Forcing Treatment

In July 2008 a horrific incident unfolded on a Greyhound bus travelling on the TransCanada Highway in central Manitoba. A 40 y/o man named Vince Li, who was in the grips of a paranoid psychosis, stabbed and then beheaded an innocent 22 y/o Tim McLean who’d done nothing except to be in the tragically wrong place at the wrong time.  The details of the incident can be found on various news websites or on Wikipedia.

Vince Li was found not criminally responsible and has been in the large psychiatric treatment center in my province since.  His name hits the newspapers periodically, especially when his case is brought before the review board.  Last week his psychiatrist presented that Mr. Li was doing well and recommended he be given increasing pass privileges.  This, as before, provokes the expression of many an opinion, including by politicians.  An editorial in the Winnipeg Free Press titled Vince Li and the Politics of Fear notes how

“Manitoba’s senior member of Parliament, Shelly Glover, uttered four sentences on the Vince Li case Tuesday. The thoughts in each sentence were emotional, irrelevant and factually incorrect. Ms. Glover’s comments merely inflamed the stigma and misunderstanding associated with mental illness and schizophrenia in particular.”

My interest isn’t the political but the practical; what is the role of forced treatment?  ACT teams frequently have clients who have histories of violence (though they are more likely to have been victims than perpetrators).

In an small volume put out by the APA’s Group for the Advancement of Psychiatry titled Forced Into Treatment: The Role of Coercion in Clinical Practice 2005 the authors write:

“Outpatient commitment is most successful when the patient is legally committed to treatment and the staff is emotionally committed to making it work. Because people committed to outpatient treatment may be relatively unattractive patients, staff members may be reluctant to become invested in their care. Although attitudes are hard to measure, and, therefore, one must rely on impressions, outpatient commitment often fails when the clinic staff seems reluctant to be part of the Forced Tx Quote 2process. Staff members may oppose coercive approaches, may dislike participating in forcing “clients” to come into treatment, and may even take the position that “forced treatment doesn’t work”.… The key to successful outpatient commitment is an aggressive clinic staff that wants to work with involuntary patients, is convinced that some of them can be helped, and is willing to make home visits, to call on the courts to take action, and testify in court.”

and

“Another key to making outpatient commitment work is rapid judicial and police action in the event of noncompliance. If there are no teeth in outpatient Forced Tx Quote 1commitment, it becomes a frustrating, demoralizing experience for the staff and a travesty for the patient.”

I believe forced treatment is of value. I don’t believe my conviction in any way diminishes my firm belief in recovery principles and client-centeredness. At times it’s the illness, not the individual that’s making the decision to refuse treatment. The goal of forcing treatment is to allow the individual to find their healthy, true voice.

My team worked closely with the Office of the Public Trustee in our province – what is called the public guardian in other places. I, as a psychiatrist did not decide for the patient, I provided information to the substitute decision maker who had the legal authority and responsibility to make the final call. I believe this arrangement worked, allowing ACT clients to live in the community, have contact with family, avoid hospitalizations and engage in meaningful recovery.

There are tough questions that follow, for example, were Mr. Li to have been living in the community, peacefully and symptom-free for a decade should he then be allowed to stop meds? (see my previous blog Recovery, Meds and When?)

This area will likely remain controversial. I believe ACT teams will be in the forefront, showing how forced treatment can, when used judiciously and thoughtfully, work.

Interested to hear your thoughts.

Shalom Coodin

5 comments

  1. Great topic, and one near and dear to my heart. It’s a very grey space to work within, and that is often underappreciated by many. In trainings, I have spoken about some teams/agencies/staff seemingly either too risk tolerant in the “name of recovery and personal choice,” and then there are those who are very quick to take control and be coercive. Finding the “sweet spot,” is knowing that conditions for outpatient commitment (as an example) are rarely black and white (“Must receive treatment” — what does that mean? receive therapy, but no meds? refuse 2 of 5 recommended meds?) — there is still personal choice within the apparent constraints of IOC/assisted outpatient treatment (AOT). It’s the skillful and caring clinician who knows how to best use such a shared decision making approach within the parameters of those leverages, and knowing the extent of the risks, which may in turn call for pushing the lever down — but in a measured way, where possible (you don’t have to go full throttle right away). For many people, whatever leverages that are in place will at some point go away, and if you didn’t do your work to build a trusting and caring relationship in the meantime, they, too, will go away when the leverage is lifted.

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