The Unwilling Patient: New Yorker Article

In balancing rights against needs, though, psychiatry is stuck in a kind of moral impasse. It is the only field in which refusal of treatment is commonly viewed as a manifestation of illness rather than as an authentic wish.
-- Rachel Aviv, God Knows Where I Am, The New Yorker, May 30, 2011

In the May 30th issue of the New Yorker, Rachel Aviv writes about the plight of a woman who does not believe she has bipolar disorder, or any psychiatric illness for that matter. It's a poignant and tragic article about a woman who is incarcerated for a crime, spends a year and a half in jail before she is found incompetent to stand trial, then goes to a psychiatric hospital where she remains until she is discharged with no plans for housing, money, follow-up, or notification of family--- it's not that the hospital wouldn't offer any help, it's that the patient wanted her freedom and would not allow interventions. Aviv gives examples of the woman's psychosis as a motive for her behaviors. Free, she finds a vacant farmhouse and breaks in. She is fearful of being re-captured, and remains hidden in the farmhouse, subsisting on 300 apples. She journals, she appreciates nature, and she reads books she finds in the attic. In mid-January, three months after her release from the hospital, and 39 days after she ate the last apple, she dies of starvation. Her body was not found until May.

Aviv's article focused on two aspects of the psychiatric system: the emphasis on the patient's insight as a focus, even requirement, of treatment, and the issues of involuntary treatment in patients who aren't posing an imminent threat of violence. I couldn't quite tell where Aviv stood on these issues--she seemed to waiver from condemning a system of forced care, to condemning a system that would let an ill patient leave untreated with no money and no notification to family members. She definitely does not like that the system would have provided for housing for this patient, but the patient wouldn't sign the requisite forms because they noted that she had a mental illness, a fact she did not agree with. Aviv mentions the concept of "thank you theory" --the idea that once patients get well they will agree that the treatment was in their best interest. She notes that only about half of patients who are involuntarily hospitalized later believe it was necessary. It's a difficult statistic to work with--because it means the other half did believe that treatment was necessary, so how, as a society, do we know what we should do? She talks about advance psychiatric directives.

I'd like to share parts of the article, but I had to buy the issue online to read it and it doesn't seem to let me copy and paste. You can listen to a podcast with the author on The New Yorker's website at:
http://www.newyorker.com/online/2011/05/30/110530on_audio_aviv

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Read more here: http://www.newyorker.com/reporting/2011/05/30/110530fa_fact_aviv#ixzz1NbdWI6sM
So really, this is a ClinkShrink article. Maybe she can read it and post again?

Podcast Number 55: What Happens to Shooters with Mental Illnesses?

There has been a lot in the media recently about mental illness and it's relationship to violence.
In this episode we have ClinkShrink walk us through what happens to a mentally ill defendant in a violent crime. First, there is the question of Competence: is the defendant able to meaningfully participate in his/her trial, this is the present mental capacity. If the defendant never becomes competent, he generally remains in a forensic facility indefinitely. At some point (10 years in our state for a capital crime), the law requires a final disposition, and the defendant who is not likely to ever attain competence will be civilly committed and will remain in a forensic facility.

The second question is one of sanity at the time of the crime. ClinkShrink talks about the complexities of insanity evaluations and the rarity of having a Not Criminally Responsible plea. We discuss the idea that incidental mental illness is not enough to be found not guilty by reason of insanity, that the mental illness must have influenced the criminal behavior or obscured the defendant's ability to appreciate the criminality of his behavior. Finally, Clink talks about what happens after an insanity acquittee is released and what type of aftercare planning gets put into place.

The photo is Billy Bob Thornton in Slingblade--he's our example of an insanity acquittee.

Once again, thank you for listening and please do write a review on iTunes.

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