Behind the Book: Dr. Dinah Miller on 'Committed'

After three years of work, Anne Hanson and I are delighted that our book, Committed: The Battle Over Involuntary Psychiatric Care was released yesterday! So how did I find myself sitting in court rooms and riding alongside a police officer? Let me tell you a little about the process of writing this book, because it was a quite the adventure for me.  The title implies that this is another book by psychiatrists for psychiatrists, but for me, the days I spent working on this manuscript were days off from psychiatry.  Those mornings I woke up a psychiatrist and felt like I walked into a phone booth (maybe it was just my shower) and emerged as a journalist.  

    Those days I spent doing research in a whole new way:  I cajoled people into talking to me, made call after call which sometimes led to dead ends, trolled message boards, shadowed a variety of psychiatrists, judges and a crisis intervention police officer, attended legislative hearings, and sat in on government work groups.  I arranged video meetings with patients, doctors,  lawyers, advocates, and adversaries by phone and Skype, including one with a psychiatrist in New Zealand—quite the challenge with the 18 hour time difference. 

     I toured psychiatric facilities,  and I had meetings and meals with the most interesting of people, including esteemed author/psychiatrist E. Fuller Torrey, the

president of the American Psychiatric Association, a Christian Scientologist whom I sort-of ambushed and who gave me a video on “Psychiatry as an Industry of Murder,” a mental health court judge and his team, a former state hospital superintendent, and a medical sociologist from Duke, to name just a few.  This is not how psychiatrists usually do research.

      Patients are involuntarily hospitalized for one of two reasons: they are acutely psychotic – meaning they have delusions and often hallucinations and sometimes their thinking is disorganized to the point of being nonsensical and incomprehensible – or they are depressed and suicidal.  Both depression and psychosis can be tormenting. Often delusions include paranoia, the idea that people are trying to harm or kill you.  If these patients are presenting a danger to themselves or others, and they refuse voluntary treatment, they can be held in a hospital against their will and forced to get treatment.  Patients subjected to these treatments get better, and they often leave the hospital within weeks, if not days.

     So what is wrong with that?  Shouldn’t people be happy that someone helped them?   Sometimes, patients are grateful for the help that was forced upon them, but we learned that it wasn’t so simple, and some people are truly traumatized by the care they get.  This care can include the loss of basic liberty, moments of humiliation, being tied down with restraints or placed in a seclusion room, and being held down by guards to be injected with sedating medications.  While many committed patients don’t experience this type of  physical force, some do.  Still, these treatments are often used in dangerous situations where there may be no good alternatives.

    As we heard story after story, we learned there are large organizations that champion patient’s rights.  There are no formal organizations of patients, however, campaigning to make it easier to commit and force care on people.  We decided that if many people leave a treatment setting feeling injured by the care they received, it was worth more scrutiny.

     I didn’t want to write a book full of facts and figures and historical perspectives, though those are all include.  I wanted a book about the human beings and their stories-- who they are and how forced care touched the lives of patients,  family members,  doctors, the police officers who brought the patients to the ER and the judges who retained them.

     So many people I spoke with had siblings or parents with psychiatric disorders, or their own histories of illness or loss.  So while being a journalist is an entirely different occupation from being a psychiatrist, the one skill that translated well was that as psychiatrists, we are good at getting people to talk about themselves, and this makes for lively and emotional stories.

      While the reader might think I was writing about psychiatry, I felt very much that I was writing about civil rights for patients and psychiatry’s role in preventing violence, since involuntary care is now presented by the media and our legislators as a way to prevent gun violence and mass murders, topics we didn’t shy away from.

     At times, it was really fascinating, but there were challenges and many people who did not want to talk to me.  Involuntary psychiatric care is a polarizing topic, not unlike other polarizing topics in our society.  It took me months to convince members of MindFreedom International to speak with me and I never did convince the leaders of a local chapter of the National Alliance for Mental Illness (NAMI) to open up. They said the subject was too sensitive, and I ended up going to Arlington to meet with one of the national organization’s attorneys.  I was determined to look at this complicated topic with respect to all who came to the table, and to work to make is to much more than a polarized “for” or “against” topic.

    And, if hunting down stories wasn’t hard enough, the topic was in perpetual motion as legislation was proposed, amended, and voted on or not, and as the number of mass murder victims escalated.  We finally realized we had to pick a point and just stop writing, knowing that it would be impossible to get the book out completely up to date because the target of involuntary care and it’s related aspects move every day.

     Behind the scenes, my co-author, Annette Hanson did the heavy lifting in a more conventional way.  While I was out meeting with fascinating people, she was hard at work reading the studies and providing the literature reviews.  If that wasn’t enough, she read every word that both of us wrote, again and again, making sure each chapter was structured in way that made sense; not an easy task.  And when Anne couldn’t get the structure right, our wonderful editor at Johns Hopkins University Press, Jackie Wehmueller, had just the knack for figuring out what was wrong and how to fix it.

     Finally, the real credit doesn’t go just to the professionals who, made themselves a little vulnerable, and trusted me to tag along with them as a ‘take a psychiatrist to work’ day.    The real credit goes to the many people I spoke to who had been the involuntarily treated.  “Eleanor” and “Lily” talked and emailed with me repeatedly, let me access their medical records, their family members, and their psychiatrists.  There were many others, and while some of their stories are in the book, I spoke with many people whose stories enriched only me. Every patient mentioned selflessly revisited an exquisitely painful period in their lives and opened up wounds for the sake of helping me to see what their lives had been like, and without this, there would have been no book. 

    I received an education that I never got as a psychiatrist.  I hope we wrote Committed in a way that grabs the reader’s attention so that education can be shared with anyone who is curious about the process of civil commitment, the rights of psychiatric patients, or the belief that involuntary care has a role in preventing violence on a societal level.  As you will see, the issue is not black-and-white and we hope to start a discussion that will not be so polarized and will allow all voices to be heard at the table.

Dinah Miller, MD, is an instructor in psychiatry at Johns Hopkins School of Medicine. Her new book, co-authored with Annette Hanson, is Committed: The Battle over Involuntary Psychiatric Care.

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