I have long been concerned with people who have mental illness and need care, but don’t recognize the need for treatment. Civil commitment (involuntary psychiatric care) can result if the circumstances dictate. But such involuntary care is controversial. Indeed, I have been conflicted about it for many years.

A personal experience has made me examine the issues involved with civil commitment square-on.  My father had involuntary psychiatric care when he was committed to a mental hospital in the 1950s. He always spoke negatively of the experience with feelings of anger. He was dangerous to himself at the time, threatening to shoot himself with a shotgun. One thing is clear however, as episodes of major depression reoccurred over the 1960’s, 70’s, and so on, he never sought help. He relapsed, got more depressed and Instead of getting care and treatment, he would attempt to take his own life. Surviving these suicide attempts, he would cooperate with the offered mental health care…. for a while.

In the 1950s, it was weak to be mentally ill and weak to be treated. I have always wondered whether the experience of forced care, of involuntary care, hurt and shamed my father so much that it clouded his otherwise good judgment.  Did it, finally, interfere with Dad’s asking for more help when needed?

To help me grapple with the issues, I’ve just completed reading the  book, “Committed, The Battle Over Involuntary Psychiatric Care,” written by Dinah Miller and Annette Hanson.(2016) Both writers are physicians.

In their research and writing, Miller and Hanson sought to refocus mental health professionals and others to consider this possibility: “Involuntary psychiatric care may be damaging. It may never be appreciated and the fear of forced care may prevent people from seeking help.”

The book presents a rounded picture of involuntary care. (Many times only one side of the story is featured.) I appreciated the fair handedness with which the authors addressed the issue. They interviewed former patients who had been helped as well as those who had not been helped by the process.

One of the biggest take home messages I learned from the book, was that even people who had been committed and HAD been helped found the experience to be traumatic. That was troubling to learn. Active mental illness itself is traumatic. We are talking about people living enduring a double trauma .

Hanson and Miller made the following recommendations:

1. Encourage people with psychiatric disabilities to prepare an advanced directive. In the document it is possible to specify which medications are preferred, which facility one is to be admitted to, and even who should care for the person’s children during a hospitalization.
2. Train inpatient and emergency room staff/personnel in the use of verbal de-escalation techniques.
3. Crisis intervention training (CIT) should be mandatory and routine for all correctional officers and all state and city police forces. (Currently, these trainings are limited to a handpicked or volunteer teams of specialized officers in some locations.)
4. Handcuffing patients who are brought to hospital by police should NOT be a standard practice..
5. Support creation of mental health courts and pretrial diversion services to shorten incarceration times pending trial and to tie a defendant closely to needed community services.
6. Expand use of mobile treatment teams, assertive community outreach, crisis centers, peer support services, patient directed initiatives, and a variety of housing options.
7. Suicide hotlines should be made available to everyone and widely publicized. (Hotlines are available now but patients/clinicians are often unaware of them.)
8. Increase efforts to detect serious mental illness in the early stages. Specifically: more training of primary care physicians and other non-psychiatrists so there is better recognition of when referrals should be made to psychiatrists. If mental disorders were recognized and treated earlier, involuntary treatment could often be avoided.

In 2018, we’ll examine some of these issues.

I appreciate your readership,

GL