Involuntary Psychiatric Treatment in Modern Psychiatry with Dr. Dinah Miller

[00:00:00] Welcome back to Psychiatry Bootcamp. Today we're talking about a topic that cannot be covered with enough reverence. We're talking about human rights, we're talking about bodily autonomy, and we're talking about how to most effectively serve our patients. To keep them safe, it would truly be impossible to cover this topic in a way that leaves every listener feeling vindicated or satisfied.

But I will say I think we've done our best to be honest and vulnerable and acknowledge areas where people are going to have good faith disagreements about this really crucial topic. We're also gonna dive a bit into the role that psychiatrists are expected to play in society at large in terms of public safety and whether or whether or not that role is appropriate.

My guest today is Dr. Dinah Miller. Uh, I've been following Dr. Miller's work for a long time. Back on Twitter when Twitter was a good place to be back to her [00:01:00] blog, and I've been wanting to have Dr. Miller on the podcast since before I started it. So standby, because we have a great episode coming for you on a really important topic.

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Welcome to Dr. Dina Miller. Welcome to Psychiatry [00:03:00] Bootcamp. Dr. Miller. I always ask our guests to introduce themself to our audience. My name's Dina Miller. I'm a psychiatrist in Baltimore. Um, at the moment, what I mostly do is private practice. Over the years, I've done lots of different things in outpatient psychiatry.

I've worked in a number of community mental health centers. I am also a writer. I think you know me from a blog I used to do with Dr. Annette Hansen and Steve Davis called Shrink Crop. That blog ran for 12 years and from the blog we had a, a podcast for a while. Um, and we wrote two books. Uh, one was called.

Shrink wrap. Three. Psychiatrists explained their work and the other was why you wanted to talk with me today is called committed the battle over involuntary psychiatric care. Full disclosure to our audience, I'm a big fan of Dr. Miller's. I've been following her work. I followed you on Twitter back when Twitter was.

A good place to be one of the best places in the internet. Uh, it's so sad. Isn't it sad? I I am a, I was a reader of the blog [00:04:00] from time to time, and I've made way my way through a lot of your book, Dr. Miller. I'm gonna start with this in training, the most difficult thing that I did, and, and. Training in psychiatry is difficult, but the most difficult thing was dealing with these issues of involuntary treatment.

And now as a clerkship director, a big part of my role is teaching, and I find that I was not alone in that feeling that a lot of trainees, this is one of the most difficult things that they do in their psychiatry training, but you have decided to make it a focus of your career. So I'd like to know why you decided to focus so heavily on this topic and what it is that really draws you to this topic.

So, you know. It's a great question, and you know what makes it an even better question? I'm an outpatient psychiatrist. I haven't seen inpatients in years, so I'm an outpatient psychiatrist in a state that until just about now, has not had outpatient commitment. So I only see voluntary. Everybody I see is there.

'cause they, well, they're not all there 'cause they wanna be there, but, um, but [00:05:00] mostly they're there 'cause they wanna be there. So then you get into the why, why did I get so fascinated by involuntary treatment that I wrote a book on? And I'll tell you that it, it goes back to the blog that when we were writing shrink wrap, when the topic came to involuntary treatment, things got very heated.

People have very strong views on this. And we started out the header on it, set a psych, a blog by psychiatrists for psychiatrists, but it's the internet. And so we had lots of other psychiatrists, but we also had lots of other people reading who weren't psychiatrists. And it was amazing how many people had really strong feelings about involuntary care, particularly people who, who were patients or who had been subjected to it.

And when people started first complaining about it, they would tell their stories. And I would think. No wonder somebody involuntarily committed you. You're, you're doing all these crazy things. But when these comments went on for literally years, I mean, we had, we had [00:06:00] tens of thousands of comments and when this went on for you, I started thinking, you know, we're doing, if, if people are so unhappy with their treat.

I think we're doing something wrong, and I just became interested in like the sides of this debate and so I, I became interested enough that I wanted to write a book on it. Yeah, I think it's difficult to paint a topic with a broad brush because there are some, I mean, there's been some really good investigative reporting recently about some, what seems to me pretty clear.

Abuses of this system, perhaps with financial incentives, sort of the one of the worst case scenarios. And then on the other hand, I've certainly treated patients myself, who we proceed with involuntary treatment and a few days later when the symptoms have been adequately treated, they are themselves very grateful for the treatment.

So I think it's a very complicated topic. Let's define our terms a little bit. So when we're talking about involuntary treatment, involuntary commitment, what are the different types of involuntary treatment or. Types of involuntary [00:07:00] commitment that we're really talking about. Okay, so I'm gonna first start by telling you that the world divides into forensic and civil commitment, and our book is on civil commitment.

We're not talking about forensic. So forensic commitment is when somebody. Because of a psychiatric disorder has broken the law and is going through the court system as a criminal or as a potential crim, as somebody, there's allegations that this person's committed a crime and there's a question of are they competent to stand trial or are they criminally responsible because, um, of a mental illness that makes it so they don't have the ability to be responsible for their behavior, right?

It's called NCR, not criminally responsible, and that's not what this book is about. And that's not what we're talking about today. Hopefully. 'cause if we were going to, we would want my co-author Dr. Anne Hansen, who is a forensic psychiatrist and a program director. Um, but she's not here. So, uh, we're talking about civil commitment.

So we're talking about something that happens because somebody is [00:08:00] ill. Somebody else is worried about their behavior or because they're in an emergency room or because they're at their doctor's office and somebody thinks you need to be in a hospital for treatment. So there's, this is a civil system, which is not about a crime.

So then you get into the, like every state has some mechanism for being able to take somebody who is mentally ill or in the middle of a, a psychiatric episode. And dangerous to themselves or others and get them hospitalized against their will for treatment for the purposes of this book. Now, now in every state it gets some places, it gets incredibly complicated.

If, if you wanna read, um, some read the chapter that I wrote about, I think it was Vermont or New Hampshire, a woman who had. Her husband had killed her children and she was committed the next day, and they have a system by which it took months till she went to court. The system in Maryland always seemed a [00:09:00] little easier to me, but every state has a way of doing this.

For the purpose of this book, we de said that if we were gonna use the case to talk about this person had to have gone to a hearing. So you can get somebody into the hospital without a full hearing everywhere sort of quickly. It's not always that easy to do, but once you sort of get the system going, you can get somebody in the hospital and at some point, often, for many states, it's 72 hours, and so they'll call it a 72 hour hold.

In Maryland, it's, you know, whatever. Whatever they f. Feasibly can do on the next Wednesday when there are commitment hearings. So if you go in the hospital on Thursday, your hearing will be on Wednesday. But we decided that you had to be actually committed, not just sent in. Does that make sense? What's the difference?

I'll walk you through what we do in Maryland. You wanna, you wanna start me on a scenario where somebody is worried? Sure. Let's say a patient is brought into the hospital by their mother. Mother [00:10:00] says, this is my 19-year-old daughter. And lately she's been up all night, every night talking to people that aren't there and saying crazy things about aliens.

I'm really worried about her and I'd like you to help me. But she was able to get the daughter to go to the hospital and be seen voluntarily. She called the police who brought in the patient, okay, so she called in the police. The police filed something called an emergency petition. They take the daughter to the emergency room where she's evaluated by a psychiatrist.

I, I'm not sure it can be somebody else. It's legally defined who can evaluate the person, and you need two people with the right degrees to sign that to get her into the hospital. So this is called. Being certified, it's not really a technical term in every, you know, if you're in Florida, you're Baker Acted.

If you're in California, you're 51 50. If you're in other states, you're put on a 72 hour hold. So she goes to the emergency room, and this is specific to, to Maryland, which I is the state I know [00:11:00] best. She's seen by somebody there and they decide first off, is she mentally ill and is she, is she a danger to herself or others?

And so, you know, police brought you in maybe 50 50 shot that you'll be held or maybe you won't. So she goes up to the floor and she stays there and she doesn't wanna sign in. And so then she goes to what's called a commitment hearing. Usually they're on Wednesdays. I don't know if that's true for every institution in the state, but, uh, she goes before an administrative law judge and she presents her side of why she isn't, doesn't need to be in the hospital.

If she wants, um, the doctors present their sides, family members might come. This can be very short and may be very short in the case you're talking about. If she's there saying, you know, the aliens are out to get me, and of course I'm gonna kill them. They're, they live next door. My neighbors are aliens. I know they're aliens and I'm gonna hurt them.

That makes it, that would make a very short hearing. I'm gonna tell you that one piece though that wasn't clear from your is when [00:12:00] the mother called the police. The police will only file a emergency petition if they see something concerning. So if they come in and the daughter who's been hallucinating and, and is not herself, looks at them and says, mm-hmm.

Sitting there eating lunch and says, I'm sorry I, I don't want to go to the hospital 'cause my favorite TV show is on in an hour. Or I, you know, I'm busy playing a game online and she's calm and collected. They probably will not take her to the hospital. And so what they'll say is, there's nothing urgent going on here.

She's not dangerous right now, meaning right now in front of me. And so we can't file an emergency petition. And what they would then tell the mother is. If you are concerned that she needs to be in the hospital and you're very worried about this, you can go to the nearest police station, ask to speak to a judge who is there specifically for filling out emergency petitions and make your case as to why [00:13:00] an emergency petition should be filed.

The judge. Might say yes, might say no, but then, then the police come and take her to the hospital based on an emergency petition that was granted by the a judge listening to the mother's concerns. Are we, are we lost yet? This is really complicated and, and in some states, this, you know, the, the, every time I would give a talk or I talk on this topic, I've learned that I should find out before I go to speak somewhere what the rules are in that state.

Otherwise I end up looking a little silly. I was asked to speak in South Carolina once I could, I, you know, I asked them to find me a psychiatrist I could ask these questions to, and I talked to 'em on the phone for an hour. And the end of that hour, I could not tell you how you got a patient certified in South Carolina.

It was really hard. I, I think if you as a psychiatrist who spoke, who talked shop for an hour with another psychiatrist about this, were still confused as to how this system works. It speaks to how painful and confusing it is for [00:14:00] patients. You know, here in St. Louis, we have a 96 hour hold, but the 96 hours doesn't start.

Ticking until you step foot on the psychiatry unit. And I work in the consultation liaison setting. So a patient hears from someone you're under a 96 hour hold, right? And they think, okay, I know how time works, but it turns out in this system you don't know how time works. And so I think it's really distressing, frustrating, these moving targets sometimes.

And it's definitely very different across states. So one, when we're talking about the battle over involuntary commitment, one of the things we're talking about is to what degree should psychiatrists should. Let's say the healthcare system be able to force someone into a psychiatric hospital, take, remove them from society in order to begin treatment.

That would be one form of involuntary treatment. Uh, is that a fair summary? Yes. What are some other forms? You know, I, uh, one, when I talk about the, the battle over involuntary care, if you're going to have a battle, you have to know what you're battling [00:15:00] for. So the first thing you're battling for is, so it's, it's a legislative battle of for making legislation that makes it easier or harder to involuntarily hospitalize somebody.

So one thing we're talking about is, is that, is it easier or harder? The second thing we're talking about is once we've got them somebody in the hospital, are we gonna make it easier or harder to give them medications if they don't want medications? The third thing which we're talking about is, are we gonna make it legislatively easier or harder to force people to get outpatient care when they're not in the hospital?

And the last thing that's on this list, it's not really sort of on the list of of, but one of the topics that comes up is, are we gonna say that that, uh. Psychiatrists have to share information with family members, even if the patient does not want their information shared, and that, that's not something I cover in the book.

I just feel like, you know, that it's a, there's a, a law called, uh, [00:16:00] HIPAA that everybody. Refers to. And a lot of times I feel like Hippo gets to be about laziness. Somebody will call a unit and say, I am looking for my son. Is he on your psychiatric unit? And the clerk will say, I can't release that information.

Well, there's nothing that says the clerk can't walk over to the sun and say, Hey, your mom's on the phone. You want me to tell her you're here? Um, right, absolutely. Uh, so that gets a little Well, and the other thing is I trained before hipaa, and so I'll tell you that before hipaa, we didn't talk to family members without patient's permission.

Right. That it, it's become this kind of funny, uh, health and health insurance portability access. Uh, it's, um, not something that, that the book is really about right. Whereas now there are specific, there is very specific guidance for when you can and cannot disclose information. And keep in mind to our listeners, if you need to obtain information about a patient to guide your treatment plan, usually there's a way to obtain that information without confirming or denying the presence of the patient.

Without giving any [00:17:00] personally protected information. So when we're talking about involuntary treatment, we're talking about involuntary commitment to the hospital. We're talking about outpatient civil commitment. We're talking about the right to refuse recommended medications. So if we're having this battle about these issues, can you define for us the different groups on the battlefield?

Who are the different parties that are interested in this topic, and what is the land that they are defending? What's the position that they're taking? Okay. Even that gets confusing. So we have the, the groups that are in favor of creating legislation to make it easier to involuntarily treat people and pe the groups that are in favor of making it harder.

And so the first group I'm gonna go with is a group called the Treatment Advocacy Center. They're a group that's founded by a psychiatrist named Fuller. He's written wonderful books on, um, schizophrenia. He used to work at St. Elizabeth's in Washington. It's a state psychiatric hospital, probably best noted [00:18:00] for the place where, uh, the man who John Hinkley, the man who tried to assassinate President Reagan was kept for years.

But Dr. Tory also, his group was heavily populated by parents of people with psychotic disorders. So people who had children, who had major psychiatric disorders, who were frustrated with how hard it is to get their children treated. So the treatment advocacy center, they have traditionally been interested in having more inpatient beds.

Um, and I'll tell you that in the 1950s in our country, we had about. Half million psychiatric beds, maybe 550,000. Back when I was researching this book, early teens, I wanna say 20 13, 20 14, we had about 44,000 psychiatric beds. Wow. So one, one 10th, the number of beds. And that during those, that period of time, our population dabbled.

And the population in jails and the homeless population grew [00:19:00] astronomically. Yes. Right. And the treatment advocacy center is very, um, for people who want you to tell, wanna tell you, we need more involuntary care. They draw a really beautiful graph that shows that like as. Hospital beds decreased the exact number of hospi of people in jails and, um, ho uh, homelessness increased.

I'm gonna tell you that I don't think those are the same people. For one thing, decades have gone by for another, the population has doubled. And for another many people who were kept, I mean, it used to be the standard in psych hospitals and some of the state hospitals that people would have a progress note written once a a year.

So lots of people in these hospitals were discharged and did just fine. Some were discharged. I mean not, not everybody did just fine. I don't wanna paint that picture. There were funds promised that we were gonna move the funds from state hospitals to community mental health centers, and we were gonna have housing and treatment for these people.

That revenue just never got. Put there. [00:20:00] So we just got rid of one form of treatment without creating necessarily treatment for everyone. But some people did leave and go, go home to be to live with their families or to live with friends, or to live in group homes, um, and get outpatient treatment and did just fine.

So you can't really make the case that those were the same people or that all of those people would've been captured. I'm sure some of those people would've been captured if we kept people in state hospitals, but we also kept people in state hospitals who would've been able to manage in the community and weren't allowed to.

Um, so you are talking about abuses of the system. I'll tell you, I, I, when I first started, um. Working in an outpatient clinic. The chairman of the hospital at that clinic, when he, he died, I learned at his funeral that his. Father had been the superintendent of a state hospital, and that as a small child for parents would go out for the evening and they would leave him with different patients to [00:21:00] babysit him.

Now, do you think that the people who are so sick and acutely ill that they need to be in a state hospital or who you would leave your child with today? I don't think so. Yeah. That's a fascinating anecdote. So, so. One of the groups on this battlefield was the treatment advocacy center. It's fair to say this is where we would place the National Alliance on Mental Illness, which is the, no.

Okay. Tell me about that. Okay, so the next group on this map is not, is the National Alliance on Mental Illness or nami. And NAMI has traditional, so. Initially, yes, NAMI was parents of people with severe psychiatric illness, but over time NAMI grew to be very big and they, they struggle a bit with like who exactly they are.

So they still have parents of people with severe mental illnesses, but now they include patients who have mental illnesses themselves, and they may include people with intermittent episodes of depression or people with anxiety disorders or PTSD. And so [00:22:00] they have a bit of a, they talk about whether they're a big tent or a little tent.

So every chapter has its own feel. I know when the book came out, there was some talk about us giving a talk in Connecticut to nami and they just were, we don't want anything to do with anybody having to do with involuntary treatment. Um, you know, so I think, I think they struggle a bit with who they are traditionally.

You're right, they do go on the side of the field of. Making it easier to have involuntary treatment, but I don't think you can say that as a sweeping. So as we move further from advocacy for involuntary care to make sure that we're not leaving anybody, uh, letting anybody slip through the cracks or go untreated as we move further along that spectrum, who do we find?

So, you know, when I do this, um. I do it with slides. I, I always say that my battlefield's orange, 'cause I like orange. I have a little cannon in one side and I move across as to you're doing with me now. And so I put a [00:23:00] PA next and the a PA is the, a group of psychiatrists. It's our, our professional organization.

And I would've said that we don't really, I mean, we don't make the laws. And we don't really take a huge stance that psychiatrists are comfortable with the standard for treatment being of involuntary treatment being dangerous. Um, but then in, oh, I wanna say maybe I used to know what year, but I wanna say it's maybe 2014.

The a PA came out with a very carefully worded statement in favor of outpatient commitment, or what they call outpatient assisted outpatient treatment, a OT. I threw them on the, um, on my babble field right at the center point, but on the side that favors easier treatment copy. So then let's go over to the other side of the field.

Um, on the other side, we have groups that are against, um, making it easier to involuntarily treat people. I go [00:24:00] with, it's not a, a cohesive single movement, but, um, or group, but the recovery movement. And the recovery movement tends to be patients who, um, or, or consumers, people who are advocating for psychiatric treatment in a way that includes the, um, the consumer's input that it's, it's more of a team effort where they're included and which.

Encourages people to live in the community as independently as possible. It tends to be people who were injured by the idea of psychiatry as a field with dismal prognosis for people. There are groups, I mean, in Maryland we have a group called on our own, a, a patient advocacy group. So that would be something of, of a bit of a recovery movement.

They're not necessarily people against Antip Psychiatry, but they're, uh, people who, who are advocating for autonomy. The other two groups I would put on that side are, there's the [00:25:00] Balon Center for Mental Health Law and there are lots of mental health law centers that are advocate for the patient's wellbeing.

Or for the patient's autonomy I should say. 'cause nobody wants to think of like involuntarily treating somebody as not being for their wellbeing. I think we all feel like the hope is that it is for their wellbeing or so the balon Center for Mental Health Law, it's an advocacy center for patient rights.

Then there are two group other groups that I look at called Mind Freedom International, which is a patient, organized, or uh, actually people who feel that'd been injured by psychiatry. It was started by David Oaks, a Harvard student in the 1970s, blanking on what it was called back then. But it's a group of maybe 10,000 people who come together and they, they pick it outside each year.

They pick it outside the American Psychiatric Association's annual meeting. And the next group is, um, CCHR or the, uh, the Assistance Commission on Human Rights. Right? The Citizens Commission on Human Rights. And I always tell, when I tell the residents [00:26:00] about them, I say, well, they have a place called Psychiatry.

The, uh, um, the Museum for the Industry of Death. I don't think I have to say much more, you know, the, I can show a slide with psychiatry. The Museum for the Industry of Death. They make videos, but they're very. Much against psychiatry and, and I didn't cover this in the book, but I'll throw in as the last, um, there's a, um, journalist named Robert Whitaker who has a website and a movement called Madden America.

His take on mental illness is, um, or is that psychiatrics drugs, they aren't harm ineffective. They aren't just harmful, they cause psychiatric illnesses. And so he'll, he'll point to the, since we've had more psychiatric medications that our rates of disability have gone up, but it's a kind of funny correlation measure.

It's like lots of other things have happened in those times. People have become more sensitive to the idea that you can apply for. [00:27:00] Disability for psychiatric reasons, and, and it's much, a much more complicated thing. But his, his take, this is like the group of people who feel like the reason for increasing mass murders is because there are more people on psych meds that they're causing these things.

Sure. And that group is, it's big and it's a little bit there. There's, it's not incredibly cohesive. There's a fair number of psychiatrists in the group, but they're also against making it easier to involuntarily treat people. Sure. So it's a very complicated issue. Obviously your perspective on this issue, it reminds me of, I think it's would be considered a parable, maybe an allegory of people standing around an elephant and you feel the leg of the elephant and you say, ah, this is a tree trunk.

I think that how close or how far you are to this issue and what your particular experience has been with this issue, um, if you're the parent of a love of a loved one and you've seen them lose everything in their life to schizophrenia, and then you've seen them make a meaningfully recovery on medication, you could see where your perspective might [00:28:00] be.

Why are more people not taking medication? This saved my child's. If you're someone who feels as though or has been really hurt by psychiatric treatment and experienced lifelong disability due to psychiatric treatment, you could see where your position on this issue might be. This is a grave injustice and I need to do everything I possibly can to make sure this doesn't happen to anybody else.

We're gonna take a quick break. When we come back, we're gonna talk about whether or not involuntary treatments actually work, what the data is. Tell us, do these actually do anything? I dunno if we're gonna talk about. We're also gonna talk about President Trump's new executive order, uh, where he is asking us to consider using involuntary treatment more liberally.

Dr. Miller has done some writing about that as well. So, uh, stay with us and we'll be right back.

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All right. Welcome back. Dr. Miller Proponent of involuntary treatment may point back to the involuntary standard of threat to self or others and frame the issue as a matter of public health or public safety. However, do we know that [00:30:00] involuntary treatments actually contribute meaningfully to public health or public safety?

That is to say, do we have data on whether involuntary treatments actually work at keeping the public safe or data that says it doesn't work? What's the state of the evidence there? Oh, Dr. Mullin, that's a hard one. I think. You know when somebody comes into your emergency room and they're. Dangerous. It's really hard to let them go.

We might be able to know for a person, but we don't have like evidence that says, Hey, if it's easier to involuntarily treat you, then we'll have less violent crimes or mass murders. Mass murders get to be a funny topic for this because we have a, a handful of mass murders a year. Maybe, maybe we have more than that now, but, um, it's, it's a very small number and there's no psychiatric illness where.

Mal killing people is one of the symptoms. We don't have a good answer as to why to some people [00:31:00] with schizophrenia would never harm anybody. And some people with schizophrenia do harm people. So we don't know. We really don't know when it comes to suicide. I mean, you can tell, you'll have patients who say to you, you know, treatment has saved my life.

But an awful lot of the people we're talking about are getting voluntary treatment. We know if involuntary treatment, I'm, it's really hard to come up with statistics on that. It's just a really hard issue to study. Right? Right. Because if you have a patient who you know has a disorganized thought process in front of you and is talking about, let's say, jumping off a bridge to see if they can fly, it really wouldn't be ethical to randomize that patient to either treating them or not treating them when.

Common sense, I think would dictate that at least taking 48 hours to think about that decision would probably be a wise idea. Um, so I we're probably never gonna get very robust, randomized controlled trials to tell us about this. And if you were to just look observationally the patients who are going to be most likely to either commit.

[00:32:00] Public acts of violence or hurt themselves are the same patients that are going to be mo most likely to be involuntarily committed. So I think you just have a lot of confounding variables and it would be difficult to, uh, really study this in a systematic way. Well, and these are very complicated issues because every state has different criteria, right?

Um, we have like very technical issues, like is there bed or is there, you know. We may wanna put you in a hospital, but if, but there was, there's no bed. I mean, in a few states they put people in jail cells, which is, can you imagine? You go to the hospital with a heart attack and they put you in a jail cell 'cause there's no bed.

I mean, it's crazy. But we also have, every state has different gun laws. Um, and so, you know, you, you sort of, they like to say it's mental illness, but it's funny that like there are countries with very few mass murders or with much less gun violence and we don't have any evidence that the rates of mental illness are different.

Among societies. So I think these issues get too, there's too many [00:33:00] variables to figure that one out. Um, I do think if you've got somebody who's acutely dangerous and. Having an episode of mental illness, it's very hard not to involuntarily treat them if they won't go in and to our listeners who are practicing clinically in to some, in some way, to some extent, it really doesn't matter how you feel philosophically about this issue.

If you find yourself on the most. Libertarian side of the spectrum and think that involuntary treatment should never be used. That's your prerogative to practice psychiatry in that way. But you do have a professional responsibility, especially if you're board certified practicing medicine, and you will be held to a professional standard medical, legally, and the professional standard.

Medical legal is really clear, I think, at least in the two states that I've practiced in. If you have a patient who is imminently dangerous to themself or other people, and one of the driving factors for that dangerousness is. Easily treat, well, I won't say easily, but treatable psychiatric symptoms. You have a professional obligation to the patient to do what is right for [00:34:00] them regardless, I think of your personal philosophy on the issue.

Dr. Miller, you mentioned ed boarding. I wanna talk a little bit about that and. I think that working on high acuity psychiatric units and you work outpatient and private practice. I work consultation liaison, but we have a very ill population generally speaking and involuntary treatment is a significant part of my practice.

These psychiatry units are not fun places to be. I think their dehumanizing places to be. We stick people in paper scrubs. Um, it's just. Really, they, they, they can be, um, very jarring places to be in for the first time and not very pleasant for our patients. The ed boarding is another serious issue, right?

Um, one of the most difficult cases I ever saw, I had a patient who we were holding involuntarily because the patient was clearly manic and had a clear history of bipolar disorder and was, to me, clearly an imminent risk of danger to self if they were to leave the hospital. And the patient ended up waiting on a bed [00:35:00] for, I'll just say.

Upwards of three days and. Significantly injured themself in the emergency department because of the frustration with ed boarding. Right? And so it's just terrible to see what, what do you think are some changes that we need to make to the system to make it more humane to patients who are being treated involuntarily?

So we have a question when you were talking about, you know, people who get better or it's easy to treat them, so you get, what's the downside? And the downside is that people feel traumatized by the care they've gotten right in ways that they carry with them sometimes for years. And we don't have any idea what percent of people have these come out with these feelings or, um, whether or not if you are in the midst of treating somebody involuntarily who's having an episode now.

Do you scare them away from ever getting treatment again? I'm not going to a psychiatrist. They're gonna stick me in a hospital and they have all sorts of beliefs and so they don't get treatment, and maybe [00:36:00] they don't get treatment at a time when they need treatment and they end up killing themselves or they end up hurting somebody else because we've scared them off of treatment and we have no statistics on things like this.

So you, you get into the like. If nothing else, we should be really nice to the people that we're treating involuntarily. I was so impressed that when I talked to people and I asked them, you know, what helped or what made it better, people would tell me things like, oh, a nurse drew a bubble bath for me, or somebody brought me a cup of tea and it was just sort of these small acts of humanity, um, that made a difference.

And so I guess I feel like. Psych psychiatric units should be nicer places. They should be places where, where people are worried about traumatizing patients. Um, but as I, as I tell the residents, it's better to have a traumatized patient than a dead patient. Um, and it's never in your patient's best interest to have them commit a crime because they would help.

I agree [00:37:00] that there are some significant risks to hospitalization, including traumatization and pushing a patient further away from voluntarily seeking help. Because if we have, let's say, treated psychosis, but simultaneously we have shredded any trust that this patient had on the psychiatric system and the long term, that might make them less likely to engage with the treatment they need and lead to some long-term deterioration.

One of the topics that you cover that I'm really interested in is language. I haven't had the opportunity to have this conversation on the podcast yet, but it's always fascinated to me that's, well, just to put it deliberately, I am a doctor and so I treat patients. That's what doctors treat. Doctors treat patients.

But I also am a practitioner in the field of mental health and a lot of people who are practitioners in the field of mental health, they would. Call what I consider patients. They would call those people clients, and we also have the word consumer or service user. What is the landscape of this terminology?

So, you know, on any [00:38:00] topic that's polarized, and this is a very polarized topic, but you can throw a stone and you can hit a polarized topic. We can, it can be abortion, it can be gun control, it can be immigration. Any topic that's heated has language with it. So in involuntary, you, you already got a few of them.

Uh, I'm a psychiatrist. I see patients, the social worker in the office next to me. She sees clients. If you're talking about a legislative session, then you're talking, or, or a legislative issue, then you're talking about consumers. It's a term I don't like, 'cause I feel like somebody's charging at me with a knife and a fork and a bottle of ketchup.

Um, but I don't, that's. That's the term people use. And if you're somebody who's been injured by the mental health system, then you use the term, um, survivor. Um, if you're talking about, and, and I'll tell you that even saying that if you've been injured, 'cause my prog. It tendency might be to say if you feel you've been injured, which then says that, ah, they haven't really been injured, they feel they've been [00:39:00] injured, and who knows what the reality is.

I mean, there's no set reality here, but, um, if you're somebody who feels you've been injured by psychiatry, then you have a reality. And your reality is you were injured by psychiatry. Um, but then you, you. You talk about being a survivor. If you are a patient taking medicines, you talk about medicines. If you're a survivor, you talk about psychiatric drugs.

If you are in favor of involuntary treatment, then you call it involuntary treatment. If you're, if you're skeptical about it or you're against it, you call it forced care. And I will tell you that my title for the book was Committed the Battle Over Forced Psychiatric Care, and my editor just said, we are not publishing a book with that, that title.

Um, the first time I spoke with Dr. Tory, he said to me, why is your book called? Maybe it was, maybe it was a secretary. But whoever talked to me on the phone said, wait, you have a book about invol called Committed the Battle Over Forced Psychiatric Care. Why isn't it involuntary? Like, so the language, I mean, it's the same, it we know where you [00:40:00] stand.

If you talk about, um, physician-assisted suicide versus medical aid and dying, right? We know which side you're on. If you're in favor of it, you call it medical aid and dying. If you're against it, you call it physician-assisted suicide. So every, every polarized topic has language. Fair enough. I'm gonna move now into a more timely content.

I, we haven't really covered politics yet on the podcast. Let's not, we're gonna go ahead and, well, we're gonna touch the fourth rail a little bit. 'cause I think that the executive disorder touches your book and you've, to be fair, this is not coming out of nowhere. You have written and published about this topic.

Right. But I will say, notice that you just called it the executive disorder. No. I, if, if so that was Freudian. I had to cry. That's hilarious. I am. Well, that's why I'm laughing to be clear. Dr. Miller, I'm asking you to get into politics. I'm the host. I have no, I will not be, I will not be delving into this too deeply.

The order is called [00:41:00] Ending Crime and Disorder on America Streets. And essentially it's an executive disorder that is imploring states to use involuntarily treatment more widely. Um. Dr. Miller, you're an expert in involuntary psychiatric treatment. What do you think about the executive order? Uh, is it ethical?

Could it actually achieve its stated goals? Are we in a place in American society where an order like this could actually be reasonably executed? What do you think? I don't know what to think. So is it, don't we find it interesting? Tell me again the name of you. Keep calling it the executive disorder and Freudian That is, but we'll go with it.

No, no. Disorders in the word ending Crime and disorder on America's Streets is what the president has title is so interesting that if you heard this ending Crime and Disorder on America Streets, wouldn't you think this was about something to do with crime For sure, or. [00:42:00] Some. So when you go into this, the, the wording on this executive order, there's nothing there about crime.

It's all about we need to have more facilities to put people in with mental illnesses and we need to get them treatment. There's nothing about crime. I think if you read this, you read the executive order and you think, ah, he wants to go back to having state hospitals someplace safe to put people for treatment.

Where there are more beds. 'cause we don't currently, in most places, at most states at this point, exec, um, state hospitals have become forensic. There are places you go while you're waiting trial or you're being evaluated or you're being made competent to stand trial. Um, they don't tend to be places where people who aren't dangerous can be so.

I think people looked at that and thought, oh good, we need state hospitals again. I mean, we certainly need more beds at some, in some form. Um, [00:43:00] even for people who are, if you wanna go in the hospital, it's very hard to get in the hospital and it's very hard to stay in the hospital for more than a few days.

So you, you work on an, on a consult liaison on your inpatient unit. What's the, what's the standard length of stay inpatient unit? I think three to five days is the number that we often quote. Right. Um. That seems short, but even if it were longer, even if it were five to 10 days, um, these problems of people who are chronically living on the street and causing quote unquote disorder, I hate that, but their problems are probably not gonna be fixed in 10 days.

So the idea of more of a state hospital someplace for people to be, to heal, to get well, and yet the term state hospital is used nowhere in the executive order. There's no mention of how this is going to be funded, so I, I don't really know what it means, but you're right, it is a call to involuntary, take people off the streets and involuntarily treat them.

I always [00:44:00] wonder, you know, they use term sort of statements like, oh, cutter of people on the street who are living on the streets have, um, mental illnesses. It's probably more than a quarter, and then you get into, well, what the, what is mental illness? Um, have you tried to define that lately? So is it somebody who has PTSD or uh, or a anxiety disorder, or is it somebody who's actively hallucinating and delusional somebody who, so, so I don't, I don't think we have any idea how this would actually be enacted or funded.

I think it's con, since you're begging me to give my opinion on this, I suppose I will. I think it's just confusing. I mean, even if you were to take the, even if you were to accept the sort of basic proposition that someone not being able to provide for their own shelter. Is in some way a grave disability.

And if you're able to associate a treatable mental illness with that inability to [00:45:00] provide shelter, then you can justify involuntary treatment. Even if you were to accept that as valid, which I personally do not think that it is. The question becomes then, what treat these people where? And if the answer is to build more state hospitals, I mean to be, to be honest, we have old state hospitals that we could probably fix up and reopen on massive plots of land, but those were, those were.

Whole. Those were basically cities where people had meaningful things to do and there were programs to spend their time and they were shut down because they had their own set of. Grave issues. My fear would be that the treatment that the administration is talking about is basically warehouses of humans, and I think that we get really quickly into some really dicey ethical territory there.

Well, I think we worry about that too, but my, my other question is why do we only care about the people on the streets that are mentally ill? What about the people who are on the streets, who are living on the streets because they're addictive or living on the streets because they're destitute? I mean, you know, [00:46:00] this doesn't cover everybody.

Does warehousing people help? I don't, I mean, maybe it helps somebody, um, and maybe it is more humane to have people somewhere than sleeping on the street. I'm not a big fan of having people sleep on the streets. I would be okay. But, you know, one other thing other than just going immediately to let's warehouse them is, well, some of them we could house if we had more housing.

Some people live on the streets often because there's nowhere else for them to stay and this, and it's interesting, but the executive order specifically calls to end housing first initiatives, which are initiatives that say, okay, we're gonna give you housing without stipulation. You're, we're gonna give you someplace to live, and we're not gonna say that you can only have it if you're not using substances and that you could only have it.

If you get psychiatric care the way we want you to, and I'm gonna tell you that the vast majority of people who have substance use disorders use substances in their own [00:47:00] houses. They don't bother anybody or they do bother somebody, but they're, um, we let people make that decision to use substances in their own houses as long as they don't come under the.

As long as the they can afford to, to pay their rent or a family member pays their rent. I mean, some of this stuff ends up being just luck. You know, if you can pay your rent and if you can, um, not get in the way of the law or come under the, if somebody doesn't notice what you're doing. Um, so I, I'm not, I don't know what the point I'm trying to make is just that like.

Poverty is not mental illness. Right. Well, and some people who are, I think if you're mentally ill, it may be very much harder to sustain a job, though certainly in in outpatient private practice, I see people who have serious mental illnesses, some of whom go to work and do fine at work and pay their bills and may or may not use substances.

Especially since a lot of substances are legal. [00:48:00] I'm gonna change gears here and talk about outpatient commitment with you. Before I ask you for your final thoughts. So you had mentioned that one of the facets of involuntary commitment is this. Or involuntary treatment is this outpatient commitment, and that is especially fascinating to me because I did residency in Omaha, Nebraska, and an Omaha, Nebraska.

A patient could be placed under an outpatient board of mental health commitment, and if they were to miss an appointment, miss a long acting injectable appointment at et cetera, that. Outpatient commitment could be invoked and the patient will be brought in for treatment. I now work in St. Louis, Missouri where there is not a shred of outpatient commitment.

Once the patient leaves their civil commitment in the hospital, there is no way to ensure follow up with that treatment plan. The only way for that patient to reengage with care involuntarily is for the patient to again, meet that standard of imminent dangerous to self or others. What are the different ways that states have tried to solve this problem?[00:49:00] 

So the place that has probably done it best and been most studied is New York because they, they put together an um. You know, outpatient, this is another one of your, your examples of wording, but, um, people refer to it as a OT or outpatient assisted treatments. There's nothing there about involuntary, and for some people, it's not involuntary.

They're willing to go in this program voluntarily, but. New York, not a place where people want involuntary treatment. It's a, it's a big human rights place. So in order to get it accepted, they put a lot of money into the regular mental health system and then they put money into giving services to people who are on outpatient treatment.

So, so there's something to the assisted other places, call it. MOT mandated outpatient treatment. Other countries call it CTOs, community treatment orders. I usually just go for ICC or outpatient civil commitment. Um, but AOT is the term [00:50:00] most people use. And so how do you enforce? So there's the question of how do you enact it?

How do you enforce it? Because it takes money to go around looking for people who didn't keep their appointments. And then what do you do with these people? Do you put them in jail because you, you violated an order or do you put them in a hospital? Is that what they do in Nebraska? Never talked anybody from Nebraska.

Um, in theory, yes, they would bring them into the hospital, yes. No, but not in theory. In practice, what happens? Somebody misses an appointment. What happens in practice? You can call. In practice, you can call the Board of Mental Health and say that you are invoking the outpatient board of Mental health commitment.

And then when the patient comes, uh, I believe then the Sheriff's Office should find the patient and bring them to the hospital. These are rarely invoked because the sheriff's office is not in the habit of tracking people down. Okay? So you, you say, my patient missed an appointment. You're not obligated to call the police and say, my patient missed an appointment.

No, you're not obligated. No. So you're only doing that if you're worried about the patient? [00:51:00] Probably. 'cause they're Correct. Somebody in their family is calling and saying they didn't keep their appointment and they're a mess. Yeah. Correct. Right. So it's not that every person who doesn't get treated gets hunted down.

Um, correct. But, and then you get to the, what if they, what if they miss an appointment? You call? The sheriff goes out, they bring, get them, they bring 'em to the hospital, and the patient is fine. What happens then, or maybe they're not fine, but they're not doing anything worrisome. They just say, I'm not taking that medicine 'cause it made me gain 40 pounds and I don't like being fat.

Yeah. To be honest, I'd never seen that happen. I don't know. Okay. Oh, you'd never see what happened. I've never seen a patient get brought in after, when an outpatient, I've never seen an outpatient board of mental health commitment be invoked and have the patient be brought into the hospital and have the assessment at the hospital be.

This patient does not need any further treatment. I've just never seen that happen. Okay. So every time they were brought in, they were kept. Which was very seldom. Yes. Right, but [00:52:00] that's because the only time anybody was going after them was when they weren't okay. They weren't just saying, you violated this order that you had to actually be sick or, because when you invoke it, basically the stumble, the sheriff then has to stumble upon the patient somewhere.

And so even after you've invoked it, the patient may not actually be brought in. So they don't go, it's not like an, um, the emergency petition I told you about here. They actually do go out and pick up the person and bring them in, usually within hours. I mean, maybe they can't find them, in which case they don't.

I think that's the question is can you find a patient? Right? But oftentimes these are people who are living with somebody, and so the family members will say like, Hey, come take him to the hospital. So New York has the best system. I don't know that it's working that well. I mean, it was costing $34 million a year, or $32 million a year, and this was all very expensive.

Um, it was only being used in certain places. So New York City, Rochester, a few other cities, but, um, a [00:53:00] fair amount of the state was not really covered by it. Um, it was being used as people were being discharged from the hospital. Um, and one of the things that people want out of a OT is to be able to have people placed on outpatient commitment, even if they're not.

So there was a criteria. If you had more than two hospitalizations and x amount of time, it may have been 36 months or 48 months. Um. Then on your third involuntary hospitalization, not voluntary, you were told you can't leave the hospital without a hearing and then you were placed on a OT and people often said, you know, they didn't contest, some of them didn't contest it.

They just said, okay, I want my hearing so I can go home. Then they were, they were given some help with things. They were put towards the front of the line for, for housing. They may have been given some case management services. You know, an awful lot of non-compliant when you're talking about street people living on the streets.

You know, patients go home, they ask you on the way out, can I have a card? Nowadays people put it in their phone, but you know these [00:54:00] desks, when I have a card and they put their, tell you, I put my car, your card on my refrigerator, and then they get their medicines and they put it on a shelf in their cabinet.

They don't have a refrigerator to put the card onto if they don't have a car or somebody to drive them to the appointment and they don't have somewhere to put the medicines. It makes it hard to comply with treatment. Some of these people just weren't complying with treatment, not because they didn't want it, but because the logistics are so difficult.

And then what are the, what's called the teeth in the law? What can you do? Do you know? Do you put people in the hospital if they don't comply? I mean, we can't, can't really do that in a place just you didn't keep your appointment or you're not taking your medicines, but you don't meet criteria for being involuntarily hospitalized.

Do we put you in the hospital and take away a bed from somebody who needs it because you didn't take, because you won't take, won't get treatment when you're, when you're fine without it. Right. Well then do we drop the, drop the commitment at that point? Yeah. I don't know. They, you know, they, they all have certain timeframes on them.

That was very insightful. I [00:55:00] appreciate the help with that. Dr. Miller, we're gonna wrap up here. Any final thoughts for our audience? Oh. This is just a difficult topic. It's hard to have my, I mean, I go back to the, you know, if you can talk people into voluntary treatment, even if it feels a bit coercive, I kind of feel like that's, that's better.

'cause it doesn't take away people's agency. Um, if you can't and if you really feel like somebody is gonna, can have a, a bad outcome if you don't or somebody is gonna end up hurt. It is better to have a traumatized patient than to have a dead patient. Um, and I think we should make an effort to, to provide a better inpatient experience for people.

People don't dread going into medical facilities the way they dread going into psychiatric facilities. And it's hard, you know, some of the dread is, is that other people in the hospital are scary and [00:56:00] how do you control who's on a, you know, sometimes I've sent people into the hospital. Not usually voluntarily, but they come back and they've made me, you know, they found people who had similar problems to theirs.

They felt relatable. They, they made friends with people. They'll continue to see afterwards. They aren't traumatized. It was a good experience. And so, but how do you control who's on a, oh, you know, having people have a good experience. Um, I think we should be trying really hard to give people good inpatient experiences.

Voluntary if possible, and as humanistic as possible to make it the most effective and, and maybe increase the chances that they'll engage with psychiatric treatment that they need in the future without the coercive practices. Dr. Miller, thank you for coming on Psychiatry Bootcamp and sharing your hard one expertise, and I look forward to talking to you next.

Thank you for having me. This was lovely.

Thanks everyone for joining us for this episode. We'd love to hear what you think of the show. We're now on Instagram and TikTok [00:57:00] at Psych Bootcamp. You can also connect with the whole Human Content Podcast family at Human Content Pods on Instagram and TikTok. You can email me directly, mark@psychiatrybootcamp.com.

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And again, I'm your host, Mark Mullen. Our executive producers are Mark Mullen, Aron Korney, Rob Goldman, and Shahnti Brook. Season four is produced by Matthew Braddock, and this episode was. Outline by Nevy Checkup. Our editor and engineer is Jason Portizo. Theme music has been generously donated by Cave Radio, one of my favorite bands.

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