Psychiatrists Dinah Miller and Annette Hanson offer a thought-provoking and engaging account of the controversy surrounding involuntary psychiatric care in the United States. They bring the issue to life with first-hand accounts from patients, clinicians, advocates, and opponents. Looking at practices such as seclusion and restraint, involuntary medication, and involuntary electroconvulsive therapy–all within the context of civil rights–Miller and Hanson illuminate the personal consequences of these controversial practices through voices of people who have been helped by the treatment they had as well as those who have been traumatized by it.
The authors explore the question of whether involuntary treatment has a role in preventing violence, suicide, and mass murder. They delve into the controversial use of court-ordered outpatient treatment at its best and at its worst. Finally, they examine innovative solutions–mental health court, crisis intervention training, and pretrial diversion–that are intended to expand access to care while diverting people who have serious mental illness out of the cycle of repeated hospitalization and incarceration. They also assess what psychiatry knows about the prediction of violence and the limitations of laws designed to protect the public.
Involuntary care is a a minefield of ethical conundrums. How do you decide who needs treatment? What if the patient calmly refuses it? Will the treatment itself be more traumatizing than beneficial? How can you ethically hold people against their will? And when is it okay to let them go?
Miller and Hanson cover as many points of view as humanly possible, from pro-involuntary treatment groups like the National Alliance on Mental Illness to anti-anything-psychiatry groups like Scientology. (Yes, they managed to interview a Scientologist for this book. It’s kind of amazing.) There are all kinds of opinions between the extremes that are also covered – those who would rather see outpatient commitment instead of inpatient, for example, and people who want to help patients recover with or without medication. They also speak with professionals that are involved in the civil commitment process, from judges and lawyers to police officers and ER doctors.
There is a ton of information but it never gets overwhelming. The narrative is loosely hung on the cases of two patients, one who had a positive experience with involuntary care and one who was traumatized by her time at the hospital. Though interviews with these patients, their families and doctors, and peeks at their medical charts, we see how forced care could be the best or worst thing to happen to someone. Their journey is covered from being picked up by police or brought in by a family member, through civil commitment trials and treatment, to how they were determined to be fit for release.
Laws widely vary across the United States and their differences are an illustrative example of what policies seem to work and which should be rethought. As a result Committed gives you a framework of possibilities that you can use to examine the laws that affect you, no matter where you live.
The thing that strikes me most about this book is the care and consideration that went into it. Miller and Hanson, psychiatrists, never deride anyone for their views. They sat across the table from people who think their profession is basically evil and held a civil, thoughtful conversation. If there’s an outrageous factual error they’ll mention it in passing with research to back them up, but otherwise everyone is allowed to say their piece exactly as they’d like in a non-confrontational environment. Mad props.
They’re also forthcoming about the circumstances surrounding their reporting. Getting an inpatient unit to agree to Miller observing was harder than they thought, and they are upfront with the fact that the only hospital that would agree has one of the best psychiatric departments in the country. And try as they might they couldn’t get anyone to talk about guns and mental illness on the record.
Doctors, [the gun club representative] noted, are seen by gun owners as an extension of the government. …people were happy to engage in casual conversation, but before they would speak in depth, they wanted reassurance that we were not in favor of gun control, regardless of whether that was relevant to the topic of the book.
Any time I thought there might be a hole in the reporting or an odd circumstance it was covered in this thorough, thoughtful manner. The authors have earned all of my respect.
Committed is a must read for anyone whose job brings them in contact with people with psychiatric illness as well as anyone with an interest in civil rights. And if you’re curious about how mental hospitals work (aren’t we all?) it’s a fascinating look at this “hidden world, open only to those who are in enough despair to gain admittance”.
Thanks to Johns Hopkins University Press and Edelweiss for providing a review copy.
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