Okay, so perhaps the photo is rather overdramatic. Still, it does a lot to capture what can be a horrific experience of psychiatric hospitalization.
I look at this issue from 2 quite different perspectives; I’m a mental health nurse and have worked on an inpatient psychiatric ward, but I also have major depressive disorder and have been hospitalized 4 times. The first two each lasted 2 months, and the others were each for 3 weeks. Only one was voluntary; the other three I was committed involuntarily. I still feel traumatized by many of my experiences in hospital, and the years that have passed since my last inpatient stay have made me even more certain that it should never have had to be that way. Because of what I have experienced I highly doubt I will ever again go to hospital voluntarily, and on multiple occasions I have resorted to lying to my doctors to avoid being committed. I doubt I’m the only one who feels this way, and this points to problems in the way that inpatient psychiatric care is being provided.
My first hospitalization seemed like one long fight with the treatment team. This earned me a diagnosis of borderline personality traits, an inaccurate label that is sadly reflective of the tendency of some health professionals to view patients who are “difficult” as having a personality disorder. I developed a romantic connection with another patient on the ward, and while I can see why they didn’t react well to walking in on us getting it on in the bathroom (hey, desperate times call for desperate measures), it just kept getting ratcheted up to new levels of ridiculousness. There was the “5-foot-rule”, that we were not allowed within 5 feet of each other in common areas. Sometimes that was expanded to a rule of not being allowed in the same room together. It really should not be surprising to staff that when you treat someone like a child, they will react by behaving like a child, yet I continue to see this sort of thing on a disappointingly regular basis in the context of my work. In my case, the childish behaviour manifested as hostility, swearing, screaming, and temper tantrums.
During my last hospitalization, when I was first transferred from the medical emergency to the psych emergency ward, the doctor had ordered my regular meds to be held for a day to give time for the pills I overdosed on to clear from my system. Except no one told me this, so I had a complete sh*t fit at the night nurse: “how the f*** am I supposed to get better if you don’t give me my f***ing meds?” The next day I applied for a review panel to challenge my involuntary committal. When it was held a couple of weeks later I lost, and I remember afterwards leaving an angry message for my community psychiatrist: “I’m stuck in this hellhole until whenever the f*** they decide to let me go.” How very therapeutic. There I was, locked on a ward, being treated by a psychiatrist that I didn’t trust and nurses whose competence I questioned (like the one who thought I was depressed because I was single, or the one who was annoyed I wouldn’t tell her what I was angry about, since if I attempted suicide I must be angry about something). I wasn’t allowed to have my cellphone, which would have been a lifeline to my social support network, and I was regularly chided for not attending groups, as if baking muffins with my co-patients would be some great panacea. The screaming, temper tantrums, and other childish behaviours continued to pop up as over and over again I was treated like a child.
The nurse side of me gets that sometimes involuntary treatment is the only way to keep people safe, and on rare occasion practices like seclusion and restraint are also necessary for safety. I’ve seen people respond very, very well to treatment they never would have gotten voluntarily. However, I think that all too often a shift in perspective is called for so that these restrictive types of interventions used only when absolutely necessary rather than as a first-line approach to care.
An important ethical issue at play here is the conflicting principles of paternalism and autonomy. The importance placed on each varies depending on many factors, including the situation and cultural norms. In general, autonomy is seen as quite important in Western cultures, with some notable exceptions. Medicine has traditionally been a field in which a paternalistic doctor-knows-best point of view has been considered acceptable. This is something that has started to change as it’s become easier for patients to inform themselves rather than relying solely on a doctor for information. The field of psychiatry has been slower to come around, and there are a number of reasons for that. Mental illness may cause”anosognosia“, or lack of insight into one’s own condition. Mental illness may also impact judgment, making it harder to make reasoned, informed decisions about treatment. This is part of why there are laws that allow for involuntary committal to hospital.
That’s fine. But the ethical reasoning process should not stop there. By stripping away a patient’s autonomy and forcing the treatment provider’s choices upon them, the treatment team is undercutting what many would consider to be a basic human right. This can cause harm, and it can cause trauma. When I screamed and swore and fought (figuratively, not literally) against the hospital treatment providers, it was because I felt like my dignity was being stripped away. I did not feel helped, supported, or understood; I felt degraded. How is that conducive to effective treatment?
Two more ethical issues that are relevant to psychiatric hospitalization are beneficence (do good) and nonmaleficence (do no harm). I honestly think that most treatment providers believe they are doing good by imposing clinical interventions, but again, the ethical reasoning process should not stop there. How often is that next step happening, to consider what harm might be done by practices such as involuntary treatment, seclusion, and restraint? Did any of the health professionals who treated me in hospital even for a moment consider how traumatizing the experience was for me? I may be biased, but I doubt it. What I have seen in my own professional practice tends to back that up. There is too often a sort of arrogant righteousness in those who believe they know what’s best for their patients.
There are ways to impose desperately needed treatment and still promote patient autonomy. Treating people with respect, compassion, and empathy and valuing their dignity can go a long way in making psychiatric hospitalization a more therapeutic experience. Making sure that patients feel heard, and that they have at least some input into their treatment plan. If I could have sent a postcard from the loony bin to those who treated me, it would say “imagine how you would feel if you were the patient”. It is only by speaking up and sharing our experiences of mental illness and its treatment that the tide can slowly start to shift.