By Dinah Miller, MD and Annette Hanson, MD;
Baltimore, MD: Johns Hopkins University Press; 2016
328 pages • $22.95 (hardcover)
In an era of extreme clashes between opposing opinions about involuntary psychiatric commitment, it is refreshing—indeed therapeutic—to encounter a thoughtful, balanced treatment of this contentious and important topic in the book, Committed. As a psychiatrist and ethicist, I have considered involuntary treatment and our profession’s capacity to override patients’ autonomy to be one of the core issues in psychiatric ethics, and one that is unique to our specialty. This issue is a major source of controversy when the public tries to understand who we are and what we do.
Drs. Dinah Miller and Annette Hanson, both seasoned clinicians who have worked in a diverse range of settings, have produced one of the most important and readable contributions to this discussion that I have encountered. This is actually a book on psychiatric ethics, but it is presented in a disarming, journalistic style. The ethical tensions with which this issue is loaded are unpacked in a clear, accessible way, articulating not just the questions, but also offering sensible and realistic conclusions.
Particularly compelling are interviews, both with patients who have experienced involuntary commitment, as well as with advocacy organizations on all points of the spectrum of opinion. The latter include voices from familiar groups such as the National Alliance on Mental Illness and the Treatment Advocacy Center, unfamiliar organizations like MindFreedom, and even places that psychiatrists typically dare not tread—like Scientology.
Dr. Miller’s interviewing style shows the openness and receptivity of a trained psychiatrist. Some representatives of organizations particularly opposed to involuntary treatment display illuminating thoughtfulness. Others have, perhaps naively, failed to accept that we have learned much about major psychiatric disorders and what treatments work and approaches that can worsen them. Yet the authors remain remarkably respectful and non-judgmental, letting interviewees speak for themselves. At times I wish they would have educated the lay reader to appreciate just how uninformed and outdated certain ideas are.
Candid and sensitive interviews with patients who have suffered from the way in which commitment and involuntary treatment were deployed are groundbreaking. For psychiatrists, who often develop feelings of stewardship for our patients’ vulnerabilities, it will touch your heart. You may gain a new appreciation of what a patient who is being committed endures. Indeed, authors describe how their own practices and feelings were altered in the course of writing the book. There are some case examples of people who felt they were helped by involuntary treatment. Not surprisingly, these patients were committed for severe suicidality, rather than psychosis.
The authors interview some other remarkable people: a patient who was involuntarily committed who went on to become a psychiatrist; a crisis intervention police officer who is followed into the field; and the celebrated Judge Leifman in Dade County, Florida, who has accomplished reform in mental health approaches for the incarcerated that is becoming a model of its kind.
Dr. Komrad is Ethicist-in-Residence for the Sheppard Pratt Health System in Baltimore, MD. He is on the Faculty of Psychiatry at Johns Hopkins and the University of Maryland. He reports no conflicts of interest concerning the subject matter of this article.