In this Episode of Family Psych Consumer:
Walking into a Psychiatric Hospital for the First Time – What to Expect, How to Behave, and Best of All, How to Make it Normal
In this episode, Tom starts at Square One for most families dealing with their first illness event – going to a psychiatric hospital for the very first time. There is so much to know and be aware of (not the least of which is “what’s it going to be like for me?”) Tom breaks it down to the basics – what to expect (or not), how to be a productive guest, who are the players, and how do you behave and participation in this unique medical environment.
Parents and families have to first understand and set aside their own biases or beliefs about this setting and understand its true nature - a place for people to regain their mental and neurological functioning. In this respect, it’s quite a benign place. But depending on the population that your hospital serves, it can be a stark but chaotic place. An inner city or suburban hospital that takes a lot of involuntary patients (translation – people who are very distressed or disabled in their thinking and behavior) can create a very jarring experience for first time visitors. Throughout this episode, Tom guides you on how to get the best out of yourself and the staff to help your loved one recover in this distressing place.
Full Episode Transcript
Hey Everyone. Welcome to another episode of Family Psych Consumer. This week we are reviewing another practical topic; visiting a psychiatric treatment unit in the hospital (or as we say casually, a psych unit). So this is more of a tactical talk about what to expect if you have never been before; how to behave when you are there; how to get the most out of your visit with your loved one and the staff (and those are two separate objectives); and how to survive it emotionally (translation? - how to normalize this event for yourself and what is medically happening to the person you love).
Let’s start with an overview of how to prepare. First, know that it will be a much more boring place than is portrayed in our popular culture; most first time visitors are surprised that it is so different than they thought.
First, the basics: they are locked, and all visitors need to be escorted in and out. This is to keep unsafe or psychotic patients from leaving (or eloping as they say in the psych world) and to legally provide privacy to the patients so strangers can’t wander in looking to validate their parking. Next, the physical environment - If you are paying privately for psychiatric hospital care, it is more hotel-like, civilized, and feels like a place any of us would want to spend a week-end. However, if insurance, including Medicare or Medicaid, is paying the bill, it is more like a sparsely furnished bus depot with a tables for meals and side rooms with hospital beds. (Now, I have been in insurance-paid hospital psych units that did have nice carpet, soft lights, and a nice space to hang out and read, but they are the exception.) Most are brightly lit, sparsely furnished, with linoleum floors, and bathrooms in the hallways. All units have a public open area called a “day room” for patients to co-mingle and hang out, which may itself be very stark, with few books or other stimulation to pass the time except for a common TV. In every psych unit there's a nurses station usually positioned in the middle of everything so nursing and staff can have eyes on everything and the patients at all times except when they are sleeping. Sometimes a nursing station is open and the patients can interact openly with the staff, but some hospitals will put their nurses behind glass or some other barrier that makes them less accessible (which makes the patients, who already feel terrible about themselves, feel stigmatized and like a lesser person – the exact opposite of our desired goal - to help your loved accept their illness as a brain event that’s not their fault so he or she can make peace with it and its treatments. Now a little nuance fact about psych units; it is common practice - maybe the right word is common strategy - that medical directors want psych units to be somewhat uncomfortable to incentive patients to want to leave. There are those patients who get comfortable being cared for or feel overly safe or pathologically inclined to stay. In the medical directors’ view, it is a place to get neurologically and psychiatrically stable and then leave. So you should expect the environment to be something less you would otherwise want for your loved one to experience if captive in a hospital.
Okay so let's talk about what to know before you go. Issue One: is your loved one a voluntary patient or an involuntary patient? If they are involuntary, they were brought into the hospital by mobile crisis unit or the police, evaluated as meeting your state law as being an imminent risk to their own safety or the community’s, and escorted to the locked unit. And they are legally being held on the unit for 3 days (in most states) to be evaluated and treated (which usually means medicated.) And just so you know, in any given city, not every hospital takes involuntary patients; usually a small handful at best take involuntary patients. But if you're loved one is a voluntary patient, then he or she walked into the hospital emergency room (likely brought in by yourself or directed to go in by their psychiatrist or therapist) and asked to be evaluated and admitted to the hospital; and as a result, he or she is legally entitled to direct their care, decide when to stay or leave, and is generally in much better mental or emotional shape to cooperate and work with the treatment team
So the next thing to know before you go is the rules on the unit psych. Psychiatric units are run a little like a barracks. When you arrive, you cannot bring anything with you and if you do, your possessions are searched; if you bring packages for your loved one, they will be gone through and anything that may be potentially used to harm themselves or others will be taken. This included even things like plastic knives or cell phone cords. This is another unfortunate characteristic in which risk management trumps patient dignity. There is common sense safety and then there is ridiculous safety.
Now, shifting topics regarding know before you go. You're going into an environment where every patient is cognitively or mentally compromised. This means that patients may not make eye contact with you, may misinterpret verbal language or body language or gestures that an otherwise well person would interpret correctly. Patients may be disinhibited and talk to you, or be psychiatrically over-stimulated and talking to themselves or behaving like someone is talking them when no one else is there. Your job is to understand that if someone's on this unit it is because their brain is malfunctioning, or their depression is shutting down all other mental and emotional functions; or they are so over-stimulated that they are having trouble slowing their thinking down; or their brain is creating unreal beliefs or voices or visions without and environmental stimuli. But this is not some mystical or scary group of people; this is simply a group of your fellow human beings who are struggling to get their brain’s back.
Regarding electronics or other personal comforts: Some hospitals let patients have cell phones or laptops after they have been evaluated (which means that cell phone or laptop use is not counterproductive to getting well. Example: some patients may be addicted to social media, or their abusive boyfriends, or are abusive themselves and weaponize the phones to harass people or family in the outside world. Sometimes cells phone or laptops help pass the time for a patient who is depressed and going through a medication change or a lengthy series of electroconvulsive therapy treatments. But most units do not allow them. So call ahead to find out the rules about what personal possessions they allow patients to have in their rooms. Also, there a set visiting hours, and rules about dropping off clothes or toiletries. And for those of you who just want to deliver things and not even see your loved one, you can do that too.
Next topic: How you are expected to behave when you are there.
First and foremost, you are entering a sacred place. A place where no one wants to be, but every person there needs to be or is forced to be. Any each one is suffering in their own way. And everyone is suffering because of a unique brain injury. So quiet your mind and leave your life at the door. You are entering a place where human respect, non verbal gestures of caring, and empathy are therapeutic to everyone you interact with, and this includes the hospital staff.
I want you to have a sense of purpose when you visit someone on a psychiatric unit. Take 5 minutes to talk to the staff to learn the state of mind or distress of who you are visiting; what you're trying to accomplish for them in that meeting. And remember, they are compromised, so they may have a limited amount of stamina to listen or process information or emotionally tolerate triggering topics like “how did you get here?”. What that means is, your job, as a visitor, is to be a constructive participant in the hospital environment; the unit staff does not want any combustible conversations because that destabilizes the patient which, depending on the patient, can destabilize the whole unit. So their expectation is that you're coming in to be a loving supportive visitor and not an agitant to their patient.
Sometimes being purposeful means assessing whether your are the right or wrong person to be visiting this compromised person at this time. You need to consider what is healthy for THEM, and thus the timing of your visit (Ask yourself: will I be a welcome visitor? Is he or she recovered enough to interact with me now? Sometime its best to wait until the patient is a healthier version of themselves, and able to tolerate seeing you, or handle the stress of even interacting. Remember, the person you love has a brain that’s not working, so making that brain talk, attend, listen, and perform for you is a LOT OF PRESSURE.) AND most patients have a lot of irrational shame about being there, which adds more stress and discomfort. So it is critical that you are sensitized to the patient’s experience. ASK them if they want a visitor. Remember still that patients have little agency over the environment they are in and NO agency over their mental state, so giving them the agency to decide who and when they receive company is very therapeutic; it helps someone feels normal and have some say about their lives (something we take for granted each moment in ours).
So generally speaking, when's the best time to make your first visit when some is admitted? Usually after the team has had a day or two to evaluate the patient after the initial admission and understand what is clinically affecting them. But remember that being in the hospital is not just a medical stabilization event, it's also a rehabilitation exercise for the family system, and it’s best to ask the staff when you should come together as a family during this treatment period.
Regarding your communication with your loved one - You want to talk and listen in a very focused and singular way; you want to be knowledgeable about the treatment plan the staff is implementing; support and repeat their instructions like taking medications, or getting sleep, or ways to quiet their thinking. Talk about today's business today, like helping him or her sign consents to share information, or helping them talk to a nurse about a concern, or getting along with a roommate. Be in the present and do not discuss past events or future plans.
Next topic - having a productive visit for you, meaning understanding the treatment team’s thinking and plan and getting connecting with the staff as a family liaison. Each unit has a social worker who is the liaison between the treatment team and the family; now, a quick request - don’t crowd the staff or the social worker on the front end of a stay. There is a flow to a patient’s care on the unit; each role engages or disengages from the patient or their family based on how quickly the patient is getting well. Regarding the treating psychiatrist, get his or her name and number and let them know you have meaningful treatment history or personal experience (and each have value) to inform their assessment. He or she usually shows up to see the patients once a day, see them individually, write orders for medications or other medical services, and talk to the team. All that happens in a matter of hours and if you are not there to talk to them, you still can find out what they are thinking. Your best shot in most cases is seeing their doctor in the morning. While you are there, tell the team you will come for a family meeting when they are ready. If your loved one is involuntary, get the name and number of the lawyer that's been assigned to your loved one and get the date for their hearing with the magistrate. Have your loved one sign the consents so you can get medical records while they on the unit; it allows you to get some medical records before he or she leaves and it makes it much easier to get records later. Make sure you bring your loved one’s outpatient team contact information for the staff. Don't assume they know everything about your son or daughter spouse; if there's a medical history write it down and bring it in as a narrative, with the names and phone numbers of the outpatient therapist and psychiatrist, when he or she first comes to the hospital.
That's my quick primer on visiting a psych unit. Much more to discuss on this topic. And if you are a veteran of visiting psych hospitals, please go to the family psych consumer podcast page and add your feedback or coaching. I’d love to hear your stories about when you first went what it was like, including the conditions of psych units that you visited. We are developing our private rating system for psych hospitals and the characteristics that contribute to recovery as well as the hospitals you think do not. Until next time, take care.