Sunday, October 28, 2007
I remember my first experience of a psychiatric hospital. It was long before I ever considered being a psychiatrist. Some one I know was admitted after a suicide attempt and I went to visit. I cannot tell that person’s story because it would be a privacy violation. But I can tell you how I felt.
I didn’t really know what to expect on a psych ward. I felt scared and bad enough about what had happened to my friend and didn’t really understand what was going on. It was a creepy place. For one thing, you have to be buzzed in through a locked door. When the door closes behind you it has a feeling of finality as if you too are being admitted for an indefinite stay and not just as a visitor. You realize that someone has to let you out. You cannot just go. At the door they ask your name and business and check to make sure no one is loitering near the exit before letting you in. If you bring something for a patient, they screen it for “sharps”—knives, razors, scissors—and other contraband, including electronic devices. Gameboys, walkmen, radios and so forth are not allowed. Don’t try baking a nail file in a cake!
The ward is full of strangers who carry that frightening label “mentally ill.” At my first visit, I’m just little more than a kid myself and full of all the strange and unfair stereotypes of the mentally ill. Will there be dangerous people there? I guess I must have been picturing my experiences of mentally ill homeless people—strange, eccentric, bad-smelling, talking to themselves or cursing madly.
I remember in actuality there was one person restrained in a chair in the hallway. I had never seen anyone in leather restraints (they really are made of leather). It is very disturbing to see someone tied down like that. One woman sat in one of those institutional chairs common to hospital waiting rooms, rocking and shuffling her feet. Now I know that she had akithisia, a kind of inner restlessness that is a side effect of certain psychiatric medications.
The ward must have been smoky although I don’t remember that. Back then, smoking was still allowed on hospital wards. A few years later I “rotated” which means did a 4-6 week educational period on that self-same ward. Patients would line up at the nursing station during a set time period to pick up their cigarettes from a nurse. Matches and lighters were not allowed to protect the patients from themselves and their fellow inmates so the cigarettes were lit by staff. During cigarette breaks the smoke made it hard for me to breathe. Cigarettes often became an occasion for power struggles between staff and patients. Someone would want their smoke at a non-approved time or would be denied a cigarette for reasons unknown. Now smoking is banned and smokers ask for a nicotine patch if they are concerned about withdrawal.
As my experience with psychiatry grew, I learned that there were times when the distinction between patient and staff become uncertain except for who had control of the keys. Sometimes the staff seemed more unreasonable and erratic than those they were supposed to help. Access to the door was used in a passive-aggressive manner. When I was a junior resident and did not yet have a ward key (this was at another hospital), staff would delight in making you wait to exit the ward. It was an insecure feeling looking at the wire mesh over the small window in the door and hoping that someone would buzz you out. If you complained about the wait too vociferously, a nasty staff person might take it out on you in some other way.
Psychiatrists refer to the entire ecosystem of a psychiatric ward as the “milieu”. There are books and journal articles written about the milieu and trainees should read about the “dynamics” of the milieu. The milieu truly is an ecosystem. At times it is in balance with caring, compassionate, well-rested staff and patients who get better and behave. At other times it feels like a prison just before a riot. The staff is burned out and vindictive. The patients are burned out, angry, manic or psychotic or in full drug withdrawal. At the worst of times, mercifully rare, there is danger on a psych ward. On occasion the stress is so extreme that we experience a bit of PTSD (Post Traumatic Stress Disorder), the modern term for “shell shock.” Even typing this has elevated my adrenaline levels.
Just as general hospital wards have a nursing station, so too do psychiatric wards. The nursing station is psych wards is generally locked away from the patients. Charts and medication are stored there. There are phones, computers, a textbook or two, and cameras to monitor the “quiet room”—a modern version of the padded cell—and the front door. Strange though the place is, after a few months of working there it starts to feel like a safe haven in a storm of wounded emotions.
Lest you think that psychiatric wards are evil, terrible places, let me reassure you. They are not fun, pretty or nice, but generally they exist to help people out of their emotional “bottoms.” There are no more straight jackets and there are strict laws and regulations to protect the rights of patients. The use of restraints is ever more “restrained” by law, custom and the emphasis on patients’-rights. Inpatient psychiatric stays are usually short, on average less than 7 days. This is dictated both by standards of patient care and by standards of “managed care.” In short, just as there have been accusations of managed care demanding “drive by deliveries”, so too are psychiatric stays shortened to save insurance companies money.
I’ve lost touch with my friend who I hope is doing well. My first experience did not frighten me away from psychiatry but it wasn’t the determining factor either. I now avoid inpatient work in my own practice. The memories, both good and bad remain. So too does my sympathy for those who spent time at the other side of the locked ward.