Since the advent of the novel coronavirus in the United States in late February, the news media have focused attention on the greater risks of catching the disease at congregate facilities, including prisons and nursing homes, where captive populations living in close quarters facilitate its rapid spread. By late March, a similar crisis among staff and patients at psychiatric hospitals had emerged, with reports of COVID clusters—and even deaths—found at Western State Hospital near Tacoma, Washington (The Seattle Times, March 26), St. Elizabeth’s in Washington, DC (The Washington Post, April 1), four facilities in New Jersey (The Trentonian, April 7), and many other institutions across the country. As of April 16, NBC News reported, nearly 1,500 inpatients of U.S. psychiatric hospitals had been infected; to date, dozens of people living in such facilities have died.
Throughout April, we saw almost daily reports tracking these stories, which pulled back the curtain on negligence, bureaucracy, and overwhelm in the face of an unprecedented situation. These stories told of “a lack of testing, P.P.E., and seclusion protocols [that] were making a difficult task—maintaining the safety of a highly vulnerable population and their care workers during a pandemic—virtually impossible” (The New Yorker, April 21). They also explored the unique challenges of trying to prevent and treat a highly contagious disease among the “seriously mentally ill” in a setting where the standard treatment is the provision of mind-altering drugs combined with group activities.
These accounts of the struggles to fight COVID in psych hospitals were solidly reported and often sympathetic. But too often, such stories attributed the difficulty in protecting patients and staff to those patients’ illnesses. Described as disoriented, self-destructive, and sometimes violent, this population was said to be unable and/or unwilling to comply with safety practices such as social distancing, mask-wearing, and handwashing. Moreover, it was reported that the traditional inpatient treatment model said to be necessary to help this population is at odds with what’s needed to stop the virus’ spread at these facilities, creating a double-bind.
This coverage revealed many assumptions about both residents of psych hospitals and the institutions themselves. In their coverage, the media missed two opportunities: to challenge stereotypes about patients in psychiatric hospitals, and to interrogate problems with current carceral approaches to mental health treatment that the COVID crisis has brought into relief.
All of the articles studied during this period point to patient “craziness” as a significant factor in facilities’ difficulties controlling the spread of disease. Seldom represented as sources in these reports, the residents and their
behaviors, attitudes, capacities, and needs were typically described by mental health professionals. Reporters quoted or paraphrased hospital nurses, social workers, administrators, and psychiatrists along with outside “experts” who presented inpatients not only as helpless victims but also as unwitting perpetrators of the disease’s spread—obstacles to the type of interventions that could help save their own and workers’ lives.
This trend was encapsulated in an NBC News story (April 17). “Coronavirus in a psychiatric hospital: ‘It’s the worst of all worlds’” spotlighted the grim statistics and institutional mismanagement in its report on the growing COVID burden at Western State Hospital. It explained that “social distancing in a psychiatric facility is easier said than done” and quotes Dr. Jeffrey Lieberman, chair of Columbia University’s psychiatry department as to why:
“People in for severe depression and suicide … may be so despondent and intent on ending their life that they might not care about the consequences….The more common situation is someone is in the hospital because of a psychotic disorder…. They’re literally out of their mind. They’re not necessarily coherent, they’re not necessarily rational, and they’re not necessarily able to follow directions.” (Italics added.)
An Associated Press story on Western State, published in both ABC News (April 28) and The Lewiston Tribune (April 29), states: “At the Washington hospital, most patients are severely mentally ill. They’re either a danger to themselves or others or have committed a crime and are being treated to restore their mental competency to face charges. Some are old and many have compromised immune systems because of their medications, putting them at greater risk if they catch the virus. But they aren’t inclined to wear masks or take other precautions.”
It goes on, “‘If you give patients Purell, they’ll drink it,’ said Ben LaLiberte, a forensic evaluator. Masks could be used to choke so are distributed carefully and usually ignored.”
That’s because, according to The New Yorker, “The very illness that brings [patients] to a psychiatric hospital may make it harder for them to follow hygiene, self-distancing, and other preventive guidelines, which increases the risk to them and everyone around them.”
Similarly, Newsday (April 27), reporting on the rash of patient COVID deaths at Pilgrim Psychiatric Center and 22 other mental health facilities around New York State, quotes academic psychiatrist Dinah Miller: “Patients who are very ill with psychiatric disorders may resist hygiene measures, and they may intrude on the personal space of others.”
The Trentonian’s April 7 story even seemed to attribute a deceased patient’s death to these poor health habits. In discussing the scandal, it focused on an anonymous source’s characterization:
“The sources identified the patient as Ed Gorecki, saying he was schizophrenic, but had no known criminal history, and had been at Trenton Psych for as long as decades.
‘If anyone would be killed by virus, I would think he would be a prime candidate,’ according to a former staffer… ‘He was a heavy smoker for years and years and years,’ the ex-staffer said. “
Blame was even reflected in the headline: “NJ health officials: Four patients dead, dozens sickened by COVID-19 at psych hospitals, Trenton patient remembered as ‘chain smoker.’”
In particular, stories portrayed psych hospital residents as aggressive, their hostile and unpredictable actions threatening caregivers’ safety. Newsday noted: “Officials say staff often face resistance from patients who can become combative when forced to wear masks, to safely handle sanitizer, and to adhere to other precautions against the spread of the virus in densely populated facilities behind locked doors.”
And two different outlets (Newsday and The Seattle Times, April 14) again quoted psychiatrist Dinah Miller, who averred, “Some patients on an acute psychiatric unit may be agitated, uncooperative, or even violent, and it’s not hard to imagine the distress of anyone who has a patient spit on them as we’re all trying to remember not to shake hands.”
Summed up a beleaguered worker to CBS News (April 20): “I think we have it worse than a traditional hospital because our patients can at any given time become violent. You know, we have patients that don’t understand or grasp of coughing into your arm or sneezing into your arm.”
Such was the stereotyped depiction of hospitalized patients. It was a one-size-fits-all presentation of this population, as though most residents of psych hospitals are “out of their minds” and aggressive.
A Threat to Psychiatry?
According to the news media, gaining cooperation from uncomprehending, hostile patients wasn’t the only challenge for psych hospitals lacking resources and precedent to deal with the COVID crisis. So were the dramatic changes to standard operating procedures that facilities would have to implement to prevent resident-to-resident virus transmission. These include quarantining the sick, keeping them in their rooms, and eliminating group activities.
As The New York Times’ April 12 story on the many cases and deaths at New York’s Rockland and Pilgrim state hospitals explained, “Psychiatric hospitals present special challenges to the strictures of social distancing, since many patients are allowed to come and go in and out of the center,” to different parts of the campus, “and once inside they are not cloistered.”
Yet according to the sources interviewed in these pieces, efforts to segregate people are not what’s best for them. Here, as NBC News put it, mental health and physical health are “competing interests”:
“Both hospital management and workers [at Western State] expressed concern that precautions due to COVID-19 may disrupt treatment of mental illness.… in mental hospitals, isolation can be dangerous, far more than in college dorms or other institutions where people live in groups. Social interaction is not a luxury; it is a therapy and it helps save lives.”
The piece portrays a pleasant routine of “communal breakfast, possibly followed by gardening, book club or music,” where residents “attend group therapy and classes at the ‘treatment mall’ and eagerly await visits from loved ones.” Now, “Almost all of that is gone or significantly changed. Group therapy and classes have been canceled, and there is a push for therapy by video chat and the discharge of patients.”
This aspect of the reportage, in contrast, portrays the hospitals as true asylums filled with “lonely, confused patients who often can’t communicate symptoms and can’t do without the daily socializing and group treatment that is the bedrock of their care,” as Newsday put it. These poor souls rely on the treatment and security they find there, it was reported. According to the anonymous staffer quoted in The Trentonian, “I know the hospital tried to discharge [the patient who died of COVID] multiple times, and he didn’t want to go. That was his home.”
However, the worry about changes to hospital routine seems to center as much on the threat to institutional norms as to staff and patient safety. As The New Yorker notes, “The coronavirus, and the public-health measures undertaken to slow its spread, is particularly hostile to psychiatric care.” In their April 27 op-ed in The Hill, psychiatrists Brian Barnett and Jack Turban write:
“Though often out of sight and out of mind, psychiatric facilities are essential to our nation’s emotional wellbeing. While coronavirus has shuttered many institutions, they don’t have the option of closing their doors, even temporarily.”
To reinforce this notion, Barnett later published an op-ed in New York Daily News on the threat the coronavirus poses to forced commitment.
Just as recent headlines about police violence have prompted a societal rethinking of law enforcement, the pandemic offers the media an opportunity to move beyond one-dimensional images of paranoid and delusional psychiatric patients prone to snap at any minute. While violence on state hospital wards is well-documented and dangerous, not every resident is incorrigible, or even “severely mentally ill.” People are admitted for many reasons, including a lack of beds in regular hospital wings for people who present at ERs for short-term crises, and to be assessed for culpability when charged with a crime (as some news outlets pointed out). A person can be involuntarily committed if a doctor or judge decides that a person is “at risk of harm to self or others”—a status with no objective criteria. Thus, psych hospital residents’ capacity for self-control and self-awareness varies by individual; many are coherent and also wish to steer clear of aggressive peers.
Indeed, research on violence in mental institutions has found that the vast majority of violent incidents are initiated by a few individuals (usually younger, male, and with a history of violence). Other research, from the National Association of State Mental Health Program Directors Research Institute, concluded that hospital policies and proactive, one-on-one measures by staff can prevent violence by identifying early warning signs and de-escalating conflicts.
An Oppressive Environment
The press also failed to question the norms and possible harms of carceral treatment for “mental illness.” For example, might these psychiatric facilities aggravate or even create some of the problematic patient behavior experts say interferes with fighting COVID? What might be safer, more therapeutic alternatives?
While professionals quoted in these stories speak of the value of social connection in a psych-hospital setting, locked wards and state hospitals are by definition isolated from the rest of society. Moreover, many psych hospital residents are involuntarily committed and medicated against their will. Demoralizing and terrifying procedures including seclusion and restraint and forced injections are used to “manage” unruly or agitated individuals. And while they may gain grounds privileges, inpatients are forbidden to leave (getting discharged often requires facing a tribunal).
While recent articles’ descriptions of art therapy and opportunities for socializing reassure the public that psych hospitals are supportive and benign environments, the U.N. Special Rapporteur on Torture this year presented a special report to that body’s Human Rights Council, which concludes that “Involuntary psychiatric interventions based on ‘medical necessity’ or ‘best interests’ may well amount to torture.”
All told, patients are rarely considered partners in their own treatment; they are to follow a care plan created by doctors and enforced by staff. In such institutions, is it surprising that residents might be uncooperative or even vehemently resistant—especially in the face of a frightening illness about which even experts know relatively little?
The Role of Drugs
Another question unexplored by the press: How much of the problem of dealing with the virus and gaining patient cooperation is due to the psychiatric drugs residents are inevitably prescribed and urged (or forced) to take? Medications for “severe mental illness,” like neuroleptics and antidepressants, can be very sedating. They can also serve to make someone more docile. As The New Yorker’s piece drily noted, “If dysregulation is getting in the way of being able to persuade the patient to observe social distancing, then it’s the doctor’s job to find the right medication until he can have a successful conversation.” Theoretically, we would expect these patients to be stabilized enough to participate in vital hygiene practices.
Too often, the opposite is true. As numerous studies and those with lived experience report, psychiatric medications can trigger aggression and akathisia, an intense inner agitation that is associated with an increase in homicidal and suicidal behavior. A 2015 literature review documented numerous cases of “treatment-emergent violence” due to adverse drug reactions. The book Medication Madness by psychiatrist Peter Breggin traces cases of homicide, suicide, and other violent crimes to these toxic reactions.
If heavily medicated people are unable to govern their own actions and self-care or to be controlled by mental health professionals, what does it say about such drugs’ effectiveness in these settings?
What do psych hospital residents themselves think and feel about a deadly disease on the wards, how these facilities are handling it, and the changes to their treatment? Whom or what do they blame or credit? It’s hard to know: With few exceptions (including Rolling Stone’s April 13 piece), we never hear from them in these stories. Reporters seem not to have sought the input of those living within hospital walls (or perhaps were not permitted to solicit interviews). Instead, the patients’ reality was defined by others.
Talking to current and former residents tells a different (or at least more nuanced) story about patient awareness, competence, and preferences. In a June 20 article, Healthline quotes from interviews with several recent psych hospital inpatients who maintained “the quality of care was subpar and COVID-19 precautions were not taken.” Lindsay Romain, hospitalized in Austin, Texas, recalled that “They mostly just medicated us and then left us alone until meal times. It was pretty traumatizing.” One of her big concerns, Healthline reported, was “that there was no discussion whatsoever of COVID-19 or the protests that had just started that week, and how that might have been affecting mental health situations.”
Moreover, while most of the mainstream press revealed how little was being done to protect workers and patients at many hospitals, only a few outlets reported that some current residents—far from resisting COVID safety precautions—are demanding government action to get it. Responding to the rapid sweep of the disease through such facilities, residents in Connecticut and the District of Columbia have mounted lawsuits self-advocating for measures to ensure their safety in the hospitals where they are, essentially, held captive.
As WAMU reported (April 16), the four plaintiffs from St. Elizabeth’s in Washington, DC claim that “the city-owned hospital is putting patients at risk for contracting the coronavirus by not isolating people who have symptoms. They also argue that it is impossible for patients to follow social distancing and allege that patients with the disease are not given adequate care” or protective equipment. And as Mad in America reported recently, former residents of Massachusetts’s public hospitals have been campaigning to hold the state’s Department of Mental Health accountable for its inadequate response to the pandemic at these institutions.
Moving Toward Alternatives
Moreover, both professionals and people with lived experience are working to find appropriate alternatives to standard care during the pandemic. For example, as the Tacoma News Tribune reported on April 5, disability-rights advocates aim to reduce the number of civilly-committed patients using “non-traditional methods.” Those include arranging for early discharge, transfer into community settings such as assisted living, and release back to their own families. In this way, the activists hoped to “reduce the population of both hospitals right away in order to most effectively protect staff and patients from COVID-19.”
These requests align with recommendations by the authors of an April 2020 article in the journal Psychiatric Services, which states:
“Patients who develop COVID-19 symptoms should be monitored closely for imminent risk of suicide, homicide, and grave disability. If the patient is considered psychiatrically stable, he or she should be discharged to outpatient care and self-quarantine. Additional considerations should be made regarding the threshold for hospitalization. Psychiatric hospitalizations that are not absolutely necessary for acute safety concerns should be minimized.”
Efforts are also emerging to vector people in mental health crisis away from being admitted into congregate “care” in the first place. Healthline cited the work of psychiatrist Dr. Scott Zeller on building “better psychiatric units that are truly rehabilitative.” According to Zeller, “it has long been recognized that the standard ED setting may actually exacerbate the symptoms of a psychiatric crisis.” So he “is working double time to make emPATH [emergency psychiatric assessment, treatment, and healing] units—which are more calming, supportive settings with trained psychiatric personnel—a reality, and would also prioritize patients’ safety needs around COVID-19.” With such proactive interventions, he maintains, “the vast majority of psychiatric emergencies can be resolved in less than 24 hours.”
Even in current settings, measures for protecting residents (and staff) from infection with the virus are possible. In an email interview, Mad in America talked with Katy M., 20, an inpatient at the public Worcester Recovery Center and Hospital in Massachusetts. (Founded on a patient-centered, community-like model, the facility recently tightened restrictions after local media reported on street-drug overdoses and assaults by forensic patients there.) She has resided at WRCH for the past nine months, after being sectioned last year for suicidality.
According to Katy, the hospital has had only a few COVID cases and no deaths, thanks in part to a quarantine ward with workers in “full protective gear,” a step-down ward, and PPE-clad staff in every unit. Patients are tested upon admission, given and encouraged to wear masks when outside their single rooms, and have access to hand sanitizer, she says. Residents may not go in each others’ rooms—although masked, socially distanced visitors are now allowed at the hospital.
In Katy’s observation, patients’ response to the pandemic has varied, but she says forgetfulness is more common than resistance. “We’ve had some patients who are scared, some who aren’t, some who think it’s cool to wear masks, and some who couldn’t care less. I think most people are extremely bored as there’s nothing to do.” She adds, “I wish people would know that we’re not all violent, and even if we are, that’s not the only thing about us and that many of us can and will go on to live productive, successful lives.”
At press time, the COVID crisis showed no sign of abating at psychiatric hospitals, as this July 3 article from ABC affiliate KSAT demonstrates. As this story continues to evolve, journalists should take this opportunity to explore the broader human-rights (and common sense) issues it raises about institutionalization.