There are many controversies in psychiatry, but the most controversial issue continues to be that of involuntary treatment. Over the past year, I have been working on a book on forced care, along with Dr. Annette Hanson, the forensic psychiatrist who also writes this Shrink Rap News column. The work I’ve been doing for the manuscript – identifying and interviewing the people with a stake in the issue – has placed me in a funny role of being more journalist than physician. It’s a role I mostly love, and if you’ve hit the midpoint of your career and have an opportunity to dedicate some of your time to doing something completely different, I highly recommend shifting gears for a little while.
One of the things I have found most surprising is the reactions of people when I ask to include them. While most people are willing, almost all hesitate a little. Some are quite eager to participate, and one group in Richmond who uses involuntary electroconvulsive therapy heard of my project and extended an invitation for me to come visit, interview them, watch the procedure, and speak with one of their patients. Many people are proud of the work they do and eager to showcase it; they want to have their viewpoint included. With others, I have needed to ask repeatedly, listen to their concerns, and offer reassurances. I’ve taken to telling people they can read a draft of what I write about them – I learned early in the process that without this offer, few people would be willing to speak to me.
I wish I could say that I’ve noticed a pattern to who is comfortable speaking and who is not. Many of the psychiatrists and researchers I’ve approached have given their time willingly without hesitation ( or at least without that much hesitation), including Dr. E. Fuller Torrey; Dr. Paul Appelbaum; Jeffrey Swanson, Ph.D.; Dr. Steven Sharfstein; Dr. Daniel Fisher; Vermont Psychiatric Society President Margaret Bolton; Dr. Bruce Hershfield; and American Psychiatric Association President Paul Summergrad, to name just a few of the many people who have shared their time, experiences, and wisdom with me. It was not as easy for me to find a psychiatrist I could observe working on an inpatient unit, and the project might have been halted in its tracks if not for the enthusiasm of Johns Hopkins psychiatry chair Raymond DePaulo, who allowed me to shadow his team while they tended to inpatients. It was surprisingly easy to find a Crisis Intervention Team police officer to ride with, a little more effort to engage a mental health court judge.
Those who oppose forced treatment initially were more difficult to engage, but with perseverance, I was able to persuade the leadership of MindFreedom International to speak with me, and well, I ambushed a barely willing Scientologist while I was in New York for APA last May. In terms of patient participation, this hesitation did not hold true – many people volunteered to speak with me about how involuntary treatment harmed them, and it was much more difficult to find patients who felt helped by the treatment that was thrust upon them. Two absolutely wonderful women gave generously of themselves so that this project would have real voices to it: both “Lily” and “Eleanor” relived difficult experiences for me and allowed me to obtain their medical records and to speak with their families and their doctors. None of this was easy for them, but it did provide me with an education I would have gotten no other way as they reflected back on the meaning it had to them to have been committed to psychiatric units.
The subject of involuntary outpatient commitment has been particularly difficult to research, in part because I live in Maryland, a state which has no provision for this. I spoke with one family member in Arizona who initially was eager to be interviewed, along with her adult child who has come to feel that involuntary care has been very helpful. When I called back, the mom had changed her mind about participating: “You’re writing a book with a balanced view. There no balance or controversy here for me; it’s a medical problem that needs treatment. ” Unless I could promise to support, unequivocally, the views she held without qualification, she was not interested in participating in our book, even if it would provide an avenue to express her beliefs about the value of outpatient commitment. For similar reasons, I had to approach Ron Honberg, J.D., at the national office of the National Alliance on Mental Illness (NAMI); the Maryland NAMI members did not want me to speak with me after two articles I wrote for this Clinical Psychiatry News column suggested that I was not wholeheartedly in favor of outpatient commitment. I was told the topic was “too sensitive” for their members to discuss with me. So while I’ve learned that the topic inspires a great deal of emotion, there are still surprises with every step.
With all that as a prelude, I am continuing to look for people to interview who are the subjects of mandated civil outpatient treatment orders, as well as their family members. I thought perhaps readers might be able to help me, and I am interested in hearing both the good and the bad. If you, your patients, or their families would like to participate, by all means contact me at DinahMiller@yahoo.com .
Dr. Miller is a coauthor of Shrink Rap: Three Psychiatrists Explain Their Work (Baltimore: Johns Hopkins University Press, 2011).