Mental Health Care - A Quirky Feature
Yesterday I visited the psychiatric unit at the local hospital, my old stomping grounds, to examine a patient. See, I picked up this side hustle as a court appointed mental health examiner. Basically this means that if a patient is a significant danger to themselves or others or unable to care for themselves, they sometimes have to go to court to determine if they will be kept in a mental health facility for up to 6 months. In a nerdy way, I find my role in this process fun. I get to interview the client, read about their case and history, talk to the doctors and nurses caring for the patient, and then form an opinion about whether I believe this patient should be committed or not. This opinion then is supposed to help the judge make their decision on whether the patient should be committed for 6 months or not. That whole thing isn’t the point of this article, but I figured it may be helpful trivia for people wondering what goes on inside the black box of the mental health system.
Anyways, on the psych unit, I saw some old friends. A few mental health techs and a couple nurses who I used to work with said hi. The nurses briefed me on the patient I was about to interview. They’re thoughts were quite different from what was in the doctor’s notes. The nurses felt like the patient was basically in the hospital because she wanted people to care for her, and that she was intentionally creating symptoms, so she could remain in the hospital and have the staff and other patients care for her.
Whatever was reality in this case, it is an example of a constant conundrum in psychiatry, a frequent lament of those who have been working in the mental health field for years: in mental health, those who don’t need care want care, and those who do need care don’t want care.
If you think about other fields of medicine, this isn’t a problem. If I start having severe chest pain, I go to the hospital - and I should. I may be having a heart attack. In this case, my goals are aligned with those of the doctor. This is the same if I have a seizure, break my arm, have visual issues, etc. I get care, and I should be getting care.
But in the mental health world, things are different. The first group mentioned, those who don’t need care but want care, show up both in the mental health clinic and in the mental health hospital. In the clinic setting, this might be a person who feels down a lot of the time and struggles with feelings of hopelessness. He is in a marriage where neither person is happy, hates his job, doesn’t exercise, is overweight, stares at a screen for hours every day, and doesn’t sleep well. Oftentimes, this person has no interest in talk therapy or changing their behavior; they want a medication that will make them happy. I look at them like a cow looks at an oncoming train, knowing how fruitless and silly their request is.
Then there is the doctoral level professional who comes in saying they can’t focus at work which is causing them to take work home, and they complain of being tired all the time. They have kids and work 60 hours a week. Oftentimes, their child was recently diagnosed with ADHD, and either from their own conclusion or at the recommendation of the provider treating their child, they think they may have ADHD and definitely need a stimulant like Adderall. They somehow are convinced that they did have attention symptoms when they were 12 years old or under (as is required for an ADHD diagnosis), but that they compensated in school with their high intelligence.
Maybe more surprising, there is a group of people who feel like they need to be on a psych unit. They often don’t admit it, but they like being on the unit. These are often people who have become their illnesses. They see themselves as permanently incapable of caring for themselves. They are profoundly lonely and no longer believe they have any control over their own life. And unfortunately, being on the psych unit, with all the care and attention they receive, their situation worsens and makes them believe that they actually needed the hospitalization. One of these poor souls would grin and high-five me when she arrived in the psychiatric portion of the emergency department after a feeble suicide attempt.
It is essential to remember (and I need to remind myself from time to time), and this is not all there is to psychiatry. The other side of the coin exists as well - those people who desperately need mental health care but refuse it. Bipolar and schizophrenia often lead to this problem because the person suffering doesn’t realize that they are mentally ill or would benefit from help. Time and again, seriously ill people, often hearing voices or thinking the FBI was after them, would be brought into the emergency department by police or by their family. But many times, because they didn’t have thoughts of hurting themselves or others and didn’t want to stay in the hospital, I had to send them home. This was in spite of parents pleading with me to keep them in the hospital. I sided with the parents, knowing these people desparately needed hospitalization and medication, but my hands were tied. These people couldn’t be held against their will because so-called mental health advocates had helped bring forth policy for them to have “the freedom to choose.” But free will in their case, with their minds poisoned by delusions and hallucinations, was an illusion.
But this can also occur in severe depression. When someone truly wants to kill themselves and has come to this decision after deliberation, they see no need for mental health care. They just go and complete the act. This highly depressed group, probably at the highest risk of dying by suicide, refuses help even though they need it.
What do I/we do with all this? I’m not sure, but knowing about it is a start. Part of the problem would be solved by changing commitment laws to allow more mentally ill people to be held and treated against their will.
I do think this conundrum can give us some insight into why those who work in the mental health field become burned out. People enter the field because they want to make a difference, to help people. But when they run into this quirk not just once but over and over, they begin to question how much good they are actually doing. Are they doing good at all? Or, God forbid, are they making things worse?
While this is a real and persistent problem, not everyone with mental health struggles falls into these two camps. That would be a deadly overgeneralization. There are those who make the suggested behavioral changes. And there are those, with bipolar or even schizophrenia, who realize they need medical help and are able to lead a relatively stable life. Maybe this makes it all worth it.