Dignity and the Inpatient Milieu

[hamstergang]

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It's been a while since residency, but I never could understand what therapeutic value there was in putting someone who was depressed on the same locked unit as a patient with psychosis. I always thought it would make the depressed patient even more depressed.

Do we really have other options that we can afford?

 

[OldPsychDoc]

Do we really have other options that we can afford?

At our place, we're fortunate to have 5 units: a high-severity "ICU" which has a higher staff-patient ratio, 2 "high acuity/low function" units which are primarily psychosis-oriented, and 2 "low acuity/high function" units which are oriented toward mood d/o and crisis stabilization. It's nice to be able to adjust programming accordingly.

 

[hamstergang]

And that's why I threw in those last 4 words. I wish what you have weren't so expensive. Sounds like a great place to work, train, and receive care.

 

[CounselortoMD]

You could always empathize with your patients' infantilization and humiliation in the therapy that you are (hopefully) getting to do with them while they are hospitalized. The skill lies in doing this without undermining the treatment process. Also, keep in mind that many "high functioning" patients who end up on psych units and sue later on for lack of pastels, etc., might be expressing some of the pathology that got them in the hospital in the first place. Finally, many patients who "decompensate" after getting on the unit were probably headed in that direction anyway, and most of these patients will often get significantly better by the time of discharge. That doesn't mean they will be pleased with having been hospitalized. Processing the hospitalization should be one of the major tasks of post-discharge outpatient follow-up appointments.

I agree! Thank you for this reality-check perspective.

 

[CounselortoMD]

You can't really use how you would feel as a patient involuntarily hospitalized on a psych unit as a basis for what an actual patient feels, since (presumably) you know that you don't need to be there. Most patients on an acute unit will usually have some understanding of their need to be in the hospital, even if they have very poor insight and demand to leave That is usually the truly humiliating fact, and not the conditions of the unit. Also, keep in mind that a medical hospitalization can also be quite infantilizing (you are lying in bed the whole time without your clothes on, for example). Yet, you are not so perturbed by them. I don't mean to say that psych units are fun places to be hospitalized. Rather, one's unease with them may have more to do with notions of what it means to suffer from a psychiatric illness, rather than the facilities themselves.

Thank you! You're exactly right once again.

 

[CounselortoMD]

I'm afraid that for many patients it is very humiliating to have a mental illness. Few patients are going to come out and say this, precisely because it is humiliating. If you don't understand this then it will be very difficult to empathize with them.

My point is not to defend psych units as free from indignity or dehumanizing forces (though I seem to be cast in this role by the OP). They are despairing and frightening places, to be sure. Rather, it is to point out that there is more to the feelings that our patients have about being hospitalized than the nature of the unit. This is why no amount of "putting yourself in their shoes" will ever help you know how it truly feels. They actually feel worse than you imagine, because they will have to explain to everyone why they went to the hospital.

Again, I challenge you to show me how a medical hospitalization is any less humiliating or dehumanizing. Have you ever had to pee in a bottle in front of another person? How about being immobilized due to a broken limb? Psych units do not have a monopoly on despair.

You all must work at nice clinics. I envy that.

But at the acute "psych" hospital where I have worked for almost ten years, nearly all of our patients have already "diagnosed" themselves with "Bipolar/Anxiety/ADHD/Fibromyalgia/Arthritis/Degenerative (idiopathic) Disc Disease/RSD/etc.", and upon arrival they are DEMANDING to be admitted into our inpatient program--whether or not they actually meet criteria for an inpatient acute psychiatric level of care--because they urgently "need" refills of their Adderall, Xanax, Ambien, MS Contin, Oxycodone 30mg q4hours around the clock, Soma, Lyrica, etc.

They typically have no interest in any form of antidepressant, NSAID, antihypertensive, insulin, etc.

 

[OldPsychDoc]

You all must work at nice clinics. I envy that.

But at the acute "psych" hospital where I have worked for almost ten years, nearly all of our patients have already "diagnosed" themselves with "Bipolar/Anxiety/ADHD/Fibromyalgia/Arthritis/Degenerative (idiopathic) Disc Disease/RSD/etc.", and upon arrival they are DEMANDING to be admitted into our inpatient program--whether or not they actually meet criteria for an inpatient acute psychiatric level of care--because they urgently "need" refills of their Adderall, Xanax, Ambien, MS Contin, Oxycodone 30mg q4hours around the clock, Soma, Lyrica, etc.

They typically have no interest in any form of antidepressant, NSAID, antihypertensive, insulin, etc.

It's all about limit setting...

 

[CounselortoMD]

I'm sorry this happened to you, birchswing. I never thought about these kinds of things as an outpatient problem because I figured that patients could just walk away. Upon reflection, I can see that this isn't necessarily so.

Bullying in Psych sucks. Sometimes I catch patients eyeing staff members like they are Nurse Ratched. Sometimes I wonder if the patients are right.

http://s3.amazonaws.com/publicationslist.org/data/philip.darbyshire/ref-45/Reclaiming Big Nurse.pdf

 

[CounselortoMD]

There are some other aspects that the previous posters have failed to mention. What you describe as dehumanizing and conditions of indignity, IMHO, has a lot to do with social inequality and the general poor funding of public psychiatric facilities in this country, due to certain biases in funding. Around the country, inpatient units serving poorly insured or non-insured patients MOSTLY lose money, which induced well publicized shutdowns of inpatient units in large hospital systems (i.e. HUP, UChicago). Most patients who are hospitalized in inpatient units are poor, SMI or both, uninsured or on SSI. Doctors are overstaffed. Nurses have low pays. Nutrition/OT/PT have really little time/resources. You are blaming a systemic problem on individual practitioners who have very little leverage over the situation.

If you want to see more patient dignity, I can point you to any number of fancy private pay resort style hospitals/rehabs around the country, catering to the most affluent clientele with generous insurance coverage as well as individual funding, affiliated with the most prestigious university hospitals and academic institutes. These patients can wear shoes, have fabulous lunches, are rarely locked up in seclusion, have individual psychotherapy, cable TV and computer access, DBT groups, in house 12 step programs, etc. etc.

Dignity is not just a matter of what you do. More often than not, it's a matter of how much MONEY you have. It's a commodity that can be bought. It may be high time to shed some naivete to realize that.

Thank you. We always blame the clinicians--but what about the "system" that oppresses us too?

 

[CounselortoMD]

One other thing that other posters have alluded to is that the dignity that patients desire and deserve really has little to do with widgets and decorations. 90% of it comes from the human interaction. Inpatient units have locked doors and it's a necessary evil. But how someone is treated in a locked unit has to do with the training and passion of nursing, housestaff, and faculty.

Dignity is not tied directly to funding. I've seen inpatient units better equipped and funded that had higher assault rates than their more fundamental neighbors serving similar patient demographics and levels of acuity. Most of the difference is who works there.

So again, Excitotox, I'd strongly recommend treading lightly as you get to know inpatient psychiatry better and why things are done (or not done). One thing I've noticed is that the harshest and sharpest criticisms of inpatient psychiatry tend to come from folks who are focused on doing longitudinal (and often private practice) psychotherapy. It's chicken or the egg as to whether their lack of interest in inpatient psychiatry leads to disdain or if their disdain lead them to a low interest in inpatient psychiatry. It doesn't much matter. But what does matter is that like any rotation you best serve patients if you keep an open mind and an open heart and work towards the mission of the unit you're on, regardless how it fits your personality or politics.

For anyone starting residency in July- if you hate inpatient psychiatry, you'd do a service to process it privately with peers or management. Being vocal about any disdain for inpatient psych or how it's practiced while on the unit may feel good (chest beating can be intensely satisfying), but it hurts morale among folks who will be doing it long after you finish the mandatory months and move on to something more to your liking.

And hurting inpatient psych staff morale is probably the most effective way to disrupt good compassionate patient care and ultimately rob patients of their dignity. Seriously. Much worse than lack of shoelaces.

Brilliant.

 

[Excitotox]

I hate inpatient psychiatry in part for the reasons you mentioned. Unfortunately the nursing staff control these units and they are still akin to the total institutions that Goffman described in Asylums (have a read of it if you haven't)... Soteria and other projects show there are otherwise do deal with even violently psychotic and suicidal individuals in more humane ways...

Also as already mention, it is not just psychiatric hospitalization that is a dehumanizing experience - being on a medically ward is bad too but not as bad as being on a psych unit. though being on the ICU is more traumatizing than being on the psych unit. More people end up with PTSD like symptoms from the ICU than the psych unit.

Hey splik,

Thanks for your reply. I appreciate the reading advice (which I quoted here in part to remind myself of what to look for!)

I do understand the need to not make waves on the unit. This is why I posted on an anonymous forum versus, say, storming around and complaining to anyone who will/won't listen. The last thing I want to is to harm my patients, but the second-to-last thing I want is to be a "problem resident." Here's to hoping that I only infrequently have to choose between the two.

Now that I've had some time to think over both my original post and all of the replies, I've been better able to hone in on the root of what is so troubling to me. I'm not wondering not about why we make patients do things that seem undiginfied. Instead, I'm wondering why we seemingly never opely acknowledge that our rules might reasonably make a patient (or any person, for that matter) feel undignified/humiliated/condescended to/etc.

On several occasions, I've taken aside prickly, cranky patients when I had a hunch about them and asked some permutation of the question, "Are you feeling humiliated by this environment right now?" Every, single time the patient has responded in the affirmative... and they have tended to calm down after we talk it out and I apologize for the way things are. Because, when you think about it, an awful lot of the things we do on the Psych unit are, essentially, huge cultural competency problems. Crayons, collages & macaroni-art are culturally associated with kids. Locks, sedation and supervised bathroom visits are culturally associated with prisoners. So why don't we ever acknowledge that patients might reasonably make these cultural connections and have negative feelings about them?

But, like I said, the only person I've ever heard do this is me. I've never heard an attending, resident or nurse acknowledge that the above rules and activities could reasonably have negative cultural meanings for patients. Which is why I've always "snuck off" to have these conversations... I had the vague sense that I would get in trouble if someone heard me acknowledge such things.

Do you think that I would get in trouble if I acknowledged such things openly to a patient in front of staff? Not in an attempt to attack the unit, but to validate a patient's sense of injured dignity?

 

[Excitotox]

The best you can do is to treat the patients as they should be treated and at least listen to their concerns. Even if you can't fix the issues, you can at least emphasize with the patients and end up gaining their trust since you're not one of the bad guys.

Here's hoping I can pull this off, hamster!

I'm curious-- have you ever acknowledged to a patient that you could understand why one or more aspects of life on the unit might reasonably be seen as (unintentionally) humiliating by that patient? How did the conversation go, and how did the patient react? Have you seen any attendings/residents/staff say such a thing?

I know it seems really simple, but after 3 months on 3 different inpatient units, I have never once heard anything like this expressed to a patient. It seems kind of self-evident to me...

 

[hamstergang]

I'm curious-- have you ever acknowledged to a patient that you could understand why one or more aspects of life on the unit might reasonably be seen as (unintentionally) humiliating by that patient? How did the conversation go, and how did the patient react? Have you seen any attendings/residents/staff say such a thing?

Well first, I want to correct myself -- I clearly meant empathize, not emphasize.

And now secondly, yes I've done it. The pt comes in upset and states that the problem is XYZ on the unit making them upset today. I say something like, "Well, I'm sorry. I wish it weren't like that here either, but it's the policy and there's nothing we can do about that. Try to put with it for just a little longer." And then transition into something about the unit/care they do like so they can see it's worth it. It's never seemed like too big a deal as most patients do realize that we're all in the same boat having to deal with rules we don't agree with made by administrators.

I think that ends up working out ok for the patient, but I could be wrong.

 

[Excitotox]

Dignity is not just a matter of what you do. More often than not, it's a matter of how much MONEY you have. It's a commodity that can be bought. It may be high time to shed some naivete to realize that.

Yes, I do have an awareness that- with deep enough pockets- almost anyone can pay others to treat them well.

But I guess my concerns are less about the rules/policies/activities themselves, and more about how we as clinicians understand those things in a cultural context. Many of the rules and activities we have for patients have strong US cultural associations with either prisoners or children. Shoelessness and safety scissors are not so terrible in themselves... it's the meaning that patients assign to these things that are most problematic.

Why don't we openly acknowledge those cultural associations, and tell patients that we can reasonably understand why it might be an assault to their pride to be treated in a way similar to how we treat one or both of these groups? But that, unfortunately, we have to do it anyway. It would only take a few seconds to say such a thing, and probably would not even require all that much empathy or effort on the part of staff.

 

[Excitotox]

There's a great deal of variety in inpatient settings - perhaps the one you worked in wasn't so great. Don't necessarily generalize your small experience to all of inpatient psych everywhere...

And what's the deal with an attending getting into a power struggle?

PS - you might want to read Kaplan and Sadock's section of Ethics in Psychiatry if you haven't done so already

Regarding variety of inpatient setting... sigh. I can believe that there are better situations out there than what I've seen. I certainly want to believe it! Tell me... when you sense that some aspect of life on the inpatient unit might be injuring a patient's pride, do you acknowledge that directly?

Regarding the power struggle, the whole thing reflected more poorly on the attending than the patient, IMHO. The attending had a not-small narcissistic component to his personality structure, and I sensed that he enjoyed being the center of the little universe that comprised the unit. Handsome and firmly in-charge, he was unused to being crossed by anyone. My attorney-patient "cross-examined" him, and managed to draw him into an argument that he clearly lost. He then wanted to hold her well past what was appropriate... in my opinion, because he wanted to show her his dominance over her.

Regarding K&S, thanks for the reading advice. You and splik will keep me busy until July!

 

[Excitotox]

I say something like, "Well, I'm sorry. I wish it weren't like that here either, but it's the policy and there's nothing we can do about that. Try to put with it for just a little longer." And then transition into something about the unit/care they do like so they can see it's worth it. It's never seemed like too big a deal as most patients do realize that we're all in the same boat having to deal with rules we don't agree with made by administrators.

Well that certainly sounds alright! Such a simple thing, but I've never heard it done. I guess I was afraid that acknowledging anything on the unit as less-than-therapeutic was like criticizing Brig Brother; anyone overheard will be re-educated.

Yeah... I've been really, really unimpressed with my inpatient experiences so far. It's a shame, because I feel more drawn to work with the acutely, floridly ill than many other patient populations within Psychiatry. But maybe that's why I've been so distressed when I've felt that such delicate patients were being treated ham-handedly.

 

[BobA]

I would definitely acknowledge to a patient that some aspect of the unit was unpleasant or even humiliating. It's a good opportunity to practice reflective listening, and build rapport with your patient. It's this rapport that will ultimately keep the patient in treatment over the long term anyway.

The ethics section in K&S isn't very long - I just read it the other day and I think it'd be worth 20-30 min of your time (might make you feel better about what you are doing).

 

[kugel]

Well that certainly sounds alright! Such a simple thing, but I've never heard it done. I guess I was afraid that acknowledging anything on the unit as less-than-therapeutic was like criticizing Brig Brother; anyone overheard will be re-educated.

Yeah... I've been really, really unimpressed with my inpatient experiences so far. It's a shame, because I feel more drawn to work with the acutely, floridly ill than many other patient populations within Psychiatry. But maybe that's why I've been so distressed when I've felt that such delicate patients were being treated ham-handedly.

Yes. I've seen (and done) this many times. And when I talk with staff about the subject, I almost invariably find that more than one other staff has talked with the pt about the humiliation and tried to help him manage the distress and how to express it in a way that doesn't do him more harm. I've seen many patients calmed and bolstered by admitting to the pt that the process is humiliating and then assisting him to write a complaint.

AND I've seen some policies change due largely to patient's written complaints about them. It's rare, but I've seen it happen (more often than when I complain about them).

 

[OldPsychDoc]

Well first, I want to correct myself -- I clearly meant empathize, not emphasize.

And now secondly, yes I've done it. The pt comes in upset and states that the problem is XYZ on the unit making them upset today. I say something like, "Well, I'm sorry. I wish it weren't like that here either, but it's the policy and there's nothing we can do about that. Try to put with it for just a little longer." And then transition into something about the unit/care they do like so they can see it's worth it. It's never seemed like too big a deal as most patients do realize that we're all in the same boat having to deal with rules we don't agree with made by administrators.

I think that ends up working out ok for the patient, but I could be wrong.

We do this stuff openly, all the time, on our units--the nurse manager responds directly and personally to complaints, tries to work things out with kindness and dignity, explains reasons for rules that can't be changed, sometimes gives a $5-10 Target card as an acknowledgment of the inconvenience....etc. It's not that hard to treat people with respect and kindness, even on an inpatient psych unit.

 

[notdeadyet]

We do this stuff openly, all the time, on our units--the nurse manager responds directly and personally to complaints, tries to work things out with kindness and dignity, explains reasons for rules that can't be changed, sometimes gives a $5-10 Target card as an acknowledgment of the inconvenience....etc. It's not that hard to treat people with respect and kindness, even on an inpatient psych unit.

Agreed. I'm not sure why folks seem to see the inpatient psych environment is a de facto obstacle to basic patient empathy. Yes, acknowledge to your patients that life on an inpatient psychiatry unit is always inconvenient, often uncomfortable, and occasionally dehumanizing. Empathize that these are not easy living conditions. Explain the rules and correlate them to why they are for the safety of the patient, their peers, and staff. Encourage them that inpatient psych unit stays are temporary and the goal of every admission is to discharge patient's to a safer, more comfortable lifestyle through better control of their symptoms and the assistance of as much social support as the locale allows. This isn't herculian; anything less is substandard care.

I like the Target card idea. Wish our county could pop for those.

 

[Excitotox]

Agreed. I'm not sure why folks seem to see the inpatient psych environment is a de facto obstacle to basic patient empathy. Yes, acknowledge to your patients that life on an inpatient psychiatry unit is always inconvenient, often uncomfortable, and occasionally dehumanizing. Empathize that these are not easy living conditions. ..

I like the Target card idea. Wish our county could pop for those.

Well that all sounds just fine! But in your initial reply to me, you didn't mention any of these things. Of course, part of that was my fault. When I asked, "Why do we have XYZ rules?" what I was really asking was, "Given that we must have XYZ rules, why don't we do everything we can to acknowledge and validate the humiliating / infantilizing meanings that such rules may have for patients?"

I enjoyed this article from the NY Times magazine. This first person account highlights the author's lost sense of "self." She argues that this loss stems from her disease, itself, but also from her treatment- both psychotropic drugs and the inpatient milieu (... and it seems that she was in a NICE facility! To be frank, such care is unheard of at any of the hospitals in my area.). My own take-home is that if a major consequence of these diseases is that they strip away the "self," we should do everything we can to protect and preserve that "self." http://www.nytimes.com/2013/04/28/m...t-bipolar-disorder.html?pagewanted=1&_r=1&hpw

 

[notdeadyet]

When I asked, "Why do we have XYZ rules?" what I was really asking was, "Given that we must have XYZ rules, why don't we do everything we can to acknowledge and validate the humiliating / infantilizing meanings that such rules may have for patients?"

Yep, that would be a different question and with an easy answer. You should empathize with your patients. In fact, you don't even have to agree that something is humiliating to express your understanding that a patient feels humiliated and you understand how much that sucks.

I had a patient outraged that the TV doesn't get better channels and call it a violation of his human rights. I may not agree with the patient, but I can still empathize and let him know how frustrating it is to not get what you feel you need.