When I was in high school, one of my friends got mono -- infectious mononeucleosis or kissing disease. He had a minor sore throat and, because his girlfriend was quite sick with mono, he went to the doctor and was tested. He tested positive, but unlike his girlfriend, he never got sick and said, "Well, I haven't tried to run a mile, but I'm pretty sure I could." Still, there is no doubt that both young people had been infected with the virus and one got sick while one did not.
One of the things I learned from the extensive research we did for our forthcoming book, Committed: The Battle Over Involuntary Psychiatric Care is that not every has the same experience of the same illness or the same treatments. Okay, I didn't have to write a book to tell you that, I see it in my office every single day with every single patient. Why does one person get a severe tremor to Wellbutrin while another with similar symptoms just gets better with no side effects? Why do some people need psychotherapy while others get better from a pill? Clearly psychotropic medications don't agree with some people, and clearly they don't make everyone with psychiatric illness all better, but there is a contingency of people who feel that since medications were for bad for them, they are bad for everyone. They are wrong.
I wrote a blog post about a NY Times op-ed piece last week called "Medicating a Prophet" by Penn psychiatrist Irene Hurford. She works with young people with psychosis, and I'm going to guess that she seen patients with a range of experiences. In her op-ed piece, Dr. Hurford makes the point that there are people who like their psychotic symptoms, who gain some comfort from them, and who suffer when they lose their delusions and get smacked with the awful reality of their illness. She doesn't say that there are not patients who are tormented by their psychosis and I'm going to make the assumption that she has met many paranoid, uncomfortable, and suffering patients -- psychosis is not fun for most people. Dr. Hurford further makes the point that forced care can be traumatic-- and, as we write in Committed, it can be for some people, even if it is appreciated by others. I read from her article not that psychosis never leads to violence, but that rare, extreme acts of violence are rate and extreme and shouldn't be what sets public policy. She is not the only psychiatrist I know of who is not gung-ho on making forced care easy policy, and I know several forensic psychiatrists who work with the most violent of patients on a daily basis, and still don't see involuntary treatment as the way to prevent these acts.
DJ Jaffe has an article over on Policy Madness in response to Hurford's NYTimes article. He writes in "Policy Madness: Serious Mental Illness is Not Enriching:"
The New York Times recently ran an op-ed declaring that being psychotic is “enriching,” and arguing against involuntary treatment of the psychotic. “The assumption that someone else’s reality is invalid can foster distrust; it sends the message that we don’t respect this person’s experience of his or her own life,” wrote Irene Hurford, an assistant professor of psychiatry at the University of Pennsylvania. This romantic, Pollyannaish, and false view of psychosis is rampant in the mental-health system, regularly parroted by the media, and dangerous to both patients and public.
Jaffe goes on to talk about people with psychosis who have killed, and how assisted outpatient treatment can be live-saving. He talks about how nurses who treat psychiatric patients have emergency buttons, but those who treat psoriasis don't. Well, there are several cases, at Harvard and at Johns Hopkins, where surgeons have been shot by disgruntled family members. Maybe everyone needs emergency buttons.
I want to borrow these articles to make the point that there is no single reality. Some patients find their psychotic symptoms to be tormenting. Some may find their private reality to be enriching, especially during a mania. Some patients with psychiatric disorders are dangerous. Some people get in cars after they've been drinking or using drugs and are dangerous. And some people are just angry and dangerous. Please, let's not assume that the experience or the needs of all people with mental disorders are the same. And let's not even assume that psychiatrists are the same -- some are quicker to prescribe, and some are quicker to commit patients to hospitals. Often studies of violence outcome look at acts like slamming doors or shoving someone. While I have no doubt that psychiatric treatment, especially treatment done with with the doctor on the same team with the patient, saves or at least enriches lives, there is no evidence beyond the anecdotal that forced outpatient care prevents murders, mass murders, or even suicide, or that other, more collaborative methods might be more effective.
And please, don't even consider reading this and thinking that I believe there aren't situations where the only option is to force a very sick patient to get involuntary care. I just don't think we should assume all people with psychotic disorders have the same experience.