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'Moments' separate treatment from tragedy

November 21, 2012
by By Alison Knopf, Contributing Writer
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Essential to any individual’s journey from mental illness to recovery are moments when they (or those they know) realize that something is wrong and they need help, that getting treatment can lead to understanding and hope, and that recovery is possible when strengths-based adaptation and ongoing effort are partnered with proper treatment.  

But many Americans who face mental health issues never get to that first moment, realizing that they need help, and of those who do, many find that treatment isn’t available or fall away from treatment before hope can take hold. Among the former group are those with anosognosia, a condition that impairs their ability to recognize that they have a mental illness.

The November 8 sentencing of Jared Lee Loughner, the 24-year-Arizonan diagnosed with schizophrenia after his arrest for the Tucson shootings that killed six and seriously injured 12, reminds us that for the few whose mental illnesses manifest in violent behavior, only moments may separate the paths that lead to treatment, or to tragedy.  

What might have been?

Could the life of Jared Lee Loughner have gone in another direction if he had received psychiatric treatment, including medications? Possibly, yes. But the case of James Holmes, the young man accused in the July movie-theater shootings in Aurora, Colorado, demonstrates that accessing care is not sufficient to prevent violence and tragedy either.  Holmes had seen a University of Colorado psychiatrist, but did not return—and was not sought out— after withdrawing from the university in the middle of June, just five weeks before the shootings.  

According to Paul Appelbaum, M.D., past president of the American Psychiatric Association (APA) and chair of the APA’s Committee on Judicial Action, when violent behavior occurs as a manifestation of a mental disorder, treatment “is likely to diminish the risk of future violence.” (He stresses that most acts of violence are committed by people who are not mentally ill.)

Where there is a connection, however, treatment can help to prevent violence by helping the patient understand that paranoia, for example, is not justified, that the world is not “out to get” them. “Someone with a paranoid delusional system who seeks revenge or preemption in violent behavior is carrying out instrumental violence,” says Appelbaum, who is the Elizabeth K. Dollard professor of psychiatry and law at Columbia University. “They think they have a goal, but it’s a delusional one, protecting themselves from imaginary, malevolent forces.”

Aggression, even when planned in advance, can be a response to being psychotic, agrees William Glazer, M.D., president of Glazer Medical Solutions, based in Florida. “If you believe your food is being poisoned, or that you are being monitored by the FBI, you are going to get very scared,” Glazer says. “At some point you may get so out of touch that you will be violent and aggressive,” he adds, noting that if a patient’s paranoia could be treated with antipsychotic medication and a trusting therapeutic relationship, then “the aggression would be treated as well.”

But establishing an effective therapeutic bond takes time. “Relationship” is the key to earning a person’s trust, convincing them to enter therapy, and motivating them to take medication when it is necessary, says Lori Ashcraft, Ph.D., executive director of the Recovery Opportunity Center at Recovery Innovations, in Phoenix, Arizona. “They know if you are on their side, if you believe in them,” she says.

But such interventions aren’t open to those who refuse treatment or those who don’t realize their own mental illness. What then?  

Involuntary commitment and treatment

Some form of involuntary commitment or treatment laws exist in every state, with New York’s Kendra’s Law (New York) and Laura’s Law (Calif.) among the notable examples. Typically, these laws allow for an individual to be court-ordered either to an institution for a brief period or to an assisted outpatient treatment (AOT) program for a longer period, or both. But laws set a high bar for any intrusion on personal freedom:  petitioners must prove that the individual is gravely disabled or represents a significant or imminent danger to self or others.

The height of the bar against involuntary treatment must be seen in light of the civil rights struggles of the 1950s and ‘60s, and the values of the recovery movement, which stresses the importance of personal choices and strengths as critical elements in the recovery process. But some worry privately that the pendulum has swung too far, making it very very difficult to compel treatment or medication even when the need appears obvious.

Convincing the patient

Persuading the patient to take medication, oral or injectable, is often part of good treatment. But, as noted, informed consent requires discussion of a potential litany of side effects, which may trigger patient concern. “But fear that the patient will say no to the medication is not a reason to deceive or to withhold information – whether they’re mentally ill, or paranoid, or not,” says Appelbaum. He believes that honesty—even about unpleasant side effects—is most likely to win a patient’s trust.

Mental Health America (MHA) recognizes that involuntary treatment may be necessary, on an inpatient basis for crisis purposes. But MHA does not support involuntary outpatient treatment. Almost everyone, including people with serious mental illnesses, “are capable of making their own decisions about whether to seek treatment and support and what treatment and support they should receive,” MHA says.

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