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.
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.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
People in distress wouldn’t mind going into hospital and talking to doctors. My son went in voluntarily but sadly the treatment he received shook him badly and was not what he expected. Nobody listened to his problem; he was sectioned and forcibly treated, there was no explanation about what was going on. He had never had anything to do with psychiatry. Doctors don’t have to behave in this way. They should stop treating people as if they were stupid and take the time to listen instead of jumping to conclusions. What needs changing is the way psychiatrists are trained.
Alix, yes sadly there is little in the way of in depth conversation between docs and patients in a hospital setting. I think this is due to a few things:
1 The payment structure. There is no incentive to talk at length when there will not be more financial reimbursement.
2. The medical model. Doctors are generally only educated in using one tool…drugs…for managing suffering.
3. Laziness. It’s a hell of a lot easier to prescribe Seroquel for confused thinking and insomnia than to sit and discuss a persons in depth issues at length.
The Insurance-Big Pharma–Doctor industry have corrupted mental health care to an astonishing degree.
Thank you for this article, Jonathan. Too many people’s idea of reform is just ranting and raving about how they were wronged. Their energy should instead be put into providing better alternatives. If humane and effective alternatives like Soteria were widely available, it could be proved that our methods are better. Once that information gets into research studies in a big way, mainstream psychiatry will have to reckon with us. This is why I think the emphasis on repealing mental health legislation is misguided. We don’t need to make it illegal so much as we need to make it obsolete. Unpopular point of view, I know.
Hey Francesca, somehow I missed your post. Yes, great point. If we create alternatives that are effective, widespread and cheaper than the insurance-pharma-doctor-hospital model, then we could see some real progress. I think avenues like Soteria and Open Dialogue are wonderful models, especially for “first-episode” psychosis where a person hasn’t been caught by the system and has been heavily medicated for a long time.
For those who want a road back to a non-medical model, it takes lots of time, perseverance and support to taper down or off of meds. That is why I support a based peer community wellness and recovery template- where meetings are frequent, everywhere and free. Though “Home based models” are wonderful for supporting people temporarily, most people need a longer system of support where they live in their own home.
But yes, I fundamentally agree. We can’t tear down the existing system without having something truly effective in its place.
I like your analysis of this. I disagree with #4. There is a widespread alternative to the medical model. It used to be called spiritual formation. It was overtaken by the medical model but there are still those who will walk beside you through extreme states and dangerous gifts. There were properties and buildings dedicated to this model all over the world. I collaborate with a group of diminishing property and building owners who would love to see these properties to be re-purposed for Soteria-like purposes. There is probably a building in every town in my state. They would need a proposal and an organization that would dispel the myths of the medical model for them. Would you be interested?
Hi RISN. Yes there are alternatives to the medical model for emergency care, but I don’t know if they are readily available to most folks who are in crisis. I think one of the ideas that we may have to move away from is the idea of creating houses for all people in distress.
Though this may certainly be a great idea for those having a first time break or for people who need intensive support, there is even more need for creating broad coalitions or peers and meetings of people devoted to a non-medical model of healing and recovery.
Many people in distress can’t leave their homes and families but need strong networks of support. I think the 12 step model of meetings throughout the country with peers and sponsors helping people to heal could be a great template for this community too.
So yes, to alternative support houses, peer recovery centers, non-medical based peer recovery meetings, holistically minded professional support…all of it!
Excellent post. Having been in advocacy to improve the psych hospital situation here in MA (and having many experiences of the problems), I completely agree that the paradigm of inpatient psych ‘care’ needs (desperately) to change.
It baffles me how many people think that inpatient hospital is the only, and best, way to get care/support in a crisis., yet the media tends to feed the public that concept. The ONLY useful purpose a psych unit has is to give some respite, and perhaps safety (from the outside world) to those in crisis – but ironically, hospitals often demoralize, disempower, even injure people. Violations of civil liberties abound, in the name of ‘safety.’ There are so many other possibilities out there for respite.
From what I’ve seen, it’s utterly paradoxical that people are hospitalized to stabilize and begin a healing path. The main objective of hospital stays is a quick med change (to satisfy the insurers that SOMETHING is being done). But medication changes take (on average) 4-6 weeks to “kick in.” Discharging people in a few days seems illogical given this fact, and I’m not trying to advocate for longer stays – but is it any suprise that people often come right back in, because their needs haven’t been met or the maelstrom of chemical changes is likely causing even more distress? What is the logical point? One thing is for sure – the hospitals will make more money, and they do. The infamous UHS chain (mostly psych hospitals, 200+ of them) has a long history of abuses and neglect, yet their profit margin averages 25-30% regularly (3 percent is considered ‘healthy.’)
#6 especially resonates with me. Having spent 10 years advocating for change in MA, I can tell you there are hotlines, and legal agencies that work very hard (but with very little funding). The “Five Fundamental Rights” law that lays out basic human rights in psych hospitals and group homes is rarely enforced, and legislation to correct that is “killed” every year. Complaints go to the Dept. of Mental Health (DMH), with a tiny investigation department that is instructed to keep these violations a low priority.
Meanwhile, the public debate is primarily about “more inpatient beds.” In MA, “Big Hospital” (yes, you can use the term!) has incredible financial and lobbying power…so much so that they deny the existence of any abuses and spend thousands battling enforcement of existing law and the humble suggestion that fresh air space should be a right!
Sadly, the misinformed public doesn’t know about these things until they happen to them. I do hope, however, that with time, things will change.
Thanks for the comments Jonathan. I agree theHospitalization model for emotional crisis needs to be seriously revamped. Like you said, medication changes seem to be the only thing really going on. Ad it’s quite bizarre to start someone on something new and then kick them out the door. “Hope that works for ya!”
And yes the supposed watchdog agencies are fairly toothless at this point and true advocacy groups with more muscle need to develop.
One of the biggest issues that you tak about is the public clamor for “more hospital beds” as if that will do much to alleviate people in crisis. We don’t need more beds, we need better options. Less expensive options. Options that are more effective and less dangerous to the welfare of vulnerable people.
Last night I heard that 6 people were boarding in the ER. One was so agitated by having to wait in this space that he was being guarded by a sitter. This is functional? It is exacerbating crisis; creating the template for further trauma.
Thanks for your good words.
Jonathon, I read your posts with interest and certainly believe it would have been nice to know people like you in hospitals in times passed. But it really is mostly true believers.
I very much appreciate that you keep your efforts out in the open and stay positive, realistic, and assertive. It’s a nice example to encounter and fits well with the survivor perspective, although sustained by its own intrinsic value–
Well thought out, clear, timely. A good standard for reminding how to keep at it.
Thanks much travailler. You know its interesting talking about these issues with my co-workers. A fair amount of them are interested in reform, and developing new paradigms for helping people in distress. But at the same time, there is a great deal of inertia and willingness to accept the status quo, deeply flawed as it is. Thanks for your kind comments.
Jonathan an excellent piece! Where hospitalization is usually associated with an intensity of care and specialization not available in the community inpatient psychiatric hospitalization is associated with little more then beds, meds, and a desultory milieu. If anyone ever questions why consumers fail to reach out when in crisis they should consider what it is like on an inpatient psychiatric unit when one hurts. Not unexpectedly many consumers don’t reach out again and afforded no other options are no longer with us.
Hey Joe, I agree with you that hospitalization is generally a holding tank, beds and meds. Its interesting to me, though, that we get many many voluntary patients and patients who return to hospitals. For some people who are homeless, it is a place to get some rest away from the street. For others, they are invested in the medical model and simply want to tinker with their meds. Some patients do feel that “doctor knows best.” And for others I have talked to, the hospital actually provides a needed respite from where and who they were living with.
But at base, this is really all that is offered out there with a few exceptions. If there were better alternatives, I am sure that many would take a different path.