My conceptualization of him
George is a peculiar case. Practically all patients who are committed to my unit for competency restoration are psychotic, and their psychosis prevents their engagement with their attorneys. They have poor insight into their illness, which leads to their commitment. On admission, I confirm the assessment of the forensic psychiatrist and start the ordered involuntary treatment on patients. Many of them are gravely disabled – making the ethical dilemma easier to navigate. For other patients, the idea that they will be kept incarcerated until found competent also makes the forced treatment a simpler decision.
George was different – his impeccable grooming, his dislike of jail food, and his request for appropriately fitting jail clothes were far from disorganized. More importantly, however, he had adequate shelter outside of jail, income for assisting Harry, and a rich network of friends. Despite being riddled with delusions, his thought process was linear, and he was redirectable – even when discussing his delusions. I conceptualized the ethical conflict as such: Not treating him might lead to a longer period of incompetence and a longer incarceration; treating him would go against his desire to remain untreated.
After contacting Harry, I was fairly certain that George had suffered from his delusions for at least a significant part of his adult life, if not in its entirety. However, Harry was infinitely thankful for George’s assistance and felt that George had a good life. This added another fundamental question: Would forcing George to engage in formal mental health treatment lead him to have a better life? He was happy, had meaningful relationships, and contributed to his life as well as his friends’ lives in a deep way.
I diagnosed him as having an unspecified psychotic disorder, likely schizophrenia; he had delusions and negative symptoms, like his impaired affect. Despite this diagnosis, I decided to hold off from using involuntary treatment. I met with him daily for more than 2 weeks, and we discussed his story, his feelings, and his beliefs. On occasion, it was hard to separate the delusions from justifiable anger at the system. He had felt that he and Harry had been wronged, when society should have protected their vulnerability. He learned to trust me, and his therapist taught him competency training. Despite a possible 1-year commitment, we declared him competent to stand trial in 2 weeks. He had learned and excelled in all facets of the training.
George still had delusions, but he understood his charges, that he had acted inappropriately in the courtroom, and how to discuss his case with his legal counsel. Harry found George to be at his baseline during visits. George acted appropriately; he followed the complex rules set on inmates and engaged in all groups that are held on the unit.
Discussion
I certainly do not question the value of involuntary psychiatric treatment for many patients with grave disabilities, violent tendencies, or incompetence. However, George’s case makes me wonder if many people living with schizophrenia can have rich and meaningful lives without ever being in contact with a mental health provider. I wonder if our almost-obsessive attention to antipsychotics makes us lose sight. Our biological reductionism may lead us to see patients such as George as someone with overactive dopaminergic pathways in need of antidopaminergic antipsychotic. Unfortunately for many, biological reductionism often is based on unsubstantiated evidence.
George reminds me that life, including schizophrenia, is more interesting and complicated than a set of genes, pathways, neurons, or neurotransmitters. Our patients’ lives may be convoluted with delusions, often stemming from truth or impaired affects, which are nonetheless genuine. I don’t know what will happen to George, but his past 50 years suggest that he will continue to have friends, and he will continue to live without being impaired by his delusions. Strangely, I worry less about him than many of my other patients.
Many mental health providers have advocated for a wider and easier access to involuntarily medicate our patients. I think that there is a misguided belief that involuntary antipsychotic treatment will lead to a rise in their use. However, if Carl Rogers, PhD, and others were right in stating that our relationship with our patients was the ultimate factor in their recovery, at what cost are we willing to jeopardize this? My fear is that this cost will be the loss of trust, which is so necessary in treatment. I hope that my short relationship with George did not scare him from ever seeing a psychiatrist again. In some ways, I suspect that by simply listening to George and withholding forced treatment, he will be more inclined to seek treatment in the future.