“I wish we could do better.” Psychiatrist Talks About SMI, HIPAA and Helping Patients

(10-08-18) I recently interviewed Baltimore psychiatrist Dinah Miller about mental health care today from her professional and personal vantage point. Dr. Miller is a  practicing psychiatrist, instructor in psychiatry at Johns Hopkins School of Medicine,  a prolific blogger and nonfiction and fiction author. Her new book, co-authored with Dr. Annette Hanson, is 
Committed: The Battle over Involuntary Psychiatric Care.

Question:   Much talk lately has been about focusing on “serious mental illnesses” as opposed to the broader range of all mental illnesses. Do you accept this delineation and, if not, why?

Dr. Miller:  Pete, this is a great question, and it’s more of a political question.  Obviously, some people experience psychiatric disorders in more chronic and/or disabling ways, and some people need more than others.  There are two things I don’t like about the designation of “serious mental illness.”  For one, it sets up a bit of an “us” versus “them” dynamic and seems to imply that there are people who are different from the rest of the population, and that this small set of of very ill people somehow stand out in a way that obviously identifies them.  People can be very sick at one point in time and very healthy at another point in time.

That division is based on the presence of specific psychiatric diagnoses: schizophrenia, bipolar disorder, or severe depression.  Our diagnoses are decided by committees, and what we designate as a disorder changes over time, and the same person may be given different diagnoses at different times; this isn’t a precise thing.

The problem is that based on this idea of ‘severe mental illness’ is the political idea that the mental health pot of dollars should be divided so that these individuals get more, at the expense of services to those who don’t have serious mental illness.  And then we get to terms like “worried well,” which serves to demean the suffering of people who do not have debilitating conditions.

But what is serious?

20% of people will have an episode of major depression in their lives (and 100% of those people are miserable), half of all people will suffer from an episode of some type of mental illness, and no one is saying that 20-50% of people have serious mental illness, it’s a term reserved for very few.

But half (or more) of people who die of suicide have never been diagnosed with a mental illness, and someone who is distraught over a romantic break or a financial downturn may attempt or complete suicide.  It’s not clear exactly who these seriously mentally ill people are, and sometimes that gets defined after a catastrophic event.   Suffering is suffering and it all deserves treatment, and of course those with chronic, disabling illnesses should get more, but disability and need aren’t determined by a diagnostic label, or a black and white division.

The National Alliance on Mental Illness, for one, has struggled with this issue in terms of defining who they serve.  No other field does this: could you imagine saying we don’t want to use health care dollars to treat early stage skin cancers because there are people with metastatic brain tumors?

I’ll end with one other thought: advocates for mental health care often talk about the mentally ill homeless population.  But what about the addicted homeless? Or the indigent homeless? Shouldn’t we, as human beings, strive to end homelessness regardless of its cause?

Question:  As the co-author of COMMITTED: The Battle Over Involuntary Psychiatric Care, you were able to interview the entire spectrum – those who don’t believe that mental illnesses exist, anti-psychiatry groups, in addition, groups such as Mental Health America and NAMI, and Dr. E. Fuller Torrey and others who support greater use of Assistant Outpatient Commitment.

First: How did a practicing psychiatrist get anti-psychiatry individuals to agree to be  interviewed and was it odd for you? 

Dr. Miller: By the time we started writing Committed, we’d had a psychiatry blog for years (Shrink Rap) where we’d been interacting with people, some of whom had very anti-psychiatry views, so no, it wasn’t strange to listen to them.

I got them to speak with me by persisting. It took months to persuade the folks from MindFreedom to speak with me, and last year I invited one of them to present at the American Psychiatric Association with me. I think I’m the first to ever invite one of the protesters in to talk at a symposium!  As far as the Scientologists go, I walked into their New York headquarters and asked to speak with someone, and yes that was a little weird.

  1. Did your point of view about involuntary commitment change after doing your research? 

Dr. Miller: Of course it did!  You know, when people go into the hospital, it usually helps: they have fewer symptoms of psychiatric illness when they leave then when they came in.  I started with  the assumption that people would be grateful for the help they received, at a time when they may have been too ill to recognize how much they needed help.

I was surprised to learn how often people resented the help they received. It was easy to find people to talk about how much involuntary care traumatized them, it was much harder to find voices of gratitude, even from people whose lives had gone well after involuntary treatment.

  1. What did you conclude from your interviews? 

Dr. Miller:   Dr. Hanson and I can (and do!) talk about this for hours.  Let me give you a few of our bullet points.

First, the history of involuntary treatment is an ugly one where people were unnecessarily institutionalized for years, and sometimes decades, and so the system needs some checks in place.  Involuntary treatment can be traumatizing to some people in a way that lingers for years –one of the women I interviewed likened it to child abuse– so it should be avoided if there are other options, and it’s worth spending time trying to convince people to go in the hospital voluntarily, and it’s worth doing things –like having more staff– so that physical force in the treatment of patients can be avoided altogether or at least minimized.

We urge clinicians to be especially kind to involuntary patients: these are our sickest and most dangerous patients and they will often benefit from remaining in our care.  Sometimes there is no option, if a patient is dangerous and can’t be persuaded to get treatment then it’s better to have a traumatized patient then a dead patient.

Question: As a practicing psychiatrist, tell us your views on what the proper role of parents should be in the parent/patient/psychiatrist relationship?

Dr. Miller: For most patients, the role of parents in the relationship is what the patient wants it to be.

I invite all my patients to bring in a family member to the first meeting, and family members are always welcome.  Not everyone wants a family member involved, and we usually respect this.  The situation gets sticky when a family member wants to be involved and the patient doesn’t want that.  I’m sometimes left to tell parents that I can’t violate someone’s confidentiality, but they have the first amendment right to free speech and they can certainly leave me a voicemail with information they feel may be helpful to my understanding of what is going on.

I’ll add that sometimes there are very good reasons that patients don’t want their family members involved and not all intrusion are helpful.

Obviously this all gets complicated if a patient has a history of repeated hospitalizations, and really needs family help to get to appointments or take medications, and both the psychiatrist and family agree that releasing information to the family would be in the patient’s best interest.  Fortunately, this is not a very common dynamic for most patients.

Question: Parents often are frustrated by HIPAA. What is your take on HIPAA protections?

Dr. Miller: I was a psychiatrist before HIPAA and before HIPAA we never released information without the patient’s permission.  If you read the privacy forms that are given out at a doctor’s office, you’ll realize that HIPAA is about who can get your information –whether or not you want it released. It does not prohibit doctors from listening to information provided by others about a patient.  See : Summary of the HIPAA Privacy Rule.

HIPAA is poorly understood, and somehow it has led to hospital workers saying, “HIPAA, I can’t talk to you.”

I hope we’re getting better, but I sometimes think that some misunderstandings with family members are the result of laziness– no one goes to tell the patient a family member has contacted them and wants information (for example, whether the patient has been sent to a particular hospital) when the patient would gladly release that information.  I do believe privacy rights are important: who would seek care if they were told that their information could be released to their families without their permission?

Question: How has psychiatry evolved since you first began treating patients?

Dr. Miller:  Oh gosh, when I was in training, the SSRI’s were introduced, as were the second generation anti-psychotics.  I remember when all we had were Prolixin and Haldol, which often made people feel horrible, and it was so difficult to get patients to take these.

Another huge change is that I went to medical school in New York City,  it was just assumed that psychiatrists saw patients for both medications and psychotherapy, even psychoanalysis.  More and more, psychotherapy is relegated to another mental health professional and the psychiatrist is just a prescriber, seeing more and more patients for shorter and shorter appointments.

And now nurse practitioners and physician’s assistants often have the prescriber role.

In hospital and clinic settings, the computer and the electronic medical records also divert the psychiatrist’s attention away from patient care.  So it’s an evolving field, though I suppose that’s true for all of medicine.

That said, psychiatry remains a shortage field and most psychiatrists find a way to practice that fits with who they are.

Question: What prompted you to enter psychiatry? What do you enjoy most about your practice? What do you dislike the most?

Dr. Miller:   I’ve always been interested in what motivates people, and I entered college with the plan of becoming a clinical psychologist. I was majoring in both psychology and the biological basis of behavior.  You know, we have to make these decisions at a young age and I didn’t really understand what the different types of mental health practitioners even did.  At the end of my sophomore year, I realized that psychiatry offered more more options — I could see patients and do research, and I would also be able to prescribe medications.  It was a good choice for me.

What I like best?

The intimacy of the therapeutic relationship and seeing people heal and grow.

What I dislike most?

Feeling helpless when the system diverts my attention to things that have nothing to do with helping people get better; things like having to get inexpensive medications pre-authorized.

I wish we could do better, and I wish we had medications with fewer side effects. We need more hospital beds.  We need more day hospital slots.  We need more access to all forms of psychiatric care.

Question: One final one. You mentioned the intimacy of a therapeutic relationship, how do you keep from getting overly involved in your patient’s life?

Dr. Miller:  Pete, sometimes I fail miserably!  We try to keep most of what goes on to the session, but when someone is in crisis, that’s not always possible.  And sometimes I go home still worrying about a patient, and sometimes there are phone calls on the evenings and weekends.  It gets hard when this is too intense, but I did realize when I went to medical school that it wouldn’t be a job where I punched a clock and left.

To learn more about Dr. Miller’s book, COMMITTED, click here. 


About the author:

Pete Earley is the bestselling author of such books as The Hot House and Crazy. When he is not spending time with his family, he tours the globe advocating for mental health reform.

Learn more about Pete.