10 Keys to Improving Inpatient Psychiatric Care

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In March 2020, as the rest of the world went into lockdown from COVID-19, I went into a psychiatric hospital. A year before, a severe manic episode led to my being diagnosed with bipolar I disorder after decades of treatment for depression and anxiety. I responded quickly to antipsychotics to bring me out of my mania, but I slid into an intractable depression that left me almost catatonic. Even basic activities, like showering or going for a walk, were daunting.

I had been working remotely, which allowed me to fly under the radar for a little while. But when my inability to work finally caught up with me and I lost my job, that was the trigger to seek more intensive treatment. At an emergency mental health facility, I agreed to a voluntary commitment wherever in the state they were able to locate an empty bed.

What I experienced was more like incarceration than a voluntary admission. And I’m not alone. A recent research article by Morgan C. Shields and Kelly A. Davis in the Journal of Patient Experience reported responses from a survey of 510 former patients of inpatient psychiatric facilities. Results fell into 10 areas in need of improvement, as described below.

Humane Care

According to the authors, “[p]articipants reported being treated like prisoners, animals, and objects during their hospitalization.”

When I was informed that a bed was found for me two hours away, I also learned that I'd have to be transported in the back of a law enforcement vehicle. And although I was cooperative, nonviolent, and wasn't threatening to hurt myself, I’d have to be transported in handcuffs attached to a chain around my waist. Within the cramped, stuffy, steel cage, I sat at an angle so that I would have room for my knees and legs. I shifted my wrists and arms to allow the handcuffs and chain to settle before finding the least uncomfortable position to rest my hands. Then I closed my eyes and tried to focus on my breathing as I skirted the edge of a panic attack for the next two hours.

Personalized Care

The authors stated that “[p]articipants overwhelmingly reported that they often received services without consideration of their specific crisis or point in recovery. Participants described staff’s attempts at therapy as lacking meaningful engagement or lacking relevance to their conditions and needs.”

Half of the patients on my ward were detoxing and no one besides me had bipolar disorder. The only topic for group therapy that cut across all patients was stress management. The lack of available beds for inpatient psychiatric care means patients from across the psychiatric spectrum are treated together, which makes as much sense as having a cardiac bypass patient on the same hospital ward and in group therapy with cancer patients.

Communication

As stated by the authors, “[p]articipants expressed a lack of communication across several dimensions, such as a lack of a ‘clear timeline for discharge’ and being held ‘for several days with no answers to my questions about what I should expect or how long I would be there.’"

Although my inpatient stay was a voluntary commitment, it felt so much like an involuntary commitment that I started asking for confirmation that I was voluntarily committed. I couldn’t get an answer. After I was there for several days, I finally got confirmation but discovered that if I decided that I wanted to be discharged, I'd have to wait up to 72 hours until a mental health professional cleared me for release. But they could also decide to have me involuntarily committed, which felt a lot less voluntary than I thought I had agreed to.

Empathic Connection

According to the authors, “[p]articipants detailed a lack of empathy, respect, and kindness, including harmful statements and gross insensitivity from staff during their stay.”

There is a well-known connection between poor sleep and the exacerbation of mental illness, which is why it is so surprising to me that staff consistently disrupted our sleep. Staff was required to check on patients every 15-20 minutes, which was more often than not achieved by shining a flashlight at our heads. Complaints fell on deaf ears.

Other Issues

In addition to the issues described above, the authors described several additional areas respondents identified for improvement:

• Whole Health/Person Approach. “Overwhelmingly, participants expressed that they lacked access to a variety of health-promoting behaviors, such as ‘outdoor activities,’ ‘healthy food,’ and ‘spiritual guidance.’“
• Physical Safety. “Participants described a need for increased staff competency in managing conflict and crisis.”
• Respecting Patients’ Rights and Autonomy.– “Participants reported providers using indiscriminate court orders, not sharing information about legal processes, threatening patients with longer stays, and lying to patients about their rights and legal status.”
• Structural Environment. “Multiple participants reported concerns about cleanliness, including rat infestations and lack of comfort, such as lack of access to blankets, comfortable beds, and depressing aesthetics.”
• Equitable Treatment. “Participants reported experiencing discrimination based on gender and disability.”
• Continuity of Care and Efficiency of Systems. “Participants reported difficulties finding outpatient providers, with sometimes limited support from inpatient staff. Discharge planners did not always build patients’ confidence and comfort with discharge timing or provide connections to appropriate services following discharge.”

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Conclusion

In spite of calls for increased investment in inpatient psychiatric beds, this study underscores inadequacies in these settings and a lack of responsiveness to patients’ experiences. When inpatient psychiatric care is nonresponsive or dehumanizing, treatment can be traumatizing and discourage patients from seeking help in the future. Facilities should measure patient experiences to reinforce and expand practices that address patient needs and to reassess practices identified as countertherapeutic.