An Optimistic Counterpoint for the Holidays


During this holiday season, I thought I would take a break from my usual criticisms to point out how well things can go when people simply refuse to give up and accept the “inevitable.”

Harry is a 36-year-old man with a long history of learning and emotional problems, complicated by ongoing alcohol and cocaine use whenever he is not incarcerated or hospitalized. He has had numerous arrests for generally minor offenses, including public intoxication, disorderly conduct, failure to identify, resisting arrest, and minor thefts or assaults.

He was remanded to my hospital for a competency evaluation about a year ago, after another arrest for disorderly conduct and resisting arrest in the context of intoxication. After assessing him over several weeks, it became clear that he had been diagnosed in childhood with mild mental retardation (now termed “intellectual disability”) and was in special education throughout his school years. He did not graduate but received a “certificate of attendance” when he turned 21.

In the intervening years, he had numerous arrests, as noted above, but he also had over 30 hospitalizations in public and private psychiatric hospitals, usually presenting with psychotic symptoms in the context of substance misuse and/or intoxication.

If the case ended here, you would be reading, once again, about misdiagnosis and misplacement of people with developmental disabilities in psychiatric hospitals which are ill-equipped to treat them. See, for example, my TCR blog on “Passing the Buck.”

However, I was unwilling to simply give up. I obtained numerous records from prior hospitalizations and reviewed his case with the mental health staff in the jail, who unfortunately knew him all too well.

I learned that while he certainly had intellectual limitations and addiction problems, it was unlikely that he had a psychiatric diagnosis separate from these two problems. However, the various systems of care—mental health, developmental disability, and addictions—had not collaborated well in coordinating his case over the years.

Given this conclusion, I convened a meeting that included many people who have interacted with Harry over the years, including representatives from his hospital treatment team, jail mental health staff, the county mental health authority, the regional developmental disabilities office (including Harry's “service coordinator“) and addictions providers. We concluded that the problem wasn't our inability to manage Harry, so much as his resistance to our efforts to assist him.

When not in a secure setting, he voted with his feet. This was a quite pessimistic conclusion, and I am certain that the court personnel assumed that we were giving up and leaving Harry to them.

Harry improved in the hospital, and ultimately he was assessed as being competent to stand trial. Reports were prepared, hearings held, testimony given; Harry was discharged from the hospital to jail to serve out his short sentence and be released. This happened in March 2011.

End of story?

On the day before Thanksgiving, I received an email from Harry's service coordinator, updating me on his progress during the intervening eight months. To my surprise, she informed me that while he left jail homeless, shortly after being discharged from the hospital, a mobile treatment team was able to slowly engage him and to “educate him about his disease and his medications.”

They gave him a medication box that he could carry with him, hoping that it would improve compliance, and they provided him with a cell phone so that they could find him. How innovative! I wish I were such an out-of-the-box thinker.

After several months, they were able to convince him that he might be better off with a home, and they found a residential program for him. The service coordinator's email concluded: “He still has some issues with drugs and alcohol, but things are better, he is generally taking his meds, and he is working on communicating with staff about when he will be at the group home.”

In my role, when I get subsequent feedback about our cases, it is never good news. You cannot imagine how wonderful it was to get this communication—and the day before Thanksgiving no less!

My conclusions about this case are:

  1. We should never give up on our clients. We can never know how many times it might take before our interventions “stick”. We all concluded that Harry was a man who just didn't want our help, and yet, look what happened.
  2. Our system often fails to recognize the efforts of the lowest paid line staff, and yet these underpaid and often undervalued individuals may see the truth better than anyone else. Harry didn't want to come in to our programs for reasons he viewed as rational. “They take my money.” “They don't let me come and go when I want.” “I like to drink.” So instead, the mobile treatment program and the service coordinator went along with him and were simply “there” when he was ready to take a step in their direction. Will they be recognized for their good work?
  3. Motivational approaches are so, so important. When we asked Harry to do what we wanted him to do, he wouldn't do it. But when these creative providers met him where he was at, eventually they enticed him to move in their direction. Client-centered approaches sound so weak because they let the client drive the direction of the intervention(s); but in so many cases, it is the strongest approach we can devise.

One point of this blog is simply to recognize publicly the good work done by our line staff, who often go unrecognized. The bigger point is that we should never give up, never listen to the naysayers who tell us that these complex, multisystem patients cannot be helped because they are “somebody else's problem.”

I hope you all had a meaningful Thanksgiving holiday and found much for which you are grateful, and all the best for a meaningful upcoming holiday season.

Erik Roskes, a regular blogger for The Crime Report, is a forensic psychiatrist and currently the Director of Forensic Services at the Springfield Hospital Center in Maryland. He welcomes readers comments. The opinions expressed are those of the author only, and do not represent those of any of Dr. Roskes' employers or consultees, including the Maryland Department of Health and Mental Hygiene. He can be found at

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