I walked up to the hospital with my purse clutched to my side and a spring in my step.
My first day as a mental health counselor in inpatient psychiatry began with the disorienting orientation. My new supervisor was late—I would soon find she’d be late or absent for most of the orientation hours due to the predictably unpredictable chaos of the 5-South unit, my new workplace. Staring at our thumbs and reading half-assed packets on hospital policy, a new nurse and I sat in the dimly lit conference room and listened to the echoing screams of patients we would soon come to know as some of Methodist’s “frequent flyers” (a fun term used by staff to obliquely refer to Methodist’s impressive recidivism rates). We strained to make small talk. She was a seasoned nurse looking for a change of pace, or a something else, or maybe just weekend work. In the quiet of those first few hours on the job, I watched a slanted smile tuck into her cheek and her eyelids droop. I watched some dull recognition rise between the two of us as the minutes dripped on and we turned our cheeks toward a leaking faucet and peeling paint on the walls.
When she arrived, my supervisor was fairly convincing in her read-through of the rules and regulations, but I would soon come to recognize that this was all more of a formality. The real concern was making sure the right papers were signed and tucked away in my file on the off chance of any kind of administrative review. At first, I had my stupid purple pen and fresh notepad out on the table. I played attentive student until I realized it didn’t matter.
Before I knew it, I was on the floor for training.
I was thrown in to observe an admission. The new patient was a severely psychotic woman who looked into the air like it was teeming with ghosts. She called us witches and warlocks and vampires. She stomped and clapped. She was swiftly given medication. Before I knew it, she was locked behind a door. Behind her face pressed up against the glass I could see the darkened, stained window of the restraint room that seemed to forever look out over a stormy landscape. I wasn’t sure what to feel. Is this really what this place is for? I thought we didn’t isolate people. Is this the safest option for everyone? How do we know whether or not to give someone a chance? What other rules am I going to see off-handedly broken without discussion? My mind was racing. I kept moving.
Over the next few weeks I learned the ins and outs of the units and some extra tips and tricks from my coworkers:
Coffee goes out at 7:30am. Breakfast at 8am. Start the morning announcement with the date and remind the patients to recite it correctly to the doctor in order to look good. Because most people are seemingly held against their will, reinforce compliance. Tell them to shower and take medication so that they can leave. When they question this, reinforce compliance. Their only problem is that they don’t do what they’re told or don’t clean up well enough.
Remind them to stop by the nursing station right after breakfast. Medicate the anger you’ve elicited. Don’t offer other explanations or treatments. Presume every person’s goal is simply to get out. Obscure the fact that the staff just don’t want to deal with any of it anymore. Listen to the hum of the hallways when every patient has finally surrendered to the dull tick of sedatives in their blood. Comment on what a good day it is—don’t use the “Q” word (“Q” for Quiet: the presumed aim of treatment and a curse word that will summon the demons awake). No one is moving.
Get patients in and out of the place quickly. No need to talk to them too much when they come in; greet them with a beeping blood pressure machine and a scale. They’re crazy anyway, what do they know? Take away their things and strip them down to nothing. Presume the worst.
Assist with ADL’s (activities of daily living). In other words, if someone is starting to smell bad, threaten them with shots and apply the good ‘ol shower “bum rush” (a friendly way to refer to surrounding a person with multiple staff members, dragging them down the hallway, and throwing them into the shower room). When they get upset about the total violation of personal space and agency, never fear! You can just close the door and whip them with a towel.
Talk to patients if you have the time. Make sure you get something to document, especially if it means asking leading questions that irritate them into sounding crazier. Dismiss their concerns as symptoms which are meant to be eliminated. If they seem to be worse off as they walk confusedly out the door with a lopsided stride on the day of their discharge, don’t pay it too much mind. They’ll be back.
Most importantly, be ready for when things go wrong. As soon as someone starts raising their voice, ready the syringes and get your gloves on. Surround them. Grab the restraint bag. You never know what could happen. Ignore how they might be responding out of fear. Call the code. Drag the patient to the restraint room. Never mind that verbal deescalation training. We need to set an example. We don’t have time for this.
As I went through the training, I convinced myself that I was the newbie employee that just had to suck it up and learn the ropes. Yet, still, something about all this didn’t seem quite right to me. Wasn’t helping people get better what we were here for? By all accounts, it seemed some of the “procedures” I was witnessing might actually make someone worse off. The best outcome seemed to be getting people to sleep and stay in their rooms or stare blankly at the day room TV as if they were toddlers. By a few weeks in, I was already seeing familiar faces. I looked for some reassurance that someone in this place knew what they were doing. Surely the doctors would?
I remember one of my first encounters with the doctors at Methodist. I hear a raised voice down the hall, and rush over only to see a doctor huffing as he hurriedly exited a patient’s room. I learn that he was just sounding off his usual mantra: “Take your medication and don’t do this again! Once you take it, then you can leave.” “Your medication” here translates roughly to “the same five medications I give to every patient that walks in this door.” This treatment plan is ineffective and unethical, but upon mentioning this to a coworker I am told “there’s nothing we can do about it, it’s always been this way.” Another coworker considers his method “just really old school, you know?”
Well, that was one down. What about the others? Another doctor admits his greed openly and criticizes my plan to go to school for clinical psychology because “that’s not where the money is.” After a hasty and awkward lunch with me one afternoon, he stands abruptly and exclaims, “Time to go heal people!” before exiting the quaint hospital cafeteria. I almost choked on my carrots. The irony was not lost on me when he demanded the immediate (and totally uncalled for) restraint of a psychotic man with grandiose religious delusions who loudly questioned his legitimacy as a psychiatrist.
Some other psychiatrists only feel comfortable meeting with patients from behind the nursing station door, as if looking at them from across a fence. The meetings last seconds if they even happen that day. Patients are left stranded, walking the desolate hallways confused and heavily medicated. I come to dread talking to new patients only to hear that they haven’t seen a doctor in multiple days after entering the hospital in crisis. I realize quickly that the doctors are as equally lost as the rest of the staff.
The staff are poorly trained, overworked, underpaid, and severely burnt out. The few that seem to take pleasure in their work really just enjoy closing doors and yelling at patients in gross displays of their daddy issues. Others enjoy the endless attempt to keep the unit under control or the endless opportunity to blame this or that person or circumstance for their woe. Most of the staff fall back on the juicebox theory, the superstitious belief that the acuity of the unit can be effectively managed through ordering enough juice so no one has anything to complain about, in lieu of attempting therapeutic interventions. When this doesn’t work and a patient still is anything but comatose, ultimately patients are still easy scapegoats and fun to complain about! Don’t worry if a patient suffers from paranoid delusions and overhears you, of course.
The selection process for patients is often obscure. Details are missed. Patients come in that staff are unable to adequately take care of. Patients come in and there is lack of clarity about their history. It becomes apparent that the logic of the hospital is more of a numbers game than an issue of what is and is not therapeutic. Patients are locked in rooms without bathrooms only to end up shitting on themselves and the floors.
I am sick of it at this point. I reach out to the supervisors to address some of my quickly growing list of concerns. Even the cases of abuse and neglect I report are not taken seriously. My attempts to start up dialogue and address some of the issues are ignored and even seen as threatening. The first supervisor I talk to gives me a stony look and explains that she is going to tell the staff not to lock doors. The second tells me how “there are five types of patients in this hospital…” and “it just gets to you, to be called a fat bitch every day.”
I am soon after blamed for a large, martial arts-wielding patient ripping out a ceiling camera, because at some point in the day I attempt to talk to him rather than endorse another injection of Ativan that puts him into an enraged stupor. I am asked if I read his chart and knew his history of repeated hospitalizations. Internally I wonder why, by that logic, they don’t just put all of these people down. The machine keeps rolling.
I start to read medical literature about inpatient psychiatry and articles about the history of medicine. I am up late at night reading about corrupted inpatient psychiatry cultures and thinking about how right Foucault was. During the day, I’m observing myself as I hold patients down to get medication. I realize the issue is larger than just this strange, nightmarish hospital I work in. I am talking with friends who are in total shock at what I’ve been witnessing. Feeling aghast as the words for what I’ve seen come out of my mouth outside of those locked doors, I am in total shock with them. I am often more shocked by the negligence and cruelty of the staff than by the bizarre and violent behaviors of patients. I start to question my own morals. I start to think everyone in the hospital is insane. I start to wonder how I could be there.
A week after I start applying for other jobs, a staff member is severely injured while I’m working. There is blood on the floor and all over her pink button-up. The patient who assaulted her asks if he killed her and when he’ll be getting dinner all in one breath while lying in restraints.
I leave. There was nothing left to do but leave the place, report it, and never come back. Job schmob, I want to be alive.
The experience was a total wake-up call for me. I witnessed things at Methodist that were not only horrific but illegal. It was amazing and disgusting how normalized these practices had become. I not only had to confront the reality of poorly understood, nigh untreatable psychiatric conditions, but also of a hospitalization system with serious and devastating flaws. I felt immensely powerless and at times became so burnt out myself that I understood how my coworkers could end up so negligent, numb, and at times abusive. I understood how patients, on the other end, could become violent or self-injurious after years in these dismal hospitals.
Understanding the systemic issues or not, there was no excuse for what I witnessed. Any incident of violence, especially patient abuse and neglect, must be acknowledged as a total failure. Instead, I saw these incidents and behaviors accepted as routine. I met so many patients with histories of trauma who had been in and out of psych wards for years and just came to expect the mistreatment.
Now I’m left with a lot of questions. How do places like Methodist become possible? What is the real goal of inpatient psychiatric care? Especially for underserved populations, what is the difference between the “inpatient psychiatric unit” and a prison? How has an over-reliance on medication promoted unethical, weak medical practices and even compromised safety? And most importantly, are these places recreating the illnesses they purport to treat?
Editor’s Note: We have removed the author’s photo and full name at the author’s request.
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.