It is a typical day on the inpatient unit. A patient is refusing medication, and I want to take her to court to compel her to take medication while her lawyer is arguing for her right to refuse.
Me: “She’s clearly psychotic. She has lost her family, and she has no place to live… all because of these delusions.”
Lawyer: “But is she behaving in a dangerous way?”
Me: “Being unable to survive in the community is not dangerous?”
Lawyer: “Well, there is no imminent risk.”
We decide to go to court, and in this case, we win. However, there are others we lose despite everyone agreeing that the individual is psychotic.
The delivery of psychiatric care differs from other fields of medicine. Most individuals in psychiatric inpatient units do not voluntarily seek care; they are brought in after their behavior becomes unacceptable in the community. More often than not, they are unaware that they have a mental illness. However, they are made aware of their rights, turning the system into an adversarial one.
This is not to say that people should be forced to receive treatments they do not want. The question is whether individuals who meet the admission criteria should have that right. The basic premise for admission to a psychiatric facility in the state of New York is dangerousness due to mental illness, with consideration given to whether the individual would benefit from treatment. It is this third component that is often overlooked by the mental hygiene legal system. Usually, two or even three physicians have already signed off on these criteria, making the need for an administrative hearing and eventually a court hearing somewhat redundant.
This system is based on the fact that we question whether the individual has the capacity to make decisions, yet one of the hallmarks of severe mental illness is this very lack of capacity and associated behaviors. To further compound the problem, there is the question of dangerousness. Dangerousness is one of the most difficult outcomes to predict. By definition, the presence of severe mental illness does increase the risk of dangerousness to self or others, but this does not mean that we can predict who or when this might occur. The reality is that the vast majority of the mentally ill will not harm themselves or others. This is perhaps why so much attention is paid when a homicide is committed by someone with severe mental illness. Thankfully, such events remain very rare.
This leads to the most common testimony: the patient lacks capacity, but odds are that nothing bad will happen to anyone else even if untreated. We are then faced with perhaps the most important questions:
Are severe psychiatric disorders treatable?
If they are treatable, do individuals have the right to treatment that will alleviate their suffering?
The severely mentally ill do suffer. Their symptoms are often frightening, they die 20 years earlier than the average person, they have high rates of unemployment and homelessness, and they make up 25 percent of the jail population in the United States. The other question is whether these disorders are indeed treatable, and the answer is to some degree. Treatment is not perfect, but it does help the individual, especially early in the course of the illness.
The final issue is the therapeutic relationship that is often fractured after the court hearing. A young man with a new onset of schizophrenia was under my care and had refused medication. A court hearing was scheduled, and the order to medicate was granted, but the patient, who had been under my care for a number of months, refused to be treated by me. The hearing is adversarial, and the patient often feels that what they have told the psychiatrist is confidential and should not be mentioned in court.
Streamlining the system would perhaps be the best option. The decision to admit and medicate should be made at the point of admission, only after two physicians have evaluated the patient. Patients should be allowed representation in cases where there are questions about the appropriateness of these interventions, but for the most part, this should be limited to cases where there is a question around the diagnosis and the appropriate treatment. Finally, the treatment team should be allowed adequate time to ensure that a full trial of treatment is completed. In cases where the individual does not require admission, the patient should maintain the right to disagree with the physician and not take the medications as offered. In the end, decreasing the time spent in court would benefit both the patient and the hospital.
Constantine Ioannou is a psychiatrist.