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精神健康:如何治疗不承认自己生病的人

更新时间:2018-9-11 21:43:03 来源:纽约时报中文网 作者:佚名

How do you treat someone who doesn't accept they're ill?
精神健康:如何治疗不承认自己生病的人

On 3 July 2014, Misty Mayo boarded a Greyhound bus bound for Los Angeles. Desperate to escape her hometown of Modesto in Stanislaus County, 300 miles north in California’s Central Valley, the 41-year-old thought the 4th of July fireworks in LA would be the perfect antidote.

2014年7月3日,米斯蒂(Misty Mayo)登上了一辆开往洛杉矶的灰狗大巴。41岁的她拼死要逃离家乡,即位于加州中央谷地以北480公里斯坦尼斯劳斯县的莫德斯托镇。米斯蒂认为,洛杉矶在7月4日燃放的国庆烟火会是完美的解药。

Even a mugging at the Modesto bus station didn’t deter her. When she arrived in LA the next morning with just a few dollars in her pocket, Misty immediately asked a police officer for directions to the fireworks display. She also knew she would need to find a Target pharmacy to refill her medication, but decided it could wait until later.

即使在莫德斯托汽车站遭遇抢劫,也没能阻止她离去的决心。第二天早上抵达洛杉矶的时候,米斯蒂的口袋里只剩下几块钱,她马上向一个警察打听烟花汇演的方向。她也知道自己需要找一家塔吉特药房去补充她需要的药,但最后还是决定等等再说。

Later came and went. With no money in a strange city, Misty found the bus system too confusing to navigate. The longer she went without her cocktail of antipsychotics to keep the worst symptoms of her schizoaffective disorder at bay, the more difficult it became to remember that she even needed medication. In the sweltering July heat, Misty roamed the streets of Santa Monica, trying to grab a few minutes of shut-eye where she could. Mostly, she was too afraid to sleep.

等等之后又是再等,一拖再拖。在一个陌生的城市里,身无分文的米斯蒂发现这里的公交系统让人摸不着头脑找不着北。控制分裂情感障碍出现严重症状的抗精神病混合药物漏服的时间越长,她就越记不住自己甚至还需要服药。在七月炎热的酷暑中,米斯蒂在圣莫尼卡的街头漫无目的地游荡,在能睡觉的地方闭眼眯一会儿。但她太害怕了,多数时候根本不敢入睡。

Misty’s worsening mental state left her combative and paranoid. Her memories of this time are vague at best, but hospital records show a series of psychiatric hospitalisations during July and August. She was arrested at least once. By now, Misty no longer recognised that she had a health problem. Not surprisingly, she didn’t take her medications once out of hospital, and the cycle repeated itself over and over.

米斯蒂不断恶化的精神状态,令她变得好斗和偏执。她对这段时间只有模糊的记忆,但医院的病历显示,在七月和八月间,她多次因精神病住院治疗。她还至少被捕过一次。但现在,米斯蒂认识不到自己有健康问题。毫不奇怪,她出院后就没有再服药,这样的一个循环一直在持续。

Back in Modesto, Misty’s mother, Linda, felt her worry turn to panic as the days passed without word from her daughter. She filed a missing persons report, and the next time police picked up Misty for her latest infraction, Linda got a phone call. Knowing where her daughter was, however, didn’t mean that she could help Misty, and she watched her daughter’s deterioration with horror and fear.

在莫德斯托,米斯蒂的母亲琳达几天一直没有女儿的消息,担忧变成了恐慌。她向警局报了失踪,随后警察以违规罪逮捕了米斯蒂,这时琳达接到了电话。然而,知道女儿在何处,并不意味着她就能帮上忙,看着女儿的情况越来越严重,她感到恐惧和害怕。

“There really isn’t anything we can do. The only time she’s going to get help is if they put her in the hospital, and the only way they’ll put her in the hospital is if she’s a danger to self or others,” Linda says. Wandering the streets and shouting at strangers, without adequate food and water, didn’t qualify.

琳达说,"我们真的是无能为力。她唯一能得到的帮助就是他们把她送到医院;但他们送她进医院只会在她的行为会危及自身或者他人的时候。"而在街头流浪,冲着陌生人大喊大叫,没得吃没得喝,这些都不算事。

What Misty needed, Linda believed, was a programme that would require her to take the medications that had been helping her in Modesto without having to be admitted to hospital. A bill in California could enforce this, but it had not been passed in Stanislaus County. Known as Laura’s Law, the bill allows courts to order what’s known as assisted outpatient treatment (AOT) to people with severe mental illness if they meet specific criteria, including previous hospitalisations or arrests, being noncompliant with outpatient treatment, and becoming dangerous to themselves or others.

琳达认为,米斯蒂需要的是一个法规,规定她必须服用在莫德斯托一直有效的那些药物,而不必住院。加州有一项法案可以强制执行这个做法,但此法规未能在斯坦尼斯劳斯县获得通过。该法案名为《劳拉法》(Laura's Law),允许法院对患有严重精神疾病的患者下令进行所谓的辅助门诊治疗(AOT)——只要他们符合一定的标准,包括此前有住院或被捕的历史、拒绝治疗、对自己或他人造成危险等。

The law, however, is not without its critics. Civil rights advocates argue that the state shouldn’t have the right to deprive someone of their liberties with forced treatment. Some psychiatrists say that AOT simply doesn’t work. Linda’s quest to get Laura’s Law passed in Modesto, together with Misty’s experiences in LA, highlight the high-stakes battle to find the best ways to help people with severe mental illness who, like Misty, may not recognise their own condition.

不过,这部法律也并非没有反对的声音。公民权利倡导者认为,国家无权通过强制治疗的方式剥夺患者的自由。一些精神科医生则说,AOT根本不起作用。琳达寻求莫德斯托通过《劳拉法》的努力,连同米斯蒂在洛杉矶的经历,凸显了寻求严重精神疾病患者(他们像米斯蒂一样,可能搞不清自己的健康状况)最佳疗法这一战之举足轻重。

As a leading neurologist at the Hôpital de la Pitié in Paris, Joseph Babinski was used to seeing all sorts of unusual phenomena. But in 1914, two patients stuck out. Both had damage to the right hemispheres of their brains, leaving them paralysed on the left side of their body (each brain hemisphere controls the opposite side of the body).

巴宾斯基(Joseph Babinski)是巴黎皮提耶医院(Hopital de la Pitie)的首席神经病科医师,精神病患者各种奇怪的现象在他眼里都习以为常。但在1914年,两名病人引起了他的注意。两人都是右脑受损,导致他们的身体左侧瘫痪(每个大脑半球控制着身体的另一侧)。

For an experienced neurologist like Babinski, this was hardly noteworthy. What did strike him was that both patients insisted they were completely normal. They were unaware that there was anything wrong with them. In a 1914 medical journal article, Babinski explained that when he recommended electrotherapy to one of these patients, she replied, “Why do you want to electrify me? I am not paralysed.” He coined a new word to describe this symptom: anosognosia, literally meaning ‘without knowledge’.

对于像巴宾斯基这样经验丰富的神经病科大夫来说,这样的病情几乎不值得注意。令他感到震惊的,是这两名患者都坚称自己完全正常。他们根本没有意识到自己有什么问题。巴宾斯基在1914年医学杂志上的一篇文章里解释说,当他向其中一个病人推荐电疗时,她回答,"你为什么要电我?我又不是瘫子。"他造了一个新的术语来描述这种症状:病感失认(anosognosia),字面意思就是"不知情"。

Unlike in denial, when an individual knows there’s something wrong but insists they’re fine, Babinski believed that his patients weren’t fibbing or confused; they genuinely had no concept that half their body was paralysed. Something in their brains – he couldn’t say what – was damaged. For the next eight decades, anosognosia featured exclusively in the neurology literature, associated with physical conditions. Not until the mid-1990s did a few psychiatrists begin to try and apply the word to their patients, too. The pushback came almost immediately.

这不同于拒绝接受现实,即当一个人知道有什么不对劲却坚持自己没事,巴宾斯基相信他的病人没有撒谎或者犯糊涂,他们是真的不知道自己半边身体是瘫痪的。他们的脑子有什么损坏了,但巴宾斯基也不知道是什么坏掉。在接下来的80年时间里,病感失认症只出现在神经病学文献中,而且只与身体状况联系在一起。直到90年代中期,才有少数精神病学家开始尝试将这个术语用在他们的病人身上。但反对声音几乎是立即冒了出来。

The idea that some people with mental illness lack insight into their condition wasn’t new. It had been codified in the Diagnostic and Statistical Manual of Mental Disorders (or DSM, psychiatry’s bible) for several illnesses, including schizophrenia and anorexia nervosa. But using the word anosognosia was another matter entirely, says Dinah Miller, a psychiatrist at the Johns Hopkins University School of Medicine.

一些患有精神疾病的人对自己的状况缺乏了解,这并不新鲜。这个医学术语已经编入了《精神疾病诊断与统计手册》(简称DSM,可谓精神病学的圣经),包括精神分裂症和神经性厌食症在内,都有可能出现病感失认。但约翰霍普金斯大学医学院的精神病学家米勒说,使用这个术语则完全是另一回事。

“It’s a politically charged word,” she says. “When someone uses it, by extension, it has come to mean that they are in favour of legislation to make it easier to treat patients against their will. Instead of being a medical treatment issue, it becomes a civil rights issue.”

她说,"这是一个带有政治意味的术语。再则,当有人用这个词的时候,就意味着他们是赞成立法的,以便违背患者的意愿进行治疗。这不是一个医疗问题,而是一个公民权利问题。"

But for Linda Mayo, the question of her daughter’s right to refuse treatment must be balanced against her right to have a roof over her head and food on the table. When she isn’t taking her medications, she ends up in jail, which also takes away her civil rights.

但对琳达来说,她女儿有权拒绝治疗的问题,必须与她有房子住、有食物吃的权利相平衡。若是不吃药,她就会被关进监狱,这也剥夺了她的公民权利。

At a snug ranch in Modesto, just a few streets away from where she raised her family, Linda pulls out a stack of photos. Legs tucked under her long, flowing skirt, Linda flips over photo after photo of what could pass for the all-American family. On top there are faded 1970s baby photos of Misty, curly blonde hair pulled back in pigtails. Then dance classes, sequined costumes, broad smiles. Middle school, her hair darkening to a medium brown, then high-school graduation.

在莫德斯托一个舒适闲逸的牧场,那里距离琳达把孩子抚养成人的地方只有几条街的距离,她拿出了一叠照片。穿着及踝的飘逸长裙,琳达翻着一张张照片,这些照片看上去跟任何一个美国家庭没有什么两样。最上面的是70年代米斯蒂小时候的照片,照片已经褪色,她卷曲的金发在脑后编成马尾辫子。然后是舞蹈班的照片,她穿着镶有亮片的衣服,脸上是灿烂的笑容。初中的照片,她的头发已经变成了不深不浅的棕色;然后是高中毕业照。

The first sign that something was wrong came as Misty started university. Her mental health took a nosedive. She became paranoid and combative, convinced people were abusing her. She experienced delusions, which psychologists define as unshakable beliefs despite overwhelming evidence to the contrary. Misty’s delusions were that she had been raped or had had some sort of medical procedure done while she was unconscious. And she found it impossible to hold a conversation, jabbering on incoherently. These are characteristic symptoms of schizophrenia, a mental illness that affects one in 100 people. It can also bring social and cognitive difficulties.

不对劲的第一个迹象出现在米斯蒂开始念大学的时候。她的精神健康急剧下降。变得偏执、好斗,认为大家都跟她过不去。她产生种种妄想,心理学家将其定义为不可动摇的信念,尽管有压倒性的证据可以证明事实并非如此。米斯蒂的妄想包括她曾被人强奸或者在她失去知觉的情况下被人动过手术。米斯蒂发现无法与人进行对话,说起话来莫名其妙、语无伦次。这些都是精神分裂的典型特征,每100个人当中,就有一人受到这种精神疾病的影响。此外还带来社交和认知方面的困难。

Despite the initial chaos in her early 20s, Misty did well after being diagnosed and starting medication. Nearly 90% of people with schizophrenia are unable to work, but Misty was a hairdresser for nearly 20 years.

尽管她是在20岁出头的时候开始出现最初的精神失常,但经诊断开始服药后,情况很不错。近90%的精神分裂患者无法工作,但米斯蒂做了近20年的美发师。

Things started to unravel again at Linda’s 60th birthday party in the summer of 2010. That day was the high-water mark in her life, the last time things were OK. She pulls out another photo. “That’s it,” she says. “That’s the last family photo we have.”

2010年夏天,琳达60岁的生日派对上,平安无事的生活再次开始分崩离析。那天是琳达人生中的高潮,也是最后一次事事顺利。她拿出另一张照片。"就是这张,"她说。"这是我们最后一次照全家福。"

Misty slowly stopped responding to medication. Her hours at a chain hairdressing salon were cut, making her ineligible for the company’s health insurance, which left her unable to pay for a new cocktail of meds that might have kept her symptoms under control. The photos at the bottom of Linda’s stack are a dramatic contrast to the smiles at the beginning. Antipsychotic medications led to dramatic weight gain. Misty dyed her hair jet black and her eyes lost their sparkle. She eventually started to refuse outpatient treatment.

药物在米斯蒂身上慢慢没了效果。她在一家连锁美发沙龙的工时被减少,因此失去了公司的健康保险,这使她无力支付一种能有效控制其症状的新的混合药物。琳达手拿的那一叠照片的下面几张,与开始的那些笑盈盈的照片形成了鲜明的对比。抗精神病药物导致米斯蒂的体重急剧增加。她把头发染成了黑色,眼睛失去了光泽。最后,她开始拒绝去看门诊。

“She got to the point where she said, ‘I don’t want to be here. I don’t need these services,’” Linda says.

琳达说, "这个时候她说'我不想呆在这里,我不需要这些服务'。"

Misty had run-ins with the police and was taken to hospital, but did not receive the intensive treatment she needed. Her sudden departure to LA made the situation even more precarious.

结果米斯蒂与警察发生冲突,被送往医院,但没有得到她需要的强化治疗。她突然跑去洛杉矶,使她的症状变得更加不稳定。

Linda knew Misty was homeless and unmedicated but had no way to contact her. Even if she did, Misty’s insistence that she was fine tied everyone’s hands, as the law requires that a person be an immediate threat to themselves or others before they can be committed to an institution for inpatient treatment against their will.

琳达知道米斯蒂无家可归,也没有药可服,但却无法联系到她。不过即使联系上,米斯蒂也会坚称自己很好,这让每个人都无能为力,因为根据法律规定,一个人必须对自己或他人构成直接威胁,才能在违背其意愿的情况下送院治疗。

In the end, Misty’s repeated arrests would be her salvation. She was remanded to court-ordered outpatient treatment as part of her parole. For the first time in nearly a decade, Misty was stable, on medication and participating in treatment. To Linda, the order of her daughter’s legal encounters (first jail, then court-ordered treatment) made no sense. What she wanted was a new first step that would prevent these difficulties.

最后,是米斯蒂的一再被捕才会拯救到她。作为假释条件之一,法庭要求她必须进行门诊治疗。这是近十年来,米斯迪第一次稳定地服药和参与治疗。对琳达来说,女儿的法律遭遇(第一步是进监狱,然后是法院的治疗令)是毫无意义的。她想要的是一个一开始就可以阻止这些麻烦事发生的新的措施。

While Linda was venting at a local support group run by the National Alliance on Mental Illness, another parent asked: “Have you heard of Laura’s Law?”

当琳达在国家精神疾病联盟(National Alliance on Mental Illness)下设的一个当地支持团体发泄不满时,一位家长问她:"你听说过《劳拉法》吗?"

With the development of effective antipsychotic medication in the 1950s and 1960s, many psychiatric hospitals in the US and other countries, including the UK, began shutting their doors. An advertisement for chlorpromazine in a US psychiatric journal boasted that “more patients will be released after shorter periods of hospitalisation and fewer patients will require re-hospitalisation. More patients can be treated in the community, at clinics or in the psychiatrist’s office without being hospitalised at all.” The change was billed as a more effective and humane way to treat people with mental illness, with the added benefit that community care cost far less than institutionalisation.

随着20世纪50年代和60年代一些效果不错的抗精神病药物研发出来,在美国以及包括英国在内的一些国家,许多精神病医院开始关门。美国一份精神病学杂志上的一则抗精神病药氯丙嗪广告吹嘘道:"更多患者将在短期住院后出院,而需要再次住院的患者将更少。更多的患者可以在社区、私人医院或精神病医生的诊所接受治疗,而无需住院。"这一改变被宣传为一种更有效、更人道的精神疾病治疗方式,此外 还有一个额外的好处,就是社区护理成本远低于入院治疗。

Antipsychotics were only one factor in the shift towards deinstitutionalisation, which also included a growing awareness of the civil and human rights abuses that often occurred inside psychiatric hospitals. In 1967, California’s then-governor Ronald Reagan signed the Lanterman–Petris–Short Act, a landmark bill intended to halt the “inappropriate, indefinite, and involuntary commitment of persons with mental health disorders, developmental disabilities, and chronic alcoholism”. The bill formed the basis of much of the psychiatric legislation for the rest of the US.

抗精神病药物只是改变了精神病患必需入院治疗的因素之一。其他因素还包括人们对精神病院内经常出现的侵犯公民权和人权行为的日益关注。1967年,时任加州州长的里根(Ronald Reagan)签署了具有里程碑意义的《兰特曼—彼得里—肖特法案》(Lanterman-Petris-Short Act),该法案旨在制止"对精神健康障碍、发育障碍和慢性酒精中毒患者不恰当、无限期和非自愿的治疗责任"。该法案构成了美国其他地方大部分精神病立法的基础。

What resulted wasn’t just a shift away from long-term psychiatric hospitalisation, but also towards giving patients greater control over their own treatment, including the decision whether to receive treatment at all.

其结果不仅仅是改变了精神病患需长期住院治疗的现象,还给病患更大的自主权力来决定自身如何治疗,包括决定是否接受治疗。

In many ways, this transition has been positive for mentally ill individuals, says Carol Stanchfield, programme director at Turning Point Community Programs in Nevada County in north-eastern California. It means patients’ rights aren’t stripped without due process, and it gives them the opportunity to live among friends and family in the community.

加州东北部内华达县转折点社区计划的项目主任斯坦奇菲尔德(Carol Stanchfield)说,从许多方面来看,这种转变对于精神病患者都是正面的。这意味着如果不经过正当法律程序,患者的权利就不会被剥夺,这使得他们有机会在社区与朋友和家人生活在一起,而不是被隔离在精神病院中。

But a major problem was that outpatient treatment was simply not as available as it needed to be. As new legislation narrowed the criteria by which patients could be involuntarily committed, many people affected by mental illness were excluded. Repeated threats of violence were no longer grounds for commitment. The result was that many of the most severely mentally ill were left to fend for themselves on the streets. By the 1980s, one observer noted that a patient’s basic rights were “being exercised in a vacuum with none of the attendant supports and backup systems in place to make it viable”. Instead of hospitals, many ended up in jail, arrested for nuisance crimes. As a result, the country’s prisons have now taken the place of its former mental institutions.

但一个主要问题是,社区门诊治疗根本无法满足病患的需要。由于新的立法收窄了对患者作强行治疗的标准,许多受到精神疾病困扰的患者结果是被排除在治疗之外。反复的暴力危险不再是关进精神病院的理由。结果,许多最严重的精神病患者被迫在街头自生自灭。到了20世纪80年代,一名观察人士指出,患者的基本权利犹如是"在真空中行使,没有任何切实可行的辅助支持和跟进系统"。许多患者没有进医院,而是进了监狱,是因为滋扰罪而被捕坐牢。结果,这个国家的监狱现在取代了以前的精神病院。

At the time, many psychiatrists failed to appreciate the impact of a person’s impaired insight on their ability to accept treatment. But if you don’t believe you’re sick, why would you see a doctor and pay for often expensive medications that come with a host of annoying and potentially dangerous side-effects?

当时,许多精神科医生都没有意识到,一个人受损的内省力或曰自知力对其接受治疗能力的影响。如果你不相信自己有病,为什么你会去看医生,购买往往价格不菲的药物呢?更何况这些药物会带来许多烦人的、有潜在危险的副作用。

“The very biggest barrier for these individuals to seek and maintain treatment is anosognosia,” says Stanchfield. “They don’t recognise that they have an illness. Of course, if they’re unaware of their own mental health condition, then they really can’t accurately see the need for any treatment.”

斯坦奇菲尔德说,"这些人寻求和维持治疗的最大障碍是病感失认。他们不承认自己有病。当然,如果他们没有意识到自己的精神健康有问题,那么他们真的无法准确地看到任何治疗的必要性。"

Stanchfield’s office is just down the hall from where, on 10 January 2001, Scott Thorpe walked into the Nevada County Behavioral Health Department and shot three people. Described as “paranoid and reclusive” by neighbours, Thorpe was intermittently receiving county mental health services, but had rejected his family’s and social workers’ attempts to have him hospitalised. Since he wasn’t ruled an immediate danger to others, no one could make him go.

2001年1月10日,索普(Scott Thorpe)走进内华达县行为健康部,开枪打死三人,而斯坦奇菲尔德的办公室就在健康部的门厅那一头。被邻居们描述为"偏执和孤僻"的索普,间歇性地接受县里的精神健康服务,但他回绝了家人和社会工作者让他住院的尝试。由于他没有被裁定为对他人构成直接威胁,所以无法强迫他住进医院。

One of the people Thorpe killed was 19-year-old Laura Wilcox. In their grief, her parents searched for something that would help prevent similar tragedies. They found Kendra’s Law, named after Kendra Webdale, a 31-year-old who died after being pushed in front of a train by a man with untreated schizophrenia in January 1999. This law in the State of New York allows judges to order psychiatric patients with a history of hospitalisations, treatment noncompliance and severe deterioration to be required to attend outpatient treatment as a condition of continuing to live in the community.

死于索普枪下的,有19岁的劳拉·威尔科克斯(Laura Wilcox)。她的父母悲痛欲绝,希望能做点什么,防止类似悲剧再次发生。他们发现了肯德拉法(Kendra's Law),该法以肯德拉·韦德尔(Kendra Webdale)的名字命名。1999年1月,肯德拉被一名未接受治疗的精神分裂患者推下地铁站台而死。纽约州的这项法律允许法官下令有住院史、拒绝接受治疗和状况严重恶化的精神病患者必须接受门诊治疗,以此作为可以继续在社区生活的条件。

Inspired by Kendra’s Law, the Wilcoxes lobbied for the creation of Laura’s Law in California. With the state still reeling from the tragedy in Nevada County, the California legislature passed Laura’s Law in 2002. One caveat was that each of California’s 58 counties would have to approve Laura’s Law individually before the law could be enacted in their jurisdiction.

受肯德拉法的启发,威尔科克斯游说加州通过《劳拉法》。由于内华达县的悲剧造成的震惊仍未过去,加州议会在2002年批准了这项法律。需要指出的是,加州58县每个县都必须各自批准《劳拉法》,之后此法才能在其管辖范围内生效。

Nevada County was the first in 2008. But only a handful of other counties followed. In Modesto, Linda Mayo wanted Stanislaus County to add its name to the list. Hoping the law would alleviate a small fraction of the worry she had experienced as the mother of a child with a serious mental illness, Linda turned into a one-woman media machine. She wrote countless editorials to the local newspaper and joined Facebook groups to promote her cause. Other families struggling with mental illness joined her, sharing stories of family members who had suffered and died because they were too sick to recognise they needed help.

内华达县在2008年第一个批准该法。但只有少数几个县跟进通过。在莫斯托,琳达希望斯坦尼斯劳斯县也能通过此法。她希望这项法律能稍微减轻自己身为一个严重精神疾病患子女的母亲所经历的沉重忧虑。她变成了单身独行的媒体机器。她给当地报纸写了无数的社论,还加入Facebook群组来宣传她的诉求。其他与精神疾病作斗争的家庭也加入了她的行列,他们分享了家庭成员因为病得太严重,意识不到自己需要帮助,结果历经痛苦而死的故事。

With a swelling homeless population, many of whom had serious mental illnesses, and against the backdrop of endless mass shootings across the country that were (rightly or wrongly) linked to mental illness, the Stanislaus County Board of Supervisors had plenty of motivation to act. And on 15 August 2017, they did, approving a three-year pilot study of Laura’s Law, becoming the 18th county in California to approve it.

随着无家可归的人越来越多(其中许多人患有严重的精神疾病),以及在全国各地不断发生与精神疾病有关(有真有假)的大规模枪击事件背景下,斯坦尼斯劳斯县议会有充分的动机采取行动。在2017年8月15日,他们批准了一项为期三年的《劳拉法》试点研究,成为加州第18个批准该法案的县。

But for opponents of mandatory psychiatric treatment, the passage of Laura’s Law in Stanislaus County was anything but a victory.

但对于反对强制精神病治疗的人来说,《劳拉法》在斯坦尼斯劳斯县的通过绝不能算是一场胜利。

The night before her graduation from the University of Pennsylvania, Emily Cutler could no longer fight the feelings of despair that overwhelmed her. As much as she didn’t want to die, she also wasn’t sure she could go on living.

在宾夕法尼亚大学(University of Pennsylvania)毕业的前一天晚上,卡特勒(Emily Cutler)再也无法抵抗那种让她崩溃的绝望感。虽然她不想死,但也不确定自己能否继续活下去。

Cutler took double her usual dose of Xanax to try and make it through the night. The extra drugs made it difficult to walk and talk, and she ended up in the emergency room. Doctors asked her if she was suicidal, and she insisted she wasn’t. She was depressed and upset, yes, and as much as she wished she might get hit by a bus, she had no plan to harm herself. The physicians weren’t convinced and placed her in a glass room for 10 hours before they committed her involuntarily to a local psychiatric hospital.

卡特勒服用了两倍于常用剂量的阿普唑仑,想要熬过那一夜。过量服用令她走不了路说不了话,最后她被送到了急诊室。医生问她是否有自杀倾向,她坚持说没有。是的,她很沮丧,也很难过,虽然她盼着自己被公共汽车撞死,但她并没有打算伤害自己。医生们不相信她的话,把她留置在一间玻璃房达10个小时,然后在她非自愿的情况下,将她送进了当地的一家精神病院。

For the next 48 hours, Cutler sat in an isolation room, having been strip-searched and forced to take medicine. Eventually, the psychiatrists agreed that she posed no risk to herself and discharged her. To Cutler, the experience of forced treatment was unbearably traumatic.

在接下来的48小时里,卡特勒坐在隔离室里,被强迫脱衣搜身及服药。最后,精神科医生认为她不会对自己造成危险,才让她出院。对卡特勒来说,强迫治疗的经历是令人难以忍受的创伤。

In the aftermath of her experience, Cutler started a group called Southern California Against Forced Treatment, which argues against Laura’s Law and any kind of forced psychiatric treatment. Her goal is to provide support for people traumatised by AOT and inpatient commitment, and she has closely followed the expansion of Laura’s Law into Stanislaus County. Cutler specifies that her group isn’t anti psychiatry; it opposes only involuntary treatment. She points to what she calls psychiatry’s double standard: “When I said I didn’t want to be locked up, when I said I didn’t want treatment, it was instantly, ‘Oh, wow, she’s so sick that she doesn’t even have insight into her own need for treatment,’” Cutler says.

在那段经历之后,卡特勒成立了一个名为"南加州反对强迫治疗"(Southern California Against Forced Treatment)的组织,该组织反对《劳拉法》和任何形式的强迫精神病治疗。她的目标是为那些因辅助门诊治疗和送进精神病院而受到创伤的人提供支持,她一直密切关注《劳拉法》在斯坦尼斯劳斯县的进展。卡特勒指出,她的组织不是反精神病学,反对的是非自愿治疗。她指出了她所谓的精神病学的双重标准:"当我说我不想被关起来,当我说我不想接受治疗时,马上的反应就是,'哦,哇,她病得好严重,她甚至不知道自己需要治疗,'"

“With any other issue that someone might have, if they don’t want a certain type of help for it, or they don’t want to take a certain type of action, we don’t use that, usually, to further justify, ‘Well look, they really need the treatment now, and we can really force it on them.’”

卡特勒说,"如果有人在其他方面有问题,如果他们不想要某种类型的帮助,或者他们不想采取某种行动,我们通常就不会以此来进一步证明:'好吧,他们现在真的需要治疗,我们真的可以强迫他们这么做。'"

San Diego forensic psychiatrist Nicolas Badre agrees that this can lead to problems: “We have the sense that people don’t have insight sometimes, like people seem to make claims or decisions that clearly seem against what we see as reality. It’s a different sort of path to go down, because then you sort of assume that everything the patient says [that] doesn’t agree with you, that’s lack of insight, or anosognosia. And it gives you free range to not listen to the patient. And that’s the real danger with it.”

圣地亚哥的法医精神病学家巴德尔(Nicolas Badre)也认为,这可能会导致一些问题:"我们感到人有时候会缺乏内省力,比如有人似乎做出了与我们所看到的事实截然相反的声明或决定。这是一种不同的行为方式,因为这样你就会在一定程度上假设,患者说的每件事都跟你不一致,这是缺乏内省力,或者说是病感失认。这个判断就会给你不聆听患者意见的自由空间。这才是真正的危险所在。"

In the end, Badre says what makes anosognosia difficult in psychiatry is a lack of neuroscientific data on the topic. “I don’t think we have evidence that schizophrenia intrinsically makes the brain have this issue.”

最后,巴德尔说,在精神病学中难以识别病患是否出现病感失认的原因是,缺乏相关的神经科学数据。"我认为我们没有证据表明,精神分裂在本质上让大脑产生了这个问题。"

Maybe not, argues DJ Jaffe, founder of the think-tank Mental Illness Policy Org and an advocate for the severely mentally ill, but a variety of brain-imaging data shows that the brain of someone with schizophrenia functions differently compared to a neurotypical brain.

智库"精神疾病政策组织"(Mental disease Policy Or)、严重精神疾病的权益倡导者贾菲(DJ Jaffe)则认为,也许并非如巴德尔所说缺乏科学数据,现各种大脑成像数据都显示,精神分裂症患者的大脑跟神经正常的大脑在机能上是存在差异的。

“The way I describe it is when you see somebody walking down the street [who thinks] they have a transmitter in their head, it is not because they believe they have a transmitter in their head. They know it. Their illness tells them so. And this is the group who won’t accept treatment, and treatment can restore their free will. Being psychotic is not an exercise of free will. It is the inability to exercise free will.”

"我的描述是,当你看到有人走在街上,(认为)自己的脑袋里面有一台发射器,那不是因为他们相信自己的脑袋里有发射器。是他们知道有发射机存在。是他们的病让他们这么认为。这就是那个不愿意接受治疗的群体,治疗可以恢复他们的自由意志。身为精神病患者,不是对自由意志的行使,而是无法行使自由意志。"

Diagnosing anosognosia does not give anyone, court or physician, the inherent right to mandate someone to treatment. What anosognosia does, Jaffe says, is provide a simple, if hard-to-pronounce, term to explain why so many people with schizophrenia and similar illnesses often behave as if they are unaware that their thinking and behaviour are so dramatically different.

进行病感失认症的诊断,并没有赋予任何人——法院也好医生也好——天然的权力去强制某人接受治疗。贾菲说,病感失认症不过是提供了一个简单的(但难发音的)术语,来解释为什么那么多患有精神分裂和类似疾病的人,经常表现得好像完全没有意识到自己的想法和行为是多么的异于常人。

Just as importantly, he says, AOT works. Six years after Kendra’s Law was implemented in New York, officials had logged a 77% decrease in psychiatric hospitalisations and a 74% decline in homelessness for people in the AOT programme; incarcerations had dropped by 87%. In 2015, seven years after the implementation of Laura’s Law, Nevada County reported that people who had completed the AOT programme spent 43% less time in hospital, 52% less time in prison and 54% less time homeless than before they were treated.

他说,同样重要的是,辅助门诊治疗是有效的。纽约州施行《肯德拉法》6年后,官员们发现在相关项目中,精神病人住院人数下降了77%,无家可归人数下降了74%;监禁人数下降了87%。2015年,在《劳拉法》实施7年后,内华达县报告说,与接受治疗前相比,完成了辅助门诊治疗项目的患者住院时间减少了43%,入狱时间减少了52%,无家可归的时间减少了54%。

In North Carolina, Duke University psychiatrist Marvin Swartz randomised individuals who met AOT criteria to receive either AOT or what he termed “assertive community treatment”, the Cadillac of public outpatient treatment, consisting of social services, including help with housing, food and transportation, as well as psychological and psychiatric services. AOT won, and although it wasn’t as crushing a victory as advocates may have hoped, Swartz’s data showed that longer court orders for up to nine months of regular treatment were associated with better outcomes than three-month orders and less-intensive treatment.

在北卡罗来纳州,杜克大学(Duke University)的精神病学家斯沃茨(Marvin Swartz)随机挑选了符合辅助门诊治疗标准的患者,让他们接受辅助门诊治疗或者他所谓的"自信的社区治疗",即公共门诊治疗的"卡迪拉克"版本,由社会服务(包括在住房、食物和交通方面的帮助),以及心理和精神服务。结果辅助门诊治疗获胜,尽管并不像支持者门所希望的那样是压倒性的胜利。斯沃茨的数据显示,法庭下达的长达9个月的定期治疗令,比3个月的治疗令和低强度的治疗效果要好。

“There is this effect of the court order in terms of issuing warnings and reminders to the patient about adherence to treatment, but there’s also a more aggressive attempt by the service providers to make sure the person gets the treatment plan that is intended,” he says.

他说:"法庭下令发出患者要坚持治疗的警告和提醒起到了作用,但服务提供商也采取了更积极的努力,以确保患者获得预期的治疗计划。"

However, when British psychiatrist Tom Burns conducted a trial of AOT in the UK, he found different results. The UK equivalent of AOT is known as a community treatment order, although these are often used as a step down from inpatient care rather than an order in and of themselves. (Involuntary inpatient commitment in the UK is governed by sections of the 1983 Mental Health Act; being held in a psychiatric hospital and treated against your will is commonly known as ‘being sectioned’.)

不过,当英国精神病学家伯恩斯(Tom Burns)在英国进行辅助门诊治疗试验时,却发现了不同的结果。英国的辅助门诊治疗被称为社区治疗令,尽管它通常被用作代替住院治疗的一个步骤,而并非什么命令。(在英国,非自愿住院令受1983年《精神卫生法》管辖;违反意愿关在精神病院接受治疗被称为"强行送院"。)

Burns found that community treatment orders had no effect on how well patients did. They weren’t hospitalised any less and didn’t show any more signs of recovery. This, combined with a meta-analysis of UK and US programmes that showed equivalent results, transformed Burns from an enthusiastic supporter of AOT to a vocal critic.

伯恩斯发现,社区治疗令对患者的治疗效果没有影响。他们的住院治疗时间没有减少,也没有任何恢复的迹象。有鉴于此,再加上对英美两国相关项目的数据分析,显示出了同样的结果,这使得伯恩斯从辅助门诊治疗的热心支持者变成了直言不讳的批评者。

“I became aware that this intervention that I’d been very keen on for 20 years, actually if you looked in the cold light of day at the evidence, was not a good intervention,” he says.

他说:"我开始意识到,自己20年来一直非常热衷的干预治疗,实际上,如果你冷静地观察证据,会发现它并非好的干预措施。"

Both sides cite the studies that support their views and criticise the ones that don’t. Jaffe says you can’t compare the UK results with what AOT is trying to do in the US because community treatment orders and AOT are fundamentally different. Burns, for his part, says that because patients in California and New York aren’t randomised to AOT, it’s impossible to tell whether they’re getting better because they have better services or because of the court order. Randomised controlled trials like the one in North Carolina are unlikely to be repeated, which means that both sides will continue to argue their points from imperfect data.

双方都引用对自己有利的研究,批评那些对比自己不利的研究。贾菲表示,你不能将英国的实验结果与辅助门诊治疗在美国要做的事情进行比较,因为两者在根本上是不同的。伯恩斯则表示,由于加州和纽约州的患者并不是随机选择的辅助门诊治疗,因此无法判断他们病情的好转,是因为他们享受到的服务更好,还是因为法庭命令。像北卡罗来纳州那样的随机对照实验不太可能重复,这意味着双方将继续用不完美的数据来论证自己的观点。

After treatment, the insight that often goes missing during a severe mental illness can return, albeit to varying degrees. A substantial number of patients have no memory of their illness at its peak. Others admit they were truly ill, even if they may share secret doubts that their symptoms were really that bad. Many, like Misty Mayo, fall somewhere in between, with memories that are jumbled and confused. She acknowledges that something was going on, but she can’t always remember what, or just how bad it got.

在接受治疗后,在严重的精神疾病期间经常缺失的内省自知力可以恢复,不过程度不尽相同。很多病人对于病情最严重的时候毫无记忆。还有一些人承认他们真的病了,哪怕他们私下里会怀疑自己的症状真的有那么严重。跟米斯蒂一样,许多人都是介于两者之间,记忆杂乱无章。她承认发生了一些事情,但她不能总是记得发生了什么,也不记得有多糟糕。

I meet Misty in San Pedro in southern LA. She lives in a group home where she has assistance with daily living, including medication, cooking and other chores. On a brightly brisk early spring morning, we drive the few blocks from her shabby two-storey adobe apartment building in an equally shabby part of town to Cabrillo Beach. Salt breeze in our faces, we sit and watch the skateboarders and picnickers. Misty turns her face to the sun and visibly relaxes. We chat for nearly an hour about her early life, her diagnosis and how she ended up in LA. Finally, I ask what she thinks of involuntary outpatient commitment.

我在洛杉矶南部的圣佩德罗(San Pedro)见到了米斯蒂。她住在一个团体之家,在那里她可以得到日常生活方面的帮助,包括药物治疗、做饭和其他家务。在一个阳光明媚的初春清晨,我们开车离开她那破旧的两层砖坯公寓楼,经过同样破旧的一片城区,来到几个街区外的卡布里洛海滩。带着咸味的微风吹拂着我们的脸,我们坐在那里,看着那些玩滑板和正在享受野餐的人们。米斯蒂把脸转向太阳,神情很放松。我们聊了近一个小时,聊她早期的生活,她的诊断结果,以及她最后怎么来了洛杉矶。末了,我问她对非自愿住院的看法。

Misty pulls a bag of tobacco out of her purse and rolls herself a cigarette. After lighting it, she takes a long drag and says, “I’m really grateful that I had to get treatment.”

米斯蒂从手袋里拿出一包烟草,给自己卷了一支烟。点上后,她深深地吸了一口,说:"我真的很感激接受了治疗。"

Misty tends to ramble and hop from topic to topic without any interlude, although it isn’t immediately obvious whether this is due to mental illness or simple loneliness. She has a therapist and a care team, and often texts her mother; she has a boyfriend who genuinely cares for her. But her life isn’t perfect. Her apartment is small and her disability income limited. She remains convinced that she has been abused and violated, as well as operated on without her knowledge or consent. If I believed similar events had occurred to me, I think I’d also be fearful and paranoid.

米斯蒂总是漫无目的地从一个话题跳到另一个话题,没有任何过渡;这是由于精神疾病所致还是纯粹因为孤独,并不清楚。她有一名治疗师和护理团队,经常给母亲发信息;她有一个真心关心她的男友。但她的生活并不完美。她住在一个很小的公寓里,残疾收入很有限。她仍然相信自己曾经受到虐待和侵犯,以及在她不知情或者未经其同意的情况下进行过手术。如果我相信自己身上发生过类似的事情,我想我也会害怕和变得偏执。

Despite this, Misty is doing alright. She continues to take her prescribed medication every day, although whether that would continue if she wasn’t supervised remains anyone’s guess.

尽管如此,米斯蒂还是恢复得不错。她继续每天服用处方药,但如果没有监督,是否还会继续服用,就不好说了。

Misty’s parole – and the court-ordered treatment it requires – will expire soon. The date looms large in Linda Mayo’s mind. She hopes Misty continues treatment willingly. But she also holds out hope that Laura’s Law will be in place to help her if Misty ever becomes unable to continue treatment in the future.

米斯蒂的假释,以及法院下令的治疗,将很快期满。这个期限悬挂在琳达的心头。她希望米斯蒂愿意继续治疗。但她也希望,如果米斯蒂将来无法继续接受治疗,《劳拉法》能够帮助她。

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