All the names and some of the identifying characteristics of patients have been changed. None of the officials or experts interviewed and quoted in this article were aware that I had been in a psychiatric ward as a reporter.
Around 3 A.M., hair uncombed, face unshaven, wearing a few layers of shabby jackets and shirts, I get off the subway outside Woodhull Medical and Mental Health Center in Brooklyn. I walk into the lobby and tell the hospital police that I’m looking for psychiatric help. An officer is amused, thinking I was brought to the hospital by the NYPD. “They just dropped you off, huh?” she says. She escorts me to the emergency room.
I go up to the counter playing my part: Brooklyn-Queens itinerant from one of those neighborhoods that used to be nice, high school education, straddling the street and minimum wage, sleeping on the floors and couches of acquaintances.
“I need psychiatric help. I called up here earlier, and they told me I could come down here and get some help,” I say. A worker takes my blood pressure and sticks a thermometer in my mouth. Another asks what my problem is. I say I’m really depressed, thinking about killing myself. A few minutes later someone with a clipboard asks me the same question. Everyone is blank faced. There’s no feedback, no reaction.
“I need to see somebody, I’m really depressed, I’m thinking about killing myself,” I say. More wordless transcribing. In a short while a young man in surgical scrubs appears, and I’m told to follow him.
In silence, I follow his back through a series of corridors, locked doors slamming behind me until we arrive outside the psychiatric emergency room. He leaves me in a small foyer with a police officer.
A nurse comes out into the foyer. She asks me what the problem is. I tell her I’m depressed, I need some help, I don’t want to go on living like this, I’m thinking about killing myself.
“You use cocaine, huh? Smoke some crack tonight, huh?” She frames it as a statement, not a question. I say no, I don’t use drugs, I’m just worn out by life, overwhelmed by poverty and stress, sick of going on. Several more times she conspiratorially asks me about the heroin or crack I’ve used. I say no repeatedly. She tells me to pull up my sleeves and looks for track marks.
She sits me down and asks about my life and circumstances, and I try to answer but she’s only half listening, alternately bored and amused, looking around, interrupting. Midway through the conversation, she cuts into one of my answers and tells me to hand over my shoelaces and belt. She puts them in a manila envelope. No explanation as to what’s happening. She makes me empty my pockets and confiscates my pen, my cigarettes and my jackets. She asks if I’ve been here before. I say no. A few minutes later she asks again, as though she doesn’t believe that either.
We go behind another locked door and enter the psych ER. Inside, a square Plexiglas-enclosed nurses’ station is surrounded on three sides by narrow corridors, off of which are several patient rooms and offices. The nurse tells me to lie down on a gurney in the hall and says the doctor will see me. She locks herself in the nurses’ station and starts gossiping loudly about food and parties with another nurse while I lie there, staring at the ceiling.
Patients moan in bed, restlessly pace the corridors, constantly knock on the nurses’ station window to ask for water, tea, milk, slices of bread, any kind of contact. The nurses tell them to just go to sleep. After a while, I get up and go into the day room, a small area with a television mounted high above, a series of plastic seats along the walls–one or two ripped off their moorings–a pay phone, what look like food stains on the walls and floor, and an overflowing garbage bag.
A clerk comes out of the station and tells me that, according to New York State law, once I come into the psych ER, I can’t leave unless I’m seen and discharged by a psychiatrist. A young black man, Todd, who’s been walking in and out of his room, comes into the day room and sits down. He says he was brought here in handcuffs and tied down to a bed and has been held in the ER for four days. “I need to get the fuck out of here,” he says. “I’m going crazy.”
Woodhull Hospital serves two of Brooklyn’s poorest communities, Bushwick and Bedford-Stuyvesant, where nearly half the residents have incomes below the federal poverty level. Woodhull is one of the city’s 11 public hospitals, operated by the Health and Hospitals Corporation, an agency that is increasingly responsible for treating the city’s uninsured poor. In 1996, HHC treated 46 percent of all psychiatric inpatients in the city.
I wasn’t suicidal when I entered Woodhull’s emergency room. I went in as a reporter. The purpose of going undercover was to evaluate New York City’s system for providing crisis-level mental health services to low-income people.
This is a story that doesn’t lend itself well to conventional reporting. A journalist is limited by confidentiality issues, access to facilities and logistics–you can’t sit in on a psychiatrist’s interview with a patient in crisis and take notes. What’s more, many psychiatry professionals are either dismissive or ambivalent about patients’ criticism of their treatment on hospital psych wards. In the course of reporting this article, I interviewed Dr. Spencer Eth, clinical director of the Department of Psychiatry at St. Vincents Hospital in Manhattan and a frequently quoted expert on mental health issues. I listed a series of complaints about treatment on psychiatric wards.
His response: “Patients who have been hospitalized often have incomplete and inaccurate recollections of the process because almost by definition they are disturbed and upset at the time…. It’s a stressful, upsetting time. Many of the patients we see are intoxicated at the time, some are psychotic, some are demented. Often you’re explaining issues to patients who are not really getting it.”
He added, by way of analogy, “Y’know, you talk to some people and they describe police brutality, you talk to other people and they don’t. What’s the truth? Well, who’s to say? Both are the truth? Neither is the truth?”
Former patients may not always be the most reliable critics of the psychiatric system. But this point of fact can easily lapse into over generalization. Darby Penney, special assistant to the commissioner for the New York State Office of Mental Health–and herself a former psychiatric patient–talks about how this perspective is often used to discount patients’ criticism. “It’s like, ‘They’re mental patients so they’re probably not telling the truth or they thought it up, they imagined it, they hallucinated it and it’s not really happening,’” she says. “People just dismiss it because they figure, ‘Well, they’re crazy, so what they say is suspect.’”
I didn’t tell Eth the origins of my list of complaints, but they all concerned situations I personally witnessed as a psychiatric inpatient at Woodhull.
The discussion of psychiatric care becomes particularly complicated where social and mental health issues intersect. Numerous studies cite poverty as a significant factor that places people at increased risk for psychiatric illnesses. Recently, a 1997 New England Journal of Medicine article linked “sustained economic hardship” with depression.
But there’s also a parallel body of literature which argues that the diagnostic process sometimes misidentifies social problems as psychiatric disorders, especially among low-income populations. A 1997 article in Community Mental Health Journal analyzed the overdiagnosis of major depression in homeless individuals and the difficulties clinicians have in distinguishing “state-dependent distress” (misery, demoralization) from actual psychopathology.
What happens when someone with no family, no money, no job, no social support, shows up at a public hospital in the middle of the night and says: I’m depressed, I’m suicidal, I don’t want to live like this anymore? Will social and economic problems be pathologized? Will psychiatric problems be dismissed as just part of the poverty package? How is a person actually treated? To find out, I followed myself through the system.
The inpatient model–treating psychiatric problems in hospital settings–continues to play a major role in mental health treatment, despite an almost 40-year movement toward deinstitutionalization, out-patient therapy and community treatment. But the venue has changed. Today, relatively few patients languish for lengthy periods in state psychiatric centers; instead they languish for three- or four-week periods in the acute wards of general hospitals.
General hospitals have become the primary providers of inpatient psychiatric care in the United States in recent years because of the profound reduction in the number of beds in state psychiatric hospitals, according to Dr. David Mechanic, director of the Center for Research on the Organization and Financing of Care for the Severely Mentally Ill at the National Institute of Mental Health at Rutgers University. He estimates that nationally, between 1986 and 1994, the total annual number of days patients spent in mental hospitals declined by more than 12.5 million.
Meanwhile, the pace of psychiatric admissions in New York City hospitals has steadily increased. In 1996, there were 55,281 psychiatric admissions to all New York City hospitals–an increase of more than one-third since 1990, when there were 40,477–according to the United Hospital Fund of New York. During that period, inpatient psychiatric care was the only category of hospital health care that wasn’t cut back. In fact, there was an increase of 161 inpatient psychiatric beds between 1990 and 1996 in New York City. In this decade, it is the only category of care that has maintained consistent occupancy rates above the 90th percentile.
Despite years of public awareness, many of the problems that fueled the deinstitutionalization movement have yet to be resolved. The current inpatient model is remarkably similar to what psychologist David Rosenhan described in his classic study, On Being Sane in Insane Places, published 25 years ago. Based on an experiment in which participants entered psychiatric hospitals undercover, Rosenhan described an environment where staff members were casually indifferent to patients, abused them verbally and segregated themselves. Patients experienced an almost traumatic sense of depersonalization; admission, discharge and diagnosis criteria were arbitrary; and patients’ natural reactions to staff mistreatment and to the hospital setting were misattributed to their psychiatric disorders. The overall environment was custodial rather than therapeutic.
Today, much of the policy, advocacy and media discussion surrounding inpatient mental health care is focused on the flaws of deinstitutionalization and on fears that managed care organizations will discharge people too soon or deny hospital treatment when it’s needed. This debate about access to care is pushing the question of what that care actually consists of further and further into the background.
“There’s a lot of things that are typical about how an inpatient ward is run, that if you really thought about it doesn’t make a whole lot of common sense in terms of trying to help people get better,” says Penney, whose state job gives her the opportunity to bring the perspective of people who use mental health services into the policy-making process. “From my own experience, the last place I’d want to be if I was in an emotionally distraught state is in an inpatient unit.”
In the morning in the Woodhull psychiatric ER, the television blasts an evangelist, then cartoons, then Jerry Springer. The ward nurse tools around, screaming orders and commentary. No beds are assigned; when I get up, another person can get into my bed. Todd yells that he’s going crazy. “You’re playing games with me, I’ve got to get the hell out of here.” A nurse tells him that he’s not going anywhere.
A psychiatrist comes in the ER and calls patients into his office. The door is wide open. Whoever wants to can listen. The psychiatrist is yelling his questions at the patients. “Where is your residence? Where is your residence? What drugs are you taking? What? What is it?”
An elderly woman sits in the day room mumbling and talking to herself non-stop. A man sits for hours curled up in a chair in a corner. The young man in my room wakens only to get medication and eat, then goes immediately back to bed. I don’t hear him say a word the entire time he is in the ER or hear anyone say a word to him.
A homeless man in a wheelchair comes in, screaming at the top of his lungs, threatening violence to police officers and nurses. He is unmanageable and demanding. He sees a psychiatrist and is released from Woodhull within a couple hours.
After he leaves, the clerk sits in the nursing station accusing the man of faking his illness, resenting the fact that he’s hiding behind his alleged disability. “If I see him on the street, I’ll beat the shit out of him,” the clerk says, as the nurse listens wordlessly.
My name is called for medication, and I’m given a pill and a cup of juice. No explanation. I ask what it is. “Mellaril,” the worker says. Several times I ask what kind of drug it is, and each time the nurse offers a vague answer (I find out later it’s an anti-psychotic). Finally, she explains, “It’s for your delusions.” I tell her I don’t have delusions and refuse it.
Eleven hours after I walked into the hospital, I’m called into the psychiatrist’s office for an interview. The door is open. “Shouldn’t we shut that?” I ask. She says no, “Nobody cares,” and “They can’t hear because of the TV.”
I tell her the same story: My life is pointless, a series of meaningless jobs. I don’t want to live like this until I’m 65. If I stay out there, I might go crazy.
She seems indifferent, clerk-like–I could have been applying for a driver’s license. She asks me questions about drug abuse and some basic autobiographical facts.
I tell the truth about my life up until my 18th year and try to keep things vague from that point on. I try not to deviate too much from my own emotional life script.
She mentions working and jobs repeatedly. I try to see if she’ll allow me a depression not directly tied to my employability. “Jobs? I’m thinking that I don’t even want to live, I don’t care about jobs,” I say.
“Okay, I’m admitting you,” she says simply. The session, which lasted about 10 minutes, is over.
I go back to pacing the corridors.
As in the Rosenhan experiment, my plan was to stop exhibiting symptoms after I’d been admitted and let the hospital decide what to do with me. But the boredom is excruciating, nothing is happening, and I think three days here will be enough. I assume I’ve been admitted as a “voluntary admission,” meaning that if I request my release in writing, I must be discharged within 72 hours (unless the hospital petitions the court for a longer period of commitment). Later in the day I ask to submit my request.
“No, you can’t do that,” a nurse tells me in a subtly mocking tone. “You’re involuntarily admitted.”
That night, still in the ER, I talk to the psychiatrist on duty and try my very best to separate myself from the crowd. I go in, attempting a caricature of normalcy and reason, and ask to be released. I make my case: I’m okay now, I really don’t think I belong here. I didn’t realize what would happen if I showed up at the ER asking for help. I just was going through some rough times and I called up and they said if I came to the psych ER I could get some help, counseling, medication. I really think I can and should be an outpatient.
He tells me I’m just as mentally ill as anyone in the ER and says, “After reviewing your file, I really think that you should spend some time as an inpatient. I don’t think there’s sufficient reason to override the other psychiatrist’s decision.”
He flips through my record. “Suicide, suicide, suicide,” he says. “It’s written all over the place.”
I ask, “How long will I stay?” He says, casually, “A week or two.” I tell him I don’t need Mellaril, that I’m not delusional. He discontinues it. The next morning I appeal to the psychiatrist who interviewed me the previous day. She tells me: Talk to them on the ward when you get moved upstairs, maybe they’ll release you in a day. Then she walks off.
That afternoon, after 34 hours in the ER, I’m told to change into a hospital gown. My clothes are stuffed into plastic bags, and a staff member and a police officer escort me upstairs.
All told, I stayed in the hospital for seven-and-a-half days. I was locked up, never told when I would get out or how I could get out and never informed of my rights. Hospital staff made almost no attempt to get to know me or my problems. I spoke with a psychiatrist for approximately six minutes over the course of six days on the ward. I was provided with virtually no counseling or other substantive treatment. I refused Medicaid coverage, and was informed that I would be billed $1,400 dollars a day.
After I was discharged, I obtained my hospital records. I asked for (and was told that I had received) my entire psychiatric record, but it included no daily records of my time spent on the ward.
Based on our interaction in the foyer prior to my entry into the psych ER, the nurse completed a “Psychiatric Emergency Room Nursing Triage & Assessment Form” on me.
In the interview the nurse asked if I heard voices. I replied, “Just my own.” She asked no further questions on the topic and checked the “Yes” box under hallucinations. Later in the record she noted: “Alteration in sensory perception as evidenced by hearing voices.”
Under suicidal attempts she also checked “Yes” accompanied by a misquote: “I tried to jump over running car couple of crazy things.” What I actually said in response to her question about whether I had ever tried to hurt myself was: What do you mean hurt myself? I’ve done some crazy things, like when I was a teenager I climbed onto the roof of a speeding car, things like that, is that the kind of thing you mean?
I told her I smoked one to two packs of cigarettes a month. It made it onto the record as one to two packs a day.
Once I was in the psych ER, a nurse noted: “Health education initiated. Encouraged to ventilate feelings. Encouraged for effective coping skill.” An entry written three hours later reads: “Will continue to encourage verbalization of thoughts and feelings + will support pt. [patient] emotionally.”
No staff member had ever offered anything approaching encouragement or support, much less “education.”
I’m also repeatedly described as isolative, withdrawn, “not interacting with anyone.” In actuality, I was in reporter mode with several patients and used the pay phone frequently. Out of utter boredom, I used all the social skills I could muster to charm a clerk to leave the door to the nurses’ station open for a few minutes of conversation. Staff members wouldn’t even acknowledge me when I stood in front of the nurses’ station window to ask a question, let alone interact with me.
The session with the admitting psychiatrist in the psych ER was the first and only time I sat down with a psychiatrist for an interview during my entire hospital stay. Yet the four page Initial Evaluation Sheet that the psychiatrist completed–the documentation that lets staff on the ward know what problems brought me into the hospital and what condition I was in–is in large parts illegible. It took two of my editors poring over each word, comparing separate letters, to interpret some of what it said. If anyone at the hospital had sought this information during my stay, they would have had a difficult time deciphering it.
The records also reflect a tendency to define me and my problem based on an assumption of who I was, rather than what I said or how I acted. (On the ward I spent my time taking daily notes and reading copies of the New Yorker that a visitor had brought me. Yet a psychiatric evaluation described my concentration as “impaired”.) I told the psychiatrist that I’d attended two drug rehabilitation programs when I was 16 years old (I’m now 32)–less for drug abuse than for parent-teenage conflict–and that I drink only casually now and don’t use drugs. It was the truth, what I would have said if I was there genuinely seeking treatment. She wrote: “Has been through many alcohol-drug rehabilitation centers.”
This later showed up on my Psychiatric Evaluation as an Axis I diagnosis: “Alcohol Abuse Disorder partial remission.” My supposed substance abuse problem is mentioned throughout my records and was constantly brought up during my stay, even though I took pains to tell everyone who interviewed me that I had no problem with drugs or alcohol. After that first night on the ER, hospital staff stopped giving me sedatives to help me sleep–which I could have used, it’s not an environment conducive to sleep–because of my “history of drug abuse,” as the ward psychiatrist explained. No matter what I said, they wouldn’t believe that I was anything other than a drug addict or an alcoholic. I was diagnosed with Depressive Disorder and Antisocial Personality Disorder–although the only deviant behavior I exhibited other than my suicidal comments was unemployment and housing problems.
According to Dennis Feld, a lawyer for Mental Hygiene Legal Service (MHLS), the state agency that provides legal representation to patients in psychiatric hospitals, New York State’s Mental Hygiene Law requires that a psychiatrist provide a patient with a form called “Notice of Status and Rights,” as well as explain the legal status of admission, the right to request a court hearing to be released from the hospital, and the amount of time patients can be held under a specific status. They must also provide patients with the name and phone number of MHLS. Woodhull did none of this for me.
I discovered my actual status only when I got up to the ward and read a wall poster explaining the different types of admissions. The doctor apparently admitted me as an “Emergency Admission,” allowing the hospital to hold me for up to 15 days. “Involuntary Admission,” which is how the ER nurses inaccurately described my situation, would have allowed them to hold me for up to 60 days and involves three psychiatrists certifying a patient as mentally ill and a danger to self and others.
In the ER, I had seen a voluntary admission patient ask to submit paperwork requesting release. A nurse told him he couldn’t fill out the form because he wasn’t allowed to have a pen. He had to ask two different workers twice more before he was finally able to complete the paperwork. He was then released.
“Patients have to be told [about their rights] when they come in, not just handed a piece of paper that says ‘You’ve got a right to call a lawyer,’” says Dr. Harvey Bluestone, director of psychiatry at Bronx-Lebanon Hospital and editor of a book on mental hygiene law. “We tell them this is your legal right, here is the lawyer you can call, here’s the number, here’s the quarter to put in the phone. I can’t swear to you what happens at 3 o’clock in the morning, but to the best that I know, this is carried out all the time.
“I think everybody’s got to be given the opportunity to come in voluntarily, and public policy is to encourage people to come in voluntarily,” Bluestone says. “All you need to do to be a voluntary patient is to be mentally competent to sign yourself in….You have to understand what you’re signing yourself into, you have to be able to understand what the exit process is….The psychiatrist who admits you is supposed to very clearly explain that to you–not have a clerk explain it to you. The psychiatrist has to do that, it’s an ethical responsibility.”
When I arrive on the ward there are approximately 14 other patients. I’m the only white male. Only two or three of the patients are actively delusional. About half are in their 20s. There are two elderly women, two patients whose English is either limited or non-existent and a transvestite, whose arrival is greeted by some patients raging about that homo, that faggot living here. Staff prepare a separate single room for him.
There is a very young black man, Freddy, who has been on the ward for five months–perfectly lucid, funny, with an encyclopedic knowledge of bad TV and films. A few years ago he stopped leaving his housing project apartment, he says, because of the amount of violence he witnessed outside. On the ward, he doesn’t participate in therapy sessions because he thinks they’re ridiculous, and he laughingly says the medication he takes has no effect on him. He spends his days watching television. The day I left, he was sent to a state mental hospital. “It’s real nice there,” a nurse informs him. “They take you downstairs to smoke.”
In the middle of the ward is a large nursing station, a Plexiglas cage with a small opening near the bottom of one window similar to a subway clerk’s booth. Patients sleep, pace the floors, go in and out of their rooms aimlessly. They spend their days being stuffed with television, snacks, medication and cigarettes, begging one another for pay phone quarters.
The television, controlled by the twenty-somethings, is constantly on, usually blaring cartoons or action-adventure films. A frail, elderly woman sits on the couch wincing and saying, “Oh, this is so stupid. I don’t care for this. Why do we have to watch this?” Nobody listens. Another elderly woman speaks only Polish and wanders around all day wordlessly or sleeps.
A delusional young woman is pacing around, bumping into walls, half-unconscious (she later complains her medicine is too strong). She wanders into my room, and one of my roommates tries to encourage her to expose herself.
My room contains six beds and a bathroom. When I first arrive the bathroom is completely flooded with water, and I have only my papery foam slippers to walk around with. I tell a nurse, who says she’ll call housekeeping, but the problem isn’t dealt with until the next morning. On other days, patients lay bed sheets on the bathroom floor to soak up the water. My bed sheets and pillowcase are speckled with largish brown stains. The bed frames are dirty, the walls and floor are stained with congealed goo (it looks like either food or blood). What appears to be a rodent hole in the corner is stuffed with toilet paper. The bathroom door is covered with graffiti.
There are no cloth towels. Patients are given a paper towel when coming out of the shower. I’m not given any soap, toothbrush, toothpaste or shower shoes, although I was classified as homeless on admission. There are no locks on any of the cabinets to store possessions (a book I’d been given by a visitor is stolen from me). There is only a pay phone to make calls, but there is no way to get change. If you have change it’s not safe to keep it in the room, and the pajamas and gowns have no pockets. I walk around for the first day or so with quarters in my sock. When I ask staff members for toiletries they respond as though I have irresponsibly tossed out soap I had been given five minutes earlier. I didn’t take a shower for my entire week on the ward; no staff member seemed to notice or care.
It seems anything can be smuggled in through visitors–my visitors’ packages were never checked. Patients in my room regularly smoke contraband cigarettes in the bathroom. In 1995, a patient on a Woodhull psychiatric unit somehow overdosed on methadone, according to an investigation by the State of New York Commission on Quality of Care for the Mentally Disabled, an independent watchdog agency. The hospital investigation never identified the source of the drug but concluded that it “…probably came from an unknown patient or visitor.” This laxity doesn’t seem to be in deference to patients’ rights–I watched a staff member rifle through my roommate’s nightstand drawers when he wasn’t around.
Each day on the ward I was being billed a minimum of $1,400 dollars. In fiscal year 1996, gross charges to Woodhull psychiatric patients amounted to $38.5 million, an increase of almost $3 million from five years ago. The majority of that–$27.5 million–was billed to Medicaid, which reimburses at a flat day rate regardless of an individual’s diagnosis or the treatment he receives.
Woodhull hospital has 133 psychiatric beds and, according to the hospital’s most recent cost report filed with federal regulators and the state Department of Health, the hospital admitted 2,047 psychiatric patients in FY 1996, up from 1,624 in FY 1992. As the number of psychiatric inpatients has increased, however, the average length of time that each patient stays has declined, from about four weeks to 22.7 days.
These trends hold true for many hospitals. Experts say that as admission rates go up and lengths of stay decline, the total cost of care should increase. This is because the intensive early stages of hospitalization are the most expensive, explains Sharon Salit, senior health policy analyst for the United Hospital Fund. The total cost of psychiatric inpatient care at Woodhull has declined slightly, from nearly $24 million to just under $23 million. Why the reduction in cost? As at all of the city’s public hospitals, there have been dramatic staff cuts in recent years. The number of full-time employees in Woodhull’s psych department has dropped substantially, from 244 in FY 1991 to just 177 in FY 1996.
In its last review of Woodhull in October 1996, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), a hospital-funded agency, gave the hospital its lowest rating, “Noncompliance,” in two areas: “Assessing Staff Competence” and “Special Treatment Procedures,” which covers psychiatric care and includes an assessment of whether certain procedures like restraint and behavior modification are carried out appropriately. It also covers whether patients’ rights and well-being are protected. Ironically, the JCAHO is often criticized–most recently in a January 1998 report by Public Advocate Mark Green–for being too hospital-friendly and for conducting shoddy or lax inspections.
More recently, the New York State Office of Mental Health issued Woodhull a two-year operating certificate for its Psychiatric Inpatient Unit on December 1, 1997, based on an inspection done 13 months earlier. They gave the facility a clean bill of health.
But there is one other agency that examines the quality of care at mental health institutions in New York State. Three months before my admission, the Commission on Quality of Care conducted an unannounced site visit of two psychiatric units at Woodhull in response to an allegation that the facility was excessively dirty.
The commission chronicled poor physical conditions, patients’ lack of privacy, and insufficient and insubstantial therapy. It detailed inadequate access to recreational supplies and reading material, as well as widespread idleness, addi