A Hard Pill to Swallow: An Exploration of Social Relationships and Antipsychotic Drugs in Involuntary Outpatient Commitment

Background and Purpose

In 2002, California signed into law involuntary outpatient commitment (IOC) to address growing problems of homelessness, incarceration, and emergency services utilization among individuals labeled with severe mental illness. Psychiatric commitment policies rest on the notion that compliance is at root of these issues which necessitates mandated services. While research has examined IOC efficacy, less examined are the real-time social processes of mandating and managing compulsory treatment. 

In a parent study evaluating IOC services in Los Angeles County, we observed that antipsychotic drug use is a central issue. Antipsychotic drug use invokes complicated processes of monitoring effects and mandating use which enjoins together various social actors. Further complicating these processes are the high rates of non-compliance, sometimes related to negative experiences with drugs. The purpose of this study is to examine how social actors mandate drug use in IOC, especially in relation to managing their plentiful and powerful effects.

Methods

The primary methods were ethnographic observations and semi-structured interviews. Overall, our team gathered 216 field notes of outreach and commitment services, and court and treatment sessions and 48 interviews from clients, family members, treatment providers, and stakeholders.

For this analysis, we utilized a case-study to gain thematic depth related to medication management over the course of one individual’s IOC treatment. The first author observed field-based therapy sessions over six-months in 2017-2018. This included observations of 3 treatment team meetings and 14 treatment sessions, and 4 interviews conducted with the individual, mother, therapist, and program manager. Data was analyzed using thematic coding related to our research question. We triangulated our findings with health services data and ethnographic fieldwork of other IOC clients to verify and contextualize themes related to this case.

Results

Beyond the committed individual, the social actors related to antipsychotic drug use consisted of two parents and a therapist, case manager, and psychiatrist. The individual refused to discuss or take medications. Thus, family members emerged as key players in the daily act of delivering medications and interpreting drug effects.

All social actors advocated that drug adherence was necessary to transition the individual to independent housing, employment, and voluntary treatment, even when the self-reported drug effects – such as drowsiness – interfered with these other treatment processes. Further, the tension related to mandating drug consumption became central across these social relationships, impacting interactions between social interactions. Because social actors mandated drug use, motivated by the belief that recovery would fail without drugs, these actors resorted to covert techniques to deliver drugs and avoid tension.

Conclusions and Implications

This study illustrates how this committed individual’s antipsychotic drug use is managed across relationships. IOC’s investment in recovery were believed to hinge on antipsychotic drug use and sustaining relationships. At times, these were components were at odds with one another, as the tension from mandating drug use was threaded through all social interactions. This indicates that drug effects can be understood as social and suggests that future research should examine how IOC shapes social relationships and consequent outcomes.