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Less Cuckoo's Nest, more Catch-22 [Aug. 30th, 2012|10:05 pm]
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[possible trigger warning: very weak examples of doubting people's claims]

The prevailing myth about psychiatry is that burly men drag you kicking and screaming to the hospital, you demand to go home, and your doctor, who is either a paternalist or a sadist, says in a sinister manner "Oh, we can't send you home until you're well." Then you will stay there forever, unless you can hatch some convoluted plan to force the doctors to release you whether they want to or not.

I have it on good authority that this is true in certain times and places, but where I work it's is exactly the opposite. The average patient is demanding to stay. Her doctor, who, okay, probably is a paternalist although rarely a sadist, tells her "Oh, we can't let you stay here forever, it wouldn't be financially viable.". Then she is kicked out, unless she can hatch some convoluted plan to force the doctors to keep her whether they want to or not.

When it gets cold or rainy, the hospital fills up with homeless people. Word has spread on the streets that if you go to the emergency room and tell the nurse that evil spirits are telling you to kill everyone, you will get a nice bed and three warm meals a day (the hospital meals, in contrast to all conventional wisdom, are really good). It can be hard to turn these people away, since bloodthirsty lawyers are circling the hospital waiting for you to make a Type II error ("So, Dr. Alexander, you're saying this homeless man walked right into your hospital and explicitly told you evil spirits were telling him to kill everyone, and you refused to even admit him to the hospital long enough to evaluate him more carefully? And this happened just before his shooting rampage at City Hall?"). Besides, many of the people with genuine mental illnesses are homeless, so you can't conclude much either way until you've done a proper evaluation which means letting them in for a few days at least.

Addicts know that if they run out of money, or their stash gets stolen, or their dealer gets blown away by the hurricane, their best bet is to go to the hospital. Drug withdrawal is a serious medical condition - even alcohol withdrawal can kill you if you've been drinking enough - and will earn you a hospital bed. There doctors will keep your symptoms under control by giving you a legal and acceptable version of your chosen drug - buprenorphine if you're a heroin addict, benzodiazepines if you're an alcoholic. Sure, eventually they will taper you off it, and eventually they will ask you to pay for your hospital stay, but that's in the future, which is not a time period addicts are known for caring much about. And when the future arrives, well, they can always fake really bad withdrawal symptoms. Ask a person being tapered off opiates how they're doing, and they will recite the Wikipedia article on opiate withdrawal syndrome: "Well, thank you for asking, Doc, I have some really bad tremors, cramps, muscle and bone pain, chills, perspiration (sweating), priapism, tachycardia, flu-like symptoms, sneezing, akathisia, dysphoria, malaise, anxiety/panic attacks, insomnia, dehydration, and dilated pupils." "Wow, that's a classic presentation of...wait a second, how do you know what your own pupils look like?"

And then there are the people coming from horrible toxic families. This includes approximately 100% of psychiatric patients. Either horrible families cause mental disorders, mental disorders cause horrible families, or (and I have yet to discount this hypothesis) all families are horrible in their own way but no one ever tells you this unless you ask "So, tell me how your family is horrible" which only psychiatrists can do non-awkwardly

(Exception: my family is awesome. And reads this blog).

Anyway, the way to spot these people (aside from that they pump blood and breathe oxygen) is that upon admission to the hospital, their condition improves dramatically before anyone begins prescribing any drugs or offering any therapy. Ask them why they're doing so much better, and you'll hear some variation of "Now that I'm not in the same house as my spouse/mother/father/brother/ungrateful children/abusive step-father/demented great-aunt/sixteen cats, life just seems so much brighter and so much more worth living!" The temptation is to answer "Hooray! You're cured!" and discharge them right back to their spouse/mother/father/brother/ungrateful children/abusive step-father/demented great-aunt/sixteen cats. This is avoided only with great effort and the help of social workers, who are the indispensible experts in these cases.

And then there are the epiphany addicts. I feel sorry for these people. After a lifetime of no one listening to or caring about their problems, they're suddenly surrounded by doctors and therapists who want to talk to them and say encouraging things to them. Their slogan is "Oh, doctor, I never realized that about myself before! As soon as I get out of here, I'm going to kick life's butt and shape up and tell my oppressive mother/father/brother/ungrateful children/abusive step-father/demented great-aunt/sixteen cats that I've gotten over them and I'm my own person now!" This is moderately believable the first time, less so the third time they're admitted for the same problem but telling you that this epiphany is the one that's going to turn their lives around.

So between the warm bed, the excellent food (seriously, it's really good), the free drugs, the lack of horrible family members, and the positive attention from doctors and therapists, you would have to be insane to want to go back on the street. I use that word consciously; there are a bunch of schizophrenics who don't want to stay in one place because the FBI might track them down, a bunch of manic people who need to get out so that they can go back to preventing oil spills by shooting positive energy rays at the ocean, and a few traumatic brain injury or dementia cases who just try the door because it seems as a good a place to aimlessly wander towards as anywhere else. I definitely don't want to go all Cuckoo's Nest and say that perfectly healthy people can't very very legitimately want to leave, especially if they're not homeless abused addicts and they have a life to get back to. I'm just saying I've noticed a trend.

If you've read Catch-22, you probably remember the book's namesake paradox: only crazy people are allowed to leave the military, but only sane people would want to. Psychiatric hospitals are much the same: many of the people who want to leave probably shouldn't, and many of the people who want to stay probably shouldn't do that either.

So doctors are caught in a...oh man, I almost forgot about the hookups. This is an unfortunate feature of the entire psychiatric support system - I met a graduate of Alcoholics Anonymous last week who informed me that hooking up with other AA members is so common it's jokingly called "the thirteenth step". It's not quite so bad at the hospitals but nevertheless wherever you collect a group of men and women with limited inhibitions and poor decision-making skills in one place, they will make uninhibited poor decisions together (one nurse said it was "like summer camp for adults"). The hospital has decided to take a zero-tolerance policy toward any hookups: even if they confirm from both parties that it is entirely consensual, these affairs rarely last and the hospital's nightmare scenario is that a jilted lover retroactively says they were raped and legal action gets taken against the hospital ("So, Dr. Alexander, you're saying that you knowingly let my client go unobserved into a private room with a dangerous psychiatric patient merely because some nurse who'd been awake thirty hours by that point has a vague memory of hearing consent from a patient who might not have been competent at the time? Or would you like to accuse my poor traumatized client of making it up?") This zero-tolerance policy is neither popular nor foolproof, and can by bypassed entirely by a patient just giving another patient her number and telling him to call her when they're both out (I like to think this conversation starts with "Hey, I just met you, and this is crazy...")

So doctors are caught in a bind between an administration that wants patients in and out so the beds are free, and patients who often want to pull out all the stops to stay in as long as possible. I am pleased to say that at least the doctors I have met ignore both and make decisions solely based on their medical judgment; if this sounds hopelessly idealistic, I can only say that I have been working with some pretty ideal doctors.

So if by chance the nightmare scenario occurs and the big burly men carry you away to a mental institution, your doctor is less likely to keep you there forever and more likely to give a sigh of relief that at least one of their patients is willing to go home without making a fuss. Your 95% confidence interval for length of stay, assuming your presenting complaint is typical, would be between two days and three weeks. Answer all the questions politely and with a (non-psychotic) smile, and you'll be out of there in a week with nothing to show for your experience but a prescription that nobody will ever check if you fill or not.

(mostly unrelated note: I've met two of the big burly guys who carry you away. They're both really kind people with great senses of humor. This is oddly disappointing.)
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Comments:
From: (Anonymous)
2012-08-31 06:48 am (UTC)

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Where are the times and places where the Cookoo's Next comparison is more apt?
[User Picture]From: xiphias
2012-08-31 11:08 am (UTC)

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In 1992, some of my friends broke another friend out of a mental hospital.

Mind you, they were all teenagers, and I'm not willing to state unequivocatably that teenagers make the best possible choices, especially when potentially exciting adventures are possible.
[User Picture]From: xiphias
2012-08-31 11:05 am (UTC)

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Either horrible families cause mental disorders, mental disorders cause horrible families,

Best evidence is that both are true. Mental disorders are both environmental and genetic.
[User Picture]From: marycatelli
2012-08-31 11:07 am (UTC)

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I recommend Theodore Dalrymple's Romancing the Opiates -- it's not that even alcohol withdrawal is dangerous, it's that it's distinctively dangerous among all forms of withdrawal.

The lying liars who think the hospital is a great place to stay -- sigh. I've heard of them before. What is really needed is a good liar detector that scans your brain for what sections activate, because they've found lying and telling the truth use different skills. But that's more suited for SF than hope at the moment.
[User Picture]From: xiphias
2012-08-31 11:10 am (UTC)

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Actually, what's needed is some sort of other livable option. . . they're acting rationally, because there is nothing else they can do to stay alive.
[User Picture]From: marycatelli
2012-08-31 01:03 pm (UTC)

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A great many of them could do a great many other things -- except that would entail their having to spend money on rent and the like. One woman I know who worked in a homeless shelter estimated that 75% of them are homeless because they prefer spending their money on drugs to rent.

Nor -- and this is where the book comes in -- is giving up drugs the wrenching experience that they claim it is. They are just looking for excuse to not give it up.
From: (Anonymous)
2012-08-31 02:41 pm (UTC)

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Even giving up tower defense games is pretty hard! An archetypical addict's life is made almost entirely of "Hey, drug time now" triggers, sucks enough that the temptation to seek relief in drugs is enormous, and has no support of any kind for quitting. Do you honestly think most people could ride it out, while in the throes of physical and psychological withdrawal? You can handcuff yourself to the heater for three weeks, but you can't stay that way for eighteen months.
[User Picture]From: marycatelli
2012-08-31 05:41 pm (UTC)

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Many people have given up drugs -- permanently -- without support.

Though it's one of those "the lightbulb really has to want to change" things -- which does mean it's foolish to throw money at helping them because it won't change their desires.
[User Picture]From: xiphias
2012-08-31 04:18 pm (UTC)

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Yes, having drug treatment options available would help. Kicking a drug habit is clearly one of the toughest things a person can do, and certainly, without help being available, it's just not going to happen.
[User Picture]From: marycatelli
2012-08-31 05:40 pm (UTC)

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People routinely quit drugs without any assistance whatsoever.
[User Picture]From: xiphias
2012-08-31 05:43 pm (UTC)

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Really? How many people have you known who've tried to quit drugs and succeeded without help?
[User Picture]From: xiphias
2012-08-31 05:52 pm (UTC)

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See, that is a remarkable statement. It goes against every study I've read; it goes against the personal experience of every person I know. I'd love to know WHERE you got that from, since it flies in the face of observation and science.

I've heard of people kicking cold turkey on their own, but it's VERY rare -- almost statistically insignificant. And, as squid314 pointed out, it can kill you dead.
[User Picture]From: marycatelli
2012-08-31 10:41 pm (UTC)

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I already told you. Romancing the Opiates. An account of opiate addiction by a doctor who worked in the slums and as a prison doctor for decades, and whose knowledge of addicts is extensive.

And what exactly did those studies study?
[User Picture]From: xiphias
2012-08-31 10:55 pm (UTC)

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Recidivism within populations who had decided to give up opiates, and different methods.

Okay, I've been looking up Theodore Dalrymple, and I can't find anyone who's actually been looking at his claims scientifically. Looking at his ovure, he looks like the kind of person who loves just claiming whatever the opposite of whatever everyone else claims, and I can't find anyone who's actually studying what he's claiming. The best I found was a discussion of the book between him and another person, which just turned into "Nuh-unh!" "Yeah hunh!" real fast.

It's an interesting thesis, but I find myself skeptical of a person whose other books are all "Western Society is doomed!" "Emotions make us all wimps!" and stuff like that. I'm not yet willing to throw out everything I've learned on the basis of one book by one guy who wants everybody to throw out everything they've learned about EVERYTHING.
[User Picture]From: marycatelli
2012-09-01 05:14 pm (UTC)

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You should try reading the book. He debunks a number of those studies and gives other that support his view.

Or you could take refuge in name-calling to avoid it.
[User Picture]From: squid314
2012-08-31 07:47 pm (UTC)

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"I recommend Theodore Dalrymple's Romancing the Opiates -- it's not that even alcohol withdrawal is dangerous, it's that it's distinctively dangerous among all forms of withdrawal."

Sorry, that was poorly phrased. I meant that I would have naively believed that alcohol withdrawal would be less dangerous than cocaine or heroin or something because it's legal. Yes, counterfactual me is an idiot.
[User Picture]From: marycatelli
2012-08-31 10:42 pm (UTC)

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It's a common view, no doubt -- not exactly helped the hoopla about opiate addict and withdrawal that's current. . . .
[User Picture]From: aiela
2012-08-31 11:08 am (UTC)

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Ten years ago I attempted suicide, and then drove me to the hospital, who then transferred me to a psychiatric hospital for a week. I am still convinced that psychiatric hospitals are intentionally boring as hell so that you either decide to quit trying to hurt yourself, or at least make a better attempt the next time.

(For the record, I got out of the hospital, left my husband, and have never been suicidal since. Depressed, yes. Suicidal, no.)
[User Picture]From: Julia Wise
2012-08-31 06:22 pm (UTC)

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I was concerned about the lack of things to do/read at the hospital where I worked, so I brought in a dozen or so books. The books disappeared within the week, just as other staff told me they would.

I like to think that for the $1 each book cost me from the thrift store, someone got at least that much relief/enjoyment out of them.
[User Picture]From: squid314
2012-08-31 07:45 pm (UTC)

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Yeah, I can see how that would happen, especially if you're not a huge extravert. I understand they don't want anything that can be used as a weapon (which is pretty much anything; I've been hearing horrifying things about the killing power of a sock with a bar of soap in it) but I still feel like they could bolt some computers down somewhere.
[User Picture]From: xiphias
2012-08-31 11:15 am (UTC)

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About dementia patients trying the door because why not, and therefore wandering off --

My favorite way that a nursing home has dealt with that problem: they built a fake bus stop in front of the hospital, well within sight of the reception desk. A dementia patient walks out, sees the bus stop, and figures, "Oh! I must be here because I'm waiting for a bus to go somewhere!" So they sit down at the bus stop to wait. The receptionist sends out a caretaker, who comes out, asks what the person is doing, tells them that the bus isn't coming for, like, another hour, and why don't they come inside for a cup of tea while they're waiting?

The dementia patient thinks this is a good idea, comes back inside to the recreation room, has a cup of tea, and forgets they ever tried to escape. Completely non-traumatic for everybody.
[User Picture]From: marycatelli
2012-08-31 01:05 pm (UTC)

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how well-organized!

I must think it works better in regions where a lot of people take the bus all the time before dementia hits.
[User Picture]From: xiphias
2012-08-31 04:16 pm (UTC)

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Yeah, I believe it was in Scandinavia somewhere.
[User Picture]From: ari_rahikkala
2012-08-31 04:42 pm (UTC)

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From: (Anonymous)
2012-08-31 03:06 pm (UTC)

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This matches my experience pretty well, except for the part where the hospital wants patients out fast to save money. I suspect the bad stuff happens more in hospitals that don't aim for high turnover.
[User Picture]From: squid314
2012-08-31 07:44 pm (UTC)

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This happened at the first (private) hospital I was at but is less common at the current (state) hospital. No one is exerting specific pressure here but everyone realizes that there's a limited number of beds and they can't just let people stay forever.
[User Picture]From: adelenedawner
2012-08-31 10:27 pm (UTC)

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I used to work in a nursing home, and yeah, approximately none of this applies in a situation where the expectation is that people are there 'till they die.
[User Picture]From: squid314
2012-09-01 12:33 am (UTC)

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My experience and what I've told also confirms that nursing homes are sometimes (often?) horrible. I always interpreted it as having more to do with some other factors, including intensity of care required, quality/training of staff, and elderly people who look different and talk different and sometimes lack basic functions activating fewer of the staff's natural sympathies than mentally ill people who mostly look and act like everyone else.
[User Picture]From: adelenedawner
2012-09-01 03:26 am (UTC)

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Seems pretty plausible.

(I do note that not everyone who tends not to activate others' natural sympathies is currently institutionalized, though, so the question of what happens to us in facilities like yours is still rather up in the air from my perspective. But that's me being pushy; I'll stop now.)
[User Picture]From: hentaikid
2012-08-31 05:42 pm (UTC)

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Yeah, a friend's daughter was committed for about a year. Recently she went back for a couple of weeks because outside life was too stressful, and he says the doctors were happy to have her because she's such a nice girl.

Everything you're saying lines up with what my friend has been telling me, including the hookups - they had to run interference between her and some drug addicted kid who got himself interned to the same hospital to be close to her.
[User Picture]From: squid314
2012-08-31 07:43 pm (UTC)

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Really? If she was in for a year that sounds like one of the long-term places, which I know nothing about and which I have received slightly more sinister vibes from. I'm glad to know they're not (always) true.
[User Picture]From: adelenedawner
2012-08-31 10:30 pm (UTC)

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That 'always' would be better as a 'necessarily'; Stockholm Syndrome is a thing that exists and could easily be relevant, among other issues.
[User Picture]From: hentaikid
2012-09-01 02:07 am (UTC)

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Hm, I can't recall right now but she might've been moved to a different hospital at one point half way through the year. I gather the delay was in getting the medication dosage just right, as she kept lapsing back to delusions and persecutory manias. I don't think they ever really nailed down what was wrong with her, the most definitive diagnosis I heard was PTSD - the family emigrated to Europe from Argentina and then the parents divorced.

[User Picture]From: hentaikid
2012-09-01 10:23 am (UTC)

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Ok, I asked, she was in two places (Three really, but the first was the same hospital which moved locations during treatment). The first hospital was a dedicated mental facility for acute cases, an "old style" asylum, far from the city, surrounded by countryside. Later on she was moved to a medium-stay facility which was just the psychiatry wing of a general hospital.
[User Picture]From: Julia Wise
2012-08-31 06:29 pm (UTC)

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We had two patients who had sex and both claimed it was unconsensual. Not sure how the human rights officer dealt with that one.

My favorite episode with the burly men:
http://jdwise.blogspot.com/2011/11/love.html

Edited at 2012-08-31 06:31 pm (UTC)
[User Picture]From: squid314
2012-08-31 07:43 pm (UTC)

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I somehow failed to connect you to the Julia who I already knew was a social worker. Now I'm going to have to read that blog.

Since you seem to be another person who blogs about your experiences in a psych hospital, do you know if there are any commonly-agreed-to standards on how exactly the patient confidentiality works? Okay if there are no names? Okay if no one could possibly recognize the case? Never okay? Or what?
[User Picture]From: Julia Wise
2012-09-01 12:28 am (UTC)

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My husband's been prodding me for months to read your blog, and I'm enjoying it very much now that I've started.

I got criticized at one point by a reader for giving details that would be identifiable by the person I was writing about, and possibly by their family. After that, I decided to disguise details enough that not even the subject would recognize themselves. But I haven't gone back and disguised things I've already written, which I probably should. Because I use my full name on the blog, I assume some patients/clients will find it someday.