Granted, the Bellevue film is old, however, I contend that much of what is seen in that film continues in many inpatient settings. Read this Blog from Jessica DeArcangells for Mad In America that she published in January, 2019. Please post a response to the questions she poses at the end of the article... then comment on at least two of your classmates' responses.
When the Hospital is Sick
By
I walked up to the hospital with my purse clutched to my side and a spring in my step.
My first day as a mental health counselor in inpatient psychiatry began with the disorienting orientation. My new supervisor was late—I would soon find she’d be late or absent for most of the orientation hours due to the predictably unpredictable chaos of the 5-South unit, my new workplace. Staring at our thumbs and reading half-assed packets on hospital policy, a new nurse and I sat in the dimly lit conference room and listened to the echoing screams of patients we would soon come to know as some of Methodist’s “frequent flyers” (a fun term used by staff to obliquely refer to Methodist’s impressive recidivism rates). We strained to make small talk. She was a seasoned nurse looking for a change of pace, or a something else, or maybe just weekend work. In the quiet of those first few hours on the job, I watched a slanted smile tuck into her cheek and her eyelids droop. I watched some dull recognition rise between the two of us as the minutes dripped on and we turned our cheeks toward a leaking faucet and peeling paint on the walls.
When she arrived, my supervisor was fairly convincing in her read-through of the rules and regulations, but I would soon come to recognize that this was all more of a formality. The real concern was making sure the right papers were signed and tucked away in my file on the off chance of any kind of administrative review. At first, I had my stupid purple pen and fresh notepad out on the table. I played attentive student until I realized it didn’t matter.
Before I knew it, I was on the floor for training.
I was thrown in to observe an admission. The new patient was a severely psychotic woman who looked into the air like it was teeming with ghosts. She called us witches and warlocks and vampires. She stomped and clapped. She was swiftly given medication. Before I knew it, she was locked behind a door. Behind her face pressed up against the glass I could see the darkened, stained window of the restraint room that seemed to forever look out over a stormy landscape. I wasn’t sure what to feel. Is this really what this place is for? I thought we didn’t isolate people. Is this the safest option for everyone? How do we know whether or not to give someone a chance? What other rules am I going to see off-handedly broken without discussion? My mind was racing. I kept moving.
Over the next few weeks I learned the ins and outs of the units and some extra tips and tricks from my coworkers:
Coffee goes out at 7:30am. Breakfast at 8am. Start the morning announcement with the date and remind the patients to recite it correctly to the doctor in order to look good. Because most people are seemingly held against their will, reinforce compliance. Tell them to shower and take medication so that they can leave. When they question this, reinforce compliance. Their only problem is that they don’t do what they’re told or don’t clean up well enough.
Remind them to stop by the nursing station right after breakfast. Medicate the anger you’ve elicited. Don’t offer other explanations or treatments. Presume every person’s goal is simply to get out. Obscure the fact that the staff just don’t want to deal with any of it anymore. Listen to the hum of the hallways when every patient has finally surrendered to the dull tick of sedatives in their blood. Comment on what a good day it is—don’t use the “Q” word (“Q” for Quiet: the presumed aim of treatment and a curse word that will summon the demons awake). No one is moving.
Get patients in and out of the place quickly. No need to talk to them too much when they come in; greet them with a beeping blood pressure machine and a scale. They’re crazy anyway, what do they know? Take away their things and strip them down to nothing. Presume the worst.
Assist with ADL’s (activities of daily living). In other words, if someone is starting to smell bad, threaten them with shots and apply the good ‘ol shower “bum rush” (a friendly way to refer to surrounding a person with multiple staff members, dragging them down the hallway, and throwing them into the shower room). When they get upset about the total violation of personal space and agency, never fear! You can just close the door and whip them with a towel.
Talk to patients if you have the time. Make sure you get something to document, especially if it means asking leading questions that irritate them into sounding crazier. Dismiss their concerns as symptoms which are meant to be eliminated. If they seem to be worse off as they walk confusedly out the door with a lopsided stride on the day of their discharge, don’t pay it too much mind. They’ll be back.
Most importantly, be ready for when things go wrong. As soon as someone starts raising their voice, ready the syringes and get your gloves on. Surround them. Grab the restraint bag. You never know what could happen. Ignore how they might be responding out of fear. Call the code. Drag the patient to the restraint room. Never mind that verbal deescalation training. We need to set an example. We don’t have time for this.
As I went through the training, I convinced myself that I was the newbie employee that just had to suck it up and learn the ropes. Yet, still, something about all this didn’t seem quite right to me. Wasn’t helping people get better what we were here for? By all accounts, it seemed some of the “procedures” I was witnessing might actually make someone worse off. The best outcome seemed to be getting people to sleep and stay in their rooms or stare blankly at the day room TV as if they were toddlers. By a few weeks in, I was already seeing familiar faces. I looked for some reassurance that someone in this place knew what they were doing. Surely the doctors would?
I remember one of my first encounters with the doctors at Methodist. I hear a raised voice down the hall, and rush over only to see a doctor huffing as he hurriedly exited a patient’s room. I learn that he was just sounding off his usual mantra: “Take your medication and don’t do this again! Once you take it, then you can leave.” “Your medication” here translates roughly to “the same five medications I give to every patient that walks in this door.” This treatment plan is ineffective and unethical, but upon mentioning this to a coworker I am told “there’s nothing we can do about it, it’s always been this way.” Another coworker considers his method “just really old school, you know?”
Well, that was one down. What about the others? Another doctor admits his greed openly and criticizes my plan to go to school for clinical psychology because “that’s not where the money is.” After a hasty and awkward lunch with me one afternoon, he stands abruptly and exclaims, “Time to go heal people!” before exiting the quaint hospital cafeteria. I almost choked on my carrots. The irony was not lost on me when he demanded the immediate (and totally uncalled for) restraint of a psychotic man with grandiose religious delusions who loudly questioned his legitimacy as a psychiatrist.
Some other psychiatrists only feel comfortable meeting with patients from behind the nursing station door, as if looking at them from across a fence. The meetings last seconds if they even happen that day. Patients are left stranded, walking the desolate hallways confused and heavily medicated. I come to dread talking to new patients only to hear that they haven’t seen a doctor in multiple days after entering the hospital in crisis. I realize quickly that the doctors are as equally lost as the rest of the staff.
The staff are poorly trained, overworked, underpaid, and severely burnt out. The few that seem to take pleasure in their work really just enjoy closing doors and yelling at patients in gross displays of their daddy issues. Others enjoy the endless attempt to keep the unit under control or the endless opportunity to blame this or that person or circumstance for their woe. Most of the staff fall back on the juicebox theory, the superstitious belief that the acuity of the unit can be effectively managed through ordering enough juice so no one has anything to complain about, in lieu of attempting therapeutic interventions. When this doesn’t work and a patient still is anything but comatose, ultimately patients are still easy scapegoats and fun to complain about! Don’t worry if a patient suffers from paranoid delusions and overhears you, of course.
The selection process for patients is often obscure. Details are missed. Patients come in that staff are unable to adequately take care of. Patients come in and there is lack of clarity about their history. It becomes apparent that the logic of the hospital is more of a numbers game than an issue of what is and is not therapeutic. Patients are locked in rooms without bathrooms only to end up shitting on themselves and the floors.
I am sick of it at this point. I reach out to the supervisors to address some of my quickly growing list of concerns. Even the cases of abuse and neglect I report are not taken seriously. My attempts to start up dialogue and address some of the issues are ignored and even seen as threatening. The first supervisor I talk to gives me a stony look and explains that she is going to tell the staff not to lock doors. The second tells me how “there are five types of patients in this hospital…” and “it just gets to you, to be called a fat bitch every day.”
I am soon after blamed for a large, martial arts-wielding patient ripping out a ceiling camera, because at some point in the day I attempt to talk to him rather than endorse another injection of Ativan that puts him into an enraged stupor. I am asked if I read his chart and knew his history of repeated hospitalizations. Internally I wonder why, by that logic, they don’t just put all of these people down. The machine keeps rolling.
I start to read medical literature about inpatient psychiatry and articles about the history of medicine. I am up late at night reading about corrupted inpatient psychiatry cultures and thinking about how right Foucault was. During the day, I’m observing myself as I hold patients down to get medication. I realize the issue is larger than just this strange, nightmarish hospital I work in. I am talking with friends who are in total shock at what I’ve been witnessing. Feeling aghast as the words for what I’ve seen come out of my mouth outside of those locked doors, I am in total shock with them. I am often more shocked by the negligence and cruelty of the staff than by the bizarre and violent behaviors of patients. I start to question my own morals. I start to think everyone in the hospital is insane. I start to wonder how I could be there.
A week after I start applying for other jobs, a staff member is severely injured while I’m working. There is blood on the floor and all over her pink button-up. The patient who assaulted her asks if he killed her and when he’ll be getting dinner all in one breath while lying in restraints.
I leave. There was nothing left to do but leave the place, report it, and never come back. Job schmob, I want to be alive.
The experience was a total wake-up call for me. I witnessed things at Methodist that were not only horrific but illegal. It was amazing and disgusting how normalized these practices had become. I not only had to confront the reality of poorly understood, nigh untreatable psychiatric conditions, but also of a hospitalization system with serious and devastating flaws. I felt immensely powerless and at times became so burnt out myself that I understood how my coworkers could end up so negligent, numb, and at times abusive. I understood how patients, on the other end, could become violent or self-injurious after years in these dismal hospitals.
Understanding the systemic issues or not, there was no excuse for what I witnessed. Any incident of violence, especially patient abuse and neglect, must be acknowledged as a total failure. Instead, I saw these incidents and behaviors accepted as routine. I met so many patients with histories of trauma who had been in and out of psych wards for years and just came to expect the mistreatment.
Now I’m left with a lot of questions. How do places like Methodist become possible? What is the real goal of inpatient psychiatric care? Especially for underserved populations, what is the difference between the “inpatient psychiatric unit” and a prison? How has an over-reliance on medication promoted unethical, weak medical practices and even compromised safety? And most importantly, are these places recreating the illnesses they purport to treat?
ReplyDeleteI’ve seen places like Methodist. I visit my clients when they’re in jail, at the local psych hospital, and local hospital psych units. I’ve been to the state psych hospital as well. They are all the same. Places like this become possible because of who is in power, money and staff burn out. The mentally ill are a tough population to work with. It is very rewarding at time, but also very draining. There is little support for staff and they are required to work long hours with little pay and little time off.
Depending on the facility, the goal for inpatient psychiatric care is supposed to be to keep people safe and stabilize someone so that they can return to the community. A trip to the hospital provides a break in a person’s current chaos and it is helpful for those who have a mild disorder. It can be scary for people who aren’t severely ill because it is so much like a prison. Everyone is treated as though they are suicidal because in Southern Maine, you have to say you’re suicidal to be taken into inpatient psychiatric care.
These facilities are not much different than jail. They have many similarities. The staff are rude, inpatient, and burnt out. Medications are forced and compliance of all sorts is the deciding factor in your release. If you mis-behave you can be put in a room alone for an undisclosed amount of time. There may be more services and opportunities in the prison system than there is in a hospital. Staff at both hospitals and jails start in the field with a desire to make a difference and within no time, they are working long hours and don’t get enough time off.
The reliance on medication has promoted unethical and weak practices because there is not enough behavioral or cognitive therapies happening in these facilities. They have some groups, but they often don’t’ keep people long enough for there to be any forming of a group cohesion. The reliance on medication has caused facilities to “treat and street” people. It’s a revolving door because people don’t get the skills they need to function in the community. They are released without services in place. They are referred to several services, but most have waitlists that are months long.
People are discharged dependent on medication and given one refill and are expected to find a primary care provider or psychiatrist on their own. Primary care providers and psychiatrist also have waitlists that are months long. People stop taking their medications and have no way of renewing their prescriptions and often don’t have a means to pay for a prescription even if they did have one.
Yes, inpatient hospitals are recreating the illnesses they are supposed to treat. The facilities start planning for discharge the day a person walks in the door. People aren’t given enough time, resources or aftercare support. My clients remember what places treated them like humans, not the places that had the best food or the nicest pictures on the walls.
Wow Danielle that's some honesty right there, thank you! Your comparison to the similiarities in prisons was so accurate and these places have unfortunately become run by money and power. These are not supposed to be run where numbers are the only thing looked at! The burn out of staff I believe is one of the largest contributors since those are the people on the front line that clients really truly remember. What's overwhelming is there isn't just one or two fixes, it's almost like because it's not embedded in the system and structure that it needs to be dismantled and started from scratch. I am a complete believer that these types of centers/jails add to an individuals trauma. Medication is a temporary fix- where that is also connected to money and power as big pharma! Outpatient services could be a bridge for this where if those where a safe place for support that could be where reports could happen as mandated reporters.
DeleteHi Danielle,
DeleteI remember visiting my uncle at the old Jackson Brooke facility. He was there for drug and alcohol addition and I remember feeling like he was in prison and not a hospital. It was very long ago but I remember his roommate was there for reasons other than addiction, I always thought it was strange that he would have been placed with someone who had different issues that needed potentially different treatment. I remember it seeming like he was in trouble with his caretakers and had to be on his best behavior. Also, it did not work, he ended up having additional issues with drugs and alcohol and it took him a long time to recover and lead the life he wanted. I always wondered if he had received treatment where we was seen and given hope and listened to instead of just a number to move through the system if he would have recovered sooner and been able to enjoy more of his life. We have to be and do better! Thank you for sharing your experiences.
Judi
Hi Danielle,
DeleteThis is a very powerful and truthful comment. You really set the stage for the blogging comment session. Your connection about your personal experience was inspiring and showed that hospitals, prisons and so forth still present this type of care. These places stay afloat and intact solely because who is in power, and who is providing the money. Society wants to become richer, rather than curing or helping individuals who significantly need the help. There is a lot of forcing to take medication rather than having a more integrated care plan. Of course medication has some significance to recovery, but it is simply not the only answer. Understanding there are more therapies that provide positive results, which are paired with medication and most often are not. Instilling hope is significantly important. Having wisdom, empathy, and kindness is also extremely important.
Danielle, there a few things I would like to address within your post as a way to hopefully explain another perspective. I have worked on an inpatient unit and loved it and it will always be a passion of mine. I'd have to disagree and say that not ALL hospitals are the same. There is a lot of moving parts and the perception given off can be harmful, inpatient hospitalizations is an uphill battle no doubt but there is therapeutic benefit!
DeleteRevolving door: you use this term and it is a term I am very familiar with when discussing inpatient hospitalizations. In mental health we always refer to the LEAST restrictive treatment and that's the approach that has to be taken. It may seem like a lack of caring or support but for a patient to qualify for certain services they need fail first. You start with the least restrictive services first and work your way up. This is not something I agree with but that is the reality of it. There may be a patient who would love to go to a group home or residential treatment but because they haven't tried every possible community resource (ACT, CRS, Case mgmt, etc.) they will not qualify. So begins the revolving door.
Discharge planning starts on day 1: this is 100% true, discharge planning starts the minute the patient works onto the unit because we immediately want to start addressing their needs and ensure we can get them what they want. You mentioned how places have long waitlists and this is again accurate which is why it's crucial to start day 1 and get patients on waitlist and engaged in services. Another huuuuge factor is insurance companies, many will not cover long term hospitalizations (more than a week) so it's important to get to work with patients ASAP.
Thank you for saying this. I work in a crisis unit and clients are often suppose to be with us for 5-7 days however, this is often not the case. We have clients that stay with us for two weeks or more. Normally when they are discharged from the hospital to us they are only given maybe a 7 day order of medications and if we are lucky we may get a month with no refills. We struggle to find them a PCP to help them continue on their meds and the waitlist for any psychiatrist or counselor is a very long wait. Even getting into a sober living place, it becomes hard as some of them are a joke. Staff are burnt out and have the means to do groups yet are pulled to other jobs or they are placed somewhere else which is more "beneficial". I agree with you and do feel the waiting lists are long and when they finally do see someone, it is a 15 minute meeting and sent out with a script for more medications. I haven't been in a psych ward for a while and was hoping things had changed but from the sounds of it, they haven't.
DeletePost 1 of 2
ReplyDeleteHow do places like Methodist become possible? – The first thing that comes to mind is stigma and the human value that we as a society place on people with mental illness. As I mentioned in the post last week, there exists a stigma surrounding mental illness and institutionalization. This stigma seems to erode the value we place on people suffering from mental illness within the context of greater society. This stigma seems to create an atmosphere of indifference where people can be dismissed as “crazy” or “frequent flyers” or needing to be kept “quiet”. This stigma and indifference may undermine how regulations, patient’s rights, and oversight of places like Methodist are enforced.
What is the real goal of inpatient psychiatric care? – I feel like the goal of inpatient psychiatric care should be to help a patient achieve their maximum levels of wellbeing and independence. Psychiatric care should help people overcome their challenges to the best of their ability and work towards achieving the maximum level of independence or self-sufficiency for their own unique life circumstances. I think the goal should not be to keep them quiet until they are able to leave, but instead to empower them towards striving to live their fullest and most independent life in alignment with their own unique set of goals and strengths. This may involve methods other than medication, for example, talk therapy and the teaching of skills to overcome challenges.
Especially for underserved populations, what is the difference between the “inpatient psychiatric unit” and a prison? – There is probably little difference between the two. Chapter two in our text notes that historically, “mental hospitals” were used as a means to extract undesirable people from society (Davidson et al., 2010, p. 59). This sounds a lot like the purpose of a prison, and this practice likely persists in our present-day culture and society (especially given the account we just read about the Methodist hospital). Within these two institutions, there is likely more of a focus on compliance and order, rather than rehabilitation. I imagine that underserved populations, like people with mental health challenges, may endure stigmas that cause them to be seen by some as “undesirable” within society, and therefore be subjected to prejudiced confinement in a prison or inpatient psychiatric unit for the primary purpose of removing them from society. For the person within one of these institutions, there is probably little difference between the institutions regarding how they are treated and the impacts of the experience.
Luke, I love your answer to what the goal of inpatient psychiatric care should be because I agree. It should be patient focused and empower the patient. In my own experiences this what I have seen staff do and it has built a therapeutic alliance between staff and the patient. It's always important to have someone on your side and there to empower you during treatment.
DeleteHi, Luke! Thanks for sharing your thoughts! I was especially drawn to your analysis of the roll of stigma for "frequent flyers". As if the stigma of having a mental illness at all wasn't enough, there also exists a hierarchy of "crazy" depending on your number of hospitalizations! Unfortunately I have seen this in action, especially when overhearing discussions of people with mental illness who often use the ambulance service as transportation. The person's symptoms are dismissed, harmful public behavior is ignored or placated to get him/her to leave, and the idea of helping or finding someone who can is never mentioned. Although I think it is primarily from a lack of knowing what to do, the stigma of the mental illness being the person's own responsibility and fault is prominent.
DeleteLuke I never looked at it that way in your last paragraph on how mental health patients and prisoners are viewed. I loved your comparison from the chapter we read about how they are viewed as undesirable. We don't want society do see how undesirable people can be so we need to locked them away or give them medications to cover it up. You also write about how there is more of a focus on compliance and order, rather than rehabilitation. I do feel this to be true in some situations where we need to hold up a certain amount of order and consistency then do actually teach or share any form of rehabilitation. Great insight.
DeletePost 2 of 2
ReplyDeleteHow has an over-reliance on medication promoted unethical, weak medical practices and even compromised safety? – Abuse and an over-reliance on medication seems to be a somewhat modern equivalent of keeping inpatients in chains. Both of these practices are a means of restraining someone. These practices seem to promote unethical and weak medical practices because the end-goal of these practices seem to be keeping inpatients subdued and restrained, instead of helping manage the symptoms of their illness. Interfering with a person’s mental state through the use of medication, or placing them in physical restraints, seem like it has the potential to compound what may be an already agitated state, therefore compromising safety. There is also the issue of vengeance – as noted in the text – to take into consideration when a person is restrained against their will. The text notes that patients who feel they have been mistreated may seek vengeance against the staff (Davidson et al., 2010, p. 36). The “When the Hospital is Sick” article notes that Ativan puts one man into “an enraged stupor”. I wonder if some of the rage could be stemming from the perceived mistreatment due to the forced administration of Ativan as a means of chemically-induced restraint? This seems like it has the potential to compromise safety.
And most importantly, are these places recreating the illnesses they purport to treat? – This question brings me back to the quote I posted about last week about stigma and how internalized stigma is reported to pose as formidable a barrier to recovery as discrimination and the illness itself (Davidson et al., 2010, p. 13). If patients are mistreated and treated as a lesser person than the staff, this could reinforce or validate their own notions of mental illness stigma and consequently add numerous new levels of negative complications on top of the mental illness they are already challenged with. For example, mistreatment (e.g. physical abuse) may lead to mistrust, and perceived inferiority may lead to a sense of hopelessness. If stigma is allowed to pervade throughout an institution, I believe institutions may recreate or worsen the illnesses they purport to treat.
Hi Luke. I like you’re analogy of medications being similar to chains. My experience has been that some people do need medications, but the inconsistency of taking them causes more harm than good. I do think that when people are admitted to psych units, their physical & mental state is so agitated thar medications are necessary to bring a person back to reality to start the healing process. I don’t like that inpatient units start someone in meds but then do not have a solid follow up plan to ensure the person can stay on them.
DeleteHello Luke,
DeleteI like how you touched on the fact that one of the several problems that exist in inpatient facilities is stigma. Medication, rather than being used as a tool of support is used as you brilliantly put it, chains or modern restraint. the fact that it is used as such makes it a punishment for illness rather than a tool to help someone through it. These place punish people for being sick when they should be focused on helping people get well.
I am starting to see that much of what occurred back in the day with treatment to individuals with mental illness has an effect on how they are treated today. A wonderful example is with Bethlem Hospital; it was specifically meant to house the homeless. I think this definitely added to the stigma of every homeless person is assumed to be mentally ill.
ReplyDeleteIn response to how to everyday hospitals end up like this example, I believe that it occurs overtime. When I was reading that it reminded me of Riverview that was closed down a few years back. A commonality I feel like exists in the same staffing and providers within where complacency occurs. Every job gets to a point of feeling like burnt out but not all have this much responsibility on their hands of human lives! I am astonished that this was just last year that the blogger posted this. It’s also those people who work there who would rather just do there job only and that’s it without jeopardizing everything by reporting people. The biggest one though; worried to ever challenge your superiors! Like just because they have been in the field longer and has more experience doesn’t mean they always do everything right. I think some ‘old school psychiatrist’ mentality lingers on from back in the day for many that still do exist or trained the now providers that way. It is quite similar to how equality in America is a movement currently for how it has happened to begin with, viewing some populations as ‘less than’. These are traditional, old school views that are embedded in so many people because of stigmas that still lie within society many that continue to keep being taught to future generations. It’s systematic!
Are these places re-creating and adding to their already illnesses? They absolutely are. Knowing what we do now of environment and looking at all people equally as human beings, it affects them negatively. The description of mind-body that paints a solid picture of how no human can possibly be considered to an animal because of our brains. We actually all ‘feel’ things! But, that this has created a problem in health care where physical and mental needs always seem to be separated… Medication compromises this on so many levels that it is almost used a form of ‘control’ that does put a person’s safety at risk. Misdiagnosis situations like with the great example of King George where it was not his mental health at all but a physical medical disease with its troubling symptoms. Then to have that and unknowingly be triggering it to be even worse with what you consume in your body. In his case it was the medications that were given to him to control his ‘madness’, that is terrifying to say the least.
Morgan, there are quite a few strong points here. Most prominent among them being that so many of the troubling behaviors by staff at this facility appear to be systemic. Right from the orientation the author of the blog informs us that this place has some deep seeded issues held among the staff (arriving late, skipping over things, minimizing other things). Then there are countless examples that reinforce the idea that you've described, that this didn't just start when the author started on the job. These were approaches to care and ways of interacting with patients that have existed for a long time. Staff are then asked to conform and behave in similar ways which normalizes the inadequate treatment of the patients. It fosters the sense that the patients should be quiet and when they're not they should "get juice boxes" rather than a conversation with a staff member. And when staff don't want to go beyond their own sense of what moral treatment should look like, they leave. I feel like that just gives those staff members that remain a new person to "train," rather than sending a message that maybe things should be done differently.
DeleteMorgan, your post highlighted several great concepts. I too thought that the Bethlem hospital was supporting the homeless initially but then it appeared all people who live in poverty had mental health illnesses. I find this stigma is still present at times and with education and awareness it is starting to shift.
DeleteBurnt out or compassion fatigue are occurring more often and I wonder why that is? Even within local DA offices who have professional training available seem to also have a higher rate of staff turnover too. It is hard to go to a supervisor about practices that are observed and not best practice but it is the ethical and right thing to do. Doing the right thing is not always easy.
Great post as I could continue to reflect from it!
Eamon+Lauren, The conformity of systemic problems seem so difficult to solve because staff keep following those similar behaviors and anyone who doesn't ends up quitting. I feel like it has to be a creative structural way to solve it so this isn't what the future will look like. It can't start at the top or the bottom but all around. Growing the workers that already exist is possible where choosing this human service career can get staff to see empathy:)
DeleteAfter reading this, there is a significant connection to how individuals with mental illness were treated in previous years. Facilities like Methodist are still running because of who is in charge. Like the author stated, they look at the patients as just numbers and not as individuals who need actual treatment and hope to achieve recovery. Presented is strictly old school views which have been embedded within the staff. The staff is significantly undertrained and many won't have a degree or experience/knowledge on mental illness. There is no structure, which is needed. The staff becomes extremely drained and burnt out due to long hours and limited time off, this takes an extreme toll on them. The main goal for inpatient care is to essentially provide individuals with a safe environment and stabilize them to then integrate them back into the community as healthy and positive as possible. When I try and visualize the words the blogger stated, I picture a form of jail or prison. If you misbehave you are placed in a room and locked in it... you are forced into taking a shower or medication in fear by the staff. Staff is burnt out and isn't challenging superiors to be better and try different methods and approaches. This is extremely important because there are a lot of "old school" psychiatrists that are blinded to new approaches and are probably burnt out as well. As times change, yes old practices are still evident but there is more being done to achieve a treatment plan and create a more positive experience. More trust is being instilled. But it is very worrisome that this blog was posted a year ago.
ReplyDeleteAre these places re-creating and adding to their already illnesses? Yes, absolutely. Behind the mental illness, there is a human that is more often seeking treatment and clarity. There is not enough resources, plans, time and more being presented. The staff is pushing these individuals out as fast as they came in, leaving them dependent on medication, which isn't the cure to all things, which needs to be noted. There needs to be a bridge between physical and mental health, they are connected and needs to be integrated care.
It also needs to be noted that practitioners are not all perfect, but there needs to be caution of language usage and how to go about certain situations. Understanding that behind the illness is a human that needs to be shown kindness, care and be presented with hope for better. There needs to be more of this and less of old school views that demean and hurt patients.
Hi Stephanie,
DeleteI totally agree with the importance of treating patients as human beings with kindness. I have been feeling a bit optimistic of the theories coming to light in today's counseling field of person-first and using empathy, kindness and offering hope to help those with mental illness recover and return to their lives. I also agree that practitioners are not perfect, no one is! This is an important fact and as long as others and the practitioners themselves see this there is hope!
Hi Judi,
DeleteThank you for your comments back to my post. I as well firmly believe that there are promising theories being highlighted now. More empathy, kindness and wisdom. Someone can have all the knowledge in the world, but if they lack kindness, empathy, and hope then there is a significant chance of mistrust. Without the trust and a positive relationships between patient and professional, there are often negative results. This is extremely important to note.
Hi Stephanie, I'd like you to know that no all inpatient hospitalizations are like this. Please know that there is some where the staff are providing empathy, kindness and support to the patients. This breaks my heart to hear how this hospital is treating their patients because it puts a big dark cloud of stigma on inpatient hospitalizations and may deter someone who truly needs this level of care into not seeking the help. I have seen patients do a complete 180 and stabilize and even THANK the staff when they leave.
DeleteHi Vessa, thank you for pointing out the importance of not casting such a negative light on inpatient hospitalizations that people in need of service may be deterred from treatment. I know that for me personally, it’s important to remember that these institutions (however imperfect they may be) provide important services to people in need. Reading an account like the one about the Methodist makes it easy to overgeneralize and view all of these types of institutions negatively. As you pointed out, this view can be problematic, and there are people who are doing good work and helping patients improve. This is a necessary reminder to be cognizant of the importance of these institutions while simultaneously bearing in mind opportunities for improvement.
DeleteThis comment has been removed by the author.
DeleteHi Vessa and Luke,
DeleteI appreciate your comments back to my post. I wanted to note that I am aware that not all inpatient hospitalizations are negative. I know this from my own personal experience. I am also fully aware that practitioners and staff are doing good work and helping patients improve with positive treatments, etc.
Reading this and the other readings for the week I keep coming back to the symbolism of those being treated for mental illness are treated like prisoners, they are even called in some places, inmates. It also appears that that they were not really treated, just band aides in place to move them through. They were told to comply in order to get out. Medicated to keep quiet. These hospitals have been allowed to operate like this for many reasons, one of the most significant, funding. Money is not given to areas that really need and can benefit from it. Our society does not put importance on helping people, most just want to get richer.
ReplyDeleteIt seems like the goal of inpatient care was not to treat and help those suffering recover but to just keep the wheel moving. Advising patients to comply with directions, obeying their "masters" like animals. constantly telling patients if they just do xyz they will be able to leave, not really looking at the problem and offering real treatment and help.
The burn-out factor is high causing practitioners to just get by the best they can. Or the old guard of "that is how we have always done it" by those who based on their feelings that since they are the doctor they know better.
I don't necessarily think they are recreating the illnesses but rather they are not treating them at all. They are not offering any kind of useful help to those in need. Perhaps this does add to the original illness as it certainly does not help the original reason the patients are there in the first place.
Hi Judi,
DeleteYou refer to individuals that have a mental illness sometimes being referred to as "inmates" and I never actually made this obvious connection. Prisoners have inmates. Individuals that come and seek help, either voluntary or involuntary should be referred to as patients not inmates. There is no need for these individuals to be treated as if they were in-prisoned, because they are not.. they are seeking help to feel safe, stabilized and want to create a positive interaction with the community. Your statement about "our society doesn't put importance on helping people, most just want to get richer" this is so spot on. Funding is one of the most potent reasonings why hospitals such as these are still operating. There needs to be a positive interaction between patients and staff, otherwise there will be no success. It seems there is just staff who are just passing these patients along, medicating them and then releasing them with no set in stone treatment plan, saying "they will be back". the primary reason they come in is to seek help and the willingness to change their lives (for the most part). Understanding that these individuals are humans behind their disability, it extremely important. There is a lack of resources being provided and that can have a toll on the situation.
Stephanie, I think you hit the nail on the head! There is an extreme lack of funding which leads to the inability to hire more staff and with a shortage of staff leads to burn out and compassion fatigue! We should also put insurance companies under a lens because I can't tell you how many times I have seen patients leave an inpatient stay too early simply because their insurance company will not cover their hospitalizations. So in that moment the patient has to decide to either stay and rack up a bill upwards of $5,000 a day or leave the hospital.
DeleteHi Judi, I think you brought up some important points about funding and the burn-out factor. From watching the Bellevue film and reading the article about the Methodist, I think it’s easy to automatically blame some of the shortcomings on the people within the institution. However, before doing so, I think it’s necessary to step back and have a larger conversation about some of the systemic issues that may be creating these problems. I think funding is a huge component. This can directly influence the working conditions and morale of the staff, as well as the services offered to the patients. I would be interested to see if there has been much research done comparing the success rates of different hospitals (serving the same type or similar populations) with the funding of each hospital.
DeleteHi Judi, your post as well as a few others made me ponder a few questions. Funding is determined by current data collection and submission of those findings. If current services are not being provided or recorded then funding could be cut. I know the mental health agency I worked for, for fourteen years required specific data collection to maintain or to help support an increase with funding. If personnel are unaware of what data to collect and how it impacts funding then their program is affected, ultimately creating less than quality care for the consumers.
DeleteGreat post!
I strongly feel that there should be a huge disclaimer that states NOT ALL INPATIENT HOSPITALS ARE THE SAME!!! I find myself getting slightly defensive just because I have worked inpatient and absolutely LOVED IT and was sad to leave but pursued a bigger career move, I intend to continue to have connections with inpatient and eventually return in some capacity once I am fully licensed.
ReplyDeleteI know that not every hospital is the same and everyone has their own experiences so I take this into account. But I ask that you keep in mind that inpatient hospitalizations and can and are beneficial and therapeutic with the right care, staff and interventions. There some points where I drew similarities as in "the Q-word" yes that is for sure considered a swear word because it is more a jinx than anything, but the reality is we just want all the patients to be able to engage in treatment and when they are having a bad day so are the staff, simply because we want to see patients succeed! Inpatient hospitalizations are difficult, typically patients come in at their absolute lowest and as staff it's our job to support them and provide unconditional positive regard.
How do places like Methodist become possible? I would say this happens due to funding cuts, shortage of staffing and lack of training. Inpatient hospitals are constantly lacking funding and due to this they are unable to hire staff or provide adequate training so the staff become burnt out and compassion fatigued leading to poor patient care.
What is the real goal of inpatient psychiatric care? I believe the real goal is to support patients who are truly at their lowest and provide a multi-disciplinary treatment modality (therapist, psychiatrist, nursing, social worker, etc.), this allows the patient to decide what is going to be best for them, of course staff would encourage the patient to take advantage of all services including medication and therapeutic interventions. The goal is to stabilize the patient and provide the LEAST restrictive care possible.
Over-reliance on medication? I can see an over-use of medication being unethical and weak medical practice, it's not a good idea to over medicate a patient because there are risks involved. If a patient is highly sedated they could fall and cause serious damage to themselves. It's important to monitor patients constantly and consistently to ensure their safety and adjust medications as needed.
Are they re-creating the illness they purpose to treat? This is difficult to answer because hospitals are held to certain standards laid out by management, insurance companies, and funding. For the most part I would say no or at least not on purpose, there's the goal for effective treatment but with funding and insurance companies it can feel like an uphill battle.
Vessa, thank you for your personal insights and thoughtful responses to the blog's questions. I agree with you, and have seen in my own experiences of yesteryear, that there are facilities that do amazing things for their patients. Then there are those that would look and feel like the one described in this blog and in the Bellevue documentary. I really appreciate that you've put this "disclaimer" out there for anyone that could feel like these examples are the norm. To be certain, environments like the documentary and this blog depict are real and unfortunately are all some individuals have for treatment. However, there is evidence that things are changing, either at an individual doctor level (training) or at the more general institutional level (reform). Team treatment plans and/or warp-around care seem to be much more common now. I think this will help everyone involved with a patient feel more safe in their own decisions, staff using their own voice (rather than the systemic hive-mind), and most importantly, the ways in which staff respond to a patient's needs.
DeleteVessa,
DeleteI appreciate your comments about how inpatient psychiatric hospitals are not all the same. This is very important for everyone to remember and consider with these questions and within this field. With dedicated employees who are trained, have professional development available/scheduled and supervision helps create a supportive atmosphere for patients who may enter their program.
Your point about the impact of funding and insurance on the staff and facility is spot on, as this can affect the overall quality of care that is provided. Without resources and support it can be a frustrating, leaving staff to implement only what they know or what they are taught. This can set up facilities to fail.
Great post!
I really appreciate your view point on this as we did get kind of a one-sided view of inpatient facilities through the post as well as the Bellevue movie. I feel that the other side is important to point out that there are places that uphold that standard of care that they initially I feel all set out to achieve. I do agree that funding has a lot to do with the quality of care, but better funding comes to those who engage in better care, so it is kind of a catch 22. When I first start the Clinical Mental Health Counseling program I too craved the inpatient atmosphere, I have still yet to get there as I have not been in the filed other than the practicum and volunteer experience thus far. But, I still would like to participate in that aspect within my training, and have been discouraged until reading your post and knowing that there are places that will put clients needs first and not just worry about keeping everyone sedated and "quiet"
DeleteVessa, I appreciate you offering a different view to what we witnessed in the Bellevue film. Obviously there is some bias extant in filmmaking and the way that its subjects are portrayed. I still adhere to the view, however, that many places like Bellevue exist, largely because the mental health profession still largely draws from the medical model. The medical model adheres to the idea or a norm and that anything irregular must be bad or wrong because it falls outside that norm. You make some valid points about lack of funding, etc. This can lead to issues such as underpaid staff and burnout, which can significantly impact how clients are treated. I do agree that these hospitals are probably not purposefully trying to hurt their clients. Nevertheless, I find it odd that using medication as treatment continues as the gold standard in many of these hospitals considering the high rate of reinstitutionalization as well as the fact that the clients (at least how they are portrayed in the film) are continually expressing how unhappy they are with their treatment and how ineffective they feel it has been for them.
DeleteHow do places like Methodist become possible? Places likes Methodist become possible by society and individuals who overtime become desensitized to the work they do. The stigmas that are made or known, creates individual judgements. What people do not know or understand can be scary. Patients at this hospital became numbers not individual human beings.
ReplyDeleteWhat is the real goal of inpatient psychiatric care? The goal of impatient psychiatric care is to stabilize the acute symptoms from individuals to help them be safe, confirm diagnosis and medication if needed. Like the author shared “wasn’t helping people get better what we were here for?”. At times individuals may be referred to impatient psychiatric care due to risk of self of harm to themselves and to others. By providing a safe place to stabilize their symptoms and develop a treatment plan, individuals can access their home and community again.
Especially for underserved populations, what is the difference between the “inpatient psychiatric unit” and a prison? Through the readings this week I am having a hard time seeing the difference between an inpatient psychiatric unit and a prison. At times, our readings mentioned how inpatient psychiatric units were used for the homeless and the less fortunate who were different to get them out of society. Psychiatric hospitals focus would be on rehabilitation while meeting the needs of their patients. Methodist hospital felt like a holding facility with no emphasis on treatment only on compliance of patients taking medication.
How has an over-reliance on medication promoted unethical, weak medical practices and even compromised safety? Over-reliance on medication has promoted unethical, weak medical practices and compromised safety as in this article they were told to comply with the medication if they wanted to get out. Assessments, confirmed diagnosis, treatment approaches such as cognitive behavior therapy, individual therapy and or group therapy should occur initially with all patients. Some of the patients disclosed significant trauma from their past which was brushed aside and not addressed. Restraints were utilized far to often and during unnecessary times. To me it felt like the medication that was pushed on patients was also a form of restraints. The more this practice occurs with staff the more normalized it gets. Some staff may not speak up as it’s a job and they need the money.
And most importantly, are these places recreating the illnesses they purport to treat? I strongly feel that some places are recreating the illnesses and at times maybe not even addressing the illnesses that are already there. Individuals who access, are referred, or brought to an inpatient psychiatric hospital are there for help. After this reading I see the injustice and why people would just comply or make things worse to get out of there. They are human and not animals yet from this article are treated harshly and without thought. We all react/advocate and express are feelings and emotions differently, yet these patients are not allowed to or more medication or isolation is thrown at them. Building a relationship and establishing trust is part of the process of treatment. I do not think you can call what the Methodist hospital did as treatment but more of a holding facility. As providers we are all not perfect, but it is our job to provide best practice to each consumer and to continue our professional education and training to ensure we are providing the best services we can.
Lauren-That word of 'desenstized' for how facilities and staff got like that wraps it up perfectly. Over time, that is the real trend that keeps occurring with no remedy on how to fix and prevent it ongoing. Medication use as a retraint mechanism is very normalized where there doesn't seem to be very many cases where it is held off to explore other options first. Injustice is exactly what's happening! There's no trust when a human being feels so violated that they will do anything to just escape. That's creating a traumatizing relationship with mental health services in general that needs attention individually for healing in the future.
DeleteIt interesting that you touched upon desensitization of staff members, I think this really relates to what I chose to discuss which was burnout. I think that the same actions and experiences result from both of our chosen descriptors. I agree with you, that I am having a hard time seeing the differences between prisons and inpatient psychiatric facilities. Especially with watching the Bellevue video. The medication and compliance situation is a touchy subject for me and reading about the push for compliance in this article really hits me the wrong way. These individuals would be more compliant if they knew what they were getting for medication, they had an active role in their treatment planning, if they were treated like human beings, and if they had more socialization.
DeleteMorgan, relationships are based on trust and without trust there is no relationship. It takes some courage and strength to access services and support. This may be the reason why people hesitate to get the help and treatment they need. Services should never be scary or create "traumatizing relationships". The services provided help create a foundation and a person-centered treatment plan meeting the consumers needs while increasing their quality of life.
DeleteThank you for your great comments!
Kailyn, I also agree with you and how individuals need to know why they are being prescribed medication and what it is. Benefits and risks of medication should be discussed prior to the script being written. Socialization and connection with the outside world needs to happen. I struggled reading these articles and how patients just wanted to go outside. Being outside has so many benefits for not only your mental health but for your physical health too.
DeleteThank you for your great comments!
How do places like Methodist become possible?
ReplyDeleteI feel as though a number of factors contribute to facilities like Methodist existing in the world. One is based on the history we’re all learning about of how individuals with mental illness have been viewed, stereotyped, and treated throughout civilization. Depending on what a staff member has learned prior to working at a Methodist, they could approach a patient in the throes of a mental health crisis with a very wide range of responses. Then, depending on what is modeled by the senior personnel around this new staff member, they may choose to shift their own beliefs to match what others are already doing; they may double-down on their own beliefs; or they may become unresponsive. This last reaction could be why certain doctors would only talk to patients from behind glass. Lastly, though I’m certain there are more factors, Methodists may also become possible because the work is hard. It’s not easy to give each of the individual patients what they specifically need, so cookie cutter approaches and responses from staff are bound to be happen. This only compounds when staff are even more shorthanded/ outnumbered.
What is the real goal of inpatient psychiatric care?
This probably depends on whom within the facility you ask. The CEO would probably say to grow the facility and, in doing so, allow the facility to service more and more people in need. Doctors would probably say to maximize their time with patients so that they have fewer plates to spin at any one time. Social Workers would probably say to stabilize patients so that they can access the work of recovering. Nurses would probably say to do right by the patients. Patients, and their families, would probably say “fix” what’s wrong with no sense of what that entails.
What is the difference between the “inpatient psychiatric unit” and a prison?
As a starting point, my understanding is that inpatient care is more often than not voluntary. At it’s most basic form, a patient has to agree to the treatment. Patients can often leave a facility whenever they want.
How has an over-reliance on medication promoted unethical, weak medical practices and even compromised safety?
Like I stated above, I think this work is hard if it’s carried out adequately. I strongly believe that medication has a place in recovery. I have also seen people who are not experts in medications speak at length about what they believe and understand to be the best regime for a patient. I therefore believe that the ease with which medications can be administered; how often they’re overprescribed; how frequently they’re carelessly mixed; and how haphazardly medications are dropped from a patient’s regime, puts patients and staff at risk of harm. I feel that the “lanes”, meaning expertise, of treatment team members should respected.
Are these places recreating the illnesses they purport to treat?
I don’t know that Methodists and similarly run facilities are recreating the illnesses, but they’re obviously providing substandard conditions for patient recovery. They’re also giving inpatient facilities the world over a bad name by furthering a narrative that they’re inadequate and in many ways harmful to individuals.
I am going to play devil’s advocate here, so stay with me. You mentioned in your post that medication in recovery is necessary, which I agree with, however is it necessary all of time? Some individuals do not benefit from medications as they would another treatment option. Or like in the video a client did not want to take medication, because he did not like the reaction that his body had to it. Was it fair for that clinician to continue to push medication onto him, without a clear explanation? Do you think that clients should be prescribed medication solely to obtain compliance? I fear that, through readings and the Bellevue video, that the purpose of medication has been forgotten and its new use is to keep everyone quiet and behaving.
DeleteCan’t wait to hear your response!
Thanks for this question, Kailyn. I purposely wrote that medication "has a place" in recovery. I say that because I'm thinking of med. management under ideal circumstances. Meaning that the medication has been prescribed by a psychiatrist that has a reason for introducing it, as oppose to just compliance and the "q" word. Again, ideally, the psychiatrist is aware of what the patient has taken previously (electronic medical records are of assistance with respect to medical histories). Ideally, the psychiatrist is receptive to the patient's feelings about, or reactions to, previous medications. Under ideal circumstances the team of staff working with an individual patient are able to give feedback to the psychiatrist to inform whether a med. adjustment is warranted. My opinion would be that there should never be medication without a specific reason for the individual patient. Hope explains my thinking.
DeletePlaces like Methodist are possible because there is no one out there telling them to stop, to reprimand them for behaving so unprofessionally. Not only that, it was clearly stated in the article, there are a lack of staff and the staff that are available are overworked and underpaid. In mental health it is so easy to get burnt out and when staffing is an issue burnout happens so much easier and quicker. Without anyone checking in with staff and making sure they are taking care of themselves it is a never-ending cycle that has negative impacts on staff and clients.
ReplyDeleteThe goal of inpatient psychiatric care should be to provide a safe environment where individuals can get stabilized work on their symptoms and illness and learn to be able to function in society safely. I think psychiatric illnesses can be a lot on families, and some are not equipped to handle them. Having a safe place for the individual to be and teaching the family what they can do is beneficial. Is this how these are utilized? Not really. I think today a lot of psychiatric facilities hold individuals that society does not really know what to do with. They can not function in society “normally”, they may not have committed a crime, so a psychiatric facility it is. For some, there is no difference between an inpatient psychiatric unit and prison. Some individuals are committed against their will.
The over-reliance on medication is an issue that I find truly frustrating. I think that, especially for inpatient facilities, staff burnout has a lot to do with this reliance. Some individuals can be difficult to deal with, taking a lot of time and energy, and for staff who are at the end of the rope this is just not possible to deal with. If a client is not going to be compliant on their own, medication will make them. I am not sure why this reliance on medication is just slipping through the cracks and why no one has spoken up about this, but it is truly sad.
I think that these facilities are absolutely recreating the illnesses they are meant to treat. These facilities have the potential to truly change individuals life and quality of life, if utilized correctly.
Hi, Kailyn! Thanks for sharing your thoughts! I agree with the overall tone of your post in that the current state of inpatient hospitalization is frustratingly ineffective. A lack of caring and knowledgeable staff, unprofessional leadership with little accountability, and the overuse of medication all feed negatively into a system that is intended to be a place of respite for those experiencing acute mental illness. By having these conversations and being aware of what NOT to do as we begin to enter the field, I hope we can begin to make the many changes necessary to make mental health care an effective instrument of healing.
DeleteHi Kailyn:) You are absolutely right that literally staff keep us this treatment because no one is telling them to treat any differently. I never saw a staff try to give an alternative opinion or anything. I think that is a theme in more than one place than just here in America with people scared in challenging the 'norm'. I really like your unique mention of how there needs to be care for the staff in order to handle that level of stress everyday in life, especially in the workplace. That no one at the time even knew how to deal with anyone, particularly in the home and social environments. I agree that helping teach others to be better prepared to understand and handle individual needs. That supporting family members and friends through this actually helps them more than they ever could imagine by providing that feeling that someone actually cares for them!
DeleteThanks Emily and Morgan for your responses. I do want to add that I know these jobs can be truly difficult and draining physically, mentally and emotionally. I have been these people before. This is why it is so important to have supervision, accountability, and self-awareness. It is not right to have staff burnout be taken out on clients.
DeleteI am simply amazed by the direct correlation between Samuel Tuke’s retreat model and the flawed mental health system we have today. It certainly makes sense to see how something like Pinel’s moral treatment has morphed into Tuke’s retreat, ultimately becoming the leveled system of institutionalized recovery due to the skewed translations of Pinel’s principles. Overall, the treatment of mental health we currently utilize as well as the stigma surrounding mental health and the abilities of people experiencing mental illness seem to stem directly from the retreat model.
ReplyDeleteThe current goal of inpatient care seems to be to get people experiencing acute mental illness – portrayed as dangerous by society – out of the public eye until the person can “get it together”. Due to a lack of insurance coverage, the next goal is to get the person stable and out of the hospital as soon as possible, usually through high doses of medication. In contrast, the goal of inpatient psychiatric care should be to provide a safe a respectful place for people experiencing acute mental illness to exercise their “rights, opportunities, and resources needed to lead meaningful and productive lives” (Davidson et al., 2010). Unfortunately, especially with the widespread use of medication, weak medical practices continue. Medications are viewed by many doctors – and pushed by many drug companies – as a shortcut around meaningful therapy and client-driven treatment. As drug use increases, the number of patients per doctor increases, leaving little if any interaction between patient and doctor aside from a prescription, as mentioned by Jessica DeArcangelis in “When the Hospital is Sick”. Instead of viewing mental health as a priority needing focus and attention to healing, such as a patient would do in a cancer or diabetes situation, these invisible illnesses are seen as an inconvenience to be hidden or lessened by one drug after another.
In many cases, people experiencing mental illness who are also part of a marginalized and/or underserved population are sent to prison when the need for focused psychiatric care may be present. Whether due to an escalated situation, a lack of insurance, or prejudice, the person experiencing mental illness may be taken to a prison where symptoms of mental illness will only be exacerbated due to stress and a lack of knowledgeable care. Even if taken to one of the less effective inpatient psychiatric hospitals, at least there would be some acknowledgement of mental illness and possible treatment as opposed to more trauma and a criminal record. Unfortunately, when considering the sad state most psychiatric hospitals are in due to a lack of funding and overworked, hardened staff, the likelihood of additional trauma in an acute mental health event is high. With no viable inpatient options available for those who can’t afford the private sector, what options are left?
Davidson, L., Rakfeldt, J., & Strauss, J. (2010). The roots of the recovery movement in psychiatry: Lessons learned. Hoboken, N.J.: Wiley-Blackwell.
Hi Emily!
DeleteYou are spot-on with the actual vs. ideal goal for psych units. I made similar points about the "treat 'em and street 'em" method used by most places due to a lack of space, resources, staff, and insurance.
I worked with a 17-year-old client a few years ago who had a few diagnoses (with which I did not agree, but that's not totally relevant) that doctors thought would be best treated with medication. Having been on medication before, this client was very clear that they would not take anything. Rather than speaking with the client about other methods of treatment, the treating physician announced that he couldn't help the client and would need to discharge. The physician *was* specifically part of the treatment team for medication management, but there was no discharge plan or titration of services to ensure this client had the supports they needed before being dropped from this provider. I believe part of the goal for this announcement was to convince the client to take medication for fear of losing the relationship they had built with this physician. It was deeply uncomfortable, certainly unethical from a social work standpoint (my field), but not illegal, so. The client was dropped and as they case manager, I was now scrambling to find other treatment modalities while the client was angry with me for "letting" the physician drop them, and their mother was upset for "letting" the client walk away. Was anyone actually concerned about the client's desires? Their needs? Why were we all working around the client, instead of WITH them?
Hi Emily G, thanks for sharing the story of your work with the 17-year-old. This story shows a couple problems in the system. First, is the issue of trust. It sounds like the doctor was trying to coerce the patient into taking medication through the use of fear. Like you said, this seems unethical. If I, as a patient (and especially as a teenager), found out that my doctor was threatening to drop me as a means to get me to do what he wanted, I would seriously question whether or not this whole process is worth my time. I would probably lose whatever trust in the system I had. Second, is the overreliance on medication as the sole treatment option. This approach was especially clear in the Bellevue film as well. I believe that medication is an important treatment option and has the potential to help some people. However, I question the medication-or-nothing approach as it appears to leave a lot of other options (e.g. talk therapy) off the table. Maybe one of these other options would work better, but we don’t know if nobody is given the chance to try them. Thanks for sharing this story. I’m wondering, in your experience, have physicians mostly been focused solely on medication, or have others embraced other forms for treatment?
DeleteHey Luke!
DeleteIn my few years as case manager, yes, most physicians I saw with clients were focused on medication to manage symptoms. And because I worked with children, the decision was up to parents and not the clients themselves (although I did have one parent who attended all med-management meetings with her 14-yr-old, but let the kid decide whether or not to take meds. Mom said "it's your body, you know what's going on inside. I can't tell you what to do here." I thought that was lovely!). I can't entirely blame the medical doctors though, as their training is in medicine and not therapy. Often, they would ask about other interventions but it was on me and the family to find, refer, and schedule with outside practitioners for things like in-home support or talk-therapy.
How do places like Methodist become possible? Places like Methodist become possible because why fix what isn't broken or if I don't see it or hear it then it isn't happening. Places like Methodist are the ones who place a bad name on mental health. If numbers are all that are being seen and not how many are not coming back then this would be way. Numbers seems to be a theme in the mental health field not how many can we adequately cure. Fix them up, make them look good, ship them out and it's their fault when they come back.
ReplyDeleteWhat is the real goal of inpatient psychiatric care? The real goal is give hope, compassion and meaning for their purpose. To give them the correct tools of success or finding ways to benefit and encourage them. Medication may be needed and sometimes is called for with certain individuals. Giving them a purpose and redirecting them with ADL's as well as helping through the funk they are currently in.
Especially for underserved populations, what is the difference between the “inpatient psychiatric unit” and a prison? According the Methodist and Bellevue the only difference would be that prisoners are treated better and more humane. They are given an education, time outside, chores, a gym, and professionals to help them with their needs. However, it should be this way on both accounts.
If prisoners are treated more kindly than a mental health patient, then there is something wrong. What is missing and why is it overlooked? Times have changed however how much have they changed and does this still occur in hospitals? Patients need that hope and compassion and maybe a reason to continue doing well.
How has an over-reliance on medication promoted unethical, weak medical practices and even compromised safety? When we rely on just medications then it can be unsafe. If someone has cancer we don't just give medications but they are given other tools such as certain foods to eat, exercises, meditations and other holistic methods. This can also be done with mental health individuals as well. They have a disease yes but there are also other methods and approaches as well then just medications. When someone is placed on certain medications it can actually make their symptoms worse and therefor their treatment must be vamped and now they are being placed on something stronger when it isn't needed. At my work we once had someone come in who was very lethargic and just continued to do the same things over and over. They were depressed and had no hope for the future. They came to us about three times and was finally admitted to the hospital. They were there for quite some time like three months and came back to us to transition back home. When they came, they were happy, joyful, had energy and tons of hope. The change? They had a thyroid issue which was never diagnosed. Once placed on medication for that and proper care and outside resources, their perspective changed. All because of a medical issue not fully a mental health issue.
And most importantly, are these places recreating the illnesses they purport to treat?I feel places like Bellevue and Methodist do recreate the illness the purport to treat. They claim they are able to help them yet when no one is watching it becomes something else. I wonder how many have been misdiagnosed or are diagnosed with something else when it could be in relation to something else. If they are able to gain recognition then they are funded and are able to gain more resources yet more often than not, this does not happen.
I like the point you made about over-reliance on medication and how a lot of facilities even today subscribe to those practices. It, in my opinion, does mask potential other symptoms that the client may be experiencing that hold more relevance than the ones that the medication is treating. Unfortunately as I stated in my post I feel a lot of the issues that come with in-patient facilities is complacency and the idea of just following the rules cause they are rules. I think we need more holistically driven clinicians to help us "fight the good fight" per say and advocate for more client connection to better services.
DeleteI agree with you Sarah in needing more holistic driven clinicians. They do reach out to other resources which may give a more significant outcome than medications. I'm not opposed to medications at all and know they do help to some extend however I feel we rely to much on them to fix the problem. Using other resources with medications is useful and typically beneficial is recovery.
DeleteI believe places like Methodist become possible out of complacency. There are some clinicians out there that still believe in certain old practices that have been since debunked but are still used. Staff and clinicians in inpatient facilities tend to become normalized to the behaviors of the mentally ill, and mostly at times the severely mentally ill, giving them a sense that they are all the same and should be treated as such. The individuality of people tends to leave, and the hoard mentality takes over. There becomes this numbness to certain situations that develops and someone that is coming in that is new to this type of environment will see all the flaws as if they are glaring in the face, yet the staff is immune to it. Compliance is not only sought after in the clients, but in the staff as well. I feel that there is this unspoken duty to continue behaviors even when they do not feel right when you are trying to make something of yourself from the start. A new clinician is not going to want to stand up to old practices upon just claiming a new position at the facility. Conform and comply. In some instances, unfortunately there is no difference between an inpatient unit and prison. They are both underserved as far as correct treatment for the clients. They are places where the individual voice is not heard, and they are places where the key is to comply, and you will be released. Not recover and thrive, it is comply and re offend. Over medicating and individual just masks what is really happening, impairing the individual to make sound decisions as well as making it difficult for the clinician to treat the individual’s underlying issues. It is unethical to utilize medications to control behaviors when alternatives can be utilized just as effectively if not more so.
ReplyDeleteHi Sarah!
DeleteI love your take on these questions. The term "complacency" is perfect. How can staff remain properly attentive and compassionate when their caseloads are crushing and their pay is dismal? What is a clinician to do if their supervisor won't take their concerns seriously?
I agree with you on the point about conforming and complying in a psych unit vs jail - the emphasis in both places is on following the rules for rules' sake. It's not really about what's best for each individual, it's about what's best or easiest for the facility/staff. The way the Bellevue staff threatened restraint and sedation to agitated patient made my stomach hurt. People are allowed to be upset, and using verbal insults toward someone is not the same as being a "danger to self and others". I made a similar point in my post - medications can mask the underlying issues by just alleviating symptoms, preventing effective treatment. It's pretty infuriating!
Hi Sarah,
DeleteYour discussion reminded me of when Jessica DeArcangelis stated "I met so many patients with histories of trauma who had been in and out of psych wards for years and just came to expect the mistreatment." I'm glad you pointed out this same phenomenon exists on the other side among staff aswell. As someone who is new a new employee to the mental health field myself, I can understand how intimidating a new position can be; especially when coupled with the insecurity that comes with lack of experience. However, none of these things are excuses for unethical treatment.
Hi Sarah,
DeleteAlthough I think complacency is part of the issue, I'd like to offer the perspective that the issue is much more complex than this. I truly believe there are flawed philosophical underpinnings that drive the systemic toxic practices of places such as Bellevue. For example, our medical system is largely based on Cartesian philosophy and the idea of a norm. Anything that falls outside that norm is deemed as a threat that needs to be corrected or extinguished.
Well said! the old school mentality is still widely recognized! I see and experience this mentality in my work in the field all the time. "Just get enough information to write a billable note" instead of doing purposeful work. My boss now worked at AMHI and he is a direct result of this type of mentality. I think it is somewhat of a generational thing because the mental health field is still so new in comparison and once the older generation retires and moves on, we may not see real change. But with our generation, it can be the fresh start and new voice the mental health field needs to move in a positive direction.
DeleteHow do places like Methodist become possible?
ReplyDeleteI think they become possible through systematic budget cuts, the undermining of mental health services, and the assumption that you can just remove mentally ill people from general society and life for everyone else can go on. There's an attitude that either every person who's mentally ill has done it to themselves or they are unfixable, and either way - it's much easier to insitutionalize than to treat/heal/recover.
What is the real goal of inpatient psychiatric care?
The goal should be to provide appropriate services in a safe environment that are conducive to improved quality of life and eventual recovery for patients who desire this kind of intervention. In practice, these facilities seem to operate more as a holding unit for "crazy" people so they can be removed from society. In my experience, clients are sent to psych units when they are in crisis and need acute care, but they are only held until they are "stable", at which point they are discharged with little more than instructions to "take your meds!"; there is no plan of care for once they have left the facility and no intention to follow up if the client is interested. This was extremely problematic when I worked with youth experiencing homelessness - they could barely keep track of their cell phones, let alone their medications and a schedule for taking them.
Especially for underserved populations, what is the difference between the “inpatient psychiatric unit” and a prison?
I'd like to say the difference is in the treatment, but I've seen many instances where folks on a psych unit are treated as "guilty" of bad behavior, regardless of their diagnosis. A person can also be admitted to a psych unit against their will without the need for any kind of formal charge. A psych unit is supposed to be for treatment that meets the unique needs of each individual that comes in, but I'm not sure this is how most of them operate.
How has an over-reliance on medication promoted unethical, weak medical practices and even compromised safety?
In a lot of cases, medication can alleviate symptoms without addressing the underlying cause. In the Bellevue documentary, there are several instances of patients being agitated, and the response from staff is to give them a medication to calm them down. That certainly makes things easier for staff, but how does that solve the problem, or give the patient any coping skills for the next time they are agitated for the same reason? The quick turn to medication in the case of any "abnormal" behavior further pathologizes vulnerable people as well as perpetuates the idea that medication is a necessity for effective treatment.
And most importantly, are these places recreating the illnesses they purport to treat?
I think it must depend on the diagnosis. I can certainly see how a poorly-run psych unit can contribute to anxiety, trauma, depression, and paranoia. Does that mean the unit is creating these problems? No, but it does mean they aren't helpful and they aren't providing appropriate, kind (moral) care for their patients. I remember an episode of Scrubs (I think) where a doctor insists that for most patients who seek treatment at the hopsital, you have to "treat 'em and street 'em"; meaning you want to do what is going to give the best results the quickest way so you can discharge and move on to the next patient. I think it becomes a bit more complex in psychiatry, but not by much.
Hello Emily,
DeleteI like the point you made in that the patients are given medication to make it easier on the staff, not the ill. This hits one one of the core problems seen in inpatient facilities today. The focus has come off of the wellbeing of the ill and has instead become how to make the life of the staff easier. Their symptoms are seen as misbehavior that needs to be punished, not as something that is causing the person with the illness distress and suffering. The focus should be on bettering the lives of the patients not the staff, but sadly in many places this seems to not be the case.
It's deeply saddening that facilities have truly not changed as much as thought since the days of the old asylums and "hospital" and "prison" meld into one. As in the old days hospitals like this exist due to the people in charge enforcing a rule of sigma and complacency toward the ill. The mentally ill are not seen as humans suffering from an illness, but more like wild animals that need to be subdued and controlled. When someone new comes in, like the author of this article, hoping to make a difference and help those in need, they are crushed down by routine. The goal of inpatient facilities should be to help sick individuals to gain the toolkit and stability they need to re integrate in the community. However this has not become the case. In both Methodist and Bellevue the goal seems to be to drug the patients into submission and get them out. These hospitals become little more than prisons. Both run to keep people with "undesirable" away form the rest of the population. They are locked away with little say in the matter or how they are to spend their day to day life. If they act up even further they are locked in isolation. An over reliance on medication has caused a fixation on hiding symptoms rather than trying to heal the cause. Just as a broken bone can't be healed by painkillers alone, mental illness cannot be cured by sedatives. In order to reach recovery, both need proper support and opportunity for proactive rehabilitation. If the paitent is never given the opportunity to work through the underlying cause and subsequent trauma of their illness, they'll have to keep coming back to the facility that will continue to fail them until they're finally given the opportunity to recover and not just be drugged.
ReplyDeleteMackenzie,
DeleteI appreciate your comments about how disappointing it is to hear that these practices we associate with "the old days" are still in use, despite the fact that it's illegal and people should just know better than to think that kind of treatment is effective for wellness. The publication date didn't really register for me until I read the whole article then scrolled back to the top to see 2019!! Only one year old! I was shocked, sad, and so disappointed all at once.
It is very sad! The stigma is real and we as a country and society still have a long way to go to understand and accept people with mental illnesses. Wouldn't it have been great if someone empowered this person who wrote the article to use her passion and motivation to make a positive change in this hospital? Instead the dragged her down to their level and lost a motivated and enthusiastic worker who could have helped many people. I hope we as future clinicians can take this as a learning experience and see that just because people have less experience as you, does not mean they cannot provide new prospective and improvement. Treat people like animal, expect they will act like animals. Great points. I love your line about the broken leg not being able to heal with just painkiller! That will stick with me in my career in the mental health field.
DeleteI think that Jessica DeArcangelis was very clear about how places like Methodist come to be when she stated “The staff are poorly trained, overworked, underpaid, and severely burnt out.” I also found her discussion about the doctors to be very interesting. The goal of inpatient services SHOULD be to offer the least restrictive services in the least amount of time possible for patients to stabilize then gain coping skills/access to outpatient services in order to return to the community. However, from the authors description it seemed when the doctors goal wasn’t about power, which it often was, it was about doing whatever was easiest for them rather than what was best for the patients. Although in theory an inpatient psychiatric unit would look much different than a prison, the description of Methodist proves that they are sometimes very similar EVEN in modern time. This kind of unethical treatment is not just something that happened hundreds of years ago. These unethical, demining and even violent “psychiatric care” practices, coupled with the general over use and forced medication/sedative regimens display very clearly that places like Methodist are not trauma informed, and therefore do not support the concept of mental illness resulting from trauma rather than a brain chemical imbalance. Otherwise they wouldn’t traumatize or re-traumatizing patients in their everyday practice and could understand that (“the same 5”) meds are not the magic fix for every situation. This type of treatment truly regards the consumer as less than human. If places like Methodist cannot treat people with basic human rights and decency, how can they claim to treat mental illness? Treating people with kindness, autonomy and empathy is this first step, and without that foundation one cannot effectively treat mental illness.
ReplyDelete
ReplyDeleteI think places like Methodist become possible due to systemic philosophical views that pervade the mental health and healthcare systems. A philosophy and worldview provides the lens through which a particular institution and powers of authority view their subjects. A Cartesian philosophy, for example, contends that mind and body are separated and should be treated as such. It contends that animals are irrational, whereas humans are rational. Therefore, anyone acting irrational should not be treated as a human but as an incapable animal. Anyone who is viewed as irrational clearly should not have a say in their treatment, because, after all, what could a “crazy” person possibly know about healing themselves? The values of a patriarchal society (dominance, competition, oppression) in which we live are further exemplified in this “father knows best” and “authority should be respected” approach to treating mental illness.
Additionally, the mental health field is dominated by a largely Eurocentric view that perpetuates the idea of a norm. Anything that does not align with this norm is deemed as wrong or as an enemy that must be extinguished or corrected. Seeing as these patients are displaying behaviors outside of what is considered normal or acceptable, their behaviors are treated as something that needs to be corrected or extinguished. The Cartesian idea that mind and body are separate as well as the idea of a norm that influences the medical model of treatment has led to unethical, weak medical practices that rely too heavily on prescribing medication as a panacea. Medical illness is being treated like a disease that can be extinguished with an antibiotic. It is being treated like an enemy that must be vanquished because it does not align with the norm. But mental illness is complex and requires more than a bandaid approach to instigate lasting healing. It is more than just a set of behaviors that need to be altered and vanquished. Medication may be effective in exterminating the origin of a virus or bacterial infection, but when it comes to mental illness medication treats the symptoms rather than the origin of the problem. Therefore, it can be expected that symptoms will continue to exist as long as the origin of the issue goes unhealed.
Places such as Methodist, ironically, tend to recreate the illnesses they purport to treat because of an ultimately flawed philosophical view of the human mind and body as well as the notion that treating mental illness requires a quick-fix of medication. Unfortunately, it just isn’t that simple.
I believe places like Methodist come to exist because of a few factors. The first being the insurance mindset where the hospitals goas are to prove the cheapest, quickest solution possible to get the patients who come in out as soon and as easily as possible. This ties into the medical model where someone who becomes paralyzed has the option to have a difficult procedure where a surgeon could perform an operation that costs $150,000 or provide someone with a wheelchair and physical therapy for $500. The insurance will always pay for the quickest and cheapest option to fix the problem. Same in the mental health field. We could utilize 12 sessions of psychotherapy and teach positive coping skills with hard work and intensive treatment or we can feel them a dosage of medication that shuts them up and gets them out of the hospital for the next person to come in. Second, would be the lack of planning when deinstitutionalization came to be. When asylums were shut down and all the patients released, and rightfully so, the plan was not in place to be prepared for the backlash that the community faced. Psychiatric hospitals just became a smaller version of jail for people who did not fit into societies mold. The article displays a jail like atmosphere where the patients are treated like prisoners if not worse than prisoners. And lastly, the sigma of mental illness still carries such a negative belief to this day. The people who become sick and hospitalized are still not thought of as equals. There were a few references in the article regarding talking in front of someone because “who cares” or “it doesn’t matter.” These are humans who are treated like animals if not worse and we expect them not to act like animals. They are locked up, with less rights, and inhumane treatment. I am not sure how I would act under these circumstances, but I would be wild I would think.
ReplyDeleteI would like to think the real goal of psychiatric hospitalization would be to stabilize the patient in crises, support them back to a baseline, and send them back into the community more prepared than before. I think after reading this, however, that this is not the norm. If you were to ask a worker from Methodist, they would say something like “shut them up and get them out.” I am not sure if there is a universal goal for all hospitals which may be a problem within itself.
By the sounds of the article, prison might be more enjoyable than this hospital. I think prisoners do not have people surrounding them and telling them what to do. There may be more socialization and outdoor time in prison. Prisoners are kept in jail because of the choice they made and a consequence for their actions, where as patient at this psychiatric unit did not necessarily do something wrong and they are still kept against their will. Prisoners are not sedated and can still think with an independent mind whereas the patients a sedated and left in isolation. Overall, there does not sound like there are many differences and I kept thinking it sounds like a prison while I read the article.
Giving people meds and leaving them to be is much easier than working hard at rehabilitation with someone who may be hard to work with. Like that lady said, “I am sick of being called a fat bitch” or getting injured by someone and the clients may be difficult to be around a tolerate and giving them a shot and having quietness is probably much easier. The problem is this is not a solution and it is not helpful. Then people are programmed to avoid the difficult work and go right for the easy solution every time. Before you know it, there is nothing but easy solutions being used all the time.
Yes, I believe this type of environment is traumatizing, threatening and harmful so these places are recreating the illness.