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.