Friday, April 25, 2008

The Myth of the Hospital

I have been unlucky enough to be the guest of two different psychiatric hospitals. In addition, I have worked in nine psychiatric hospitals in a professional capacity. Most people, even professional psychiatrists, have a rather naive view of what happens in a mental hospital. Private psychiatrists who spend most of their time treating private patients for depression and anxiety may have very little experience with a real psychiatric hospital. Ordinary people may get their views of psychiatric hospitals from books and movies, such as the extremely optimistic "Girl, Interrupted," during which a forced psychiatric patient rediscovers her joy in life while receiving a great deal of individual therapy and developing relationships with other inmates.

The reality of the psychiatric hospital is, unfortunately, much bleaker than even popular culture would lead us to believe. The hospital is a good place for low-functioning people with thought disorders or severe personality disorders to get stabilized on their meds. The hospital is no place for a high-functioning depressive.

What could you expect if you were involuntarily hospitalized? First, don't expect for there to be people like you around. Most people involuntarily hospitalized are the aforementioned low functioning folks with thought disorders (like schizophrenia) and severe personality disorders (like borderline personality disorder). "Low functioning" means that these people will mostly have a hard time engaging in normal activities of daily living, like washing themselves, feeding themselves, and having a conversation. You will share a room with one or more of these people.

You won't get individual therapy (one-on-one talk therapy). It's too expensive, and not very effective for the hospital's normal clientele, those low functioning folks with thought disorders. The usual plan for low functioning people with thought disorders is to "stabilize them on meds" - they come in psychotic, they are given antipsychotic medication for a while, and their psychosis disappears. (Medication may be forced in most states. Some states require a hearing before forced medication may happen; these are generally rubber-stamp proceedings.) This process has a very high success rate for low functioning people with thought disorders; individual therapy is not seen as effective or necessary.

Generally, hospitals try to apply the stabilize-on-meds approach to high functioning depressives, with mixed results. As mentioned above, individual therapy is not available. Instead, expect mandatory "group therapy." Group therapy, in a private, outpatient setting, is often interesting and productive, given a group of intelligent, high-functioning, thoughtful people. You will not find that in a hospital. Instead, you will find yourself in group therapy with that same group of low functioning people with thought disorders that you've been rooming with and eating with and smoking with during your stay. Often, group therapy takes the form of practicing activities of daily living - say, writing a letter, or washing oneself. This would be very helpful for a low functioning person with a thought disorder; it is humiliating and harmful for a high functioning depressive.

You may meet with a doctor once or twice during your stay. The doctor does not want to talk to you. The doctor wants to know if you are tolerating your meds, and if you have figured out how to answer questions about your suicidal intent correctly, so that you may be released. Most suicidal high functioning depressives quickly figure this out, and answer that they feel much better, that the meds are working fine, and that they have no further suicidal ideation.

The stabilize-on-meds approach for depressed patients is especially ridiculous, given that anti-depressant medications don't work any better than placebos. Given that the hospital doesn't help the high functioning depressive, except to medicate him or her, the purpose of the hospital in this context becomes clear: it is a prison. Hospitalization doesn't help people become non-suicidal. It merely teaches the high functioning depressive to make sure he or she succeeds the next time he or she attempts suicide. And never to be honest with a doctor again about suicidal ideation.

19 comments:

  1. Do you read RadGeek? This on mental institutions might be of interest to you.

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  2. TGGP, I hadn't seen that, thanks so much for the link. It's nauseatingly horrible. I never witnessed anything like that either working in mental hospitals or, uh, resting in them, thankfully, but I am definitely aware that it happens. And imagine how hard it must be for a patient to get his or her claim of abuse taken seriously!

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  3. Found this after searching Google. I can say from experience myself that this hits the nail on the head. I was almost taken aback by how similar what you said was to what I've been through.

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  4. Interesting, and thanks for your input - yes, when I've explained this to private-practice psychiatrists, they've mostly been very surprised to hear it - they have a very different view of what the hospital is for and what it is like, especially older psychiatrists. But no "consumer" (patient) I've talked to has reported a different experience.

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  5. Curator, do you know of the deceased playwright, Sarah Kane? She killed herself at 28. Was hospitalized and "supposed to be put on round-the-clock watch", but when the nurses were "negligently" not looking, she managed to complete her desired act. Watch this old news clip. Her father does seem to blame the hospital for not intervening, even though throughout the narrative, it is made clear that Sarah wanted to die, and did so for much of her adult life, at least.
    http://www.youtube.com/watch?v=ueQt7ENn9fI

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  6. PS - this was Sarah Kane's last play. Based on its subject matter, it looks like something that would interest you, if you're not already aware of it.

    http://www.youtube.com/watch?v=pvnNnH2GZyI&NR=1

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  7. Well that's beautiful and terrifying. Thanks, I hadn't heard of her or her work.

    You almost always hear the family blame the hospital (or other institution) when a patient commits suicide - part of that is probably legal, the negligence lawsuit, but I also think it's a lot to expect emotionally of a family member to accept a suicide as a voluntary act. Especially (a) since they are constantly fed the line that "all suicides are preventable," and (b) since the suicide frequently comes as a surprise to family members, since suicidal people must hide their suicidal ideation to avoid unpleasantness (like hospitalization).

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  8. I have to disagree that anti-depressents don't work. I was on Prozac for ten years. It is the only time in my life since i was 14 that I never had a suicidal thought.

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  9. I must disclose that I take antidepressants (in various combinations, as my GP prescribes, adjusted every couple of months since they don't actually do anything from my point of view) - they don't remove my death wish, but they seem to make the people around me feel better.

    It definitely seems valid that they work for some people. Cetalopram, for example, works about 15% better than placebo - that's 15% more people who respond to it than respond to placebo, which is 15% more people who aren't suffering as much. That's purely good. I think it's important for people to try them - in fact, I think it's the polite and socially responsible thing to do. My main point is that they don't work as reliably as is widely supposed.

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  10. Thank you so much for this post, Curator.

    I have spent but a week in the Mental Health system for being suicidal. It was the worst week of my existence. Utter hell.

    Sometimes it's encouraging to know that there are people like you out there that feel the same. If I could do just the smallest part to fight against these injustices I could die a happy man. But I have no idea how to fight against this. Sometimes it just seems like Everybody just accepts these peoples authority, and I have no idea what to do.

    Sorry to gush. Thanks again for this Blog,

    Arthur

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  11. Arthur, I really appreciate it.

    One major problem is just that most people don't understand how awful and degrading forced hospitalization is, especially for high-functioning people. This is going to sound flaky, but just "making our voices heard" is doing something to combat that. People need to understand what the reality is behind euphemisms like "getting treatment" and "getting the help he needs."

    I keep meaning to post about this - a 2007 paper in the Archives of General Psychiatry called "High income, employment, postgraduate education, and marriage: a suicidal cocktail among psychiatric patients" found that these characteristics of a high-functioning person actually dramatically increased the risk of suicide after discharge for inpatients hospitalized in a psychiatric facility. (In the general population, the association is exactly the opposite - all those characteristics are protective against suicide.) One possible conclusion is that the current model of the mental hospital is failing high-functioning people in a serious way.

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  12. The citation is Agerbo, E., "High income, employment, postgraduate education, and marriage: a suicidal cocktail among psychiatric patients." Arch Gen Psychiatry 64(12): 1377-84 (2007). Here's a Medline link.

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  13. I had a manic reaction to Effexor (which I was put on for OCD, mainly). I ended up admitting myself to the psych ward when things got completely out of hand. My experience was basically the same, except it wasn't about suicide. It was clear that the psychiatrist wanted certain responses (about my sleep, my thoughts, etc.). Since they were holding me against my will (even though I came in voluntarily), I sat there and told him what he wanted to here, day after day. As well, over 8 years of SSRI/SNRI usage has left me with a plethora of neuroendocrine complications (look up PSSD, for instance). Anyways, it wasn't about actually getting the help I needed, least of all from a psych ward. I've come to terms with the fact that one should not expect the problem makers to double as problem solvers.

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  14. I have only now just come across your site. One week ago, I was finally discharged after being involuntarily committed for 11 days. So much of what you said was spot on, but especially so with the last paragraph. Diagnosed with BP I and BPD for quite some time (after being mis-diagnosed with just major depressive disorder and put on anti-depressants which only triggered my first “official” manic slamdance), I am no longer on anti-depressants; however, I was prescribed two mood stabilizers. Earlier this year I was laid off and could no longer justify the horrendous costs of continued medication. Yes, I knew better but felt I had no choice.

    Well, I finally hit the proverbial brick wall on 10 October at 0300. I have no memories of how the person ended up knowing to call 911, how the paramedics gained access to my house (I live alone and no one has a key), and the entire experience at the ER. When I woke up, all I remember is thinking I must be in some kind of hospital room, but why is there a security guard posted outside my room (the entire wall opposite my immediate field of vision was glass)? Oh, yeah, and by the way, where are my clothes, how the hell did I get here, and what the crap is going on (well, not my exact words). There was no call button to summon a nurse and no one would talk with me. The guard threatened me with restraints if I didn’t return to my bed immediately.

    Finally a social worker came in and explained that I was in an observation room off the main ER hallway and was under a 72-hour protective custody hold awaiting transfer to a local psychiatric facility due to my suicide attempt (apparent drug overdose accompanied by alcohol). What suicide attempt? Not that I said any of the following to anyone, I did think: yes, I had felt quite suicidal these last couple of months, but my method of choice had not yet been provisioned. I certainly wasn’t going to risk swallowing a boatload of pills and chasing them down with alcohol only to vomit up all my resources. No, rather, my intended solution would be swift and immediate (translation: no ability for resuscitation…I’m no fool. If anything, this past experience only fortified my reasoning. Besides, due to my mind-altered state with the increased alcohol levels, for some reason I must have communicated something to someone that prompted the 911 call. That won’t be repeated.).

    What did I learn during those 11 days? To perfect my façade and play their game. My sole goal was to get out of there by any means necessary. Now? Well, re-read the last three sentences of your last paragraph. I have certainly learned my lesson!

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  15. Hey Alix -

    In this case, I hate being right. But the hospitalization experience is one of the most dehumanizing things likely to happen to a person in the first world with the approval of government. I am so sorry - the inappropriate medication triggering a manic episode is the worst.

    I recently got lucky with medication and other interventions, and my life has become relatively tolerable - but it's no excuse for the involuntary hospitalization that preserved my life against my will. Judging from your blog, you are very sensitive and intelligent - I hope you get lucky too, and hit upon the right medication, doctor, illegal drugs, whatever, that make your life feel pleasant to live. But I know it won't justify what was done to you.

    I am in favor of inviolable rights trumping the preservation of life. I think people who have experience what you and I and too many others have experienced - forced hospitalization - have been violated. That they may later find life to be pleasant is no excuse for that violation.

    Please email me, by the way - I'd like to talk to you.

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  16. I've been hospitalized twice in two different facilities. The first time for a serious suicide attempt. The second time was for an aborted attempt (I came very, very close to attempting again, but ultimately decided to go to the emergency room instead). I voluntarily committed myself, but was told both times that it was extremely likely I would be involuntarily committed if I did not.

    I have to say absolutely nothing in this article was true to me. There were low-functioning individuals, but most people there were relatively calm and friendly. Group therapy was mandatory for the first visit, but completely voluntary for the second (but not going definitely did not help you get out any sooner). The actual therapy was extremely random... one day pet therapy, the next day it would be anger management, etc.

    The first time I saw 3 different doctors. One I saw once about every 4 days. The other two I saw when I first came in and when I left. The second time in a hospital, I saw either a psychiatric nurse, a social worker, or a doctor every other day. The day I was released, I was seen by the social worker, a psychiatric nurse, and two doctors in a large conference room. It lasted about 45 minutes.

    Maybe I'm just lucky, but the hospitals helped me. The only dehumanizing thing I can remember is when I was being prepared for the unit (having to give up shoelaces, etc), but it wasn't that bad.

    Btw, I my stay at both hospitals was slightly over two weeks.

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  17. I voluntarily committed myself to a mental hospital for 4 weeks. It was dull and annoying, but I knew what I was there for and I got it. Someone I met there who has become a close friend had the same experience, although she needed about 6 weeks, and eventually found an effective medication. (I haven't, and I'm planning to make more drastic alterations soon — no, not killing myself, far from it.)

    Of course, hospitals vary a lot, and fully voluntary is not the same as involuntary, or "voluntary" under the inflence of alcohol or something else.

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  18. Just stumbled across your blog, which I adore, by the way. It depends on your hospital. Not all hospitals are as you describe. My first one was, certainly, but low functioning people were not forced to do group therapy, as we were divided into groups. Those low functioning people just walked mindlessly around all day in the acute ward, often engaged in their own little worlds. I was there for a week and hated it. I was misdiagnosed with major depressive disorder and put on a short-term antidepressant that made me go manic. But my second hospitalization, I quite enjoyed, because when one falls from a manic episode, one often crashes into a deep depression and the pace at this hospital was just right for me, considering I was just so blood fatigued all the time. But group therapy was not forced. You weren't even forced to eat meals. You could stay in your room all day if you wanted, and there were a variety of activities you could do. The nurses seemed more than happy to attend to your every whim, considering the ward was very small anyway. But there were no low functioning mood disorders in this ward. I believe those people had an entirely separate psychiatric unit, namely a more long-term one. I was there for only four days, mainly due to being treated for a UTI past doctors weren't concerned with treating. But I had to be hospitalized to finally get on a mood stabilizer for my bipolar because in my area, there are ungodly waits to see psychiatrists and I couldn't tolerate being in a mixed episode for a week longer. I tried getting a hold of the psychiatrist at my first hospital, even pleaded the third time, but she never got back to me.

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    1. The more voluntary we can make hospitalization, the better! It sounds from your account like it was more effective for you that way - having some control over what happened to you. This was not my experience, and this may be why my experience was so negative compared to yours.

      Best of luck with your mood stabilization - much as I joke about wanting to experience a manic episode, I know it's no picnic and I hope you figure out how to have a happy life!

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