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.
