This article seeks to articulate the challenges with treatment of Severe and persistent mental health diagnoses for persons (SPMI) non-adherent to the clinical recommendations of their providers. It is the intent of this author to outline why it is so important to seek out available treatment early on before symptoms worsen to the point where reality, judgement, and impaired insight preclude the afflicted individual from buying into available treatment options to experience relief from what could become chronic and persistent symptoms.
The available options for a course of treatment targeting chronic mental illness of course becomes more limited and more restrictive as the degree of chronicity increases and insight and judgement decrease to the point in which capacity is lost by the patient. In this article the open dialogue approach will be evaluated for its limitations and benefits for SPMI populations as well as two available courses of forced treatment in both in patient and community based settings.
In the recovery movement today, the open dialogue approach to treatment is showcased and renowned as the most effective treatment for SPMI populations and argued to be the only approach that works for producing long term positive lasting outcomes. It is an approach that stresses a shared conversation between consumers and providers about forming a treatment pathway and medication regimen that is acceptable to all parties to promote adherence and reduction of non compliance.
This really needs further unpacking though because if someone is in need of an extremely high level of care their symptoms may be so serious and chronic that relief or remission is often not realistic. This has been evidenced by research time and again. I’ve even experienced it as a patient with lived experience during multiple in patient hospitalizations and as a clinician practicing in the community.
There is no question the open dialogue approach is effective, humane, and appropriate for those who are accepting of their condition and have the insight and judgement to move forward in their recovery, but these are people who are adherent to treatment and on board with treatment recommendations from the onset of diagnosis so of course their rate of experiencing improvement in their condition is expected.
I’ve seen first hand in state and local hospitals where people are placed in long term care indefinitely because they refuse medication and all other treatment recommendations, experience no relief from their symptoms and are in turn too dysregulated to maintain their own safety in the community.
Forced treatment in certain severe cases would provide many people, people like myself and others like me with a chance to live in the community again and re regulate enough to continue their care and perhaps experience further improvement on an outpatient basis instead of locked away in a state ward for years or maybe decades.
Forced treatment can occur in an in patient hospital as medication over injection or in the community with AOT Assisted Out Patient treatment in which the county mental health department monitors specific high risk individuals through a series of paper trails and reports which are reviewed every year or so to determine if the person can return to a lower level of care and voluntary treatment. AOT is usually provided by ACT teams and providers which conduct home visits as this population experiences issues with connectivity to clinics and benefit from closer monitoring from community based treatment teams.
Who determines when forced treatment is warranted? I imagine to get around the concept of “informed consent” there has to be some sort of court order or guardianship petition, be it by hospital staff or family members.