I am a 29-year-old survivor of child abuse, poverty, and substance addiction. I am also a clinical social worker and now a graduate student seeking my Ph.D. in psychology. From the age of 25 until I entered graduate school at 28, I worked twelve-hour days, four days a week in a university psychiatric hospital as the lead inpatient therapist. In this story, I reflect on my actions while working in the inpatient ward and how this work changed me. Throughout the essay, I put certain words in quotation marks. They indicate words I once used compulsively as a psychiatric provider. These terms came to influence how I saw patients and, eventually, the world around me. These marks also reflect the fact that, after I learned the purpose and harm of these words, I chose to no longer use them.
When I began my work, I truly believed that forced hospitalization, psychoeducation, medication, and confinement were viable solutions for healing “mental illness.” I believed this because I was taught that “mental illness” manifests from within the person. Thus, during my month-long training in the inpatient ward, the mechanisms of medication (involuntary or otherwise) and confinement were explained as pivotal in reducing illness and promoting well-being. But mostly I believed in psychiatric hospitalization and medication because I witnessed “hypomania” replace “hypermania,” “elevated mood states” supplant “depression,” and trust replace “paranoia.” Mere days after hospitalization, I watched people “re-regulate” and de-thaw from the icy hand of illness. I thought inpatient treatment was a panacea.
After training, I was champing at the bit to help people and to shift from believer in traditional care to provider of traditional care. After all, I felt I was uniquely qualified to do so. My history of child abuse, poverty, and substance dependence granted me a perspective that I perceived many other professionals lacked. In fact, I would be lying if I stated that I did not feel as though the “patients” gravitated toward me more than my nurse or psychiatrist colleagues. Whether or not this was because I was a therapist or because kindred spirits sense one another, I do not know.
My schooling and on-ward training with the psychiatrists had indoctrinated me into the traditional medical model of health and well-being. I acted out this programming almost immediately. In my first week, I met a young woman who was “delusional.” She said snakes were crawling in her stomach. She wanted to get them out. The nurses impressed upon me that she was refusing medication and that she had requested therapy. They hoped I could persuade her that medication was a good idea (perhaps the most common request I received during my time as a therapist). So, I set forth on my first solo encounter. I recall listening to her talk. I remember noting that her feelings seemed real and that her belief about the snakes appeared as strong as any belief I held. But I did not remark much on her feelings or beliefs. I told her that her medication would help. When she refused, I told her the snakes wouldn’t go away unless she took the medication. That seemed to do the trick.
She only grumbled to me about snakes once more during her weeks-long stay. We perceived her reduced complaints as proof that the medication had worked. A chalk mark in the win column. Thus, I perceived my first encounter as a victory and was hungry to continue. Yet, I remember hearing this “patient’s” remark that she frequently talked about the snakes among her peers in the ward. Today, I cannot help feeling that she stopped talking about the snakes to me because she’d lost trust in me, not because the medication worked. That chalk mark should have been in the loss column.
Some months later I was put in charge of running group treatments. I thought this was a great opportunity to educate group members on the reasons they were “sick.” During each group, I drew a large circle on the whiteboard. I then “cut” the circle into four pie slices labeled Biology, Psychology, Social, and Spirituality. I instructed the “patients” that their biology was faulty. I told them how this faulty biology influenced their psychology, causing deregulated thought processes. I told them how their illness prevented them from having social engagements, which in turn minimized their spiritual well-being. I usually concluded by telling them how their medication could be combined with a good diet and good friendships to make them less ill. I failed, however, to tell them how to establish good nutrition or to find friends and rebuild trust with others. Nonetheless, I went home many nights to sleep well, feeling assured that I was helping others find freedom from their “illnesses.”
Shortly after working at the psychiatric hospital, I began to notice personality changes. When I would go out to the gym, grocery store, or to socialize with friends, I began to expect people to talk to themselves or to shuffle amotivationally. At work, I would frequently hear a high-pitched buzzing sound. This meant that I had to spring into action because someone was having a violent outburst and I had to calm or hold someone down long enough to allow a nurse to inject emergency medicine. Sometimes in public, I would hear a similar sound. The hairs on my arms would stand on end. I would stand up in my seat, ready to act.
Furthermore, I began to “diagnose” my friends, family members, and romantic partners. I could be with no one without seeing sickness. I left several partners because they expressed some thought I found bizarre; I assumed they had the “gene” for “schizophrenia.” And I did not want to be around when some stressor activated that gene. Though I would hear friends express understandable emotions stemming from stress, I would mentally label them with some diagnosis. I even occasionally suggested they pursue medication. I became guarded in personal relationships, indifferent to suffering I could not “cure,” and advocated for hospitalization or medication whenever I saw people in emotional distress.
This was the insidious effect of psychiatric work. I became an instrument of psychiatry. Wherever I went, I anticipated illness and sought out people to diagnose and treat. I became a boundaryless tool of psychiatry.
Cracks in the Hull
For about two more years, I worked with unskeptical enthusiasm. But during my final year, my skepticism mounted. There was an intimidatingly large person who came into the unit about every three months. He had a low, booming voice and spoke eloquently. He always had disheveled hair, patchy facial hair, and was usually dirty when he entered care. Slowly, he and I became friends. Building this friendship took considerable time.
The last time I saw him, he was dirtier and more disheveled than usual. I left him alone for the first day, knowing that he would want to sleep. The next day, I engaged him. He told me the governor was throwing thought bombs into his head and that his thoughts were being broadcast. This was a normal conversation for us, but this time he was unusually animated. I was worried. I asked him if he wanted to take medication. Often when I made this suggestion, he would say yes. This time he yelled at me: “THESE MEDICATIONS DON’T WORK A DAMN! IF THEY DID, I WOULDN’T HAVE TO KEEP COMING HERE!”
I was shaken. He had never yelled at me before. Moreover, this was the first time I had been forced to reckon with this idea. If these medications were supposed to cure, why were these people still coming and why would medication stop working? Did it ever work at all? I felt a seed of doubt plant itself for the first time. As it turns out, this seed would sprout more quickly than anticipated.
Later that day, my friend raised his voice at the psychiatrist. Undeterred, the psychiatrist turned to the nurse and swiftly told her to get his meds to avoid an emergency. To this day, I know the psychiatrist misjudged the situation. My friend only wanted to be heard. However, I dared not speak up. Fear of losing the clout I’d gained rocked my bones.
My friend knew the psychiatrist’s words meant forced medication. He barricaded himself in the television room. The buzzing alarm was sounded and a troop of technicians dutifully rolled into the ward. Their militant posture betrayed any notion that they were there to help. They were eager to engage. My friend held the door and they pushed and kicked it in. The door lurched inward on my friend and scraped off his toenails. He howled and my stomach turned as I watched them pull him to the ground while the nurse injected him with medication. He never spoke to me again. In many ways, this episode mirrored my first therapeutic encounter at the ward. Trust built through laughter, candidness, and months of earnest sharing dissolved instantly as I stood by watching the psychiatric machine swallow my friend’s dignity.
Days after the incident, I filed a complaint. My complaint disappeared into the ether of the healthcare system, where all things that enter dissipate, never to be seen again. I also spoke with the attending psychiatrist. She reminded me that had my friend not barricaded himself and taken his medication, the situation would not have unfolded the way it did. I soon recognized that my complaint would not be heeded and that the psychiatric treatment team could see no harm in what they had done.
During my last year at the hospital, many incidents occurred that I found unsettling. Strangely, many of them were things that would not have bothered me in previous years. When I would see people readmitted to the hospital only days after they’d checked out, I could no longer place the blame on lack of “adherence to treatment.” I conducted a survey and found that over the past year, our re-admission rate was higher than 50 percent. This was hardly a re-admission rate one would expect to see if medications and inpatient treatment definitively worked.
Then I began to run groups differently than I had before. Instead of drawing pie charts, I asked people the reasons for their hospitalization. The answers ranged from child abuse to drug dependence. Many individuals were homeless. Mothers had been admitted to the hospital after their children’s deaths. Young adults checked in because they felt suicidal after a devastating breakup or the loss of a loved one. These answers to “why are you here?” differed drastically from the reasons ascribed by our treatment team. Not one person mentioned that they’d been hospitalized due to “atypical treatment response” or medication “non-adherence.” Though their charts attributed their hospitalization to these reasons, I heard no mention of these terms from the people themselves. We could not treat the real problems, though, if they were not identified in the charts.
I also stopped “psychoeducating” in groups. Instead, I began to ask for people’s stories, and we all took turns sharing. When someone refused medication, I no longer saw a renegade with “anosognosia.” Instead, I saw a person making a choice, and connected them with a peer who then connected them with alternative recovery methods.
In my final months at the hospital, I recognized that people entered care for understandable reasons. I discovered that sharing stories brought people to life and created connections that sometimes went beyond the hospital walls. I stopped diagnosing my friends and family. I’d learned that diagnoses can be isolating labels disguised as treatment tools (and evidence from research indicates this as well). Of equal importance, I dove into literature on psychiatric medication. I learned about the iatrogenic effects they can cause and that medication effects often mimic “illness” symptoms. I wondered: How can I disentangle the degree of current distress from medication side-effects?
During my last month at the psychiatric hospital, the facility released a survey asking former “patients” their thoughts on treatment. Overwhelmingly, those who responded hated being locked up and given medications or ECT (obviously). On the other hand, I am proud that in the survey section labeled “enjoyable activities during stay,” many people discussed how sharing their life stories in groups made them feel human. I recognized that the prerequisite state for this comment is that previously, people had felt dehumanized. That I had done something to reawaken their humanity is the reason I embarked on the professional course I am now pursuing. Paradoxically, to do so, I had to eschew traditional treatment paradigms.
In this story, I reflect upon actions I took that hindered people’s freedoms and perhaps violated their human rights. People sent back into the community often came back to the hospital in similar or worse distress than upon our first meeting. They often lost trust in us providers and frequently complained that the medications we gave them prevented them from working, driving, talking, and living. To me, this meant that our treatment methods did not work. These realizations drove me to apply for a Ph.D. in psychology. I realized that I must research new ways to help people recover from distress.
Today, I refuse to use terms such as “mental illness,” opting instead to use words like distress. I also refuse to use the terms “patient” “client” or “recipient” and instead call those I work with people. I advocate for the use of peer-supported treatments and press my peers to ensure that any help we provide is collaboratively developed and engaged in voluntarily.
Though I am still in the belly of the beast, I am aware that traditional psychiatric and psychological treatment can be colonizing, labeling, harmful, and dehumanizing. If we are going to change traditional mental health care, researchers need to actively seek and share critical voices for whom the traditional model does not work (which is a considerable number). Until transformative system change occurs, new communities of practice must be developed and instituted. During my studies, I read a journal article stating that psychiatrists often involuntarily hospitalize people because they have no less restrictive alternative. These alternatives must be generated. Experts-by-experience and experts-by- study can be the stopgap between distress and hospitalization.
I look back on my work at the psychiatric hospital with mixed emotions. There were times when I saw people get connected to housing services after being homeless for long periods of time. I also saw people get rest in a safe, warm bed after days of little to no rest. At other times, I saw nurses and doctors act with sincere compassion. But I recognize that whatever good I have witnessed, all of it can be accomplished in less restrictive—and less harmful—settings. For me, an abrupt awakening altered my worldview completely. I suspect that for traditional psychiatric hospital care, gradual enlightenment backed by mountains of evidence and social activism will be the means by which we can dismantle this machine and replace it with more helpful, collective, and humanizing means of recovery.