Over the last few years, I have spoken to many people about their experiences with involuntary psychiatric hospitalizations. While the stories I’ve heard are anecdotes, often from people who have reached out to me, and not randomized, controlled studies, I’ve taken the liberty of coming to a few conclusions. First, involuntary hospitalizations help people. Most people say that they left the hospital with fewer symptoms than they had when they entered. Second, many of those people, helped though they may have been, are angry about the treatment they received. An unknown percentage feel traumatized by their psychiatric treatment, and years later they dwell on a perception of injustice and injury.
It’s perplexing that this negative residue remains given that involuntary psychiatric care often helps people to escape from the torment of psychosis or from soul-crushing depressions. While many feel it should be easier to involuntarily treat psychiatric disorders, there are no groups of patients asking for easier access to involuntary care. One group, Mad in America – formed by journalist Robert Whitaker – takes the position that psychiatric medications don’t just harm people, but that psychotropic medications actually cause psychiatric disorders in people who would have fared better without them. It now offers CME activities through its conferences and website!
When the March 1, 2018, New England Journal of Medicine featured an essay about a patient who had benefited from involuntary psychiatric care, I read “Out of the Straitjacket” with interest. Michael S. Weinstein, MD, a trauma surgeon at Jefferson Medical College in Philadelphia, wrote:
“In the middle of elective inpatient electroconvulsive therapy for treatment-resistant depression, he had become profoundly depressed, delirious, and hopeless. He’d lost faith in treatment and in reasons to live. He withdrew to bed and would not get up or eat. He had to be committed for his own safety. Several security guards had to forcefully remove him from his bed.”
The patient, he noted, was injected with haloperidol and placed in restraints in a seclusion room. By the third paragraph, Weinstein switches to a first-person narrative and reveals that he is that patient. He goes on to talk about the stresses of life as a trauma surgeon, and describes both classic physician burnout and severe major depression. The essay includes an element of catharsis. The author shares his painful story, with all the gore of amputating the limbs of others to the agony of feeling that those he loves might be better off without him. Post-hospitalization, Weinstein’s message is clear: He wants to help others break free from the stigma of silent shame and let them know that help is available. “You would not be reading this today were it not for the love of my wife, my children, my mother and sister, and so many others, including the guards and doctors who ‘locked me up’ against my will. They kept me from crossing into the abyss,” he writes.
The essay ( N Engl J Med. 2018;378:793-5 ) surprised me, because I have never heard a patient who has been forcibly medicated and placed in restraints and seclusion talk about the experience with gratitude. I contacted Dr. Weinstein and asked if he would speak with me about his experiences as a committed patient back in early 2016. In fact, he said that he had only recently begun to speak of his experiences with his therapist, and he spoke openly about what he remembered of those events.
Dr. Weinstein told me his story in more detail – it was a long and tumultuous journey from the depth of depression to where he is now. “I’m in a much better place than I’ve ever been. I’ve developed tools for resilience and I’ve found joy.” His gratitude was real, and his purpose in sharing his story remains a positive and hopeful vision for others who suffer. Clearly, he was not traumatized by his treatment. I approached him with the question of what psychiatrists could learn from his experiences. The story that followed had the texture of those I was used to hearing from people who had been involuntarily treated.
Like many people I’ve spoken with, Dr. Weinstein assumed he was officially committed to the locked unit, but he did not recall a legal hearing. In fact, many of those I’ve talked with had actually signed themselves in, and Dr. Weinstein thought that was possible.
“When I wrote the New England Journal piece, it originated from a place of anger. I was voluntarily admitted to a private, self-pay psychiatric unit, and I was getting ECT. I was getting worse, not better. I was in a scary place, and I was deeply depressed. The day before, I had gone for a walk without telling the staff or following the sign-out procedure. They decided I needed to be in a locked unit, and when they told me, I was lying in bed.”
Upon hearing that he would be transferred, Dr. Weinstein became combative. He was medicated and taken to a locked unit in the hospital, placed in restraints, and put into a seclusion room.
“I’ve wondered if this could have been done another way. Maybe if they had given me a chance to process the information, perhaps I would have gone more willingly without guards carrying me through the facility. I wondered if the way the information was delivered didn’t escalate things, if it could have been done differently.” Listening to him, I wondered as well, though Dr. Weinstein was well aware that the actions of his treatment team came with the best of intentions to help him. I pointed out that the treatment team may have felt fearful when he disappeared from the unit, and as they watched him decline further, they may well have felt a bit desperate and fearful of their ability to keep him safe on an unlocked unit. None of this surprised him.
Was Dr. Weinstein open to returning to a psychiatric unit if his depression recurs?
“A few months after I left, I became even more depressed and suicidal. I didn’t go back, and I really hope I’ll never have to be in a hospital again.” Instead, he notes that medication changes, cognitive-behavioral therapy, and sessions with his psychotherapist were helpful. “They changed my perspective.”
Dr. Weinstein also questions if he should have agreed to ECT. “I was better when I left the hospital, but the treatment itself was crude, and I still wonder if it affects my memory now.”
I wanted to know what psychiatrists might learn from his experiences with involuntary care. Weinstein hesitated. “It wasn’t the best experience, and I felt there had to be a better way, but I know everyone was trying to help me, and I want my overall message to be one of hope. I don’t want to complain, because I’ve ended up in a much better place, I’m back at work, enjoying my family, and I feel joy now.”
For psychiatrists, this is the best outcome from a story such as Dr. Weinstein’s. He’s much better, in a scenario where he could have just as easily have died, and he wasn’t traumatized by his care. However, he avoided returning to inpatient care at a precarious time, and he’s left asking if there weren’t a gentler way this could have transpired. These questions are easier to look at from the perspective of a Monday morning quarterback than they are to look at from the perspective of a treatment team dealing with a very sick and combative patient. Still, I hope we all continue to question patients about their experiences and ask if there might be better ways.
Dr. Miller, who practices in Baltimore, is coauthor with Annette Hanson, MD, of “ Committed: The Battle Over Involuntary Care ” (Baltimore: Johns Hopkins University Press, 2016).