Mixed Bag #16: Dinah Miller on Involuntary Psychiatric Treatment

“Mixed Bag” is a series where I ask an expert to select 5 items to explore a particular topic: a book, a concept, a person, an article, and a surprise item (at the expert’s discretion). For each item, they have to explain why they selected it and what it signifies. — Awais Aftab

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Dinah Miller, MD, is a psychiatrist in Baltimore, Maryland, and author of “Committed: The Battle Over Involuntary Psychiatric Care” (Johns Hopkins University Press, 2016). She 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.

Miller: Involuntary psychiatric treatment is psychiatry’s most contentious subject—like all heated topics, it has gotten politicized and polarized, and there is not much left in the way of middle ground. I’m an outpatient psychiatrist in a state that does not have outpatient civil commitment (one of 3 left, and just barely), so this is an unusual topic for me to have adopted.  

From 2006-2018 I blogged at Shrink Rap along with psychiatrists Steven Daviss and Annette Hanson, and every time the topic of involuntary treatment came up, the comment section got heated. At first, people told stories where I couldn’t help but think, “No wonder these people were committed!” But as time went on, it seemed to me that something was wrong with a system where so many people felt so injured by treatment, where patients identified themselves as “survivors,” not of mental illness but survivors of psychiatric treatment! We clearly help people; why did so many people feel so injured by treatment that likely helped them?

There are advocacy groups that are in favor of legislation to make it easier to involuntarily treat people—they consist typically of parents of people with psychiatric disorders and psychiatrists. Then there are advocacy groups that oppose legislation to make it easier to involuntarily treat people—they consist of people with psychiatric disorders and lawyers. Yet, there are no advocacy groups led by patients saying that involuntary care helped them and should be more accessible to others who are ill. It makes you think.

My interest grew and Anne Hanson was kind enough to put up with writing a book with me: Committed: The Battle Over Involuntary Psychiatric Care. We worked hard to take a balanced look at this uncomfortable topic, and give everyone their say. I loved being more journalist than psychiatrist, and I think our book would be of great interest to readers of Psychiatry at the Margins.

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Book—Crazy: A Father’s Search Through America’s Mental Health Madness by Pete Earley  

Miller: Journalist/activist/novelist/blogger Pete Earley goes to pick up his college student son who is in the midst of a first psychotic break. They drive from New York to his home in Virginia and to the emergency department at Inova Fairfax Hospital. The younger Earley is disorganized, delusional, and suicidal. The roller coaster ride begins.

Pete taught me so much with this book—I read it just as my interest in involuntary treatment was beginning and it was from this book that I really gained entry into the world of parents and how difficult it is to stand by and helplessly watch your beloved child descend into the well of psychosis. In Maryland, I’m sure the son would have been hospitalized, involuntarily if necessary, but Virginia has so many of its own issues. I’m still amazed at how one event can shape a life: if the Earleys had made a pit stop in an emergency department in Baltimore, the son would have been hospitalized, and Crazy would never have been written, Pete’s career would not have taken its activist/blogger detour, and we never would have become friends. It was a wonderful springboard for my own education, ultimately culminated in the book Anne Hanson and I wrote— with a foreword by Pete Earley.

Concept—Anosognosia 

Miller: This is a term that has been stolen from neurology—it is used to describe when a patient is unaware that they have a neurologic deficit after a stroke, and has been borrowed in psychiatry to mean that a patient is unaware that they are suffering from a mental illness. That doesn’t seem like it should be an interesting concept, after all, we’ve always talked about patients who lack insight into their illness, but this term has become sharply politicized and has been used as justification for mandating treatment. Once this term gets used, you know the speaker is in favor of legislation to make it easier to force treatment. Funny, I picked the concept, and you’ll never hear me use it except as an example of a word that has a place on the battlefield of involuntary care—along with patient/client/consumer/client, medicine/psychiatric drug, force/involuntary.

Person—Elyn Saks, author of The Center Cannot Hold: My Journey Through Madness

Miller: Elyn is one of those amazing people; she’s an attorney and founder of the Saks Institute for Mental Health Law, Policy, and Ethics at USC, she’s completed training in psychoanalysis, she was a MacArthur Fellow who has written her memoir and given a TED talk, and she’s a person living with schizophrenia. My favorite Elyn Saks quote regarding involuntary care:

“While I was preparing to write my student note for the Yale Law Journal on mechanical restraints, I consulted an eminent law professor who was also a psychiatrist and said surely he would agree that restraints must be degrading, painful, and frightening.  He looked at me in a knowing way and said, ‘Elyn, you don’t really understand. These people are psychotic. They are different from me and you. They wouldn’t experience restraints as we would.’ I didn’t have the courage to tell him in that moment that no, we’re not that different from him. We don’t like to be strapped down to a bed and left to suffer for hours any more than he would.”

Article—“Medicating a Prophet,” by Irene Hurford in the New York Times

Miller: I liked this article because it is a nuanced look at forcing care that takes into consideration how the patient may view being involuntarily treated. It’s three dimensional and allows for the indignity and trauma that may come with mandated care, but also brings out how difficult a decision this is for a psychiatrist, especially one that doesn’t subscribe to the idea that forced care is always the right choice.

Surprise—One Flew Over the Cuckoo’s Nest (see excerpt of a scene on youtube)

Miller: I’m going to go with a movie, an oldie, One Flew Over the Cuckoo’s Nest, and I’ll link to a youtube excerpt. What a great movie! But from a historical perspective, I’m not sure any one thing has ever harmed psychiatry in the way this movie has: it has left generations of people afraid of psychiatric hospitals and ECT, and shows psychiatric care as cold, demeaning, vicious, and controlling, in a way that has stigmatized our profession and scared off people who would have benefited from getting treatment. The movie swept the Academy Awards as the best movie of 1976, along with best actor, actress, and director.  It was great entertainment but an unfortunate depiction of psychiatry, and a miserable depiction of involuntary psychiatric care.

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See previous posts in the “Mixed Bag” series.

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