You are speaking with a patient in your office. It is clear to you that your patient is acutely suicidal and needs to be treated in a secure hospital setting to make it through this crisis. However, if you hospitalize him, he is very likely going to lose his job. He refuses voluntary hospitalization. A colleague is treating someone over objection on an inpatient unit. She has been treated by court order against her will and has now recovered capacity to make her own decisions. Two weeks after hospital discharge, the patient stops taking medication and rapidly deteriorates. On presentation to the emergency room a week thereafter, she is acutely ill and once again requires treatment.
Involuntary psychiatric hospitalization and treatment are among the more controversial aspects of modern psychiatry. When a physician abrogates the civil rights of individuals by hospitalizing them against their apparent will, or seeks treatment over their objection, multiple conflicts come into play. In Committed: The Battle over Involuntary Psychiatric Care, Dinah Miller, MD and Annette Hanson, MD do an excellent job of presenting the views of multiple stakeholders. Despite my years as a psychiatrist, I came away from reading this book with a much more nuanced understanding of the benefits, complexities, and challenges of involuntary psychiatric care.
The organization of the book itself reflects a very thoughtful approach. The foreword is written by Pete Earley, author of Crazy: A Father's Search for America's Mental Health Madness. His personal experience in coping with this problem helps to provide a poignant context for the intrinsic contradictions and limitations of our existing system. Part 1 of the book sets the stage, with case presentations of two representative individuals with very different outcomes and perceptions of their involuntary hospitalization and treatment. These represent the polar opposites of benefits and appreciation after the fact. Their complex stories unfold and are interwoven throughout the subsequent chapters of the book. In Part 2, arguments for and against involuntary treatment are presented. Arguments in favor of involuntary treatment are presented by the representatives from the Treatment Advocacy Center, the National Alliance on Mental Illness, and the American Psychiatric Association. Arguments in counterpoint are presented by the leaders of the Citizens Commission on Human Rights, Mind Freedom International, the National Empowerment Center, and the Bazelon Center for Mental Health Law. Each side presents cogent aspects of concerns from the perspectives of both the right to treatment and the right to autonomy. The role of society in the need, or lack thereof, to intervene in someone's life is starkly articulated.
Part 3 presents civil rights concerns. The civil commitment process and the history of civil commitment laws are discussed in the context of the evolving ability of society to cope with and recognize that mental illness is a set of often-treatable conditions. The evolving role of individual rights versus individual and community safety is also presented. Part 4 focuses on the role of the hospital itself. Beginning with the interface of law enforcement and crisis intervention teams, the presentations proceed to the emergency department, to the hospital experience, and the use of seclusion and restraint. Involuntary treatment, both by court-ordered involuntary medication and the use of electroconvulsive therapy are presented, as are introductory first-person accounts of the potential benefits and downfalls of these interventions against will.
Part 5 transitions from the inpatient hospital context to the expanding role of involuntary outpatient commitment. Ambulatory civil commitment is a process ordered by the courts where the state has legislated authority to do so. The successes and limitations of this approach are presented, as is the potential role of mental health courts. Part 6 addresses dangerousness, whether to self or to others. Dangerousness drives most of our clinical decisions that relate to involuntary hospitalization. Our ability to prevent suicides associated with mental illness is arguably focused at such times of crisis. Similarly, these are opportunities to intervene when someone, driven by mental illness, may be at high immediate risk of harming another. Discussions about access to guns, risk of violent behavior, and the potential opportunities and limitations for preventing mass murders are presented in thoughtful, fact-based sections.
The book ends on the topic of the potential to transform current arguments in the field. It should come as no surprise to anyone that our current ability to intervene in mental illness is still very limited for many people with severe illness. The continued debate and articulation of the strengths and weaknesses of each approach are a necessary part of our evolving ethics and legal understanding. This book includes the perspectives of many individuals who are stakeholders in psychiatric care and is an important contribution to the field. Although the questions and challenges are clearly delineated, it is not unexpected that no conclusions are reached. The data on the risks, benefits, and limitations of involuntary psychiatric treatment and hospitalization are still very limited and subject to many interpretations.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2017 American Academy of Psychiatry and the Law