Friday, January 13, 2012

I'm Sorry

Rob wanted to know if I was reading the comments on Dinah's post about involuntary treatment. He thinks that psychiatrists may read these comments, shrug and say, "Well, sometimes it's necessary."

I did read the post, and the comments. I can tell you that the decision to involuntarily admit or treat someone is never a "shrugging" issue. This is something psychiatrists hate to do. I mean, literally hate. We know it's something that can destroy a therapeutic relationship and undermine someone's willingness to seek care in the future. We know that psychiatric units can be horrible places to be and that admission is expensive, humiliating and sometimes traumatic. The decision to seek involuntary treatment is not done lightly or easily. You and some others may feel it should never be done, but I think that's an issue that may never get resolved between us. Maybe someday medicine may develop better ways to diagnose and treat mental illness, or society may evolve and decide that psychiatric patients are worthy of the time and money spent on other suffering people but we're not there yet. We deal with the present, as it stands, with what we've got.

Remember that there are comments that you don't read here. The missing comments. The comments that can't be posted because the suffering people are dead. On behalf of those folks, and the people who care about them, I'm sorry. I'm sorry that psychiatry as a profession and the mental health system failed you. I'm sorry that you had to hide your suffering from your friends and family, or maybe from your doctor, because you thought you had no choice. Clearly, something needs to change.

This is why Dinah posted about the issue and why I'm following up. As a group, we need to figure out better ways of doing things. The Shrink Rappers don't have the answer. We need to hear concrete ideas and suggests. General comments like, "Stop treating me like a child" or "Don't be a jerk" honestly aren't helpful. The commenter who suggested that patients should be allowed to have cell phones on the unit, to call friends or family when in crisis on the unit, now that's the kind of idea we psychiatrists need to hear. The discussion about post-discharge aftercare and the continuity gap is crucial. Please tell us more about that and about what kind of services or support would have been useful and what we need more of. I like the idea that this could also help catch people in early relapse. We need to answer the questions about these services: what, when, where, who and how.

Now let's get started.

Recent posts on forced treatment:
Jan 9: Forced Treatment: Does it Help? ("make psychiatric care something patients want to get")
Jan 13: I'm Sorry ("I'm sorry that... the mental health system has failed [those who have died due to hiding from 'treatment']")
Jan 14: What We Need (list of 12 things readers are saying they need from the MH system)
Jan 14: Poll: Involuntary Commitment: Would you do it again? (a survey for those who have been committed in the past)


nononononono said...

At least one of the missing comments is from man who committed suicide the day after his discharge. I know that it is not completely fair to say this but there is some truth in the statement that plenty of suicides happen once the person has lost nay faith that anything can help. Often, they have been through the hospital system and somehow, no shred of memory remains that this was helpful to them because the likelihood is that is probably was not.
I would have liked my cell phone. I would have liked one person to have looked at me and seen a human being. Years ago, while a student, during my first admission, one person did that for me, talked with me, helped me get though an awful night. Today, i am not sure whether she was real or I made her up. I am pretty sure she did exist.
We will never get cell phones. They will say that is for privacy reasons just as they are banned in locker rooms.

Anonymous said...


Robert Whitaker is leading the discussion regarding the issues you have raised. If you mean what you say, I would invite him to write a guest blog post. Let me know if you want more information.


rob lindeman said...

"This is something psychiatrists hate to do. I mean, literally hate."

Because I feel like I know you well enough, Clink, I will stipulate that you speak for yourself. I have a very difficult time believing that you speak for your colleagues.

wv = vossfu; newest expletive banned by FCC for radio and television, permitted on satellite radio

Anonymous said...

Given my experiences with forced inpatient treatment, it would take a miracle to ever persuade me to walk in those doors voluntarily no matter how desperate I was, but here are some things that might help:

1) good healthful food that accommodates patients' dietary needs (it took one hospital nearly the entire week I was there to accept that I am a vegetarian; before that I didn't eat because everything they sent me contained meat. They didn't notice.)

2) trained, accessible staff (the same hospital relied on "psych techs" to manage the patients. These people had no actual education or training in psychotherapy; their job was to do 15 minute checks and unlock the bathroom doors. One of them flat-out told me once they weren't paid to talk to patients. Nurses spent their time behind the desk and doctors and social workers were never available. Patients in immediate crisis talked to each other.)

3) Incorporate approaches to treatment that don't involve medications. (The entire time I was in the hospital I struggled with my doctors over meds I did not want to take. They had no other treatment options available.)

4) Be honest. (My doctors and social workers lied to me, lied to my family, lied to my outside therapist, lied to a judge at my commitment hearing. It was obvious but there is absolutely nothing I could do about it. Complaining about it just got me tagged as a problem patient.)

5) Treat patients like adults. (I am a college-educated, well-read, well-traveled person who has held the same job for 20 years. I own a home, take care of several pets, and manage a stock portfolio. Yet I had to ask to have the bathroom unlocked so I could pee? I had to beg an uninterested nurse to make a phone call or get my hairbrush? Really?)

6) Pleasant environment (one of the hospitals I was in smelled like urine, had peeling paint, filthy furniture, broken televisions, ugly metal doors, papered over windows, and painted over cinderblock walls. Another had big, uncovered windows looking out over trees and grassy areas, a pleasing color scheme, comfortable furniture, non-flourescent reading lights in the rooms, private bathrooms, carpets, a small library, and a kitchenette for patients to use. Can you guess which one felt therapeutic?)

Anonymous said...

Great comments. I agree with Jessa. It's important to address the harm of treating adults like children or staff being jerks when looking at why people don't seek further care. I didn't go back for more treatment for that very reason. I put physicians I knew in my place as a patient and I know none of them would have tolerated the staff's behavior. It's called self respect, and if I'm going to have any then I'm not going to tolerate that.

You will not save someone who is depressed mostly due to a h/o sexual assault by ripping their clothes off and putting them in a room with a metal door. You will however re-traumatize them and give them PTSD. They will replay this event over and over and over and over in their mind for a long time to come. You will make it more difficult for them to turn to anyone for help, because this is not helpful. Could they not have patted down my pockets? Why stop at ripping off their clothes? Why not just continue on with a body cavity search? Please keep in mind I committed no crime, I was depressed and sad.

I was so traumatized by this experience that I felt it important to at least try and improve things for other patients who had no voice, because I was tormented with worry about others going through this. So, I volunteered to serve on a board at that hospital as the token "consumer."

One of the interesting things is how this hospital defined successful treatment. They kept track of all the unduplicated admissions. This is considered a sign of success. So, my leaving traumatized and more despondent than I went in, fearing further treatment was defined as successful treatment - simply because I was not readmitted there. Ludicrious. Of course people are going to try and avoid bad care. Who wants to go through that again? A better measure would be to see how many people hospitalized there showed up at their outpatient follow up appointments.

Another suggestion I have is to mail the patient satisfaction surveys AFTER the patient is discharged (like regular hospitals do), instead of forcing patients to fill it out as a condition of discharge. You will get more accurate data when people no longer feel threatened.

Third, like Jessa I had no idea that the psychiatrist absolutely hated to involuntarily hospitalize people. This was certainly never conveyed to me. They used threats, "If you don't sign this consent, we are going to sign it for you." This is not a valid informed consent by the way.

It matters little if the psychiatrist is kind during the 5 minutes that they come by to talk with patients in the hospital if the rest of the 24 hrs patients are being treated disrespectfully.

I think we need to open the doors to family and friends, so that there is more accountability by staff. A lot of what goes on would not go on if people from the outside were witness to what is happening. JCAHO visited during a psych hospital stay and I was amazed at how respectful staff could be when they had to be. So, I know they can do it, they just need more accountability.

Anonymous said...

(part 1)
From my inpatient experiences I have lots to say.

First off, ALL treatment should match the NEED of the patient. I have pretty bad PTSD. I was hospitalized due to suicidal thoughts from symptoms of PTSD. I was put in a ward with a myriad of other mental illness, given medication with questionable effectiveness,...and told not to discuss even vague details of the things I was exactly suicidal over. Due to the nature of the unit (all things) I saw people restrained, lots of power control issues which of course, with people with a very abusive background, just deeply scared me. In addition over 25% of the ward told me privately that they'd been sexually abused in some way- and those were the ones that admitted it. It was never addressed by staff, except that I should not discuss it as it was upsetting others.I recieved no therapy. I recieved no referals. I recieved medication, with no address for side effects or complaints.

In every hosptial I have been in- side effects of extreme drowsyness have been discounted. Those people have been ridiculed, thrown out of bed and completely ignored. Medications were not changed.Sometimes they were discharged.

They released me in three days with a plan of pretty much good luck. I was back in two days. I begged and pleaded for care about the trauma. Because I knew if they let me go without some type of proper treatment I would kill myself. It was seriously my plan.

Luckilly I had my mother looking out and advocating for me- she found me a specialized trauma unit that could take care of me.

The experience was so vastly different. The ideas of a respectful community, ideas of fostering safety, given room and space to discuss serious topics, and the most important thing SKILL BUILDING. I needed ways to cope that were concrete and in my control to utilize. In two-three weeks, I had a much better perception on how to live in the world with flashbacks and such. Now, it was not perfect, nor did it solve my feelings and/or problems. But the skills I could use in outpatient therapy.

Yes, it was still an inpatient unit...but it was one that took in mind and was designed for someone with my particular mental health concerns.

I think even people with serious mental illness can learn basic coping skills.Many people with mental illness learn myriad of different ways avoid being made in-patient again, regardless if they are getting treatment or need some sort of treatment. They learn to adapt.
General inpatient units are not designed to teach skills at all.
The lessons I learned from my general inpatient stay were "pretend you are well, say and do exactly workers say and don't complain"

Anonymous said...

(part 2) And the groups they try to have are a joke. A 'dbt' class were some poor worker has to read a whole bunch of pages to a group of people who get no actual practice using the skill or discussion about it is absolutely useless.

A video on bipolar that is 20 years old, and all the repeats have seen multiple times. Those who don't have the illness get nothing (or something irrelvant) while even most of those who DO have it are repeats enough to know what the video is saying.

When people who are living in the world for some reason or another are not getting healthy coping skills, what is the justification for providing a 1 hour lecture read by some person in a monotone voice? It isn't how people learn. And I hate how f the hospital aims for engagement, instead of actually having structured activities, the worker will just make patients read it to each other in monotone voices, as if that increases the learning potential.

I also think medication side effects are widely discounted, and trivialized unless its an extremely serious reaction.

On the specialized trauma unit I was on: One lady had to become non-complaint and stop taking her meds one at a time ( with lack of information on side effects, denial by the staff and psychiatrist) and be written up every day for medication non compliance. She basically would stop taking a med for about a week and then try another one until $20,000 (20 days later) she found the right med and stopped it. Suddenly she was active, but still had her mental illness issues, but because her insurance decided she was 'remarkably better.' Sadly, 25,000+ was spent for her to be her own doctor and fix mistakes- and the therapeutic benefit of the unit was lost. She also had a ridiculous bill that she could not dispute.

I really wish that general units could at least treatment match somewhat. Making tracks where specific goals are relevant are important. I think it should be a goal to have inpatient individuals establish visits to an outpatient therapist (under a personnel transportation and/or therapist visiting the unit inpatient) prior to discharge instead of a referral.

I also think that there needs to be a valid complaint process. Where patients can be heard, and needs addressed. To many individuals are simply discounted.

I think that listening and remembering that individuals are people goes a long way. Involuntary commitment is a shock. It also is a loss of control and difficult to figure out. There are outside needs that do need to be addressed.

I also think that consistency is extremely important. A LARGE part of the inpatient experience is figuring out who allows what, and what peoples pet peeves are. Mrs. X doesn't like questions but Mrs. Y will actually tell the doctor your questions.Mrs. Z will let you make a 20 minute phone call instead of 10, but Mrs. A doesn't want any phone calls at all.

And as one last thing... there is such a dramatic difference between high quality inpatient care, and a general catch-all unit. That gap needs to be narrowed significantly.

Anonymous said...

I think blogger ate my comment.

Jen said...

I'm going to agree with Rob in that Clink, you really only can speak for yourself in this issue, not for psychiatrists at large -- just as I can only speak for myself and not generalize it to the entire american public, or even to just all the american psychiatric patients. I am a highly functioning individual with multiple post-graduated degrees, an important career and all the rest of that stuff. I also have MDD. I had a psychiatrist-who-also-did-therapy for half a decade who routinely terrorized me with the threat of hospitalization. the issue was not if hospitalization was necessary, but rather that the psychiatrist did not want to deal with anything beyond the "walking well". It is one thing to truly believe inpatient care is necessary to help the patient; it is another entirely to simply want to not worry about a patient in crisis and pack him off to hospital-babysitting. Psychiatrists have a unique job and an amazing opportunity for changing lives, but with it comes tremendous responsibility. I have no doubt that is absolutely abused, all of the time.

I was hospitalized twice (not with this psychiatrist) and had positive and negative experiences each time. Both were on different campuses of the same highly regarded academic medical center, paid for primarily with insurance. With a given that people are individuals, both patients, doctors, nurses, and aides, there are numerous concrete changes I'd like to see.

I would like to see additional - substantial - training for techs and nurses, the people who spend the most time with the patients and have the least training.

I would like to see accountability, and patients given clear directions who to contact in case of abuse, breach of confidentiality, etc -- all of which I watched firsthand. It needs to be made clear that there will not be punitive action taken against the patient. It needs to be more then a flier with a phone number, or a survey at the end of the hospitalization.

I would like to see occupational therapists who provide "therapy" that has anything remotely to do with the lives of the patients there.

I would like to see a team assigned to each patient, not just a psychiatrist and social worker who does discharge only, to mitigate some of the damage caused by a bad psychiatrist, or even just a lousy match.

I would like to see social workers with familiarity with the various discharge options and the ability to make appropriate (including health, level of functioning, financial, insurance, location factors) referrals to them.

I would like to see a discharge system that works - that means, appropriate referrals that the patient and doctor are both comfortable with. A concrete plan for the immediate days following discharge.

I would like to see it made very clear to patients that if something about the discharge plan/outpatient treating isn't working, that there are other options, to call the treatment team and get additional recommendations.

I'd also like to see edible food and less restrictive visiting rules, but let's not push it.

That said, how can these possibly be implemented? It's unfortunately simply unrealistic.

Dinah said...

Unfortunately, many of the problems that people have cited are issues that are subject to interpretation. One person's version of being treated like a child can be another person's version of being treated kindly and gentle. Sometimes we all agree that a certain event the product of an evil person with evil intention, but that is rare.

Things like cell phones...yes, I do agree that people should be allowed to have them and I certainly would like them. But one could imagine certain difficult issues-- the patient in the hospital after a suicide attempt prompted by a fight with boyfriend who keeps calling and texting, the patient taking phone calls when the doc needs to talk to her (my patients often take phone calls during sessions--they are adults, they're paying for my time, I'm not setting rules about such thing), the people on the unit who are horrified that they're photo's were taken and placed on facebook (how would you feel?) from a cell phone...

Unfortunately, I think all patients suffer from the shoe bomber phenomena. One person once tried to blow up a plane with liquid in his shoes, now millions of us have to take off our shoes for every flight. Makes no sense, slows things down, and is annoying. Violence is not rare on inpatient units, and the staff worry for their own safety as well as for that of the patients. It's hard to get the lines perfect and some people are more sensitive than others. Since I am one of the more sensitive souls who would be offended by many of the things our readers describe, I do think staff should try hard for a gentler balance.

I am all in favor of kinder, gentler, cleaner, and more respectful environments.

Liz said...

this would be a conversation i would LOVE to have face to face.

invite the family/involve the family EARLY ON in the hospitalization, if the client desires this. my family WANTED to share what they knew about me and to know what was going on-- basically, to be involved in my treatment, and i wanted them included, but they were often made to feel like pests when they called. BUILD THEIR education/participation into the system.

ensure that the patient has access to appropriate care upon discharge-- by appropriate, i mean an appointment with a counselor within one week, and an appointment with a psychiatrist BEFORE meds run out. this sounds so simple, but it hasn't happened the majority of the times i have been hospitalized.

respect the client's wishes, especially concerning medications. for example- if a patient says a medication is making them EXHAUSTED and complains about it, yes, you may be able to force that client to take it in the hospital, but they probably won't once they are gone.

DIGNITY. RESPECT. and let people dress in their own clothes and use their own grooming products as soon as possible. it's hard to get better when you are dirty and in a hospital gown.

there is so much more, but i'm tired and can't think straight right now! i might post again later....

Anonymous said...

I've heard a thousand and one reasons and excuses for maltreatment in psychiatric hospitals - liability, safety, etc. But, there is no justifiable reason for taking a woman who has been sexually assaulted and ripping her clothes off to treat her for depression. None. It's sick, it's dehumanizing, and it's wrong.

One thing I would tell women who have been through what I have been through is that you do not deserve to be treated like that. I would also say that there are people who work in this field who absolutely do not support forced treatment. I found one of those people and she has walked beside me through a lot of my darkness. And, she did it with compassion and no force involved.

Don't settle for forced treatment. You deserve better.

Anonymous said...

Things I like about the hospital I end up in:

- Ability to leave the ward works in levels. Level 1 has to stay on the ward at all times, all hospital garb. Level 2 must be accompanied outdoors, may only wear personal articles during the outside leave. Level 3 can leave the ward for short periods of time (15mins per hour), and may wear their own clothing (including shoes with laces) while on the ward. You start at level 1 and work your way up.

- Prior to discharge you receive "leave tickets". These run for between 2hrs and 6hrs. This helps to reintegrate the person into the real world in small doses, rather than just throwing them out the door. On return the nurses assess your demeanor right after you walk in the door, following up further by asking about your day and how things went, what you did, if you remembered to take any assigned meds, etc.

- Aggressive behaviour on the part of one patient results in a short-term lockdown of sorts. Patients are removed from the room where the aggressive patient is located, and ordered to stay in areas deemed safe until told otherwise. It's a bit scary, but a hell of a lot less scary than either becoming the patient's target of aggression or having to witness the eventual tackle and jab if the patient can't be talked down. And they do make every attempt to talk the person down first.

- The bathrooms weren't locked. They weren't private washrooms, it was a group of stalls with doors. I didn't have to ask for permission to relieve myself. Each room had a sink and vanity in it, no plug of course, don't want me drowning myself. ;)

- Ativan. Seriously, how can you not love Ativan? Mania keeping you awake? Ativan. Can't stop moving? Ativan. Sudden urge to crawl the walls and gouge your eyes out? Ativan and Loxapine! You know what I *really* like about the Ativan though? They ask you if you want it, they don't force it down your throat. If you'd rather sit and stare at the ceiling all night, suffer through the crawlies, generate your own little earthquake go for it! Let me know when you want the Ativan.

Things I didn't like:

- I couldn't have my cellphone while on the ward, because it had a camera. Otherwise, cellphones are fine. I could have my iPod though, and they'd hold the cellphone so that when I go out on my allotted 15min leaves I could use it as I please.

- Food sucks. DON'T eat the "quiche". Thankfully, family could bring food in, which had to be eaten in the cafeteria.

- There's no regard for side-effects. You can tell them your Zyprexa's giving you an insatiable appetite that mentally hurts because you simply cannot feel fulfilled, but hey you're seeming a little less manic today and that's all that matters. Let's up it to 30mg! Mind you, the minute I get out of the hospital I'm going to stop taking my meds, because I can't tolerate the side-effects. Seroquel making you sleep 18hrs? Well, at least you're no longer suicidally depressed! Mind you, that's only because I can't keep myself awake for long enough to hang the rope. GRATE JAWB THAR!

- Interns. My limit's one. Per week. Any more than that and I'm going to make your poor interns suffer for my own personal enjoyment. If you're going to torture me with a new strange looking intern every day expect me to torture back. You're going to ask me the same damn questions when they're done anyway, and that's infuriating. What am I, your busker monkey? Perform tricks so my little interns will thrive! I'm not your damn study guide.

Anonymous said...

You do not get it, any of you shrinks. Yeah, it is all open to interpretation and yours is the right one, always because you can not imagine that any of us freaks are smarter than you are, maybe have the same quals as you do but don't use them. No, i would not want my face on Facebook but there are ways around that and I will tell you that it is one hell of an awful experience to be 'cared" for by people who barely passed a community college program to become an aide.

Anonymous said...

Hey Anon Jan 14, your state is ahead of ours. We require a GED for psych techs.

Anonymous said...

I am a psychology student and am pursuing my masters. I have not had much of an experience in the issue stated in this post. But then I can completely understand. The reason I took up this course and chose this field of study was to help patients like these. I have encountered in real life a few cases who were just out of control, people feared them, people thought they were infested with a demon or something and yet I could help them out with mere talking. I could help them by being human for them. The rules should not under any circumstance let the psychiatrists forget that those whom they are treating or are about to encounter are humans. They too have a life and needs. As one of the commenters rightly said, "treatment should be based on the needs of the patient". I believe that being able to understand the patients on a personal level and bringing together all of their personality, history, previous behavior cycles, family and friends and every bit of information about them would indeed help much more than mere treatment process. It is essential that they be understood on a personal level, achieving that is not something a mechanical degree holder can accomplish, for it calls for a distinct sense of service and sensitivity towards the patients on the part of the psychiatrist or the clinical psychologist. I hope that things change for the better and I hope people won't be losing lives in spite of treatment and that the stigma associated with mental illnesses would be eradicated completely some day. Thanks.

Anonymous said...

See, I have to disagree on the day pass issue. Whether your stay is four days or fourteen, having even one day where you're out on a pass is not only beneficial to the patient in reentering the world, but it's a good assessment tool to be certain the patient is actually as well as the hospital thinks they are. A few examples, if I may:

- If they leave the hospital on their day pass and return a wreck then there's something that needs to be addressed, something that's keeping that patient from maintaining the stability they've just regained while in hospital. Is family an issue? What's happening at home? What does this patient need to continue to thrive outside hospital walls?

- Did your patient spend the day acting on delusions in possibly inappropriate ways? Have they returned with newspaper clippings that, as a secret government spy, they need to decode to find their next mission? Were you aware that their delusions were still this strong, or did the hospital staff miss this because the client tended to keep mum while on the ward?

- If they leave and return with twenty pairs of new socks, your patient's probably spent the last three days downplaying their symptoms of mania in an attempt to get off the ward.

- If they leave and come back without having taken their meds, a cue is given that this patient needs assistance in remembering to take their meds and a plan should be made between themselves and some other support (whether outpatient services or family) to keep them on the road to recovery.

- If they leave with family or a friend, and that friend returns telling you that all they talked about the whole time was suicide, should you perhaps be concerned that they've been playing the happy card in order to escape the hospital and fulfill their plan?

The "general thinking" you speak of is very inaccurate. It promotes falsifying your wellness for quick release, and increases the frequency and likelihood of the patient ending up back in hospital sooner.

With regard to a number of your points, mental health advocates or law societies exist in most communities, and posting of how to contact said advocates or law societies within the ward would go a long way in improving hospital care. On being admitted to the ward, staff are required to provide an information sheet to the patient that tells them their rights under our local mental health laws, which also includes information on contacting a lawyer or mental health advocate. We also have the right to obtain a second medical opinion, so if your first psychiatrist is an idiot without ears, your second one may be of more assistance. The patient may also apply for a review panel if they believe they are still being treated unfairly, and further make applications to the court. All of this, plus all other rights the patient has, are lined out in an information sheet that, per our mental health laws, must be provided to the client upon admission, a second time if their admission is extended or if they transfer hospitals, and of course any time they request a copy of this sheet it must be provided.

Anonymous said...

Woops, posted that last comment to the wrong entry. It's meant for Clink's "What We Need" entry.

Anonymous said...

1. It was three days and yes, it was traumatic and humiliating.

2. The outcome was a cocktail of three drugs, all off-label, with no disclosure of that fact. The psychiatrist described the entire issue of adverse effects as "neither here nor there." (The psychiatrist I saw after I was discharged laughed and got me off all of them, and off all drugs.)

3. A social worker lectured me to be "more passive."

4. The food sucked. Thank God my son brought me Frapuccinos!