Cultivating Thoughtfulness in Involuntary Care: A Q&A with Dinah Miller
Cultivating Thoughtfulness in Involuntary Care: A Q&A with Dinah Miller
“if you start with the idea that involuntary care may be traumatizing, you do it much less often and much more thoughtfully”
Dinah Miller, MD, is a psychiatrist and author of “Committed: The Battle Over Involuntary Psychiatric Care” (co-authored with Annette Hanson, Johns Hopkins University Press, 2016). She has a private practice in Baltimore, Maryland, is faculty at Johns Hopkins School of Medicine, and also writes for Clinical Psychiatry News and Medscape. Her career has been a wonderful mix of patient care, writing, education, and advocacy.
Aftab: I really enjoyed reading Committed. Kudos to you and Annette Hanson! It is by far the most balanced discussion of a complicated topic that I've seen. (Readers can see Mark Komrad’s review of the book for Psychiatric Times.)
I want to start with a 3-paragraph excerpt from the final chapter of the book because I think this quote goes to the heart of what you are advocating for:
“If you begin with the idea that psychiatric treatment is in the best interests of the patient—whether they recognize it or not during an episode of mental illness—then you do what is necessary to get that person help. You make treatment decisions with the idea that the end result of helping a very sick patient get better may be worth some indignities, and you hope that patients will later understand and appreciate that you’ve done what was needed to help them heal. Involuntary treatment then becomes a means to a desired end.
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—especially action that might be viewed by an ill person as either a restriction of their rights or a physical assault. We’d like to refocus mental health professionals to consider this possibility: involuntary psychiatric care may be damaging. It may never be appreciated, and the fear of forced care may prevent people from seeking help.
If you begin with the idea that forced psychiatric care and its components—restriction of freedom, restraint, seclusion, forced medications—may traumatize patients, you still do it if someone’s life is in danger. And you may still do it, though perhaps more gently, if their illness leaves them with intolerable suffering, even if there is not the imminent prospect of death or injury. However, if you start with the idea that involuntary care may be traumatizing, you do it much less often and much more thoughtfully.” (p 258)
I cannot agree more. Which leads me to my question: how do we get our fellow psychiatric professionals to appreciate, really appreciate, that many patients are indeed harmed by involuntary psychiatric care, and that we need to take that harm into account? When I talk to fellow psychiatrists, I confront a tremendous state of complacency that is bolstered by denial, rationalization, and, at times, a flat-out refusal to even acknowledge that this is something that needs addressing. They call it a “necessary evil” and basically shrug off any harm as unavoidable. Have you had more success in your efforts?
Miller: Awais, first, thank you for your kind words. I hope our book has had some impact, and as you know, I’ve been writing for Clinical Psychiatry News for years, and more recently for Medscape as well. At times, I use my columns to focus on some of the ideas that we addressed in Committed—for example, the idea that involuntarily treating people is not the answer to mass shootings, or that hospitals should not be doing indiscriminate strip searches on patients at admission. This is not to say that if a person with psychosis is talking about killing people and won’t sign in voluntarily, we shouldn’t involuntarily hospitalize that patient, or that there is never a reason to search a patient, but I’d like us to aim for a kinder, gentler, more respectful psychiatry. Psychiatric inpatient units are really good at treating people, but they aren’t much for healing. And finally, I give a talk each semester to the PGY-3 residents, and if you want to change a system, it’s good to get the students thinking. Involuntary care is one of our polarizing topics and it’s hard to get people to change their minds about what is right and what is wrong.
Aftab: You offer a number of helpful recommendations in the book regarding future directions. My summary of these recommendations is as follows:
Increase utilization of psychiatric advance directives
Enhance due process protections in civil commitment hearings, allow for vigorous patient representation and an opportunity for patients to tell their side of the story.
Eliminate hospital policies, such as strip searches, that can be distressing and humiliating for patients.
Ensure robust mechanisms for patients to report mistreatment at psychiatric facilities.
Provide staff training in verbal de-escalation techniques.
Mandatory crisis intervention training for correctional officers and police officers
Create mobile crisis teams with trained mental health professionals
Increase availability of intermediate levels of care, such as mobile treatment teams, assertive community outreach, crisis centers, peer support services, patient-directed care initiatives, and a variety of housing options
Invest in the development of newer medications and interventions that are better tolerated and aren’t perceived as being “mind-numbing” by the patients.
Items I’d like to add to this list would include:
Transparent reporting of data pertaining to utilization of involuntary psychiatric care from every state.
Tracking of (and more research into) clinical outcomes of involuntary psychiatric care.
Ensure availability of non-pharmacological treatments for serious mental illness (including individual psychotherapy) in the context of involuntary commitment
The cost of involuntary psychiatric care should be shouldered by the government
Political advocacy from psychiatric associations to pursue legislative actions that are necessary.
Allow patients an abundance of food and amenities.
Offer more flexible visitation and access to internet in inpatient facilities.
Provide single rooms to patients on psychiatric units.
Create voluntary, open-door psychiatric units in addition to locked-door units.
Allow discharge against medical advice for voluntary patients.
Is there anything more you’d like to say about these recommendations?
Miller: Awais, this is a good list, but it’s not in the order or precise wording I would put it. The main thing I heard over and over is that it is so hard to get care quickly, easily, affordably, as someone is getting ill, that things escalate until there is a crisis, and then we’re all about involuntary treatment. So my #1 would be to make it easier for people to get voluntary, outpatient psychiatric treatment.
Miller: The main thing I heard over and over is that it is so hard to get care quickly, easily, affordably, as someone is getting ill, that things escalate until there is a crisis, and then we’re all about involuntary treatment. So my #1 would be to make it easier for people to get voluntary, outpatient psychiatric treatment.
1. Advance directives are good—they may allow you specify specific medications or what hospital you prefer (alas, if there is a bed available there), but they don’t let you say that if you show up in an ED delusional and dangerous, you aren’t allowed to be involuntarily hospitalized.
2. I believe that patients are assigned attorneys and are given the right to testify at commitment hearings. In some places, these hearings are perfunctory, but in other places, they are full hearings with lots of research. So for example, we talked about Vermont where it can take a couple of months for a patient to get a hearing because of the preparation. It seems like once a patient has been observed on an inpatient unit for a few days, a trained psychiatrist should have some idea of how sick and dangerous they are. But yes, reasonable representation.
3. I am absolutely against blanket policies that humiliate and distress patients, such as strip searches on admission for everyone. There is no evidence that increases safety or decreases hospital liability. There may be reasons for individual patients why it would be necessary, say if the patient has a history of violence with weapons, or say they have a razor with them, or that they have already injured themselves.
4 and 5. Yes!
6. I’m not sure how I feel about mandatory crisis intervention training for police officers. People don’t like what they are made to do—perhaps there can be incentives—but everyone is not cut out to be a mental health crisis cop.
7, 8, and 9. Definitely. Also invest in getting people hooked into outpatient care easily — often it doesn’t need crisis teams or outreach or housing.
I agree with your additions. I think there are unlocked voluntary units in some places, but as soon as one patient becomes a risk for ‘eloping’ the whole unit ends up being locked. And I believe voluntary patients can sign themselves out. In Maryland, a patient has to give 72 hours so the staff can figure out if they need to be held for safety and get the paperwork in order, but if the patient is not felt to be dangerous, they may be released without that waiting period.
Aftab: You write:
“In the course of writing this book, I came to believe that involuntary treatment could be damaging and should be avoided whenever possible. I have spent more than 20 years working in four different community mental health centers in the greater Baltimore area. In addition, I’ve had a private practice in a state without laws for mandated outpatient care; in this setting, involuntary treatment is a rare event. Still, there have been times when I became deeply concerned about the safety of several of my patients. In these cases, the patients refused voluntary hospitalization. Believing that forced care could be traumatizing, I tried other methods to avoid involuntary treatment. When possible, I involved family members, and I had daily contact and frequent appointments with the patients I was concerned about. I wondered—and I still wonder—if my work on this book clouded my judgment and endangered my patients. In the end, no one was injured, and no one said they wished I’d had the police haul them off to a hospital, but the truth is that if anyone had died, my stance would have been unforgivable. I lost sleep over these cases, and I still feel a little queasy when I think about how high the stakes were.”
I relate to your sense of discomfort and ambivalence! I have also come to believe, not only in the course of my engagement with the literature on this topic but also in the course of working as an inpatient psychiatrist, that involuntary is damaging for some people. I similarly worry about negative outcomes and high stakes. I am mindful, however, that such worries are subject to a tremendous status quo bias. People rarely seem to worry if current psychiatric training, with its focus on risk and liability, clouds our judgment and makes patients vulnerable to harm! Sometimes doing the right thing results in a negative outcome. At times when I’m debating softly bending some rule to offer a patient more autonomy and flexibility, I joke with the trainees, “No good deed goes unpunished!” We live in such a risk-averse medical culture that we internalize these norms. I’d like to believe that there is a healthier balance to be found between safety and well-being, but it’s difficult to find in a lawsuit-heavy culture like the US.
Miller: It is. There are no great answers here — patients die by suicide and their clinicians may get sued, and patients die by suicide on inpatient units. Personally, I worry much more about clinical outcomes and doing right by my patients than I do about being sued, but you are right that that weighs heavily for some physicians, and certainly for institutions. And while involuntary care traumatizes some people, we really have no idea how prevalent that is. We need to ask people at the end of their hospitalization how they felt about what transpired. The people who reached out to me were the people who were traumatized, and they were easy to find. While I skew in favor of avoiding involuntary treatment and not using it as a knee-jerk response, I also believe that a traumatized patient is better than a dead patient. It’s never in anyone’s best interest to die of suicide or to physically harm or kill another person. Sadly, psychiatrists are not provided with crystal balls, and so much of what we choose to do depends on what patients tell us, and someone who does not want to be in a hospital may not be truthful with us. Also, suicide can be impulsive, so a person may say they have no intention of harming themselves at one moment and be dangerous to themselves at another. Having said that it’s never in a patient’s best interest to die of suicide, I feel compelled to add that there are entire countries that don’t agree with me on this: Belgium and the Netherlands allow physician-assisted suicide for mental illness, and it seems likely that Canada will as of March 2024.
Aftab: Many patients don’t respond very well to antipsychotic medications, and many others find them poorly tolerated. Do you think safeguards should be built into the forced medication treatment pathways that look into treatment-resistance and tolerability in addition to the usual considerations of decision-making capacity?
Miller: I live in a state where we don’t force outpatients to take antipsychotic medications (at least not patients who are not in the forensic system). If you are going to mandate a person to take a long-acting (injectable) anti-psychotic, of course you should assess whether the medicine is helping with the person’s symptoms and with their quality of life. I do seem to know a fair number of people who respond well to antipsychotics and don’t have side effects from them. Everyone has a different biology. Some resistance to taking medication is for very valid reasons—who wants to live with side effects? And many people just don’t like taking pills of any kind, people are not all that compliant with cardiac medications either. Then add the stigma of taking psych meds. And there are people who would benefit from taking medications who just don’t believe they need them; they may not recognize their psychosis as such, or normalize their anxiety, or feel their depression/OCD/PTSD is justified and minimize the dysfunction it causes.
Aftab: Do you think suicide hotlines have an obligation to be transparent about the fact that they will send police or emergency services if a person feels there is an imminent risk of self-harm?
Miller: Why would anyone assume they would call any other human being and say they are about to kill themselves and have that person stand by and do nothing? I don’t believe that hotlines should say they are fully confidential if it’s not true, but perhaps they should say nothing. Calling the police or emergency services is not involuntary hospitalization — it may lead to it. In Maryland, if the police arrive at the home and don’t see anything worrisome, they leave. If they have reason to believe someone is imminently dangerous, they take the person to an Emergency Department for an assessment and after the assessment, the person may be hospitalized or released — or they may decide to sign in voluntarily. Each state is different with regard to involuntary treatment laws.
Aftab: Well, when the limits of confidentiality are not made clear to people, people assume all sorts of things. It would also not be obvious to many callers what degree of expression of suicidality on the suicide hotline leads to the police showing up at your door. Saying you are going to kill yourself or that you are in the process of doing so is a pretty clear-cut scenario, but things get gray pretty quickly with softer forms of suicidality. Online forums are full of stories of people who called suicide hotlines and then found themselves in trouble in ways they had not anticipated. A very common question on online forums is also, “How do I avoid the suicide hotline calling the cops on me?” There is nothing wrong with suicide hotlines having a policy of calling emergency services if there is imminent risk, though I also think there is a legitimate role for suicide hotlines that don’t adopt such a policy; I personally think it becomes problematic if suicide hotlines are not transparent about their policy to the public. (I want to note here that the 988 lifeline official website FAQ does acknowledge, “The 988 Lifeline recommends crisis counselors contact emergency services (911, police, sheriff) for assistance only in cases where risk of harm to self or others is imminent or in progress, and when a less invasive plan for the caller/texter’s safety cannot be collaborated on with the individual. Less than two percent of 988 Lifeline calls involve emergency services.”)
Miller: I think there needs to be really good training for people working the suicide hotlines. It’s a natural part of major depression to have dark thoughts, and you have to flush out is this person actually planning to harm themselves, or is it just a thought with no intent? For many people, thoughts of suicide are comforting — they know that if things were to get too bad there is theoretically a way out, but that’s different from wanting to imminently act on a suicidal impulse. And even the most skilled of psychiatrists don’t have crystal balls. Unfortunately, in a litigious society, we go quickly to ‘better safe than sorry’ where safe is hospitalization. I am aware of at least one case where someone sued for wrongful detention.
Aftab: You write:
“Although a large number of people agree that involuntary treatment should be a last resort, health-care policies and institutions don’t always agree on what “last resort” means and how much effort should go into the first resort of engaging people in voluntary treatment. Sometimes, involuntary treatment ends up being used as the only resort.”
I think this gives us a clue about why so many activists find no comfort in endorsing the view that involuntary treatment should be the last resort… because endorsing it doesn’t lead to any systemic change! Systems continue to ensure that involuntary treatment is often the only option. I feel as if activists are pushed towards a rigid, inflexible stance on involuntary treatment because that may be the only way to keep the debate alive in public consciousness.
Miller: And add to that the fact that some activists don’t believe that psychiatric treatment is effective or useful, don’t believe that psychiatric disorders even exist, or they believe that psychiatric treatments are outright harmful. But I don’t think it’s true that the system doesn’t change. We use much less seclusion than we used to, and rates of physical restraint are way down (as a result of that perhaps, rates of violence on inpatient psychiatric units are up). If you read Elyn Saks’ book The Center Does Not Hold, she talks about how it was believed that restraints were therapeutic. I do think we now see physical restraints as a way to keep people safe, and not a therapeutic measure. There is a chapter on restraints where my co-author, Anne Hanson, M.D. talks about how she was assaulted on an inpatient unit in a forensic hospital by a patient who had assaulted someone earlier that day. Because the patient calmed down immediately, they were not restrained or secluded. Yet on the other hand, there are places in this country where is if someone needs a psych bed and one is not available, they are put in a jail cell to wait — talk about disgraceful!
Aftab: You are very right that some activists don’t even accept that treatments are effective or useful, and many seem to even deny that psychopathology exists in any meaningful clinical sense. This ultimately only creates polarization and hinders meaningful change. As I noted in my discussion with Rob Wipond, when activists and journalists take hardline positions that involuntary treatment is never necessary or that there is no such thing as loss of insight, they are so disconnected from the experience of patients, families, and clinicians that they lose credibility.
What's your take on the current political landscape around involuntary psychiatric care? Are we heading in the right direction?
Miller: Maybe. A psychiatric hospital near me built a whole new facility a number of years ago—all the rooms are singles; no one has to have a stranger sleeping in the same room. And while it’s not all good, hospital stays are much shorter, and state hospitals are forensic hospitals — our book is on civil commitment, that is involuntary care for people who are not in the criminal legal system. So people may be involuntarily hospitalized for an average of 10-12 days, not months to years to decades as was the case a few decades ago. But if they need inpatient care for longer, there is nowhere for them to go. Oh, and the insurance companies decide on admissions… it’s not all about what the doctor thinks is in the best interest of the patient.
Outpatient commitment is being used more and since that is very expensive to do right (or at all if you are going to enforce it), it’s not clear what that actually looks like. Certainly, it helps some people, but then you hear about Britany Spears and her 13-year conservatorship, and I cringe. The studies on outpatient commitment are limited, and now dated — they had some good outcomes in New York where a lot of money was put into the system and outpatient commitment came with added services. That degree of financing has not continued; it was very expensive, and it only covered New York City and a few urban areas of New York State. Large areas of New York did not have outpatient commitment. Just a couple of days ago, the New York Times had an article on 94 cases of violence by homeless people with mental illnesses — outpatient commitment is not the panacea that some people hope it will be. There was a study that looked at outpatient commitment without added services in rural North Carolina and found that those on outpatient commitment did better (i.e. fewer hospitalizations and incarcerations—fewer, not zero), but it was a small study using data from the 1990’s. This study gets quoted a lot, but I’m not sure that it generalizes to 2023. I’ll add a shoutout to Marvin Swartz. M.D. and Jeffrey Swanson, Ph.D. at Duke for their work—these are not easy studies to do.
Aftab: Thank you!
This post is part of a series featuring in-depth interviews and discussions intended to foster a re-examination of philosophical and scientific debates in the psy-sciences. See prior discussions with Diane O’Leary, Richard Gipps, David Mordecai, Emily Deans, Nicole Rust, Rob Wipond, Martin Plöderl, and Peter Kramer.
See also:
So... maybe a traumatized patient is better than a dead patient. But what if the trauma of involuntary commitment makes some people kill themselves when they eventually get out? Maybe years later, so the clinicians who had them committed don't think of the two events as connected? Might even, mistakenly, think that the now-dead patient lived longer than they otherwise would have thanks to the coercive treatment, when it's actually the other way around? What if forced medication with horrible side effects makes some people kill themselves?
I'm not saying this because I think involuntary care shouldn't exist at all. I'm just saying these are also factors to be considered, if we're talking trauma vs suicide.
Btw, I've talked to madpeople who say one should never call a suicide hotline, because you never know what will happen if you do, you might end up in deep shit as a result. With some personal experiences to back that up ... This is in support of Awais' point, that transparency is important, because a lack of transparency can scare people off!
Final point: In Sweden, if you call the emergency number 112, they can connect you to institutions like the police, ambulance services, the mountain rescue, fire department, the normal stuff - or a priest. Since we're a secular society nowadays and the church isn't part of the state anymore, it happens from time to time that parliament looks at this list and goes hm, the priest is surely the odd one out here, maybe they should be removed? And then some researchers look into the matter, and every time this has happened, said researchers conclude that the priest should stay on.
Lots of suicidal people, lots of people in serious distress, opt to talk to a priest instead of suicide hotline/mental health services - and not necessarily because they're religious. Even atheists may prefer to talk to a priest because they're AFRAID of calling a suicide hotline/mental health services. Take the priest off the emergency number, and lots of people will just not call anyone at all.
I think this is some serious food for thought.
This discussion touches on issues that I care deeply about, have studied some, and have devoted a considerable amount of time to promoting in meetings and testimony at state legislative hearings in Texas. My comments:
“If you start with the idea that involuntary care may be traumatizing, you do it much less often and much more thoughtfully.” Yes. And if psychiatrists recognize that inpatient care can be traumatizing, why have inpatient settings not become more pleasant? Many maternity centers look nicer than my bedroom, pediatric hospitals have made their rooms more cheerful for children, and modern dentists have committed to pain-free dentistry.
“1. Increase utilization of psychiatric advance directives.” Okay, but where I live a patient can reject the psychiatric advance directive in a crisis and it becomes null and void. Include parents who devote years to caring for ill children in deliberations about involuntary hospitalization and listen without biased assumptions about their responsibility for the illnesses of their children.
“2. Enhance due process protections in civil commitment hearings, allow for vigorous patient representation and an opportunity for patients to tell their side of the story.” If psychiatry too readily chooses involuntary hospitalization, then civil rights attorneys from groups like Disability Rights Texas and judges who know too little about how profoundly the symptoms of psychotic disorders can affect a patient’s ability to make rational decisions too readily favor civil liberties over a need for treatment with consequences that too often lead to homelessness, imprisonment, or death.
“3. Eliminate hospital policies, such as strip searches, that can be distressing and humiliating for patients.” This will increase injuries to clinicians. In Texas, a state law doctors and nurses lobbied for made it a felony for a patient to assault a doctor or nurse while they are on duty. This has increased the number of patients going to jail. Why not, instead, lobby for a law that requires safety protocols in medical settings to prevent injuries? Such a law would be better for clinicians and patients.
“4. Ensure robust mechanisms for patients to report mistreatment at psychiatric facilities.” Yes and install cameras so accusations of mistreatment can be verified. Are reports of mistreatment often true or generally related to paranoia and delusions? Either way, what can be done to improve the patient experience? My adult daughter who once spoke glowingly about caregivers at a residential treatment center where she stayed for six weeks now talks of how traumatizing it was for her. When she began home visits later in her residential stay, she wanted to return in time for movie night with her friends. She wanted to give clinicians flowers and gifts. She hugged a clinician she saw at a grocery store. Now, as her delusions and paranoia have worsened, she has nothing good to say about her experiences in residential treatment.
“5-7” Related to crisis response and de-escalation training. Why has psychiatry not consistently taken a leading and outspoken role in advocating for a medical response rather than a criminal justice one? As pointed out earlier, doctors and nurses in Texas focused on punishment of those who assault them rather than prevention. Training in verbal de-escalation techniques is fine, but as Dinah Miller points out its effectiveness may depend on the personalities of those who are trained. Chuck Wexler, founder and director of the Police Executive Research Forum (PERF)* wrote that he does not think all police officers should be trained and deployed to psychiatric crisis situations for the same reason that not all officers should be trained in SWAT tactics—some just do not have the aptitude for such duties. He has also written that police can do a better job of using less force in situations where no gun is involved and it will be applicable to situations where mental illness is involved:
*From the PERF Guiding Principles on Use of Force: “Our work has centered on how the profession can improve in the key areas of use-of-force policies, training, tactics, and equipment. We have focused especially on two types of police encounters: 1. With subjects who have a mental illness, a developmental disability, a condition such as autism, a drug addiction, or another condition that can cause them to behave erratically or threateningly; and 2. With subjects who either are unarmed, or are armed with a knife, a baseball bat, rocks, or other weapons, but not a firearm. It is these situations—not incidents involving criminal offenders brandishing guns—where we see significant potential for reducing use of force, while also increasing officer safety.”
Early studies on the effectiveness of police de-escalation training often based their findings on the answers that participants gave to a questionnaire at the end of the training and not on actual results in the field. And one researcher found Crisis Intervention Training (CIT) to vary greatly in content from 40-80 hours of classroom training in some agencies to watching a short video in others. Gary Cordner and Harry Steadman have studied these issues and found the culture among city leaders, police chiefs, and police officers is more important than technical training. The US Department of Justice investigators of use-of-force incidents to wrote “culture eats policy for lunch,” paraphrasing the words of management consultant Peter Drucker who said “culture eats strategy for breakfast.” Recent studies of results of de-escalation training as applied by police in the field find that officers must react quickly when confronted with aggression in crisis situations and often resort to using force to resolve conflicts, which is unsurprising since they receive far more training in using force than in using de-escalation. Seth Stoughton, a former police officer and now a faculty member in criminology, says when police respond at least one gun is introduced to a situation where they may have previously been none. He believes police must be trained to be confident in their ability to use less deadly force. I think he is right, but I also think psychiatry has a role and responsibility to provide a medical response to medical emergencies like clinicians do for other types of medical emergencies. And, advocates cannot be allowed to parrot the anti-stigma line that persons with psychiatric illness are generally non-violent or more likely to be victims of violence while doing nothing to address the real over-representation of those with mental illnesses in jail and among those killed by the police due to symptoms that can include violence. Here are some ideas: (1) One African American activist told me that his people avoid calling the police and rely on one another for safety. NAMI should train family caregivers to avoid calling 9-1-1 and rely more on themselves and friends for de-escalation. (2) Pay peers to do wellness checks by phone and video chat. (3) Send unarmed responders and invite persons in crisis to come outside and talk rather than going into an unpredictable and potentially confining indoor situation much like the CAHOOTS teams do in Oregon. (4) Responders should bring along free snacks or pizza. (5) If there is no gun present, the response to aggression need not introduce a gun if clinicians and police are properly trained.
(continued)