Hindsight is always 20/20, according to an old adage. Anna-Lisa Johanson now knows that committing a loved one with mental illness can be a lifesaving act inspired by love—but she learned this lesson the hard way.

Johanson’s mother made headlines when she took her own life at the age of 46 by kneeling before a speeding train in October 1998. In her lifetime, Mary Margaret Ray gained notoriety in the media because of her bizarre delusional behavior and stalking of comedian David Letterman. Ray was diagnosed with schizophrenia and schizoaffective disorder.

"I lost my mother because I didn’t know how to commit her," Johanson told a room of mental health professionals, family members, and people with mental illness at the 2001 convention of the National Alliance for the Mentally Ill (NAMI) in Washington D.C., in July. The only psychiatric treatment her mother received was through the criminal justice system during repeated incarcerations, she noted.

Now, however, Johanson is well on her way to becoming an expert in commitment law.

Johanson is finishing a joint program in law and public health at Georgetown University and Johns Hopkins University and is interested in pursuing a career in mental health advocacy.

She also has a new daughter and works part time at the Treatment Advocacy Center (TAC) in Arlington, Va., where she helps people with mental illness and their family members understand commitment laws.

TAC is a nonprofit advocacy organization dedicated to removing legal and clinical barriers to psychiatric treatment for people with severe mental illness.

Johanson also co-authored the book I Am Not Sick, I Don’t Need Help: Helping the Seriously Mentally Ill Accept Treatment with Xavier Amador, Ph.D., published by Vida Press in 2000.

"My father is an old Swedish socialist," said Johanson. "The reason he never committed my mother was that no matter what, he would never violate her independence or her rights."

Johanson said that she grew up believing that personal freedom and self-determination were sacred. But now she thinks differently.

"There is a certain point where a brain disorder takes over, and you no longer possess free will—it has been obliterated because of a chemical imbalance," said Johanson.

After taking an informal poll of NAMI members in the room, Johanson found that many felt dread at the thought of committing a loved one, and many feared being committed themselves. Johanson empathized. "I suffer from bipolar disorder. It has never been far from my mind that a week or two beyond medication and I could be at a point where my loved ones would have to commit me."

Johanson advised family members and people with mental illness to research the commitment process and have all the necessary steps taken care of ahead of time, so that the commitment process is less traumatic if it ever needs to be used.

For instance, people with mental illness can shop around for a psychiatrist they trust and can talk with openly. People can also call the emergency room or psychiatric unit of their local hospital and ask if they have a partnership with the police department, Johanson suggested.

She also said that it is useful for people to find out if the police department has an officer who is specially trained to work with people with mental illness, and if so, keep the number of that officer handy.

Beyond this, there is one crucial measure that people with mental illness should take. "See if your state has something called an advance directive for mental health care," said Johanson.

This is a legal document that allows people with mental illness to exert some control over the terms of their commitment prospectively through written instructions about psychiatric care. The advance directive also appoints an agent to ensure that the instructions are carried out (Psychiatric News, December 15, 2000).

This legal document is useful, Johanson emphasized, for people who may want to plan ahead for their own possible commitment.

In this scenario, someone might first choose a psychiatric hospital where he or she would prefer to be treated. Then, he or she can go with a loved one to an attorney and sign an advance directive specifying that if two doctors decide that he or she needs help, this is the person’s hospital of choice.

"It is empowering to set up this safety net for yourself," Johanson emphasized.

As of last count, 13 states recognize psychiatric advance directives, according to Bob Fleishner, J.D., who is an attorney at the Center for Public Representation in Northampton, Mass. Fleishner said that all states do have general advance directive laws that allow for instructions for mental health care, however.

"It is a little late now, but had I been able to, I would have committed my mother," said Johanson. "It would have been the greatest service to her, and she would be here today to meet her granddaughter." ▪