Insight and involuntary outpatient treatment
The risk of labeling people with anosognosia is that we might cease to see them as humans, that we might write off their resistance to treatment as simply an inability to know what’s best for them, in a way that enables us to close our ears to what may well be their valid concerns. It may become too easy to say that the court order calls for the medications, and changing doses or medications to alter the risks or the side-effect profile is no longer part of the effort. Such a mind-set may lead the psychiatrist to complacence and disregard for the patient’s concerns.
Why take the time to know the patient, to develop rapport, to convince the patient to come to therapy and to try medications on his terms, when a court order might cut all those corners and a nurse can administer an injection? That’s not the targeted group of patients, you say, that’s not whom AOT captures. If we’re not careful – if we feel that addressing the concerns of our patients is simply a "waste of time" because, after all, they have no insight – then we risk losing sight of what needs to be our real goal: helping patients to live the lives they want to live in productive and meaningful ways. Forcing treatment may get one person help at a particular period in time, but it comes with a cost: It leaves some patients afraid to seek voluntary care for fear of what may occur down the line, and it stigmatizes our profession. Finally, it makes us the adversaries of the patients we serve.
It would be easy to read this and think I’m against involuntary outpatient treatment, and that’s not completely true (ah, it’s mostly true). If involuntary treatment is limited to those patients who cycle in and out of hospitals and jails because of noncompliance, who become dangerous when ill, for whom treatment has proven to be effective, and who have failed thoughtful attempts at voluntary care, then forced care with its array of ancillary services and housing provisions may be a reasonable resource, regardless of the patient’s level of insight. Still, I remain interested in making our treatments more palatable to all of our patients – those who are forced into care as well as those who come willingly – and I believe it’s a mistake to see that effort as a waste of anyone’s time.
Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).
