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Committed: The Battle Over Involuntary Psychiatric Care: Page 2 of 2

Committed: The Battle Over Involuntary Psychiatric Care: Page 2 of 2

Beyond the conundrum of hospital admission against a patient’s will, the authors delve into involuntary treatments that can occur once a patient is hospitalized. Starting from a compelling personal anecdote, Dr. Hanson, a forensic inpatient psychiatrist, leads us through a very reasoned and experienced discussion of seclusion and restraints. She concludes that restraining a patient is, in rare cases, necessary—especially when staff and patient safety is a concern.

There is a robust chapter on Assisted Outpatient Treatment (AOT). The laws in different states are so diverse and inconsistent that it is somewhat overwhelming to metabolize the highly variegated array of processes, strengths, and loopholes in all states. Maybe that was the intended effect. Yet readers might welcome a more systematic and organized presentation, perhaps sorted into different categories of features or limitations. Overall, though, the message conveyed is that AOT, without extensive (and expensive) services to accompany it, is unlikely to be very effective: “It must come with services that obligate society to the best interests of the individual patient.”

The authors make an interesting and timely diversion into the loosely related issue of guns and mental illness. They conclude that the majority of behaviors that would make people likely to shoot others may reflect unstable traits and coping mechanisms, not specific psychiatric diagnoses, or even necessarily “mental illness” at all.

In the final chapter, the recommendations for changes in how we practice and run our institutions, as well as how we train our staff, courts, and correctional officers, serve as a manifesto for the future of mental health care. This is worth the purchase price alone.

Overall, the authors make a strong case—not against involuntary treatment, but how it is done, and the threshold for its use. Speaking specifically to treating professionals, they write:

Involuntary treatment needs to be limited to situations where the only agenda is the best interest of the patient after other options to engage the patient have been exhausted. . . . If you start with the idea that involuntary care may be traumatizing, you do it much less often and much more thoughtfully. . . . 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 prevents many from seeking treatment. . . . It’s simply not possible to write a script with the exact guidelines for what to do when the question comes up about usurping a patient’s autonomy. The only clear answer is in retrospect.

This is the rare book that will appeal to trainees, seasoned professionals, and lay readers alike.

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Disclosures

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.

 
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