I read the Shrink Rap blog and found the recent post there on a reaction to one of the blog's posts on the violation that people feel after psychiatric hospitalization. A direct attack on the author was certainly predictable especially given some of the sources quoted in the article. As expected none of the author's intentions were captured by these responses. Her intention was explicitly stated in the following 2 sentences:
"I realize that some people who are involuntarily hospitalized are terribly traumatized, which is why I'm writing the book. I don't think psychiatrists see that and I think if it were figured it into the equation, maybe less people would be involuntarily hospitalized (certainly, no one should be forcibly hospitalized for 'sadness' as one of the MIA commenters put it), other alternatives could be found, and more of an effort would be made to treat those where there are no options but involuntarily hospitalized with respect and kindness."
I worked in an acute care inpatient setting treating very acutely ill patients for 23 years and thought I would give my impressions to the statement about what psychiatrists see or don't see in people who have been acutely hospitalized, especially on an involuntary basis. I think that there are several critical factors that determine what the experience will be like during those circumstances. There will be considerable variation in the experience based on how these factors are approached.
1. The pre-hospital experience
On the units where I worked, voluntary admissions were in the minority. Most people were brought in to the emergency department (ED) by the police or paramedics. They are usually involved when there is an acute behavioral change leading to a safety issue. In that pre-hospital encounter some people are beaten up, maced or tasered by law enforcement. If that happens and the person is in the ED wearing handcuffs that are too tight it can have an effect on the perception of the hospital and its staff following admission. It is also an extremely traumatizing experience. Years of observing this problem led me to problem solve with patients affected by these situations on how they could avoid confrontations with the police. That is not the only source of trauma prior to admission. Fights, accidents, self inflicted injuries, and near death experiences with suicide attempts and accidental overdoses can also happen prior to admission. In some cases, people are transferred from intensive care units where they have been stabilized.
2. Intoxication states
Intoxication states including alcohol, cocaine, amphetamines, hallucinogens, and marijuana as well as the associated drug induced mental disorders are overrepresented in the population that gets acutely and/or involuntarily admitted. People with substance use disorders have been systematically discriminated against by the insurance industry for the past thirty years. At that time functional detoxification was not allowed and any patient who was intoxicated was generally denied care in psychiatric units by these same companies even if they had a significant psychiatric disorder. They were supposed to go to "social detox" in county detox units, at least until most counties learned from insurance companies that it is cost effective to not have any resources and just deny care. That means that today more people never get sober and are more likely to have increasing numbers of encounters with the police. All it takes is an episode of aggression or suicidal statements while intoxicated and it can lead to transportation to specific psychiatric hospitals that receive patients from the police and paramedics. In many cases, the hold is dropped after the person is detoxified and they no longer have the behaviors that occur in the intoxication state. In other cases, there are semi-permanent or permanent changes secondary to the substance use and that results in a longer hospitalization.
Intoxication states including alcohol, cocaine, amphetamines, hallucinogens, and marijuana as well as the associated drug induced mental disorders are overrepresented in the population that gets acutely and/or involuntarily admitted. People with substance use disorders have been systematically discriminated against by the insurance industry for the past thirty years. At that time functional detoxification was not allowed and any patient who was intoxicated was generally denied care in psychiatric units by these same companies even if they had a significant psychiatric disorder. They were supposed to go to "social detox" in county detox units, at least until most counties learned from insurance companies that it is cost effective to not have any resources and just deny care. That means that today more people never get sober and are more likely to have increasing numbers of encounters with the police. All it takes is an episode of aggression or suicidal statements while intoxicated and it can lead to transportation to specific psychiatric hospitals that receive patients from the police and paramedics. In many cases, the hold is dropped after the person is detoxified and they no longer have the behaviors that occur in the intoxication state. In other cases, there are semi-permanent or permanent changes secondary to the substance use and that results in a longer hospitalization.
3. Acute psychotic states
Some patients who develop acute psychiatric states can experience similar changes in their conscious state that result in violent or suicidal behavior. It is common rhetoric to hear that patients with mental disorders are no more likely than non-patients to be violent or aggressive. Averaged across the entire population that may be true but it is also true that there are very high risk groups of people with mental illness. The civil commitment laws in most states were designed for this contingency and a lot of these stories make the front pages these days. Acute agitation and aggression in public or at the time of an emergency call places the person at high risk for a confrontation with the police. In these confrontations anything can happen. One of the functions of the hospital staff is to come up with a plan that will minimize any future risk of this kind of confrontation and to immediately address any physical or psychological trauma that occurred prior to admission. In some cases, ongoing high levels of aggression in the hospital can result in additional physical intervention. The goal of that physical intervention is much different that the police goals and staff have to be trained to provide this kind of treatment. Medication can also be administered in emergency situations and according to state statutes to reduce the risk of injury to patients and staff.
Some patients who develop acute psychiatric states can experience similar changes in their conscious state that result in violent or suicidal behavior. It is common rhetoric to hear that patients with mental disorders are no more likely than non-patients to be violent or aggressive. Averaged across the entire population that may be true but it is also true that there are very high risk groups of people with mental illness. The civil commitment laws in most states were designed for this contingency and a lot of these stories make the front pages these days. Acute agitation and aggression in public or at the time of an emergency call places the person at high risk for a confrontation with the police. In these confrontations anything can happen. One of the functions of the hospital staff is to come up with a plan that will minimize any future risk of this kind of confrontation and to immediately address any physical or psychological trauma that occurred prior to admission. In some cases, ongoing high levels of aggression in the hospital can result in additional physical intervention. The goal of that physical intervention is much different that the police goals and staff have to be trained to provide this kind of treatment. Medication can also be administered in emergency situations and according to state statutes to reduce the risk of injury to patients and staff.
4. Suicidal states
One of the more complex aspects of inpatient care is assessing suicide risk and attempting to reduce suicide risk on the inpatient setting. The problem is complicated by the fact that a lot of people with chronic suicidal thinking are assessed as being acutely suicidal and they are admitted. In many cases it is a fine line between thinking about injuring or killing yourself every day for years and then one day deciding that you are going to do it. In many cases people will injure themselves and demand to be released from the hospital. They will deny making the statements even though the documentation is very clear. They will be unaware or dishonest about their potential for suicide or self injury. They may be indignant about being in a hospital even after a serious suicide attempt. Others have very serious suicidal thinking and are quiet and cooperative but may at very high risk for suicide if they are released prematurely. The worst case scenario is the person who suicides in the hospital or shortly after release. The majority of people are able to recognize that there is a problem and work with the staff on resolving it and get released on a voluntary basis as soon as possible.
One of the more complex aspects of inpatient care is assessing suicide risk and attempting to reduce suicide risk on the inpatient setting. The problem is complicated by the fact that a lot of people with chronic suicidal thinking are assessed as being acutely suicidal and they are admitted. In many cases it is a fine line between thinking about injuring or killing yourself every day for years and then one day deciding that you are going to do it. In many cases people will injure themselves and demand to be released from the hospital. They will deny making the statements even though the documentation is very clear. They will be unaware or dishonest about their potential for suicide or self injury. They may be indignant about being in a hospital even after a serious suicide attempt. Others have very serious suicidal thinking and are quiet and cooperative but may at very high risk for suicide if they are released prematurely. The worst case scenario is the person who suicides in the hospital or shortly after release. The majority of people are able to recognize that there is a problem and work with the staff on resolving it and get released on a voluntary basis as soon as possible.
5. Friends and family
In many cases of acute involuntary hospitalization, the chain of events starts with a family member or friend long before there is any suggestion of hospital involvement. Family members often find themselves in the precarious situation of being concerned about the future patient, but not able to do anything about it. They may have false information and believe that nothing can be done until the person actually "does something." They are fearful about the patient's behavior and the fact that they have become unpredictable. In some of these situations the first event leading to the hospital is an act of aggression or a suicide attempt. The police are called, a crisis intervention team is activated, and the person is placed on a transportation hold and taken to the hospital.
Family members respond differently when the patient is admitted to a psychiatric unit. Some family members are angry that the patient was admitted and insist that the patient be admitted to a medical or surgical service. These patients are often geriatric patients who become aggressive at home. Some families are relieved that the admission occurred and their member is in a safe environment and treatment can start. Some families do not want the patient to know that they were involved in getting them to the hospital. Some families get angry and demand that the patient be immediately released. In some cases family members can become violent and threatening themselves. Communication with the family can prevent a lot of misunderstandings and give them a clear idea of what the assessment and plan will be. In some cases, the patient will refuse to sign the necessary releases to allow this communication.
In many cases of acute involuntary hospitalization, the chain of events starts with a family member or friend long before there is any suggestion of hospital involvement. Family members often find themselves in the precarious situation of being concerned about the future patient, but not able to do anything about it. They may have false information and believe that nothing can be done until the person actually "does something." They are fearful about the patient's behavior and the fact that they have become unpredictable. In some of these situations the first event leading to the hospital is an act of aggression or a suicide attempt. The police are called, a crisis intervention team is activated, and the person is placed on a transportation hold and taken to the hospital.
Family members respond differently when the patient is admitted to a psychiatric unit. Some family members are angry that the patient was admitted and insist that the patient be admitted to a medical or surgical service. These patients are often geriatric patients who become aggressive at home. Some families are relieved that the admission occurred and their member is in a safe environment and treatment can start. Some families do not want the patient to know that they were involved in getting them to the hospital. Some families get angry and demand that the patient be immediately released. In some cases family members can become violent and threatening themselves. Communication with the family can prevent a lot of misunderstandings and give them a clear idea of what the assessment and plan will be. In some cases, the patient will refuse to sign the necessary releases to allow this communication.
6. Probate and criminal court officials
Statutes vary from state to state, but in the two main states where I have worked probate courts make the decisions about involuntary hospitalization, civil commitment, guardianship, involuntary administration of medication, and conservatorship. The process is advanced by screeners who gather evidence that can be tested against the statutory language for civil commitment and other proceedings. Contrary to a recent Internet post on the "medical model", impaired insight is not a criterion for commitment and neither is "sadness" as suggested in the original post. The probate court staff and not the hospital staff need to come up with all of the actual behavioral evidence to proceed with the original hold order and any further legal proceedings toward civil commitment.
One aspect of these court proceedings that nobody pays much attention to is that (like all American legal activity) these proceedings are contentious. There are two sides and both sides want to "win" according to that model. If any paternalism enters into the picture it typically happens when the patient's attorney recognizes that they are too ill to function and strikes some kind of bargain with the court. Speaking for the clinician side I can say that quality treatment is a more realistic goal than "winning" in any usual sense of the word. The patient, their family, and their attorney can decide that they will advocate for a position that is the opposite of what the hospital staff recommends. In that case, there will typically be a lot more emotion than if there is no apparent alignment opposing the treatment team.
Statutes vary from state to state, but in the two main states where I have worked probate courts make the decisions about involuntary hospitalization, civil commitment, guardianship, involuntary administration of medication, and conservatorship. The process is advanced by screeners who gather evidence that can be tested against the statutory language for civil commitment and other proceedings. Contrary to a recent Internet post on the "medical model", impaired insight is not a criterion for commitment and neither is "sadness" as suggested in the original post. The probate court staff and not the hospital staff need to come up with all of the actual behavioral evidence to proceed with the original hold order and any further legal proceedings toward civil commitment.
One aspect of these court proceedings that nobody pays much attention to is that (like all American legal activity) these proceedings are contentious. There are two sides and both sides want to "win" according to that model. If any paternalism enters into the picture it typically happens when the patient's attorney recognizes that they are too ill to function and strikes some kind of bargain with the court. Speaking for the clinician side I can say that quality treatment is a more realistic goal than "winning" in any usual sense of the word. The patient, their family, and their attorney can decide that they will advocate for a position that is the opposite of what the hospital staff recommends. In that case, there will typically be a lot more emotion than if there is no apparent alignment opposing the treatment team.
7. Medical staff
In addition to the usual medical and psychiatric tasks of diagnosis and differential diagnosis and treatment of these diagnoses, the main task of inpatient staff is to maintain a safe and therapeutic environment. Given the marginal existence of some of these units that is no easy task. I can recall working on units where all of the patients stood on the other side of the glass and the activity was dominated by young aggressive men with severe personality and psychiatric disorders. If an intimidating environment like that is allowed to exist a significant number of people in that environment will be frightened and in some cases traumatized. Patients who are disruptive due to inappropriate social or sexual behavior or because of dementia can also frighten or anger other patients and that can lead to some level of traumatization or a reactivation of that dynamic. The staff all need to be acutely aware of these potential problems and act to address them. This requires an physical presence of medical staff on the unit. Given the current levels of acuity, inpatient units cannot be run remotely or by administrators. The medical staff present has to be well trained, comfortable with treating severe psychiatric problems, cohesive, and proactive.
Physical interventions to prevent aggression or self injury are potential flash points for trauma. Many people who are acutely hospitalized have a high likelihood of past trauma or abuse. The best overall approach is to keep any physical interventions to the minimum and keep the staff well trained in the concepts or therapeutic neutrality and verbal deescalation. In the cases where physical intervention is required, strict protocols need to be followed and quality assurance programs need to be in place to assure that these measures are kept to the very minimum periods of time.
In addition to the usual medical and psychiatric tasks of diagnosis and differential diagnosis and treatment of these diagnoses, the main task of inpatient staff is to maintain a safe and therapeutic environment. Given the marginal existence of some of these units that is no easy task. I can recall working on units where all of the patients stood on the other side of the glass and the activity was dominated by young aggressive men with severe personality and psychiatric disorders. If an intimidating environment like that is allowed to exist a significant number of people in that environment will be frightened and in some cases traumatized. Patients who are disruptive due to inappropriate social or sexual behavior or because of dementia can also frighten or anger other patients and that can lead to some level of traumatization or a reactivation of that dynamic. The staff all need to be acutely aware of these potential problems and act to address them. This requires an physical presence of medical staff on the unit. Given the current levels of acuity, inpatient units cannot be run remotely or by administrators. The medical staff present has to be well trained, comfortable with treating severe psychiatric problems, cohesive, and proactive.
Physical interventions to prevent aggression or self injury are potential flash points for trauma. Many people who are acutely hospitalized have a high likelihood of past trauma or abuse. The best overall approach is to keep any physical interventions to the minimum and keep the staff well trained in the concepts or therapeutic neutrality and verbal deescalation. In the cases where physical intervention is required, strict protocols need to be followed and quality assurance programs need to be in place to assure that these measures are kept to the very minimum periods of time.
8. Relevant demographic factors
The most relevant demographic factor on the part of the patient is a history of abuse, a diagnosis of post traumatic stress disorder and how those variables currently affect them. Some studies suggest that as many as 30-40% of patients have one or both problems. The is relevant not only in understanding their current presentation but it should also guide how the staff interact with them. In an informed environment, with resources it can suggest a course of psychotherapy, but very little psychotherapy typically occurs in most inpatient units. Sociopathy and psychopathy are also relevant variable, since it is unlikely that people with these problems can be integrated into a population of more vulnerable patients without the odds of victimization being very high. Substance use issues can also be very disruptive, especially in environments that are not very secure and increase the risk of contraband being brought into the hospital.
9. Personality and anger control factors
Anger is an interesting emotion for a number of reasons. It is hardly mentioned in psychiatric diagnostic manuals but it plays a significant role in inpatient psychiatry. An inpatient psychiatrist can walk in and find that most or all of the patients to be seen that day have significant problems with anger. Anger is frequently seen as a non-specific symptom of psychosis, mania, or personality disorders but it is more complicated than that. There are often different formulations of anger control problems on inpatient units. Assuming the person is not intoxicated it can be paranoia, projection, projective identification, grandiosity, irritability and various symptoms associated with the psychiatric syndromes that correlate with anger and aggression. But there is also the element of anger and how it affects decision making. If you are angry (irrespective of the real cause) you will have a tendency to see your problems as being attributable to another person and to see that other person as being responsible for your problems. This means that if you were angry before you were hospitalized you will see the inpatient staff as being responsible for your problems, even though they had nothing to do with the circumstances of admission. It is also true that is almost all of the situations that I have encountered, the inpatient physician did not initiate the emergency hold. It is typically initiated by an outpatient or ED physician or in some states - law enforcement. Most people in this situation can recognize what happened, but some cannot. Some will remain angry the whole time and for a long time after they are discharged.
Anger is an interesting emotion for a number of reasons. It is hardly mentioned in psychiatric diagnostic manuals but it plays a significant role in inpatient psychiatry. An inpatient psychiatrist can walk in and find that most or all of the patients to be seen that day have significant problems with anger. Anger is frequently seen as a non-specific symptom of psychosis, mania, or personality disorders but it is more complicated than that. There are often different formulations of anger control problems on inpatient units. Assuming the person is not intoxicated it can be paranoia, projection, projective identification, grandiosity, irritability and various symptoms associated with the psychiatric syndromes that correlate with anger and aggression. But there is also the element of anger and how it affects decision making. If you are angry (irrespective of the real cause) you will have a tendency to see your problems as being attributable to another person and to see that other person as being responsible for your problems. This means that if you were angry before you were hospitalized you will see the inpatient staff as being responsible for your problems, even though they had nothing to do with the circumstances of admission. It is also true that is almost all of the situations that I have encountered, the inpatient physician did not initiate the emergency hold. It is typically initiated by an outpatient or ED physician or in some states - law enforcement. Most people in this situation can recognize what happened, but some cannot. Some will remain angry the whole time and for a long time after they are discharged.
10. Officials who monitor medical staff and hospitals
There is a long line of administrators whose only job is to make sure that patient rights are guaranteed and that no patient is abused or treated in a disrespectful manner. The first official is usually a patient advocate who is a permanent employee of the hospital or clinic. In the state where I work the next line of oversight is an Ombudsman for mental health and developmental disabilities appointed by the governor who has investigative oversight into any hospital or clinic activity that a patient or their family finds to be unacceptable. The Ombudsman can come in to any facility and interview all of the people involved and make their own determination of the merits of the complaint and what corrective action needs to be taken. In the case of physicians the Board of Medical Practice (BMP) has ultimate authority over any licensed physician in the state. All it takes is a brief note on a complaint form to initiate a full investigation into a physician's behavior that involves all of the relevant medical records being sent to the BMP. Complaints are never questioned as far as their accuracy or coherence. The physician in question needs to respond in detail to the complaint. Physicians are never exonerated, a complaint is never assessed as to whether or not it had merit, and complaints are kept on permanent file even if the complaint is dismissed. A finding against a physician can result in fines and restriction or suspension of their license to practice medicine.
11. A reasonable discharge plan
In the most straightforward scenarios people sober up and/or resolve their crises and they are discharged as soon as any hold can be dropped. In the case of acute intoxication states that don't require extensive detoxification it could happen in less than a day. People are frequently discharged as soon as they are admitted from the ED (they are essentially admitted for a second opinion from a psychiatrist). In more complex crisis situations, collateral information is usually needed to corroborate the patient's baseline behavior and document whether the relatives have had any concern before the hospitalization. As noted in the family section, relatives have varying degrees of anger. Some may show up either demanding the immediate release of the patient or threatening to sue the medical staff if the patient is released and not treated. In some cases there are threats that legal action will be taken if the patient commits suicide or harms someone. All of these factors and any medical and psychiatric diagnoses and treatment plans have to be negotiated in the discharge planning.
In the most straightforward scenarios people sober up and/or resolve their crises and they are discharged as soon as any hold can be dropped. In the case of acute intoxication states that don't require extensive detoxification it could happen in less than a day. People are frequently discharged as soon as they are admitted from the ED (they are essentially admitted for a second opinion from a psychiatrist). In more complex crisis situations, collateral information is usually needed to corroborate the patient's baseline behavior and document whether the relatives have had any concern before the hospitalization. As noted in the family section, relatives have varying degrees of anger. Some may show up either demanding the immediate release of the patient or threatening to sue the medical staff if the patient is released and not treated. In some cases there are threats that legal action will be taken if the patient commits suicide or harms someone. All of these factors and any medical and psychiatric diagnoses and treatment plans have to be negotiated in the discharge planning.
12. A general lack of knowledge and sophistication about emergency hospitalization
It should be well known in our society that people are conflicted about mental illness and its treatment. At the level of the healthcare business there is no conflict. Healthcare companies are in business to make money and to a large extent that is how people keep circulating in and out of psychiatric hospitals and emergency rooms. To my knowledge, nobody is ever educated about preventing these kinds of emergencies and avoiding contact with the police and hospitalization. Instead we seem to have plenty of advocates for more risk rather than less. That includes the recent pendulum swing toward more permissive attitudes involving drug and alcohol use. Recognizing that a problem exists that could lead to this pathway is critical for prevention of these episodes and by definition prevention of any trauma that might be incurred on inpatient units.
Conclusion:
All things considered, I encountered very few situations where there was a question of a person being traumatized on an inpatient psychiatric unit where I worked. I agree that this is an area for further study and that study would need to be carefully done. I know that many people do not disclose what they were thinking or feeling in the hospital until well after they have been discharged. A possibly useful approach might be to offer a post discharge assessment that focused only on the issue of trauma that occurred in the hospital and was totally independent of a treatment plan for the primary diagnosis.
In any situation this complex is it possible that some people are traumatized by the experience? Of course it is. Is it possible that some people actually create trauma for their fellow patients and staff? Most definitely. Is it possible that some if not most people recognize that there were major problems before admission that led to this situation and are able to work with the hospital staff to resolve the situation in a timely manner? The answer is again - very definitely. There are a number of mechanisms available to people who feel traumatized or treated unfairly as outlined above. These safeguards vary from state-to-state but similar agencies are available across the United States. In the case of Medicare patients, each state also has a unit to investigate complaints of Medicare patients if they believe they have received suboptimal care or care that was in any way abusive. All of the agencies outside of the hospitals are free of conflict of interest and in many cases they consider it a political plus to take action against any abuse that occurs in a health care facility. As a past Medicare reviewer, all reviews are conducted by physicians who are carefully screened for any potential conflict of interest.
Utilizing these resources and conducting further research on this problem is the best possible approach. It is far superior to political debates on the Internet or attacking a person who is interested in studying the problem.
In any situation this complex is it possible that some people are traumatized by the experience? Of course it is. Is it possible that some people actually create trauma for their fellow patients and staff? Most definitely. Is it possible that some if not most people recognize that there were major problems before admission that led to this situation and are able to work with the hospital staff to resolve the situation in a timely manner? The answer is again - very definitely. There are a number of mechanisms available to people who feel traumatized or treated unfairly as outlined above. These safeguards vary from state-to-state but similar agencies are available across the United States. In the case of Medicare patients, each state also has a unit to investigate complaints of Medicare patients if they believe they have received suboptimal care or care that was in any way abusive. All of the agencies outside of the hospitals are free of conflict of interest and in many cases they consider it a political plus to take action against any abuse that occurs in a health care facility. As a past Medicare reviewer, all reviews are conducted by physicians who are carefully screened for any potential conflict of interest.
Utilizing these resources and conducting further research on this problem is the best possible approach. It is far superior to political debates on the Internet or attacking a person who is interested in studying the problem.
George Dawson, MD, DFAPA
References:
1: Bruce M, Laporte D. Childhood trauma, antisocial personality typologies and recent violent acts among inpatient males with severe mental illness: Exploring an explanatory pathway. Schizophr Res. 2015 Mar;162(1-3):285-90. doi: 10.1016/j.schres.2014.12.028. Epub 2015 Jan 28. PubMed PMID: 25636995.
References:
1: Bruce M, Laporte D. Childhood trauma, antisocial personality typologies and recent violent acts among inpatient males with severe mental illness: Exploring an explanatory pathway. Schizophr Res. 2015 Mar;162(1-3):285-90. doi: 10.1016/j.schres.2014.12.028. Epub 2015 Jan 28. PubMed PMID: 25636995.
Supplementary:
I am interested in any additional factors that I may have missed in terms of sources of trauma on inpatient units. E-mail me what you think and I may include it in an updated table.
