1.5.3 Coercion in Psychiatric Rehabilitation

Mr. Smith is a 38-year-old single, unemployed man who lives on his own in subsidized housing. He has been an outpatient of yours for the last year or so, and he also has a community case manager who has known him for the last decade or so. He has been diagnosed with schizophrenia, paranoid type, since he was 19 years old, and he has also been diagnosed with cannabis abuse since he was 25 and with non-insulin-dependent diabetes mellitus for the last two years (with no history of hypo/hyperglycemic coma). He is treated with oral antipsychotic medication and a low-sugar diet and has declined other treatment suggestions such as depot (injectable) antipsychotic medication and oral hypoglycemics. He is considered capable of consenting to treatment but not of managing his finances, for which the public guardian and trustee is the substitute decision-maker. Lately he has had an exacerbation of auditory hallucinations and related death wishes without suicidal intent. The identified trigger to this exacerbation is an increase in his cannabis intake due to peer pressure. The identified trigger for many of his previous psychiatric exacerbations, some of which have led to hospital admissions, is non-adherence to antipsychotic medication. Mr. Smith does not have a history of physical aggression or suicidal acts. Although Mr. Smith insists on maintaining his subsidized housing as he likes his independence, his case manager approaches you with the request to collaborate with her in creating and implementing a plan to coerce Mr. Smith into moving to a group home, where his adherence, substance use and diabetes can be monitored closely and addressed. She states that, with your support, the public guardian and trustee could be convinced to discontinue Mr. Smith's payment for subsidized housing and to divert it to group home payment.