Close Quarters & Cold Turkey:
Trends in Inpatient Psychiatry
Jonathan Dosick
Fresh air is an integral part of life. Exposure to it has historically been a vital part of psychiatric treatment. However, citing security concerns, several local psychiatric units have barred all outdoor access for patients. Since lack of outside time essentially means that all patients can't smoke, the anguish of nicotine withdrawal is often added to the experience. I believe that these restrictions violate patients' civil rights and wellbeing.
Look at the typical patient's experience: Take cramped and uncomfortable spaces,
constant scrutiny (and occasional condescension) from overworked staff. Add
the torment of illness and adjustment to medication changes, and it's obvious:
respite is necessary.
I am not against hospitals or against psychiatry. But I strongly believe that
fundamental changes are necessary in the way psychiatric hospitals are run.
More value must be placed on the dignity and respect patients deserve. Hospitals
need not be so dismal and depersonalizing. Sadly, the dismal state of health
care (i.e., budget cuts, understaffing, and managed care) exacerbates the
refrain: "We don't have enough money", which then becomes an excuse
for inaction.
FRESH AIR ACCESS:
IT'S ONLY COMMON SENSE
In the 1800's, hospitals were designed with open air in mind. Writes a Washington landscape architect, "Psychiatric institutions were planned with outdoor spaces…to screen patients from curious spectators…views were created to provide comforting experiences." Gardens and landscaping were planned with an emphasis on patients' wellbeing.
Most, if not all, of the various treatment programs I've attended have stressed
the therapeutic importance of fresh air, walks, and exercise. It's common
knowledge that the body's release of endorphins works as an antidepressant.
Why, then, are consumers denied open-air time, when prison inmates are guaranteed
it by law? Speaking to an administrator at a nearby 'no outdoors' hospital,
I'm told that there has been a dramatic increase in patient escapes ("elopements"),
in the recent past. Also cited by him were: pressure from insurance companies,
neighborhood resistance (stigma?) towards new construction, and lack of money
and space for the construction of a 'safe' outdoor area. Unfortunately, this
administrator was not available for more detailed comment.
Most of the hospitals that have banned outdoor access are located in urban
settings. I have identified seven such hospitals in the Boston area. This
is most likely due to the possibility of traffic accidents, which could be
either purely accidental or intentional, I'm told. But isn't the extremely
thorough 'evaluation' process during the ipatient admissions process intake
designed to measure patient safety? Unfortunately, going outside will always
involve risks to safety. But does that justify compromising the quality of
life for all patients? What about the 'privilege' system?
I was hospitalized for over a month in early 2002 (one of ten times). I remember
how I craved the short nightly walk to and from the local coffee shop, despite
the extreme cold. I have been to McLean Hospitals as well, whose park-like
campus is ideal for walks. I was there on September 11, 2001, and holding
group therapy outside helped us [consumers] try to process the day's trauma
- plus, it was an important break from watching TV news coverage all day.
SMOKING:
THE LESSER OF TWO EVILS?
Many doctors believe that since hospitals are 'places of health', there's no reason to allow smoking in or around them. Some see it as an essential treatment issue: "Tobacco-free [psychiatric] programs understand any use of tobacco products is incongruent with a lifestyle free of addictive drugs", one article maintains.
Well, if so, why not deny television, which numbs the mind? If kept inside,
patients won't get any exercise. That's not healthy either. What about the
sugary snacks served on the units and the junk food at the hospital cafeterias
and gift shops? And is it not true that psychiatric hospitals have a long
tradition of giving out cigarettes as 'rewards'?
Yes, smoking is a lousy habit. I don't smoke and don't encourage it. In fact,
I find the high rate of smoking amongst consumers disturbing. But regardless,
I find it very upsetting that people who are already in crisis are being forced
to simultaneously suffer the agonies of 'cold turkey' nicotine withdrawal!
Research also finds that nicotine withdrawal often leads to under and over-diagnosis
of illness, and can at times cause wild fluctuations in med levels. If the
goal of an inpatient hospital is to stabilize people on meds as quickly as
possible, why add further variability?
Research has found that people with schizophrenia receive therapeutic value
from nicotine. Again, not a reason to condone smoking, but a fact to consider.
And consumers will always have the option of cutting down and/or quitting
AFTER hospitalization and crisis, when they are more stable.
An aside: Massachusetts' Fiscal Year 2004 budget has devastated health and
human services programs, including mental health services. It's interesting
to observe that funding for the state's Tobacco Control Program has also been
slashed from $48 million to $2.5 million (by 77%) in Fiscal Year 2004 alone!
LEGAL/CIVIL RIGHTS ISSUES
So I set about researching
the legal issues around fresh air and smoking access - here's what I found:
· the Massachusetts Department of Mental Health's (DMH) Patient's Rights
Policy states that: "To the maximum extent possible, all Clients have
the right to an opportunity for physical exercise and access to the outdoors
consistent with requirements to safety."