Granted, the Bellevue film was a bit dated, however, I contend that much of what is seen in that film continues in many inpatient settings. Read this Blog from Jessica DeArcangells for Mad In America that she published in January, 2019, and then respond to her questions in your comments, then comment on at least two of your classmates' comments.
When the Hospital is Sick
By
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?
In order to best respond to these questions, I feel as though I must begin with a story from my professional history. When I graduated with my undergrad degree (Go UMF!), I was hired at a hospital as a CNA. I wanted to work my way up and felt that starting on the ground-floor was my best option. I was not working on a mental health floor, though I did rotate to one when needed. I was working instead in a long-term care unit with residents who were of all ages. I met a new resident after about a year who was transferred to us due to his medical and psychological needs. He had been diagnosed with a slew of medical diagnoses, not the least of which were his desperate need for dentures due to constant infections in his mouth. Unfortunately, he had a blood disorder and the tooth extraction would be far too dangerous for him to undergo. He begged, but the doctor said no, “it would most likely be lethal.” He had also been diagnosed with Borderline Personality Disorder. My coworkers were baffled by this diagnosis, as well as his presentation when they interacted with him. He was tearful, apologetic, depressed, anxious, and verbally aggressive. He would make threats toward staff and then cry uncontrollably thereafter. After several months, our floor was notified that this patient’s family was revoking their agreement to bring him home. This patient, 55 years old, would most likely be with us for the remainder of his life. The staff collectively balked, stating that he was “too much” and “too hard to deal with.” I sat in the nurses station, horrified, as the doctor entered the patient’s room only two days later to announce to him “I have great news! I have scheduled your dental work and tooth extraction!” The patient cried with happiness, only to pass away from blood loss during the surgery. I reported what I saw immediately, but my report was given a simple shrug and a “Thanks, we will look into it.” Within two weeks, I gave my notice at the hospital. Going back to the questions posed by the author, I think that these “interventions” become possible because doctors and staff get too lax, too comfortable, too lazy, and they don’t believe they have to resources to do better, even if they really do. My coworkers cried that our patient would be “too much,” but would he have been? No. Of course not. Would he have required more support and assistance than our other patients? Certainly. But that does not mean they he is not entitled to it, and it certainly does not mean that he doesn’t deserve it. Though my patient may not have been released due to his medical conditions, he had every right to decent quality care, particularly for his mental health needs. If he had been treated with respect and the time he needed, his outcome could have been incredibly different. The real goal of inpatient psychiatric care is supposed to be rehabilitation and recovery, but it is not always upheld. In many cases, particularly as described in this article, patients are medicated and loosely followed. They are encouraged to comply in order to be released, though their complicity does not always yield the results they want. Instead of recovering, I do believe that patients in these settings are being (re)traumatized and injured far beyond the illness that brought them there. Had I read this article prior to my work in an inpatient unit just 10 years ago, I would have questioned its age. I would have argued that these things most likely happened deep in our past, because they are such egregious claims. Unfortunately, I saw them happen first hand in a local hospital, and I know how hard we have to fight to end it.
ReplyDelete(Posted by Kaitlynn Littlefield)
Kaitlynn,
DeleteThank you for sharing this patient's story. How heartbreaking. I agree with you that instead of the rehabilitative care that people deserve, patients in institutions like this seem to be experiencing more trauma that can often make things worse. Getting patients to comply seemed to be a big goal in the Bellevue film, too. I'm not sure how that directly relates to recovery, though. It doesn't help an individual to feel more empowered and in control of their life.
Kaitlynn,
DeleteWhat a horrific story! I also feel challenged when co worker balk at a "high needs" person that requires a little bit of strength and a lot of empathy to work with. I think that anything in the medical field are stressful positions, it is important to always keep sight of the humans that one is dealing with, whether they are "easy to work with" or not. I am saddened by the thought that this gentleman could still be alive today, were he given the care that he deserved.
Erin
In my opinion, a bulk of the questions at the end of the blog can be answered by a response Jessica received from a co-worker during her inquisitions about the hospital practices. Her co-worker stated, "there's nothing we can do about it, it's always been this way." Just because something has always been a certain way does not mean it is the right way. If our society chose to continue to do the same thing, day after day, after day, after day, we would never see change. One of my favorite quotes comes from song lyrics; the song Time Marches on by Tracy Lawrence. The song says, "the only thing that stays the same is everything changes" and I truly believe that change; albeit change can be intimidating and/or scary, is a good thing. The treatment the patients received in the hospital Jessica worked in was inexcusable. Her question of 'what is the real goal of inpatient care?' is a realistic take-away from her work within the hospital. What was the purpose? To operate as a temporary holding site while time passes? To not use anything we (as providers) have learned about de-escalation or alternative methods of treatment? Personally, I do not have experience working in an inpatient treatment facility of any sort; however, I work in a Maine State Prison for four years. I can tell you first hand, the treatment of the prisoners was FAR better than that hospital could ever say they provided. Firstly, the Inmates were provided with opportunities such as work, education, recreation, etc. Secondly, basic human rights – BASIC. HUMAN. RIGHTS. – were first and foremost a necessity. Now, I am not naive, many inpatient settings can impact behaviors in both positive and negative ways. I think that people can walk away with greater/newer behaviors (often worse) than when they arrived. But, what that hospital is doing is creating dependencies on medication and systems rather than rehabilitation and recovery. Lastly, the unethical behaviors of staff within the hospital are most certainly creating additional symptomology within the patients who reside there. There is no sense of positivity, recovery, or even kindness. It is merely four walls and roof to unethically contain individuals while they are being over medicated into compliance, so they are return to the community the reside in.
ReplyDelete-Ashley Williams
I agree with many points you made Ashley. I think it is clear from Jessica's description of Methodist that significant changes need to be made with medical directors and staff training. I think by implementing more rehabilitative practices, they may see less frequent flyers and more success for patients in their recovery even while staying at the hospital. Change can be very scary and intimidating like you said and I think in the situation of Methodist, its scary for staff to change their thoughts and behaviors just as much as it's scary for patients to be there and expected to change.
DeleteAbove post by Lindsay Hill
DeleteThis was a really powerful situation to read about. When reading Jessica's story I could see each new situation playing out in my mind and was really just so furious about the level of harm that was being caused to the people seeking care, and the level of stagnant care that was being provided. I do have a hard time relating to these stories on a personal level simply because I have not worked in a part of the field that was similar to inpatient care. I can however, take these situations and see parts of them in my own experiences with employment focused fields. Although I have never experienced violations of safety, I have been exposed to violations of basic human rights at times. For example, when I speak about my work as a VRC to people around me like friends and family, I often hear "well those people must be so happy with any job you get them" or things of that nature. To me, even this sort of attitude feeds into the violation of human rights. No, not any old job is enough for "those people", would any old job be good enough for you? As far as the example in the blog with Methodist, I think places like this become reality partly because our society still very much posses an out of sight out of mind point of view about mental health treatment. Most folks just see a place like Methodist as a place for people with mental health problems to go and think "oh thats so great, they are doing outstanding work there", and never ever think to question the care that is really happening. I think a lot of the issues come from our societies need for speed, need for quick treatment. I honestly think that we would see such great improvements in our care system if we simply gave a little more time to create a relationship with the people we serve, across all forms of service, not just inpatient care. I think we should employ more doctors and have more true one on one time without the quick medication "fix". With the over reliance of medication it is fairly easy to see how unethical or weak practice is common within doctors. I mean if a doctor can just give someone a med to make them quiet for a few hours it means much less actual work needs to be done at that time for that patient. Medication has made it so that some doctors dont need to actually practice at all, simply hand out meds. Its just not personalized enough to keep doctors engaged in their practice. The final question is about if places like Methodist recreate the illness they are meant to support, and I think in a lot of situations, yes they do. A lot of folks probably deal with trauma over and over again each time they enter these types of facilities, and that trauma im sure leads to flares in their other mental health symptoms. I think we need to give the people that receive services from places like this a lot more credit, they know that the system is not helping, even if society fails to acknowledge it most of the time. Sorry if this seemed like a rant!
ReplyDelete- Spencer
Spencer,
DeleteYour point about how people react to your work as a VRC stands out to me. I work with folks with disabilities, and I often hear similar sentiments. I think that stigma and even dehumanizing attitudes that we see toward people with disabilities and mental illness do stem from the Descartes philosophy idea that humans only have value if they can be rational. People are thought of as "less than" if they are not as "rational." They aren't believed to be capable of making rational decisions about their own lives. I've thought a lot about how we can shift this harmful attitude, and the only solution I can see is fostering personal relationships among people with and without disabilities/mental illnesses. For example, Pinel seemed to be more immune to the societal view of people with MI because he had a close friend with that lived experience.
Spencer,
DeleteI could really feel your passion for equality through this post and I loved how you related this to your personal experiences of people and any job will do. I too have witnessed people who have expressed stigma but without realizing they have, that's where the work doesn't stop for me, and where we have to keep fighting the fight. Recently I heard someone in the profession mention how well "these people" will only get minimum wage jobs. first of all these people are people first and why? why wont you provide the services and support to get the job they want and are skilled for and ignore the wages.
Either way I couldn't agree with you more!
-Sean K
These places become possible because society is overwhelmed with the amount of care needed for people with mental illness. Instead of doing more extensive research about mental illness and creating positive resources for these people, mainstream lumps mentally ill patients into one large “problem” and the solution being, institutionalization. As the author states, most of these places are understaffed, due to low funding to pay staff adequately, as well as the fact that it has a high burn out rate. Consequently, patients are treated badly, mostly due to the fact that staff is too tired and too defeated to develop treatment plans that are truly helpful to the patients. Burn out creates resentment and staff is likely to take their anger out on the patients, possibly unconsciously, but harmful all the same.
ReplyDeleteI think the goal of inpatient psychiatric care is to evaluate each individual as they first come in, focusing on the history of mental health issues that the patient presents and making them feel comfortable. Then, if medication is deemed to be helpful a doctor could suggest to the patient as an option to use the meds to help stabilize them (especially psychotic patients or those in crisis.) After evaluating the effects of the medication, doctors and therapist should work together to create a treatment plan of recovery for the person, that the patient is a part of planning. Unfortunately, this is not the environment in many cases. Psychiatric units can be very similar to prison units in terms of patients and prisoners getting lost in the shuffle of the institution and never being able to learn the skills they need (and want to learn) when they are discharged, making them vulnerable to crisis. Therefore, they have another mental health break, or commit another crime, or use substances again, etc. Also, the over-reliance of medications as a means to an end has been completely abused by psychiatric units. Generally, medications given are some kind of sedative, which may relieve symptoms initially, but will put patients in a complete mental fog where treatment (if they receive any) is not retained. Safety of course, is a major issue within the medicative practices at psych units. A patient may refuse to take meds because they see how all of the other patients look like zombies. In some cases, such as with schizophrenia, medication is something that can help alleviate paranoia, which could cause a patient to self-harm or harm others. So often, these hospitals are just another cycle for patients with mental illness to live through, over and over, without change. For instance, an alcoholic check in the hospital and seems to have symptoms of ADHD. Doctors prescribe a stimulant such as Ritalin, to treat her, and instead of helping, this medication crates an intense craving for alcohol and she ends up checking herself out, only to be brought in next week for screaming a people walking down the street to give her money – and on and on it goes. Bottom line is the staff at these facilities need to have adequate training and rules and regulations to follow when working with people with mental illness. Medications need not be given out like candy, and treatment plans need to be established with the patient themselves.
I completely agree that there is an over reliance on medications in the treatment of mental illness, especially when it comes to places like pysch hospitals, where the need is immediate and acute. I feel a little discouraged when it comes to thinking about how to solve this problem or how to make it better, as it seems we have quite a culture to shift and overcome. I am curious if you have thought of any possible ways to change the field.
DeleteThis is tragic and scary all at the same time. I read this merely hours after watching the Bellevue video. Not only did I not realize initially this was written in 2019 but couldn't have fathomed that the person is still actively engaged in this field.
ReplyDeleteSadly, I believe many medical practices whether for inpatient, outpatient MH centered or not is too focused not he billable and the need to crunch numbers. We are a society stuck on the funding in order to access or receive treatment. There are no people first in these cases. Second to that Pharmaceuticals sadly hold a great control over all medical systems here in the USA. Medication is the answer, whether you need a prescription for ten days or a week, you will probably get the 90-day refill as its the preferred method through insurance. To early do we conform to those systems that we forget what we actually needed in the first place.
I remember early on after completing my undergrad (beaver pride!) that someone was frustrated at a client for not remembering all of their medications and dosages. While I was fresh faced and thought I knew the reason and symptoms each medication treated I was baffled by the volume of similar medications and that the client indeed was taking. Later I understood that systems do not communicate, and people try to easily fix a situation with one medication or another regardless if the side effect that clashes with another medication indeed requires..... you guessed it... another medication. Who knows what recreating of dx or symptoms is happening in the facilities we have read/watched today, but I imagine we at timeshare is more being created than treated.
In my most current role at VR I worked hard to create a change on caseload sizes for new hires. People couldn't believe new hires where getting caseloads that where manageable in size (80). and that in their day when they started, they got almost 200, it’s hard to make change, but just because so many people started that way it did not mean it was right. it did not mean that we couldn't change that and support people by providing a more quality service from the get-go. Change is hard especially in larger systems, but I hope through advocacy and some positive people out there in this field like Jessica, we can get there.
- Sean K
Reading Jessica's piece also made me think a lot about the impact of health insurance when someone receives treatment in a hospital. While I understand the necessity of health insurance guidelines and policies, I also wonder about how often those get reviewed and looked at to make changes. It is hard because everyone is different and has different needs so a cookie cutter approach to treatment won't work for everyone. But I think that is what is happening is the same treatment is being used on a wide variety of presenting symptoms when that may not be the best approach. And the same for when a person discharges, there are going to be the ones who do utilize the community supports and begin their recovery while others struggle to connect with supports and end up at the hospital weeks or months later.
DeleteAbove post by Lindsay Hill
DeleteThe long history of inhumane treatment of individuals with mental illness diagnoses make places like Methodist possible today. The belief in the Descartes-ian philosophy that humans are only human if they are “rational” persists to this day and manifests in institutions and individuals treating people with MI like they are animals. The goal of inpatient psychiatric care, currently, and on an institutional level, does not seem to be rehabilitation. The “care” seems to be more custodial management. The inpatient psychiatric unit, as described in this article and as seen in the Bellevue film, does seem to have many similarities with a prison. I was shocked to read about the Doctor that gives all patients the same five medications, regardless of their history and needs. We also see in the Bellevue video lots of confusion around medications, as there seems to be a lack of education around the medications that are prescribed to individuals. Patients are just told that they need to take their meds. That practice takes away a person’s opportunity to make informed decisions about their care. As for the author’s final question, it does seem that, in many ways, inpatient psychiatric care facilities are recreating the illnesses they purport to treat. We see in the Bellevue film that the environment itself is not conducive to recovery. One patient, Connie, describes the atmosphere as “very enclosed, you feel like you’re never going to get out.” That does not seem like an environment that would be conducive to healing.
ReplyDeleteBreena, I agree with you that care is more custodial and rehab is not present in many inpatient psychiatric facilities. Pison and psychiatric hospitals have many similarities; maybe the only difference is prisoners have more freedom. I was also shocked at the doctor who distributed the same five medicines each person is not going to have the same reaction to the medications given to them. I do believe these hospitals need to change their philosophy to help patients effectively.
DeleteI completely agree with your take, Brenna. Something that just occurred to me after reading your post (in regards to the Cartesian Philosophy) was our society's hyper-focus on quantitative data, rather than qualitative. Not only are practitioners more focused on numbers & statistics, but the studies they pull from are also done through that lens, as well. This perspective permeates all facets of our healthcare system, and it's at the expense of the knowledge to be gained from individual stories, from more subjective data. If we as counselors (and researchers) learned to value people as more than just a statistic, or a list of prescriptions, what would we learn? How much more effective would our treatment be? How much easier would it be to establish a solid working relationship with our client?
DeleteP.S. I studied French in undergrad and I STILL hate Descartes. Ugh.
Brenna,
DeleteLike Victoria said above, it is horrifying how there are some doctors who prescribe the same medications, regardless of history or presentation. I do think this still happens today. There are so many providers who are stuck in their beliefs of what mental illness is and how it should be treated. If they feel that one medication has worked in the past, or they get a kickback from it, that becomes a go to. The "Let's try it and see what happens" mentality is frightening to me. How many times does this need to happen before our community says "enough"?! I am hopeful it will not take a new generation of providers to change this, but I do not know how to change a philosophy that is so stuck in the past. How can we make it happen?
Kaitlynn Littlefield
Many psychiatric hospitals around the world are unfortunately run the same way as Methodist. Instead of therapy, professionals tend to medicate the patients beliving it fill heal or fix them, and all their problems will be solved. I believe the reason places like Methodist are still going is that not many people want to work in that environment. Those who do can do it any way that will make them stay employees of the hospital. The real goal of inpatient psychiatric care is not about the patient's goals or truly helping get them better. It is about keeping them out of the community and medicating them even when they are not posing a threat to themselves or another. In my opinion, there is not much of a difference between prison and inpatient psychiatric units. At least in prison, you have more freedom and are not medicated every 2 or 3 hours for not being quiet. People say our prison system needs to be re-constructed, which I agree. First, our psychiatric hospitals need to be re-constructed on providing moral treatment. Our society has over allied on a medication causing for professionals not adequately to do their job and become lazy. Professionals over-rely on medication and not their education this is not just ethical but not safe. If each day patients are taking to much medication or getting chemically restrained one day he is going to die, our bodies can only take so many chemicals. I do believe that these hospitals are making the illnesses worst they are trying to help. When a patient is isolated, it gives them more time to listen to the voices in their head or think of a way to harm themselves. What should be happening is patients should be getting therapy as long with medication. There are many ways to treat people with a mental illness other than physically or mentally restraining.
ReplyDeleteVictoria, you bring up a point that was not raised in the article or other readings this week which is the fact or bodies are not designed for so many chemicals. Sadly, in my short career I have already seen the burden an toll continuous medication can take on t he body and in how it can decrease life expectancy. I have worked with some individuals who have passed away so young through "natural causes". I wonder how natural at times that can be or how that problem will be tackled in the future.
DeleteSean
Sean, I can totally relate to your points. While I was in my undergrad I was a “big sister” to a young lady. We established a relationship that developed through time. She came to my house. We took her horse back riding etc.. As time passed we lost touch. I was somehow invited to a team meeting. She had been hospitalized in a psych facility. At this meeting I share pictures of our activities. The professionals could not believe it. She was at a point where she had no balance and had multiple physical issues. These were all side effects of her medications. I feel like they were doing exactly what you were mentioning. Adding more and medications. I was thankful I was able to advocate for her. I am afraid that people do fall through the cracks. In echoing your point, through advocacy (and small caseloads) we can get there. Your work as a manager and keeping caseloads small is admirable.
ReplyDeleteThank you Becky, I am so happy to hear that you have had the opportunity to support someone through those crazy concoctions. It such a fine line. i am not 100% opposed to medications as i have seen it do wonders for some but again they had a great team surrounding them and such supports in place really matters. i'll finish with i think caseload sizes are an e topic too, depending on what someone is doing, my goal as a manager is to make caseload sizes manageable.
DeleteSean
There are many times when I meet with my VR clients and if they are discussing their medications, they will say they take a certain medication for these symptoms, but then they take another medication because of the first med's side effects. And their list of medications just goes on and on and on. I would think at some point, a doctor would start to look at the list and wonder if all of these are causing more harm than good. And is it possible for a person to learn to cope with certain side effects to avoid taking another medication that may cause even more side effects.
DeleteIn this weeks materials I was horrified to learn the history of metal illness. I have a greater appreciation for those before us that advocated for reform.
ReplyDeleteIn reading Laura Elliot's blog, I found the quote from Dr Cross right on target.
“What I'd like to see is for our patient group - everybody - to have higher expectations when they come in front of a healthcare professional, and I want every healthcare professional to think it's absolutely normal that they need to think about this person's mental and physical wellbeing in tandem, depending on where they are in the care pathway."
This philosophy matches my beliefs. As mental heath is a pathway.
From the power point slides I learned that people used to travel to Bedlam on vacation (Christmas and Easter).
This is sad as the people there were held against there will and treated poorly.
As I write this post, I’m in Maine vacationing. I had a chance to walk the Marginal Way (an ocean path) Thus is where joy can be found and wellness.
Our history is horrifying.
Let’s hope we continue to focus on wellness.
Please excuse little post. Typed on cell phone.
DeleteBecky, As you stated, I was also horrified with the history of mental illness. I am so happy people advocate for reform to get patients to get the help they need. I hope we will be able to change the way we treat our patients with the wellness model.
DeleteI agree..only us as counselors have the power to continue to seek more humane and just ways to treat people with mental illness - not by shoving meds on them, but by truly learning the bio, environmental and psychosocial backgrounds of the people
DeleteThese were good points, Becky! One of the things I think about when I read historical accounts of mental healthcare is, despite how horrifying and inhumane they sound, it's important to remember how far we HAVEN'T come in terms of treatment and our approach. I think as modern future (or current) practitioners, it's so easy to fall into the trap of thinking that the worst is behind us, and that all patients receive at least the same standard of care no matter where they are, when that's just not the case. Mental health treatment, like any form of health care, is really dependent on several different factors (including race & socioeconomic class, etc.). And some pretty awful examples of malpractice exist in our country today! I think as providers, we must always be sure to practice self reflection to ensure that we're practicing ethically (like Jessica did, despite the push back she got from the rest of her team) and that we continue to treat our clients/patients as the experts of their circumstances with all the respect and compassion they deserve.
DeleteBecky, I am so glad that you brought up the example of travelers gawking at Bedlam patients. Our history is so marred by injustices. As we discussed in our last class, so often individuals who have been diagnosed with a mental illness are treated as sometime to watch - a sideshow, almost. They are treated as less than. They are treated as side-shows. I try to imagine what it would be like to have been a patient who watched as strangers paraded through my forced-on-me-home, gawking at my every move. It hurts to even ponder the idea of it, and yet it is a very real part of our society's history. In some ways, we are still treating individuals with disabilities or illnesses this same way. I am horrified by the actions of those we read about this week and last, and I am disappointed that it is still all too real. We must do better. My question is, how do we get there? We have made so much progress, but how to do keep the momentum going and create genuine, lasting, positive change? So much work still needs to be done. -Kaitlynn Littlefield
DeleteKaitlynn, you are right that we must do better. Jessica DeArcangelis article clearly depicted the focus on medication and forced compliance. The bathing technique seems horrid. I think we must start with wellness at really young ages. In my daughter’s preschool they talk about there feelings (red, angry blue, hopeful etc.)
DeleteI think people, teachers, counselors need to use the deescalation techniques as trained. I am sad staff in Jessica’s post were not encouraged to listen or spend a lot of time interacting. I am hopeful that things will get better. My friend went to Washington to speak on behalf of patients and unnecessary restraints.
Post from Lindsay Hill
ReplyDeleteThis was a powerful piece to read, especially after watching the Bellevue video. Some of my first thoughts about the Bellevue video was about how it was filmed a long time ago but then to read about Jessica’s experience most recently in a psychiatric unit that sounds worse than Bellevue from her description is alarming. I think places like Methodist become the way they are for several reasons. Jessica stated one of the obvious things she noted about the unit was “the staff are poorly trained, overworked, underpaid and severely burnt out.” This situation can drastically change the treatment people receive when they are patients. I also wonder if they are short staffed as well due to the high turn over rates of jobs in the mental health field. Staff may be doing the work of two positions in the 8, 10, or 12 hour shifts they are working which means less adequate care for the patients they are working with. Working in the mental health field in any capacity can be stressful, overwhelming and demanding and in the hospital, they are working with people who are currently in crisis and need immediate treatment to keep themselves and others safe. Jessica also mentioned how a coworker described one of the doctors as using “old school ways” and I think that also can create the environment in which patients are being treated at Methodist. If there is never change in leadership and direction and changes aren’t made in training and education for staff, nothing will ever change. As we are beginning to learn in our readings, the “old school way” of treating psychiatric patients has not always been the best way. When you have a doctor, who received his education and training in the 1970s compared to someone who received it in the 2000s, I would hope there have been some changes in the way things are taught so changes can start happening in inpatient units such as Methodist. But even Jessica, herself, left the environment when she realized nothing would change. Another factor with inpatient psychiatric care is health insurance. Health insurance is a huge driving force in how someone is medically treated in a hospital and dictates how long a person can be receiving services in an inpatient setting, especially in a psychiatric unit. I think health insurance has changed the goals of a person in inpatient psychiatric care because once they meet certain criteria set by the health insurance, they are released from the hospital because they have been determined to be more stable, experience less symptoms and it is assumed they can take care of themselves. To answer Jessica’s question about places like Methodist recreating the illnesses they treat, I think the answer is yes because they are not always focused on rehabilitating the person in a holistic manner and have little control over what health insurance will or will not approve for services. As a VR counselor, we will receive applications from people who are being discharged from Maine General but it’s not always the most appropriate time for the referral for VR services. The social worker is doing their job by ensuring they have provided information to the patient about all the community services available to them but I’m not sure how much follow up is done about actually setting the client up with receiving the service. In my opinion, it is hard to help someone with employment and education when they do not have a roof over their head, clothes on their back and food in their belly and a support system in place to maintain their mental health symptoms and keep themselves (and the public) safe. This is what the goals of psychiatric care should be but is not always what is practiced.
Lindsay,
DeleteI like how you highlight appropriate use of referral, too often we see people referred for services because I think some providers do not know what else to do. With the state of Maine having employment first legislation we see too many time a client during their annual team meetings being referred to VR even if they have a current case open or if they have current basic needs met as you mentioned. Understanding how many services can work for a client in tandem to support success is an important element in promoting clients independence.
Sean K
I think that the last question that Laura poses (And most importantly, are these places recreating the illnesses they purport to treat?) is a vital one. So often in my work I see men and women get blamed for their mental illness, as if they woke up one day and said to themselves - "you know what, I think it would be really fun to have bi-polar disorder today." People are shamed and shunned and told repeatedly that if they are not getting better, then they are not trying hard enough.
ReplyDeleteIt gives me great sadness the damage that social workers, psychiatrists and other mental health practitioners can do to the patients and clients that we are supposedly trying to treat and serve. We get caught up in our egos and our educations, and the "we know better thans." I believe that places like the hospital described in Laura's blog exists because treatement for mental illness is underfunded and undersupported, and staff get overwhelmed and burnt out. However, I think that it goes beyond that as well. I believe that places like this still exist because we, as a society (and even as a profession), still subscribe to the idea that those with mental illness are "other." This is especially pertinent to those living with diseases such as personality disorders and schizophrenia, that are still highly stigmatized. We often forget the human behind the disease or illness.
I have worked in housing the past four or so years, working down at Preble Street with the veteran population. I am reminded of a veteran that I worked with that had been homeless off an on for a decade. He suffered from psychosis, often having thoughts of grandiosity. The beauty of the work that I did with him was that it was focused on housing first. I was not there to challenge his delusions and I was certainly not there to medicate him.Instead, I worked with him in the way that I worked with any other client - we worked on finding him an apartment, and when we did that, we worked on keeping him there. We worked together for over a year, and while it was an uphill battle, that veteran is still stably housed today. He does not take medicine to rid him of his delusions, but he does pay his rent and bills on time. He is a good neighbor and adheres to his lease. My point in bringing him up is that he taught me that folks living with severe mental illness can and will be successful, given the right supports. This veteran benefited from the professional relationship that he and I had - one in which helped him problem solve and connect him to services he needed - but didn't necessarily challenge what his reality was. I hope to remember this case as I continue on with my social work career.
Erin,
DeleteYour comment that hospitals exists to this day treating their patients the way they do because our society still views people with mental illnesses as "others" is striking and true. Our media represents mental illness as something dangerous, horrifying, and nothing more than a side-show. Even today, the news and politicians blamed violence on mental illness without any facts, evaluations, medical records, etc. Over the decades and centuries it has become a catch-all for any negativity that happens in the world. I have fought this when I have seen it in front of me, with my clients and without them. I have corrected strangers on the playground, in the grocery store, and even during gatherings with friends. I have no tolerance for this argument because it is based on false information. Thank you for mentioning your client, as he DOES show a very accurate picture of what living with a mental illness can look like. It should never be a one-size-fits-all discussion.
Kaitlynn Littlefield
I've definitely thought about how we, as counselors, can help change the driving force of medication in the field. One option could be hiring psychotherapists or social workers in the office that could be paid privately (without relying solely on the state). Many psych hospitals are funded by the state (especially criminal hospitals) and therefor few therapists and social workers desire to work there because they get paid the bare minimum. The burn out rate increases and this is why there are so few counselors to work with patients in these hospitals and find out the underlying issues without just hastily prescribing any medication. Patients need to be listened to and recognized as suffering people, not criminals. Until our society believes these jobs are important enough to pay adequately, we may stay stuck in this negative cycle.
ReplyDeletethat last comment was meant as a reply to Erin's reply to me :-\
ReplyDeleteAfter having watched the Bellevue film and reading this post, it’s not surprising to me that Jessica compares the in-patient psych ward at Methodist to a prison. After hearing some of the patients talk about the lack of windows and/or access to the outside air, it must certainly feel that way. Also, based on my new understanding of the Tuke/Quaker perspective on moral treatment, I can also see exactly how the focus of care in the United States for patients with mental illness would evolve into one of behavior management rather than recovery or rehabilitation. Added to that the goal of making money, and it’s no wonder the providers described in this post are clearly more focused on forcing compliance, keeping the peace, and discharging patients as soon as possible instead of focusing on individualized care, fostering collaborative relationships with their patients and practicing effective methods of treatment. It’s a broken system that allows malpractice to go unanswered and that eschews unique strengths or perspectives. I remember interning at the women’s homeless shelter in Portland and working with one of the nurses from Maine Med on behalf of one of the clients there. The nurse was frustrated at my client’s behavior, wanted her discharged as soon as possible, and implied that my client was essentially taking advantage of the system in order to receive medical treatment. Despite the fact that my client was experiencing homeless, didn’t have insurance, and was suffering from acute symptoms of mental illness, this nurse clearly felt little to no respect for my client. This perspective was one I heard all too often during the course of my internship, but I for one can’t imagine experiencing severe symptoms of mental illness, carrying immense prior trauma, and having the medical staff treating me dismiss my needs as unimportant, or accuse me of being just another drifter bleeding the system dry. Today’s over reliance on prescription medication has not only led to the opioid epidemic, but it also devalues individual strengths and the power of the therapeutic relationship in recovery. The culture of treating people like products to be pushed down an assembly line rather than individuals with unique histories, experiences and strengths makes effective recovery and rehabilitation infinitely more difficult than it must already be.
ReplyDeleteHi Megan,
DeleteYou mentioned something in your post that throughout all of this weeks material, I never thought about myself - MONEY!. Maybe I just have to much faith in our system that I try and make myself believe that care, and the services that we provide to people in need in our society today do not fully revolve around financials, but then again doesnt everything revolve around financials? Its just so sad that we put greed over the true wellbeing of others. I always find myself thinking, do these kinds of practitioners just not have the resources, education, or time that they need to do a good job, but in reality this way of thinking may just be making excuses for people who have everything they need to do the right job and just have other priorities like money. Its just crazy how many different factors play a role in the rehab process we use today.
Hey Spencer - thanks for this response! You're absolutely right - "Its just so sad that we put greed over the true wellbeing of others." It is sad that money enters into this equation at all, as far as I'm concerned. The nature of capitalism means that profit is always going to be the bottom line, so our culture's choice to monetize things like health care, education and the criminal justice system leaves some people without. This is the result, and it hurts to read about it.
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ReplyDeleteIn my opinion, inpatient care should have the goal to help stabilize the clients before they are integrated back into their communities with plans to support the transition and allow the client to be successful. Bellevue documentary and Jessica's piece highlights some critical flaws in our inpatient and outpatient facilities. Our system is broken as evident by Jerry's quick deterioration when he is released from Bellevue. There are a plethora of resources but many facilities are not in synchronization when one client is discharged. It becomes the responsibility of the client to maintain their stability when in reality the significant structure of the hospital aided their stability. Client's in the community most likely will relapse or lose motivation to comply with the treatment recommendations given by their doctor. If there was a way that the resources were able to communicate to each other and implement a plan that allows a coordination of care, then there would possibly be a higher level of success.
ReplyDeleteBecca, I have seen this happen so many times. Frequently, staff and providers at in-patient level of care units feel that they do not have the time, nor the appropriate resources, to fully help their patients. They are overwhelmed by the number of patients on their floors, and they are overwhelmed by staffing issues. These should never be excuses, but it happens all of the time. I agree with you when you say that inpatient care should focus on stabilizing the clients prior to their discharge. The fact that this is overlooked and forgotten shows what an integral flaw there is in the entire system. It is doing such a gross disservice to all who require care. -Kaitlynn Littlefield
DeleteI think one of the flaws of inpatient facilities is how it is dictated by health insurance because there is a one size fits all approach to the majority of people who need to utilize the service. Social workers who work in the facility can advocate for long periods of admission if they can justify why it is needed and also explain their plans of discharge because that will also need to be approved through health insurance for ongoing coverage for support. I understand its a necessary evil of health insurance but I think it can impact services more than provide services for people at times.
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