Saturday, February 21, 2015

Are There Ways To Lessen The Violation That People Feel After Psychiatric Hospitalizations?


In last week's New York Times there was an article with a rather interesting title: "Doctors Strive to do Less Harm by Inattentive Care" written by Gina Kolata.  The amazing idea here was that doctors should spend some time listening to their patients (~as an aside, I am so very glad I'm a psychiatrist/psychotherapist), and doctors should acknowledge that people in hospitals may be suffering, not just from their illnesses, but perhaps also from the insensitive treatment that has been inflicted on them such as 4 AM blood draws and unnecessary noise.  Kolata writes:


They found several categories. Communications — for example, a doctor blurting out, “Oh, it looks like you have cancer.” Or losing a valuable, like a wedding ring. Or loss of privacy — a doctor discussing a patient’s medical condition where an adjacent patient could hear.
“These are harms,” Dr. Sands said. “They elicit suffering. They can be long lasting, and they currently are largely unquantified, uncounted, unrecorded.”

So let me tell you why this article caught my attention, and how I'd like your help and input. Bear with me for a little bit here.

As our readers know, we're working on a book, Committed: The Battle Over Forced Psychiatric Care.  In my research on involuntary psychiatric care, and even on coerced care and some voluntary care, I've heard people talk about how traumatizing treatment can be.  Not everyone says this, not even most people, but some people are very sensitive and some care is very callous.  I'm finding that a little of the care is unnecessarily brutal, but this has really gotten so much better in recent years.  People are rarely restrained in your average psychiatric unit (I've been peeking in mostly empty seclusion rooms and asking lots of questions), because regulations restrict this.  But sometimes it really is still necessary; as much as we like to say that psychiatric patients aren't dangerous, some are.  Some kill people, and psychiatric hospitals are not necessarily the safest places to be.  In one forensic hospital in our state, in a one year period, three patients were killed by other patients.  In one community hospital, a patient poked out the eye of a nurse.  Staff are assaulted regularly, and even our own blogger ClinkShrink was punched in the head by a patient who had no prior contact with her and no reason to assault her as she was leaving the unit.  Clink was this patient's second assault victim of the day.

But let's move away from the extreme cases of violence.  Patients are traumatized by more benign things --- being asked to participate in activities that don't feel therapeutic when they are feeling miserable and depressed and would rather stay in bed.  Having nurses shine flashlights on them to tally their hours of sleep.  A lack a of privacy and a constant sense that they aren't trusted.  What? I can't have a belt on the unit?  I like my pants to stay up! Patients don't control the temperature of the rooms, the volume or programing of the TV, what foods they are fed, when they can exercise, when they simply take a walk outside, if they can have wine with dinner, a smoke after, and sex when the urge strikes with an appropriate love partner.  They may not know what the consequences might be for refusing to swallow a medication that makes them nervous to ingest, and there are circumstances where are injected with medications against their will.  They may find treatment to be very disrespectful and very demeaning.

Some of these things have no great answers.  The staff can't magically predict who is dangerous and there are sometimes concessions to comfort and human rights. Obviously everyone isn't held in restraints because of what they might do, and people are allowed to leave the unit and usually nothing bad happens --but believe me, everyone remembers when something really bad does happen.   

Many of the patients leave the hospital so much better.  Their depression has started to lift, their agitation is quelled, they aren't suicidal, they aren't terrified of delusional events that were never happening or hearing voices that aren't there.  They're sleeping and eating better and not so irritable or not so manic as to be uncontainable.  And yet, these so-much-better people, some of them feel so violated and so angry about what has transpired in the name of getting them help.  Maybe it's all a lack of insight, but I want to wonder if it's more than that, and this where I'd like your input.  As with the cancer patients Ms. Kolata wrote about, it's a field with so little research.  People are very different, and we simply don't know who gets distressed and what might mitigate that distress.

This is what I wonder.  Would it help to have an exit interview?  To listen to what of the treatment made patients suffer.  To listen, not to to throw in people's faces that it had to be done because they were embarrassingly out of control, but to acknowledge that the treatment was difficult, hard to endure at times, and to simply validate the distress the patient felt without the assignment of blame to either party?  

I'm going to go one step farther, please hang in here with me.  I recently spent a day with a wonderful mental health court judge.  If you know nothing about mental health court, the short version is that some people with psychiatric disorders are offered the opportunity to plead guilty and participate in mental health treatments, and if they do so successfully, they can avoid serving time in jail.  In some cases, their record can be cleared.  So these are people who have committed crimes, but the team is like a hospital team -- social workers, prosecutors, defenders, the most amazing of probation officers, and comprehensive services are put together to include drug treatment, clinic appointments, vocational rehab, housing, and weekly check-ins with the probation officer who talks to everyone from the patient's psychiatrist to the patient's mom.  It's the legal system taking over a medical role but the person at the head of the table is a judge and not an attending psychiatrist.  I'll tell you that I found it really weird.  And so you know, this is behind the scenes, it's not a public discussion.

Later, however, there is a quick public court hearing.  The defendants come to court once a month (or more) and if all is going well, the court has a celebratory feel.  There's a quick report and the judge congratulations the defendant on a job well done.  There may be applause, there may be certificates, the defendant is asked if he has anything he wants to add, and a subpoena is given for the next month.  These are criminals, and yet their successes (which are simply the lack of more failures and compliance with recommended treatments) are being celebrated and publicly acknowledged. Every few months, there's a graduation ceremony for those who finish the terms of their probation...food is served, families come, boyfriends and girlfriends come, photos are taken with the judges.  It's all good, people are happy and they've been given the opportunity to get treatment and turn their lives around.

So would it help when people left a psychiatric hospital feeling badly, violated perhaps, and certainly shamed because this is something we hear over and over even if the patient did nothing shameful at all, if we listened?  What if we acknowledged how difficult it can be to get treatment and participate in it, to let people know what a tremendous job they've done in getting through such a difficult time (even if it wasn't all graceful)?  Would it help to have a celebration when someone was discharged --even if just pizza or cake or something a little healthier, but to bring in family and print up a certificate to be read aloud and not make this all about shame?

Obviously it might be nice, but what I want to know is would there be a reasonable shot that this might mitigate the trauma of the hospitalization?  That it might lessen the sense of violation and reduce the idea that if an illness remitted and another hospitalization was needed, that it wouldn't necessarily be all that bad?  I'd love to hear what you think, and if I'm wrong about this, I'd love to know what you think might make for a easier re-adjustment with less dwelling on the injustice of it all?  And yes, this time, I'm more interested in hearing from patients who've been hospitalized.  Thank you so much.

63 comments:

Rachel said...

Hi Dinah, Clink & Roy,

I write this comment as someone who wears multiple hats - both an individual with lived experience of mental illness, and someone who works within the mental health world providing peer support to others experiencing challenges and wishing to move forward in life.

I have had a fair number of hospitalizations over the years, and they have spanned across the spectrum of useful, useless and in between.

My best experiences have been the ones where the staff psychiatrist, his resident(s) and the nursing staff have taken on a partnering role, and have empowered me to use the time while as an inpatient to think through different aspects of my life while dealing with meds and symptoms. In those experiences, the staff were open to feedback about what was working, and what was not, and were open to making changes.
Granted, in these best case scenarios, safety remained the #1 issue, but my safety was considered along a spectrum. I will also add that I have typically presented as someone who is much more dangerous to myself than I have, or most likely will ever be, dangerous to others, and I'm sure that fact was taken into account as well.

My worst hospitalization experience was more recent, and though there were many things that were wrong with the entire affair, it could be boiled down to a physician who was very obviously not enthused or interested in his work, and displayed this in his interactions with me, the patient, his resident and the nursing staff. I'll also note, this happened in the same setting as the aforementioned very positive hospitalization, and so there were many constants across both experiences in terms of nursing and peripheral staff, physical setting, policies, etc.

I currently advise senior residents at a large teaching institution about how they can incorporate principles of recovery-orientation and wellness into their practices.
Language makes a huge difference, as does a practitioner's attitude about their patient's outcome. If one believes that even in the most dire of circumstances, there is hope for a patient, call it placebo effect or expectancy effect, the chances of a better outcome are higher. Professional hopelessness about one's situation translates to learned helplessness which is rampant in inpatient psychiatric settings.

Physicians, particularly those who have been in practice for many years, need to remain hopeful about the possibility of good outcomes. What a good outcome could be must be contextualized individually and cannot be generalized. That being said, within my work, I continue to hold hope that the individuals I work with and support can continue to grow and move forward in their lives even while experiencing severe and intractable mental illness.

The physicians who have been the most helpful in my life have been excellent physicians. But more than that, what they have done goes beyond the scope of psychopharmaceutical or psychotherapeutic care; what they did was continue to see me as someone bigger than the sum of my symptoms, and over time I began to see myself in that vein as well.

Practically speaking, I think it's important that individuals have an opportunity to provide feedback to facilities and practitioners about their care. Aftercare and discharge planning is crucial for individuals to feel like there is continued support after an inpatient stay where there is 24/7 staff availability and support.

Happy to have further conversations about this with you further, Dinah.

Anonymous said...

I'd like to write a longer response, but I don't have the time right now. I just wanted to say how wonderful your ideas are: an exit interview and discharge as a celebration.
Brilliant!
When are these changes going to be established internationally?
BecB

Anonymous said...

I have not been hospitalized, but I have worked on a unit at a state hospital.

The nurses are not psychologically trained or psychologically-minded people, and they were able to do a lot of harm.

I felt so bad for the non-violent, shy, with-it patients. Even being around those other patients--and the stench of the ones who refused to bathe could be strong--had to have been awful.

There were some very good staff too, so it wasn't terrible, but it was really about protecting people from hurting themselves rather than actively therapeutic.

But these were hospitalizations of at least 3 months, of people who had already failed a hospitalization at an acute care hospital.

Unknown said...

Thank you for trying to grapple with these difficult questions. As a 15 year patient advocate and someone who's been hospitalized numerous times myself, I have some thoughts.

Any kind of involuntary care is inherently traumatizing to the person. While it's noble to try to mitigate the trauma of forced treatment, we need to do better.

Part of what you describe is due to the nature of hospitals themselves. They tend to be understaffed. Also, staff are generally not well trained in de-escalation techniques to soothe a person in distress, or they may not have time to use them due to the demands of their job caused by understaffing.

Given the nature of many of psychiatric hospitals, it would be good for us all to focus on diverting as many people as possible. We need more places like the Living Room or peer run crisis respites as an alternative to the hospital for those who would desire an alternative.

Not sure if you're aware of the literature of trauma informed care. TIC approaches have been developed over the last 20 years with continuous input by patients. Hospitals have used them to reduce and eliminate the need for S&R and chemical restraint. But TIC is not just about how to reduce these most damaging interventions. It is about how to create treatment environments and cultures that do not re-traumatize people. SAMHSA has a guidebook that's a good introduction. http://store.samhsa.gov/shin/content//SMA14-4884/SMA14-4884.pdf

Here's another introductory piece. http://store.samhsa.gov/shin/content/SMA14-4816/SMA14-4816.pdf

As to your specific question. I like the idea of an exit interview...but will the hospital use the feedback for quality improvement purposes? Otherwise it seems like a waste of everyone's time. Equally important is to ensure that the person has good follow up care after discharge, which strangely tends to fall through the cracks all too often.

A pizza and cake "celebration" idea is more complex. It could be perceived as forced or infantilizing if it becomes a standard thing done every time someone is discharged. Leaving the hospital can be a scary time. People are at high risk of suicide after a hospitalization. I think having some kind of gathering with the person's friends and family, to honor the person's strength and courage, and to send them off with continued wishes for recovery (and actual connections to peer support), would be nice. But only if the person wants it. :)

Sean Erreger said...

I agree with the comments on trauma. As a provider (social worker),Trauma Informed Care(TIC)should start even before the consumer walks through the door. I used to think that inpatient and ER visits were the "norm". I think we get lulled into a false sense of just how complex this process is. A good place to start is acknowledge that anyone who walks into an inpatient unit is experiencing a trauma (let along the other potential traumas that brought them into care). Once that tone is set by leadership, treatment teams and frontline staff will follow. This will hopefully permeate the rest of the care experience.

Jen said...

My immediate response is NO to an exit interview because it would be inescapably not-anonymous. I have had one positive-ish hospitalization, and one extremely negative hospitalization (both voluntary for severe suicidality (depression) I have a PhD, a job, a family, a home, etc. I am not violent, have never been psychotic, work hard with my treatment team. My biggest problem in care is that I have a hard time talking to new people and am treatment resistant to most meds.) After both hospitalizations, I was terrified that I would come back again as a patient. During both stays, I saw competent and even helpful phsyicians, nurses, techs, etc, but I also saw damaging, hurtful, HIPAA-violating, humanity-violiating physicians, nurses, techs, etc. I would not participate honestly in an exit interview because I would be too afraid that my words would come back on me, and future care would be (even more) compromised.

I completed the anonymous press-ganey surveys, and I named names and gave specific and clear examples of both good and bad treatment I received. One example included the treating psychiatrist I assigned who was a bully - cut me off any time I opened my mouth, and did the same to family and friends, accused me of all kinds of things, did not take my concerns into account, etc. I later heard from a therapist who works with her that she had received a lot of similar feedback and had taken it on herself to get additional supervision and change some traits. I thought that was great, and hope my surveys played a role in that. But again, they were anonymous. After I was discharged, I also made it a point to write thank you cards to the head of the unit naming the individuals who gave good care as well as to the individual treaters (psychiatrists, psychologist, social worker, nurses, techs) themselves who were fantastic, or even those who did 1 or 2 things that helped me in moments. Research shows us that reinforcement is stronger then punishment and if these largely unappreciated workers are getting at least a bit of appreciation and positive feedback, hopefully they will carry on with their ways and pay it forward.....

That said, I was discharged from my terrible hospitalization (from the #2 psych hospital in the country at the time) without a discharge plan--and then no private practice doc would take me post-a-hospitalization-for-suicidality. So I was just out of the hospital and could not access any treatment. Talk about traumatizing, and incredibly dangerous. My insurance contacted me and let me know that was illegal, and proceeded to file a formal complaint. I sincerely hope that made a difference for later patients, and it's too bad that one of the only things that can is threats from huge insurance companies.

Jen said...

Also, I really don't love the idea of a celebration at discharge.

Several reasons: 1)some patients may genuinely feel that they aren't better, and making a celebration of it is adding pressure. Immediately following discharge is the highest risk of suicide...don't add more pressure to be okay, to celebrate health, progress, improvement, etc, to that. While many patients are discharged feeling better, many patients don't feel better, or feel slightly more stabilized, but nowhere near better.
2)Many patients may not WANT to celebrate with family or friends. Perhaps family and friends aren't involved in the treatment or aren't supportive. Perhaps family and friends don't even know what's going on. Perhaps the patient is not publicly "out" about their mental health.
3)I would have personally felt patronized and mocked by staff if a celebration was held - the same staff who made my stay very difficult and treated me as an incompetent and non-functional individual (I have a PhD, family, home, job, good ability to communicate, good support system, no history of violence or psychosis, ability to pay for treatment and no difficulty in treatment other then TRD). Or the staff who publicly shared confidential information in an extremely judgmental manner during visitation hours in the hearing of both patients and visitors. ("patient X is deliberately lying about x y and z so that he can x y and z. I hate having to deal with him." Another day heard in the public area: "patient X is just a b*tch." Identifying details removed.;) Or the staff who were so removed that they were publicly masturbating while they were on duty at the door to the unit. (Yup, I reported that one.) I wouldn't want any of them "celebrating" anything about me. They didn't respect me as a person, I didn't respect them as a professional, let's leave it the way it is and not pretend.
4)Perhaps the patient doesn't want to celebrate with other patients. In one voluntary hospitalization for severe depression, I was inexplicably placed in a ward with mostly people suffering from severe personality disorders including many (7!) who were waiting hearings to be remanded to jail, some for violent offenses. I wouldn't want them knowing anything about me and certainly don't want to be forced to celebrate with them.
5)How will the treating physicians possibly find the time to come to them? My strongest relationships were with my treating psychiatrist and social worker, both overworked and overbooked. If they weren't able to come to this "celebration," I'd have been crushed.
6)Who will bear the cost of these parties?
7)And to point out the obvious - if you have celebrations for some and not for others - ie only those who want - you're tossing in a slew of pressure and potential psychological issues into the mix.

(Please bear in mind these experiences were all from the #2 psych department/university hospital in the country, so I really hesitate to think that these experiences aren't just as common - or worse - throughout the country.)

Overall, a celebration is a nice thought, but it's from a very staff-oriented and simplistic perspective. It's not taking into account patient perspective at all.

Jen said...

As far as what made it easier for me to leave feeling somewhat whole: When I was discharged from my positive hospitalization, each member of my treatment team (psychiatrist, resident, psychologist, social worker) met with me individually and over the course of the conversation, made sure to list the reasons she thought I would be okay. I really remembered (to this day) the things they said and have held them close to my heart over the years during difficult times.

I think one thing that would be helpful would be to know that a patient could contact their treatment team again if s/he needed a referral (theirs didn't work out, but I was too scared of protocol to call these treaters back for another referral). Alternatively, making sure each patient has several referral options when they are discharged would be a good start.
Okay, I'm done now.

Anonymous said...

Dinah,

I am curious why there aren't similar type efforts to reform psych hospitals similar what was mentioned in the NY Times article regarding "regular" hospitals. It seems that would do alot more to make psych hospitals less traumatic than any of the suggestions you mentioned in your blog entry.

And by the way, I disagree that getting a flashlight shined in your eye is a benign concern. Surely, as a psychiatrist you understand that many people folks with MI have difficulty with sleep and the least little intrusion can wake them up, particularly in trying to sleep in a psych hospital which doesn't do much to improve mental health. It just seems like there is a better way to measure sleep than shine a flashlight in someone's face.

Agnes said...

Since in many hospitals, MI is still very stigmatized as are patients, I would not want an exit interview done. I'd feel as though it were a sham process. Reform first. Treat patients as people coping with a diagnosis or maybe just human difficulties and not as walking diseases.That means NO flashlights in your face at night; they are not used to log sleep since by their nature they wake you. They are used to make sure you have not escaped, are not in bed with your roommate or smoking a cigar. So, they are a symbol of control and a reminder that as a patient, you have none. There is no legitimate reason for their use.
Also, as you know, the majority of people have very short term psych stays and are discharged quickly, often too quickly. They leave feeling very shaky emotionally and dealing with new side effects in many cases. This is a lousy time for an exit interview.

I would certainly not be in favor of a celebration. When you have just been released, all you want to do is go home and die, if you have a home, that is. Families are often in shambles or at least reeling from your latest hospitalization and it is the rare family that is in the mood to come to your party. More like a silent drive home and months spent tiptoeing around one another.
Not everything is traumatizing about the hospital. It does not have to be if docs and nurses and others treat the patient as they would like to be treated. Yes, a violent patient will need to be dealt with to make sure no one is harmed but I have seen people tied down for looking at a doc the wrong way and I have heard some incredibly disrespectful words from nurses in situation is which the patient did nothing to provoke.
I agree with Unknown. Change the system because it is really broken. I don't want parties and interviews within the present system.

Anonymous said...

Back to the nonsense.

As somebody who has suffered only one involuntary psychiatric incarceration -it happened several years back- I have only this to say: I rather die than go through that again.

I refuse to call my experience "hospitalization"; the treatment that I received was worse than what we reserve for animals or criminals.

For reasons that are too long to explain, I have been able to be off psychiatry's radar as a productive member of society. This has been the case for many years now and I pray the Lord that He keeps me free from psychiatric oppression.

Involuntary psychiatry is the only form of institutionalized civil rights abuse that remains in the books today. The question should not be how we make the abuse nicer but rather how we make it go away completely.

Dinah said...

Rachel: Thanks for your input. There will always be good and bad clinicians. Sometimes it's so individual -- I know docs I wouldn't let treat my turtle who have patients that swear they are the best. (0kay, I don't have a turtle, but if I did). Sometimes it's so hard to fill a job that someone who is suboptimal stays because there is no one to replace them. Just not good, what can I say, we need to try harder.

Hope is absolutely essential, and since shrinks don't have crystal balls and the courses of illness vary, unless the patient is dead, we need to stay hopeful.

BecB: Thanks!

Unknown: I agree, hospitals need more staffing, people should not be placed in seclusion when they could simply be watched.

I have a problem with "trauma informed care." I think everyone should be treated as gently and respectfully as possible (while keeping everyone safe) and that should apply whether or not someone has been a trauma victim. Let's just pretend everyone was traumatized in some way. And hospitals do use seclusion and restraint so much less then they used to. Agreed, there is room for improvement, but do be aware that as the use of S&R has gone down, injuries to staff and patients have gone up in some settings (and down in others). No easy answers here.

"Exit interview" may be too strong, but maybe a conversation of what was most helpful to you, what was most difficult, and an acknowledgement that being in a psych hospital is by definition a terribly difficult time in someone's life. We all go through rough times, and it would be nice if we could suggest that the patient survived a rough period and did hard work to get themselves to a better place. It would be good to avoid blame on either end, to help the patient process a difficult experience in a way that might minimize any shame, and give the patient a chance to be heard, whether or not complaints were something that could be immediately fixed.

Obviously, a celebration should not be a large forced event. But maybe just asking if the patient would like to invite family or friends (or others on the unit if desired) to share some cake or pizza, and a few words to acknowledge the patient's hard work and progress, but only if the patient wanted this, and only to share with desired people. It does seem to be a popular event for mental health court so I was just thinking....attendance is certainly not mandatory.

Jen-- I hear you, we need better, more comprehensive discharge plans with no room for falling through the cracks.

Again I've learned: everyone is different.

Joel Hassman, MD said...

"mitigate the trauma of hospitalization"? Why, or equally how? With the way mental health has morphed into these past 10 or more years per inpatient care, where is an inherent pervasive "good" or efficacy these days? Better living through chemistry as I have seen sold doesn't significantly lessen the psychosocial stressors that often play a role in the admission in the first place.

Pts duration of stays in private or short term care facilities are woefully short now, at best 5-7 days on average, they are given "cocktails" of polypharmacy, the better word to me is "shotgun" of giving an antidepressant, antimanic, antipsychotic and anxiolytic all simultaneously to hope one or more will have an impact by those 5-7 days, and what responsible and effective psychiatrist can see 15 or more people on a unit daily and have an impact to then "celebrate" a discharge?

You want to start a real honest, candid conversation about lessening the trauma of hospitalization for mental illness? Here is what 20 years of working CMHC work and receiving these patients can offer as ideas, if interested:

1. Give patients at least 2 weeks of medications so they won't have to scramble for finding a psychiatric follow up and add to their panic upon leaving the hospital. Oh, and write a schedule of use for the real world, not based on 24 hour nursing that ensures this alleged TID to QID med use no one on earth can maintain on their own.
2. Don't tell patients, especially those who are beginning psychiatric care from this hospitalization, they are disabled and need to pursue disability, wow, what a message for someone looking for hope and return to function.
3. Give discharge paperwork that says something coherent and instructive not only for the patient, but follow up clinicians, as we all know discharge summaries won't be available for weeks more often than not, and maybe lucky such summaries that get to outpatient providers offer something of substance to really relate what the inpatient experience offered for a diagnostic impression and onset of care interventions.
4. Finally, let's have a moment of brutal candor, what is the most likely reason for involuntary admission until proven otherwise? Noncompliance with multiple facets of less than responsible choice, be it prior care needs, refusal to accept reasonable and fair limits by those dealing with said patient in the community, lack of tolerance to consider sobriety if coexisting substance abuse is occurring, and, accepting a biopsychosocial model to illness.

I could be wrong in the above opinion, but, I think 20 years of getting patients referred to me from inpatient stays shows the above patterns to being more prevalent and acceptable to too many peers in my profession.

People don't want a cake and a song, they want to simply hear something like this:

"Mr/Mrs 'X', I think you have really made some progress and I think if you seek out the discharge recommendations for follow up, you will hopefully make this a one time experience. These last days got you on your feet, I hope you walk the path and find a happy, healthy direction for hope and faith."

Yeah, that might lessen the violation that people feel after psychiatric hospitalizations.

Agnes said...

Cake and pizza to go with your Risperidone or Zyprexa or Seroquel?

Then again, hospitals do not serve healthy food. No wonder so many people die in them.

Again, just the idea of cake and pizza sounds so infantilizing. Sure, who doesn't like a slice now and then, but it's not your kid's fourth birthday party.

Dinah said...

I love cake and pizza. Mental health court serves fried chicken. I don't think the food matters, just that it should be something people like. I get that Agnes would vote No and we should all respect that. Might someone else find it helpful? Validating? Reparative? Healing? Some way of making what might have been an awful experience marked by psychosis/depression/suicidality/ and psychic pain into something that ends with just a hint that we're acknowledging that healing has happened and will continue to happen?

Joel, I actually agree with some of what you said. But if it troubles you that people are sent out the door way to quickly on haphazard pharmaceutical cocktails, then why does it trouble you that they might not continue to take them as prescribed? Most hospitalizations are about "non-compliance" whether it's with meds (cardiac patients are no more likely to take their meds either), avoidance of substances, exercise, lifestyle issues, speeding, wearing seatbelts, walking on ice when they shouldn't be. In fact, most people end up sick and in hospitals because they are imperfect humans. If you're better than that, bless you. I try, but I hold no claim to living the perfect life. Let's have a little mercy on our fellow humans and their failings.

Jen said...

I'll be honest - Dinah, when you talk about mitigating the violation people feel after psychiatric hospitalization with pizza and cake, I'm just getting more and more that you don't actually have any idea exactly how traumatizing inpatient psychiatric hospitalization actually is.

Joel Hassman, MD said...

"In fact, most people end up sick and in hospitals because they are imperfect humans. If you're better than that, bless you."

Uh, we are all imperfect humans, me included. God knows I cannot make a difference with the way mental health care has eroded to these past 10 or more years, so if I was perfect, I could navigate that hideous maze of intrusions, micromanagement, and disruptions and get pts the care they need, at least as a start.

Frankly, I would prefer a candid reply of saying "Your way isn't the only way", which would be true, but, my way is not some exotic esoteric and extravagant effort at interventions. No, I strive for standards of care, and that isn't going on in most inpatient settings anymore, thanks to managed care, politicians, and clinicians who's idea of advocacy is such a pin hole appraisal of the patient, even a medication molecule would barely fit through that hole!

Staff by in large don't make the time for the biopsychosocial eval anymore. They claim they do, but, even the patient won't embrace that ideology because it really isn't explained nor applied to the hospitalization. Oh, and when the admission is based on an involuntary premise, adversarial and punitive measures are not congruent with alliance and insight.

Sorry to all those dynamic oriented mentors out there who want to dance and tease out the defenses brought by the patient. Life is too short to negotiate with denial, minimization, deflection, and frank rationalization that has been an abject failure that led to the admission in the first place.

Besides, to all in these threads at this blog who bloviate so bitterly how unfair it is to be involuntarily hospitalized, well, I guess you just think the alternatives of incarceration or burial are reasonable and fair, eh? Well, again, a little brutal candor, people involuntarily admitted aren't winning realistic and fair allies out there in the community to champion such patients should be left alone to continue the status quo of behaviors, actions, and goals, thus forcing the short term loss of independence and autonomy.

Keep dancing around that measurable percentage of patients involuntarily admitted who have one of the following of primarily Axis 2/addiction/ hostile psychosis as the root to the admission. Fascinating those groups are often the least likely to respond to meds, thus why the hospitalization is so prolonged.

Hey, as always said, just my opinion, and I guess now to include just my imperfect opinion.

Agnes said...

Jen, You hit the nail on the head. That is what I feel and what I should have said. It really feels to me that this seemed like a good book opportunity, not that D has really hasn't perhaps TRIED to maybe attempt to imagine what it might be like, and not that she has not had trauma in her life, but no, she does not come across as understanding or to put it better being able to show that she has true empathy for what a full on involuntary psych hospitalization can be like, and of course, some people say it was just dandy.

Anonymous said...

Joel,

"Besides, to all in these threads at this blog who bloviate so bitterly how unfair it is to be involuntarily hospitalized, well, I guess you just think the alternatives of incarceration or burial are reasonable and fair, eh? Well, again, a little brutal candor, people involuntarily admitted aren't winning realistic and fair allies out there in the community to champion such patients should be left alone to continue the status quo of behaviors, actions, and goals, thus forcing the short term loss of independence and autonomy"

As the Anon that made the comment "rather dead than suffer another psychiatric incarceration", I will put the issue to you -and to Dinah and every single psychiatrist who defends the brutality of involuntary psychiatric incarcerations- differently. You should give it a try and tell us how it feels. And please, spare me of one of your speeches "I am not antisocial therefore that would never happen to me". That's a distraction. I am saying, if you truly want to know why I said what I said, you should try being involuntarily incarcerated for psychiatric reasons, then share your experience.

I know psychiatric survivors who defend involunary psychiatric incarceration. I respect their opinion -although I don't share it- because at least they can claim first knowledge experience being at the receiving end of one such incident. I still don't get why they want to impose their opinion on survivors like me who unequivocally reject involuntary psychiatric incarceration for ourselves. Do you want to be involuntary incarcerated next time a shrink thinks you should be, fine. Don't force me to agree to the same thing.


First knowledge experience as incarcerator makes as much sense as saying that a prison officer knows what's like to be incarcerated despite being innocent because he works with prisoners all day long.

Psychiatric incarcerations outside of the criminal justice system is for people who have not committed any crimes. From my point of view, those who defend the practice are seriously disturbed individuals mentally speaking. Which is not surprising since every single psychiatrist that I met during my own incarceration was nutty.

Dinah said...

So, I'm thinking about this and having acknowledged that there are people who feel very distressed, violated, and even traumatized after psychiatric hospitalizations, I noted that it seems less so with mental health court where criminals are turned into celebrants for succeeding with treatment, and I wondered if there are things that might help people feel less violated. By an "exit interview" -- I really meant giving people the option to be heard and acknowledged about the violation they felt, and by pizza or chicken or whatever, to borrow the idea of acknowledging that the process was terribly difficult and that someone who has gone through it and started to get better might like their hard work noted/celebrated (---or not, these were ideas to throw out, not mandates, graduates don't have to go to the mental health court graduation celebrations and people are always free to say 'I don't want to talk to you about how awful this was."

So I'm throwing out ideas in a way that acknowledges patient distress -- something I think many psychiatrists are not even aware of or may be sometimes dismissive about. And what I'm told is that since I have presumably have never been involuntarily hospitalized, I'm incapable of empathy here (I admit, that may well be true). So no one who hasn't been in those shoes should even try to ask what may help, or throw out ideas or suggestions? I find that insulting.

And I don't believe I have ever defended brutality. My stance has clearly been to oppose involuntary treatment except as a last resort, that all treatment should be as kind and gentle as possible, but the sad truth is that there are some people who get so out of control (because of psychosis, not simply because of insensitive mental health professionals escalating them). What about the nurse at a nearby hospital who had her eye poked out by a patient? What about the 3 patients in a psychiatric hospital in our state who were killed by other patients on their unit (one of whom had already killed his outpatient psychiatrist)?
I believe that involuntary treatments are overused and that there are ways of avoiding many and of de-escalating many situations, but I also know that there are patients who get so sick they do things like kill people they don't know for delusional reasons, or are at risk of killing themselves (for any number of reasons) and that perhaps holding them in a safe environment for a bit may some people safer.

Joel, mostly I agree with you. And I think it's a good point that people should work on ways to keep themselves out of the hospital if they find it traumatizing (some times people want to go...), but I don't see the world as neatly dividing into compliant AXisI patients vs substance abusers/personality disordered pts/criminals. People have problems, they get intermixed, no one wants an addiction or a difficult personality.

So I'm happy to hear other suggestions for how to lessen the violation that people feel, but if the response is going to be "this didn't happen to you, you can't empathize," then why should anyone bother to try to fix a broken system?

Anonymous said...


And what I'm told is that since I have presumably have never been involuntarily hospitalized, I'm incapable of empathy here (I admit, that may well be true). So no one who hasn't been in those shoes should even try to ask what may help, or throw out ideas or suggestions? I find that insulting.


Insulting as it might be, it's the truth. Nobody said that the truth had to be pretty.


And I don't believe I have ever defended brutality. My stance has clearly been to oppose involuntary treatment except as a last resort, that all treatment should be as kind and gentle as possible, but the sad truth is that there are some people who get so out of control (because of psychosis, not simply because of insensitive mental health professionals escalating them). What about the nurse at a nearby hospital who had her eye poked out by a patient? What about the 3 patients in a psychiatric hospital in our state who were killed by other patients on their unit (one of whom had already killed his outpatient psychiatrist)?
I believe that involuntary treatments are overused and that there are ways of avoiding many and of de-escalating many situations, but I also know that there are patients who get so sick they do things like kill people they don't know for delusional reasons, or are at risk of killing themselves (for any number of reasons) and that perhaps holding them in a safe environment for a bit may some people safer.


What you describe to justify involuntary incarceration for psychiatric reasons is clearly criminal activity. So I am all for treating criminals as criminals (I am also in favor of the death penalty for the case of the guy who killed three other people). I do not believe in the concept of "insanity defense"; the outcome of the American sniper trial makes me believe that most Americans don't either.

I am also in favor of the right to commit suicide for any reason, even for people who might later regret the decision. Not because I am heartless, but because our society is fairer when psychiatry has no power over these things than when psychitry has power, even if that power is presented, as your are doing now, as "tiny".

Psychiatry has historically used any legal openings to commit brutal abuses. From my point of view, all involuntary incarcerations for psychaitric reasons on non criminal defendants are exercises of brutality.

Dinah said...

Anon:
This is the wrong blog for you. There are many where you'd be more comfortable, MindFreedom,CCHR, MadInAmerica. Just to begin to name a few. You may want to start your own.

Dinah said...

Joel:
I have an email from you that should be a posted comment. You said that I deleted a comment you wrote on 2/27, but I have not been moderating comments and have not deleted anything from this post. I looked in my email and the trash and can't find your comment from 2/27. Also, the comment where you complained that I had censured you did come to my blog email notification, but as of yet, it does not seem to have posted to the comments.
A blogger glitch?
Not something personal. Maybe google thinks you're a robot?
Dinah

Dinah said...

Posting for Joel.

Joel Hassman, MD has left a new comment on your post "Are There Ways To Lessen The Violation That People...":

And yet, Dinah, you struck my rebuttal comment to Anonymous February 27th from the thread, so, sorry to say, as I am in your "living room", but, censorship has its cost. Thus, your blog and your editorialship choices, but, I have the right to rebuke people who lump all psychiatrists into one appraisal. You chose to delete it, so I respectfully say as my last comment here both now and hereon, I think most of the commenters here know exactly what they are doing, so "protecting" them from my opinion isn't serving an alleged intention of dialogue at the end of the day.

Thank you for the previous times allowed to comment, hope your book benefits the majority of readers and people in need of psychiatric care.

Any one interested in reading at my blog later tonight or tomorrow, I will try to replicate my previous comment to Anonymous as accurately as I wrote it yesterday, unless Dinah wants to be kind enough to forward it to me via a comment to my site. I will then copy and paste it to use as the basis of the post, thus protecting emails or other identifying information.

In conclusion, I do not think this dialogue is genuine or sincere by all parties. That was my point yesterday.

Just my imperfect opinion.

Sincerely,
Joel Hassman, MD

Anonymous said...

Dinah,

I hope you realize that with your invitation that I stop commenting in this blog -after you were unable to provide a coherent answer to my point that you have no bragging rights to empathy on this issue as long as you haven't suffered the experience yourself- you made my point.

You have a dogmatic belief, which is, that incarcerating somebody else -not yourself- who has committed no crimes because you, or somebody who is a psychiatrist, says so (aka "involuntary psychiatric incarceration") is all fine and anybody who challenges that dogma is unwelcome here.

As I said, every single psychiatrist that I met during my own experience was nutty.

PS: I regularly visit those blogs. You are wrong in stating that they are similar. The approach of Mad In America, MindFreedom and CCHR could not be more different (and their reasons for confronting psychiatry too).

Joel Hassman, MD said...

After I posted it around 730ish last night, it did register as the 20th comment and I reread it just to make sure the post was accurate, as I always do when I make comments on a thread.

So, I am glad you did not delete it intentionally, but, it was there last night briefly. Oh well...

Anonymous said...

hey dinah-- hope you are doing well, and glad you are considering how to make care less traumatic. i don't think the celebration idea is a good one for short term stays so often in use today.... for instance, people come in post overdose, stay three days, then have some cake and go home? it feels kind of trite. the exit interview could be helpful as long as it didn't take the place of anonymous options to provide feedback, but i think hospitals already do a lot of surveying to no benefit...... in my opinion, there are several areas that need work. the clinicians need both empathy and boundaries. in addition, whenever possible, client autonomy should be respected. patients are adults and should have as many rights as possible without ridiculous risk to themselves and others. for instance, at one hospital, i had to ask to get hygiene items, and was only able to use them at certain times. i hated that.... maybe it would be dangerous to enable me to access my own shampoo or conditioner, but honestly, it felt so childish and degrading to have to ask for soap at the front desk. at one point, after an "exercise group" i was refused my hygiene items to freshen up as it wasn't hygiene time.... seriously? i don't think patients should have to share rooms as this can be unsafe. i do think patients should have better access to phones/computers/etc. patients should be able to awaken and sleep as they see fit, as adults should, though may be encouraged to maintain healthy patterns.... working with families more. providing greater food choice/nutrition education.... "groups" should be more positive/helpful/able to be implemented. for instance, i never had a "how to find a psychiatrist who accepts your insurance/has a sliding scale" group, lol. oh and don't even get me started on discharge planning..... that was a nightmare that almost killed me. there is so much more to say, but i hate typing while nursing. in short, yes there are ways to make care less traumatic. let me know if you want more info :-).

liz

Dinah said...

The time helped, I found it in my trash on my cell phone but not on my computer. How can that be?
Posting for Joel:

>
> Joel Hassman, MD has left a new comment on your post "Are There Ways To Lessen The Violation That People...":
>
> To above Anonymous:
>
> Let's not be disingenuous or dishonest here, while there is a 5-10% of the involuntary admitted population who are unjustly/unfairly admitted and retained, that other 90% plus who are forced into inpatient care do not show the insight and judgment to avoid the situation in the first place. And, I think you know that to some degree, maybe your situation was that 5-10% scenario, but you then unrealistically try to apply your experience to the rest, and that is just disingenuous or dishonest if I am on the mark.
>
> And, while there is a percentage of psychiatrists working inpatient units who don't problem solve nor approach patient care in an individual basis, that is not all of us, again, lumping one physician with poor judgment as an indictment of all of us is, disingenuous and dishonest.
>
> Plus, this direct analogy that hospitalization is completely equivalent to incarceration is just lame. If you have been incarcerated, you cannot honestly and sincerely tell us all that an inpatient environment is just like a jail or prison. Have worked both, and while there are limits and strong boundaries on a psych unit, it is not a jail per physical space and access to the outside world per calls and visitors. So, yes, there are restrictions and loss of independence, but it is not determined by a judge alone and you are not behind bars every single night.
>
> That said, with psychiatry allowing more forensic overlap on psychiatric units, well, you have a population experience that has unfortunate similarities with jails, but, as long as psychiatry has no real clue to advocate for separate systems for forensic care, then you can thank politicians and ignorant, complicit physicians for setting up a system to fail as it is now. And direct that criticism to them, not to psychiatry in general!
>
> So, you can frame us, who try to explain the system has it's reasonable and fair purpose to involuntary care, as "seriously disturbed individuals mentally speaking", but, be ready I will reply back that those like you villainizing us as just evil and unjust people are at least rigid and inflexible in seeing life issues as gray.
>
> Do you honestly think I like seeing people be forced into treatment options? No, I hate it, but, I also have a realistic appraisal that returning the patient to the status quo is only going to risk more morbidity and mortality for said patient.
>
> Micheal Faumon, my outpatient supervisor in residency, was right, everyone thinks they are a psychiatrist until the proverbial stool hits the fan when poor judgment and lack of realistic appraisal of situations plays out with the uninformed and well intended but poorly trained "clinicians" trying to direct care. The road to hell is paved with good intentions.
>
> You want us to walk in your shoes and be involuntarily hospitalized, why don't you seek out a way to be a psychiatrist for a few days or week and see what is on our shoulders?! Easy to be critical, but not so easy to take responsibility for other peoples' lives, eh?
>
> And I think a lot who comment here need to gain some insight to step back and honestly assess are you really doing the best job to be managing your own lives to avoid risks to be involuntarily committed. Dinah won't say that, but, I will!
>
>
>
> Posted by Joel Hassman, MD to Shrink Rap at February 27, 2015

Dinah said...

I think we need to be careful to say "this wouldn't be helpful to me," or even to most people, but not to say something should never be offered to anyone, because we learn by trial and error.

Liz: Thank you so much, I can appreciate that you wouldn't want pizza or another survey, and that you would want shampoo and conditioner. But what I really appreciate is the idea of giving examples of what you troubled you -- It does seem like unless their is something really weird going on then people should have unlimited access to soap and conditioner, and I'm with you all the way on single rooms. The idea of sleeping in the same room with a stranger creeps me out and I've never understood why any hospital setting would subject sick people to each other's germs/loud guests/snoring/television volume issues or general invasion of privacy. Money I suppose.

Joel Hassman, MD said...

Thanks for finding and posting that comment from yesterday. Still done at this thread and most likely the blog, again wish you well in your mission.

Joel H

Anonymous said...

Mr Hassman,

Sure, let's not be disingenuous.

The reasoning,


while there is a 5-10% of the involuntary admitted population who are unjustly/unfairly admitted and retained, that other 90% plus who are forced into inpatient care do not show the insight and judgment to avoid the situation in the first place. And, I think you know that to some degree, maybe your situation was that 5-10% scenario, but you then unrealistically try to apply your experience to the rest, and that is just disingenuous or dishonest if I am on the mark.


Is typical among those who have justified other civil rights abuses in the past, from slavery (most blacks are unable to survive outside the plantation you know), to women (most women are later thankful to have been forced into their first sexual experience as a rite of passage), to gays (most gays were thankful to have been forced into conversion therapy since that improved their lives), etc.

When it comes to violations of civil liberties, analyses like the above are irrelevant by definition. Somebody's retrospective validation of the abuse he/she suffered has no bearing on whether the practice constitutes abuse or whether it should be legal in the first place. In fact, the sole reason the US Supreme Court allows for involuntary psychiatric incarceration is "danger", ie, it has not considered the "retrospective validation" argument as valid from a legal point of view. In fact, in all case law regarding involuntary psychitric incarcerations, the US Supreme Court has repeatedly stated that said interventions do violate civil rights -the right to personal liberty to be more precise-, only that they are allowed in narrow circumstances to meet what is loosely defined as a "compelling government interest". Needless to say psychiatrists have sought to expand the use involuntary interventions with the sole goal of justifying their own livelihoods.

So let's be candid. The only reason every single psychiatrist that I know justifies involuntary psychiatric incarcerations is because their existence goes hand in hand with the the flow of money to psychiatry and psychiatrists. Without coercion (which implictly means that the opinion of psychiatrists is legally binding in many cases), government would not invest a single dime in organized psychiatry or psychiatrists. So while many psychiatrists make a living without receiving public money directly or indirectly, it is the fact that psychiatry functions as a tool of government sanctioned "social control" that makes psychiatry relevant in society.

We live in a "theocracy", in which the Bible or the Khoran have been replaced by the DSM, as far as the US government is concerned. This is not an exaggeration since the DSM is explicitly mentioned in state "mental health" laws as to who can be at the receiving end of involuntary psychiatric incarcerations and other abusive forms of coercive psychiatry.

So indeed, I believe that only individuals who are "seriously disturbed mentally speaking" would want to be part of such profession. Every interaction that I have with a psychiatrist, including the ones in this thread, reaffirms my belief.

Matt said...

I have been there a few times usually so manic I never slept and I always found the nurse Ratched of the units too and her and I never got along, I used to just talk all day and night. I would also sing and just drive everyone nuts, I was manic and loud and argued with cops and got tasered or beat up and I was pumped with energy earlier. I still getting lugged in and then the social worker who I would laugh at and enrage. I never go into the hospital by choice LOL never as a kid either because my first manic episode was at age 6 and it lasted all summer long. Singing and not sleeping at all and I took of in the middle of the night and everything. My last trip was in 2007 and I have been sane since and I had my first paranoid psychotic experience and I was nuts so I have stopped riding the manic high. I am usually mean to all of them though. I had one place that wasn't that bad but most sucks.

Matt again... said...

I had incidents with violence as a teen though but part of that was age too. I was a demon child too. I was horrible.

Thorn105 said...

Speak8ng from a patients pointbof view here. The staff were unnecessarily rude, vindictive and took much joy in upsetting me and other patients. Mental patient abuse is very common, and I have been i n private and state funded facilities, its the same everywhere,so maybe you should start there, and ask patients about it.We dont want a damn party and certificate. We want, need, and deserve to be treated like human beings. Fortunately, I have family.members that are staff at the hospital I have to go to 9n occasion, and due to me su8ng and winning a couple physical abuse lawsuits, the staff no longer dares screw with me. They are briefed before I get there that I know and exercise my rights. However many patients dont know how to exercise and enforce their rights, and this is when problems start. Many psychiatric aides are 20 somethings, who are many times sadistic, and relish the power they have over sick people. I am say8ng, THAT is where the problem lies and the violation occurs. No damned party and certificate will fix that. The staff know that their word will always be taken over the patients word, the patients know this and are reluctant to make th8ngs worse for themselves by report8ng sad8stic behavior of the staff. You may like to think mental patient abuse is non existant now compared to early psychiatric facilities, but the truth of the matter is it has merely taken another form and 8s more subtle and just as damag8ng to the mentally ill. Physical abuse does occur, I paid for a new car and now own my house because of m9ney I won quite easily. I am bi polar, and dont go completely nuts before hospitalization, so I can tell you exactly why this experience feels like a violation.

ILuvCats said...

I mostly just lurk on this blog now, but I've posted about this issue before. My experiences were sometimes like Thorn's, particularly at the state hospital the one time I was in there. The "nice" staff all knew who the abusers were, the doctors knew it was happening, and nobody did anything. An outpatient psychiatrist I had a few times claimed that all the losers who were fired from community hospitals ended up in the state hospital. My own doc said do whatever it takes to get the heck out of there ASAP because it is a bad place. But nobody fixed it. I complained, the administrator said she was shocked at my allegations, which she confirmed were true and a staff member was demoted and pay cut for 2 (whoooppee - these patient-haters did NOT belong in a job caring for vulnerable people!!!). I got my medical records before I complained so they couldn't be altered. I was terrified, but I did it for the patients who could not advocate for themselves. I'm like Thorn - bipolar. I function well much of the time. I felt obligated.

I don't understand what all the controversy is over this kind of thing - my outpatient psychiatrists thru the years are clearly embarrassed, sad and frustrated with the horribly abusive care some of their patients receive. No question they believed my story. Mine's not the only one. Social workers I've had will say the same thing. They have other clients who are terrified of the hospital just like I am. It's an open secret that outright abuse and rights violations are occurring to psych patients, because they have little voice. ???

It is such a shock to compare care in the orthopedic unit vs mental health, in the same hospital. A shock. They fawn all over patients in ortho, as if patient are nobility in the days of old (total overkill and imo, disrespectful to these trained professionals providing top notch care). In mental health, you are for sure going to run into patient haters from time to time. What use, the kind staff who provide professional, compassionate care, when one patient hater undoes all the kindness of 10 others? Even some of the medical doctors who are brought in for physicals seem to hate patients. WTH? I never had a patient hating family doc until I was inpatient for psych.

The best defense for a mental patient is to have a family member with them at all times, just like a close family member will hang around all day in the ortho unit etc. I don't know if that's sufficient prevention, but then there is at least a non-mentally ill witness. Ah, but it's not allowed! Virtually no visiting hours, even though there are no groups in mental units anymore. So then the abuse keeps happening, out of sight.

I get it some patients are very difficult people - I see this on bipolar support groups. People lie. They disrespect for no reason. They might be psychotic. Etc. But I didn't lie or disrespect and I was treated like crap pretty often, and I saw it happen to lots of sweet people who were crushed by bad events etc. I suspect they were targets of the patient haters because they knew those patients wouldn't fight back. Other times, maybe it wasn't patient haters, but just total disrespect of adults -talk to them like they are children, and geez, this even happens among the folks with bipolar, a lot of them I've met over the years were degreed professionals. Voice an opinion, and get talked to like a 6 year old. Unbelievable. Never happens in ortho, I suspect. I have seen it happen to old people too, though - folks assuming they have dementia talking to them like little kids, which is damned insulting.

ILuvCats said...

I see I edited out something by mistake - I think there is a lot in common between mental patients with serious mental illness and old people (frail elderly or with dementia). Abusers in nursing homes are not dealt with either, if I can believe what I read in the newspaper. They just get fired and go abuse old people in another nursing home. Nobody prosecutes them. We all see that old people are frequently disrespected. I've certainly read that they are drugged to shut them up, because it's not legal to tie them up anymore. Very similar to my experiences, it seems to me. In fact, in one mental unit, the psych patients and dementia patients were in there together, and dementia patients were mistreated similarly. Many staff were incredibly kind, as well. A mixed bag. But it made my blood boil to see some very sweet people mistreated, people in there for horrible problems that might drive anyone to suicide, or they were frail and had dementia but very fun and apparently loving people with good stories from the old days. I still have my old notes that I took when I was inpatient.

Whoa, I really like the new checkbox robot thingie.

jen said...

Dinah _

You're getting defensive. Not directly experiencing the trauma of psych hospitalization doesn't mean you shouldn't try to fix a broken system, but when you ask for feedback from those of us who have been through it and receive near unanimous agreement that you're on the wrong track, you should listen, not get defensive.

You're putting yourself right up there in the camp of those shrinks who "aren't even aware" they are traumatizing people except you're almost worse, because we're telling you you're on the wrong track with your pizza and cake and you're insisting that no, you know better the those of us who have had the actual experiences. Cut it out. Or just don't ask our opinion if you have no intention of taking dissenting (all) opinions into account.

Dinah said...

Ok Jen and others, so we're clear here: the unanimous consensus is that patients should be not be given an opportunity to discuss why they felt violated, and there should be no acknowledgement event (and certainly not with food because that would be demeaning) to note the hard work they've done in making progress in getting better. Even offering or suggesting would be insulting. The fact that some who've graduated from Mental Health Courts choose to attend such events with their families and friends is a different thing and we should not assume that any of those experiences might generalize.

When it comes to language, it's very hard to find words that are universally heard by all people in the same way. Apparently, we can't even decided if a given dress is gold/white or blue/black.

To the commenter who wrote so poignantly about being abused, I wish you would give precise examples. One person's comfort can be another's humiliation with respect to words and actions. It's easier to understand when someone tells you they were struck, or cursed at, or denied access to soap with no logical reason as being distressing then to know what to make of complaints that staff were mean or demeaning. And please don't think that means I don't believe you, I just want to understand better.

Anonymous said...

Dinah,

I am glad that you eventually published my comment . Since it was directed at Mr Hassman, I also posted it here.

I also welcome your more open mind to the issue.

You ask for specific examples. I do not want to share my own experience because, as I said, being off psychiatry's radar is one of my life priorities. But there are plenty of other examples we can discuss in the open.

Consider the two that you gave in your column "Distinguishing the killers among us".

Your high school classmate was lucky that the incident didn't happen in the age of Facebook. His life would have been ruined, literally, because there is no way such a thing can be kept private these days.

Similarly, you were ready to ruin a friend's child life because you didn't like that she posted some lyrics you found disturbing. Your friend's child was lucky that her mom protected her from you. This guy wasn't so lucky.

You conclude your column admitting that you have low tolerance. What you still seem to have a hard time understanding is that your "low tolerance" -as you call it- because of your license to practice psychiatry in the United States makes you dangerous for other people's well being.

So your friend's child could have ended up restrained, taken to a hospital, being forced into drugs and being forced to agree that she was "mentally disturbed" as a condition of discharge. Every regular person that I know would consider forcing somebody into such experience because you don't like some lyrics the result of a "disturbed mind". You however, want that we accept your personal judgement and that we should instead focus on pizza during the exit interview because after all, you see yourself as a do-gooder that can do no wrong.

With all due respect, with your license to practice psychiatry, you are dangerous to the well being of other people. As long as you don't see this, you will remain tone deaf to the issue of involuntary psychiatric incarcerations.

Dinah said...

This is my last thought on this topic.
There is an assumption here that we know the outcome before the completion of the act and that when in doubt, involving psychiatry is always wrong. This belongs on another blog, we are mainstream psychiatrists and see patients who voluntarily see us, pay for our services, and say they are helpful. And sometimes people feel helped by involuntary interventions.

While I'm glad there was no facebook then, I do truly believe that involving the authorities when I was in high school was the only option. A boy came to school with a large knife and told me he was going to kill a classmate. He had some type of psychological intervention and his life went on; I believe this was a better outcome than prosecuting him as a criminal, and I believe that because he went on to be a productive person. If he had later killed a bunch of people, I would have thought it would have been a better outcome for him to have been locked in prison so he couldn't have killed innocent people, but we never have the benefit of hindsight.

You completely overblew the story where I called a friend to say her daughter had posted suicidal sounding lyrics on Facebook. There was never a question or suggestion of hospitalization or drugging her, simply "check on your kid." I would want to be called if my kid said something worrisome. The kid in question appears to have some issues and has not attended school or ever gotten a job and has refused to learn to drive. It was not totally in left field that I would be concerned about finalizing lyrics, and don't worry, the family has been content to leave the kid alone and not sought mental health treatment.

In our town, one morning a boy posted on Facebook that it would be his last day alive. Many people saw it, no one felt inspired to act. He did live and will live his life out in prison because he went to school with a gun on that first day of school and randomly shot a handicapped child who was eating lunch in the cafeteria. A teacher tackled him and saved many lives. Maybe if someone had notified his mother, or gotten him help, he would not be imprisoned and the other boy would have been spared being shot.

I say you need another blog not because I'm not interested in hearing why you believe psychiatry is bad; I've been reading these comments for 9 years; they've certainly changed me and interested me in things that I wasn't interested in before, and made me aware of how damaged some people feel. With my daily work, I just don't come to psychiatry is all bad, and I have heard all the many many "psychiatry injured me" posts from so many people --they aren't saying something new when they don't add specific recommendations and I don't believe I will change your mind, nor that you will change my mind.

One friend tells me that all the negativity has stifled wonderful and creative discussions and turned off readers.

ILuvCats said...

Most hospitalizations seem to be only a few days now and people are so drugged up when they leave. My first hospitalization, even though they misdiagnosed me and made me worse with high doses of antidepressants, was actually very helpful in that they taught meditation, had groups, etc. But that was 3 weeks I was in there, at a fine university hospital. Those days are gone. One thing that seems like it wouldn't work with the getting out of hospital party is that from what I saw, most patients never had any visitors. Maybe one visitor each night for 15 patients. I think a heck of a lot of people who are inpatient have been abandoned by their families, right or wrong. The system seems to discourage visitors, even though there are no groups anymore and patients just watch TV all day. The nurses try hard to spend time with patients, but they are in their glass office doing paperwork almost the entire time. I rarely had a hospital psychiatrist who was willing to take 5 minutes to talk to my spouse.

I see it from both sides so far as I have mental problems and have relatives with problems, problems that are very upsetting, ruined their quality of life, and also life threatening. A person wishes they could get some sense into them, but there is no way. I am disinclined towards forced psychiatric hospitalization because I think it's ineffective. Nothing is offered inpatient nowadays but drugs. I don't know anyone who got better with drugs, long term. Therapy, yes, at least some. I think the discharge is probably based entirely on what will insurance pay for, not if the person got stable in 4 days. I think it's probably ok to involuntarily hold someone if they are imminently going to harm themselves, but dammit, stop keeping track of this stuff and reporting it to the government! If a person never threatened anyone else, leave the info in the medical records and nowhere else. It's THEIR life (I know that psychiatrists did not create that part of the system). My experiences were so bad, sometimes, that I would not willingly return no matter how bad the situation is.

The 3 week hospitalization at the university hospital where the staff were nice, even though I was no better when discharged, pizza would have been nice. There was a lot of good group stuff going on there. I learned a couple life changing things there. I appreciate that a lot. But, I know a lot of really poor folks on SSI who have serious mental illness, and I bet they would enjoy a little party like that a hell of a lot more than me. I can afford to go out for pizza whenever I want, but most of my support group type buddies thru the years were on SSI and that was a rare treat. The sorts of overeducated folks who comment on this blog are not the same as the rural poor patients I know thru social services programs.

To me, psych hospitalization would be better if 1) get rid of the abusers & RESPECT people, even if they are stuck there on a 72 hour hold 2) put meaningful treatment in there, not just drugs 3) didn't mention it before, but people are just DUMPED HOME with no way to follow up on anything. I 100% agree with Dr. Hassman on this one. (It's the same deal with other medical problems, not just psychiatry) (I mean COME ON I was dumped home on megadoses of antipsychotics that they knew were not covered by insurance so it was $1200 a month, which I am lower middle class, and also I TOLD them I am the only driver - my spouse and nearby sibling can't drive?) 4) stop reporting suicidal people/72 hour holds to the government, for those states that keep track (unless it was threat to others, but even that can be tricky because people lie to put folks on a hold, seen it happen, and holds are for psychiatric evaluation, not to ban firearms ownership or put people on lists of any other sort. Should require a hearing in court if people are gonna be put on a list)

Anonymous said...


Oh and another comment, I guess off topic, but I don't comment much. In my area we have one of those medical home things going, where people with serious, complex medical problems have appointments set aside for them, and there is a team of RN's to work with the patient/caregiver & streamline things. OMG that has been a lifesaver! LITERALLY! I wish there was something like that for psychiatry/counseling. You know, a counselor on call or something, since mental illness doesn't need vital signs stabilized or anything like that. Consumer warmlines are potentially something good there (never called one), but idk how they deal with people in a really bad way or if they refer them to the stupid completely useless suicide hotline. Home mental health workers used to be great, but nowadays all they do is type on their computers, so I quit. It's all FAKE HELP from hospital to home. There are so few resources allocated to mental health, imo, the government/insurance/"they" may as well not bother. Those small number of people for whom the drugs are a godsend, well they are lucky indeed because the system is entirely set up for them, because it's cheaper. When no mental health care is provided inpatient anymore, isn't it just incarceration? I worry for my relatives and my relatives worry about me, and I think those 72 hour holds would be a lot less onerous and/or traumatic if patients are respected as much as possible and the SWAT team doesn't come ransack the house for guns (such as in CA). Which that means purge the patient haters and make it clearer to legislators that if you punish people for getting mental health care, they will avoid it.

I just don't see much help for the mental health system the way it's done, for SMI. May as well not bother. I am appalled over the whole thing. It is a sick joke. For a few years, the social workers made a valiant effort to make up for the shortcomings of care for SMI, but now they just type on their computers. There is nothing but drugs, and crap on those who don't get much help from the drugs, or get worse. There is NOTHING NADA EMPTY SET for that group of folks unless they have the resources to go see their own therapist including having a car to drive. At least half the folks I'm talking about don't own cars or not allowed to drive anymore due to mental issues other than addiction. Some have kids and no money for day care. Some have agoraphobia or whatever in addition to bp schizoaffective etc. Woe to the Medicare folks with SMI- they gotta find someone with a masters in social work or a PhD or insurance won't pay, unless that changed recently.

I don't know if many of my ideas would help because seriously, most folks around here literally believe that they 1)must take drugs for their condition, (implied: whether the drugs work for them or not!!!) and 2)counseling/lifestyle change is worthless, because they have a chemical imbalance of the brain that they have genetically inherited. This is what was TAUGHT to them, somewhere. Part of the mantra to take their pills, take their pills take their pills and doctors will say anything to get the patient to take their pills? I really don't know! The whole thing seems rather hopeless to me.

ILuvCats said...

PS When I made a comment about overeducated folks, I was sort of kidding and I'm overeducated, too.

Dinah said...

I'd like to make one quick comment about the pizza/cake idea for an event to note progress. It was a quick thought, and I picked foods that are both cheap and liked by many (and vegetarian), because I did think this was something hospitals could afford and people might like, but honestly if there was funding to pay for it (a private appreciative donor? Insurance companies eager to have their clients see themselves as better and no longer in need of expensive hospitalization), you could sign me up for lobster with butter, Maryland crabcakes, even a really good burger. I never meant it to be comparable to a child's birthday party, I just think all celebrations call for food of some type and I do know the Baltimore MHC serves fried chicken. Healthy stuff is fine too if people would appreciate it, but I imagine there are those who prefer cake to veggies and dip. I was going for the idea, and yes, yes, I've heard many think it's a bad one and I don't run an inpatient unit, so it's all fantasy anyway.

ILuvCats said...

There is not enough money in the budget for a person to paint more than one little box that costs about $2 at Michael's craft store. The occupational therapy people limit it to one a week (and most people are not there a week anymore). NO KIDDING. It's so obvious that mental health is a money loser for hospitals, or else just treated that way, and ortho a cash cow. There was a party at the end of my spouse's 4 day knee replacement stay, and a follow up party several weeks later, after rehab (we didn't go). Plus we got a free high quality zippered tote bag, Tshirt and water bottle. SAME HOSPITAL where I was mistreated (and others much more so), same hospital where there is only one little $2 wood box per customer, per week, and so on. ALL the other rooms in the hospital are palatial, with lovely pictures on the wall and wonderful quality new furniture, kinda over the top, imo, but in mental health ONLY, it's the old vinyl chairs that are literally from the 80's. Now, I wouldn't care because I think hospitals are for medical care, and aren't resorts, except that there is the CONTRAST between mental health and all other rooms I've seen in that hospital. I just had surgery last week (different hospital) and it makes me cry to experience how kind those treating professionals were, compared to what I've received at times in inpatient mental health. REALLY hit or miss for mental health.

I don't get it why care must be forced onto "the mentally ill" anyway, in particular on those who have LONG TERM made it clear, leave me alone! It seems most alcoholics are left to drink themselves to death, no matter how tragic, unless they get caught driving drunk. Lots of people with diabetes don't manage their care well, and end up with terrible complications that didn't have to happen. Geez, we are sending voluntary medical patients home with the most incredibly complex home care required, families struggling to cope with IV pumps, ventilators, this medication 4 times a day without food, that one 3 times a day with food, monitor the patient for falls 24 hours a day, etc. Well, I'm sure there are plenty of folks dying because their relatives at home have the mental impairment of not being RN's and they make a mistake. There aren't enough resources to be forcing care onto people who don't want it!

I think perhaps more attention could be focused on advance psychiatric directives. Some people want forced care, some do not. What they want probably reflects on the care they had in the past, along with what their particular experience of mental illness/crisis is.

Anonymous said...

One night, after wearing the same clothing for several days waiting to be admitted, a nice nurse let me do laundry even though it was after hours. Then the shift changed before it was done. And the night nurse wouldn't let me get my ONLY PAIR OF UNDERWEAR out of the dryer and made me sit around commando all night long.

I don't want a party. I want to be treated like a human being. An adult, intelligent human being, worthy of respect. JS

Anonymous said...

But let me add, I appreciate that there are doctors out there at least trying to think of ways to make it better. js

Agnes said...

Dinah,

To be clear, I do believe that is possible to empathize without ever having experienced a psych hospitalization. That is pretty much what empathy means. It doesn't at all mean you must have had the exact same life experience, nor did I suggest that. It seems to me that you are trying but not quite getting it and you do seem defensive when that is pointed out, as another poster said.
I see someone who seems to empathize, others who have not. I have friends who do and some who do not.
Please don't twist what I said into something completely different.

Thank you

jen said...

Dinah, if I was giving responses as defensive as yours, I'd get slapped with a personality disorder DX in less then 5 minutes. You don't understand the magnitude of psychiatric abuse and violation that routinely takes place on inpatient psych units. Accept that as fact, hear what those who have experienced are telling you, and go from there.

Anonymous said...

I would veto the pizza and cake. I wouldn't have stayed for that. What they need to do is stop treating psychiatric patients with such disrespect. I have countless examples that I experienced and that I saw with other patients. They treated me with contempt, and they got it right back. They need to fix their attitudes.

Like ILuvCats, it's a complete 180 when I was hospitalized with pyelonephritis. The nurses were so kind. I had a fever of 105, and the nurse asked me if she could get me something to drink. Never once did a psychiatric nurse ask me if I needed anything. Not once. I couldn't even get a toothbrush the entire time I was hospitalized even though I repeatedly asked. They didn't care.

I really don't think a physician observing a psych ward is going to learn how things really are. It's kind of like when JCAHO shows up and staff are suddenly on their best behavior. They're not going to act like an ass in front of the physician unless they know the physician is ok with it. I know it is possible for inpatient psych staff to treat patients respectfully, because I was inpatient once when they were surveyed and they suddenly became "nice" and attentive when JCAHO showed up. So, I know they can do it if they choose to.

It's not about taking away a belt that is the problem. It is the threats, it's forcibly stripping people, the way they talk to you're a child or ignorant, and so forth. I dared accidentally step over a black tape line in front of the nurse's station once, and they bit my head off. If a nurse acted like that on regular med/surg unit they would be let go. It wouldn't be tolerated.

If they had offered me cake and pizza after treating me like total crap, I would have given them the finger.

P-K

Anonymous said...

I read the NYT article this post is in response to and I'm having a difficult time seeing the correlation in topics presented. The NYT article talks about practices in hospitals that are perceived as traumatic that could be reduced with simple common sense and 'bed-side manner' fixes. Had the NYT article talked about restraints placed on patients with dementia that are pulling out IVs or sedatives given to such patients because they become aggressive/difficult to monitor because they wander the hall confused then conflating the practices of restraints and forced medication in psychiatric hospitals would make more sense.


Because you mostly ignored the myriad of ways common courtesy is ignored and patients are treated as nearly invisible by doctors (i.e. five minute interviews with a dr. that then prescribes medications one feels they must take in order to 'get out') you have written a post that seems to be saying there is already and assumption that psychiatric patients are DIFFERENT people, a different class of citizen.

I agree with Jen who commented, "I'll be honest - Dinah, when you talk about mitigating the violation people feel after psychiatric hospitalization with pizza and cake, I'm just getting more and more that you don't actually have any idea exactly how traumatizing inpatient psychiatric hospitalization actually is."

I was excited to read this article. I thought, 'great, a common sense discussion on how we could change some very simple things to improve basic care'. I even thought you may go deeper into things other commenters have mentioned that seem common sense to me like: give people a couple of weeks worth of medication when they leave...

This post was so discouraging. And, once I finish my comment I am going to try to forget I ever read it because I found it insulting.

A pizza party? Do you know what discharge is actually like for most people? Yes, people leave not in the midst of crisis (hopefully) but they do not leave 'better'. I can say from personal experience that they leave just about the same as the few days before they reached crisis point but with the memory of hospitalization that at best was humiliating and difficult and at worst abusive and totally traumatic. I get a lot of people working in mental health must lie to themselves a bit to get through the day, the system is so bad but I would have guessed most are not as clueless as what I am hearing here.
One is discharged from hospital already with happy-happy, good for you, you're better yeah attitudes. I remember feeling hopeful the few hours before leaving because this was the attitude given me and I would participate. Then, I'd walk out the door and the realization nothing had changed would hit home. Maybe I'm kind of dumb but it took me multiple hospital stays to not give a darn what was said as I left (knowing it didn't matter) and vowing to die before I ever let myself end up in hospital again.
The exit is already patronizing (the multiple exit interviews a commenter posted where staff talked about their strengths sounded really good). A pizza party? That would only aggravate the insult of being treated in sub-human ways, being giving inadequate care and being tossed out the door unprepared. There is nothing to celebrate right now about psychiatric hospitalization in the U.S..

Anonymous said...

"Are There Ways To Lessen The Violation That People Feel After Psychiatric Hospitalizations?"
Are there ways to lessen the violation that people feel after being kidnapped, raped and tortured? Forced psychiatric treatment is torture and the only way to "lessen" it's ill effects is to stop it entirely once and for all.

Dinah said...

I don't condone brutality against anyone, ever. But to those who believe that forced care is only in psychiatry, please be aware that if you're on a medical unit and they are afraid you'll get up and fall, they may tie you down. If you raise a ruckus, they may medicate you. I suppose if you have an IV line, it feels less 'forced' because they just shoot the sedative into the line. If they ask you if you want ECT and you you're too sick to speak, they appoint a lawyer and have a hearing. If they decide to try ECT to stop your seizures in an ICU, they just do it, they don't consult with you about it. And you don't need to be mentally ill to be tied down and have your rights restricted, it can happen just because someone decides it's in your best interest. http://www.kevinmd.com/blog/2015/01/forced-chemotherapy-teen-exploring-ethics.html?utm_content=buffer03c05&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer

I am not defending any of this, just noting that it is. And it is ridiculous that other specialties get nicer furniture and environs; psychiatry is a money loser --some hospitals just close their units. The patient still deserves healing surroundings.

Penny said...

I have been hospitalized 16 times anywhere from 2 days to a month at a time, following my first diagnosis in 2007. I've been hospitalized because of suicidal thoughts or attempts (diagnoses: bipolar II, borderline personality, etc.).
Most psychiatrists and residents have been good to work with, though there is often stigma from nurses or psychiatric nurses. Some residents and nurses can be very judgmental-without realizing about the impact of what they say.
Some psych wards in hospitals are very pushy about their inpatient programs, even when some parts of the programs are not of use to specific patients.
I find being with other patients while an inpatient is the most therapeutic thing hospitals can offer. It decreases isolation, helps pass time and is useful to have others with mental illnesses to chat with. Having books, a computer, and a piano on a ward has also been very helpful.
These days my prime motivation is to stay out of hospital- both inpatient psychiatric and emergency. It is my outpatient psychiatrist who makes this possible as we have a good therapeutic alliance, and I am able to let him know I have suicidal thoughts without worrying that he will stick me in hospital just for those thoughts (which is what other psychiatrists/residents seem to do). It is very difficult to have made suicide attempts and then have outpatient programs in hospital shut their doors on you - to get excluded not only for the suicide attempts but also for your diagnoses. When an outpatient,I could take a multi-month course specifically for those who had made 2 suicide attempts or I could take mini dialectical behaviour courses, but I could not get into day treatment following hospitalization because of exclusions. Talk about stigma. My psych at the time also suggested I try to get into another course at an outside clinic - I had an hour interview and filled out a 100 item interview for one course. They phoned and said I was excluded because I was bipolar and had some borderline traits.
I work full time for a government commission and did so both before and after hospitalizations. I have taken work-related courses, the last two of which were offered by a joint law school/university after returning to work. However, the psychiatric system excludes me from anything but the course for those who have committed suicide or a dialectical behaviour course. I find this very limiting. I think if the patient's outpatient psych supports the patient taking other outpatient courses a hospital might offer, then the patient should be interviewed for the course. There needs to be more accommodation for competent psych patients following hospitalization. I did find the stigma and judgmental comments, primarily from nurses, including psychiatric nurses, hard to get out of my mind for years. I think nurses need more training in dealing with psychiatric patients and avoiding hurtful comments. don't have the same training as a psychiatrist.
The best way to make post-hospitalizations for patients who have suicidal ideation less traumatic, is to completely change the thinking that a hospital is the only place to deal with the problem. Yvonne Bergmans, St. Michael's Hospital, suggested that she would love to be able to raise money for a place where people with suicidal ideation could go to keep safe until the feelings/thoughts waned without hospitalization.

Anonymous said...

Dinah,
Your preoccupation with responding only to comments that are against involuntary psych holds or criticizing pizza and cake as unhealthy food choices is telling.
To me, your defensive replies illustrate further the disconnect with the reality of inpatient psychiatric care many commentators are pointing out with examples for you.
I believe it is unfortunate that psychiatry and psychiatrist have to deal with so much stigma and derision towards the profession. I am not ant-psychiatry, medication or forced hospitalization. I belive strongly all these things can be useful and helpful.
Repeat: I am for involuntary psych holds, pro medication and am an individual that has used and respected the knowledge of psychiatrist.
I think your article was troublesome and portrayed naivete. I think your replies illustrate a very black/white and defensive/hostile thought process that as anither person mentioned would likely get you a birderline personality diagnosis in a hospital. Maybe applying some DBT techniques at this time woyld be helpful fo you. I'd rather you deal a bit more with your own issues before looking to "help" anyone like me.
p.s. I'm also the ideal psych patient. I'm quite, docile, helpful (helped nurse give paranoid patient meds once by ok-ing the meds for the patient because she trusted me), participate, med compliant... inpatient psych wards can ne hell and there is always something trsumatizing whether it happened at er, in route or during one's stay it is a traumatic experience and many small things can be done that would go along way to improve upon this but ypu don't seem to be acknowledging those...

Joel Hassman, MD said...

Why do you even attempt to dialogue with these ardent dissenters? Point well taken about what occurs on medical units. But, doesn't fit the antipsychiatry narrative, Dinah.

Dinah said...

Thank you, Joel. I am feeling rather disheartened by this discussion. I know there are some people who feel very violated after being hospitalized, and I think our field should acknowledge and address this. In my own practice (exclusively outpatient) I have taken to asking people who have previously been hospitalized (not by me) if they were mistreated/distressed/or traumatized --- all say it was a hard time because they were in a bad place, but few dwell on it, some say it was helpful. Some don't want to talk about it. But I do know that it is not 100% of people, even with involuntary care,who would compare it to rape and torture. I actually don't know what percent of people feel violated, but since it is clearly some, I feel we should try to address this and change what we can. Maybe if it wasn't so awful, people would get help voluntarily?

I hear clearly that the majority (but not all) responders here would feel belittled by a slice of pizza or piece of cake and I wish I had not chosen those foods because of their association with childrens' birthday parties; maybe I should have kept with what helps in Mental Health court and suggested Fried Chicken-- but I don't think the food matters, I'm hearing that our readers feel that's too little, too late. And they are already too distressed and burdened with too many questionnaires to want to talk with anyone about how violated they felt. Someone told me that part of the violation is that it never gets acknowledged, and while I don't think anyone is going to say they are sorry for restraining or medicating a violent psychotic person, maybe they could acknowledge that this was difficult and painful for the patient and ask if they have better suggestions for how to handle these distressing situations. We have gotten better in that seclusion and restraint are used so much less than in the past.
But I hear our readers say no, they don't want to be given an opportunity to talk, but I'm wondering how the system can change if the patients are unwilling to give feedback? I hear the staff can be mean -- this is hard. If they're cursing at patients, they should be fired. But sometimes someone talks as though they are talking to a child and one person feels demeaned, while another says they had a kind soothing manner. One person's Horrible psychiatrist is another's Hero. I'm also hearing that some of this is absolutely not subjective and every field has bad folks. But how do you get rid of them if the victims won't tell someone? I know people may say they aren't listen to, but I still believe that if enough people complain about one person's manner, they get talked to, told to change, and eventually fired or moved elsewhere.
I don't have exact answers, but what is really disheartening is that simply by asking the question "Can we acknowledge how badly some people feel and make it better," I've become the subject of what feels to me to be abusive, unhelpful discussion. I'm sure I'm feeling what they feel, along with a "well what's the use of trying?," sense I now have. Nothing will please these people, if you suggest that their concerns are valid and suggest ways to help, they attack.

Please don't take this as a rant against all the commenters here. Those who didn't attack me but simply said that they don't like my suggestions and why (without the whole 'you're a defensive personality disordered' rant) -- not liking the suggestions is fine. Now I know not to suggest these things, and I did ask. And if you said concrete examples of how you were mistreated, then you provided a service.

Mostly, the comments and suggestions and the chance to hear what's troubled people has been helpful. But the few haters do make a blogger want to roll up the rug and find another project.

Jen said...

I don't know. I started out by giving you clear reasons why I disagreed. When what I got in response was sarcasm and defensiveness, well, let's just say that your friend who commented that "all the negativity has stifled wonderful and creative discussions and turned off readers" may well be responding to your defensive yet dismissive responses to the question that YOU asked in the first place. I know that I am.

Jen said...

Also - this: "And they are already too distressed and burdened with too many questionnaires to want to talk with anyone about how violated they felt" -- you have missed the most key element which I know has been pointed out. It's not feeling too distressed or burdened, but due to the already violating, abusive, coercive, humiliating (you fill in the verb, they all fit) care which inpatient psych patients receive, whether voluntary or involuntary, in public and private hospitals, creates a scenario where the very idea of honestly speaking out about what you experienced is impossible: what if the patient has to return to the unit in the future? Based on the already abusive, humiliating treatment -- it will be immeasurably worse if these "treatment providers" know you have spoken out and named names. There were people on my private, university hospital inpatient (voluntary hospitalization) unit who had been there 10-15 times.

It's offensive to me that you label and minimize my experience as merely burdened or distressed and assume that I wouldn't work to improve the status quo merely over being "burdened" by questionaires. There is a very realistic fear of reprisals and/or additional abuse.

Portland17 said...

As a mental health professional with thankfully very limited experience in psych wards (doing detention evaluations), I would have to echo Jen's comments - it seems very unlikely that anyone who has just experienced an involuntary psychiatric detention is going to feel safe enough to be open about what their experience was like. Those who had a bad experience are generally at a place where they feel they need to smile and say the right things so they'll be let out again. Many I've spoken with report having been punished for dissenting with treatment or criticizing the staff's demeaning treatment of them, including being restrained or force medicated for speaking their minds. So the only ones who will give feedback will be the ones who had a good experience, which will distort the observers' view of the situation

I think it would be a lot more helpful to talk to folks who have had this experience in the relatively distant past (at least a year or two ago) who now have some perspective on the experience. The person doing the interview would have to be someone not associated with the hospitalization and would have to create a very safe space where it's OK to say whatever is on one's mind without fear of retaliation. And it should not be focused on trying to make the recipient feel better about his/her experience, but in seeking real examples of abuse and disrespectful behaviors and some concrete suggestions on how to improve matters. This would feel more respectful and give some meaning to the negative experiences as learning opportunities for the hospital.

This would require a humility on the part of the hospital staff that I find unfortunately rare. It is very, very easy to believe that we "know better" than these "poor, suffering souls" and to overlook our own condescending and disrespectful behavior due to our professional one-up power position. Until folks can truly put themselves in the position of the patient, they won't ever really understand why things that seem normal to staff seem threatening and disrespectful and dangerous to the patients.

Of course, the best way to lessen the sense of violation coming from psychiatric hospitalization is to avoid using it whenever possible, and when not avoidable, to recognize, expect, and respect the normalcy of strong negative emotional reactions. The best way to reduce feelings of violation is to violate people's rights and integrity less often and less severely.

Thanks for starting this important discussion!

Nathan said...

Dinah,

I do appreciate you thinking of ways of making involuntary treatment less traumatic. I agree with many here that making involuntary treatment better and less common are more important goals, but I know you are not attempting to prioritize strategic reform here.

I can see how mental health court's process can seem less traumatic, celebratory, and healing even. Though I get the sense, and this could be my bias, that the process your describe as seeing in mental health court is infantilizing and oppressive in that folks who are most compliant (infantile) are ones who are rewarded and then the fact that some people do well in these programs inadvertently makes not doing well more stigmatizing and damaging to the folks who don't. It creates a false, stark division between "made some mistakes good patients" and the "real crazy bad criminals" that benefits some people in the system (the ones who play along the most or have qualities that are already priviliged in the system like wealthier families, better lawyers, higher education/job status, etc.) at the expense of making folks who don't participate in the way that is rewarded appear more deranged and more susceptible to harsher disciplinary and coercive punishment and treatment. What if people don't do well in their program? What if they do well but still don't find it celebratory, and come to court to find a celebratory atmosphere for something that felt traumatic for them? What questioned about who are they going to invite to their party is upsetting because their family is not behind their treatment or recovery experience or a source of trauma? I bet exit interviews for people who had better experiences would be more common and skew self-perception of a treatment staff, as folks with negative views would choose more often not to participate in fear of retaliation. Not choosing to participate may itself be seen be noted as a kind of noncompliance or a negative experience, interfering with that celebratory, healing goal.

Let me know if I'm wrong, but I think you are offering options for some patients to feel better as a matter of choice, and that seems like it is something that people want (choice, feeling better). But, in doing so, I'm not sure you realize that when offering optional exit interviews and celebrations at discharge may stack the deck worse for people who find the system as is challenging while benefiting the people who would have the easiest time anyway.

I do think you are correct to note that sometimes non-medical team leads work better than medical ones (which I think is good evidence that what we consider mental health problems are not always well treated through mental health interventions), but I don't think the options you suggest are going to do much to mitigate trauma of hospitalization, or more specifically, the benefits of your suggestions for the people who may benefit from them do not outweigh the costs for the people who do not benefit. I like the idea of feeling validation for hurt experienced through forced treatment experiences, but I have a hard time seeing how that is done with the team who were part of that hurt, unless they are really open about being accountable for that. This doesn't even happen in voluntary treatment well, and don't imagine it happening well in involuntary treatment. What does this look like? I don't think just listening cuts it. I hope medical professionals can look engaged for half an hour as someone is talking to them, especially when they are in a vulnerable position sharing deep hurts that were caused/made worse by the same medical professionals. But just listening to it doesn't validate it nor feeling heard lessen trauma.

Dinah said...

Nathan, I have answers for you on mental health court, but you may have to wait and read the book.

Thank you all for your input, I am sorry it came off as sounding like I thought a piece of cake would make up for the indignities of a very difficult process at a very difficult time in people's lives. I am sorry that people suffer so much, and I do hope that our book will decrease the quickness which people seek to use involuntary treatments, and advocate for respectful care. Thank you for letting me know that there is a group of people who would see certain efforts as salt in the wounds, and I am sorry if reading any of this brought bad memories back to life.

You have been very helpful to me.

It's time to close this subject.

George Dawson, MD, DFAPA said...

Hi Dinah,

I linked to your post form my blog and posted my experiences baed on 23 years of high intensity inpatient work. I would appreciate any thoughts that you might have on my table. Thanks, G. Dawson
http://real-psychiatry.blogspot.com/2015/03/a-polarizing-post-about-psychiatric.html