Magazine article Behavioral Healthcare Executive

'Moments' Separate Treatment from Tragedy: When Violence Stems from Mental Illness, Meds May Be First Step in Treatment

Magazine article Behavioral Healthcare Executive

'Moments' Separate Treatment from Tragedy: When Violence Stems from Mental Illness, Meds May Be First Step in Treatment

Article excerpt

Essential to any individual's journey from mental illness to recovery are moments when they (or those they know) realize that something is wrong and they need help, that getting treatment can lead to understanding and hope, and that recovery is possible when strengths-based adaptation and ongoing effort are partnered with proper treatment.

But many Americans who face mental health issues never get to that first moment, realizing that they need help, and of those who do, many find that treatment isn't available or fall away from treatment before hope can take hold. Among the former group are those with anosognosia, a condition that impairs their ability to recognize that they have a mental illness.

The November 8 sentencing of Jared Lee Loughner, the 24-year-Arizonan diagnosed with schizophrenia after his arrest for the Tucson shootings that killed six and seriously injured 12, reminds us that for the few whose mental illnesses manifest in violent behavior, only moments may separate the paths that lead to treatment, or to tragedy.

What might have been?

Could the life of Jared Lee Loughner have gone in another direction if he had received psychiatric treatment, including medications? Possibly, yes. But the case of James Holmes, the young man accused in the July movie-theater shootings in Aurora, Colorado, demonstrates that accessing care is not sufficient to prevent violence and tragedy either. Holmes had seen a University of Colorado psychiatrist, but did not return--and was not sought out--after withdrawing from the university in the middle of June, just five weeks before the shootings.

According to Paul Appelbaum, M.D., past president of the American Psychiatric Association (APA) and chair of the APA's Committee on Judicial Action, when violent behavior occurs as a manifestation of a mental disorder, treatment "is likely to diminish the risk of future violence." (He stresses that most acts of violence are committed by people who are not mentally ill.)

Where there is a connection, however, treatment can help to prevent violence by helping the patient understand that paranoia, for example, is not justified, that the world is not "out to get" them. "Someone with a paranoid delusional system who seeks revenge or preemption in violent behavior is carrying out instrumental violence," says Appelbaum, who is the Elizabeth K. Dollard professor of psychiatry and law at Columbia University. "'They think they have a goal, but it's a delusional one, protecting themselves from imaginary, malevolent forces."

Aggression, even when planned in advance, can be a response to being psychotic, agrees William Glazer, M.D., president of Glazer Medical Solutions, based in Florida. "If you believe your food is being poisoned, or that you are being monitored by the FBI, you are going to get very scared," Glazer says. "At some point you may get so out of touch that you will be violent and aggressive," he adds, noting that if a patient's paranoia could be treated with antipsychotic medication and a trusting therapeutic relationship, then "the aggression would be treated as well."

But establishing an effective therapeutic bond takes time. "Relationship" is the key to earning a person's trust, convincing them to enter therapy, and motivating them to take medication when it is necessary, says Lori Ashcraft, Ph.D., executive director of the Recovery Opportunity Center at Recovery Innovations, in Phoenix, Arizona. "They know if you are on their side, if you believe in them," she says.

But such interventions aren't open to those who refuse treatment or those who don't realize their own mental illness. What then?

Involuntary commitment and treatment

Some form of involuntary commitment or treatment laws exist in every state, with New York's Kendra's Law (New York) and Laura's Law (Calif.) among the notable examples. Typically, these laws allow for an individual to be court-ordered either to an institution for a brief period or to an assisted outpatient treatment (AOT) program for a longer period, or both. …

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