Dinah Miller and Annette Hanson are two of the three psychiatrists who blog at Shrink Rap. After I started blogging, I began to search out other blogging psychiatrists and I found them. They also have articles published in Clinical Psychiatry News. My impression is that they are decent, well-meaning, and thoughtful psychiatrists (not unlike most of the psychiatrists I know) who want to demystify our profession. Their writing is clear, straightforward, and accessible. Like me, they are all practicing psychiatrists and they deal with the pragmatic challenges we face in our daily work. They offer critical views but they overall seem proud of their profession and their careers. While I respect their work, in that area we seem to differ; they do not seem to be burdened by the professional existential angst that besets me.
On one topic we agree — the subject of involuntary care is the most vexing, contentious, and troubling topic for psychiatry. To their great credit, they have directed an enormous amount of attention and effort to this subject in their latest book, Committed: The Battle Over Involuntary Psychiatric Care.
The book attempts to cover this topic from a multitude of perspectives. First of all, they tell the story of two women — true stories using pseudonyms — who had each been committed to a hospital, had good outcomes in the sense of being able to resume their usual lives, but had differing views of the experience. Both women identify themselves as having been in a psychotic state at the time of admission and they both agree that their level of distress created understandable concern for others. But one of them, Lily, is grateful that she was forced into a hospital and the other, Eleanor, remains scarred by the experience.
These stories — which are introduced early and then returned to throughout the book — form the backdrop and frame one of the many conundrums addressed in the book: how can the same thing be both helpful and harmful? It also sets the tone; the authors try to represent varying perspectives and treat each source with respect.
After introducing the stories of Eleanor and Lily, they lay out the basic arguments both for and against involuntary interventions. They describe some of the history of the civil commitment laws in the US. They then walk the reader through the ways in which individuals may encounter force, starting with the role of the police, then moving on to emergency rooms, inpatient hospitals, commitment procedures, and involuntary drugs. In each of these chapters, they interview people directly involved and try to present their experiences and opinions with their usual down to earth tone.
They then discuss involuntary outpatient commitment (and to their credit, they did not adapt the euphemism of “assisted outpatient treatment”), mental health courts, and the intersection of mental illness and violence. They conclude with some recommendations.
This is quite a feat in 265 readable pages. I applaud the authors for their work.
As I was reading it, I was thinking about this review (I was sent the book by the publisher with the agreement that I would write a review for Mad in America). I knew this topic would be contentious and I was thinking about how others might read it. I respected what the authors had attempted and accomplished, and yet I had this sense of uneasiness which I will try to articulate here.
Not surprisingly, even though multiple perspectives were represented, the book was written from a decidedly psychiatric perspective. By that I mean that the nature of the problems that beset the people who wound up facing involuntary interventions were conceived of as fundamentally medical problems, “mental illnesses.” This illness frame is accepted without question.
It reminds me of the famous story about the fish who asks “What is water?” When one is raised, so to speak, in a world in which these problems (paranoia, heightened disorganization of thought and behavior, marked elevations of mood and energy) are known to be illnesses, then the examination of the problem starts, in my view, midway down a road. The questions asked have to do with how to best treat the illness over the person’s objection. If, however, one starts from a premise of uncertainty — accepting that these are complex situations whose cause and etiology are unknown — then one might be more cautious about jumping into framing the problem as one of access to treatment. One might start from wanting to know more about the nature of the problem.
This difference in perspective was particularly striking in Eleanor’s story. In the midst of some major life stresses, she went into an altered state for the first time in her life. Her condition was only exacerbated by her surprising admission to a hospital where she felt her life was in danger. She was agitated and ended up getting forced drugs and forced seclusion. She was eventually discharged and, over seven years, has never experienced another episode like this. The hospital records include information about her mental state but little attention seems to be given to the antecedents to her condition or whether there are ways to be of help aside from getting drugs into her system.
Almost in passing, it is mentioned what to me is a shocking cocktail of drugs she was on at discharge: olanzapine 25 mg, aripiprazole 20 mg, haloperidol 10 mg. Three antipsychotic drugs, each at or above the manufacturer’s recommended dose! When her inpatient psychiatrist learns years later that she is doing well off medications, what is his response? “She’ll get sick again.” The unexamined confidence that so many of the psychiatrists in this book held for the treatments they were offering, while not surprising, was striking. The failure of any of them to consider treatment as something not entirely synonymous with drugs was also not surprising, but nevertheless disappointing. But these are the experts in these cases and that should give us pause.
To their credit, the authors admit that this book was transformative for their own thinking. In talking to people who had experienced forced care, they accepted that even if well-intentioned, this can do harm. They learned that this perspective was not readily acknowledged by their colleagues. Yet they point out how acceptance of the harm that can be done by forced care will change the way one thinks about it.
“If you begin with the idea that psychiatric treatment is in the best interest of the patient…then you do what is necessary to get that person help. If you begin with the idea that involuntary psychiatric treatment might leave the patient feeling distressed and traumatized for years, then you start with a different mind-set and a different propensity to take action.”
The end is telling. Dr. Miller describes how her belief that forced care is traumatizing led to her efforts to avoid it with the people under her care. To her knowledge, no one was harmed, but she still wonders “if my work on this book clouded my judgement and endangered my patients.” I am not critical of this statement; I understand. I have similar worries. When one makes a decision to force a person into a hospital there are two kinds of errors one can make — to force hospitalization when the person without it would not have harmed himself or anyone else, or to not force and have the person go on to harm himself or others. It is hard to know for sure, but I think that most of the time, we are more willing to accept the first error than the latter.
I am not sure exactly what it is in our training or disposition that leads us in this direction, but I would be dishonest to not admit that I feel that pull as well. That difference in perspective may be one of the greatest divides between my profession and the most ardent critics of forced care.
As for solutions, the authors point out the limits of forced care and argue that it is not likely to solve many of the problems — homelessness or incarceration, for example — that proponents claim it will. They argue for more services, earlier engagement, more support for individuals and their families. Pete Earley writes an introduction and they refer to his story in the book. Earley talks about the lack of any care offered when his son was not deemed to pose an imminent risk. Initially, the only help offered was pleas for him to take his drugs. After my years of studying Open Dialogue practices, while I can’t predict a different outcome, I also can’t read this story without seeing that so much more can be offered. So much more.
Dr. Sandra Steingard is Medical Director at HowardCenter, a community mental health center where she has worked for the past 21 years. She is also clinical Associate Professor of Psychiatry at the College of Medicine of the University of Vermont. For more than 25 years, her clinical practice has primarily included patients who have experienced psychotic states. Dr. Steingard serves as Board Chair of the Foundation for Excellence in Mental Health Care.