If you go into your internet browser’s search bar and type in the word “asylum,” a host of terrifying images of dirty hallways, rusty beds, and screaming faces will pop up. Let’s face it — asylum is mostly known as a negative word, a place where unspeakable things occur in the movies that keep us awake at night. Regardless of its roots in providing protective safe haven, the concept of asylum receives a bad reputation mostly because of historical documentation of the awful and dehumanizing conditions of psychiatric hospitals.
“It’s not easy to talk about. You don’t want people to think you’re ‘nuts’ when everyone in there is not nuts,” Ann explains while sipping a cup of coffee. “During certain stays I had dignity, but there was one hospital where there were bed bugs all over. They had to keep changing my sheets and the staff would come in to clean them out of the lights.” Now in her fifties, Ann has experienced many years of hospital stays at different institutions while combating major depressive disorder (MDD).
“We were all put together even though some people were heroin addicts, while others were… really, really disturbed. There was one guy who came and in and he really needed help,” Ann says softly. “He thought he was everybody and anybody, would put on tights to perform for us when he was a ‘dancer,’ wouldn’t take a shower… there were things that just made this guy a walking target on the outside. He was there for no more than 48 hours and they got rid of him. He didn’t have any health insurance.”
In the 1960-80’s, key decision makers in the U.S., most with little to no knowledge on mental illness, decided to drastically cut mental health funding and close many psychiatric institutions.(1) This had a grandiose butterfly effect, something that was thought to be a small change, yet truly had a huge impact on the future of mental healthcare. “Deinstitutionalization” was sold to the public as a way to have states and local communities take on more responsibility for mental health, and suddenly psychologically distressed individuals were released from hospitals with no discharge plans or assistance integrating into society. No wonder the butterfly effect is part of chaos theory.
It is difficult enough that the serious societal taboo around mental health hardly makes it a topic to discuss in any circle, even with those who are intimately effected. Without encouraging, well-organized, and affordable access to services, many who need assistance ultimately become estranged from their families before entering prisons or living on the streets. But that doesn’t impact you, of course. Aren’t those are the other people?
When one in five Americans — about 20% of the nation — experiences a mental illness each year, suddenly the “others” are a significant portion of the population. (2) To give relative perspective, mental health episodes occur roughly 30 times more than all cancer diagnoses made annually. (3,4) How often have you heard of someone who you know become affected by cancer? Probably more than once. What about mental instability? It’s likely that it is not spoken about as openly, even though it is happening often. Think it’s just America? One in five Canadians and Australians also suffer from mental illness.
Earth is the Insane Asylum of the Universe
Stories like Ann’s could be part of why funding has been drastically cut for decades and continues regardless of research showing that when those with serious mental illness receive protection in family homes, care facilities, or psychiatric hospitals, they can obtain a much higher quality of life. (5,6) The idea of expanding long-term care has been promoted by psychiatrists for many years and is now gaining popularity as the lack of mental healthcare in America becomes an increasingly serious issue.
It must be noted however, that certain asylums provide better standards of care, safety, and comfort than others. Inconsistencies in services and varying amenities makes it difficult to judge whether or not psychiatric hospitals are helpful or harmful for patients, as quality can be significantly different from place to place. Both Ann and her daughter become uncomfortable as they speak about the degrading tones taken by some of the staff members at a particular hospital. “When I would visit I noticed that it was almost military oriented, where care assistants would yell orders or threats at patients openly. It was so degrading… they couldn’t relate or empathize with the patients,” her daughter recalls.
“As soon as I got in there I was given such little information,” says Ann “I remember asking about how to get treatment after I would leave the hospital and there was not help available or even someone to briefly talk to me about it. I didn’t feel like a person — you felt like all of your rights were basically stripped. And not everyone on the inside cares or likes their jobs. With some of the staff, I feel like they think ‘this is Psych and no one is going to believe them,’ so it doesn’t always matter what is said or done. And you’re like, wow, is this really happening to me? Am I in a time warp?”
Since the major global expansion of mental hospitals in the 1700’s, cruel maltreatment of the sick has been testified by patients, family members, workers, and frequently reported by journalists and law enforcement. Many studies have shown consistently high burnout rates amongst mental health workers, with emotional exhaustion being the most prominent complaint. (7,8) When asking employees what contributes to this, issues such as understaffing, verbal abuse from patients, and disorganization in the workplace are described.
These factors may make one wonder, do the hospital stays actually help? “Some did and others made me feel worse,” Ann explains while shyly looking down. “One facility had showers that were disgusting. Those things made the depression worse because you’re living in filth. When I left I had to live with my children and still felt like there was so much grief. Everyday there was nothingness… I felt empty. I never knew you could have a real pain in your heart, but I had it. It hurt.”
Although burnout rates are high amongst workers at these institutions, there are divergent reports of positive patient-clinician relations and personal accomplishment levels. While some staff members project their discontent onto visitors, others feel extremely connected to helping patients in a meaningful way. In a study of over 350 nurses working in U.S. psychiatric inpatient units, lower burnout and higher work satisfaction was associated with skillful management leadership, comfortable facility features, and stronger nurse-physician relationships. (9)
“Of all my stays, only in the city [Manhattan] did people really help,” Ann remarks. “You had to obey their rules, which were basically don’t act out and keep people calm. That I can understand. People can bring you food and you can all sit and talk — you feel human. The rooms were clean and I didn’t have doctors just throwing medication at me. I also had one on one and group therapy with many doctors. They were listening and attentive and actually were working to take care of what needed to be taken care of. The people inside had mixed conditions as well, but an entire team got to speak with each person separately, so it was different.”
Ann’s daughter, who worked in a psychiatric facility while doing clinical research, discusses the need for more individualized treatment.
“There are different severities of mental illness that need to be differentiated in order to give people the best treatment. We see this in special education — where schools may separate children by those who are auditory versus visual learners and then help them through ways that are most impactful. In most institutions they group everyone together regardless of their condition, yet everybody needs a different approach to help get them past what they’re going through. They need to be better understood, especially during a terrible time.”
Hallucinations from schizophrenia may be an extreme that affects 1% of people, but depression is the leading cause of disability globally and is still a condition that is grossly underserviced. (1) Unfortunately, the media has been focused on the same wild-haired, ranting image of “crazy” for centuries, putting respectable people in an animalistic light. This skewed perception was born from a small number of situations and has powerfully influenced a fearful idea of mental illness in the minds of most of the American public. Interestingly, those living with severe mental illness tend to be introverts who are not any more vicious than the broader population. Sufferers are actually 10 times more likely to be victims of violent crimes than the general public. (10)
There may be a need to alter practices at some existing mental health institutions, but essentially they operate with the intention to help in a different way than just confinement from others. After experiencing prison, one may think of the concept of a psychiatric facility in a different light.
This is the first of a three-part series about the state of mental health care in America. Stay tuned for parts 2 and 3 over the next two days.
References:
1. Russell K. Schutt (2016), Social Environment and Mental Illness: The Progress and Paradox of Deinstitutionalization, in Brea L. Perry (ed.) 50 Years After Deinstitutionalization: Mental Illness in Contemporary Communities (Advances in Medical Sociology, Volume 17) Emerald Group Publishing Limited, pp.91 – 118
2. NAMI: National Alliance on Mental Illness. (2015). Mental Health By the Numbers. Retrieved from http://ift.tt/1GXpF17
3. American Cancer Society. Cancer Facts & Figures 2010. Atlanta: American Cancer Society, 2010.
4. Mental Health Myths and Facts. (n.d.). Retrieved August, 2016, from http://ift.tt/1U4rT5H
5. Lamb, H., & Weinberger, L. E. (2016, March). Rediscovering the Concept of Asylum for Persons with Serious Mental Illness. Journal of the American Academy of Psychiatry and the Law Online, 44(1), 106-110. Retrieved from http://ift.tt/2eObWSC
6. Rogers, S. (2015). Expanding Long-term Care Options for Persons With Serious Mental Illness. JAMA, 313(17), 1755. doi:10.1001/jama.2015.3500
7. Bogaert, P. V., Clarke, S., Willems, R., & Mondelaers, M. (2012, August). Nurse practice environment, workload, burnout, job outcomes, and quality of care in psychiatric hospitals: A structural equation model approach. Journal of Advanced Nursing, 69(7), 1515-1524. doi:10.1111/jan.12010
8. Paris, M., & Hoge, M. A. (2009). Burnout in the Mental Health Workforce: A Review. The Journal of Behavioral Health Services & Research, 37(4), 519-528. doi:10.1007/s11414-009-9202-2
9. Hanrahan, N. P., Aiken, L. H., Mcclaine, L., & Hanlon, A. L. (2010, March). Relationship between Psychiatric Nurse Work Environments and Nurse Burnout in Acute Care General Hospitals. Issues in Mental Health Nursing, 31(3), 198-207. doi:10.3109/01612840903200068
10. Mental Health Myths and Facts. (n.d.). Retrieved August, 2016, from http://ift.tt/1U4rT5H
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