Review: Committed, Dinah Miller and Annette Hanson

Note: I received a copy of Committed from the publisher for review consideration.

I maintain a master list of Claims that Require Heightened Scrutiny, and the number one item on my list — indeed the reason I started to maintain the list — is this: Any claim that a complicated problem has a simple solution. Nothing infuriates me more1 than people insisting that a complicated thing is actually very simple if people would just look at it in a new way. No! Systems are complicated! Even when there is a simple solution (e.g., we have a vaccine that prevents polio), the implementation of that solution remains immensely complicated, because there are a lot of other factors in play besides the obvious medical one.

So Dinah Miller and Annette Hanson’s book Committed: The Battle over Involuntary Psychiatric Care (pubbed by Johns Hopkins University Press) is balm to my soul, acknowledging as it does that the question of involuntary psychiatric care is a complicated issue to which there may possibly be no good solutions.

CommittedI come to this book with a history of being both a consumer and a provider of mental health care myself (I have depression, and I spent a number of years volunteering on a suicide hotline), and of knowing lots of people who consume and provide mental health care. People I love have been involuntarily committed, and people I love have recommended involuntary commitments, so while I am far from an expert, I am at least aware of some of the problems with both sides of this argument.

On one hand, involuntary commitment can be tremendously traumatizing. Standards of inpatient mental health care vary wildly, and underfunding of the mental health system means that many service providers are underpaid, under-trained, overworked, exhausted, and not remotely respectful or kind to people with serious mental illnesses. If you come to an emergency room with a mental health issue — often having tried to get outpatient mental health care from other resources and failed because we as a society have so massively under-prioritized those vital services — you may get an emergency room physician like this one:

If someone is suicidal, I can’t think of a time I would send them home. I’m very cautious about letting someone go home when they’ve changed their mind about being suicidal. I let the mental health professional make that decision, but when it comes down to it, if I am the physician of record, then I have to be accountable. So I give great deference to a mental health professional, but I don’t give them the complete latitude to discharge our patients. . . Once the flag is raised and I’m worried about someone, why wouldn’t we err on the side of giving them more services and not less?

What freaks me out is that he’s talking about suspending someone’s civil rights and then making them pay a really large amount of money for that suspension, and he doesn’t seem to realize that’s what he’s describing. His personal comfort with the idea that someone who has experienced suicidal ideation — regardless of the level of risk the mental health professional has assessed in their examination of the patient — is the deciding factor for whether a person is kept against their will. His comfort trumps research and experience, is what he’s saying, and unfortunately, this reflects exactly what I have heard from friends who work as mental health professionals in hospitals.

So that’s on one hand: The civil rights of mentally ill people are regularly taken away on the basis of one doctor’s opinion, which is informed more by a CYA mentality than the assessment of the in-house mental health professional. Legal procedures designed to protect patient rights are frequently perfunctory, with patients given inadequate representation and information about what’s happening to them.

On the other hand, advocates of involuntary treatment like E. Fuller Torrey argue that mentally ill patients who display anosognosia (a lack of awareness that they are ill) require medication and therapy before they can meaningfully consent or withhold consent for treatment.2 If we blanket oppose involuntary treatment, what becomes of suicidal and homicidal patients who won’t seek help for themselves? Do we permit patients who are a danger to themselves and others to leave the hospital untreated, or do we have a responsibility to help them (even if it’s against their will)?

See. It’s tricky.

Miller and Hanson explore the issue from a wide range of perspectives, speaking with experts in the field, medical professional, mental health care professionals, patients with both good and bad experiences of inpatient mental health care, and police departments that have implemented mental health training for their officers (chronically mentally ill people who don’t get treatment often get funneled into the criminal justice system, which is very ill-equipped to deal with them). They consider the various — and they truly are various, since there are no nationally accepted standards for inpatient mental health care — policies that govern the use of seclusion and restraint, forced medication, and even involuntary electroconvulsive therapy. They explore evidence into the links between gun violence, particularly mass shootings, and untreated mental illness, and whether involuntary mental health care offers a solution to those problems.

Unfortunately — for people who want things to be simple — the answer, if there is an answer, is that if we want to achieve both the goal of protecting the civil rights of mentally ill patients and the goal of minimizing the chances that such patients will harm themselves or others, we’re going to have to pay for it, with time and money. Many of the ethical and medical problems around involuntary commitment arise because these patients have no other treatment options. The emergency room, which should be the last resort, becomes the first resort, simply because community mental health care is lacking. Hanson and Miller note that in half of all US counties, there are no mental health professionals at all. And the more money we pour into involuntary commitments, the less money is available for maintenance mental health care.

At the end of the book, Hanson and Miller make a number of policy recommendations, most of which require — surprise! — investment in a mental health infrastructure. This data nerd reader would also love to see better record-keeping on involuntary commitments nationwide, as I suspect that race, class, and gender are all factors in the decision of whom to commit against their will. Committed provides an insightful, balanced look at the many complex factors that influence involuntary mental health care. If you’re remotely interested in mental health or civil liberties, I highly recommend this excellent book.

  1. Well, probably some things do, but I can’t think of them right now.
  2. You’ll have spotted this leads to kind of a Catch-22: If they know they are sick they’ll want treatment; if they don’t want treatment, they must not know they are sick and thus should have treatment.
  • TheShrinkette

    1. I need this book.
    2. I agree, nothing infuriates me more than when people trivialize complicating something, because that’s simply their way off washing their hands off said something.
    3. Professionally speaking, nothing about mental health is ever simple. Our behavior is shaped by our environment, and it is unbelievable how many factors actually exist in the immediate environment of an organism that could evoke any responding. The principle may sound simple, but the fact of the matter is that individuals are different and therefore their behaviors are shaped and maintained idiosyncratically. Because of this, nothing about having to make decisions for someone else (such as committing them) is ever simple, because it is nearly impossible to objectively make that decision, and one has to wonder how much this has to about the committee vs. the committed. Having spent most of my professional life (not a long time, btw) working with adults with developmental/intellectual disabilities, it is a slippery slope between advocating with someone vs. for someone, especially when we’re questioning decision-making/self-preservation competency. This is before you start cross-examining with factors like racial/class/sex/gender/ability/religious bias, one’s own history of consequences with a person/group, policy, funding, etc. It’s also astounding how there’s an unequal availability of data between various methods of treatment and support. So many layers, so many complications. Imma stop rambling now, and go ahead and put this title in my shiny new TBR spreadsheet.

    • I need to hire a skywriter to plaster “nothing about mental health is ever simple” across the sky every day for the rest of forever. People are always trying to act like it’s simple and it is SO complicated. Even when we’re talking about things we think we know, we don’t actually know that much still, like why antidepressants work (when they do) and what causes mental illness and ALL THIS STUFF, because brains are terribly messy. So. Yeah. Lots of layers, and public discourse around these issues typically ignore most of those.

  • Your second note re: the catch-22 reminds me of that ‘Ten Days in a Mad House’ exposé by Nellie Bly. She faked mental illness to get into an asylum to investigate its conditions/treatments from the point of view of a patient, but even when she began to act “sane” again they wouldn’t let her go, precisely for that reason you described — she must not even know she’s sick, therefore she must be kept institutionalized. “Strange to say, the more sanely I talked and acted, the crazier I was thought to be,” she wrote – from mental_floss: http://mentalfloss.com/article/29734/ten-days-madhouse-woman-who-got-herself-committed

    • This book mentions that book! They mention a more recent thing (I can’t remember the dates or specifics off the top of my head) where some people did a similar thing, faking mental illness, and then they were not able to get out again. A lot of mental health treatment requires the patients to know and enact really specific shibboleths, and that’s one of the problems I have with it.

  • Jeanne

    I would never have considered reading a book like this before reading your review, but what you say about it dovetails with some of the reading I’ve been doing about incarceration in the U.S., so I may have to read it now, to get the bigger picture.

    • Do! It’s just good information to have — I feel like after every mass shooting, involuntary mental health commitments come up, and it’s rare that people actually know what that entails or how it happens. So this book is a really great antidote to that.

  • Stefanie@SoManyBooks

    Sounds like an excellent book! Mental health care in this country is shameful and the stigma that still gets attached to the mentally ill is heartbreaking. I used to do tech for a local nonprofit that provided mental health services specifically for women and the place had a forward thinking co-occurring disorders program that helped women recovering from drug addiction. We were one of the few places that offered these services and the need for them was great. It was a good place to work until it got swallowed up by a larger nonprofit and everything went to hell. So much needs to be done in providing affordable services but it continues to be ignored.

    • Yeah, it always gets ignored, and unfortunately yours isn’t the only story I’ve heard (or, like, lived through) about an effective mental health services provider becoming abruptly ineffective under new leadership. There’s such a chronic lack of resources. 🙁

  • Aarti

    Wow. This is hugely complicated. I did not even have a sense in my head that this was an issue so many people faced, but now that I think about it, I can see how it has HUGE repercussions. I’m glad people are thinking about it.

    In many ways, I feel like basically all recommendations are always “more investment.” Which is fair as we probably do need more, but we could also pour more money into one thing and not solve it, and probably still the answer would be “more investment.” I do not at ALL mean that mental health is something that we pour money into (we don’t), but I just mean in general, it frustrates me that “more investment” is often the solution to problems that people generally kind of *know* that we won’t pour money money into. Does that make sense? Or maybe that’s super-cynical of me, too.

    • No, that does make sense, and you’re not wrong. The issue for me is that “more investment” is literally the only answer. Nothing else works. There’s no magic bullet. This is a thorny and intractable problem, and pretending that we can solve it without an influx of money is just nonsense. So while I agree that we’re most likely not going to make the kind of expensive institutional changes that would be required to deal effectively with mental health in this country, I’m adamant about saying that’s what would have to happen if we want to solve some of these problems. And if we’re not going to do it, then we have to just say as a country (or a state or a city) that we do not care enough about mental health issues to spend the money. We can’t play like we care but not act like we care (is kind of where I’m at).

  • This immediately made me think of a series of posts by one of my favorite bloggers, who is a therapist (among other things) and works both with private clients and at clinics. Her post Why You Can’t Find a Therapist, No, Really is about the economics of therapy, particularly in our health care system. It’s sad, but it’s very interesting, and it comes at the problem of the infrastructure of mental health care from a different direction.

    • Oh excellent! I’ve bookmarked it to read for later — yeah, there’s a ton of different perspectives on this issue, and zero simple solutions.

  • This is SUPER interesting to me. My undergrad degree is in psychology, and I spent three years volunteering at a suicide hotline in college and I’m always open to reading more about mental health and/or civil liberties – basically this book is exactly what I need/want to read. I didn’t know you also have experience working at a suicide hotline – how long did you do that and when?

    • I did it for five years starting when I was in college! I stopped when I moved to New York — it was difficult work but very rewarding, and I think it gave me a more realistic sense of the many many mannnnnyyyy mental health problems our country has yet to deal with.

  • Alley

    If you decided to share your list of Claims that Require Heightened Scrutiny, I would not be opposed to that.

    This is super interesting and also depressing. I appreciate, as you said, the book doesn’t try to provide a simple answer because as awesome as simple answers would be, they aren’t real.

    • I am nervous to share my list because I know it’s tragically incomplete. I am adding things as I think of them, and I am afraid people will see my incomplete list and say “pooh pooh! you have left out an obvious thing! the whole list is hereby invalidated!”

  • Wow, this sounds so good! I also always appreciate books that acknowledge the nuanced nature of the issues they address.

  • Awesome review! And, yes, a very tricky situation. It makes me wonder what the policies surrounding this issue are here in Canada. I know the mental health infrastructure is hugely lacking – we have the same problem of people needing medical help ending up in the prisons. 🙁