> 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.
I had an unambiguously good experience at a mental hospital, but I know that was a fluke. It was in a small city, which I think helped. I had been trying to tell the people around me to take me to take me to the hospital for hours but wasn't able to communicate clearly enough. Getting to the ER was an enormous relief. I was barely able to sign myself in voluntarily but they were super patient with me. I needed to be put on new medication so once I was checked in to the psych ward they basically just started giving it to me and watched me stabilize for four days, much of which was spent sleeping. The whole thing was triggered by a meditation retreat, and when I refused to go to their mindfulness class they didn't give me any flack. I was pretty confused and trippy the entire time so I didn't feel bored or restless. They gave me vegan food. It just seemed like a really nice hospital.
I was terrified by what happened to me so I was really happy to be safely institutionalized and I thought they could fix me. Had I gone for depression it would have been different, I'm sure.
Thank you for writing this. I have somewhat-mild obsessive-compulsive disorder, and back when I was in therapy for it, I'd avoid mentioning certain thoughts regarding suicide and depression. This was out of an abundance of caution for avoiding being committed. I even made a plan for how to get help/protect myself outside of the normal mental health system if I become dangerously suicidal.
Was all of this stuff unlikely to happen and something I shouldn't worry about? Maybe; after all, the symptoms of the mental illness I was trying to get help with include unwarranted fears and doing questionably-useful things to stave off things that won't happen anyway. But I still did avoid talking about those things with my therapist, and probably wouldn't have if the system were set up differently.
As someone who works in the inpatient setting, my view is that this state of affairs -- which seems so absurd, why would anyone design it like this! -- is the result of thousands of iterations of minimizing “risk” and “liability.” Anyone attempts any kind of self-harm within hospital grounds, anyone tries to elope, anyone sneaks in drugs, anyone violates privacy, patient goes on leave and does something, hospital finds ways of reducing the chances of that happening again. I’ve been in these administration meetings & the people running the hospitals care nothing about patient dignity and comfort. They only care that they don’t get sued, or don’t get dinged for whatever quality metrics government had set. You repeat this process again & again & again, and the result is a system barely different from the prison.
Half the time, when I dig into why something is working horribly for everyone, the reason turns out to be "so that nobody can be held legally responsible for anything bad happening".
> because it seems like a functional person won’t do that.
I think "won't" should be "would".
> I know a lot of people who have been hospitalized.
I would clarify that this refers to mental hospitalization rather than regular. (Since the previous sentence was talking about regular hospitals, the sudden context-switch is disorienting.)
This was really interesting, thank you. Are there any countries that are doing a significantly better job in mental health provision for people who are severely depressed? I was just wondering if there are places where your suggested reforms (or something similar) have been implemented. I tried googling this but didn't get very far.
When I worked at a suicide hotline I was surprised by how many callers had positive things to say about psych wards. I'd heard almost entirely horror stories (including my friend who nearly bled to death at the best post-partum mental hospital in the state), but I want to say it was about 50:50 at the hotline? Big error bars on that, it's been a long time and I didn't keep a strict count, but there was a definite contingent of people who found it helpful.
There's probably an incentive problem in there somewhere, similar to the ones with regular hospitals (or public schools, for that matter); I'm not aware of patients being able to choose which mental hospital they're sent to, and so there's no competitive pressure* to make them any better. This is definitely an argument from ignorance, though, so salt accordingly.
*Other forms of pressure still exist, which is why they're not just oubliettes.
> 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.
Why attempt suicide in a way that might fail? Especially in the US, where one can just buy a gun, I don't understand why people "attempt" suicide rather than succeeding, unless they actually don't want to die and are just doing it for attention.
Many depressed or otherwise mentally ill people are not very good at executive functioning. Someone who can't reliably eat dinner is going to struggle to come up with an effective suicide plan.
Many suicides are impulsive and the people use what they have to hand. The pain is so intense that the person just tries to make it stop however they can, without being especially strategic; it feels unendurable to wait long enough to buy a gun. (This is me.)
People who have been involuntarily committed can't buy guns in the U.S.
That makes sense, thanks. Why do you think the thinking is so short-term with regards to planning-ahead and pain-ending, but the longer term threat of institutionalization still works as a disincentive?
I am capable of recognizing that if I attempt suicide the pain will not stop, I will instead be in worse pain, because I am in the hospital. So I go "I'll hold on for long enough to try to strategize [insert more effective suicide plan here]."
So far I've always felt better before I managed to take meaningful steps towards a more effective plan, but I do think that the threat of hospitalization increases the chance that, conditional on a suicide attempt, I actually die.
some suicide methods are more viscerally appealing than others. I will get impulses to stab myself (never really acted on), and while this might be a self-harm impulse, it crosses over into suicide when I was feeling that way. Shooting myself with a gun sounds way scarier than stabbing myself with a knife for reasons I cannot explain.
Also, suicide is also extremely socially unacceptable (no one will agree that you are better off dead, and might send you to jail for it), and so one prone to behaving in weird ways around it similar to other deeply suppressed desires like sex or whatever
When I was contemplating suicide, I was very concerned about doing it in a way that would be minimally traumatizing to my loved ones and/or whoever found my body. Many people are afraid of violence and pain even if they want to die. I find your comment ignorant and callous.
> I was very concerned about doing it in a way that would be minimally traumatizing to my loved ones and/or whoever found my body.
Ah, that makes sense. Though I think there are still pretty reliably non-gross-looking ways to do it? Suffocation, etc.
> Many people are afraid of violence and pain even if they want to die.
That's true, but I'm not sure it's relevant? Dying of a gunshot is painless. And many of the ways people choose to attempt and fail suicide are quite painful, like wrist-cutting.
> I find your comment ignorant
What does this even mean? The whole point of a question is that I don't have information and would like to acquire it...
> and callous.
How would you suggest phrasing the question to not invoke that reaction?
Many suicidal people are really upset by "just doing it for attention" because it feels dismissive of how much pain they're in-- like people attempt suicide for the same reasons they might dye their hair pink. You'd probably get a better response if you dropped that.
A more neutral way to say the thing you might have meant is something like "a cry for help."
I see. I thought of using that phrase instead, but wanted to be more general, since some people may not actually need help and just want attention for other reasons. But it makes sense that actually-suicidal people get accused of that much too often and it's become a trigger for them, so I'll try to avoid that framing in the future.
This is more general than Ozy's suggestion, but I think it is actually as widely applicable as it sounds:
If one is confused by some human behavior, and the only hypothesis one can formulate is that the people involved in the behavior are misrepresenting or misunderstanding their motives, experiences, etc., and one is interested in having other hypotheses presented, one simply should not mention the single current hypothesis.
After all, in this scenario, the current hypothesis is not very good. That's why one is interested in hearing about other hypotheses. But at the same time, the people who have that experience will often (quite understandably) perceive a question or statement of confusion coupled with "the only explanation I have is that those who report this experience are misrepresenting themselves" as not really an invitation to dialogue, but a rhetorical maneuver for advancing a critical perspective.
This advice—notice when you're confused about some human behavior, and let the "this experience is misrepresented or misunderstood" hypothesis lay to the side when discussing the source of confusion—is actually pretty hard for me to implement, personally. But I think it exhibits both epistemic and interpersonal humility, and serves one well in otherwise touchy conversations.
> 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.
I had an unambiguously good experience at a mental hospital, but I know that was a fluke. It was in a small city, which I think helped. I had been trying to tell the people around me to take me to take me to the hospital for hours but wasn't able to communicate clearly enough. Getting to the ER was an enormous relief. I was barely able to sign myself in voluntarily but they were super patient with me. I needed to be put on new medication so once I was checked in to the psych ward they basically just started giving it to me and watched me stabilize for four days, much of which was spent sleeping. The whole thing was triggered by a meditation retreat, and when I refused to go to their mindfulness class they didn't give me any flack. I was pretty confused and trippy the entire time so I didn't feel bored or restless. They gave me vegan food. It just seemed like a really nice hospital.
I was terrified by what happened to me so I was really happy to be safely institutionalized and I thought they could fix me. Had I gone for depression it would have been different, I'm sure.
Thank you for the anecdote! It's good to hear things that go against my narrative.
Thank you for writing this. I have somewhat-mild obsessive-compulsive disorder, and back when I was in therapy for it, I'd avoid mentioning certain thoughts regarding suicide and depression. This was out of an abundance of caution for avoiding being committed. I even made a plan for how to get help/protect myself outside of the normal mental health system if I become dangerously suicidal.
Was all of this stuff unlikely to happen and something I shouldn't worry about? Maybe; after all, the symptoms of the mental illness I was trying to get help with include unwarranted fears and doing questionably-useful things to stave off things that won't happen anyway. But I still did avoid talking about those things with my therapist, and probably wouldn't have if the system were set up differently.
Excellent post and all great point. You may find this recent post of mine to be of interest: https://awaisaftab.substack.com/p/asking-better-questions-about-involuntary
As someone who works in the inpatient setting, my view is that this state of affairs -- which seems so absurd, why would anyone design it like this! -- is the result of thousands of iterations of minimizing “risk” and “liability.” Anyone attempts any kind of self-harm within hospital grounds, anyone tries to elope, anyone sneaks in drugs, anyone violates privacy, patient goes on leave and does something, hospital finds ways of reducing the chances of that happening again. I’ve been in these administration meetings & the people running the hospitals care nothing about patient dignity and comfort. They only care that they don’t get sued, or don’t get dinged for whatever quality metrics government had set. You repeat this process again & again & again, and the result is a system barely different from the prison.
Seems like a common story.
Half the time, when I dig into why something is working horribly for everyone, the reason turns out to be "so that nobody can be held legally responsible for anything bad happening".
Some typos:
> So there should absolutely nothing to do
Missing the word "be".
> dangling the change to leave
"Change" should be "chance".
> because it seems like a functional person won’t do that.
I think "won't" should be "would".
> I know a lot of people who have been hospitalized.
I would clarify that this refers to mental hospitalization rather than regular. (Since the previous sentence was talking about regular hospitals, the sudden context-switch is disorienting.)
This was really interesting, thank you. Are there any countries that are doing a significantly better job in mental health provision for people who are severely depressed? I was just wondering if there are places where your suggested reforms (or something similar) have been implemented. I tried googling this but didn't get very far.
When I worked at a suicide hotline I was surprised by how many callers had positive things to say about psych wards. I'd heard almost entirely horror stories (including my friend who nearly bled to death at the best post-partum mental hospital in the state), but I want to say it was about 50:50 at the hotline? Big error bars on that, it's been a long time and I didn't keep a strict count, but there was a definite contingent of people who found it helpful.
There's probably an incentive problem in there somewhere, similar to the ones with regular hospitals (or public schools, for that matter); I'm not aware of patients being able to choose which mental hospital they're sent to, and so there's no competitive pressure* to make them any better. This is definitely an argument from ignorance, though, so salt accordingly.
*Other forms of pressure still exist, which is why they're not just oubliettes.
> 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.
Why attempt suicide in a way that might fail? Especially in the US, where one can just buy a gun, I don't understand why people "attempt" suicide rather than succeeding, unless they actually don't want to die and are just doing it for attention.
Many depressed or otherwise mentally ill people are not very good at executive functioning. Someone who can't reliably eat dinner is going to struggle to come up with an effective suicide plan.
Many suicides are impulsive and the people use what they have to hand. The pain is so intense that the person just tries to make it stop however they can, without being especially strategic; it feels unendurable to wait long enough to buy a gun. (This is me.)
People who have been involuntarily committed can't buy guns in the U.S.
That makes sense, thanks. Why do you think the thinking is so short-term with regards to planning-ahead and pain-ending, but the longer term threat of institutionalization still works as a disincentive?
I am capable of recognizing that if I attempt suicide the pain will not stop, I will instead be in worse pain, because I am in the hospital. So I go "I'll hold on for long enough to try to strategize [insert more effective suicide plan here]."
So far I've always felt better before I managed to take meaningful steps towards a more effective plan, but I do think that the threat of hospitalization increases the chance that, conditional on a suicide attempt, I actually die.
some suicide methods are more viscerally appealing than others. I will get impulses to stab myself (never really acted on), and while this might be a self-harm impulse, it crosses over into suicide when I was feeling that way. Shooting myself with a gun sounds way scarier than stabbing myself with a knife for reasons I cannot explain.
Also, suicide is also extremely socially unacceptable (no one will agree that you are better off dead, and might send you to jail for it), and so one prone to behaving in weird ways around it similar to other deeply suppressed desires like sex or whatever
When I was contemplating suicide, I was very concerned about doing it in a way that would be minimally traumatizing to my loved ones and/or whoever found my body. Many people are afraid of violence and pain even if they want to die. I find your comment ignorant and callous.
> I was very concerned about doing it in a way that would be minimally traumatizing to my loved ones and/or whoever found my body.
Ah, that makes sense. Though I think there are still pretty reliably non-gross-looking ways to do it? Suffocation, etc.
> Many people are afraid of violence and pain even if they want to die.
That's true, but I'm not sure it's relevant? Dying of a gunshot is painless. And many of the ways people choose to attempt and fail suicide are quite painful, like wrist-cutting.
> I find your comment ignorant
What does this even mean? The whole point of a question is that I don't have information and would like to acquire it...
> and callous.
How would you suggest phrasing the question to not invoke that reaction?
Many suicidal people are really upset by "just doing it for attention" because it feels dismissive of how much pain they're in-- like people attempt suicide for the same reasons they might dye their hair pink. You'd probably get a better response if you dropped that.
A more neutral way to say the thing you might have meant is something like "a cry for help."
I see. I thought of using that phrase instead, but wanted to be more general, since some people may not actually need help and just want attention for other reasons. But it makes sense that actually-suicidal people get accused of that much too often and it's become a trigger for them, so I'll try to avoid that framing in the future.
This is more general than Ozy's suggestion, but I think it is actually as widely applicable as it sounds:
If one is confused by some human behavior, and the only hypothesis one can formulate is that the people involved in the behavior are misrepresenting or misunderstanding their motives, experiences, etc., and one is interested in having other hypotheses presented, one simply should not mention the single current hypothesis.
After all, in this scenario, the current hypothesis is not very good. That's why one is interested in hearing about other hypotheses. But at the same time, the people who have that experience will often (quite understandably) perceive a question or statement of confusion coupled with "the only explanation I have is that those who report this experience are misrepresenting themselves" as not really an invitation to dialogue, but a rhetorical maneuver for advancing a critical perspective.
This advice—notice when you're confused about some human behavior, and let the "this experience is misrepresented or misunderstood" hypothesis lay to the side when discussing the source of confusion—is actually pretty hard for me to implement, personally. But I think it exhibits both epistemic and interpersonal humility, and serves one well in otherwise touchy conversations.