When someone is in severe crisis due to feeling emotionally overwhelmed, one of the main access points for receiving care is an inpatient hospital setting. People come for mental health care in a hospital when they are feeling suicidal, have attempted suicide, or are becoming increasingly confused, have strange distorted thoughts or are hearing malicious and scary voices.
In the best of worlds, the hospital setting would be a sanctuary, a place for respite and nourishment, where the mind and body can find a place of ease and stillness before returning to the outside world. People who have experienced severe emotional trauma and cannot think clearly need a place to rest and get support.
For the past eight years I have worked as a therapist in psychiatric units of a hospital. As a therapist my main job is to listen to patients, help them navigate the maze of inpatient hospitalization, and offer them support and comfort measures. I also help patients if they become severely agitated. I spend time trying to hear their concerns, sometimes helping them find a comfortable and safe space to vent. And yes, I have taken part in restraining individuals and delivering injections of medications to patients who become severely hostile, threatening or self-destructive.
When someone becomes severely confused, psychotic, or suicidally depressed, one of the main options for helping an individual is to bring them to a hospital. Though many disparage the hospital setting, there are few alternatives to this setting during an acute mental and emotional crisis. The positive aspect of a hospital setting is it provides the space and time for an individual to go through severe crisis before returning home or to a step down facility. At the same time, there are also a number of barriers to individuals getting optimal care, and there are numerous stories of individuals being treated harshly, restrained with excessive force, forcibly medicated, “treated like a child,” and treated with condescension by doctors.
I will try to examine some of these barriers and some of the main critiques of hospitalization.
Critique 1: “They over medicated me.”
One of the main critiques of hospitalization is that the fundamental way of treating individuals is prescribing them strong medications with side effects that can cause long-term adverse health problems. Not too long ago, doctors would sit and do “therapy” with a patient. The doctor would help explore and navigate the myriad social, family and individual barriers to greater health and well being. Since the 80’s that has really shifted towards a medical model of managing mental illness as a disease. The underlying philosophy is that mental illness is a permanent condition based on organic and chemical imbalances that can be fixed, or at least managed, with pharmaceutical medications. As Robert Whitaker, and many others have pointed out, the idea that medications fix chemical imbalances is simply erroneous.
Medications such as atypical antipsychotics and mood stabilizers do indeed exert a profound effect on the brain’s chemistry and often act to sedate patients so that the extreme symptoms of their illness – such as loud intrusive voices and manic behavior – is quelled. These medications do not actually “fix” the underlying brain chemistry that lead to altered states of mind, but for someone who is overwhelmed, agitated, not sleeping, confused and plagued by delusions, a sedative drug can be a very helpful short-term measure. It allows the body to rest, get some sleep, reset, and try to find some balance.
However, the long-term use of these potent medications can also bring a host of complications. Psychiatric medications often come with a side-effect profile, and withdrawal can be extremely challenging. Worst of all, though they can sometimes be effective in the short term, they tend to lead to the need for an escalating level of medication; a cocktail of anti-depressants, mood stabilizers and anti-psychotics. For some, these medications can have a cumulative effect that leads to a variety of health complications. I have seen patients started on a commonly prescribed anti-psychotic come back in 6 months having gained over 50 pounds. Others develop tardive-like twitches, and akathisia, severe lethargy, foggy brain, high blood pressure, dizziness and diabetes.
When doctors have conversations with patients, there is rarely any talk of side effects, long term health concerns or potential problems with withdrawing. In a hospital setting, a doctor/patient conversation is often quite short, and in that brief assessment, medication is prescribed that can change the whole course of a person’s life, especially if they are going through their first psychotic episode. Each individual needs to weigh the pros and cons of taking medications and, for some, medications and their associated risks and side-effects will seem a better choice than being plagued by delusions, confusion and roller coaster ups and downs. However, I believe the choice to take medications needs to be a much more informed one.
Critique 2: “They restrained me and shot me up.”
When someone has come to the hospital because they are extremely psychotic, agitated and acting in a threatening or self-destructive way, there is a strong chance they will receive forced medications and sometimes restraints if they don’t willingly take medication orally. The first point of contact is the emergency room of a hospital and if a patient becomes severely agitated, there are few options for staff. Generally, staff take the time to try and talk to the patient, offer comfort measures and help divert them, but if a patient escalates to a point of being threatening, staff will call a “code” and restrain and give a patient a forced medication.
The tip-over point of when a code is called is a subjective one that depends on the specific staff. There are staff that are better or worse at helping calm patients, and some that are way too hair-trigger in their move to force such as chemical and physical restraint.
In my hospital, I have seen a lot of movement away from restraints and a lot more attention placed on trying to gain an alliance with a patient, offer them a safe and supportive environment to vent and be intense and angry without moving towards a “code”. At least in my hospital setting, the prison guard mentality has largely disappeared though I am sure that it still exists in many hospitals around the country.
Though restraints are very uncommon on the unit at this point, they are still used, and mainly because the patient has become so violent that they are attacking staff or other patients. Some good questions to ask are, “Why has the patient become so violent?” and “Could the patient have de-escalated if he had been listened to and offered support before he became violent?” As staff become trained and supported in a culture that promotes listening and de-escalation, restraints become increasingly rare.
In terms of forced medication, it is generally given only in two situations. The first is when a patient has become extremely self-destructive, threatening or violent. If the person doesn’t de-escalate after prolonged staff interaction, or will not take oral sedative medications, I support the limited use of injectable medications to help stop violence.
I know this is a highly controversial subject for many members of this community who have been horribly abused by overzealous and harsh hospital staff trying to exert control and force in a humiliating way. At the same time, when an individual has shifted towards being actively violent towards staff and patients, there comes a point when it is essential to protect these people. There is no easy answer to this. Forced injections are by nature traumatic. But staff and patients being violently attacked by a psychotic patient is also traumatic. I think many “codes” can be dramatically reduced by making effective non-hierarchal alliances with patients and supporting them before they become violent. At the same time, if all other measures have been tried and a patient continues to be violent, there are sadly few options left to protect other staff and patients.
The other situation for forced medications is for patients who have been involuntarily committed by a judge and continue to choose not to take medications. In this case, a doctor (and a second opinion doctor) decide to administer medications involuntarily to a patient in order to “help them stabilize.” I don’t support this form of forced medication for a few reasons. For one, the long term use of medications can have serious health implications and I believe an individual needs to partner in that decision. Secondly, a patient who is forced to take medications in a hospital setting is very unlikely to voluntarily take those meds once he returns to a less secure setting. Once he goes off the meds, he is likely to experience the myriad withdrawal effects from a very quick taper off a neuroleptic. The withdrawal effect from quickly going off the drugs often can spike psychotic symptoms and lead to being hospitalized again. Finally, the notion of forcefully administering a very potent drug to an individual that doesn’t present an imminent danger to self or others seems unethical to me, personally.
Critique 3: “They don’t listen to me”
A hospital setting is by its nature very hierarchical. When an individual comes to a hospital seeking care for mental health concerns, they are treated primarily by a doctor. That doctor gives orders for medications and other treatments that the nurses, therapists and line staff follow. As I have said before, conversations with doctors are usually very short and for some patients, they feel that they are not getting their needs met, are being prescribed meds that are too potent, ineffective or that are causing side effects.
Instead of a therapeutic alliance, for some people the relationship to the doctor can feel paternalistic and lacking in any meaningful connection. The doctor is placed in the impossible role of trying to solve mental health issues and complex myriad social and family of origin issues with short 5-minute conversations and prescribed psychiatric medications.
One of the main reasons for “not listening” is that insurance companies have moved towards managing mental health with medications and do not effectively reimburse any long conversation with a doctor. In essence, it doesn’t pay to talk.
The other main reason for not listening is that doctors have been trained in managing illness with medications and are not trained in integrating psychological methods or more holistic ways of managing mental health such as mindfulness training, nutrition, or healthy coping strategies. Sadly, those ideas are often left to therapists as an after-thought while the emphasis is on medication.
The other aspect of hospitalization is that the process has become quicker with patients cycling in and out at a much faster rate. Insurance companies don’t want to pay for long hospitalizations so they push for rapid stabilization and then try to get them moved out as soon as possible. This has changed the face of hospitalization dramatically. In the 70’s, patients stayed for quite a long period of time and now many of them leave within a few days.
Patients are admitted, prescribed medications and then a quick plan for outpatient care is provided. Nurses and therapists are often busy with the process of admitting and discharging patients, and less time is available for one-to-one contact. They are also busy at computers monitoring the thousand tasks they are assigned and have much less time to interact with patients. This can also lead to a feeling of being isolated and “not listened to”.
Hospitalization: New Models of Care
In this framework, is there any way for hospitalization to work more effectively and provide a greater degree of care and support for those experiencing a mental and emotional crisis?
The main good thing I see is a strong movement away from using coercive tactics such as restraints and injectable medications for “managing” agitated patients. My hope is that this trajectory can continue and a strong emphasis can be placed on developing therapeutic alliances and utilizing de-escalation skills, such as offering a safe space and comfort measures, as an alternative to the traumatic practice of restraining and forcibly medicating people.
However, even in the context of a less coercive environment, the disease model of mental health care underlies much of the care that people receive in this setting. Long-term care with potent medication is the main course of treatment one receives in a hospital setting. Alternative treatment models may have to come from outside of the framework of a hospital setting.
In a perfect world, those experiencing severe emotional crisis would be able to find true sanctuary; a place for rest and healing. The primary goal would be to allow them to cycle through their altered state with the support of compassionate and caring staff. Instead of incorporating a disease model of mental illness, these facilities would present a recovery-model based on the belief that with enough time, nourishment and self-care, people experiencing severe emotional distress can and do get better.
Perhaps alternatives to hospitalization can be developed that are not as costly. The average stay in a psychiatric unit of a hospital is over $1200 a day. I believe a “sanctuary” model of respite homes for mental health crises could be created that would be much cheaper if the staffing were weighted more towards peer counselors, and less dependent on highly paid medical staff. If they were much cheaper, perhaps insurance companies and state and federal agencies would agree to pay.
This model of treatment has already been developed and implemented with good success. Loren Mosher’s Soteria houses in the 70’s and 80’s, for example. In these settings, patients received care from staff who treated the patients as peers and worked with them in running the home and doing the chores. Psychotropic medications were administered occasionally, but usually in low doses and with no coercion.
In these calm and quiet facilities, people who were experiencing severe altered states and emotional distress were able to return to a greater state of health and well-being over time. Soteria Houses have been duplicated in Scandanavian countries and in Germany with much success. I believe there is no reason we can’t develop new “Soterias” in the US; respite houses for those experiencing severe emotional distress to come and find rest and healing.
In the coming years, I hope that the work of this community will propel a movement that creates viable alternative structures for the care of those who are experiencing severe mental and emotional distress. Perhaps the model of care we develop for those in crisis will be one of sanctuary; a true place of rest and healing.