I had a client once whom I'll call Julio, who was NGRI for attempted murder -- long Thiem date, big-time Axis-I diagnosis, the works. He went back & forth from Elgin Mental Health Center to Chester Mental Health Center a couple times. He didn't like taking meds, so he stopped without mentioning it to his treatment team.
Maybe he wasn't too good at "cheeking" the meds. I don't know. But somebody at Elgin suspected him, and they put him on crushed meds mixed in his food. He still managed to not take all his meds somehow. (I never wanted to know his particular technique or slight-of-hand, that would ruin the magic.) Right around this time he called me, because it wasn't easy.
Julio wanted me to convince his treatment team to put him back on the regular meds in pill form so he'd be able to cheek them more easily. I told him, well, I could do that maybe, but I really wanted him to come clean and refuse meds overtly. After a couple months he did that. Awhile later he was advising people that aliens were going to attack them spiritually, and the only way they could escape was to commit suicide. Of course, they sent him back to Chester.
Julio agreed to take some meds at Chester, and stopped talking about aliens and being Christ. The Chester psychs soon decided he was well enough to go back to Elgin. Thus the stage was set for an interesting meeting, which is my main story here....
Elgin, being a medium security facility, had to agree to take Julio back from Chester, which is a maximum security institution. So they all had a big video conference. The object was to figure out whether this patient was really better and could be trusted not to warn anyone about aliens or think he was Christ, in a setting which was not maximum security. It was sort of a parole hearing.
Julio was a smart man. He could put on a very professional face, with loads of intelligent confidence and agreeability. He admitted to everyone in the big video conference that he had "decompensated" and become delusional about the aliens and Christ and so on, at Elgin. He explained in great detail his own understanding of how that had occurred. He answered questions from various inquisitors readily as required. He really seemed like the kind of guy that any medium security nuthouse would be quite happy to have as a patient....
But his previous psychiatrist at Elgin was not buying it. She'd been fooled for months by this guy, when he'd told her he was taking his meds but it was a lie. Her only real job had been to prescribe the meds, manage the meds, evaluate how the meds were working. He had made her look very stupid, and she bore a grudge.
Everybody wanted to know Julio's attitude about meds. Why had he stopped taking them previously? How was he doing with them now? What was the dose? Did he understand that they helped him? Did he agree that he needed these meds to keep the delusions about aliens and Christ from coming back? (It was Abilify as I recall.... Nobody quite asked if he recognized that those delusions had been caused by an Abilify deficit in his brain, at least not in so many words. But they came pretty close.)
Then came key question from the Elgin psychiatrist: "If you're allowed to come back to Elgin, will you promise in advance to take whatever medication any doctor prescribes, and take it in crushed form, and take it in whatever dose your doctor thinks is right, and agree to change the dose or the medication whenever the doctor wants to?"
Julio had explained that the reason he had surreptitiously stopped taking meds was that he was afraid he'd be taken to court and forced to take them if he told anyone he just couldn't deal with the side effects anymore.
In one breath, all these "clinicians" insisted that the whole trick was collaboration. If Julio would just be open and honest with his treatment team, tell them his thoughts and his symptoms, etc., everything would work out well. This should be true. This is the theory of the forensic mental health system, and even the theory of mental health treatment in general, as it's presented to the public.
But in the other breath, the Elgin psychiatrist demonstrated exactly why it was impossible, why it's all a lie: "Promise in advance to take whatever meds your doctors tell you no matter what you think, or you'll never get out of Chester."
That's the way it still is in the state nuthouse system, and probably always will be.
"Take the meds we tell you to take no matter how bad you think they are, no matter how much they hurt you, or you'll never get out of here. Now admit that this is a hospital, and we're all collaborating to help you."
The terms Soviet psychiatry and psychiatric coercion are redundant. Voluntary psychiatry and psychiatric help are oxymorons.
George Orwell, how do you do!