Hospitalization: A Crisis in Crisis Care

This Wednesday, March 19th I will be speaking with the wonderful folks at Rethinking Psychiatry in Portland Oregon.  These amazing individuals are working on reforming the mental health system and creating practical alternatives such as a Soteria-based housing model in the community.

As I look at the present state of how we help people in severe emotional crisis I see enormous problems from beginning to end.  I want to outline some of those main problems and then look at some ways we could work to reform them.

1. No Options 

When people are in severe crisis there are few options in the community. How often have we heard stories of people who desperately wanted an alternative to a hospital for their care?  But the options are limited.  If family members, peers, therapists, and other providers cannot provide enough care, then often people are forced into the decision to come to a hospital setting.

Reform:  Many of us have been working on creating alternative models and there are a number that have been quite effective such as Second Story in Santa Cruz and Soteria in Alaska.  Burlington Vermont is also working on creating a Soteria-like alternative.  There is an increasing need for “non-medical model” recovery based peers who can act as a backstop to help prevent hospitalization.  Peer based meetings, on-line support groups, slow taper support networks, peer based respite, short and long term housing based on holistic wellness are all ways to create alternatives to the medical model crisis intervention.

2. One Size Fits All

People with a wide variety of backgrounds are all funneled into the monolithic mental health system.  If you go to an inpatient hospital setting, you will see elderly people with dementia, developmentally disabled people who have become increasingly confused and agitated, young people going through a first time episode of psychosis, older people who have cycled in ad out of hospitals and taking large cocktails of meds, those experiencing psychosis who are more predatory on vulnerable people and those trying to get off drugs and alcohol.

This is a wide array of people with vastly different personal narratives. But generally the treatment is the same.  Get them started on meds, restart their meds, or up their dose of meds.

Reform:  Different people need different support.  Though someone who has had a first break may fit in well to a Soteria like environment, someone who has been taking large cocktails of psychiatric drugs for many years may need a very different type of care environment.  Those who have been in the system for a long time may need support with slow tapering off their meds while also being supported holistically with good nutrition, enough rest and support from the community.

3. The ER is a Horrible Place to Go When You Are in Crisis

You all know the setting:  Bright florescent lights, noisy sterile hallways, busy and sometimes imperious medical staff, security in uniform, and then a small unfurnished room with a bed.   Right now in Portland the increasing lack of psychiatric beds means many people in distress “board” in these rooms for long stays, sometimes up to several days.  Imagine if you are in crisis and you are made to stay in this setting for days at a time.  If you are already experiencing confusing hallucinations, frightening thoughts and ideas, or are going through severe depression with suicidal thoughts, this setting is likely to make you feel worse, not better.   Often this can be a trigger point for violence as individuals are made to change into scrubs, give up their belongings, and are often told they will be made to stay in a locked unit.

Reform:  Ultimately, I believe that states should adopt a model where those in emotional distress no longer come to hospitals.  Hospitals are filled with medical professionals and “healing” is based largely on pharmaceutical drugs and surgery.  I believe there should be a center where people can go for help when in severe distress.  I will not be pollyanna and I acknowledge that there are some people who probably need to restart their drug medications and then develop the tools to slowly taper them down.  And some people who are both experiencing psychosis and are acting violently towards others may need a locked facility to protect them from the community.  But this center could also have units that do not use drugs as the primary method of care and instead promote non-drug wellness based models of care instead.

Instead of an emergency room for this facility, there would simply be an admissions are to a Care Center.  The architecture and lighting could be more conducive to feeling calmer and more relaxed.   Though doctors and nurses could help those who need or want to take psychiatric drugs, most of the employees would be non-medical staff trained in non-hierarchal, recovery based care.

4. The Medical Model

There is no widespread alternative to the medical model for working with people in crisis at this point.  Right now, if people come to a hospital, the main goal is “rapid stabilization” and then discharge as quickly as possible.  Rapid stabilization means drugging a person until they are more sedate, and less actively symptomatic or suicidal.

Due to funding cuts and an insurance model based primarily on cost cutting, there has been an increasing move towards getting people out the door as quickly as possible.  People who feel fragile and vulnerable are generally given strong doses of drugs, a prescription and then often ushered out the door within a few days.  (In fact, from my recent survey, more than 25 % of people are made to leave the following day after being admitted.)

Reform:  The establishment of the drug based medical model as the primary care option for those in emotional distress needs to be radically overhauled.   When interacting with patients who are considering taking a drug for the first time, I believe a doctor should give a “Miranda Rights” explanation to the patient.  That means, that a doctor would need to specifically and carefully lay out the problems inherent in taking a psychiatric drug including the side effects, the long term health implications and the serious issues with trying to withdraw off these drugs.  If someone had cancer and talked to their doctor about starting chemotherapy, there generally is a long conversation about the pros and cons of starting such a regimen.  This is almost never the case for psychiatric drugs.   This needs to change.

5. Doctors With Extrajudicial Authority

Right now an ER doctor, along with a psychiatrist, have the power to hold a person in a locked facility for at least several days.  (In Oregon, a hold can run for up to 7 days.)  That is an amazing amount of power we give to an medically trained individual who has very little oversight in their position.  They also have the incredible authority to order forced drugging of individuals who have been court committed for up to 180 days.  This is an amazing abrogation of our constitutional rights and an extrajudicial use of power that is supported by many “for the greater good.”

Reform:  We need to seriously reexamine the idea that doctors can be given the right to hold a patient for a period of time in a locked facility.  In Portland, Oregon, doctors are compensated up to 800 dollars for each admission of a patient.  In essence there is a financial reward for holding a patient against their will in a hospital setting.  This leads to a serious potential for corruption and abuses of a vulnerable population.  Also, many people are placed on a hold as a way to get compensation from the county for payment for the psychiatric bed.  They may not present any grave threat to themselves or others but the need for financial compensation leads to an abuse of civil liberties.  Finally, the power to mandate forced drugging of patients is a practice that needs to end.  It is a violation of civil liberties and deeply harmful to the long term health of individuals.  This entire aspect of crisis management needs to be completely overhauled as well.

6. Minimal Oversight

In hospital settings throughout the country, staff have the authority to order a “code” and put hands on a patient, restrain them, seclude them and give them forced injections.  This again is an amazing amount of extrajudicial authority to grant medical staff.  Right now there is no formal outside oversight over these codes.  With police, there is often intense scrutiny of their interactions with the community.  There is often film to watch, eyewitness community members and formal organizations to examine police behavior.

Reform:  We need to develop outside watchdog agencies that specifically examine how hospitals work with patients in these “codes.” There should be a hotline where patients can report incidences of abuse.  Hospitals should move towards creating a universal template of care that seeks to minimize any hands on approach to patients through deescalation skills, non-hierarchal communication, greater listening skills, and offering comfort measures and a space to express anger and frustration in a safe setting.

Conclusion

There are no easy answers to how to help people in crisis due to severe emotional distress but the answers we have now are not only lacking, they are often dangerous to the immediate and long term welfare of many individuals.  While reforming the medical model structure of crisis management, we need to create a template of holistic and alternative care with a multitude of options for a wide variety of people with unique narratives.  Changing our approach to crisis requires a multi-level approach that involves legal challenges, in-system changes and grassroots development of practical alternatives.