Inpatient Psychiatry: Not all Needles, Drugs And Locks

I worry the images you have of inpatient psychiatry scare you and prevent you from seeing me as an ally.
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The Defective Delinquent and Insane by Henry Cotton. Princeton: Princeton University Press; London: Oxford University Press, 1921

A typical dinner conversation when I am meeting new people goes something like this:

“Hi. What do you do for a living?”

“I am a doctor.”

“Oh, what kind?”

“A psychiatrist.”

Usually what follows next is a long pause, and then the conversation can go a few directions. Sometimes people don’t know that psychiatrists are doctors, and that’s somewhat understandable (especially given its phonetically similar relative psychology) and easily corrected with a bit of education. Along these same lines, I’ve been around plenty of peers who are somewhat shocked to learn that “locked wards still exist.”

Other times, people will either divulge a deep secret about themselves or their friends/family or create a newfound barrier with me, asking if I am “analyzing them” or “reading their minds.” However, what frustrates me most are the times when after describing my day-to-day as a psychiatry resident, I am met with bewilderment, followed by misplaced sarcasm as I am asked, “And why would you want to do that?”

After reminding myself not to get defensive (as I continued to do throughout writing this piece) or just stop the conversation completely, I became intrigued. While doctors may not evoke the same respect and adoration of the days of house visits, no one asks the other doctors (non-psychiatrists) in my family with such strong negative connotation why they chose their respective specialties.

I began to wonder if it’s because the difference between a locked ward and a medical ward can seem confusing and scary to an outsider or a patient. Without knowing the safety rationale, it can feel degrading to have your clothes taken away, along with your cell phone, shoelaces, and sharp objects, only to sleep in a boring room with heavy, non-moveable (or throw-able) furniture. If you lack insight into your illness and do not understand the necessity of hospitalization, it can feel prison-like to be on a locked ward without the ability to leave it. And, without understanding the therapeutic benefit of engaging in connections with others on the unit, it can feel restrictive to have visiting hours and not be able to have a significant other or family member spend the night.

Dear future and past patients: I. COMPLETELY. GET. IT. Nothing about being on a psychiatric ward is typical, even for a medical setting. But I (and every nurse, social worker, psychologist, occupational therapist, physical therapist, nursing assistant, and physician I have ever worked with) also really want to help you. That is why I chose a career in medicine, and even more true of the reason why I chose to specialize in psychiatry. I worry the images you have of inpatient psychiatry scare you and prevent you from seeing me as an ally. Even when I tell you that I am here to help, I can see the skepticism in your eyes and hear the fear in your voice. I am trained to observe, after all.

It is not surprising, then, that when I read descriptions or see my job portrayed as forceful or horrific, I want to take the time to correct them. I am not doing this simply because I want to protect my profession, but am actually doing this in defense of and in support of anyone who might need mental health help in the future. Stigmatizing attitudes toward psychiatric illnesses already exist; fear of psychiatry and seeking care do not need to be added to the equation.

Well described in the literature and in particular in Jeff Lieberman’s book Shrinks, gone are the days of long-term institutionalization, Nurse Ratched, and gross misuse of psychiatric settings. Yet you would not know it by watching television or the movies.

Even popular Halloween destinations cannot escape from perpetuating the myth of the “scary psychiatric ward.” Recently, Knott’s Berry Farm had a ride named Fear VR 5150 (for the 72-hour involuntary psychiatric legal hold in California), in which attendees were first “strapped to a chair” and admitted to a mental hospital and were later chased by a “demonic patient.”

While Knott’s Berry Farm shut down the ride due to protests by the mental health community and issued an apology (stating that it was not meant to portray mental illness), a petition to reverse the decision signed by thousands on stated, “Closing the attraction is not going to help advocate the increase of knowledge on the subject either. People are still going to be afraid of what they do not understand in regards to mental illness.”

Maybe the psychology student who started the petition is right. Maybe people will always fear psychiatry, mental illness and what they do not know, and maybe an amusement park ride is not the issue. But maybe those attitudes can be changed and as mental health advocates, we need to do everything we can to assuage those fears. Unfortunately, even well-meaning former patients perpetuate those fears, whether inadvertently or because of the limited lens through which they viewed their own hospitalization.

In one such patient story, a patient wrote, “a while ago, the staff used to fetch two mattresses and, in phalanx formation, would march toward each other from opposite directions, sandwiching the distressed patient. I can’t see what tactics staff are using to take down Marcus, but, when they let us back into the halls, we find him sprawled unconscious on a bed in one of the smaller rooms, a brown cotton-lined cuff attached to the bed rail and to his wrist. He sleeps for two days.”

While I was not in the room for this patient encounter, the fear that this narrative evokes (especially the image of the “patient sandwich”) is striking. To tell her truth, the author necessarily leaves out the intricacies of our roles, the evolution of our field, and the clinical value and necessity of inpatient psychiatric treatment. What she may not be aware of is the very real issue of safety on the unit and the training, empathy, and thought that goes into each and every one of these escalated situations. I’ve been screamed at, cursed at, rushed towards, demeaned and have seen patients and nurses get seriously injured. Even still, I do not make these decisions lightly or lead a conversation with a needle.

Like any doctor, psychiatrists fiercely advocate for our patients and for their wellbeing. Our field is somewhat unique, however, in that sometimes patients with mental illness lack the needed insight to recognize this advocacy. I have never enjoyed a situation where a person is legally required to remain in the hospital or take medication against their wishes, and despite popular belief and imagery, physical restraints are very much a last resort. I am not discounting how frightening or confusing these observations may be to a patient bystander, and there are undoubtedly ways we can better support patients during and after these experiences. Yet, more awareness is needed about the intricacies of our decisions as psychiatrists; increased emphasis on the humanity of our day-to-day job is crucial to the narrative. As psychiatrists we know all too well the fears that exist about psychiatry, and instead of ignoring them, we run head on into them, aiming to practice with empathy and assuage those fears. We also are human beings and don’t see ourselves as outsiders untouched by mental anguish, but rather, as those trained to provide relief of suffering in situations of great pain and imminent risk to the patient or others.

Given the responses to our career selection in casual conversation, it is probably not shocking that I (and my peers) can sometimes hesitate to say my medical specialty, despite having no shame or regrets about my decision. Knowing now that hiding my profession only further contributes to its stigma, and without a voice or a face, psychiatrists and their patients will always just be a part of a power struggle and a scary amusement park ride, I will never again shy away from it:

I am a psychiatrist-in-training. My job is complicated, weird, unique, fun, fulfilling, and challenging… but that’s what makes it beautiful.

The opinions expressed herein are solely my own as a psychiatry trainee and mental health advocate. I receive no support from any pharmaceutical or device company.

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