Years ago, during my grad school clinical internship in the late 90s, I was assigned a rotation on the locked unit of a mental health hospital in Indianapolis, Indiana. I spent several months working on the unit, and while I have by now forgotten many of the daily details of that experience, the overall impression has remained strong in my memory. The place was no healing sanctuary, no oasis of respite for the soul. In fact, the hospital had the look and vibe of an insane asylum from an old movie, or worse, a depressing and alienating prison, which in a sense it was. Heavily medicated patients shuffled aimlessly through the hard-lit barren corridors with vacant eyes, mumbling to themselves.
I remember thinking how ironic, even tragic, it was that the environment we’d created for helping the most mentally vulnerable was one of alienation, confusion, and helplessness—the very qualities that exacerbate such vulnerability in the first place. I also remember noticing that a defining feature of the inpatient ward was that the people with the least training and preparation for handling mental fragility had the most contact with the mentally fragile patients. Psych techs, as they were called back then, poorly paid and trained, roamed the halls of the unit at all times. The psychiatrists, handsomely paid and thoroughly trained, would show up perhaps once a day for two hours.
I thought then that the place was a dying remnant of an old system, and an old consciousness. Our mental health system was surely moving in the direction of creating treatment environments and models that would actually help vulnerable patients stabilize, recover, and heal.
Many years have gone by since then during which I had no further involvement with the inpatient psychiatric hospital system. But recently, a close relative of mine suffered a psychotic episode that landed her in the locked unit of a Midwestern private psychiatric hospital. I therefore had a chance, through visits to the hospital and through conversations with her, other visitors, and some of the staff, to revisit the inpatient hospital environment.
It was a shocking and disturbing experience. In fundamental ways, nothing has changed. In fact, in some ways, things appear to have gotten worse.
My relative, I’ll call her Claire, was brought to the hospital from the emergency room after she had a scary hallucination earlier in the day following a period of intense stress and anxiety. After she was admitted, she was examined (apparently to make a record of any marks on her body to ensure the hospital couldn’t be blamed for existing bruises) and then left in her room. She did not receive any orientation, was not told where the nurses were, and was not given a schedule, a welcome pack, or information on the rules, whom to talk to—nothing. Neither Claire nor her family received instructions about the hospital’s discharge procedures. She wasn’t told when she would see a doctor, nor was she given any medication (until she asked for some), or any other advice or assistance.
The next day, Claire later told me, was mostly spent waiting, with not much to do except watch junk TV, play cards, or lie in bed. There was one TV set receiving few stations, a few puzzles, Pictionary, two decks of cards, and four books on the unit. The nursing staff mostly stayed in their office and interacted little with the patients. A few rudimentary group sessions run by Techs were offered, including a group “art therapy” session, which consisted of being offered coloring books to fill in. For reasons that were not explained to her (or her family), Claire was placed in the Dual Diagnosis unit for addicts even though she is not a substance user. Group sessions were about substance abuse and as such were not relevant to her situation whatsoever. Nevertheless, the staff clearly implied that she would be deemed uncooperative if she did not attend. Being uncooperative would mean she might be forced to stay in the hospital longer. The clear underlying message was: "do what you're told no questions asked, or else," which sounded to her (and sounds to me) much more threatening than therapeutic.
Claire was not suicidal or homicidal during her episode (or ever in the past, for that matter). She was hospitalized primarily for the purpose of receiving thorough observation and evaluation, a proper diagnosis, and proper prescription medications. None of that took place. Claire spent most of her time alone in her room or in therapeutically and diagnostically useless group activities. She didn’t see the psychiatrist until roughly 35 hours after admission. That encounter, which lasted less than 10 minutes, served as the sole basis for her diagnosis. No formal diagnostic testing was performed, no structured interview protocol used. The diagnosis and its implications were never explained to Claire. Moreover, even though her main complaint was severe anxiety, and her main symptoms anxiety-related, she was not prescribed anxiety medication upon leaving the hospital.
Reflecting on her experience, Claire later calculated that of a total of 57 hours she spent on the unit, she had one-on-one time with a mental health professional (nurse, psychiatrist, or social worker) for a maximum of 40 minutes. None of these interviews were conducted with a concern for her (and other patients’) privacy or confidentiality. She received no individual therapy sessions, and was given no reassurance or coping strategies for the anxiety she was experiencing.
Medication education and oversight, core hospital functions, were also neglected: Claire was given no information about side effects or drug interactions. Moreover, she had to keep track of which medications she had already been given, since the nursing and support staff changed frequently during the day and night.
Rules for the patients seemed unnecessarily harsh and restrictive: they weren’t allowed to have their cell phones, and patients had to line up once a day for five minutes of phone time. The lack of privacy for these short calls meant Claire overheard others calling their parole officers, for example. Patients also had to line up to walk to the cafeteria and back, like a group of elementary students.
My wife and I visited Claire twice during her stay, in the only times allowed for visitors (6:30-7:30 p.m.). The sights and sounds of the hallways and visitation room brought back sour memories. The place was drab, impersonal and ill-lit. Every wall and piece of furniture screamed “institution!”
Not only were phones and other electronic devices not allowed for patients, visitors weren’t allowed to bring them in either. Our bags were searched as we entered. The safety (or therapeutic) rationale for this procedure was not clear, and it contributed to the strong feeling of visiting a prison. We were also unclear as to why visiting hours were so short. There seemed to be no therapeutic justification for that practice.
By the time we first visited, it was clear that the closed, bereft, and alien institutional environment was creating undue stress for Claire while offering no therapeutic benefits. During our visit the family received no instructions about hospital procedures, and was not formally introduced to the patient advocate on the unit (or even made aware of his presence). Luckily, by eavesdropping on a conversation at the next table we were able to identify the patient advocate, whom, after some interrogation, informed us that Claire needed to submit a handwritten "72-hour letter request for release" before the discharge procedures could be initiated. She did that on the spot.
The next day, Claire was informed that she’d have to spend yet another night in the hospital. In speaking with her and with the hospital staff I could find no valid medical reason for this decision. But I could easily see a financial reason. Every additional night on the unit is one more charge to add to the bill.
Quite scandalized by what I saw, I went to check out the hospital’s website. Not surprisingly, the promotional materials presented a picture quite unlike the reality on the ground:
“Our compassionate, licensed clinicians,” thus went the promotional material, “give free and confidential comprehensive assessments which allow them to create an individualized treatment plan to fit your unique needs. … Our acute inpatient psychiatric hospitalization program provides 24-hour care in a private, confidential, and non-institutional environment conducive to healing and recovery … Individuals in acute inpatient programming require close observation, assessment, treatment, and a structured therapeutic environment. … Treatment in our inpatient treatment program includes … individual therapy … Therapeutic activities designed for individual abilities and needs, such as arts and crafts, games, yoga, meditation, gym, or aromatherapy.”
Finally, to add insult to injury, Claire left the hospital with bed bug bites.
The whole episode seems nightmarish in retrospect. But my sense is that Claire’s dismal care experience was not unique. Moreover, problems of poor mental health care are, of course, not limited to the U.S.
Still, Claire was lucky in many ways. With support and advocacy from her well educated, well connected, and resourceful family, Claire was able to persevere through her time on the unit and get out after only two and a half useless, disorienting days. Many of the patients inside do not have those advantages and are likely to be held longer, and treated more poorly, even in cases where remaining hospitalized offers no therapeutic value—at a crushing financial cost.
Mental health professionals know that the first step in solving a problem is becoming fully aware of it. Right now, we seem to lack a true awareness of how insufficient—in fact counter-productive—our inpatient care system often is. The inpatient population is not a wealthy, vocal, and well-organized pressure group, and in our current cultural moment, if you don’t have a strong voice in the halls of power, you may well end up wandering aimlessly down the drab corridors of an ill-staffed and ill-equipped hospital ward, talking to yourself.