk to the sane part of the patient and ignore the “crazy” part.”

    Interesting thought. I wonder if this approach is applicable to day-to-day conversations? To political conversations?

    Could you expand a bit as to how one goes about addressing the sane part?

  3. The 70-something brother of an acquaintance of mine is schizophrenic. As I understand the story his schizophrenia was under control until he was either widowed or divorced and stopped taking his meds. Then he became a menace to himself and others, and was subjected to occasional brief institutionalizations for observation, during which he was medicated and his behavior became normal. But it was impossible to keep him institutionalized or medicated. Eventually he got caught breaking into a house and is now in jail where his schizophrenia gets treated. I gather from my acquaintance that the people who were involved in his brother’s case were relieved that they finally had a way to compel him to get treatment.

  4. If I have this backward, and you are actually in favor of more commitment,I will only point out that hospital care is already a large part of state budgets, and we would need 10 times the hospitals. It is labor intensive.

    What is your estimate of the percentage of the prison and jail population that is psychotic ?

    Here is one estimate.

    More than two-fifths of State prisoners
    (43%) and more than half of jail inmates
    (54%) reported symptoms that met the
    criteria for mania. About 23% of State
    prisoners and 30% of jail inmates
    reported symptoms of major depression.
    An estimated 15% of State prisoners
    and 24% of jail inmates reported symptoms
    that met the criteria for a psychotic

    That’s pretty expensive, too.

    Could you expand a bit as to how one goes about addressing the sane part?

    I spend some time on it in both my books but especially the “War Stories” one. This was after the early anti-psychotic drugs but before the modern ones. The patients were not violent or shouting or indulging in the behavior one sees on the street.

    I had conversations with psychotic men who could describe the sensation of having delusions, for example. At times they knew the delusion was not real.

    With others, and I relate one example of a man I called “Roy,” who was grossly psychotic and talking in a sort of “word salad.” When talking to him, I could figure out some things he was trying to say and when I responded to what I thought he was trying to say, he agreed that I was interpreting him correctly. At the end of my summer period, he came to me to tell me how much he enjoyed our talks and told me that his mind was like an iceberg. The more we talked, the more it rose out of the water. It was an eerie conversation I have never forgotten

    It’s been over 50 years and I don’t recall the exact conversations but, with time, we seemed to be able to communicate better. It was exhausting to do this and I would come home at the end of the day drained.

    Some of the methods were in Glasser’s book, “Reality Therapy”

    Glasser was one of Harrington’s UCLA residents and the book was recommended in the LA schools at one time when Los Angeles was interested in teaching. It was recommended as a way to deal with difficult students,

    I was not actually there to do psychotherapy but to do annual physicals on 200 psychotic men. For almost all, it would be the only physical they would have for years.

  5. Yes, the prison population has grown just about as much as the hospital population has shrunk since deinstitutionalisation. Not a coincidence. Prisons are also expensive, but only about 1/10th the cost as a hospital. One of the dirty little secrets of government.

    As for talking to the sane part, yes, absolutely. The temptation is very great to argue with the crazy part, but it turns out to be useless. I did psychosocial histories today, and all four patients could tell me lucidly about their early years – their siblings, their schools, what age they were when they moved. It is usually the last few years where all the arguing comes in, because their behavior or ideas are coming into conflict with the reality around them. But you can still talk about whether they can afford that apartment, whether they should focus on getting their driver’s license back, that sort of thing.

    @ Mike K – If you liked reality therapy, you would probably like motivational interviewing.

  6. The Wiki is pretty good. It is an art more than a science, and was developed originally for alcoholics. It assumes ambivalence in the patient to make changes, and that this occurs along a continuum. Free-floating exploratory therapies assume that the patient will eventually find answers and changes will flow from that. This has been spectacularly ineffective over the years, with some studies showing that people get worse under psychoanalysis and even Rogerian therapies. The other extreme, that you have to take over the treatment from the patient and make him make good choices actually does work sometimes, just not enough. That would be what religious groups, behaviorists, and courts do. As I said, sometimes those do work. Most of us don’t change until we are backed into a corner.

    By assuming the middle ground, the therapist can review with the patient 1) what would you like the end result to be? 2) how have your previous choices worked? 3) what would Change X likely result in? 4) What would making no change result in? 5) What are the costs and side effects of X? 6) Is there a way you can try it out at low cost? You can see how this could get people off the dime in terms of trying something. If it sounds very California loosey-goosey, know that in the hands of a skilled interviewer it is one of the most confrontative therapies, if one will only take the time to listen, consider the patient’s goals and desires, and be willing to let the patient experiment. Put yourself in the gambling addict’s shoes. After a few weeks of exploration, one arrives cornered at the idea that things cannot go on as they have. The choices are few, but real. Pick one. We will talk later (outpatient, in a week; inpatient, tomorrow) about what you will choose. The emphasis then is that Not Choosing is actually a choice. I never watched Dr Phil, and he may be just pop psych, but the line “How’s that working out for you?” is a good one.

    I can sense Mike K automatically applying this to obesity, smoking, and the dozen other things doctors want their patients to change. The technique doesn’t work that well in the insurance-driven fifteen minutes the PCP is allotted, but it’s still great.

    @ Mike K – Working in a state institution, I always worked with a lot of foreign doctors. My longterm observation is that the “If you keep on doing this, you are going to die much sooner” speech is much more effective with a foreign accent. I sort of understand that. An elderly Italian physician I knew in the 80’s had the best version of this I have ever heard.

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