I recently watched a film - a terrible film - which had an archaic, grotesque depiction of life in a psychiatric ward. I won't tell you what film, as I do not wish to promulgate my disdain for it. After I recovered from the boredom, I woke up, wiped dribble from my shirt, and then started to ponder over it. It was frustrating to think that people who have no experience of this kind of environment may be influenced by such a portrayal. I thought I'd share my experience of psychiatric wards in the interest of decreasing unjust stigma, related to mental illness and to educate the people who read my blog regularly.
Both of them. (Hi Mum, by the way).
I've worked on five different general adult psychiatric wards, six months in each, including two in Sydney, and have been summoned onto around 20 more whilst doing on-call out of hour shifts. There are of course specialists wards too - I've worked on Learning Disability wards, old age wards and currently work on forensics wards - with mentally disordered offenders.
As with all public services, the layout of the ward, the quality of care and the ward routine varies significantly between disparate wards. As does the atmosphere.
How do people end up on these psychiatric wards?
Good question.
In essence, a psychiatric doctor (often a trainee) has to make the final decision to admit a patient, though this could be brought to attention by another professional (e.g. a social worker or a Registered Mental Nurse), a family member, or even by the patient themself. There are numerous forms of mental state deterioration that can raise concerns. For example, somebody could be severely depressed with thoughts of suicide, or lacking the volition to eat. Someone could be very paranoid to the extent that they are uncharacteristically aggressive or pugnacious. Somebody could be suffering from dementia, and wondering onto the streets with no regard for their own safety.
Despite numerous presentations of mental illness, the avenues of contact with psychiatric services in any given area, actually depends more on the healthcare facilities available in that area.
In psychiatric hospitals that I have worked in, the majority of patients are directed from Accident and Emergency departments, with the next most common routes of admission being via their GP, or the local Community Mental Health Team, who may have seen the patient in an outpatient clinic or at their home. Some hospitals have a kind of 'drop-in centre' where patients or family members can turn up, if they are worried about a person's thoughts or behaviour. That person is then triaged; spaces are scarce and are in high demand, and so a professional (usually a trainee psychiatrist) has to do a thorough assessment and prioritise who needs to be admitted. If they are not deemed to need treatment inside a hospital, they can be linked In with various other services in the community.
Aren't all the people there against their will?
Contrary to what most films depict; no.
In my experience, around half of inpatients are 'sectioned' - i.e. they are detained under the provisions of the Mental Health Act (first written in 1983, but recently revised in 2007). The others are there as a voluntary 'informal' admission, which means they have the right to leave or refuse treatment.
I've been involved in several situations where a voluntary patient has wanted to leave against medical advice. Sometimes staff are worried about them (e.g. because there is suicide risk or because the patient is vulnerable). In such an event, a psychiatric doctor usually does a thorough assessment of the patients mental state at the time. If they are deemed to be safe, they can go, and will hopefully be offered follow-up. If there are concerns, then an emergency Mental Health Act assessment is arranged, and is conducted by two senior doctors and a social worker. People under a section are essentially there against their will, or are so unwell they lack the capacity to make the decisions about their treatment.
What does being sectioned involved?
No men in white coats. No straight jackets. No big van. Lots of paperwork.
Detaining somebody under the provisions of the Mental Health Act is a serious, detailed and time-consuming process. It is never done flippantly. Stringent procedures follows strict guidelines. The people involved and the documents are highly scrutinised. The assessment must be carried out by two senior doctors, who are independent of each other as well as an experienced social worker. Of the two doctors, at least one has to be in a special position of authority - i.e. "approved under Section 12 of the Mental Health Act". To achieve this, they have to undergo rigorous training, assessments and have references. To pass, they need an in depth knowledge of the Act, and when it is applicable and appropriate. I did this training myself around two years ago. Likewise, the social worker is a senior professional with specialist training and qualifications.
It's not enough that the professionals want to detain the patient in order to treat them. They must prove that they believe the patient needs to stay in hospital for their own health, or their own safety or because someone else's safety would be under threat if they were released. Indeed, there are hundreds of people with active symptoms of mental illness, who are not a danger to anybody. They survive perfectly well without their freedom being restricted. And rightly so.
For professionals to 'section' people who are more unwell, they must also prove that the patient would not recover without this enforced treatment, and that there isn't a less restrictive option. This must all be documented thoroughly. There are various legal safeguards to ensure this process is not abused, including scrutiny by hospital managers, lawyers and sometimes judges.
The nuances of the Mental Health Act and the difference sections it encompasses are intricate and specific. I think they deserve a blog of their own.
Maybe I'll write one...
What kind of mental illnesses do people on these wards have?
In my experience, the majority of patients suffer from schizophrenia or a mood disorder such as severe depression or mania (when people with a bipolar illness are in a 'high' phase). However, I've also been involved with treating patients with more unusual psychiatric diseases such as catatonia (a severe psychosis which can render the patient completely mute and sedentary, as if paralysed), and AIDS-related early dementia.
What are the patients like? Are they disturbed?
That's like asking "what are humans like?"
As with other people, there is a huge variety of presentations amongst patients in psychiatric wards, and even amongst patients who have the same disorder. On the worst end of the spectrum, some people with schizophrenia can be extremely disturbed, suffering from hallucinations (such as hearing voices) or delusions (such as very strong paranoid beliefs) and some people with depression can lack the drive to do much or say much. But to assume that all patients are like this would be a misdemeanour. Some people have recovered fully and are in a long process of incipient rehabilitation. They may present identically to before their mental illness took hold of them, have long periods of leave and live with a high level of ability and independence.
It can occasionally be quite an intense and intimidating environment. I've been spat at, shouted at, threatened and even hit. As have other staff working in the mental health arena. If you speak to somebody working in this setting who isn't faced with some form of regular confrontation - then maybe they need to leave their office a bit more.
However, the majority of patients are friendly and interact in the same way as the average person on the street. Additionally, the staff are usually very well equipped and experienced to deal with disturbed behaviour and can perform miracles in terms of placating, de-escalating, and most importantly listening to unwell patients. Nurses are particularly adroit. All staff should have been trained in safety procedures - e.g. carrying alarms, and knowing where people are and what they are doing on the ward.
It annoys me to see the portrayals of psychiatric patients in most films. They are usually completely crazy, and out of touch with reality, or dribbling wrecks, rocking in a corner. To show people in that state and to suggest that they are all that disturbed is unfair and immoral in my opinion.
Perhaps more importantly - it's inaccurate.
Like all hospitals, psychiatric ones are places of healing. Depending on the profile and of the patients and the quality of the staff members, some wards can be peaceful therapeutic places. I've witnessed tremendous compassion and support between patients. Sometimes the most mentally unwell people find solace amongst those in similar positions.
So, what happens on psychiatric wards?
People live there, and gradually recover.
More modern facilities tend to have individual rooms and other entertainment such as TVs, video games and a pool table. Older places tend to have draconian dormitories. Patients live together, and some integrate well and support each other. Others may value their privacy and choose to isolate themselves more. This could be down to mental illness leading to paranoid or negative thoughts. Equally, it could just be down to personality.
There are nurses on site, 24 hours a day. I've worked in places with really well motivated and caring nurses who engage patients in conversation and activities every day. Unfortunately, I've also worked in places where this doesn't happen.
Every patient has assigned to them a Consultant Psychiatrist - the boss. They are ultimately responsible for salient decisions such as medication, leave and discharge, though a good consultant will liaise with and seek counsel from the nurses and the rest of the team. They have many other duties outside of the ward, such as outpatient appointments, home visits, and writing psychiatric reports. Therefore they tend not to be on the ward on a daily basis, but instead usually have weekly "ward rounds". Here, each patient is invited to discuss their progress and any issues. There are also junior doctors on the ward, who review the patients regularly and feed back to their consultants. They themselves are usually in training to become consultants one day, and only years of clinical experience, and a plethora of gruelling exams and assessments are in their way.
Patients are given three meals a day. Most are given medication once or twice a day, though occasionally are offered some extra if they become particularly distressed. Therapeutic activities should be offered throughout the day, and other members of the multidisciplinary team (see later) make appointments, and visit patients to spend some time with them.
Is it true that people are locked up for years?
Rarely. Length of admission varies significantly and depends on the situation.
I've treated patients who have literally stayed for one night only; I remember a young woman who became psychotic after taking a cocktail of methamphetamine and ecstasy while celebrating her 18th birthday. She returned back to an embarrassing lucid sobriety the next day, after the substances had left her system. An extreme introduction to adulthood!
Conversely I've know of people with puissant mental illnesses who lack insight or are unlucky enough to need several trials of medication before they find one that works effectively . They can have admission is that last several months, or even years.
There are many other factors which affect length of treatment and hospital stay. Again, this merits its own blog, if anybody is interested ...
Isn't everybody just doped up?
Not at all.
From working abroad I've seen some places where the ethos is to medicate people immediately with high doses. In England the approach is much more... softly, softly, catchy monkey.
With new patients when the extent and type of illness is unknown, there tends to be a period of observation for several days or even weeks before a decision is made on what medication should be used, if at all. Ultimately these decisions are down to the treating consultant, but good practice is to start at low doses and increase gradually depending on response. The benefits and side effects of any "psychotropic" (i.e. psychiatric) medication varies significantly between patients, and are unpredictable. There is no right or wrong answer. Decisions are made from years of clinical experience. Treating mental illness is an art form as well as science.
In an ideal world, there should be other staff members that can contribute to recovery. These include psychologists who can meet patients individually or in groups and use talking therapy and thinking exercises to help nurture the patients' insight and ability to reflect on their mental illness, personality and behaviour. Occupational Therapists help provide activities including sports and art therapy and assess people's ability to carry out tasks of daily living that other people may take for granted. They can also help patients find work that is appropriate yet challenging, both inside the hospital, and in the long-term, after discharge. Social Workers help with a variety of issues such as communicating with and educating family members, managing benefits and finances and finding appropriate accommodation after patients leaves hospital. All of this is available in an ideal world.
But I've only ever worked in the real world, where some patients have to wait for month after recovery to have their accommodation sorted and some people never see a psychologist even though it would be of great benefit. Underfunded and under-resourced services lack basic necessities. This can make reintegration back into society much more of an uphill struggle for some people.
What is the patient experience of being on a psychiatric ward?
In my career I've talked to many many patients about this, both whilst they were in patients and also afterwards. Their experience and their opinions vary dramatically.
This is a complex, important and vast issue, which I have a lot to say about. Again, I think it deserves its own blog.
What about you, Dear readers?
Have any of you had experiences of either yourselves or loved ones being on a psychiatric ward? If so, how did you find the whole episode? Were you happy with the quality of care you received? If not, what could have been done better?
The film was Sucker Punch, by the way.
I wouldn't recommend it, unless you're suffering from insomnia, or have a particularly horrible shirt that you want to dribble upon.