A while back one of my patients was having a foot problem, so I consulted the hospital podiatrist. He met me in my workroom, and I explained exactly what I needed from him, but over the course of the explanation he started looking more and more uncomfortable and distracted, so finally I stopped and was just like “Okay, out with it, what’s your problem?”
And he said: “That guy with the wild hair pounding on the window and shouting threats and obscenities at us.”
And I said: “Oh, him? That’s just Bob. Don’t worry about him, he always does that.”
The podiatrist seemed inadequately reassured.
I thought about this because as of today I am halfway done with my four-year psychiatry residency.
One of my teachers told me that you go to medical school to learn things, and then you go to residency to get used to them. It’s not quite that simple – you certainly learn a lot in residency – but there’s a lot of truth to it. I remember that my first week on call, somebody had a seizure and I totally freaked out – AAAAH SEIZURE WHAT DO I DO WHAT DO I DO? – even though I had previously been able to pass tests on that exact situation. But my last time on call, somebody also had a seizure, and I sort of strolled in half-asleep, ordered the necessary tests and consultations and supportive care, then strolled out and went back to bed.
And then there are the little things, like learning to tune out a psychotic guy banging on the window and yelling threats at you.
It’s interesting that psychiatric hospitals are used as a cliche for “a situation of total chaos” – I think I’ve already mentioned the time when the director of a psych hospital I worked at told us, apparently without conscious awareness or irony, that if Obamacare passed our hospital would have too many patients and “the place would turn into a madhouse”. There’s a similar idiom around “Bedlam”, which comes from London’s old Bethlehem psychiatric hospital.
In fact, psych hospitals are much more orderly than you would think. Maybe 80% of the patients are pretty ‘with it’ – depressed people, very anxious people, people with anger issues who aren’t angry at the moment, people coming off of heroin or something. The remaining 20% of people who are very psychotic mostly just stay in their rooms or pace back and forth talking to themselves and not bothering anyone else. The only people you really have to worry about most of the time are the manic ones and occasionally severe autistics, and even they’re usually okay.
For a place where two dozen not-very-stable people are locked up in a small area against their will, violence is impressively rare. The nurses have to deal with some of it, since they’re the front-line people who have to forcibly inject patients with medication, and they have gotten burned a couple of times. And we doctors are certainly trained to assess for it, defuse it, and if worst comes to worst hold our own until someone can get help.
Yet in the two years I’ve worked at Our Lady Of An Undisclosed Location, years when each doctor has talked to each of their patients at least once a day, usually alone in an office, usually telling them things they really don’t want to hear like “No, you can’t go home today” – during all that time, not one doctor has been attacked. Not so much as a slap or a poke.
I am constantly impressed with how deeply the civilizing instinct has penetrated. When I go out of the workroom and tell Bob, “I’m sorry, but you’re disturbing people, you’re going to have to stop banging on the window and shouting threats, let’s go back to your room,” then as long as I use a calm, quiet, and authoritative voice, that is what he does. With very few exceptions, there is nobody so mentally ill that calmness + authority + the implied threat of burly security guards won’t get them to grumble under their breath but generally comply with your requests, reasonable or otherwise.
I’d like to say I’ve taken advantage of this to go mad with power. But it’s actually a really crappy situation for everyone involved.
The most common reason for admission to a psychiatric hospital is “person is a danger to themselves or others”. The average length of stay in a psychiatric hospital is about one week.
Some clever person might ask: “Hey, don’t most psychiatric medicines require more than a week to take effect?” Good question! The answer is “yes”. Antidepressants classically take four weeks. Lithium and antipsychotics are more complicated, but the textbooks will still tell you a couple of weeks in both cases. And yet people are constantly being brought to psychiatric hospitals for dangerousness, treated with medications for one week, and then sent off. What gives?
As far as I can tell, a lot of it is the medical equivalent of security theater.
The most common type of case I see is “person who was really angry, said ‘I’ll kill myself’ in a fit of rage, and then their partner called the cops and they were brought to hospital.” These people stop being angry after a day or two and then no longer make these comments, even assuming they meant it in the first place which most of them don’t.
The second most common type of case I see is “person who was really angry, did try to kill themselves, and it didn’t work.” Again, these people have stopped being angry. Failed suicide attempts also have their own interesting way of clearing the mind for a little while, so they’re in a sort of grace period. Sending these people to a psychiatric hospital makes the public feel good because they’re Doing Something About Suicide, and makes psychiatrists feel good because after a few days they’ve stopped being suicidal so it looks like we’re Making A Difference. There is no way we could leave this equilibrium now even if we wanted to, because if we didn’t keep these people for a week and they ever attempted suicide again, we would get sued to oblivion.
The third most common type of case I see is “severely mentally ill person who’s been living at a care home for twenty years, but then they got in a fight and so their care home sent them to the hospital.” We shuffle their medications around and send them back to the care home where they’d been living happily for twenty years until some random trigger set them off.
We don’t call this “security theater”. We do sometimes call it a “holding environment”. Psych hospitals are kind of boring. There’s no boyfriend to get in a screaming match with, no boss pushing you to work harder, and no drug dealers to get heroin from. On the other hand, there’s lots of structure – art therapy at 10, meeting with your doctor at 11, recreation group at 12, and so on. It’s like a terrible vacation in the world’s least attractive hotel. People get a chance to cool off and forget about whatever set them off. Then they go back to their life. If they’re lucky, our social workers have managed to connect them to a better outpatient psychiatrist, care home, or support group, and maybe that will improve their lives sometime down the line. But I don’t think anyone imagines there was some fundamental Quality Of Dangerousness in them which is now gone.
To the degree that it is all security theater, it’s really hard to give an honest answer to a patient asking why they have to stay in hospital.
When I first started this work, my reaction to these people was “Come on, it’s only a week, it’s not like you’re stuck here forever, just deal with it.” This lasted until I remembered that when some stupid policy forces me to come into hospital on a day I would otherwise have off, I freak out, because I value my free time too much to be okay with having it taken away from me for bad reasons. Heck, my power was out the past couple of days, and I couldn’t use the Internet, and I was calling the power company and being like “COME ON YOU NEED TO FIX THIS ALREADY I AM LOSING DAYS OF MY LIFE THAT I COULD OTHERWISE BE SPENDING IN IMPORTANT STUFF.” So now I try to avoid throwing stones.
(there’s another aspect of this, which is that people constantly protest that horrible things will happen to them based on that week. For example: “My boss said if I miss one more day of work, I’ll lose my job, and then I’ll have no way to support my family.” Or: “My rent payment is due tomorrow, if I miss it I’ll be evicted and all of my stuff will go to the landfill, and there’s no way I can handle this through Internet or telephone or asking a friend to help.” I assume 90% of these stories are false, but the 10% that are true are still bad enough to more than outbalance any good we can do.)
After that, my reaction to these people was “Yes, you may be angry now, but you will thank us later.” This is true of many people, including some of the most histrionically upset. But I’ve since learned that it’s probably not true of the majority. The Shrink Rap blog surveyed former psychiatric inpatients and found that 62% said their experience was not helpful and they were “the same or worse at discharge”. I’d like to dismiss this as people just carrying a grudge for having to be there at all, but the same survey finds that a very similar 56% of voluntarily admitted patients said the same thing (although not all “voluntary” admissions are as voluntary as the name expects). Now, I don’t know for sure what to think about that survey – a lot of people describe their hospitals as doing things which are super illegal and which I wouldn’t expect a hospital to be able to get away with and stay open for more than twenty-four hours, and the population of psych patients who read psychiatric blogs is probably a nonrandom sample – but I no longer feel like I can confidently say that our patients will thank us later.
(none of this is to say that you shouldn’t check yourself into a hospital if you’re feeling suicidal – you’ll get the holding environment that makes sure you don’t kill yourself for the immediate future, you’ll get connected to a system that can give you useful referrals and medications much faster, and 38% will also end up being directly helped.)
So now what I tell people is the Cliffs’ Notes version of the above – “I’m sorry you have to be here, but we are going to keep you for a few more days to evaluate you, your estimated day of discharge is X but that’s not a promise, if there’s anything specifically making you uncomfortable please let me or the nurses know and we’ll see what we can do.”
I can’t figure out a good way to say the spiel without the last sentence, which is too bad because then they do let me and the nurses know things. Most of them are things that I, as a low-ranking doctor who cannot totally rearrange the unit according to my will, have no ability to change. Some of them are things nobody can change.
Like! It turns out when you lock constitutionally anxious people in a new environment full of psychotic people, they become really really anxious. They tend to request antianxiety drugs. I am happy to give them reasonable doses of the non-addictive anti-anxiety drugs, which then totally fail to do anything, because their idiot outpatient psychiatrist was giving them heroin mixed with horse tranquilizers every day or something. They demand whatever they were getting on the outside, but twice as much, and I can’t give it to them even if I want to because of our safety policies. And now I’m the bad guy.
Or! Some people don’t like noise. I sympathize with this as I am just about the most misophonic person in the world. On the other hand, there’s always one screamer in a psychiatric hospital. Sometimes this screamer chooses to do their thing at four in the morning. The law gives us limited ability to lock them in a soundproof room, and definitely not all the time. So if you are startled by loud noise, you are kind of out of luck. Even if we can put you on the other side of the ward, you’re still going to be bothered by staff coming in your room every fifteen minutes to make sure you haven’t killed yourself, which they are legally required to do. You can complain that the lack of sleep is hurting your recovery, and I believe you, but aside from showing you where we keep the earplugs there’s not much I can do. Once again, now I’m the bad guy.
Add to this people with picky tastes that our kitchen can’t satisfy, people who get bored in the absence of some kind of entertainment we can’t provide, smokers who are unsatisfied by nicotine patches, and the occasional very honest drug addict who just wants some drugs, and I spend about 30% of my day patiently explaining to people why their preferences are totally reasonable and I realize they’re in pain but there’s nothing I can do for them at this moment.
And I know it sounds really selfish of me to say so, but this is really exhausting.
Sometimes I wonder if the concentration camp guards in Auschwitz ever had this problem. Like, the ones who weren’t especially sadistic, but who took it because it was a 9-5 job, and word around the water cooler was that it was an easy way to make Scharführer after a few years. And every night they would come home to their wives and be like “Gott in Himmel, Helga, you have no idea what I have to put up with every day, all of these prisoners won’t stop asking me for food and water and stuff, and I try to give them a couple of extra scraps when the regulations allow, but even after I do that they just want more food and they never stop, don’t they realize it makes me feel really guilty and there’s nothing I can do, and every day is more miserable and draining than the last, and I mean, seriously Helga, how entitled can people get?”
I know that’s a horrible metaphor, and our hospital is really good and run by some of the best staff and nurses and doctors I have ever met and tries 100% to help patients whenever it can. It’s just how I feel sometimes.
As you may have guessed, I do not very much like inpatient work. You can adjust to having to treat someone having a seizure. You can adjust to somebody banging on the window and screaming. But it’s really hard to adjust to constant moral self-questioning.
Now I am halfway done with my residency. I will be switching to outpatient work. Everyone who sees me will be there because they want to see me, or at worst because their parents/spouses/children/friends/voices are pressuring them into it. I will be able to continue seeing people for an amount of time long enough that the medications might, in principle, work. It sounds a lot more pleasant.
I have two equal and opposite concerns about outpatient psychiatry. The first is that I might be useless. Like, if someone comes in complaining of depression, then to a first approximation, after a few basic tests and questions to rule out some rarer causes, you give them an SSRI. I have a lot of libertarian friends who think psychiatrists are just a made-up guild who survive because it’s legally impossible for depressed people to give themselves SSRIs without paying them money. There’s some truth to that and I’ve previously joked that some doctors could profitably be replaced by SSRI vending machines.
The second concern is that everybody still screws it up. There’s an old saying: “Doctors bury their mistakes, architects cover theirs with vines, teachers send theirs into politics.” Well, outpatient psychiatrists send their mistakes to inpatient psychiatrists, so as an inpatient psychiatrist I’ve gotten to see a lot of them. Yes, to a first approximation when a person comes in saying they’re depressed you can just do a few basic tests and questions and then give them an SSRI. But the number of cases I’ve seen that end in disaster because their outpatient psychiatrist forgot to do the basic tests and questions, or decided that Adderall was the first-line medication of choice for depression – continues to boggle my mind. So either it’s harder than I think, or I’m surrounded by idiots, or I’m an idiot and don’t know it yet. In which case I’m about to learn.
Still, if it’s a disaster, it will be a different type of disaster.
And the thing I love about psychiatry – other than, I am contractually obligated to say, The People You Meet and The Chance To Make A Difference – is the lore. If all science is either physics or stamp collecting, psychiatry is stamp collecting par excellence with the world’s most interesting postal system, hunting through this incredibly confused and unsystematic mass of work done by thousands of brilliant people and trying to drag some kind of meaning out of it. Sometimes that involves dredging up weird drugs that no one else thinks about or remembers but which are perfectly suited for the precise situation at hand. Sometimes it’s disentagling complicated claims about what does and doesn’t work so you can be sure to give your patients the former. Other times it’s something totally out of left field, like reading this study and massively increasing the amount my consult patients liked me pretty much overnight with zero work.
I think outpatient will be good for this. There’s more freedom, more focus on treatment rather than warehousing, and a little bit more of an academic bent to it.
In the meantime, I am now a third year resident. There are people beneath me, and sometimes they do what I say! I get enough of a raise that I can say, for the first time in my life, that I am making the US median household income! I mostly get weekends off, except when I don’t!
And in two years, I’ll be done in Michigan and maybe I can move somewhere else and hang out with some of you people full-time.