MS. DIANE REHMThanks for joining us. I'm Diane Rehm. Many psychiatric patients say that forcing them to get treatment has traumatized them. Some patients end up so scarred by the experience, they're unwilling to get further mental healthcare. That's according to two Baltimore-based psychiatrists, Dr. Dinah Miller and Dr. Annette Hanson. Their new book is titled "Committed: The Battle Over Involuntary Psychiatric Care." They join me in the studio along with author Pete Earley who wrote the bestseller, "Crazy: A Father's Search Through America's Mental Health Madness."

MS. DIANE REHMAnd throughout the hour, we'll be taking you calls, comments, questions, 800-433-8850. Send an email to drshow@wamu.org. Follow us on Facebook or Twitter. Thank you all for being with us.

DR. DINAH MILLERThank you for having us.

MR. PETE EARLEYThank you.

DR. ANNETTE HANSONThank you.

REHMDr. Miller, I'll start with you. Briefly lay out for us the pros and cons of involuntary commitment.

MILLERSo the pros are easy. If you have somebody who is really unwilling to get care and is very sick and maybe -- by very sick, we might mean psychotic. And I'm going to define that term because we may use it on and off during the show. But psychotic is somebody who is having -- either hearing voices or seeing things that aren't there, what we call hallucinations, or has beliefs that are unreal, such as that they're being followed or monitored in a way that just can't possibly be.

MILLERSo if somebody really is being followed or monitored, they're not paranoid, but sometimes the stories are just so bizarre. And then, the third part of psychosis is that some people's thinking gets so disorganized that they can't put thoughts together in a way to make meaningful sentences. So if somebody is psychotic and they're refusing treatment and sometimes they don't even know they're sick, they believe somebody's following them, what would taking a medicine or seeing a therapist do, then forcing them to get care may make them better and may make them able to go on with their lives.

MILLERThe con of forcing someone to get care is that if they don't go along with it, it can be very traumatic. Often, a family member will call the police to have them brought in and so somebody who hasn’t committed a crime will be brought into the emergency room for evaluation. They may well be taken away in front of their neighbors or their coworkers or their families by a police car in handcuffs. In the emergency room, they may be put in a seclusion room. They may injected with medications against their will and they may be held down in restraints, tied down.

MILLERAnd if they continue to refuse medication, sometimes they talk about four people holding somebody down. It can be physically very traumatic. And then, there are people who aren't physically traumatized, but the loss of liberty and this weird sense of do I know when I get out and I have to take these medicines I don't like, even if you swallow them and you're not being injected, it leaves people feeling very badly about the system.

MILLERSo it depends on, in the end, even people who are helped sometimes feel badly.

REHMDr. Hanson, I know you and Dr. Miller talked to a lot of people for this book. Give us, if you will, some specific, but anonymous, examples of the kinds of reaction people had.

HANSONOh, we talked to a number of different people. Dinah actually did the majority of the interviews. But people reported experiences like being thrown into a seclusion room, being brought to an emergency room expecting to get helped and being committed to an inpatient unit instead. A lot of people felt that their concerns were dismissed and that's understandable because when someone has a delusion, it's a fixed false belief that most people would not agree with.

HANSONAnd yet, if someone has a firmly held delusional belief, that's a really sincere issue and a point of suffering if they really believe that people are going to kill them. We also heard experiences on the other side of the spectrum where small kindnesses on the unit could make a tremendous difference. People talked about having a nurse that would take the time to explain what was going on or ask them if they were comfortable and so you'd see these extreme variations in care between hospitals and between patient experiences.

REHMYou, Dr. Miller, talked with someone we'll call Eleanor who said she'd rather die than be hospitalized again.

MILLERYes. And isn't that an extreme thought? I mean, Eleanor was in the hospital for three weeks during which time she got much better. She actually will say that she went for help and she would've voluntarily signed in. She got some medicine in the emergency room and she felt much better and no one explored whether or not she could go home.

MILLERSo she had a husband who she lived with. If she had gone home, if she wasn't doing well, she could've come back, but she went looking for help and she was willing to sign in. And they signed her in and she insisted that she got sick because of the medicine. And I actually couldn't find anybody who said she was delusional before. The doctor who sent her to the emergency room did not expect her to be hospitalized.

MILLERShe, then, was in a day hospital for three weeks and then her life went on. It went on well. She got another graduate certificate. She changed careers. She has not had a recurrence of this psychotic episode and yet she feels she was so badly treated. And I asked her, what could they have done differently because she was really doing disruptive things. She was pulling fire alarms. She was running into other people's rooms and telling them they were all on a mental health reality TV show. And her answer was, they could've been kind.

REHMPete Earley, you've had firsthand experience with the idea of involuntary commitment. Talk about your son.

EARLEYWell, no one likes to force anyone and it's always traumatic to force someone and it's easy to say, oh, we should never force anyone, but if you're a parent and your son's sitting in front of a television set with a tin foil wrapped around his head talking about how he's going to marry Natalie Portman, if your brother is sending his paycheck to Nigerians every week because he's convinced they're going to give him $10 million, if your mother is sleeping under a car and eating her own feces, then it changes your perspective about stepping in and doing something.

EARLEYOne of the things that hasn't been mentioned yet is in all three of those examples, you could not step in because it has been ruled that those are not dangerous acts. And because of the trauma in taking someone's rights away by putting them involuntarily in a hospital, we have a very high bar. Someone has to be dangerous to themselves or others. I also would like to point out that involuntary treatment, involuntary hospitalization is not the same as getting treatment.

EARLEYYou can be involuntarily committed and refuse treatment, which puts a parent in a terrible position because they insurance company will call up and say, we're not paying for treatment for someone who's not getting services. And the hospital will call and say, we're not going to keep your child here if no one's going to pay for it. And so there's a financial aspect as well as a personal and traumatic side of this.

REHMAnd talk about your son. This became such a huge issue for you because you did have your son committed.

EARLEYI did. I rushed him to a hospital. He had been diagnosed with bipolar disorder. He had stopped taking his medication, which happened to help him. I took him to Fairfax Inova Hospital outside of Washington D.C. We waited for four hours and the doctor, literally, said -- when I finally grabbed him and brought him into the room, there's nothing I can do for your son, even though he had told me -- he'd asked me how I'd feel if someone killed himself, my son was not showing signs of dangerousness.

EARLEYSo I was told to bring him back when he either hurt me or hurt someone else. My son slipped out of the house. He broke into a stranger's house and luckily no one was there. He broke in to take a bubble bath. It took five officers to get him out. Now, Diane, this is where it gets interesting because they took him to a mental health center and when I went over there, a policeman was outside and he said, even though your son is bipolar, he's off his medication, we picked him up in a house taking a bubble bath. Unless you tell that psychiatrist your son has threatened to kill you, he will go to jail and you don't want that.

EARLEYAnd so, quite frankly, and it really hurt my relationship with my son, I went in and lied and said he'd threatened to kill me. And that was good enough to get him on a 72-hour hold and then at a hearing, he voluntarily decided to go ahead and go in.

REHMAnd all of which you've just heard from Pete Earley would suggest that the rules are so complicated to try to get someone help who really needs it, Dr. Miller.

MILLERSo the striking thing about the story with Pete's son -- and I read "Crazy." I think I've read "Crazy" several times -- is that because the rule was that you can't help someone against their -- you can't hospitalize somebody against their will if they're not dangerous, the son told somebody at intake that he didn't want to take medication and the doctor walked in and said, there's nothing I can do. Nobody from the story, and Pete will correct me if I'm wrong, but nobody in the story sat down and tried to voluntarily talk Mr. Earley's son into coming in.

REHMDr. Dinah Miller, she's an instructor in psychiatry at the Johns Hopkins School of Medicine, co-author of the new book titled, "Committed."

REHMAnd welcome back. We're talking to the co-authors of a new book titled "Committed: The Battle over Involuntary Psychiatric Care." They're Dr. Dinah Miller and Dr. Annette Hanson. Dr. Miller is at the Johns Hopkins School of Medicine. Dr. Hanson is at the University of Maryland Forensic Psychiatry Program. We are going to open the phones shortly if you'd like to join us, 800-433-8850. And if we don't get to your question during the program, you can join psychiatrist Dinah Miller and Ann Hanson for a live Q&A on our Facebook page, right after the show at facebook.com/thedianerehmshow.

REHMPete Earley, before the break, you were talking about having had to lie to get your son involuntarily committed, and Dr. Miller, you were mentioning the fact that nobody talked to him.

MILLERWell you know, involuntary care is a topic that's polarizing, like so many topics in our country today. You're either for, or you're against. And what makes so little sense, what's crazy actually, is that we talk so much about involuntary care when it's so hard to access voluntary care.

REHMJust because Dr. Hanson, there are not enough doctors?

HANSONThere is a shortage of psychiatrists nationwide, and it's been estimated that fewer than 50 percent of the counties in this country even have one mental health professional. And this is a serious problem. It's been projected that we're going to have an increasing need, about 12 percent by the year 2020, of a need for psychiatrists, and we just aren't producing enough mental health professionals, even if we had enough psychiatric beds for everyone.

REHMPete?

EARLEYWell a good sign of how broken the system is is the fact that again, my son was then arrested, and we have 365,000 people with schizophrenia, bipolar disorder and major depression in our jails and prisons. More than two million go through the criminal justice system every year. And, you know, when -- let's back up with my son's story. When he was first diagnosed, the doctor said to him, look, I'm not going to sugarcoat this. You have a life-long illness. You will have to take medication all of your life. It will cause you to gain weight. You'll probably never work. It'll be hard for you to get married. And I remember when we walked out of that room, my son turned to me, and he goes, man, that guy's crazy.

EARLEYAnd, you know, my wife had kidney cancer. And we looked at the odds, and we said, we're going to beat it. Well, he did, too. He looked at that and said, I'm not one of those homeless people on the street. And so he fought the whole idea of treatment. He fought the whole idea of medication. And then eventually we went on this train where he got arrested.

REHMAnd then what happened?

EARLEYWell, we went through five hospitalizations. And we also, at one point, I called and said, look, my son's off his meds. And they said, look, is he dangerous. And I said, no, but listen what happened last time. They said, you can't judge him on what happened. Call us when he's dangerous. And I called the Fairfax County Mobile Response Team, and they said, now wait a minute, is he dangerous or violent? Because he was violent. And they said, oh, we don't come if he's violent, and call the cops. So I called the police, and they came and they shot him twice with a taser and took him away.

EARLEYNow this is after I'd written my book, and I had worked at the Washington Post, I had connections in Fairfax County, and I couldn't get my -- now what chance does somebody who has no connections, no knowledge, of getting into the system? But it's an interesting point because when I first started, Diane, I thought just involuntary, loosen, get rid of dangerousness, put people in the hospital, and then I realized with my son that forcing someone is a temporary Band-Aid. It's an emergency -- you have to get that person engaged because my son repeatedly went in and out and in until I could get him to accept he had a mental illness and want to change, I couldn't change him.

EARLEYI'm not sure that's possible with everyone. That was the trick.

REHMAll right, and joining us now from a city in the Pacific Northwest is Lily. She is an administrative assistant living out there. She's been diagnosed with a bipolar disorder and psychosis. Lily is of course a pseudonym. Her story is described in one of the chapters in the new book we're talking about, "Committed: The Battle over Involuntary Psychiatric Care." Lily, thanks for joining us.

LILYYou're welcome.

REHMI know you were diagnosed with bipolar disorder over 20 years ago. But then you started to have psychotic episodes when you were in graduate school in Ohio. Tell me what you thought was happening.

LILYWell, I came to believe that there was a massive conspiracy, that people believed I had committed multiple murders and that I had sexually abused people, and everything in my environment was most likely a sign that I was being pursued for that crime.

REHMAnd you were already seeing a psychiatrist. I gather he became very concerned about your behavior and had you involuntarily committed to the hospital. So what was that like for you?

LILYWell, I was taken away by the police and then sent to the emergency room, and I was really, really terrified, and I was -- when I was in the hospital, it took me a long time to get better, but some of the nurses were helpful because I would believe my delusions, and then I would talk to the nurses, and they would kind of talk me down and reassure me that what I believed was incorrect and that I was just mentally ill.

REHMWhat kinds of treatments were you receiving?

LILYI received a lot of anti-psychotics, and at the time they felt that I might be schizoaffective, and it took a long time for the medicines to work, and they were very powerful medicines.

REHMSo then I gather after you were released from the hospital, you went to live with your family and got additional treatment. Did you then continue to improve, or were there setbacks along the way?

LILYWell, I would say both of those things. I continued to improve, but I still saw indicators in the environment that indicated there was some conspiracy and that people were after me, and it took a long time for me to get really better, but I did improve and gradually kind of those feelings eventually diminished, and yeah.

REHMTell me how you are now.

LILYI'm doing great. I am very happy. I have a good job, and I haven't had any hospitalizations for I would say maybe 10 years.

REHMOh Lily, I'm so glad for you.

LILYThank you.

REHMAnd thanks for being with us.

LILYSure.

REHMLily is an administrative assistant in the city in the Pacific Northwest. She was diagnosed with a bipolar disorder, and of course the name Lily is a pseudonym. Later in the program we'll talk with another person who was forced into psychiatric care, who unfortunately did not have a positive experience. Dr. Miller, I know you spoke with Lily. You must be so pleased at the outcome.

MILLERI'm pleased at the outcome. I am thrilled that she was happy to be on the show with us today, and I spent a lot of time talking to Lily, and one of the things she has said is that she was really grateful for the involuntary care that she got, that it turned her around. And I spoke with Lily's brother. I spoke -- I tracked down one of her doctors, who moved to another country. It was wonderful to get to know her. And she did appreciate the help she got.

MILLERAnd one of the things that when we argue against involuntary care is we have to remember there are Lilies out there. There are people who feel helped by this, who are grateful for it. It doesn't mean it's always the right way to go. And she did -- I think what's different about Lily than many patients is that she already had a doctor.

MILLEROften people come into the emergency room, and say somebody's worried that they're going to commit suicide. They're not in treatment. You can't get them an appointment the next day or two. So what happens is the doctor in the emergency room, and this may be somebody without a psychosis, is worried that if I let this person go, they'll kill themselves, and nobody wants that on them.

MILLERSo the patient gets committed because the doctor would rather be safe than sorry.

REHMAnd Dr. Hanson, what about the acts of violence we've seen around the country committed perhaps by individuals who should have been either in treatment or involuntarily committed?

HANSONWell that's where my piece to the puzzle is a little bit different from what you've heard up to this point. I'm a forensic psychiatrist, which means that I work with people with mental illness who are involved in the criminal justice system. And from what I see, these acts are extraordinarily rare. I think it's been estimated that fewer than four percent of violent crimes are due to people with serious mental illness. They're much more likely to be victims of violence than perpetrators of violence.

HANSONIt's also incredibly difficult to predict which person with mental illness will be violent. The best predictor is past violent behavior, but as you've already heard, you can't use that as a basis for involuntary care. So we're kind of up a creek. Now the good-news piece to that is that there is treatment available, unfortunately, at the door of the criminal justice system, and working in jails and prisons, I see many people who have been in the community for months, trying to access care, and haven't been able to get it until finally they're incarcerated.

HANSONSo I think what we need to do is stop thinking in terms of dichotomies, jail versus hospital, hospital versus community, and look at all of these systems as part of a spectrum of care.

REHMPete, do you want to comment?

EARLEYYeah, you know, Diane, I've -- since the publishing of my book, I've been to every state but Hawaii, and the number of parents who come up to me, and they say, the police said get your kid arrested, if he gets in jail, he'll get help, and that's just so backward. And yet that's the kind of system we're doing. We have closed down hospital beds, we're not providing services, we've overwhelmed, and so the attitude is, well, if you can get them arrested, they might get help.

EARLEYAnd that is a fallacy. Not only are jails and prisons not equipped to help people, but when you go in on a charge, treatment is not the goal, it's competency, making you competent to stand trial. And in -- for instance and when I did my research in Florida, that meant taking a woman who was homeless on the street, longtime schizophrenia, into a room and showing her three chairs, one marked judge, one marked defense attorney, one marked prosecutor, and when she could say who sat in that chair, she was competent to be at trial. That's a lot different than actually treating someone for a serious mental illness.

REHMPete Earley, and you're listening to the Diane Rehm Show. Let's open the phones now, 800-433-8850. First to Lauritte in Shadyville Valley -- Shady Valley, Tennessee, you're on the air.

LAURITTEYou did pretty well with that name.

REHMThank you.

LAURITTEYou're welcome. It doesn't happen often. I am not -- well, I do volunteer work right now, but I was a psychiatric RN for 30-plus years, mostly in states' mental institutions, mostly with adolescents though some geriatrics and some adults, and have pretty much seen it all over the years, including, you know, the early demise of state mental institutions back in the I guess late '80s, maybe, closing up left and right across the country.

LAURITTEAnd, you know, if they say money is the root of all evil, I think money is the root of many problems in the psychiatric treatment world. So I have worked with excellent people, wonderful aids and staff, and I have worked with thugs. And most of the places I have worked were -- they were chronically short-staffed. The reason a lot of those people didn't lose their jobs was because there was no one to replace them. And then there was just nobody, and administration felt like their hands were tied.

LAURITTELike, you know, is it better to do without or better to overlook things that happened? And so I understand both sides of the issue of involuntary commitment, but I am a staunch supporter of involuntary commitment and forced medications because if you don't get folks in to a secure facility, and then medication is kind of the first line of defense to just get your toe into the mental door to just take the edge off from them so that they can take in information and attempts at people trying to help them, you're nowhere.

REHMDr. Hanson?

HANSONOh that -- everything she says is correct. I mean, it's very important, medication unquestionably is the first line of defense in the treatment of serious mental illness. The challenge we face is that as Pete already mentioned that sometimes it's not possible to medicate people. He gave the example of someone who is incompetent to stand trial, and that has been an issue in some systems, where even though the person might be accused of very serious crimes like one or more murders, if they behave themselves in the hospital, they can't be medicated against their will. And that's a serious problem.

REHMDr. Miller?

MILLERI guess one of the things I would say is I think that, you know, everybody talks about involuntary care as a last resort, and I think last resort means different things to different people. And so I believe that -- and sometimes on some of these patients you can work with them and form a rapport, and then they'll take medications. And I just want to add one thing about we keep talking about less hospital beds, but just to get an idea of what we're talking about, in the 1950s there were over a half-a-million state hospital beds in this country.

MILLERThere are now 44,000 state hospital beds in this country, and we have twice the population. So the number -- you're talking a loss of 90 percent of our beds. There's nowhere for patients to go.

REHMDr. Dinah Miller, she and Dr. Annette Hanson are co-authors of a new book titled "Committed: The Battle over Involuntary Psychiatric Care." Short break here, we'll be right back.

REHMAnd welcome back as we talk about involuntary commitment. Joining us now by phone from New York is Jamie, a social worker there. Jamie is not her real name. She's been diagnosed with a psychotic disorder. She's been involuntarily committed into psychiatric care more than a dozen times. Jamie, thanks for joining us.

JAMIEThank you.

REHMI gather you have a psychotic disorder, you've been hospitalized against your will. Tell us about that.

JAMIEYeah, I've been hospitalized quite a few times involuntarily, and I haven't -- the issue of dangerousness hasn't really been part of that equation. It's a little bit more complicated, although I really appreciate Mr. Early and Dr. Miller and Dr. Hanson's views, actually a lot. But depending on where you are and where you live, it can be quite a bit easier to become involuntarily hospitalized.

JAMIEThere's absolutely no question that I needed care, and I don't want to pretend that wasn't the case. But doing it through an involuntary admission wasn't only unnecessary and ineffective in my case, it was harmful. And in the end it really just intensified my sense of isolation and drove me further into my own world. So I got worse over time both in terms of sort of objective psychiatric status but also my subjective sense of well-being.

REHMCan you describe to us briefly why you were involuntarily committed?

JAMIEI can. So I experienced hearing voice. They tend to be derogatory and toward me, not directed towards other people. I struggled a lot in school in particular and would become essentially not clinically, but in the colloquial terms, catatonic. I just -- I wouldn't -- I couldn't move, I couldn't -- sort of paralyzed. And I sometimes entertain or have entertained thoughts that are clearly not consistent with what's going on in the world.

JAMIEThere's no question that something needed to be done. I just -- doing it involuntarily wasn't the way to go.

REHMAnd who -- who did the involuntary commitment?

JAMIEIt would depend on the situation. There have been times I've been taken to the hospital by police. There have been times where psychiatric emergency room has made the decision. And there have been -- well those are the primary ones. There have been times where I've gone to the psych ER knowing something was wrong and not been given the opportunity to voluntarily admit myself or to leave, yeah.

REHMI see. So I gather you don't feel that being committed really helped you. In fact, you felt traumatized by it.

JAMIEIn my case there's no question, there's no question it was traumatizing and harmful. I know that's not everyone's experience, but it was for me, yeah.

REHMHow so?

JAMIEA lot of ways. First the things that were mentioned at the beginning of the show, restraints, seclusion, you know, being injected with medication immediately upon, you know, sort of entering the ER, all take away any sense you have that you're a human being. They -- it's a complete negation of your humanity or I experienced it as such. But also it created a profound sense of shame and helplessness and self-doubt.

JAMIEI felt humiliated and degraded. I knew something needed to be done, but there was no effort to engage me at any level beyond, you know, shoot up the medication and confinement.

REHMSo what finally did help you or has helped you?

JAMIEThere are a lot of things. They are not all psychiatrically related. One most important to me getting better has been relationships with my husband and a few close friends, returning to school, I'm a doctoral candidate, and I don't mind saying this, at NYU's School of Social Work, where professors and students know my situation and have been profoundly supportive throughout my time there.

JAMIEI have a community -- a community athletic program actually that really helps. And those sustain me. And then I also have a psychiatrist and a therapist who are -- who support me in those efforts. They listen, they take me seriously, they respect me as a person, they know I have a low threshold for coercion, and my psychiatrist allows me to -- he doesn't just allow, he encourages me to suggest, you know, when I need to increase, decrease or discontinue medication.

JAMIEAnd my therapist doesn't try to change who I am or how I -- you know, my values or whatever, but she helps me move through the world. You know I move through the world a little differently than some people, and she helps me do that in a way that's safe for everyone and productive for me and my community.

REHMBut Jamie, I gather through all these experiences you are not totally against all involuntary commitment.

JAMIEI'm not, I'm not at all. I am against, and I want to make the distinction clear, involuntary outpatient commitment or AOT. It's a different issue, but I just want to be clear about that. I think there has to be a mechanism to keep people safe when a real risk presents itself. I believe families like Mr. Earley's, who feel there's a genuine risk of harm to or by the person they're worried about, there needs to be some mechanism available to support them.

JAMIEBut I have huge caveats to that position. And there's probably not time for them, but I -- it shouldn't be the default mechanism we use. It should be used sparingly, for as little time as possible. And I'm not convinced that the bed issue is the real issue. I think the real issue lies somewhere else. But no, I'm not completely against it.

REHMJamie, I want to thank you so much for joining us. I'm glad you're doing so well.

JAMIEThank you.

REHMJamie is a social worker in New York who's been diagnosed with a psychotic disorder, and her name, Jamie, is actually a pseudonym. Pete Earley, I want to turn to you again because I think it's important to talk about the fact that your son really got so angry with you when you did have him involuntarily committed.

EARLEYWell not only did he get angry, and it's understandable, I mean, I lied about it, and even though he's psychotic, he knew I was lying. He never threatened me. But it's what Jamie talked about. It's a complete stripping of your rights once you're labeled as crazy. Nobody believes what you say, so the parent can step in and do that. But it's also the system, Diane, that set it up as an adversarial system, where I had to say this is my son, he needs to be in the hospital, and then he had an attorney, who was saying, well, why does he need to be there, well can't this and can't that.

EARLEYAnd at the end of the day, all of the doctors, all the therapists, all these people could have their opinions and make decisions about my son, but at the end of the day I was the one he went home with. And so you create a system that fractures the family and turns people against each other, and then you walk away and leave the pieces.

REHMHas any of that changed since Virginia State Senator Creigh Deeds tried to get his mentally ill son into a hospital? What happened there, and what has changed since?

EARLEYWell that was a bed issue. There were no beds available locally, and so he was sent home with his son, who then attacked him, and then the son took his own life. And I serve on a committee with -- or a task force for Creigh Deeds. It's important to note what Jamie said. You've got to understand that hospitalization today, people look at it, and they think in terms of the old days.

EARLEYIn Virginia, if you're involuntarily hospitalized, it lasts about three days, and all it is, is take your meds, take your meds, take your meds, take your meds, and they shove you out the door. If you're really, really psychotic, you can go to a state hospital, it's about 30 days, that's the average. So it's not this long term that some people need.

EARLEYAnd what you really need -- the focus shouldn't just be on hospital beds. One of the things nobody realizes about Creigh Deeds is there were 180 people in the state hospital system ready to leave with nowhere to go. And that bottlenecked the system. So son couldn't come in. So we need housing first. we need act teams. You know, not everybody needs to be in the hospital. Now she didn't like assisted outpatient treatment, but that's one way to keep people from being hospitalized is you have a court order that says you have to have a case manager, or you should be under treatment. Nobody likes force, but that's another way to avoid hospitals.

REHMDr. Miller?

MILLEROne of the things I want to point out is that every state has very different laws. And Virginia, which seems to have a lot of problems, has very strange laws. So in Virginia if a patient goes into an emergency room, a physician in the emergency room can't hospitalize that patient. They have to call an outside community service board to have a case manager sent in to evaluate the patient and decide whether or not they can go into the hospital.

MILLERNow a clock is going this whole time, and the case manager may have to drive from quite a distance. So one thing I heard about on Pete's son was that he was seen by an emergency physician who didn't talk to him, who didn't try to involuntarily -- to try to get him to come in voluntarily, and the community service board never came out. For Creigh Deeds' son, the community service board did come out, and everybody agreed that this young man was very sick and very dangerous. They had a clock going, and the person who tried to get him a bed could not get him a bed within the six-hour time frame.

MILLERSo he discharged him. I don't think that happens in other states. In Maryland, certainly the doctors can admit patients. You need to do an evaluation in the emergency room and have two people agree that somebody needs admission. In New York it's easier. But that whole wall -- I mean, could you imagine if you went into an emergency room with a heart attack and were told, I'm sorry the cardiologist can't admit you, we have to call somebody who lives four hours away, we're not sure they won't get a flat tire on the way, and they have to decide as a non-physician whether or not you need a cardiac ICU bed?

REHMAll right, to Amber in Alexandria, Virginia, you're on the air.

AMBERWell thank you, Diane, it's a pleasure to be with you, and thank you, panel, for this very important conversation. I have a couple of comments, really. I am a licensed clinician here in the state of Virginia, I've been licensed since 1996, I've been licensed in about four states in the United States, and I've worked both statewide, and I've worked through the DOD for their military mental health services across the country.

AMBERI say all that, and now I set that aside, and I say am the daughter who hospitalized her own mother when I was about 22 years old, just fresh in from university here in Virginia, to Southern Virginia, not too far from the Deeds family. So I kind of come at this subject today from a number of ways. I think the comment I want to say, because I could say -- I could say absolutely yes to everything that's been said in this whole conversation, I've experienced some portion of everything that's been discussed today.

AMBERBut what I want to really say is that even though I've worked from a private practice viewpoint, as a hospitalist across managed care.

REHMSure, sure.

AMBERAnd Department of Defense work, Diane, I am now -- I have shifted my career away from direct care or even secondary or tertiary care, from a managed care viewpoint, into more health care operations because I don't believe that at this time in the expression -- this is where my consciousness and spirituality comes in, that's how I work this issue now for -- kind of from a population health viewpoint.

AMBERI don't think that at this time in our human expression on the planet we are ready to care well, fully, for psychic and psychological pain.

REHMDo you agree with that?

HANSONI do. I think, you know, one of the things that treatment, when we talk about treatment, that everyone seems to be saying is medicines. And there are other treatments we have to offer, like psychotherapy or occupational therapy or even just bonding with a patient and understanding them. Now obviously if somebody comes in agitated, fighting, violent, incoherent, then that's not -- then you do need to medicate them.

REHMAnd you're listening to "The Diane Rehm Show." Here's an email from Renee. Can you talk about what can be done to better train police departments about how to handle people with mental health issues? Are there any initiatives on this, any exemplary departments in the country at this time?

EARLEYAbsolutely. You know, because our system is failing us, we're turning to law enforcement to save us, and officers see more people with mental illnesses than psychiatrist do on a daily basis, I believe. Crisis intervention team training out of Memphis, 40 hours, is the classic model. It's sweeping the country. Almost every major police department has it. These are officers who are trained to recognize mental illness and to not go in like Rambo but to, as Dr. Miller said, to talk to someone, give them their space, try to partner with them, just as a parent tries to partner with them, or should, to try to get them to move to the next step forward.

EARLEYSo -- and right now, this week, the House and Senate will vote on a major overhaul of the mental health system and increase funding for CIT mental health courts, so that if you're stuck in the criminal justice system, you can go into treatment rather than go through the normal thing, and all kinds of intercept programs while you're in jail and trying to get out and not just be dumped on the street but housing. So yes, police departments all over.

REHMDr. Hanson?

HANSONOh, I would totally agree with that, and I would also add the other initiative that can be very helpful is the idea of the mental health court, which I believe the bill also is going to provide some funding for. I've seen mental health courts in practice, and they are tremendous things. So this would involve someone who's involved in the criminal justice system, usually a misdemeanor, nonviolent offender, who is given an opportunity to re-engage with community services as an alternative to incarceration.

HANSONSo -- and it's a judicial way of monitoring someone and supervising them long-term, until they can get on their own feet and stand on their own two feet and engage in the community again. It does involve community resources, and that's everything we're talking about right now. It takes money to do this. You have to invest in housing, you have to invest in mental health professionals, you have to provide transportation for people who can't get to their appointments or services to bring the treatment to the patient in the form of mobile treatment teams. It's a short-term investment for a long-term gain.

EARLEYAnd, you know, we're already spending that money. In Fairfax County, it's $50,000 a year to keep somebody in the jail. Now which is better, to keep somebody in the jail or spend that $50,000 on housing first, which -- and an act team, which would be at least half that?

REHMPete Earley, he is the author of more than a dozen books, including the best-seller "Crazy: A Father's Search Through America's Mental Health Madness." Dr. Annette Hanson and Dr. Dinah Miller are co-authors of a brand new book. It's titled "Committed: The Battle over Involuntary Psychiatric Care." I want to thank you all so much for being here, such an important topic, thank you.

EARLEYThank you.

HANSONAnd thank you for having us.

MILLERThank you.

REHMAnd thanks, all, for listening. I'm Diane Rehm.