On Mental Hospitals

They suck

The first mental hospital I ever went to. Aw, memories. Horrible, horrible memories.

I.

Mental hospitals are a depressogenic environment.

Let’s imagine we were trying to design a location that gave people depression. Familiar places are comforting and grounding, so we should force the patients to leave their homes and live in a totally different building. It’s well-recognized that people feel less depressed when they get out of the house and do something, so we should forbid them to leave the building. If they can leave, they might participate in a Pathfinder campaign, garden, go for a long walk in a botanical garden, or even just have a cup of coffee and a bagel at their favorite little place.

We should definitely forbid them going to work. Stress about falling behind on work or losing your job is very depressing.

Therapy appointments too. What would we do if the therapist helped?

We should remove our patients from their social support networks as much as possible. Some of that we’ve accomplished already: can’t visit friends or go to a meetup or party if you can’t leave the house! We can get rid of the Internet and make them share one phone with thirty other people. Their friends and family can only visit them one hour a day, and never mind if it doesn’t work with the friends’ work schedules or childcare. Speaking of childcare, we can just ban them from seeing their kids.

Fresh air and sunshine makes people less depressed. Therefore, our patients should get exactly fifteen minutes of outside time a day. It’ll take place in a small concrete area with no plants and walls so high they can’t see the horizon.

Exercise makes people happier. We won’t have weights or exercise machines of any sort. If someone decides to jog down the hallway or do pushups anyway, we’ll diagnose them with psychomotor agitation.

Poor sleep causes depression and anxiety. We’ll have a strict sleep schedule that leaves half our patients jetlagged in various directions. The beds will be uncomfortable; the blankets, scratchy; the room temperature, impossible to adjust. They’ll have roommates who are total strangers, for that extra bit of discomfort. We’ll arrange for their sleep to be occasionally disrupted by nurses coming in to check on them and by the next-door neighbors screaming from horrible nightmares.

Drug withdrawal makes everyone miserable, so we’ll deny everyone nicotine and caffeine.

There are some limits on food—apparently we do have to feed people “a healthy diet.” But at the very least it can taste terrible and we can fail to accommodate any dietary restrictions. Vegans can eat eggs, right?

Most of all, the hospital should be boring. We need to leave our patients alone with their thoughts of how they are worthless, evil failures who deserve to die. If the patients have distractions, they might experience happiness. So there should be absolutely nothing to do. There should be one TV for all thirty people, and it should get only a handful of channels. There should be either no books or only book three of various obscure fantasy series. If we offer crosswords, they should be very easy and we should only have three of them.

Some people might cleverly bring in their own hobby materials. We can’t have that. Every hobby material we can possibly ban for being a weapon or a way to smuggle in drugs should be banned. What if the patients tried to put someone’s eye out with the knitting needles? What if they drank the paint? What if they used the string of the cat’s cradle to hang themselves?

Also, we’re banning stuffed animals. Hugging a stuffed animal might be comforting.

We can remove the doors from the bathrooms so that strangers can look at the patients peeing.

It might seem unwise to offer group therapy, because group therapy could potentially be interesting. But, if well-done, group therapy could make our patients way more depressed. For example, you could have them set daily goals and watch them squirm to come up with something other than “nothing, because there is nothing to do here.” You might hire Christian group therapists who tell non-Christian patients that they can only get better with the help of Jesus.¹ You might tell a group of people who have been mentally ill for years or decades about this new thing called Deep Breathing and make them pretend to find it insightful. And you can humiliate people by making them look forward to lessons about Deep Breathing because at least it’s something new.

Finally, we should transform the experience into a Kafkaesque-Orwellian hellscape.

Our patients are here voluntarily. Of course, if they try to leave, we’ll force them to stay. But knowing this fact, they chose to stay of their own free will. Be sure to remind them of this regularly.

You can only keep someone involuntarily for three days, but you can keep someone “voluntarily, but if they try to leave they’ll be stuck here for three days and if they go along with it they might get to leave sooner” for as long as you like.

We’ll let our patients go when they aren’t depressed (or manic, or psychotic). Of course, they are depressed, because we spent all this effort making the environment depressing, and it doesn’t do much for mania or psychosis either. They only get to leave when they successfully keep up the facade that they are happy, the environment helped, they’re so grateful to all of the staff, and the group therapy gave them a bunch of important insights that they can’t wait to apply to their lives.

We have other incentives, of course—restraint, forcible drugging—but dangling the chance to leave in front of them is the most powerful of them all.

Sad people usually feel better when they get to cry it out or seek comfort. Depressed people generally have distorted thoughts, and one purpose of therapy is to help them figure out a more accurate view of the world. We remove all these options. Instead, we force a level of self-monitoring on them more typical of spies and courtiers of the more dysfunctional Chinese emperors. No matter how miserable they are, they must smile. If they want to stop being jailed, they must thank their jailers, sincerity in their voices and their eyes.

(Of course, they’re not very good at lying. Most people aren’t very good at it; depressed people especially aren’t. They don’t need to be good at it for the expectation to make them miserable.)

The beautiful part is that people self-police. No one knows what will cause them to be restrained; best not to object to the fellow patient who keeps petting your hair, just in case. They don’t know how depressed is too depressed to leave. Is it best to claim not to have any distorted thoughts, or is that disobedient and they should make up their own distorted thoughts? Do they want to bet on it being all right to cry? Perhaps the staff won’t take offense if a patient disagrees with them, but it’s safer to agree and agree and agree. Maybe it’s fine to refuse the mind-altering substances they don’t want, but do they really want to take the risk? Some patients can even get quite superstitious—pacing only in their own room and stopping as soon as any staff member walks by, or brushing their teeth three times a day because it seems like a functional person would do that.

II.

I know there’s a lot of discussion about abuse at mental hospitals, and I don’t want to detract from that.² But even when all goes well mental hospitals are horrible. Most of the complaints are kind of petty: you don’t like watching CNN? You missed a party you were looking forward to? The food tastes bad? You want a cup of coffee? You want to hug your stuffed animal? It feels stupid to make those complaints.

But, like… the plurality of the population of mental hospitals is people who felt so miserable that they wanted to kill themselves, and then almost died. Maybe we should be nice to people in this situation. Maybe they should have a chance to talk to the people who love them as much as they want. Maybe they should get good food and coffee and stuffed animals.

When someone is in the hospital for a physical condition, if it’s physically safe, their family can visit as much as they want. I’m just saying.

I know a lot of people who have been in mental hospitals. I have not met anyone who unambiguously benefited, and I have met half a dozen people who were seriously harmed in ways that made their lives worse for months or years.³ Some friends of mine have met people who just needed a safe place to calm down for a few days after a suicide attempt, and the mental hospital helped. It’s not clear to me that mental hospitals outperform a hotel room that someone has checked for knives.

If you work for a mental hospital, and you’re like “but all of my patients say that the hospitalization really helped them”… they’re lying so they can get out. Sorry.

The threat of hospitalization harms more people. Many people—suicidal people, psychotic people, people with certain types of OCD—don’t get therapy because they’re afraid of being hospitalized. Many people who do get therapy don’t disclose the true extent and nature of their mental illness, which means that the therapist can’t help with the problems that are most serious. Some people avoid telling certain medication side effects to their psychiatrists for similar reasons. One of the most important therapeutic tools is the strength of the therapist-patient relationship; how much damage does it do to the relationship if the therapist can, at any time and without meaningful due process, put the patient into jail?

Many parts of the mental health community have a wild understanding of suicidality. It happens in discrete episodes of a few hours or maybe a day, right? Most suicidal people have eight or nine of those in their lives? There aren’t any people who want to die every single day of their lives and who endure because they have responsibilities or because they are frightened of the pain or because they aren’t good enough at taking actions to execute a plan? I think that these conclusions have been drawn because patients systematically lie to their therapists about their suicidality because, like, why risk it.

I do think the existence of mental hospitals has substantially decreased the chance that I’ll attempt suicide. It’s the swift and certain punishment thing. I know that if I survive a suicide attempt I will go to jail, so I don’t attempt suicide. And there’s a nice veneer of medicine over it, so people can feel kind and compassionate and don’t have to consider whether they actually think attempting suicide should be a crime.

I’m not blaming the employees of mental hospitals. Most of them are doing the best they can, within constraints that they did not choose. In a system which is a bastard child of Kafka and Orwell, it means a lot even to be treated like a person. I have seen and heard of a lot of employees bend the rules out of kindness or pity. Some psychiatrists at mental hospitals try to let as many people as possible out. Many employees believe they are helping. Many other employees are just trying to get through the day and pay their rent, same as everyone else.

And, God, there are hard cases. I hate mental hospitals, but if you can’t be dissuaded from threatening yourself with a gun in front of a child, I will try to get you institutionalized.

No one is going to put me in charge of mental health policy, but if I did here are the reforms I’d make, in order from the ones I’m most sure of to the ones I’m least sure of:

1. If the commitment is voluntary, then the patient has to be allowed to leave. If leaving would be seen as grounds for involuntary commitment, it is involuntary from the start.

2. The three-days involuntary commitment counter begins the moment the patient sets foot in a hospital. If the hospital has, say, not managed to get the patient to see a psychiatrist for diagnosis by the time the three days are up, then it does not get to detain the patient for longer to make up for its own incompetence.

3. If you are in the mental hospital against your will, the government pays for your treatment.

4. “I believed that involuntary hospitalization was not in the best interests of the patient” is a defense for mental health professionals facing a malpractice suit about a suicide.

5. A patient who is allowed to sign contracts can sign a legal document saying they don’t want to be hospitalized against their will, and then it is illegal to do so.

6. If both the patient and the patient’s next of kin want the patient to leave the mental hospital, the patient is allowed to leave.

7. Mental hospitals should give up all pretense of treating people for mental illnesses. They should just be dorms with regular meals and someone to remind you to take your meds, and where it would take a lot of creativity to find something to kill yourself or other people with.

1. This happened to two different people I know at two different hospitals.

2. I don’t know much about how common horrifying abuses are, but I’ve gone to mental hospitals three times in my life. Twice I went to a hospital which was the subject of a Buzzfeed News investigation for refusing to let patients go so that they could earn as much money as possible. The third time the doctor lied to me and told me I almost died. Then I spent two days in an ER because they couldn’t find me a placement, begging them to let me call my husband while they told me that ER policy was that psychiatric admits couldn’t talk to their loved ones because it might cause trouble. Eventually a nurse broke the regulations to give me her cell phone.

So my guess is “lots” but I could just have bad luck.

3. Not just abuse but medical bills they can’t pay, being put on inappropriate medications…