Committed: The Battle Over Involuntary Psychiatric Care
by Dinah Miller, MD and Annette Hanson, MD
Reviewed by Lloyd I Sederer, MD
Americans act as if they have a covenant that demands of them considerable liberty and privacy. These warranties have, at times and in my opinion, exceeded other warranties such as public safety and the public’s health – sometimes even common sense.
For the practice of psychiatry this has meant substantial constraints on the clinical care of very ill patients, with clear impact on them, their families and their communities. The battle grounds have been drawn, especially in the past few decades, between those who demand liberty and privacy for psychiatric patients and those who advocate for a reasonable freedom on action in these arenas to better serve patients, families and the public.
Liberty refers to the right for freedom from societal constraints, in this case involuntary commitment to hospitals and in the community as well as involuntary treatments. Privacy refers to the right of a person to not have others know their personal, and in this case, medical information – including close family members unless given consent or in emergency situations.
No other issues in mental health seem to ignite flames as great and persistent as do liberty and privacy. When I was a resident, many decades ago, doctors could do what they wanted in admitting and treating psychiatric patients against their will – often irrespective of the wishes of the patient. It was a far more patronizing, “doctor knows best” form of medicine that was undone by psychiatric activists, early on by Dr. Thomas Szasz (a mentor and friend of mine, now deceased) with his disruptive book The Myth of Mental Illness.
Many other civil libertarians followed; then the lawyers and courts got involved. Fast forward to today where it can be more difficult, some say, to involuntarily admit and treat and retain (involuntary) care in the community as it is to be admitted to Harvard College. And others hold opinions as passionate in polar ways, and have become integral to efforts to protect these rights.
Indeed, the pendulum has swung – and needed to – from the unfettered power of doctors and hospitals to do as they may to the right of patients to say no to treatment unless a court mandates such an intervention. But has it swung too far? What is abundantly clear is that just about no one is satisfied, on either side of the “battleground”, with the way things are. But where might the point of equipoise exist?
This is the important question and challenge that Drs. Miller and Hanson have undertaken in what is an exceptionally intelligent, clear, readable and well researched manner. They do have a POV (point of view), which they express early on and weave into the book’s narrative: they call for “…the judicious and limited use of involuntary and humane psychiatric care, as a last resort, after every attempt has been made to thoughtfully engage patients in accessible, kind and comprehensive services on a voluntary basis.” (p. xx).
The debate hinges, of course, on how judicious and limited are defined and acted upon. The authors’ ability to explore the answers to these fundamental questions gives the book great thoughtfulness and substance. And they, as does about everyone else, emphasize that the mental health (and substance disorder) services in this country are woefully underfunded, understaffed, and vary tremendously in the quality and kindness of the care delivered.
Their book first describes the “for” and the “against” arguments for involuntary treatments. They have tapped the nation’s authorities on these subjects so we gain access to the clearest and most informed of sources. Then comes a section on “Civil Rights”, where we learn about the history and processes of commitment laws. The authors then turn their attention to hospitals (general, public and private hospitals), and their delivery of emergency room, inpatient, crisis and outpatient care. They handle this (in fact, all material) in a story-based manner with abundant actual clinical examples, using pseudonyms to protect privacy. It is like we are there to share the dilemmas that patients, families and clinicians face in profound and uncertain ways.
One terribly ironic example they provide (p. 157), faced by many doctors and hospitals in some states (state laws vary), is that even while someone may be involuntarily committed, is in fact quite dangerous to themselves or others, they are not bound to take treatment; as a result, no treatment may be rendered unless a second court action is successfully undertaken leaving the patient locked up and unable to be discharged.
The critical and contentious subject of involuntary outpatient commitment is the subject of their next section. The use of this ongoing restriction in liberty displays an uneven landscape throughout the country (even though extant in 45 states), and even when it exists it may not be adequately funded or actual access to services sufficient. Their next section examines the concepts of “A Danger to Self or Others.” They are not daunted by taking on the subjects of guns, violence among people with serious mental illnesses, mass murders, and the people who take their lives – a preventable tragedy that increases year after year, and the only one of the top ten preventable causes of death that has not decreased in the past ten years.
They demonstrate that the most robust factors that drive violence are not simply the presence of serious mental illness but alcohol and drug use, younger age, psychopathic personality traits, being male and living in poverty. The greatest predictor of violence is a history of violence. In other words, solutions that may decrease mass murders cannot be achieved by singling out people with mental illness, which continues to be a refrain we hear from politicians and gun industry spokespersons.
My brief summary here does not do justice to breadth and depth of their explorations and explanations of involuntary treatments, and the complex of social, economic, political, and ideological forces that surround this topic. They leave us with a final message about how the “battlefield” might be transformed. They do so knowing the enormity of such a transformation and assert that needed changes will be incremental, are possible, and will not just save lives but will provide for fuller and more rewarding lives for those with mental illness and their families. That’s a battle worth fighting.
Dr. Lloyd Sederer is a psychiatrist and public health doctor. The opinions offered here are entirely his own. His latest books are Improving Mental Health: Four Secrets in Plain Sight (2017) and Controversies in Mental Health and the Addictions (2017). His book on drugs in America will be published by Scribner (Simon & Schuster) in early 2018.