It is not home: Unfortunately, no matter how much a modern day hospital attempts to make patients feel at home, the reality is that a hospital is not a home. Most hospitals are cold, uncomfortable, expensive (if the person does not have insurance), and psychologically overwhelming. I once accompanied a young client to a hospital on a 201 status (voluntary commitment) and during this process, my young client sat close to me during the entire process of signing herself in due to overhearing another client screaming, fighting staff, and cursing. This patient’s behavior far exceeded violent and required physical and chemical restraints. The fear, the uncertainty, and the shock on my client’s face opened my eyes to how much patients can be emotionally affected by observing another patient within this type of setting.
- It can lead to “institutionalized thinking”: When I speak to parents about the importance of building structure in the home after a child has been institutionalized, many parents say: “I can’t get Bob to stop acting out at home. When he was in the hospital, he behaved differently. Now that he is at home, I can’t control him.” The problem most likely involves the fact that when an individual is placed in an institution for psychiatric care (long-term treatment facility, hospital, or another inpatient setting like rehab), there is a great deal of structure and routine that the individual learns to adjust to over time. Like many of us in society, we find a routine to be very helpful and comfortable. Sometimes we cannot break our habits because we appreciate the ease a routine provides. It can be very difficult to get out of a particular routine and structure especially if an institution provided structure for long periods of time (months, years, etc). Therefore, when an individual is placed back into society or a home environment, it can feel like culture shock. This is why it is very important to work with a case manager, therapist, or social worker before returning to the community or home environment.
- It is easier to get out than to get in: Most hospitals are looking for ways to reduce the number of patients they have to admit to a hospital. A lower number of patients means lowered financial costs and greater work productivity in an atmosphere where most staff are burned out. In order to get admitted to a hospital, the individual must exhibit a high level of lethality (i.e., a harm to self or others) and/or show a slow decline in the ability to care for self in appropriate ways. Activities of daily living (ADL’s) such as eating, sleeping, hygiene, etc. must be poor before a hospital would consider a patient on a 302 (involuntary admission). Many hospitals across the nation are sending needy individuals back into the community to reduce the number of patients in a hospital. The minimum stay in a hospital is 3 days while the maximum might be 5+ days with the goal of sending the individual back into the community with another type of mental health service. In other cases, the minimum stay might be a few hours if the hospital believes that an individual does not need to be admitted to the hospital.
- Other patients might be intimidating: As described above, other patients can truly interfere with an individual’s emotional and psychological stability. Observing restraints, fights between patients, and overhearing screaming, cursing, or other odd noises can be very frightening. Let’s face it, no one wants to be placed in an environment where life is unpredictable and intimidating. A 13-year-old client once said to me during a session: “I don’t feel safe enough to sleep because I am afraid someone might hurt me.” Another one of my former clients mentioned an incident in which an 18-year-old patient grabbed her hair (and would not go) while they were casually talking during lunch.
- It can smother independence: It is a sad reality but anytime a person has to be placed in the care of a healthcare professional that individual must do what is asked of them. Someone who is committed to a psychiatric hospital has to tend to hygiene, wake up and sleep, eat, and take medications when told. If the individual is a child or adolescent in a residential setting, that child or adolescent has to appropriately engage with peers and follow activities of daily living (tending to hygiene, eating appropriately, taking medications, etc) when told or there could be consequences such as loss of privileges or longer term stay. For example, I have worked in residential facilities for children and adolescents who have a token economy system in which all residents must engage in the activities of the day (washing clothes, making one’s bed, taking medication, going to school, eating, socializing, etc) in order to receive tokens or privileges. Independence is often “smothered” by this kind of system which is why there are patients who will refuse to follow the “rules.”
- It is a revolving door: Sadly, for many individuals who are struggling with chronic psychiatric symptoms, hospitals are not the best places to receive long-term help. Hospitals are now intended to provide acute stabilization in order to return the individual back to the community. There once was a time when hospitals provided long-term care where patients could remain in the hospital setting for weeks and sometimes months and years. Unfortunately, today’s hospital criteria to be admitted is only for temporary treatment. Many individuals are not stable enough to return to the community but are “forced” out of the hospital and told to follow up with a mental health professional or local crisis support team. Severely ill patients never follow up with the appropriate services and end up in the hospital again and again.
- Kids can use it as a way to manipulate: As much as I love working with youths and advocating for them, we must take into consideration that there are manipulative youths who will attempt to use the hospital for various reasons other than for treatment. For example, someone with a personality disorder (narcissism, borderline personality, antisocial, etc) might engage in self-injurious behaviors or make suicide attempts that almost always result in a transport to the hospital to get attention, make them feel wanted or cared for, and/or to distract from the real issues going on in their life. Other individuals might engage in making suicide attempts or writing suicide letters to get a point across to someone (a parent, a significant other, bully, etc.). Manipulation by some kids does not mean that all kids never feel suicidal or self-injurious and require hospital care. But what I am saying is that some kids will engage in manipulative behaviors that result in hospital admissions.
- It stays on your record: One of the biggest fears many of my clients have is whether their mental health record will follow them. I always inform the client that their psychiatric record is primarily protected by HIPAA laws, the Health Insurance Portability and Accountability Act, which means that no one is able to obtain medical or mental health information without their consent. However, this usually is not enough to calm their fears. Some individuals worry that they will be discriminated against by medical professionals who can see their past treatment, especially if they consent to the medical professional receiving their entire health portfolio. Unfortunately, there is nothing that can be done about the “paper trail” that can be created after treatment has been received. Most people would prefer to avoid psychiatric care for this very reason.
- You can’t go if you are exhausted, emotionally labile, or just need a break: As stated above, psychiatric hospitalization is very different than it was in previous years. Before hospitals began abiding by strict state laws, most people could easily sign themselves into a hospital (voluntary admission) for a few days to recover from emotional or psychological exhaustion. In today’s world, hospitals are mainly looking to admit individuals who are a danger to themselves or others. Hospitals are looking to reduce the number of patients admitted to the hospital. This makes signing oneself into a hospital a bit tricky. In many, many cases individuals are turned away from the hospital and asked to call a crisis line or crisis intervention service for mental or emotional exhaustion. Other client’s are referred to outpatient counseling services or respite. But for individuals who need a place to stay for a short period of time with 24/7 supervision, calling a crisis line is only a temporary band-aid.
What are some of your experiences? Unfortunately, many of my client’s are in need of longer-term psychiatric services such as residential treatment or hospital treatment but refuse to seek this help. I was able to “interview” some of them on reasons for why they refuse treatment. Many of their responses are above. I always enjoy your questions and input. Feel free educate us all!
All the best