Dedicated and hard working people staff psychiatric facilities. But they are over-stretched in the work they have to do. They often have to hurry from job to job, and statutory requirements are great – they have to keep enormous records and too much of their time is spent on clerical, as opposed to clinical, tasks. So they have little time to talk with people or sit with people – just getting to know people well; that is one part of their legitimate clinical task that they cannot do physically.
The facilities too are not good enough – particularly in the public sector. They are often crowded and environmentally sub-standard. Some of them are very old and well past their "use by" date. Furniture is too often dull and tired. Hospital planners have several problem here – they could easily use more money and on a defined and often crowded campus planners have what is like a domino problem – they can only replace a unit by tearing it down and rebuilding. And then they have to house the patients somewhere else temporarily while they rebuild. So, they need some spare space to use temporarily before they go tearing down old facilities. There is at least one facility in which a bulldozer, driven very fast, would be the best option. The problem for the hospital is to allocate priority for this rebuilding in line with the many capital requests before it, together with what to do with the patients while the facility is rebuilt (as it needs to be).
Psychiatrists take calculated risks too every time they make a decision about a patient – for example the decision to grant leave or the decision to move a person from a closed to an open ward or the decision to use a drug that increases appetite and weight or the decision to discharge a patient. We pay them to get those guesses right and to minimize risks. So we get tales of innocent third parties being bashed or abused by psychiatrically ill fellow patients. The only way to avoid risk completely is to lock people up alone for a long time - and that kind of risk-averse behaviour has its own problems. But, what we need to avoid too is discharge being made because a bed is needed rather than on proper clinical grounds – it happens now in spite of official protestations to the contrary.
The private and public systems operate in a kind of symbiosis. The private hospitals take many of the less sick patients, who still need hospitalisation, while the public hospitals take the very sickest patients. The two systems could not operate independent of each other. The private hospitals generally transfer to the nearest public facility anyone who needs a certificate written, while the standard for admission to public hospital beds is set very high. But the public hospitals rest more secure knowing that the private hospitals are taking many of the less sick patients, and the private hospitals rest more secure knowing that the public system is there as a back-up for it.
In the community, it is striking just how much professionalism and caring there is. Staff is competent and hard working. Sadly the professionals are also very busy and the clerical demands on them are great. Nevertheless, the "clerking" is often of good standard, and the knowledge of clients is great. Since much of the work takes place in the homes of clients, the physical state of community mental health facilities is less important – but many of the facilities are quite good.
One administrative problem is lack of parking in hospitals (which makes employment in certain facilities unattractive) and a lack of preferential and safe community parking. There is no good sense in someone being seen in their home and the nurse who sees them receiving a parking ticket for their trouble – it is not beyond the realms of possibility or practicability that this problem could be fixed. That it has not been fixed already probably reflects some decision not to bring it to the attention of top people. Staff is often engaged in a risky activity, and should not then be penalised.
Another of today's problems is the acute mania that occurs for 36 hours with some psychoactive illicit substances. As use of these substances is increasing in our society, so is the number of people with acute mania who will be "better" in 36 hours. By the way, if you had no job, no education and no future prospects, might not the use of drugs (legal or illicit) be an attractive alternative?
The "conventionality" of many of our beliefs is a worry too. Did you know that in the old Soviet Union people were sometimes put in psychiatric hospitals because they rejected communism – because such a rejection of communism was not in line with community beliefs. We need to protect people with heterodox views from admission to psychiatric institutions solely on account of those views. Luckily, most psychiatrists are aware of this danger and do their best to avoid it.
Change is occurring very fast in all the healing areas. There must be a capacity for the psychiatric services to embrace change – they have done well over a generation and change will keep occurring rapidly over the next decades.
There has been some improvement in many institutions and practices over years and it is to be hoped that more improvements will occur. Nevertheless, the clinical staff is pushed enormously and some consideration needs to be given to how to reduce the load that staff carries.
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