AMA Journal of Ethics^®

Case

Dr. Jacobson, a psychiatrist working at an outpatient clinic in Cleveland, was waiting for his next patient, Mr. Miller, an Army veteran who had been living in a homeless shelter. Mr. Miller had been diagnosed with paranoid schizophrenia 10 years earlier following sporadic hallucinations and delusions that alienated him from friends and family. He had tried to cope with his illness by smoking marijuana and, for a time, became addicted to cocaine. On several occasions, he had become verbally assaultive and threatened strangers, prompting brief periods of incarceration. As part of his court-ordered release, Mr. Miller was required to participate in "outpatient commitment"--an arrangement that required him to attend weekly therapy sessions and self-help groups and submit to a supervised medication regimen.

Twenty minutes passed before Mr. Miller arrived at his therapy session and blamed the clinic office staff for his delay. Dr. Jacobson was weary of the excuse; Mr. Miller had used it before, and it always turned out to be false. Furthermore, Dr. Jacobson sensed that Mr. Miller had become more anxious and irritated during sessions, but he was not sure why. Outpatient commitment had worked for Mr. Miller for several months, but Dr. Jacobson was uncertain about the best way to handle Mr. Miller's change in behavior. If he reported Mr. Miller's behavior, he jeopardized their therapeutic relationship. Nevertheless, Mr. Miller's noncompliance was harmful to himself and possibly others. Dr. Jacobson asked himself whether his decision making would differ if Mr. Miller were not homeless.

Commentary 1

In an ideal world, no patient would be coerced into treatment. It may be even more important to strive for this ideal in the field of psychiatry where self-motivation is a necessary perquisite for meaningful change. There are cases, however, in which a physician must intervene despite a patient's opposition. Traditionally, psychiatrists have used involuntary inpatient commitment as an intervention to address acute, life-threatening situations. More recently, outpatient-commitment laws have been developed as interventions for less-acute situations. These laws were initially proposed in the late 1980s to manage "revolving-door" patients who received periodic inpatient treatment but often relapsed because they did not become engaged in outpatient maintenance.

Outpatient-commitment laws were later expanded in part because of societal fears that individuals with mental illness were violent and uncontrollable. Kendra's Law in New York and Laura's Law in California are examples of legislation influenced by murders committed by mentally ill patients who refused or avoided treatment. In contrast to these motivations, families have advocated for outpatient commitment out of concern for the safety and quality of life of their mentally ill relatives who reject treatment because of their psychiatric symptoms. For physicians, outpatient commitment raises the complicated issue of paternalism and potential conflicts between societal and patient interests. In this commentary I argue that, despite the potential problems associated with outpatient commitment, it is an intervention that, when used with compassion and respect for the patient's dignity, can greatly improve his or her quality of life.

Establishing a Patient-Physician Relationship

Mr. Miller is a patient with whom it is difficult to establish a therapeutic relationship. He has significant paranoia, thought disorder, and impaired judgment. Furthermore, his experience with the legal system has most likely left him with an aversion for institutional authority figures, including, in this case, Dr. Jacobson. Therefore, Dr. Jacobson is in a double predicament; Mr. Miller is unlikely to engage in voluntary treatment, and the coercive nature of outpatient commitment is a major barrier to establishing a therapeutic relationship. Specifically, coercive treatment is likely to aggravate Mr. Miller's paranoia and inhibit the development of a trusting therapeutic bond. Dr. Jacobson must work to make the empathic nature of the relationship apparent, while unambiguously communicating the requirements of the situation.

The situation can create inner tension in Mr. Miller; he will have to accept Dr. Jacobson as both an authoritarian representative of the court (which will lead to anxiety) and an empathic healer who is trying to provide help (which will lead to hope). In nonpsychotic patients with better coping skills than Mr. Miller's, similar feelings of ambivalence often result in treatment noncompliance (lateness for therapy appointments, skipping medications, etc.). It is unreasonable to expect a psychotic patient to be able to follow a regular treatment schedule without exception. Furthermore, Mr. Miller's recent behavior is not surprising and may represent a normal phase of treatment.

Motivating Treatment

Unfortunately, Mr. Miller is at high risk for discontinuing treatment, and it is essential that Dr. Jacobson address two issues. First, he must determine why Mr. Miller is becoming more irritable and anxious. It could be a symptom of worsening depression or psychosis or a relapse to cocaine use--conditions that might require medication changes. As alluded to above, however, these symptoms might also be a consequence of Mr. Miller's struggle to establish trusting relationships with his therapist and self-help groups. Dr. Jacobson's second important task, then, is to convince Mr. Miller that, regardless of the underlying cause of his increased anxiety, the possible consequences of his behavior are severe. If he is brought before the court he risks a return to jail. Here, the court can be used as a third-person authority to substitute for the patient's impaired ability to make good decisions. For example, Dr. Jacobson may frame the treatment goal as, "How do we keep you out of jail?" The approach establishes an alliance with Mr. Miller by providing a concrete goal to motivate treatment. It also has the advantage of focusing on an element of reality that both the doctor and patient agree is important. Mr. Miller may not agree that stable housing, reduction of psychotic symptoms, or decreased cocaine use are important goals, but he is likely to be motivated by avoiding incarceration.

Improving Compliance

Dr. Jacobson must decide whether to report Mr. Miller's recent behavior to the court. In my opinion, he should not report him at this point. In the absence of dangerous behavior, treatment should focus on strengthening the therapeutic alliance. Mr. Miller's inability to conform to structured systems, such as those imposed by employment and social relationships, is a fundamental aspect of his disorder and will always be a factor in his treatment. Rewards like food vouchers, clothing, bus tokens, and hygiene products are much more likely to improve compliance than are punitive measures. If down the line Dr. Jacobson becomes concerned about worsening psychotic symptoms that could lead to potentially aggressive behavior, then inpatient hospitalization is the appropriate decision because it will provide an opportunity to directly treat the underlying condition.

In sum, outpatient commitment creates potentially difficult therapeutic situations. With a patient like Mr. Miller, however, whose psychiatric disorder has led to recurrent social and legal problems, it can be argued that outpatient commitment is the only tool that will afford the opportunity for psychiatric treatment. In the absence of coercion, Mr. Miller will not adhere to treatment, and without it he will continue to have social and legal problems.

Many aspects of Mr. Miller's behavior will be difficult to understand, and those who treat him must be careful to avoid paternalistic assumptions regarding some aspects of his current situation. For example, some individuals choose to be homeless even when provided safe, individual housing. Therefore, the treating team must recognize Mr. Miller's impaired judgment but respect his right to self-determination. Certain aspects of his behavior, however, require clinical attention. Mr. Miller's paranoia and verbally aggressive behavior, for example, should be interpreted as the result of depression, fear, and anxiety. Ultimately, the goal of his treatment should be to relieve the symptoms that often remain unarticulated in patients like Mr. Miller. By using his mental well-being as the frame for treatment and recognizing his need for dignity, outpatient commitment is an intervention that can achieve therapeutic goals.